Transcript Weight loss surgery

Clinical update: bariatric surgery
by Michael Korenkov and Stefan Sauerland
Article Adaptation presented by: Tami Hedglin, R.N.
Definitions for you to know

Bariatrics-a branch of medicine that deals with the control
and treatment of obesity and allied diseases.

Diabetes Mellitus-a disorder of carbohydrate metabolism,
usually occurring in genetically predisposed individuals,
characterized by inadequate production or utilization of
insulin and resulting in excessive amounts of glucose in the
blood and urine.

Hypertension- a common disorder in which blood pressure
remains abnormally high (a reading of 140/90 mm Hg or
greater.

Cardiomyopathy-Any of various structural or functional
abnormalities of the cardiac muscle, usually characterized by
loss of muscle efficiency and sometimes heart failure.
More definitions

Sleep apnea- A temporary suspension of breathing occurring
repeatedly during sleep that often affects overweight people
or those having an obstruction in the breathing tract.

Asthma- A common inflammatory disease of the lungs
characterized by episodic airway obstruction.

Osteoarthritis-A form of arthritis that is characterized by
chronic degeneration of the cartilage of the joints. Also
called degenerative joint disease.

Hyperlipidemia- An excess of fats or lipids in the blood.
Is there a need for bariatric
surgery?

Studies shows that surgically induced weight loss
provides a survival benefit for morbidly obese
patients.

In two recent cohort studies, bariatric surgery was
compared with conservative weight-loss
management.


reduced long-term mortality in morbidly obese patients
The decrease in mortality rates in the two studies
amounted to 29% and 40%, respectively.
Are you a candidate for
surgery?

Bariatric surgery is appropriate for adult
patients with a body-mass index (BMI) of
35 kg/m and over with obesity related co
morbidities. These include







type 2 diabetes mellitus
hypertension
cardiomyopathy
sleep apnea
asthma
osteoarthritis
hyperlipidaemia
Contraindications for surgery

those with severe mental or cognitive retardation

those who will not comply with follow-up
requirements

those with psychiatric disorders such as:




psychotic, personality, or affective disorders
alcoholism
drug abuse
However, preoperative evaluation sometimes
requires consultation by a psychiatrist and
nutritionist.
Types of Bariatric surgery

Two categories of Bariatric procedures



those that reduce food intake (ie, gastric
restriction)
those that reduce food uptake from the
digestive tract (ie, malabsorption).
The two most common procedures
worldwide


laparoscopic adjustable gastric banding
Roux-en-Y gastric bypass


done through open approach
done laparoscopically
Lap banding




band is placed around the upper third
portion of the stomach to create a small
stomach pouch
initially holds 2 ounces of food, and
eventually holds up to 4 to 6 ounces
causes a longer lasting feeling of fullness
works by slowly allowing the food you eat
to be released into the lower portion of the
stomach for digestion.
Lap banding
Roux-en-y gastric bypass

The Roux-en-Y gastric bypass procedure
involves creating a stomach pouch out of a
small portion of the stomach and attaching
it directly to the small intestine, bypassing
a large part of the stomach and
duodenum.

Not only is the stomach pouch too small to
hold large amounts of food, but by
skipping the duodenum, fat absorption is
substantially reduced.
Roux-en-Y gastric bypass
Biliopancreatic diversion
 In
a biliopancreatic diversion,
a portion of the stomach is
removed. The remaining
portion of the stomach is
connected to the lower
portion of the small intestine.
Biliopancreatic diversion
biliopancreatic diversion with
duodenal switch

In a biliopancreatic diversion with
duodenal switch, a smaller portion of
the stomach is removed, but the
remaining stomach remains attached
to the duodenum (the upper part of
the small intestine). The duodenum is
connected to the lower part of the
small intestine.
biliopancreatic diversion with
duodenal switch
Roux-en-Y
bypass/biliopancreatic diversion




greater potential for serious perioperative
complications, including lethality and
malnutrition
associated with better long-term outcome
in terms of weight loss
requires less dietary restrictions
appears to be more effective than both
standard Roux-en-Y method and
laparoscopic adjustable gastric banding in
terms of weight loss
Complications of Roux en Y
/biliopancreatic diversion
 leakage







stoma stenosis
gastric distension
gastrointestinal hemorrhage
small-bowel obstruction
gastrojejunal ulcers
nutritional deficiencies
inadequate weight loss
Lap sleeve gastrectomy

Laparoscopic sleeve gastrectomy can be done as
an initial weight-loss procedure followed by
second-stage duodenal switch for high-risk
patients or in addition to gastric banding when
weight loss is insufficient.

Biggest drawback of this procedure is the potential
for sleeve dilatation, resulting in a stop in weight
loss or even a gain.

Can be used as a stand-alone bariatric procedure
for some special groups of high-risk patients.
Lap sleeve gastrectomy
Which is safest?

In accordance with current opinion, laparoscopic adjustable
gastric banding is generally considered to be the safest and
quickest, but the long-term outcome and quality of life,
especially for eating patterns, have been questioned.

Band-related complications include band slippage, leak,
intolerance, infection, and migration, as well as insufficient
weight loss.

The management of these complications includes:





band replacement for slippage
band removal for infection
band removal plus Roux en-Y gastric bypass for intolerance
band in situ plus sleeve gastrectomy for insufficient weight loss
addition of biliopancreatic diversion or band removal plus the
Roux-en-Y technique for insufficient weight loss
How to choose?

choice of surgical procedure partly depends on the
repertoire of the surgeon

most surgical centers cannot offer the full range of possible
operations.

Some centers prefer Roux-en-Y gastric bypass or
biliopancreatic diversion, while others have nominated
laparoscopic adjustable gastric banding or laparoscopic
sleeve gastrectomy as their first-choice procedure and do
the Roux-en-Y technique or biliopancreatic diversion only
when the laparoscopic procedure has failed.

On the balance between risks and benefits, patients with
more severe obesity ( BMI>50) are generally considered
good candidates for Roux-en-Y bypass or biliopancreatic
diversion, whereas adjustable gastric banding or sleeve
gastrectomy may be more appropriate in milder degrees of
obesity.
Further findings…

The effectiveness of obesity surgery has been traditionally
measured only in terms of excess weight loss, for which
data clearly indicate the effectiveness of all procedures.

Today, research emphasis is more on the effect of surgery
on obesity-related comorbidites, which can affect
metabolic, cardiovascular, respiratory, gastrointestinal,
musculoskeletal, and urological organ systems.

Additionally, the psychological benefits of weight loss are
being investigated. New data indicate that at least some
bariatric procedures exert their beneficial metabolic effects
not only by weight loss but also through a change in
hormone release (ghrelin, peptide YY, and glucagon-like
peptide 1) from the gut.

This finding corresponds to clinical observations that
obesity in patients with diabetes is especially amenable to
bariatric surgery.
Remember!
As can be expected from other
surgical disciplines, the results of
surgery critically depend on the
expertise of the surgeon and the
multidisciplinary team.
 Mortality in high-volume centers is
lower than in lower-volume centers.

In conclusion
There is good evidence to show that
bariatric surgery is more effective
than non-surgical approaches in the
therapy of morbid obesity.
 However, no single operation is ideal
for every morbidly obese patient, and
all operations also entail some
disadvantages.

References:

1 Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical
procedures. JAMA 2005; 294:1909-172 Sjöström L, Narbro K, Sjöström CD,
et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N
Engl J Med 2007; 357: 741-52.3 Adams TD, Gress RE, Smith SC, et al.
Long-term mortality after gastric bypass surgery. N Engl) Med 2007; 357:
753-61.4 DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med
2007; 356: 2176-83.5 National Institutes of Health Consensus Development
Panel. Gastrointestinal surgery for severe obesity. Obes Surg 1991; 1:25765.6 Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a
systematic review and meta-analysis JAMA 2004; 292:1724-377 Colquitt J,
Clegg A, Sidhu M, Royle P. Surgery for morbid obesity. Cochrane Database
Syst Rev 2003; 2: CD003641.8 O'Brien PE, Dixon JB, Laurie C, et al.
Treatment of mild to moderate obesity with laparoscopic adjustable gastric
banding or an intensive medical program: a randomized trial. Ann Intern
Med 2006; 144: 625-33.9 Sauerland S, Angrisani L, Belachew M, et al.
Obesity surgery: evidence-based guidelines of the European Association for
Endoscopic Surgery (EAES). Surg Endosc 2005; 19: 200-21.10 Black DW,
Goldstein RB, Mason EE. Psychiatric diagnosis and weight loss following
gastric surgery for obesity. Obes Surg 2003; 13: 746-51.
References:

11 Puzziferri N, Austrheim-Smith IT, Wolfe BM, Wilson SE, Nguyen NT.
Three-year follow-up of a prospective randomized trial comparing
laparoscopic versus open gastric bypass. Ann Surg 2006; 243:181-88.12
Suter M, Giusti V, Worreth M, Heraief E, Calmes JM. Laparoscopic gastric
banding: a prospective, randomized study comparing the Lapband and the
SAGB: early results. Ann Surg 2005; 241: 55-62.13 Weiner RA, Korenkov M,
Matzig E, Weiner S, Karcz WK. Initial clinical experience with telemetrically
adjustable gastric banding. Surg Technol Int 2006; 15: 63-69.14 Buchwald
H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg 2004; 14:
1157-64.15 Moon Han S, Kim WW, Oh JH. Results of laparoscopic sleeve
gastrectomy (LSG) at 1 year in morbidly obese Korean patients. Obes Surg
2005; 15:1469-75.16 De Luca M, Segato G, Busetto L, et al. Progress in
implantable gastric stimulation: summary of results of the European multicenter study. Obes Surg 2004; 14 (suppl 1): S33-39.17 Brolin RE. Bariatric
surgery and long-term control of morbid obesity. JAMA 2002; 288: 279396.18 O'Brien PE, McPhail T, Chaston TB, Dixon jB. Systematic review of
medium-term weight loss after bariatric operations. Obes Surg 2006; 16:
1032-40.19 Rubino F. Bariatric surgery: effects on glucose homeostasis.
Curr Opin Clin Nutr Metab Care 2006; 9: 497-50720 Flum DR, Salem L,
Elrod J A, Dellinger EP, Cheadle A, Chan L. Early mortality among Medicare
beneficiaries undergoing bariatric surgical procedures. JAMA 2005; 294:
1903-08.