Bariatric and Metabolic Surgery

Obesity as a global epidemic has rapidly increased in incidence in the recent few decades and represents one of the biggest public health challenges. Obesity plays a major risk for various diseases such as cardiovascular disease (CVD), diabetes mellitus (DM), hypercholesterolemia, osteoarthritis and some form of cancers. Bariatric and metabolic surgery provides the best solution for obesity and its associated comorbidities. This chapter will discuss in detail the commonly performed bariatric and metabolic surgeries

Preoperative Endoscopy and Its Impact on Perioperative Management in Bariatric Surgery

BACKGROUND The role of preoperative upper-gastrointestinal endoscopy for bariatric surgery is still understood only with controversy. The aim of this study was to evaluate the prevalence of endoscopic findings and its impact on perioperative management. METHODS Patients who underwent bariatric surgery at our center between 2010 and 2013 were systematically analyzed from a prospective database. RESULTS Two hundred and twelve patients with a median body mass index of 50 kg/m(2) (range 29-87) underwent 216 bariatric procedures at our center between 2010 and 2013. All patients received preoperative upper endoscopy. In 159 cases (75%), the endoscopy was performed at our center. These cases were included in this study. In 37 cases (23%), no abnormal findings were detected. In 122 cases (76%), upper endoscopy revealed pathologies. No further treatment was necessary in 24 cases (15%). Medical treatment was changed in 81 cases (51%). The operation was delayed due to medical treatment and re-endoscopy in 13 cases (8%). The surgical approach was changed in 4 cases (3%). CONCLUSION Routinely performed preoperative endoscopy before bariatric surgery revealed a high prevalence of gastrointestinal diseases with a significant impact on perioperative management in two thirds of the cases. Therefore, we recommend routine gastroscopy about 2-4 weeks prior to surgery

How do patients' clinical phenotype and the physiological mechanisms of the operations impact the choice of bariatric procedure?

Bariatric surgery is currently the most effective option for the treatment of morbid obesity and its associated comorbidities. Recent clinical and experimental findings have challenged the role of mechanical restriction and caloric malabsorption as the main mechanisms for weight loss and health benefits. Instead, other mechanisms including increased levels of satiety gut hormones, altered gut microbiota, changes in bile acid metabolism, and/or energy expenditure have been proposed as explanations for benefits of bariatric surgery. Beside the standard proximal Roux-en-Y gastric bypass and the biliopancreatic diversion with or without duodenal switch, where parts of the small intestine are excluded from contact with nutrients, resectional techniques like the sleeve gastrectomy (SG) have recently been added to the armory of bariatric surgeons. The variation of weight loss and glycemic control is vast between but also within different bariatric operations. We surveyed members of the Swiss Society for the Study of Morbid Obesity and Metabolic Disorders to assess the extent to which the phenotype of patients influences the choice of bariatric procedure. Swiss bariatric surgeons preferred Roux-en-Y gastric bypass and SG for patients with type 2 diabetes mellitus and patients with a body mass index >50 kg/m(2), which is consistent with the literature. An SG was preferred in patients with a high anesthetic risk or previous laparotomy. The surgeons' own experience was a major determinant as there is little evidence in the literature for this approach. Although trends will come and go, evidence-based medicine requires a rigorous examination of the proof to inform clinical practice

Two-stage laparoscopic biliopancreatic diversion with duodenal switch as treatment of high-risk super-obese patients: analysis of complications

The aim of this study is to retrospectively analyze the incidence of complications after two-stage laparoscopic biliopancreatic diversion with duodenal switch (Lap BPD-DS) in high-risk super-obese patients and explore the possible predictive factors of specific complications after laparoscopic sleeve gastrectomy (SG). High-risk patients-body mass index (BMI) > 50 kg/m(2) with at least two major comorbidities: type 2 diabetes, obstructive sleep apnea syndrome (OSAS), hypertension-undergoing two-stage laparoscopic BPD-DS were retrospectively analysed. The SG pouch volume was 100-150 ml; in the second stage, the common channel and the alimentary loop were 100 cm and 150 cm, respectively. Eighty-seven patients (50 female, 57.5%) underwent SG (two open). The mean age was 41.8 +/- A 10.22 years with BMI of 55.2 +/- A 6.69 kg/m(2). Four patients had Prader-Willy syndrome. Fourteen (16.46%) patients (6 female, 42.8%) had postoperative complications such as bleeding, fistula, pulmonary embolism, transitory acute renal failure, and abdominal abscess. One patient died at postoperative day 5 of pulmonary embolism. One patient was reoperated for hemoperitoneum by laparoscopy. The risk of complications after SG was lower in patients where reinforcement of the suture line was used (0.492), while it was higher in men (1.780). Neither difference was statistically significant [p = not significant (NS)]. After 9-24 months, 27 patients (BMI 43 +/- A 8 kg/m(2)) underwent a second stage of BPD-DS (two open). Major postoperative complications were registered in eight patients (29.6%): three bleeding, four duodeno-ileal stenosis and one rhabdomyolysis. Two cases of internal hernia required laparoscopic reoperation. The reoperation rate was 1/85 (1.2%) after SG and 2/27 (7.4%) after second stage. Complications after SG greatly decrease after the learning curve period and can be successfully managed without need of reoperation. Suture-line reinforcement, at least selectively in the middle-upper portion of the staple line and in super-super-obese patients, is recommended to decrease the incidence of specific complications

Laparoscopic Sleeve Gastrectomy with partial antrectomy and omental patch

Alcoy Hospital, Clínica San Jorge, Alcoy, España, Al XI-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova și cea de-a XXXIII-a Reuniune a Chirurgilor din Moldova „Iacomi-Răzeșu” 27-30 septembrie 2011Introducere: Sleeve Gastrectomia laparoscopică (LSG), în ciuda popularității sale, nu este o tehnică standardizată. Rezultatele pe termen lung sunt variabile, iar motivele controversate sunt: 1) Volumul tubului gastric residual; 2) Metoda de protecție a liniei de sutură a regiunei esofagogastrice pentru a preveni o eventuală scurgere; 3) Efectuarea unei antrumectomii parțiale. Începând din 1997 am folosit o sutură sero-seroasă invaginantă în peste 1200 de LSG izolate sau asociate cu Duodenal Switch (laparotomic sau laparoscopic) pentru a acoperi zona de sutură. Gagner a descris procedeul în anul 2000.Background: Laparoscopic Sleeve Gastrectomy (LSG) is, even if popular, a non-standardized bariatric technique. The results varied and there are controversial issues such as: 1) Size of the sleeve; 2) Protection against esophageal-gastric junction (EGJ) leaks; 3) The use of partial antrectomy. We have always used, since 1997, in more than 1200 isolated or combined open or laparoscopic Duodenal Switch (LDS) a continue inverting Lembert-type sero-serosa suture to cover the staple-line. Gagner reported the first operation in 2000

¿La cirugia bariatrica mejora sensiblemente la calidad de vida del paciente?

Objective: The aim of this investigation was to assess the effect of malabsorptive bariatric surgery (BS) on the quality of life (QoL), applying the Nottingham Health Profile (NHP) and the bariatric analysis and reporting outcome system (BAROS). Design: A prospective cohort study was performed in 100 adult patients (> 18 years) undergoing bariatric surgery by malabsorptive technique for one year. Research methods and procedures: Patients were monitored from the beginning of the BS program until a year after the intervention, applying the NHP and the BAROS test. At baseline, the mean weight of the women was 132 ± 22 kg and the Body Mass Index (BMI) was 50.7 kg/m2. Results: The values obtained from different areas applying the NHP questionnaire showed statistical significant differences (p < 0.001) with respect to baseline values. According to the BAROS test, 48% of patients lost 25-49% of weight excess and 80.8% had resolved major comorbidities at 1 yr. According to the Moorehead-Ardelt QoL score, there were major improvements in employment and self-esteem in 89% and 87% of patients, respectively, and improvements in physical activity, sexual and social relationships. According to the total mean BAROS score, the outcome was considered “very good”. Conclusion: NHP and BAROS questionnaires appear to be useful and easily applicable tools to assess the QoL of obese patients.Introducción: La obesidad mórbida suele acompañarse de enfermedades graves asociadas que provocan una menor expectativa y peor calidad de vida (CV). Objetivos: evaluar el efecto de la cirugía bariátrica (CB) por técnicas malabsortivas sobre la CV, utilizado (Perfil de Salud del Nottingham (PSN) y el Bariatric analysis and reporting outcome system (BAROS). Material y métodos: Estudio prospectivo, descriptivo, desde Octubre del 2002 hasta Mayo de 2006, seguimiento a los pacientes desde el inicio al protocolo de CB hasta el año post-intervención., donde se incluyeron 100 pacientes. El 86% mujeres, el peso inicial medio 132±22 kg y IMC de 50,7 kg/m2. Se aplicaron 2 cuestionarios: PSN y el BAROS. Resultado: Los valores obtenidos de las diferentes áreas aplicando el cuestionario PSN al año de la intervención muestran diferencias estadísticamente significativas (p < 0,001) con los valores iniciales. Según BAROS: Porcentaje de sobrepeso perdido (%SP). El 48% de los pacientes perdió entre el 25 y el 49% de su exceso de peso. Condiciones médicas. El 80,8% habían resuelto todas las comorbilidades mayores. CV de Moorehead Ardelt. El aspecto más mejorado fue el empleo el 89% , autoestima solo el 13% no presentó cambios, las áreas de la actividad física, relaciones sexuales y sociales fueron consideradas como mucho mejor. Basándonos en esta clasificación nuestros resultados se pueden calificar de “muy buenos”. Conclusión: Los cuestionarios PSN y BAROS parecen ser herramientas útiles y de fácil aplicación para evaluar la calidad de vida de los pacientes obesos

Outcome of gastric bypass surgery in Iceland 2001-2015

Efst á síðunni er hægt að nálgast greinina í heild sinni með því að smella á hlekkinnInngangur: Magahjáveituaðgerðir með kviðsjártækni hafa verið framkvæmdar á Landspítala frá árinu 2001. Aðgerðirnar eru mikilvægur með- ferðarmöguleiki fyrir sjúklinga með sjúklega offitu. Markmið þessarar rannsóknar var að kanna langtímaárangur slíkra aðgerða hérlendis. Efniviður og aðferðir: Rannsóknin tók til 772 sjúklinga sem gengust undir magahjáveituaðgerð á Landspítala árin 2001-2015. Upplýsinga var aflað úr framskyggnum gagnagrunni offituaðgerða sem er hluti af sjúkraskrárkerfi spítala. Fullnægjandi þyngdartap var skilgreint sem annaðhvort þyngdarstuðull undir 33 kg/m2 eða meira en helmingstap af yfirþyngd (%EBMIL skilgreint sem prósenta af tapi á yfirþyngd, umfram þyngdarstuðul 25 kg/m2 ). Niðurstöður: Meðalaldur sjúklinga var 41 ár. 83% voru konur. Meðal- þyngd sjúklinga var 127 kg (±20) og líkamsþyngdarstuðull (BMI, kg/m2 ) var 44 (±6) að meðaltali. Meðal %EBMIL var 80% eða 57 kg (±15) eftir 1,5 ár, 70% eða 50 kg (±15) eftir 5 ár og 64% eða 48 kg (±14) eftir 10-13 ár. 85% sjúklinga náðu fullnægjandi þyngdartapi með meðaleftirfylgni 7,4 ár eftir aðgerð. Sjúklingar voru að meðaltali með 2,8 fylgisjúkdóma offitu fyrir aðgerð. 71% sjúklinga með sykursýki af tegund tvö fyrir aðgerð fóru í fullt sjúkdómshlé eftir aðgerð. Rúmlega þriðjungur sjúklinga með háþrýsting eða blóðfituraskanir urðu lyfjalausir eftir aðgerð. Snemmkomna fylgikvilla fengu 37 (5%) sjúklingar og fór helmingur þeirra í bráðaaðgerð. Síðkomna fylgikvilla eftir aðgerð fékk fjórðungur sjúklinga (174). Hjá flestum sjúklinganna (78%) þurfti að gera endurteknar breytingar á inntöku vítamína og bætiefna í samræmi við niðurstöður blóðprufa í eftirliti. Ályktun: Magahjáveituaðgerð hjálpar meirihluta sjúklinga að ná tilsettu þyngdartapi. Samhliða því fékk meirihluti sjúklinga bót á fylgisjúkdómum offitu. Snemmkomnir fylgikvillar voru fátíðir en um fjórðungur sjúklinga fékk síðkomna fylgikvilla sem stundum kröfðust nýrrar aðgerðar. Sjúklingar sem fara í magahjáveituaðgerð þurfa á ævilöngu eftirliti á næringar- ástandi að halda.Introduction: Laparoscopic roux-en-y gastric bypass (LRYGB) has been performed at Landspitali University Hospital (LSH) since 2001. The procedure represents an important treatment option for morbidly obese patients. The aim of this study is to evaluate the long-term results of these operations in Iceland. Material and methods: All 772 consecutive patients undergoing LRYGB at LSH during 2001-2015 were included. Information was collected from a prospective database. Successful weight loss was defined as body mass index (BMI) less than 33 kg/m2 or excess body mass index loss (EBMIL) more than 50%. Results: Mean age of patients was 41 years and 83% were females. Mean pre-operative weight was 127 kg (±20) and mean BMI was 44 (±6). Mean %EBMIL was 80% after 1.5 year, 70% after 5 years and 64% after 10-13 years. 85% of patients had successful weight loss with a mean follow-up time of 7.4 years. Pre-operatively patients on average had 2.8 obesity related comorbid diseases. 71% of patients with type 2 diabetes were in full remission after surgery. One third of patients with hypertension and one third of patients with hyperlipidemia achieved full remission after surgery. 37 patients (5%) had an early complication and 174 (25%) had a late complication that frequently needed surgical solution. Most patients (78%) needed repeated adjustment of vitamins and minerals often many years after surgery. Conclusion: Majority of patients achieved a successful weight loss and most obesity related comorbidities are still in remission 7.4 years after surgery. Early complications were rare but one fourth of patients had late complications. Life long follow-up is of utmost importance after gastric bypass surgery