Types of Bariatric Procedures. Tejal Brahmbhatt, MD General Surgery Teaching Conference April 18, 2012
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1 Types of Bariatric Procedures Tejal Brahmbhatt, MD General Surgery Teaching Conference April 18, 2012
2 A Brief History of Bariatric Surgery First seen in pts with short bowel syndrome weight loss First weight loss operations (ca. 1950s) Intestinal bypass Low-risk surgically BUT many patients developed serious and often fatal complications
3 Types of Bariatric Surgery Purely Restrictive Gastric Balloons (not approved for use in USA) Vertical-banded gastroplasty / sleeve gastrectomy Gastric adjustable banding Restrictive > Malabsorptive Short-limb/Roux-en-Y gastric bypass Long-limb/distal Roux-en-Y gastric bypass Malabsorptive > Restrictive Biliopancreatic diversion (BPD) BPD with duodenal switch Very long limb Roux-en-Y gastric bypass Purely Malabsorptive Jejunoilieal bypass Jejunocolonic bypass
4
5 Adjustable Silastic Gastric Banding (ASGB): LapBand TM GENERAL FEATURES Inflatable balloon within the band orifice can be adjusted via a reservoir under the skin Average Weight loss 50% of excess weight
6 Adjustable Silastic Gastric Banding : Complications Splenic injury Esophageal injury Wound infection Persistent vomiting Acid reflux Band slippage Reservoir leak/deflation Band erosion Re-operation 5-20 % Death 0.3 %
7 Vertical Banded Gastroplasty (VBG) General Features Pouch size: 1 oz Triple staple line Pouch opening: 0.5 in Average Weight Loss 50 % of excess weight
8 Vertical banded gastroplasty: Complications Stomal narrowing with persistent vomiting Staple line leak or disruption Band erosion Wound infection or hernia Death 0.1% Overall re-operation rate 43 %
9 Types of Bariatric Surgery Purely Restrictive Gastric Balloons (not approved for use in USA) Vertical-banded gastroplasty / sleeve gastrectomy Gastric adjustable banding Restrictive > Malabsorptive Short-limb/Roux-en-Y gastric bypass Long-limb/distal Roux-en-Y gastric bypass Malabsorptive > Restrictive Biliopancreatic diversion (BPD) BPD with duodenal switch Very long limb Roux-en-Y gastric bypass Purely Malabsorptive Jejunoilieal bypass Jejunocolonic bypass
10
11 Roux-en-Y Gastric Bypass (RYGBP) General Features Pouch size: 1 oz, 5cm Pouch opening: 0.5 in Roux-en-Y limb Standard: cm Average Weight Loss 70 % of excess weight
12 MALABSORPTIVE + RESTRICTIVE ROUX-EN-Y GASTRIC BYPASS: Small proximal gastric pouch divided and separated from rest of stomach; food passes through this Larger portion receives no food but secretion of gastric acid, pepsin, intrinsic factor continues Short proximal (biliopancreatic) limb, the Y- loop, transports secretions from pancreas, liver, gastric remnant Longer distal portion, the Roux limb, anastomosed to small pouch and receives its food Y-loop and Roux limb connected distally to feed into jejunum; most digestion in this common channel
13 Gastric Bypass: Complications Early: Staple line leak 1-5% Acute gastric distention Roux-Y obstruction Death 0.5 % Late: Stomal narrowing /vomiting 15 % Marginal ulcer 13% Heartburn / inflammation of esophagus Anemia Folate deficiency Vitamin B12 deficiency Iron deficiency Calcium deficiency / osteoporosis Gallstones 10 %
14 Types of Bariatric Surgery Purely Restrictive Gastric Balloons (not approved for use in USA) Vertical-banded gastroplasty / sleeve gastrectomy Gastric adjustable banding Restrictive > Malabsorptive Short-limb/Roux-en-Y gastric bypass Long-limb/distal Roux-en-Y gastric bypass Malabsorptive > Restrictive Biliopancreatic diversion (BPD) BPD with duodenal switch Very long limb Roux-en-Y gastric bypass Purely Malabsorptive Jejunoilieal bypass Jejunocolonic bypass
15
16 Biliopancreatic diversion: Horizontal partial gastrectomy Closure of the duodenal stump Gastrojejunostomy with a 250 cm Roux limb Anastomosis of long biliopancreatic limb to the Roux limb 50 cm proximal to the ileocecal valve Creating an extremely short common channel
17 Duodenal switch operation: Lesser curvature gastric tube, approx 100 ml Greater curvature gastric resection, preserving pylorus, dividing duodenum Closure of distal duodenal stump Anastomosis of enteric limb to the postpyloric duodenum Common channel, as practiced in the USA today, varies in length (75 to 150 cm)
18 Biliopancreatic Diversion with Duodenal Switch (BPD-DS) General Features Gastric pouch size: Standard: 14 oz (1.5 cups) Three segments Alimentary tract: 6.5 ft Biliary tract: 13 ft Common channel: 1.5 ft Average Weight Loss 80 % of excess weight
19 Duodenal Switch (BPD-DS) : Complications Protein malnutrition 15% Anemia < 5 % Marginal ulcer < 3 % Peripheral neuropathy 1.3 % Night Blindness 3 % Osteoporosis 14 % Renal stones Nausea 65 % First 6 mo Diarrhea 62 % Vitamin deficiencies: A, D, E, K, B 12 Incisional hernia 10 % Death 1.1 %
20 Weight Maintenance after Bariatric Surgery Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26
21 POST-OP COMPLICATIONS Phase I: one to six weeks Phase II: seven to twelve weeks Phase III: thirteen wks to 12 months Overall operative mortality = 1%
22 POST-OP COMPLICATIONS: PHASE I Medical: -pulmonary embolism (1%) -myocardial infarction -respiratory failure -pneumonia -urinary tract infection Surgical: -anastomotic leak (2-3%) -postop bleeding -bowel perforation -bowel obstruction -wound infections
23 POST-OP COMPLICATIONS PHASE II RESTRICTIVE: -staple line disruption or band erosion -pouch/esophageal dilatation -port failure -GERD/ulcers -infection (foreign body) ROUX-EN-Y: -gastric remnant distention perf -stomal stenosis -wound infection -cholelithiasis -ventral hernia -incisional hernia
24 POST-OP COMPLICATIONS PHASE III -GERD/esophagitis/gastritis -small bowel obstruction -staple/band erosion -dehydration due to severe constipation or freq vomiting
25 INTRA-GASTRIC BALLOON What the.?
26 Types of Bariatric Surgery Purely Restrictive Gastric Balloons (not approved for use in USA) Vertical-banded gastroplasty / sleeve gastrectomy Gastric adjustable banding Restrictive > Malabsorptive Short-limb/Roux-en-Y gastric bypass Long-limb/distal Roux-en-Y gastric bypass Malabsorptive > Restrictive Biliopancreatic diversion (BPD) BPD with duodenal switch Very long limb Roux-en-Y gastric bypass Purely Malabsorptive Jejunoilieal bypass Jejunocolonic bypass
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