Magdy Giurgius.MD
No Financial disclosure
1-History 2-Gastric Banding 3-Adverse events 4-Multidiscplinary approach
The prevalence of obesity in the Western world, especially in the United States, has been increasing. From 1980 to 2004, individuals with a body mass index (BMI) of 30 kg/m 2 doubled, representing almost one-third of the US population. The prevalence of overweight children increased from 1999 to 2004.
71% Females Average age 42 Average BMI 45 Average co morbidities 3.2 54% married 62% employed Often overweight since childhood
The first bariatric procedure to be preceded by animal studies and subsequently presented to a recognized surgical society and published in a peer reviewed journal was that of Kremen and associates in 1954. (Kremen, Linner et al. 1954) The story of surgery for Obesity ASBS 1999
The case which they presented was of a jejuno-ileal bypass.(jib).
Payne et al. reported results of ten patients in whom an end-to-side jejuno-colic shunt had been performed These patients had episodes of uncontrollable diarrhea, dehydration and electrolyte imbalance.
Payne and Dewind subsequently advised against jejunocolic anastomoses, instead recommending end to side jejuno-ileostomy anastomosing the first 14 inches of jejunum to the last 4 inches of ileum.(payne and DeWind 1969)
End-to end anastomoses of the proximal jejunum to distal ileum.
Both these variants a total of only about 35 cms (18") of normally absorptive small intestine was kept. In consequence, malabsorption of carbohydrate, protein, lipids, minerals and vitamins occur. End-to-side technique was used, reflux of bowel content back up the defunctionalized small intestine allowed absorption of some of the refluxed material resulting in less weight loss initially and greater subsequent weight regain.
Bile has an important role in fat digestion, emulsifying fat as the first stage in its digestion. Bypassing the major site of bile acid reabsorption in the small intestine therefore further reduces fat and fat soluble vitamin absorption
As a result, huge amounts of fatty acids which are normally absorbed in the small intestine, enter the colon where they cause irritation of the colon wall and the secretion of excessive volumes of water and electrolytes, especially sodium and potassium, leading to diarrhea.
Mineral and Electrolyte Imbalance: Decreased serum sodium, potassium, magnesium and bicarbonate. Decreased sodium chloride Osteoporosis and osteomalacia secondary to protein depletion, calcium and vitamin D loss. Protein Calorie Malnutrition Hair loss, anemia, edema, and vitamin depletion Cholelithiasis Enteric Complications: Abdominal distension, irregular diarrhea, increased flatus, pneumatosis intestinalis, colonic pseudo-obstruction, bypass enteropathy, volvulus with mechanical small bowel obstruction.
The multiple complications associated with JIB led to a search for alternative procedures. 1983 Griffen et al. reported a comprehensive series comparing the results of jejuno-ileal bypass with gastric bypass. 11 of 50 patients who underwent JIB required conversion to gastric bypass within 5 years, leading Griffen to abandon jejuno-ileal bypass. (Griffen, Bivins et al. 1983ss)
Malabsorption is defined by the incomplete uptake of calories and nutrients and occurs via two mechanisms. First, the bile and pancreatic fluids released into the duodenum to digest food and break down fats, carbohydrates and proteins are diverted away from ingested food hence the name, biliopancreatic diversion The second mechanism through which malabsorption occurs is by decreasing the amount of small intestine through which the ingested food passes
A modern improvement of the Jejuno-ileal Bypass (JIB) is Biliopancreatic Diversion,(BPD), a procedure which differs from JIB in that no small intestine is defunctionalized and, consequently, liver problems are much less frequent developed by Professor Nicola Scopinaro, of the University of Genoa, Italy. (Scopinaro, Gianetta et al. 1996)
A modern improvement of the Jejuno-ileal Bypass (JIB) is Biliopancreatic
72% excess body weight loss maintained for 18 years Disadvantages of the procedure are the association with loose stools, stomal ulcers, and foul smelling stools and flatus. The most serious potential complication is protein malnutrition, which is associated with hypoalbuminemia, anemia, edema, asthenia, generally requires hospitalization and 2-3 weeks hyperalimentation
Because of this potential for significant complications, BPD patients require lifelong follow-up
In 1988, Hess, using a combination of Scopinaro's BPD and the duodenal switch described by De Meester in 1987, developed a hybrid operation with the advantages of the BPD but without some of the associated problems. The duodenal switch, originally designed for patients with bile reflux gastritis, consists of a suprapapillary Roux-en-Y duodeno-jejunostomy
This allows the first portion of the duodenum to remain in the alimentary stream thus reducing the incidence of stomal ulcer. When combined with a 70%-80% greater curvature gastrectomy (sleeve resection of the stomach) continuity of the gastric lesser curve is maintained while simultaneously reducing stomach volume.
A long limb Roux-en-Y is then created. The efferent limb acts to decrease overall caloric absorption and the long biliopancreatic limb diverting bile from the alimentary contents, specifically to induce fat malabsorption Hess in 1992 and first published in a paper by Marceau, Biron et al in 1993 is known as Biliopancreatic Diversion with Duodenal Switch (BPDDS)
BPD/DS Deep vein thrombophlebitis 0.7% pulmonary embolism 0.5% Pneumonia 0.5% Acute respiratory distress syndrome 0.25% Splenectomy 0.9% Gatric leak and fistula 2.0% Duodenal leak 1.5% Distal Roux-en-Y leak 0.25% Postoperative bleeding 0.5% Abcess unrelated to leaks 0.25% Duodenal stomal obstruction 0.75% Small bowel obstruction 2.0%
1960s Gastric Bypass (RGB) was developed by Dr Edward E. Mason, of the University of Iowa, based on the observation that females who had undergone partial gastrectomy for peptic ulcer disease, tended to remain underweight following the surgery, and that it was very difficult to achieve weight gain in this patient group Professor of Surgery at the University of Iowa
(Mason and Ito 1967) With the availability of surgical staples, he was able to create a partition across the upper stomach using staples, and did not require removal of any of the stomach
Subsequent modifications of the technique include a pouch of 50 ml or less, a gastro-enterostomy stoma of 0.9 mm, use of the Roux-en-Y technique to avoid loop gastroenterostomy and the bile reflux which may ensue
Lengthening of the Roux limb to 100-150 cms to include a greater element of malabsorption and improve weight loss and the use of the retrocolic and retrogastric routing of the gastrojejunostomy to ease the technical difficulties of the procedure and improve long term weight loss results Gastric Bypass has also stood the test of time, with one series of greater than 500 cases, followed for 14 years, maintaining 50% excess weight loss.
Early: Leak Acute gastric dilatation Roux-Y obstruction Atelectasis Wound Infection/seroma Late: Stomal Stenosis Anemia Vitamin B12 deficiency Calcium deficiency/osteoporosis
The use of rings to control the stoma size, proven with Vertical Banded Gastroplasty, has led to their adoption by some surgeons as an addition to gastric bypass procedures However, because the muscular stomach wall has a tendency to stretch, the stoma can widen thus permitting greater food and calorie intake To reduce this possibility, weight loss surgeons place a silastic ring as a sort of "collar" around the stoma, to prevent stretching and enlarging of the passage into the lower (distal) stomach.
During World War II, the Russians, as part of their war effort, developed a series of surgical instruments which would staple various body tissues together as a simple and rapid method of dealing with injuries. This concept was adapted and refined by American surgical instrument makers after the war, leading to the surgical stapling instruments in use today
In Bariatric Surgery The idea being that food which the patient takes in is held up in the segment of stomach above the staple line causing the sensation of fullness. The food then empties slowly through the stoma into the stomach below the staple line. Unfortunately, the stomach wall has a tendency to stretch and the stoma enlarges (Gomez 1981),used this technique which was only partially successful
The search for a better gastroplasty was pursued by Dr. Edward E. Mason in 1982. He realized that the lesser curvature part of the stomach had the thickest wall and was therefore least likely to stretch, so he used a vertical segment of stomach along the lesser curvature for the pouch. Modification which he made was to place a polypropylene band (Marlex Mesh) around the lower end of the vertical pouch, which acts as the stoma, to fix the size of the outlet of the pouch, preventing it from stretching
He defined the size of the pouch, measuring it at surgery under a standard hydrostatic pressure, and has shown that best results follow the use of a very small pouch, holding only 14 mls of saline at the time of surgery.
A surgical variant of the VBG is the Silastic Ring Vertical Gastroplasty (SRVG) which is functionally identical to VBG but uses a silastic ring to control the stoma size.
Leak Stenosis with persistent vomiting Ulcer Incisional hernia Wound Infection Band erosion
Several things all happened in the early 1990s 1993:The first Laparoscopic Gastric bypass Bariatric surgeons learned from each other
Laparoscopic Roux GIB with hand sewn gastrojejunostomy First case took them 8 hours
Dr. Alan Wittgrove, is known as the father of laparoscopic gastric bypass: he performed the first laparoscopic gastric bypass in the world as primary surgeon in 1993. This was performed in San Diego, California
Vertical Sleeve Gastrectomy (VSG) The earliest forms of this procedure were conceived of by Dr. Jamieson in Australia (Long Vertical Gastroplasty, Obesity Surgery 1993)- and by Dr. Johnston in England in 1996 (Magenstrasse and Mill operation- Obesity Surgery 2003). Dr Gagner in New York, refined the operation to include gastrectomy(removal of stomach) and offered it to high risk patients in 2001
Alternative to a Roux-en-Y Gastric Bypass The Vertical Gastrectomy is a reasonable alternative to a Roux en Y Gastric Bypass for a number of reasons Because there is no intestinal bypass, the risk of malabsorptive complications such as vitamin deficiency and protein deficiency is minimal. There is no risk of marginal ulcer which occurs in over 2% of Roux en Y Gastric Bypass patients. The pylorus is preserved so dumping syndrome does not occur or is minimal. There is no intestinal obstruction since there is no intestinal bypass. It is relatively easy to modify to an alternative procedure should weight loss be inadequate or weight regain occur. The limited two year and 6 year weight loss data available to date is superior to current Banding and comparable to Gastric Bypass weight loss data(see Lee, Jossart, Cirangle Surgical Endoscopy 2007).
Effect of Bariatric Surgery on Medical Diseases
The global prevalence of Type 2 DM is increasing, and is estimated to reach > 366 million individuals in 2030 The American Diabetes Association estimates that in 2020, the annual cost of caring for persons with diabetes will approach $192 billion Postgrad Med. 2011 Jan;123(1):24-33
Bariatric Surgery in Patients with Type 2 Diabetes Because of its increased safety and efficacy, bariatric surgery, particularly LAGB, has gained acceptance as a potential therapeutic tool in patients with T2DM who have a BMI of > 35 kg/m 2. Roux-en-Y gastric bypass appears to have remained the procedure that has shown the most dramatically effective weight loss when compared with LAGB; however, in one systematic review, LAGB had lower short-term morbidity and higher reoperation rates. Postgrad Med. 2011 Jan;123(1):24-33
IMPACT ON OBESITY-RELATED DISEASES Can improve or resolve more than 30 obesity-related conditions, including Type 2 diabetes, heart disease, sleep apnea, hypertension and high cholesterol Gastric bypass resolves Type 2 diabetes in nearly 87% of patients Band surgery resolves Type 2 diabetes in 73% of patients Cuts risk of developing coronary heart disease in half Resolves obstructive sleep apnea in more than 85% of patients
BARIATRIC SURGERY: RISKS VS. BENEFITS In 2007, federal government (Agency for Healthcare Research and Quality) and clinical studies report significant improvements in safety. o Risk of death from bariatric surgery is about 0.1% Bariatric surgery increases lifespan, as compared to those who do not have surgery o Patients may improve life expectancy by 89% Patients may reduce their risk of premature death by 30 to 40% Dramatic reduction in risk of death from obesity-related diseases, as compared to those who do not have surgery o Risk of death from diabetes down 92%, from cancer down 60% and from coronary artery disease down 56%
LONG-TERM EFFECTIVENESS OF BARIATRIC SURGERY Typically patients have maximum weight loss within 1-2 years after surgery and maintain a substantial weight loss, with improvements in obesity-related conditions, for years afterwards Patients may lose 30 to 50% of their excess weight 6 months after surgery and 77% of their excess weight as early as 12 months after surgery Long-term studies show up to 10-14 years after surgery, morbidly obese patients who had surgery maintained a much greater weight loss and more favorable levels of diabetes, cholesterol and hypertension, as compared to those who did not have surgery
Meta-Analysis: Surgical Treatment of Obesity Surgery is more effective than nonsurgical treatment for weight loss and control of some comorbid conditions in patients with a BMI of 40 kg/m 2 or greater. More data are needed to determine the efficacy of surgery relative to nonsurgical therapy for less severely obese people. Procedures differ in efficacy and incidence of complications. April 5, 2005 vol. 142 no. 7 547-559
Original Article Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects The prospective, controlled Swedish Obese Subjects study involved 4047 obese subjects. Of these subjects, 2010 underwent bariatric surgery (surgery group) and 2037 received conventional treatment (matched control group) Maximum weight losses in the surgical subgroups were observed after 1 to 2 years: gastric bypass, 32%; vertical-banded gastroplasty, 25%; and banding, 20%. After 10 years, the weight losses from baseline were stabilized at 25%, 16%, and 14%, respectively. There were 129 deaths in the control group and 101 deaths in the surgery group Bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality N Engl J Med 2007; 357:741-752August 23, 2007
Surgery is the only way to obtain consistent,permenant weight loss for morbid obese patients Indications: 1-BMI of 40 or over 2-BMI 35-40 with significant comorbidity 3-Documented dietary attempts ineffective 4-VBG & Gastric bypass are identified as the safe and effective surgical treatment for obesity
The field grew but complications grew as well!!!!!
Leak rate 2-5 % Major infections 2-5% Incisional Hernias 10-20% Bleeding less than 2 % Clot related?????
Complications Port related Stapler related Tube and dilator related
Too many trained too quickly -Lap.Gatsric bypass is a complex operation often done on sick patients -A week end is not enough to learn about the prinicples of Bariatric procedures -People got into Bariatric surgery for wrong reasons. Many for the money
Development of courses,fellowships and preceptor ship NIH update-consensus conference May 2004 Meta analysis Creation of surgical review corporation(src) Work with Medicare
1. Bariatric surgery is the most effective therapy available for morbid obesity and can result in improvement or complete resolution of obesity co morbidities. 2. Types of operative procedures for morbid obesity have increased since 1991 and are continuously evolving; there are currently four types of procedures that can be used to achieve sustained weight loss: gastric bypass (standard, long-limb, and very long-limb Roux), alone or in combination with vertical banded gastroplasty; laparoscopic adjustable gastric banding; vertical banded gastroplasty; and biliopancreatic diversion and duodenal switch.
3. Both open and laparoscopic bariatric operations are effective therapies for morbid obesity and represent complementary state-of-the-art procedures. 4. Bariatric surgery candidates should have attempted to lose weight by nonoperative means, including self-directed dieting, nutritional counseling, and commercial and hospital-based weight loss programs, but should not be required to have completed formal nonoperative obesity therapy as a precondition for the operation. 5. The bariatric surgery patient is best evaluated and subsequently cared for by a multidisciplinary team
Forsell- March 1996 developed SAGB laparoscopic Technique. Based on Pars Flaccida dissection in open technique. Catona A et Manna L and Forsell P. The Swedish Adjustable Gastric Band: laparoscopic technique and preliminary results. Obes Surg 2000Feb :10(1)15-21
Position : -Lithotomy vs Supine Surgeon s preference -Operating table in reversed Trendelenberg
Angle of His Dissection Preserve gastro-phrenic attachment
Five trocars are placed in the following sequence: a 10 mm trocar for a 30 optical system 6 finger breadths below the xyphoid a 10 mm trocar for the liver retractor (sub-xyphoid) a 10 mm trocar for the grasping forceps and the Lap-Band Closure Tool (in R upper quadrant) a 5 mm trocar for the cautery hook, needle holder and grasping forceps (in L upper quadrant) 10 mm trocar for the atraumatic grasping forceps for band introduction and reservoir placement (on the L anterior axillary line below the costal margin).
Incise lesser omentum in avascular pars flaccida region Blunt dissection along the medial border of the right crus picture
Minimal Force should be needed 5 mm articulating dissector (golden finger) other dissectors or a grasper can be used
Check band and tube for leaks Aspirate all air from the Balloon Tighten Knot on tube
15 mm trocar Minimal force Grasp the band flap with the grasper
Pass and hook the suture loop arround the endoscopic dissector tip slot Pass Band first instead of tubing first
Two Balloon types available -Symmetrical -Asymmetrical Inflate with 15 cc saline
Grab the suture loop Pass and pull through the buckle till locked
Standard of care in USA In many other countries they do not plicate A curved needle may assist with good bites in the small space between the band and the cardia Deflate and remove the gastric calibration tube before placing sutures.
Bring the free end of the tubing out of the peritoneal cavity through the selected Trocar port site. Leave sufficient tubing length within the peritoneal cavity to avoid tension on the gastric band. Placement of the injection port above the fascia
1-Slippage/prolapse Anterior Posterior it is uncommon with pars flaccida technique
Remove fluid If prolapse small and symptoms improve: -re-train patient,behaviour modification eating rules -Re adjust band slowly If prolapse large -Revision surgery in the form of pulling the stomach through and resuture.
Chronic enlargement of gastric pouch Different than slippage/prolapse concentric Presentation -Hunger/Larger portions/no weight loss -Obstructive symptoms: Vomiting/reflux/regurgitaion
A. Conservative -Band deflation -Behavior modification -Reinforce eating rules -Frequent follow up visits -slow adjustments Nutritional and psychological support
B. Surgical Treatment Reposition the band Band explant Convert to RNY
Etiology 1-Serosa injury from dissection 2-Excessive tissue tension 3-Excessive vomiting C/P Asymptomatic Lack of restrictions Latent access port infection
Dysphagia Epigatsric pain Diagnosis Barium study Barium is flowing around the eroding band
Upper GI endoscopy -Definitive diagnostic tool -A normal barium study does not exclude Erosion
A. Laparoscopic : Removal and close gastrotomy B. Endoscopic: -Totally endoscopic removal -Laparoscopic assisted endoscopic removal
Etiology Stitch pull through causing gastric leak C/P Acute presentation few days post-op Consistent with peritonitis UGI study may not show a leak CT may be more helpful Laparoscopy best approach &Band explanation
Clinical scenario -Usually patient doing well and after adjustments develops obstruction not improving with band deflation -Unusual dysphasia, fluid collection,abscess UGI or CT may be helpful Laparoscopy---inflammatory reaction Turbid fluid or pus. Treatment Band Explanation
Uncommon Etiology -May be unclear -Iatrogenic needle, grasper, instrument
On Suspicious of leak -Aspirate all fluid -Under fluroscopy inject contrast -If no leak detected aspirate contarst and inject saline instead.
Natural Orifice Translumenal Endoscopic Surgery (NOTES ) Under trials
The multidiscplinary approach is not a luxury but rather mandatory as mandated by various guidelines and criteria.
Programs need to address preoperative and long term management Patients require long term follow up including nutritional counseling and biochemical surveillance. Surgeons need to be aware of the needs for morbidly obese patients in terms of facilities,supplies, equipment, staff, and procedures
Multidisciplinary approach including medical management of co morbidities, dietary,instruction, exercise training, specialized nursing care and Psychological assistance Well trained team familiar with equipments, instruments and techniques of bariatric surgery
To deliver Optimal Bariatric surgical care Education of patients Develop a process to assess each program objectively (know the data)
Documented In-service education. Commitment up to the highest level Minimum 50 cases per surgeon per year. Institution maintains Minimum 125 cases /year.
Program maintains a program director who participates in the relevant decision making meetings Well equipped ICU with trained personal Obesity safe environment Beds, Radiological equipment,.etc
RN Clinical and non-clinical responsibilities. Certified Bariatric nurse.
Maximizing adipose tissue loss by minimizing lean muscle mass loss 60-70 gm of protein daily Cultural preferences Vitamin needs
Exercise is a key for maintaining long term weight loss Physical disabilities or limitations should be addressed Motivation, encouragement, reassurance and customization.
A systematic approach helps with data recording and reporting. COE requirement Insurance companies requiring data as well Allows opportunities for research.
Support the patient Trained to pick up disorders and potential red flags Depth of understanding of Bariatric surgery Available for consultation Pre operative Psych assessment per ASMBS requirements
Supports pre and post operative patient care Educates about different aspects of Bariatric needs Coordinates with other members of the team : Nurses, Psychologists, Dietitian, Program coordinator.
Specialized and ongoing clinical training Competent in complication recognition Understanding Bariatric procedures Empathy training
It has to be a dedicated team focusing in Bariatric patients,understanding their needs and give them the tools and guidance to optimally achieve their goals.
The goal is 75% long term follow up at five years. -Provide SRC (Surgical Review Corporation) and annual update -HIPPA compliant -Early and late complications
Morbid obesity surgery is a curative tool when indicated. Need for a center of excellence to practice Multidisciplinary approach is the way to go Use of different techniques Fellowship programs Trained nursing staff
Thank you