GISURGERY

Lecture topic: surgical management of obesity (2 lectures)

Lecturer: Dr. Mahmoud Abu-Khalaf
Written by: Moa'th Al-Hamad
Lecture #1(from slides):
Incidence, prevalence and demography of obesity
Etiology of obesity
Energy metabolism and biochemistry of obesity
Obesity comorbidities
Longevity and obesity
Social and implications of obesity
Economic implications of obesity
Dietary management of obesity
Drug management of obesity
Nonsurgical methods of weight loss
Diet
Behavioral modification
Exercise
Surgical management of obesity
Multidisciplinary team in bariatric surgery program.
Allied science team in bariatric surgery program.
The Roles of the Gastroenterologist:
The gastroenterologist can contribute to the preoperative
evaluation of bariatric surgery patients, to help prevent
complications of weight loss surgery, and to manage the GI
complications of obesity itself:
o GERD
o Colorectal polyps
o NAFLD
Most of the late complications of weight loss surgery arise
from the GI tract.
o Structural changes in GI tract
o Micronutrient malabsorption

 Endoscopic treatment of obesity

The preoperative evaluation:
Lecture #2: (slides + additions):
Few words about non-surgical methods for wt. control:
Drugs:
In Jordan: drugs for wt. reduction are sold OTC.
These drugs have many side effects.
The wt. reduction effect of these drugs is transient.
So there is NO effective drug in the management of
obesity.
Any modality of wt. control MUST be accompanied by: diet
modification, exercise & behavioral modification.
The best diet to be followed to control wt. is the
Mediterranean diet ( fruits, vegetables, unsaturated oils,).
Excersice: at least 1hr/day 5days/week.
Behavioral modification include:
Eating regularly 3 small meals /day.
NOTHING between meals.
Eating in a small dish!!
Surgical management of obesity is NOT advised before trying
the triad of diet modification, exercise & behavioral
modification.
Indications and requirements for surgical management of obesity:
Weight:
BMI > 40.
BMI > 35 if there is any associated co-morbidity that
can be treated by wt. loss.
Other modalities should be tried for a reasonable time before
indicating a surgery for wt. loss.
The patient should be evaluated by a gastroenterologist (see
above).
The patient should be evaluated by a psychologist for
depression.

 The patient should undergo pre-op evaluation for obesity comorbidities:

Respiratory
Cardiology
Evaluation of his diabetic state: fasting blood sugar,
Post-prandial blood sugar, & glucose tolerance test.
Levels of electrolytes in his blood.
(the need for these and other pre-op evaluations justifies the need
for a multidisciplinary team to deal with the patient who will
undergo a surgery for wt. control. And this is what is present now
in the U.S.)

The patient should not have any risk for surgery.

Surgical Management of Obesity: Operative Procedure:

Surgical operations for wt. reduction are divided into 3 main
categories:
1) Restrictive procedures: restrict food intake by limiting
the space that receives food in the stomach.
2) Mal-absorptive procedures: lead to decreased absorption
of eaten food.
3) Procedures that are both: restrictive and mal-absorptive.
The most common surgical procedures for wt. reduction are
1) ROUX-EN-Y gastric bypass (RYGBP):
Anastomosis between a small pouch of the stomach and the small
intestines.
Can be done via open surgery or laparoscopic surgery.
Procedure: the stomach is divided into two portions: a large distal
portion that is kept in it's place and drains into the duodenum (this
part does NOT receive food), and a small proximal one of 15-30 ml
volume that servers as a reservoir for the incoming food and is
connected to the small intestines distal to the duodenum.
Can be done in many techniques: (these techniques were mentioned but
NOT explained by the dr. The following figures were taken from the doctor's
PowerPoint)

1) The linear technique:

2) The circular techniques:

3) Hand-Sewn Gastro-jejunostomy Technique:

2) Long-Limb Roux Gastric Bypass: (this procedure was NOT explained by

the doctor).

3) Banded Gastric Bypass: (this procedure was NOT explained by the doctor.
The following figure was taken from the doctor's PowerPoint).

4) Laparoscopic Adjustable Gastric Banding (LAGB)

A ring that is attached to a balloon is placed around the outside of
the upper portion of the stomach and is sutured in place to prevent
slippage. This ring divides the stomach into a small proximal
pouch and a larger distal one, & this in turn leads to restriction of
food intake. The balloon is attached to a subcutaneous inflation
device that allows the size of the proximal pouch to be adjusted
postoperatively by injection of saline.
This procedure is performed via laparoscopic surgery.
This procedure was popular in the 80's. Now, it is becoming less
common.
The following figures are from the doctor's PowerPoint:

5) Vertical banded gastroplasty (VBG): (was NOT explained by the doctor!)

6) Biliopancreatic diversion(BPD):
This procedure delays the contact between food and pancreatic
juice and bile, thus preventing complete absorption of fat. It also
eliminates the role of 75% of the small intestines in absorption.

7) Biliopancreatic diversion with duodenal switch:

This procedure delays the contact between food and pancreatic
juice and bile, thus preventing complete absorption of fat. It also
eliminates the role of large portion of the small intestines in
absorption.

8)Duodenal Switch and Sleeve Gastrectomy:

The stomach is converted into a tube!!
This procedure is not common and used only for specific cases.
9) stomach pacemaker: (Implantable Gastric Stimulation):
Still in the research phase.
The idea depends on that electrical stimulation of the wall of the
stomach by a pacemaker device will send signals to the brain that
inhibit the desire to eat.

Endoscopic procedures for wt. control

o These procedures are still in the research phase.
o Example: putting a balloon inside the stomach by
endoscopy and inflating this balloon so that it fills
part of the stomach restrict food intake:
This procedure allows for loss of only 15-20 Kg
of body wt.
Not good for a person who needs much more
wt. loss to
correct co-morbidities.
The balloon should NOT be left in the stomach
for more than 6 months, or it will cause
erosion of the stomach wall
Not a permanent solution

 Gastric Bypass Vs. Gastric banding:

Bypass:
Leads to loss of 60-70% of excess body weight.
The main disadvantage is that it is a major surgery
that is associated with 1-2% mortality rate.
Banding:
Advantages: adjustable, done via laparoscopy, a
simple procedure.
Average wt. loss is only 40% of excess body wt.
Wt. loss is slow ( it takes about 3years to stabilize the
wt. of the patient who underwent banding).
Not good for patients with certain personalities (for
example, those who depend heavily on the band and
INCREASE their food intake after the surgery and as
a result gain more and more weight!!).
NOT good for patients with GERD.
Long term wt. control is NOT as good as that of
bypass.
BOTH gastric bypass & banding:
The operation will help to decrease food intake, but
exercise and behavioral modification are mandatory.
Patient's who undergo any of the surgical procedures
should take multivitamins, iron and B12 for the rest of their
lives.
In majority of patients who undergo surgery, wt. loss leads
to:
Increasing self-esteem.
Decreasing co-morbidities:
70-80% of morbidly obese diabetics are cured by
decreasing their wt.
Also 70-80% of morbidly obese patients with
HTN.
Obstructive sleep apnea, stress incontinence,
benign intracranial hypertension and many other
co-morbidities are corrected in morbidly obese
patients by loosing wt.

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 How much safe is the wt. control surgery??!

Mortality rates in persons with low to moderate risk for
surgery:
Laparoscopic banding: mortality rate is < 1%.
Gastric bypass: mortality rate is 1-2%.
Other health problems:
The patient is liable to develop the complications
associated with any other surgery: infections, bleeding,
.etc.
The patient after surgery is liable to develop iron
deficiency anemia & vitamins deficiency. So he/she
must be kept under medical supervision for the rest of
his/her life.

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This is what is written in Schwartz about the surgical management of obesity:

Operations for Morbid Obesity

A variety of criteria have been used for defining morbid obesity; perhaps
the most commonly accepted definition is 100 lbs over ideal body weight.
The pathogenesis of such obesity is poorly understood, but includes a
genetic influence, metabolic abnormalities, disorders of satiety, and
psychological abnormalities. Morbidly obese individuals typically
develop problems by puberty.
In many people, it is related to excessive intake; in others, the problem
may be related to a low basal energy expenditure or an inability to burn
off excess calories.
Severe obesity is associated with a variety of complications and with
excess mortality.
Complications include coronary artery disease, hypertension, impaired
cardiac function, adult-onset diabetes mellitus, pulmonary dysfunction
including hypoventilation and sleep apnea, hypercoagulability,
degenerative arthritis, cholelithiasis, and gastroesophageal reflux. Low
self-esteem and depression are not unusual.
Criteria for operation vary, but typically complete metabolic and
psychological evaluation is necessary; most surgeons require documented
evidence of participation in a supervised dietary management program
without success. Although 100 lb over ideal weight is required,
exceptions may be made for patients with a weight-related medical
problem.
Surgery for morbid obesity has undergone considerable evolution.
The first operation was the jejunal bypass, in which the proximal
jejunum, usually 20 cm distal to the ligament of Treitz, was anastomosed
to the terminal ileum, usually 10 cm from the ileocecal valve. Although
this produced significant weight loss, it was associated with
complications, including significant liver disease in 5 to 10 percent of
patients, related both to protein- calorie malnutrition and to factors
released by the bacterial overgrowth that invariably develops in the
bypassed segment. Arthritis, cholelithiasis, nephrolithiasis, and metabolic
abnormalities were common. This procedure has been largely abandoned.
The most commonly performed procedures today are the vertical banded
gastroplasty and the Roux-en-Y gastric bypass. Both operations are
performed using a combination of surgical staplers to create a proximal
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gastric pouch with a capacity of approximately 30 mL. This significantly

limits intake, producing weight loss. The patients are maintained on a
1000 kcal or less diet with nutritional supplements. The bypass does not
allow the meal to enter the distal stomach, adding an element of
maldigestion. There may also be a component of dumping syndrome as
the gastric contents directly enter the small bowel. Several studies have
suggested that the bypass may be superior, and it is becoming the
procedure of choice. There are now several surgeons performing the
procedure laparoscopically.
Morbidly obese patients are at particular risk for postoperative morbidity.
Atelectasis and pulmonary infection are most common. In these patients
postoperative mobilization may be particularly difficult, and venous
thromboembolism can be a major problem. Wound infections are more
common and more difficult to diagnose in the morbidly obese.
Intraabdominal complications, such as anastomotic leak, can be difficult
to detect.
Weight reduction with these procedures is significant. The average loss is
one-half to two-thirds of the excess weight at 1.5 years, at which point
weight typically stabilizes. This has shown to be associated with
improvements in diabetes, hypertension, mobility, pulmonary problems,
and arthritis. In addition, patient self-image is often markedly improved.
The operations have not clearly demonstrated a reduction in the excess
mortality of the morbidly obese, though it seems likely with longer
follow- up.

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