Bariatric Surgery Pros and Cons

Raed ABOUHARB, M.D.

D.I.S.,D.I.U.,D.U.,C.A.M.U.-France

جامعة دمشق -كلیة الطب

الیوم العلمي للرابطة السوریة لطب وجراحة الصدر مستشفى األسد الجامعي بدمشق

19/1/2019

• The surgical procedures performed to manage obesity are collectively referred to as metabolic or "bariatric" surgery (from the Greek words "baros" meaning "weight" and Greek words "baros" meaning "weight" and "iatrikos" meaning "medicine").

BMI

●Underweight – <18.5 kg/m2 ●Normal weight – ≥18.5 to 24.9 kg/m2 ●Overweight – ≥25.0 to 29.9 kg/m2 ●Obesity – ≥30 kg/m2 ●Obesity – ≥30 kg/m2

•Class I – 30.0 to 34.9 kg/m2 •Class II – 35.0 to 39.9 kg/m2 •Class III – ≥40 kg/m2 (also referred to

as severe, extreme, or massive obesity)

Waist circumference

2.Waist circumference

A waist circumference of ≥ 102 cm for men and ≥ 88 cm for women is considered elevated and indicative of increased cardiometabolic risk indicative of increased cardiometabolic risk

The waist circumference is measured with a flexible tape placed on a horizontal plane at the level of the iliac crest.

Waist circumference

Bariatric surgery

• Term used to describe an operation that helps people lose weight by altering their digestive systems

• There are actually four types of bariatric • There are actually four types of bariatric surgery, but only three are widely used. They include laparoscopic adjustable gastric band, usually referred to as just gastric band; gastric sleeve surgery, also known as sleeve gastrectomy; and gastric bypass, or Roux-en-Y.

• Ghrelin is a peptide hormone secreted in the foregut (stomach and duodenum) that stimulates the early phase of meal consumptionconsumption

• The normal pulsatile release of this orexigenic(appetite-producing) hormone appears to be inhibited in gastric bypass and in laparoscopic sleeve gastrectomy

Ann Surg. 2008;247(3):401.

• An exaggerated response of peptide YY (PYY) may also contribute to the loss of appetite

• Reduced ghrelin levels may eventually increase to their normal levelsincrease to their normal levels

• Hormones such as glucagon-like peptide-1 (GLP-1) and cholecystokinin (CCK), which are increased after RYGB, may promote an anorectic state

J Clin Endocrinol Metab. 2005;90(1):359.Obes Surg. 2012 Jul;22(7):1084-96.

Gastro Intestinal Hormonesin

Bariatric Surgery• Ghrelin orexigenic (appetite-producing)

hormone

• Peptide YY (PYY) also contribute to the loss of appetite of appetite

• Glucagon-like peptide-1 (GLP-1), promote an anorectic state

• Cholecystokinin (CCK). promote an anorectic state

• Candidates for a bariatric surgical procedure include :

●Adults with a BMI ≥40 kg/m2 without comorbid illness≥40 kg/m2 without comorbid illness

●Adults with a BMI 35.0 to 39.9 kg/m2 with at least one serious comorbidity, including

Ann Surg 2011; 253:484.

• Type 2 diabetes • Obstructive sleep apnea (OSA).• Hypertension.• Hyperlipidemia.• Hyperlipidemia.• Obesity-hypoventilation syndrome (OHS).• Pickwickian syndrome (combination of OSA

and OHS).• Nonalcoholic fatty liver disease (NAFLD).

• Nonalcoholic steatohepatitis (NASH).• Pseudotumor cerebri.• Gastroesophageal reflux disease.• Asthma.• Asthma.• Venous stasis disease.• Severe urinary incontinence.• Debilitating arthritis.

• Impaired quality of life.• Disqualification from other surgeries as a

result of obesity (ie, surgeries for osteoarthritic disease, ventral hernias, or osteoarthritic disease, ventral hernias, or stress incontinence).

• ●Adults with BMI between 30.0 to 34.9 kg/m2 AND one of the following comorbidconditions, although there is no long-term evidence of benefit to support routinely performing a bariatric operation. There is performing a bariatric operation. There is growing evidence that for Asian patients, the BMI criteria can be lowered by 2.5 kg/m2 per class related to a higher prevalence of truncal obesity (ie, visceral fat), which is felt to be more hazardous than peripherally located fat

CONTRAINDICATIONS

• Bariatric procedures should not be performed for glycemic or lipid control or for cardiovascular risk reduction independent of the body mass index (BMI) parametersthe body mass index (BMI) parameters

• Bariatric surgery in advanced (above 65 years) or very young age (under 18 years) is controversial but is considered when comorbidity is severe

Obesity (Silver Spring) 2013; 21 Suppl 1:S1.

• Untreated major depression or psychosis• Uncontrolled and untreated eating disorders (eg,

bulimia)• Current drug and alcohol abuse• Current drug and alcohol abuse• Severe cardiac disease with prohibitive anesthetic

risks• Severe coagulopathy• Inability to comply with nutritional requirements

including life-long vitamin replacement

• A meta-analysis of 22 behavioral weight loss studies showed just over 4 percent average loss compared with 1 percent for the control groups, with maximal effect within the first six months after the initiation of treatment after the initiation of treatment

• Maintenance of these initial weight losses has been difficult

• Bariatric surgery, which results in 15 to 30 percent total weight loss that can be sustained for years.

J Am Coll Cardiol. 2014;63Ann Intern Med. 2011;155(7):434.

J Consult Clin Psychol. 2001;69(4):722

Intragastric balloon

• The intragastric balloon (IGB) consists of a soft, saline-filled balloon that promotes a feeling of satiety and restriction

• An IGB has been advocated for use as a bridge • An IGB has been advocated for use as a bridge to a more definitive surgical procedure

• Approved for patients with class I obesity (body mass index [BMI] 30 to 34.9 kg/m2).

Gastrointest Endosc. 2005;61(1):19.

Obes Surg. 2004;14(4):539.

• Three IGB devices, Orbera, Obalon, and ReShapeballoons, have been approved by the US Food and Drug Administration (FDA) to treat obesity in adults with a BMI of 30 to 40 kg/m2 with one or more comorbid conditions such as diabetes,

Intragastric balloon

more comorbid conditions such as diabetes, hypertension, or hypercholesterolemia.

• Other IGB systems are commercially available in various regions and countries but have not received FDA approval, including one that does not require endoscopic placement or retrieval

• percent excess weight loss (%EWL): 6.5 -33.9

• Six months after removal of the device, patients kept off 70 percent of their initial

Intragastric balloon

patients kept off 70 percent of their initial weight loss.

Obes Surg. 2005 Sep;15(8):1161-4.

Surg Obes Relat Dis. 2015 Jul-Aug;11(4):874-81.

• Candidates for a bariatric surgical procedure include :

●Adults with a BMI ≥40 kg/m2 without comorbid illness≥40 kg/m2 without comorbid illness

●Adults with a BMI 35.0 to 39.9 kg/m2 with at least one serious comorbidity, including

Ann Surg 2011; 253:484.

Adults with a BMI 35.0 to 39.9 kg/m2 with at least one serious comorbidity

• Type 2 diabetes• Obstructive sleep apnea• Hypertension • Hyperlipidemia• Obesity-hypoventilation

• Pseudotumor cerebri. • GERD• Asthma• Venous stasis disease. • Severe urinary incontinence• Obesity-hypoventilation

syndrome • Pickwickian syndrome • Nonalcoholic fatty liver

disease• Nonalcoholic

steatohepatitis

• Severe urinary incontinence• Debilitating arthritis. • Impaired quality of life. • Disqualification from other

surgeries as a result of obesity

Ann Intern Med. 2006;144(9):625. Surg Endosc. 2009 Jul;23(7):1569-73.

Adults with BMI between 30.0 to 34.9 kg/m2 AND one of the following comorbid

conditions,

• Uncontrollable type 2 diabetes

• Metabolic syndrome

CONTRAINDICATIONS (I)

• Bariatric procedures should not be performed for glycemic or lipid control or for cardiovascular risk reduction independent of the body mass index (BMI) parametersthe body mass index (BMI) parameters

• Bariatric surgery in advanced (above 65 years) or very young age (under 18 years) is controversial but is considered when comorbidity is severe

Obesity (Silver Spring) 2013; 21 Suppl 1:S1.

• Untreated major depression or psychosis• Uncontrolled and untreated eating disorders (eg,

bulimia)• Current drug and alcohol abuse

CONTRAINDICATIONS (II)

• Current drug and alcohol abuse• Severe cardiac disease with prohibitive anesthetic

risks• Severe coagulopathy• Inability to comply with nutritional requirements

including life-long vitamin replacement

Bariatric Surgery Pros and Cons

Pros for bariatric surgery

• Weight loss

• Diabetes mellitus

• Hypertension

Cons for bariatric surgery

• Operative Challenges

• IntraoperativeComplications• Hypertension

• Dyslipidemia

• Obstructive sleep apnea

• GERD

• Pain and physical function

• Decrease overall mortality

• In-hospital PostoperativeMorbidity

Pros for bariatric surgery

1. Weight loss: weight loss occurs rapidly over the first few months, then continues over the next year to year and a half until weight loss reaches a plateau. In a Finnish multicenter randomized trial (SLEEVEPASS) of 240 patients with severe obesity, patients who had undergone LRYGB had (SLEEVEPASS) of 240 patients with severe obesity, patients who had undergone LRYGB had slightly greater percentage excess weight loss than patients who had undergone sleeve gastrectomy at all points, including at five years: 50 percent after LSG versus 57 percent after LRYGB.

2. Diabetes mellitus : An RCT showed that obese patients (body mass index [BMI] 27 to 43) with uncontrolled type II diabetes undergoing an RYGB (n = 50) or an SG (n = 49) plus an RYGB (n = 50) or an SG (n = 49) plus medical therapy were significantly more likely to achieve the main outcome of a glycatedhemoglobin level of 6.0 percent or less at 12 months compared with patients managed by intensive medical therapy alone (n = 51).

• Another showed that the proportion of patients who were diabetes-free at five years was still higher with bariatric surgery than with medical management (50 versus 0 percent). management (50 versus 0 percent).

• A study showed that distal peripheral neuropathy may also improve following RYGB.

3. Hypertension: Studies found that patients undergoing an RYGB plus intensive lifestyle medical management were able to achieve a similar reduction in systolic blood pressure at 12 months compared with patients managed with lifestyle medical modification alone. However, months compared with patients managed with lifestyle medical modification alone. However, patients who underwent RYGB reduced antihypertensive drug use by ≥30 percent, and more surgical patients achieved remission of hypertension, compared to none among the medical management alone group.

4. Dyslipidemia: a study showed that one year following RYGB, the mean total cholesterol levels decreased by 16 percent, triglyceride levels decreased by 63 percent, low-density lipoprotein cholesterol levels decreased by 31 percent, very-cholesterol levels decreased by 31 percent, very-low-density lipoprotein cholesterol decreased by 74 percent, In addition, 23 of 28 (82 percent) patients requiring lipid-lowering medications preoperatively no longer required medical therapy.

5. Obstructive sleep apnea: the AHI (the number of apneas and hypopneas per hour of sleep) was measured before and after different types of bariatric surgery, resolution or improvement of bariatric surgery, resolution or improvement ranged between 79 and 86.

6. GERD: improvement in this outcome depends on the type of surgery.While the prevalence of GERD is significantly lower at six months following the RYGP operation compared with following the RYGP operation compared with preoperative prevalence. SG may be the least efficacious procedure to reduce postoperative GERD, and may induce symptoms in previously asymptomatic patients.

7. Pain and physical function : studies showed significant improvements in body, hip, and knee pain as well as physical function, compared with their presurgical conditions. compared with their presurgical conditions. Between years 1 and 3, improvements were sustained in knee and hip pain.

8. Bariatric surgery retrospective cohort studies have shown that is decrease overall mortality compared to obese controls.

• I.Operative Challenges

• II. Intraoperative Complications

• III. In-hospital Postoperative Morbidity

Cons for bariatric surgery

Cons for bariatric surgery

I. Operative Challenges: Operating on the obese individual can be technically

challenging even for the most experienced anesthesia and surgical teams. Anatomic and physiologic characteristics of obesity are physiologic characteristics of obesity are associated with difficult intubations and drug management, while the thicker abdominal wall and visceral adipose tissue can obscure visualization of critical structures during surgery.

Operative Challenges

• Airway management

• Altered drug pharmacokinetics

• Respiratory dynamics

•• Body habitus

Airway management

• Airway management, including mask ventilation and intubation, can be arduous in morbidly obese patients. The risk of a difficult direct laryngoscopy is six times higher than that of the nonobese general population and is proportional nonobese general population and is proportional to the larger circumference of the neck . Other physical attributes that increase the difficulty of airway management include limited flexion and/or extension of the cervical spine, restricted mouth opening, and redundant oral tissue.

Best Pract Res Clin Anaesthesiol. 2011 Mar;25(1):83-93.

Altered drug pharmacokinetics

• In addition, morbid obesity alters the pharmacokinetics of lipophilic anesthetics (eg, barbiturates, benzodiazepines).

Respiratory dynamics

• High pressures required to insufflate the abdomen during laparoscopic bariatric surgerycan result in increased intrathoracic pressures and decreased functional capacity, and decreased functional capacity, pneumothorax, extraperitoneal insufflation, gas embolism, and surgical emphysema

J Obes. 2012;2012:781546.

Body habitus

• Obese patients have a variety of factors that render surgical operations technically challenging, such as a thick abdominal wall (more often identified in obese women), or (more often identified in obese women), or extensive visceral fat (more often found in obese men)

Surgery. 2007;142(4):621.

• II. Intraoperative Complications:

Cons for bariatric surgery

II. Intraoperative Complications

laparoscopic

• Anesthesia events (1%)• Instrument/equipment

failure (0.8 %) • Bowel injury (0.8 %)

open surgery

• Revision of anastomosis(2.0%)

• Bowel injury (1.0%) • Bowel injury (0.8 %) • Hepatic injury (0.4 %), • Anastomosis revision (0.3

%) • Splenic injury (0.2%) • Major blood vessel injury

(0.1 %)

• Instrument/equipmentfailure (0.6%)

• Anesthesia events (0.4%)

• Hepatic injury (0.2 %)

• Major blood vessel injury (0.2%)

J Am Coll Surg. 2012 Aug;215(2):271-7.Arch Surg. 2012 Sep;147(9):847-54.

III. In-hospital Postoperative Morbidity

• Anastomotic leak (0.8-6%)

• Hemorrhage ( 0.4-4%)

• Venous thromboembolism (DVT-PE) 0.4%

• Postoperative Myocardial infarction 0.2%• Postoperative Myocardial infarction 0.2%

• Pulmonary complications (pneumonia 0.4 %, acute respiratory failure 1.35 %, Atelectasis)

• Surgical site infections 1.1 %

• The risk of a major complication immediately after the operation ranges from approximately 0.2 - 10 % in contemporary series, depending upon patient comorbid illnesses, type of

III. In-hospital Postoperative Morbidity

upon patient comorbid illnesses, type of procedure, surgical approach (laparoscopic or open), and surgeon expertise

Anastomotic leak

• The anastomotic leak remains the most dreaded technical complication of bariatric surgery, and is one of the most challenging complications of weight-loss surgery . The risk complications of weight-loss surgery . The risk of a leak ranges from 0.8 to 6 percent depending on procedures chosen as well as technical and patient factors involved

Obes Surg. 2012 Aug;22(8):1214-9.

Hemorrhage

• Significant hemorrhaging after gastric bypass has been described in 0.4 to 4.0 percent of patients

Surg Endosc. 2008;22(12):2554.

Surg Obes Relat Dis. 2010 Nov;6(6):643-7.

Venous thromboembolism

• Based upon the information from the BOLD database with almost 74,000 patients undergoing a bariatric operation, the overall incidence of a venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism vein thrombosis (DVT) and pulmonary embolism (PE) was approximately 0.4 percent . Of the 260 patients who developed a VTE, most occurred following discharge; 2 percent occurred intraoperatively and 25 percent occurred prior to hospital discharge

Surg Obes Relat Dis. 2011 Mar;7(2):181-8.

Myocardial infarction

• The incidence of a postoperative MI after a bariatric operation is approximately 0.2 percent

Surg Endosc. 2008;22(12):2554.

Pulmonary complications

• Major postoperative pulmonary complications include pneumonia and acute respiratory failure. Atelectasis is common after all types of surgery that require general anesthesia, and is surgery that require general anesthesia, and is more prevalent in the morbidly obese.

• postoperative pneumonia was 0.4 %• acute respiratory failure (ARF) was 1.35 %

Arch Surg. 2012 Sep;147(9):847-54.

Surgical site infections

• Surgical site infections (SSIs), which often are localized to the incision but can extend into deeper tissues, are the most common nosocomial infection nosocomial infection

• overall incidence of SSIs of 1.1 %

Arch Surg. 2012 Sep;147(9):847-54.

IV. Late complications

IV. Late complications

Roux-en-Y gastric bypasscomplication

• Complications of RYGB are diverse and vary based upon the specific technique. Some complications are relatively specific to the surgical approach (open versus laparoscopic). surgical approach (open versus laparoscopic). Certain complications are seen during the early postoperative periods, while others may present weeks to months following the surgery.

• Gastric remenant distension (rare but potentially lethal)

• Stomal stenosis ( 6- 20%)• Marginal ulcers (0.6- 16 %)• Candy cane Roux syndrome (blind afferent limb)• Cholelithiasis (38 % of patients within six months of surgery)• Ventral incisional hernia(0- 1.8%) in Lap RYGB• Internal hernias (0-5%)• Small bowel obstruction (3 - 5 % )

Roux-en-Y gastric bypass complications

Small bowel obstruction (3 - 5 % )• Short bowel syndrome ( 4%)• Dumping syndrome ( up to 40%)• Nephrolithiasis and renal failure (RR:1.79)• Metabolic and nutritional derangements (iron, calcium, vitamin B12, thiamine and folate)• Postoperative hyperinsulinemic hypoglycemia• Change in bowel habits (diarrhea)• Gastrogastric (GG) fistula (1-2%)• Failure to lose weight and weight regain (15-20%)

• Gastric remenant distension (rare

but potentially lethal)

• Stomal stenosis ( 6- 20%)• Marginal ulcers (0.6- 16 %)• Candy cane Roux syndrome

(blind afferent limb)• Cholelithiasis (38 % of patients

• Short bowel syndrome ( 4%)• Dumping syndrome ( up to 40%)• Nephrolithiasis and renal

failure (RR:1.79)• Metabolic and nutritional

derangements (iron, calcium, vitamin B12, thiamine and folate)

Roux-en-Y gastric bypasscomplications

• Cholelithiasis (38 % of patients within six months of surgery)

• Ventral incisional hernia(0-1.8%) in Lap RYGB

• Internal hernias (0-5%)• Small bowel obstruction (3 - 5

%)

vitamin B12, thiamine and folate)• Postoperative hyperinsulinemic

hypoglycemia• Change in bowel habits

(diarrhea)• Gastrogastric (GG) fistula (1-

2%)• Failure to lose weight and

weight regain (15-20%)

• Gastric remnant distension is a rare but potentially lethal complication following gastric bypass . The gastric remnant is a blind pouch and may become distended if paralytic

Roux-en-Y gastric bypass

pouch and may become distended if paralytic ileus or distal mechanical obstruction occurs postoperatively.

J Gastrointest Surg. 2007;11(6):708.

Maingot's abdominal operations, 11th ed, Zinner, MJ, Ashley, SW (Eds), McGraw Hill, New York 2007. p. 471.

Stomal stenosis

• Stomal (anastomotic) stenosis has been described in 6 to 20 percent of patients who have undergone RYGB

J Laparoendosc Adv Surg Tech A. 2003;13(4):247.

Marginal ulcers

• Marginal ulcers have been reported in 0.6 to 16 % of patients

• Occur near the gastrojejunostomy and result from acid injuring the jejunum from acid injuring the jejunum

• They can be associated with a gastrogastric or, rarely, gastrocolic fistula .

Surg Obes Relat Dis. 2006;2(4):455.

N Engl J Med. 2017 02;376(5):476-482.

Candy cane Roux syndrome

• Candy cane Roux syndrome in patients who have undergone RYGB refers to an excessively long blind afferent Roux limb at the gastrojejunostomy causing postprandial pain often relieved by vomiting. It is believed that often relieved by vomiting. It is believed that the blind afferent limb ("candy cane") acts as an obstructed loop when filled with food (often preferentially), and the distention of the loop causes pain until the food either spills into the Roux limb or is vomited back out

Candy cane Roux syndrome excessively long

blind afferent Roux limb at the

gastrojejunostomy

acts as an obstructed loop obstructed loop when filled with

food

distention of the loop causes pain until the food either spills into the Roux limb or is vomited back out

Cholelithiasis

• Cholelithiasis develops in as many as 38 % of patients within six months of surgery

• up to 41 percent of such patients become symptomatic • Rapid weight loss can also contribute to the

development of gallstones by increasing the development of gallstones by increasing the lithogenicity of bile

• The high frequency of cholelithiasis can be reduced to as low as 2 % with a six-month course of UDCA; given prophylactically after weight-loss surgery

Am J Gastroenterol. 1991;86(8):1000.

Gastroenterology. 1992;103(1):214

Am J Surg. 1995;169(1):91.

• The decision to perform a cholecystectomy at the time of bypass is controversial. Some surgeons recommend performing cholecystectomy at the time of bypass if a patient has symptomatic gallstones patient has symptomatic gallstones preoperatively. The surgical opinion about asymptomatic gallstones is more divided, and studies have failed to demonstrate a benefit for simultaneous cholecystectomy for incidental gallstones at the time of RYGB Obes Surg. 2004;14(2):206.

Obes Surg. 2003;13(1):76.

Ventral incisional hernia

• Ventral incisional hernias occur with a frequency of 0 to 1.8 percent in laparoscopic series and as high as 24 percent in open series, underscoring a clear advantage of the series, underscoring a clear advantage of the laparoscopic approach in this regard

Ann Surg. 2001;234(3):279.

Obes Surg. 2000;10(6):509.

J Am Coll Surg. 2000;191(2):149.

Internal hernias

• Internal hernias have been described in 0 to 5 percent of patients after laparoscopic gastric bypass

Small bowel obstruction

• Small bowel obstruction (SBO) can occur at any time after a RYGB, with a lifetime incidence of 3 - 5 %

Short bowel syndrome

• RYGB and other bariatric procedures can be complicated by short bowel syndrome (SBS) that result from small bowel resections for internal hernias or bowel obstruction from internal hernias or bowel obstruction from adhesions. In a retrospective review of 265 patients, 11 developed SBS following bariatric surgery

Am J Surg. 2006;192(6):828

Dumping syndrome

• Dumping syndrome can occur in up to 50 percent of post-gastric bypass patients when high levels of simple carbohydrates are ingested ingested

Nutr Clin Pract. 2005;20(5):517.

Metabolic and nutritionalderangements

• Decreased oral intake as well as altered absorption of food from the stomach and small bowel reduces absorption of various micronutrients, particularly iron, calcium, micronutrients, particularly iron, calcium, vitamin B12, thiamine and folate.

Nephrolithiasis and renal failure

• RYGB has been linked to metabolic changes that could alter urine chemistry profiles, resulting in both higher calcium oxalate supersaturation and urine oxalate, lower supersaturation and urine oxalate, lower citrate, and lower volume. Consequently, patients have a higher risk of developing nephrolithiasis after RYGB (pooled relative risk 1.79, 95% CI 1.54-2.10)

Surg Obes Relat Dis. 2016;12(8):1513.

Postoperative hypoglycemia

• A small number of patients develop blackouts and seizures after weight-loss surgery due to a severe form of recurrent hyperinsulinemichypoglycemia

• Pancreatic nesidioblastosis has been proposed as a mechanism for the pathologic finding of beta islet hypertrophy in these patients, although a few cases of insulinomas have been found N Engl J Med. 2005;353(3):249.

Change in bowel habits

• Loose stool and diarrhea are more common after BPD and RYGB. Constipation is more common after gastric banding

Obes Surg. 2008;18(10):1287.

Gastrogastric (GG) fistula

• A gastrogastric fistula is a channel that develops between the gastric pouch and the excluded stomach remnant, allowing ingested food to enter the bypassed foregut (stomach food to enter the bypassed foregut (stomach and duodenum). GG fistulas occur in approximately 1 to 2 percent of patients after RYGB and most commonly cause marginal ulcers or weight regain

Surg Obes Relat Dis. 2005;1(5):467.

Failure to lose weight and weight regain

• Failure to lose weight following Roux-en-Y gastric bypass is rare and is often due to maladaptive eating patterns during the early postoperative period. By contrast, significant late weight regain occurs in up to 20 percent of patients, especially those with super-obesity (body mass index [BMI] occurs in up to 20 percent of patients, especially those with super-obesity (body mass index [BMI] >50 kg/m2) at the time of the initial operation. It is often due to progressive noncompliant eating and other behavioral habits ,development of a functional GG fistula, gradual enlargement of the gastric pouch, or dilatation of the gastrojejunalanastomosis. Obes Surg. 2002;12(2):270

• Vagal blockade

• Aspiration therapy

• One-anastomosis gastric bypass

•

INVESTIGATIONAL PROCEDURES

• Single anastomosis duodeno-ileal bypass

• Endoluminal vertical gastroplasty

• Endoscopic gastrointestinal bypass devices

INVESTIGATIONAL PROCEDURES

• Vagal blockade :The abdominal vagal nerve controls gastric emptying and signals the satiety center in the brain. A surgically implanted device that sends intermittent electrical pulses to the abdominal vagal nerve has been approved by the FDA as a possible treatment for obesityabdominal vagal nerve has been approved by the FDA as a possible treatment for obesity

• Aspiration therapy :Aspiration therapy induces weight loss by removing a portion of ingested caloric intake after each meal via a modified percutaneous endoscopic gastrostomy tube system.

• One-anastomosis gastric bypass :The one-anastomosis gastric bypass (OAGB) is a modification of the loop gastric bypass and technically easier to perform than a Roux-en-Y technically easier to perform than a Roux-en-Y gastric bypass (RYGB) because it requires only one anastomosis

• Single anastomosis duodeno-ilealbypass (SADI)

• Endoluminal vertical gastroplasty :Endoluminalvertical gastroplasty (EVG) is an endoscopic approach for suturing the stomach that offers the potential to perform gastric-restrictive potential to perform gastric-restrictive procedures endoluminally.

• Endoscopic gastrointestinal bypass devices (EGIBD) :A barrier device is deployed to prevent luminal contents from being absorbed in the proximal small intestine