BARIATRIC SURGERY

Dr. Onkar Singh, Dr. Shilpi Gupta,Dr. Praveen Baghel, Dr. Mohan Soni

-MGM Medical College & MY Hospital, Indore, India.

Dr. Ankur Hastir-MGM Medical College & Hospital, Bombay, India.

BARIATRIC SURGERY

Bariatric surgery: Surgical t/t for morbid obesity

Alteration of metabolic process & durability of weight loss

1st malabsorptive operations was done in 1950

Indications:

a) BMI > 40 or BMI > 35 with co morbid conditions {BMI=Wt / (Ht*2)}

b) Failed dietary therapyc) Psychiatrically stable without

addictionsd) Motivated individualse) Medical problems not precluding

probable survival from surgery

Co-morbid conditions: CVS: HTN, DVT, Pulm. HTN ,

cardiomyopathy Pulmonary: obstructive sleep apnea ,

asthma Metabolic: diabetes , hyperlipidemia GIT: GERD , Cholelithiasis Musculoskeletal: osteoarthritis, ventral

hernias

Co-morbid conditions:

Genitourinary: stress incontinence, end stage renal disease

Gynaecologic: menstrual disturbances Skin: fungal inf., boils, abscess Oncologic: uterus, breast, colon Neurologic: stroke, pseudotumor

cerebri Psychiatric: depression Social: discrimination, abuse

Pre-op investigations: Weight , height , BMI CBC , BT , CT , PT LFT , RFT , blood sugar, lipid profile X – ray chest PFT ECG , 2 D Echo Thyroid profile Insulin levels Serum cortisol

Pre-op investigations:

UGI Endoscopy Barium meal Venous doppler lopwer limbs Ct abdomen

Pre-op preparation: 1st generation cephalosporin– 24 hrs

before surgery Prophylaxis against DVT: 1. subcutaneous heparin 2. early ambulation post op

Operations & Mechanisms: RESTRICTIVE Vertical banded gastro-plasty Lap adjustable gastric banding Sleeve resection

LARGELY RESTRICTIVE/ MILDLY MALABSORPTIVE Roux-en-Y gastric bypass LARGELY MALABSORPTIVE \ MILDLY RESTRICTIVE Bilio-pancreatic diversion

(BPD) Duodenal switch

Sleeve resection

Operative details:

Patient position: Supine, hips flexed at 30 degree & abducted , anti trendelenburg position

Surgeon position: French position Assistant 1st: Right side of pt. Assistant 2nd: Left side of pt.

Operative details: Port placement:

supraumblical- 10 mm optical portRt. subcostal- 12 mm retracting portLt. subcostal- 05 mm retracting portRt. umbilical- 05 mm working portLt umbilical- 10 mm working port

Resected specimen:

Greater curvature

Fundus (upper end)

Body pylorus junction(Lower end)

Postoperative care: Appropriate fluid resuscitation Foleys catheter – 24 hrs Adequate analgesia DVT proohylaxis GIT radiographic study Dietary management Long term follow up

Lap adjustable gastric banding

ADVANTAGES:

1. Short duration op2. Early discharge3. Flexibility4. Resolving of comorbid conditions:

DM, HTN, dyslipidemia , GERD ,

DISADVANTAGES:

1. Band slippage2. Erosion3. Port access site problems4. Leakage of access tubing5. Kinking of the tubing

Roux-en-Y gastric bypass

DISADVANTAGES:

1. Anastomotic leak2. Bowel obstruction3. Stenosis of GJ4. Marginal ulcer at GJ5. Dumping syndrome & dehydration6. Iron & vit b12 def

Bilio pancreatic diversion

DISADVANTAGES:

Protein malnutrition1. Abdominal bloating2. Elevated parathyroid hormone levels3. Bone pains4. Iron & vitamin def5. Marginal ulcers

Duodenal switch

DISADVANTAGES:

1. Same as BPD2. 2 stage operation