Bariatrics: Bariatric operations

Question 1

What are the two main categories of bariatric surgical options?

Answer 1

Restrictive procedures and Malabsorptive procedures

Restrictive procedures lead to less weight loss compared to malabsorptive procedures.

Question 2

What is an example of a restrictive procedure?

Answer 2

VBG and Band

VBG stands for Vertical Band Gastroplasty.

Question 3

What are the examples of malabsorptive procedures?

Answer 3

BPD and DS

BPD stands for Biliopancreatic Diversion and DS stands for Duodenal Switch.

Question 4

What does a combination procedure in bariatric surgery involve?

Answer 4

Bypass, which is both restrictive & malabsorptive

Bypass procedures combine features of both types for weight loss.

Question 5

What are the advantages of laparoscopic procedures compared to open surgeries?

Answer 5

Shorter hospital stay and decreased incisional hernia rate

The incisional hernia rate for laparoscopic procedures is 5% versus 39% for open procedures.

Question 6

What is the rate of respiratory complications in laparoscopic procedures?

Answer 6

Reduced respiratory complications

Laparoscopic procedures generally result in fewer respiratory complications compared to open surgeries.

Question 7

What was the finding regarding early complications in the bypass group?

Answer 7

Small increase in early complications

This refers to complications that occur shortly after the procedure.

Question 8

Which group experienced more delayed complications, bypass or lap band?

Answer 8

Lap band group

Delayed complications were more frequent in patients with a laparoscopic band.

Question 9

What is the weight loss percentage comparison between lap band and bypass after 2-10 years?

Answer 9

50% for lap band vs 70% for bypass

Excess weight loss is significantly higher in patients who undergo bypass.

Question 10

Fill in the blank: Laparoscopic procedures are associated with a ______ hospital stay.

Answer 10

shorter

Laparoscopic procedures typically result in less recovery time.

Question 11

True or False: Malabsorptive procedures carry fewer metabolic complications than restrictive procedures.

Answer 11

False

Malabsorptive procedures are very effective for weight loss but carry significant metabolic complications.

Question 12

How does a lap band restrict gastric volume?

Answer 12

less common now

compartmentalizes the upper stomach by placing a tight, adjustable prosthetic band around the entrance to the stomach

High volume (9mL), low pressure bands preferred

Question 13

What is the mechanism of action of lap band surgery?

Answer 13

Purely restrictive

Question 14

What are the pros and cons of lap band bariatric surgery.

What is the efficacy of lap band surgery?

Answer 14

Weight loss

Less than other techniques

40-50% wt loss at 2yrs

Pros
- Relatively easy surgery
- Reversible
- No risk of nutritional defecits
-Can easily be converted to roux-en-y/sleeve

Cons
-Faliure of wt reduction in up to 50% at 3 yrs
-High complication rate (up to 20%)
-High rate or reoperation ~ 20%

Question 15

What are the early complications of lap band surgery?

Answer 15

Port infection

Food bolus obstruction

Question 16

What are the late complications of lap band surgery?

Answer 16

Band slippage – 15% 1st 3 yrs, >50% at 10 yrs
- Typically at 2-3 yrs
- Ix – AXR to look at PHI angle
- Contrast swollow
- Tx = deflate band and removal of band (or reduction of stomach)
- Can lead to ischemia of fundus
- Recognised by loss of normal phi angle (10-60degrees)

Erosion ~ 1%
- Presents loss of restriction, ‘red port sign’
- Ix – CT scan to look for leak/collection
- Gastroscopy to look for band erosion
- Tx by removal of band

Oesophageal dilation

Tubing and port complications
- Leakage of access tubing 10%
- Port rotation 5%

Question 17

What is a roux en y gastric bypass and how does it work?

Answer 17

Involves formation of small gastric pouch and variable length of limbs for Roux-en-Y reconstruction

Both restrictive and malapsorptive

Length of BP limb determines weight loss long term. Most people use 80-100cm.

Roux limb should be at least 1m

Question 18

What is the mechanism of action of a roux en y gastric bypass, and what is it’s efficacy as a bariatric operation?

Answer 18

Restrictive and malapsorptive.
~70% weight loss at two years.

Question 19

What are the pros and cons of roux en y as a gastric bypass?

Answer 19

Pros
- Comorbidity reduction:
- 70% remission of T2DM
- HTN resolved in 70%,
- OSA resolved in 80%
- Improves GORD in 90% of cases
- Improves gut hormone profile to reduce appetite - PYY + GLP-1 induce satiety
- Less risk of malabsorption that BPD/DS but more than GS/AGB

Cons
- Steep learning curve
- Difficult to perform ERCP after roux-en-y
- Generally only recommended in high-volume centres
- Resonable cost given longer operative time and longer inpt admission
- Moderate complication rate: 10% MR 0.3-1%

Question 21

What are the early complications of roux en y gastric bypass

Answer 21

Leak 3% (usually at gastrojej)

Staple line bleed 3%

Stricture

Roux-en-O configuration (requires re-do surgery)

Question 22

What are the late complications of roux en y gastric bypass and how are these managed?

Answer 22

• Internal hernia 2% (usally months/years later)
  
  • Ix – CT scan (70-80% sensative) therefore needs to go to OT if SBO on CT.
  • Mesenteric swirl sign
  • Increased volume of bowel in LUQ
  • Closed-loop internal hernia
    3 locations:
    
    • Petersons space (behind roux limb)
    • Mesocolic space (if retrocolic)
    • Mesentertic defect at jej-jej anastomosis
  • Needs to go to OT as can decompress biliary limb AND increased risk of vascular compromise
• Higher in laparoscopic and if mesenteric defects closed but can never prevent 100% risks.

Stricture of gastrojejunostomy up to 10 %
- Balloon dilate unless associated with marginal ulcer, in which case you need to re-operate

**Gastrogastric fistula **

Marginal/anastomotic ulcer 2-10%
- Incidence can be reduced by preoperative treatment for H. pylori
- Present with constant boring epigastric pain
- Usually settle with medical treatment

**Dumping syndrome **
- Recommend small frequent meals
- Low CHO intake
- Octreotide can help if dietary modification fails

Question 23

How is a single anastomosis/mini bypass formed?

Answer 23

The sleeve is created first

A single anastomosis is then created between the side of the first or second part of the duodenum and the distal jejunum/proximal ileum, creating an afferent limb of biliopancreatic fluid and an efferent limb that acts like a common channel 

Question 24

What is the mechanism of action of a Single Anastamosis (mini) Bypass

Answer 24

Restrictive + malabsorptive,

Depends how small pouch is

Question 25

What is the efficacy of Single Anastamosis (mini) Bypass

Answer 25

Weight loss Similar to RYGB 70% at 2yrs

Question 26

How do Single Anastamosis (mini) Bypass early complication rates differ to RYGB early complications? How about late complications?

Answer 26

Early: Less anasatomic leak complication Late: the same as RYGB

Question 27

How do you create a sleeve gastrectomy?

Answer 27

Sleeve gastrectomy (SG) is a partial gastrectomy in which the majority of the greater curvature of the stomach is removed and a tubular stomach is created ( created over a bougie) Bougie size 32-40F

Question 28

What is the mechanism of action and efficacy at 2 and 5 years for sleeve gastrectomy?

Answer 28

Restrictive. Weight loss is 70% EWL at 3 yrs but only 50% at 6 yrs

Question 29

What are the pros and cons of laparoscopic sleeve gastrectomy?

Answer 29

Pros: - No anastomosis - No risk of hernias - Normal intestinal absorption – no risk of malabsorption - No foreign device - Pylorus preserved (prevents dumping) Cons - Results are less durable - Weight gain eventually - ? Less effective for T2DM than GB

Question 30

What are the early complications of sleeve gastrectomy?

Answer 30

Staple line leak 2-3% (at angle of his as thinest and avascular part, also if narrowed sleeve (stricture) increased pressure) Ix – Contrast swollow CT – 80-90% sensitivity Fluroscopy = 70% sensativity Tx – Return to OT Can oversew staple line + Drain Can use cover stent to assit closure Post-operative haemorrhage 3% Bleed from staple line MR 0-3.3%, major complications 12%

Question 31

What are the late complications of sleeve gastrectomy?

Answer 31

**GORD** – 20% of patients with new onset GORD (some patients report improvement, especially if hiatus hernia repaired with procedure. Most patients manage with PPI, some require conversion to BYGB **Stricture** – Diagnosed easily on swallow or endoscopy. Manage with endoscopic dilation, laparoscopic myotomy or wedge resection. Some patients require RYGB **Twist/kink (Dysphagia)** – usually hold up at incisura. Usually managed with conversion to RYGB

Question 32

How do you make a duodenal switch? Describe the resulting alimentary tract.

Answer 32

First step - Sleeve gastrectomy - 60F Maloney dilator - aim 150-200mL volume Then - Duodenum divided 2cm beyond pylorus - Do distal connection as per BPD but at 100cm - Proximal anastomosis = antecolic end-to-side duodenoenterostomy Result: - Very short ! Common channel = 75-100cm - Entire alimentary tract = 100-250cm | ???DS has a sleeve component. bilioopancreatic diversion doesnt

Question 33

What is the mechanism of action of a duodenal switch/and or biliopancreatic diversion

Answer 33

Primary Malabsorptive -Concerns re: potential metabolic & nutritional sequelae Also restrictive if DS (i.e. gastrsleeve formed)

Question 34

What is the efficacy of duodenal switch/biliopancreatic diversion

Answer 34

Weight loss 70 to 80 percent or 40 percent total body weight loss

Question 35

What are the pros of duodenal switch surgery?

Answer 35

Pros Excellent wt loss and prolonged duration Excellent T2DM remission rate (80-90%) Good for revisional surgery Can be used a rescue operation if regain after sleeve Pylorus preserved so ? reduced risk of dumping

Question 36

What are the cons of duodenal switch surgery?

Answer 36

Cons High risk of malnutrition If get severe protein malnutrition may need to revise/ lengthen common channel Needs close and long term followup Two to four bowel motions per day, excessive flatulence, foul stools Patients will still absorb simple sugars, alcohol & SCFA well – so overindulgence will increase weight

Question 37

What is the difference between early and late dumping?

Answer 37

**Early dumping** – Within 30min of meal, rapid filling of proximal small intestine with hypertonic food leads to rapid movement of fluid from extracellular compartment into gut, triggers neurohormonal response. Causes palpitation, bloating, cramping, diarrhoea, nausea. **Late dumping –** occurs 2-3 hours post meal, characterised by faintness, severe hunger, dizziness, cold sweating (symptoms of hypoglycaemia). Rapid inflow of carbohydrate to jejunum causes oxyhyperglycaemia (rapid spike in glucose from fast transit) which induces hyperinsulinaemia followed by hypoglycaemia. Glucagon-like peptide 1 (GLP-1) is secreted by proximal jejeunum and may play a role. Patients who develop these symptoms should carry dextrose tablets/sachets to take at first sign of symptoms