University of Medicine and Pharmacy Gr. T.

Popa Iasi, ROMANIA

The 3rd Surgical Unit, Sf. Spiridon Hospital

Bariatric & metabolic

surgery
Dr. Dan Timofte

What is Bariatric &metabolic

surgery?
Bariatric

surgery, from the Greek baros meaning

weight, is synonymous with weight loss surgery.

preclinical

research indicates that bariatric surgery

can alter the body's hormonal mechanisms and its
ability to manage nutrients.

This

would mean that the vicious cycle is broken,

hormonal triggers are reset, and patients may be
able to achieve weight loss without fighting their
own hormonal regulatory mechanisms

Obesity is a health condition where the

natural energy reserve stored in the fatty
tissue is increased to a point where it is
thought to be a risk factor for certain health
conditions. These conditions include:

Hypertension

Cancer

Type 2 Diabetes
Mellitus

Sleep Apnea

GERD

Premature Mortality

Cardiovascular
Disease/MI

Taking care of patients can be extremely challenging

At their most basic, the words overweight and obesity

are ways to describe having too much body fat.
The most commonly used measure of weight status today is
the body mass index, or BMI.
BMI uses a simple calculation based on the ratio of
someones height and weight (BMI = kg/m2).
For adult men and women, a BMI between 18.5 and 24.9 is
considered healthy.
Overweight is defined as a BMI between 25.0 and 29.9; and a BMI of
30 or higher is considered obese.

1.6 billion people world wide are at least

overweight
The highest prevalence in Canada.

Almost 25% of people in the UK are overweight or obese.

Even Asian countries are noticing and increase
One can be obese yet malnourished

The most common way

to define obesity, and the
definition used in most
research studies, is BMI
or Body Mass Index. BMI
is calculated by weight,
times 703, and then
divided by height in
inches squared. A BMI
score over thirty is
considered obese
(What Health, 2011)

Effect of obesity on hormones

Leptin
Leptin

deficient mice overfeed and rapidly become

hyperinsulinemic

Long
PI3

arm of leptin receptor (LRb) activates

kinase

MAPK
STAT

(signal transduce and activator

transcription)

C-fos

mecanism

Adiponectin

Most abundant adipokine

Important insulin sensitizing agent

Inverse association of adiponecitn concentrations and

cancer

Antiproliferative effects
ERK
ERK1
MAPK

kinases

Induces

p53 and Bax

The metabolic dysregulation cycle

Eligibility Criteria

BMI 35 with risk factors

OR

BMI 40
BMI < 18.5: Underweight
BMI 18.5 - 24.9: Normal
BMI 25.0 - 29.9: Overweight
BMI 30: Obese

Recommended treatment depends on

the severity of the disease

Surgery can interrupt the metabolic

dysregulation cycle

The range of surgical options

Gastric

Sleeve
Gastric Banding
Gastric Bypass
Gastric Plication

Gastric Sleeve
Sleeve Gastrectomy or Gastric Sleeve

The vertical sleeve gastrectomy, also known as the

sleeve gastrectomy or gastric sleeve, restricts the
amount of food you eat by reducing the size of the
stomach. The minimally invasive procedure removes a
portion of the stomach, making the stomach roughly the
size and shape of a banana.

Patients who have a sleeve gastrectomy feel full after

eating much less. In addition, the surgery removes the
portion of the stomach that produces a hormone that
can make you feel hungry, so you won't want to eat as
much.

This procedure can be an excellent alternative to gastric

bypass or gastric banding. Sleeve gastrectomy is a
simpler operation than the gastric bypass procedure
because it doesnt involve rerouting or reconnecting the
intestines.

Advantages of Sleeve
Gastrectomy:

Fewer food intolerances than with gastric banding.

Weight loss generally is faster with the sleeve than with gastric
banding.

There is no implantable band device, so slippage and erosion are

not a risk.

The surgical risk is lower than with gastric bypass procedures,

but the weight loss is similar.

No device that needs adjustment is inserted, so the follow-up

regimen is not as intense as it is with gastric banding.

Disadvantages of Sleeve
Gastrectomy:
Sleeve

gastrectomy is not adjustable or reversible.

Complication

risks are slightly higher than with the

band.

Risks/Complications:
Standard
Leakage
Blood

risks associated with surgery

at the suture site

clots

Sleeve Gastrectomy Animation

Gastric Banding
Gastric Banding with the LAP-BAND or REALIZE Banding Systems

With gastric banding, an inflatable band is

placed around the upper part of the
stomach.
The band creates a smaller stomach
pouch, restricting the amount of food that
can be consumed at one time.
The band also increases the time it takes
for the stomach to empty.
As a result, patients achieve sustained
weight loss by limiting food intake,
reducing appetite and slowing digestion.

How Gastric Banding Works

The gastric banding procedure works by restricting the amount of

food the stomach can hold by placing an adjustable band around
the upper part of the stomach.

There is no cutting or stapling needed to separate the upper

stomach pouch from the lower stomach. Unlike stomach stapling,
the gastric band can be adjusted to suit your needs.

Minimally Invasive

During gastric banding surgery, the surgeon makes a few small incisions in
the abdominal wall. Using laparoscopic techniques, a silicone adjustable
band is secured around the upper part of the stomach, creating a small
stomach pouch.
The band is connected to tubing which attaches to an access port fixed
beneath the skin of the abdomen. The port cannot be seen and can only be
felt when pushing on the abdomen. The port and tubing allow for
adjustments to be made. Read more about adjusting the gastric band.
The stomach pouch created by the adjustable band controls the amount of
food taken in. It allows a small amount of food to pass through, delaying
the emptying of the stomach into the intestines. This process creates the
sensation of fullness sooner and over time, hunger decreases.
The procedure takes about 40 minutes and can be performed on an
outpatient basis with no required hospital stay. Recovery times may vary,
but patients can generally return to work and normal activities within four
to seven days.
Because the surgery uses laparoscopic techniques, patients experience
less post-operative pain, recover quicker and are able to return to normal
activities sooner, compared to other forms of bariatric surgery.

Gastric Banding Animation

Gastric Bypass
Minimally Invasive Gastric Bypass Surgery

Gastric bypass limits the amount of food that you can eat and
digest.

In a Roux-en-Y gastric bypass, the stomach is made smaller by

creating a small pouch at the top of the stomach using surgical
staples or a plastic band. The resulting pouch is only about the
size of a walnut and can hold about one ounce of food. After the
pouch has been created, most of the stomach and part of the
intestines are bypassed by attaching (usually stapling) part of the
intestine to the small stomach pouch. As a result, a gastric
bypass patient cannot eat as much and absorbs fewer nutrients
and calories.

This minimally invasive, laparoscopic method allows for less time

spent in the hospital and faster recovery and healing time.

Advantages of Gastric Bypass:

Rapid initial weight loss

Approach is minimally invasive approach

Longer clinical experience in the U.S.

Slightly higher total average weight loss reported than with

purely restrictive procedures

Rapid improvement or resolution of type 2 diabetes and

metabolic syndrome

Disadvantages of Gastric Bypass:

Cutting and stapling of stomach and bowel are required

More potential operative complications

Portion of digestive tract is bypassed, reducing absorption of

essential nutrients

Potential complications due to nutritional deficiencies

"Dumping syndrome" can occur

Procedure is not adjustable and difficult to reverse

Higher mortality rate

Risks

Mortality rate: 0.5 - 2 percent

Total complications: 23 percent

Major complications: 2.1 percent

The most common complications include:

Standard risks associated with major surgery

Nausea and vomiting

Separation of stapled areas (requires major revisional surgery)

Leaks from staple lines (requires major revisional surgery)

Nutritional deficiencies

Gastric Bypass Animation

Gastric Plication
Gastric Plication - The New Weight-Loss Surgery

Laparoscopic gastric plication is a newer minimally invasive weight-loss

surgery technique that reduces the size of the stomach capacity to
approximately three ounces.

Gastric plication procedure folds the stomach in on itself to reduce its

size.

The procedure does not involve the use of an implanted device (such as
gastric banding). Also, unlike the gastric sleeve procedure, gastric
plication may be reversible because a portion of the stomach is not
removed. In addition, unlike gastric bypass, gastric plication does not
involve rerouting and reconnecting the intestines.

It is a restrictive weight-loss surgery, meaning that it restricts the

amount of food the stomach can hold. You will feel full sooner so you
wont want to eat as much.

Gastric plication uses laparoscopic techniques resulting in faster

recovery and less scarring than open surgery.

Advantages

No rerouting of intestines as with gastric bypass

Does not involve implanting a banding device around a portion of

the stomach

No adjustments are needed as with gastric banding

Procedure may be reversible, unlike sleeve gastrectomy or

gastric bypass.

Disadvantages

Gastric plication is a newer procedure and hasnt been tested as

long as sleeve gastrectomy, gastric banding or gastric bypass.

It is not covered by insurance at this time

Risks

Standard risks associated with surgery and general anesthesia

Nausea and vomiting

Separation of stitched areas (requires revisional surgery)

Leaks from sutured areas (requires revisional surgery)

Gastric Plication Animation

Results: Weight Loss Measures

Pathophysiology - Changes in Satiety and Hunger
Ghrelin - stimulates hunger
Decreased

Leptin - decreases hunger, sends signals to brain when

full
- the more fat mass the more leptin you produce
Peptide YY - peptide released by cells in response to
eating
Increased

Potential Complications & Side

Effects
Early Complications
Bleeding
Abdominal pain,bloating
Dumping syndrome
Late complications
Nausea or vomiting
Excess or loose skin
Small bowel obstruction
Ulcers
Bacterial overproduction
* Electrolyte and nutrient deficiencies

Surgery
Teens cannot expect a quick fix in losing weight
because they need time to adjust mentally

Results: Quality of Life Outcomes

Prognosis

After surgery, life expectancy increased to 80-81 years compared

to no surgery at 78 years

Mortality rate of 0.3%

Meta-analysis: 136 studies and 22,094 patients Diabetes was

completely resolved in 76.8% and resolved or improved in
86.0%Both hyperlipidemia and hypertension resolved or
improved in 87.1%

Figure 6. EQ-5D Results 6 Months

Post-Surgery (n=31)

Obesity-related diseases improved

with bariatric surgery

Results: Improvements in
Comorbid Conditions
Type 2 Diabetes Mellitus
Defining Glycemic Control

Glycemic Control at Baseline (n=66)

Risk of premature death reduced

89%

Very Low Calorie Diet (VLCD) +/Behavior Modification

Dyslipidemia
Changes in Lipid Profile

NEJM Summary of Results

Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects, by Sjstrm et al.

Sjstrm,

et al conducted a prospective,
controlled study comparing severely obese
patients desiring bariatric surgery with equally
obese patients not desiring surgery.

The study concluded bariatric surgery for severe

obesity is associated with long-term weight loss
and decreased overall mortality.

29% reduction in death was found after an

average follow up of 10.9 years.

 The

study concluded that long-term mortality for

gastric-bypass patients was significantly reduced.
Overall deaths were reduced by 40%
Deaths from diabetes were reduced by 92%
Deaths from heart disease were reduced by 56%
Deaths from cancer were reduced by 60%

More than 30% of what gets us

old or ill it's not about our genes,
it's about our life style.

Dr. Dominique Lanzmann-Petithory, Hpital Emile Roux, Val

de Marne, Franta.