1. Bariatric Surgery Richard S. Gordon, MD, FRCSC, FACS
General, Minimally Invasive and Bariatric Surgery
Tampa Bay Surgical Group

2. 1954 First metabolic surgery: jejuno-ileal bypass
1966 modified RYGB was performed for ulcers
1980 first stand alone Duodenal Switch
1997 open sleeve gastrectomy was part of Duodenal switch

3. Early operations simulated short gut syndrome by bypassing small intestine to cause varying degrees of mal-absorption Remained the standard for next 20 years
Long-term complications became known leading to newer procedures being developed

4. Most common procedures today
Laparoscopic sleeve gastrectomy (>50%) 1
Roux-en-Y Gastric Bypass 2
Duodenal switch 3
Gastric banding (least common now) 4

5. Indications Most insurance companies based on CDC recommendations
BMI > 35 (with comorbidities) or BMI >40
Comorbidities include DM, HTN, OSA, hyperlipidemia for the most part which insurance companies looking for
History of failed diet attempts (reason why many patients have to do 3-6 months of preop dieting for approval)
No reversible causes of obesity (e.g., hypothyroid, steroids)
No uncontrolled psychiatric conditions
Indications

6. Normal anatomy

7. Normal Anatomy

8. Roux-en-Y Gastric Bypass
15 to 25 ml gastric pouch with 1 cm outlet
Bypass distal stomach, duodenum, first segment of jejunum
Bypass 75 – cm jejunum
Restrictive and Malabsorptive procedure
Metabolic procedure: Changes in gut hormones, appetite hormones
Can cause dumping

9. Normal Bypass on UGI

10. Sleeve Gastrectomy
Large portion of stomach removed to leave a pouch that holds ~80 mls
No disconnection from intestine as in RYGB so no need for anastomoses
Restrictive procedure
Metabolic procedure (similar to RYGB)
May increase GERD, may improve
Often repair associated hiatal hernia (unclear if benefit or not)

11. Normal Sleeve on UGI
Normal imaging findings after sleeve gastrectomy. Supine spot image from single-contrast upper GI barium study shows tubular narrowing of gastric pouch (arrows) secondary to resection of greater curvature of proximal and mid stomach. Note relatively abrupt widening of gastric antrum, which is preserved.

12. Gastric Banding Band around upper stomach creates 15ml pouch
No physiological changes or restrictions
Port of adjustment attached to abdominal wall
Inflate/deflate 6 times a year
Restrictive procedure only
No hormonal changes
Day surgery
Fallen out of favor in bariatric surgical community

13. Normal Band on fluoroscopy

14. Duodenal Switch Combination of sleeve and intestinal bypass
Most technically challenging, especially laparoscopic
Least common as a result
Excellent weight loss results and diabetes resolution
Restrictive and malabsorptive procedure
Metabolic changes

15. Complications

18. Gastric Bypass
Early (within 30 days): Leaks, bleeding, and early postop SBO
Mortality 0.1% (similar to lap chole)
Late (after 30 days): Internal hernia, strictures, and marginal ulcer, vitamin deficiencies

19. The top 3 concerns should be leak, leak, and leak; most commonly from the G-J anastomosis (RYGB) or near GE Junction (Sleeve) but can be from any anastomosis or staple line.
With current techniques and technology in surgical stalking, leak rate now less than 1%
Most early complications of laparoscopic gastric bypass or sleeve can be managed laparoscopically in experienced hands, but do not hesitate to convert to open as needed.

20. Late – leaks, stricture, vitamin deficiencies
Sleeve Gastrectomy
Early – leaks, bleeding
Late – leaks, stricture, vitamin deficiencies

21. Leaks
Signs of uncontained leak should prompt immediate surgical exploration, otherwise a contrast swallow study should be obtained (CT or combined UGI followed by immediate CT have highest sensitivity).
reliable only for leaks from G-J (arrow in figure), can easily miss leaks from J-J or from gastric remnant (although these are fortunately much less common)

22. Leaks Management Early Leak
Laparoscopic or open exploration with drainage
If site identified can attempt repair
Drain, drain, drain
Control of sepsis is key
Later leaks
Usually can be managed conservatively
Radiology or laparoscopic drainage of abscess/fluid collection
Endoscopic stenting, flipping, fibrin glue, or combination
Possible NPO/TPN, distal feeding tube
Surgical revision if fails
Leaks Management

23. Small Bowel Obstruction
Not as much a concern after Sleeve gastrectomy but could get port-site hernia
Early SBO after laparoscopic gastric bypass is rarely due to adhesions, and is more commonly due to: 1) technical error with narrowing or kinking of the J-J, 2) intraluminal obstruction from a formed hematoma, or 3) a port-site hernia.
luminal J-J obstruction due to a formed hematoma can be a surgical emergency if completely obstructing
early obstruction proximal to the J-J will cause afferent limb dilation and possible emesis - these are both risk factors for disrupting the G-J anastomosis if not promptly treated
NG tube may help symptomatology but risk of NG placement early postop
obstruction at or distal to the J-J will also dilate the both limbs and gastric remnant (GR in figure), which has no outlet for decompression. This is a surgical emergency

24. Gastric Remnant Dilation
Rare complication of Gastric Bypass
Presents with tachycardia, feeling of doom, pain – similar to uncontained leak
Imaging shows dilated remnant
Can perforate if left untreated
IR or surgical decompression with G-tube

25. Strictures - Sleeve Uncommon esp if Bougie size >32F during surgery
Can attempt dilation endoscopically
Seromyotomy
Revision to RYGB
Strictures - Sleeve

26. Strictures/Ulcers – Gastric Bypass
At the gastrojejunal anastomosis
Often related to anastamotic ulcers
Approximately 10% incidence
Smoking, NSAIDS are risk factors for ulcers
Treatment includes PPI’s, Carafate
EGD for diagnosis and balloon dilation for treatment of strictures
Often requires multiple attempts to give relief
Revision of gastrojejunostomy in rare cases
Strictures/Ulcers – Gastric Bypass

27. Bands - Slippage Late (after 30 days): Band slippage
The primary reason for an acute emergent presentation with a prior AGB will be a slippage of the band causing gastric obstructive symptoms and possible strangulation of the stomach above the slipped band (Figure).
*note band has slipped distally, and excess fundus/body is herniated upwards. In addition to obstructive symptoms this can cause acute gastric necrosis if left untreated

28. Bands Erosion Not common Can present as port site infection]
Treated by removal of eroded lap band
Can often be done endoscopically

29. Multivitamins, B12, and calcium are important life-long
Vitamin D deficiency also common in sleeve/bypass patients
Due to reduced stomach size, reduced binding enzymes (such as intrinsic factor), bypass of proximal small bowel
Chronic deficiency can delete stores and cause serious neurological and other complications
Vitamin Deficiencies

31. Results – weight loss and diabetes
Procedure
5 years
>10 years
DM years
DM Remission >5 years
RYGB*
65% (range 42-93%)
59%(range 52-82%)
84%
~60% (range 29-82%)
Sleeve*
58% (range 40-86%)
28% (range 28-81%)
81%
~60% (range 9-85%)
BPD/DS*
66% (n=50)**
70% (n=373)**
98%
~98%(range %)
Lap Band
48%****
47.5%
73%***
14%
*ASMBS Position Statement on medium and long term disability of weight loss and diabetic outcomes after conventional stapled bariatric procedures. Dan Azagury, M.D., et al. SOARD 14 (2018)
**Limited data due to relative uncommonness of BPD/DS compared to RYGB and LSG; based on 1 study of indicated sample size.
***Resolution of Type 2 Diabetes Following Bariatric Surgery: Implications for Adults and Adolescents . Radha Nandagopal, M.D., et al. Diabetes Technol Ther Aug; 12(8): 671–677.
****.The bariatric surgery and weight losing: a meta-analysis in the long- and very long-term effects of laparoscopic adjustable gastric banding, laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy on weight loss in adults. Golzarand M. et al. Surg Endosc. 2017 Nov;31(11):

32. Case Study year old female c/o acute epigastric pain, nausea and vomiting. Previous gastric lap band.

33. Conclusion: Slipped lap band
UGI swallow
Dilated pouch
Retained contrast
Abnormal band position
Conclusion: Slipped lap band

34. Case Study 2 28 year old female.
2 weeks post-op gastric sleeve, presents to ED with pain that has increased each day in left upper abd. Nausea. No vomiting.
Fever 101.6
Pulse 112
UGI shows

35. Case Study year female with history of Bypass surgery 8 years ago presents to ED with nausea, vomiting and abdominal pain for 4 days. CT shows: