1. Clinical update: bariatric surgery by Michael Korenkov and Stefan Sauerland Article Adaptation presented by: Tami Hedglin, R.N.

2. Definitions for you to know Bariatrics-a branch of medicine that deals with the control and treatment of obesity and allied diseases. Bariatrics-a branch of medicine that deals with the control and treatment of obesity and allied diseases. Diabetes Mellitus-a disorder of carbohydrate metabolism, usually occurring in genetically predisposed individuals, characterized by inadequate production or utilization of insulin and resulting in excessive amounts of glucose in the blood and urine. Diabetes Mellitus-a disorder of carbohydrate metabolism, usually occurring in genetically predisposed individuals, characterized by inadequate production or utilization of insulin and resulting in excessive amounts of glucose in the blood and urine. Hypertension- a common disorder in which blood pressure remains abnormally high (a reading of 140/90 mm Hg or greater. Hypertension- a common disorder in which blood pressure remains abnormally high (a reading of 140/90 mm Hg or greater. Cardiomyopathy-Any of various structural or functional abnormalities of the cardiac muscle, usually characterized by loss of muscle efficiency and sometimes heart failure. Cardiomyopathy-Any of various structural or functional abnormalities of the cardiac muscle, usually characterized by loss of muscle efficiency and sometimes heart failure.

3. More definitions Sleep apnea- A temporary suspension of breathing occurring repeatedly during sleep that often affects overweight people or those having an obstruction in the breathing tract. Sleep apnea- A temporary suspension of breathing occurring repeatedly during sleep that often affects overweight people or those having an obstruction in the breathing tract. Asthma- A common inflammatory disease of the lungs characterized by episodic airway obstruction. Asthma- A common inflammatory disease of the lungs characterized by episodic airway obstruction. Osteoarthritis-A form of arthritis that is characterized by chronic degeneration of the cartilage of the joints. Also called degenerative joint disease. Osteoarthritis-A form of arthritis that is characterized by chronic degeneration of the cartilage of the joints. Also called degenerative joint disease. Hyperlipidemia- An excess of fats or lipids in the blood. Hyperlipidemia- An excess of fats or lipids in the blood.

4. Is there a need for bariatric surgery? Studies shows that surgically induced weight loss provides a survival benefit for morbidly obese patients. Studies shows that surgically induced weight loss provides a survival benefit for morbidly obese patients. In two recent cohort studies, bariatric surgery was compared with conservative weight-loss management. In two recent cohort studies, bariatric surgery was compared with conservative weight-loss management. reduced long-term mortality in morbidly obese patients reduced long-term mortality in morbidly obese patients The decrease in mortality rates in the two studies amounted to 29% and 40%, respectively. The decrease in mortality rates in the two studies amounted to 29% and 40%, respectively.

5. Are you a candidate for surgery? Bariatric surgery is appropriate for adult patients with a body-mass index (BMI) of 35 kg/m and over with obesity related co morbidities. These include Bariatric surgery is appropriate for adult patients with a body-mass index (BMI) of 35 kg/m and over with obesity related co morbidities. These include type 2 diabetes mellitus type 2 diabetes mellitus hypertension hypertension cardiomyopathy cardiomyopathy sleep apnea sleep apnea asthma asthma osteoarthritis osteoarthritis hyperlipidaemia hyperlipidaemia

6. Contraindications for surgery those with severe mental or cognitive retardation those with severe mental or cognitive retardation those who will not comply with follow-up requirements those who will not comply with follow-up requirements those with psychiatric disorders such as: those with psychiatric disorders such as: psychotic, personality, or affective disorders psychotic, personality, or affective disorders alcoholism alcoholism drug abuse drug abuse However, preoperative evaluation sometimes requires consultation by a psychiatrist and nutritionist. However, preoperative evaluation sometimes requires consultation by a psychiatrist and nutritionist.

7. Types of Bariatric surgery Two categories of Bariatric procedures Two categories of Bariatric procedures those that reduce food intake (ie, gastric restriction) those that reduce food intake (ie, gastric restriction) those that reduce food uptake from the digestive tract (ie, malabsorption). those that reduce food uptake from the digestive tract (ie, malabsorption). The two most common procedures worldwide The two most common procedures worldwide laparoscopic adjustable gastric banding laparoscopic adjustable gastric banding Roux-en-Y gastric bypass Roux-en-Y gastric bypass done through open approach done through open approach done laparoscopically done laparoscopically

8. Lap banding band is placed around the upper third portion of the stomach to create a small stomach pouch band is placed around the upper third portion of the stomach to create a small stomach pouch initially holds 2 ounces of food, and eventually holds up to 4 to 6 ounces initially holds 2 ounces of food, and eventually holds up to 4 to 6 ounces causes a longer lasting feeling of fullness causes a longer lasting feeling of fullness works by slowly allowing the food you eat to be released into the lower portion of the stomach for digestion. works by slowly allowing the food you eat to be released into the lower portion of the stomach for digestion.

9. Lap banding

10. Roux-en-y gastric bypass The Roux-en-Y gastric bypass procedure involves creating a stomach pouch out of a small portion of the stomach and attaching it directly to the small intestine, bypassing a large part of the stomach and duodenum. The Roux-en-Y gastric bypass procedure involves creating a stomach pouch out of a small portion of the stomach and attaching it directly to the small intestine, bypassing a large part of the stomach and duodenum. Not only is the stomach pouch too small to hold large amounts of food, but by skipping the duodenum, fat absorption is substantially reduced. Not only is the stomach pouch too small to hold large amounts of food, but by skipping the duodenum, fat absorption is substantially reduced.

11. Roux-en-Y gastric bypass

12. Biliopancreatic diversion In a biliopancreatic diversion, a portion of the stomach is removed. The remaining portion of the stomach is connected to the lower portion of the small intestine. In a biliopancreatic diversion, a portion of the stomach is removed. The remaining portion of the stomach is connected to the lower portion of the small intestine.

13. Biliopancreatic diversion

14. biliopancreatic diversion with duodenal switch In a biliopancreatic diversion with duodenal switch, a smaller portion of the stomach is removed, but the remaining stomach remains attached to the duodenum (the upper part of the small intestine). The duodenum is connected to the lower part of the small intestine. In a biliopancreatic diversion with duodenal switch, a smaller portion of the stomach is removed, but the remaining stomach remains attached to the duodenum (the upper part of the small intestine). The duodenum is connected to the lower part of the small intestine.

15. biliopancreatic diversion with duodenal switch

16. Roux-en-Y bypass/biliopancreatic diversion greater potential for serious perioperative complications, including lethality and malnutrition greater potential for serious perioperative complications, including lethality and malnutrition associated with better long-term outcome in terms of weight loss associated with better long-term outcome in terms of weight loss requires less dietary restrictions requires less dietary restrictions appears to be more effective than both standard Roux-en-Y method and laparoscopic adjustable gastric banding in terms of weight loss appears to be more effective than both standard Roux-en-Y method and laparoscopic adjustable gastric banding in terms of weight loss

17. Complications of Roux en Y /biliopancreatic diversion leakage leakage stoma stenosis stoma stenosis gastric distension gastric distension gastrointestinal hemorrhage gastrointestinal hemorrhage small-bowel obstruction small-bowel obstruction gastrojejunal ulcers gastrojejunal ulcers nutritional deficiencies nutritional deficiencies inadequate weight loss inadequate weight loss

18. Lap sleeve gastrectomy Laparoscopic sleeve gastrectomy can be done as an initial weight-loss procedure followed by second-stage duodenal switch for high-risk patients or in addition to gastric banding when weight loss is insufficient. Laparoscopic sleeve gastrectomy can be done as an initial weight-loss procedure followed by second-stage duodenal switch for high-risk patients or in addition to gastric banding when weight loss is insufficient. Biggest drawback of this procedure is the potential for sleeve dilatation, resulting in a stop in weight loss or even a gain. Biggest drawback of this procedure is the potential for sleeve dilatation, resulting in a stop in weight loss or even a gain. Can be used as a stand-alone bariatric procedure for some special groups of high-risk patients. Can be used as a stand-alone bariatric procedure for some special groups of high-risk patients.

19. Lap sleeve gastrectomy

20. Which is safest? In accordance with current opinion, laparoscopic adjustable gastric banding is generally considered to be the safest and quickest, but the long-term outcome and quality of life, especially for eating patterns, have been questioned. In accordance with current opinion, laparoscopic adjustable gastric banding is generally considered to be the safest and quickest, but the long-term outcome and quality of life, especially for eating patterns, have been questioned. Band-related complications include band slippage, leak, intolerance, infection, and migration, as well as insufficient weight loss. Band-related complications include band slippage, leak, intolerance, infection, and migration, as well as insufficient weight loss. The management of these complications includes: The management of these complications includes: band replacement for slippage band replacement for slippage band removal for infection band removal for infection band removal plus Roux en-Y gastric bypass for intolerance band removal plus Roux en-Y gastric bypass for intolerance band in situ plus sleeve gastrectomy for insufficient weight loss band in situ plus sleeve gastrectomy for insufficient weight loss addition of biliopancreatic diversion or band removal plus the Roux-en-Y technique for insufficient weight loss addition of biliopancreatic diversion or band removal plus the Roux-en-Y technique for insufficient weight loss

21. How to choose? choice of surgical procedure partly depends on the repertoire of the surgeon choice of surgical procedure partly depends on the repertoire of the surgeon most surgical centers cannot offer the full range of possible operations. most surgical centers cannot offer the full range of possible operations. Some centers prefer Roux-en-Y gastric bypass or biliopancreatic diversion, while others have nominated laparoscopic adjustable gastric banding or laparoscopic sleeve gastrectomy as their first-choice procedure and do the Roux-en-Y technique or biliopancreatic diversion only when the laparoscopic procedure has failed. Some centers prefer Roux-en-Y gastric bypass or biliopancreatic diversion, while others have nominated laparoscopic adjustable gastric banding or laparoscopic sleeve gastrectomy as their first-choice procedure and do the Roux-en-Y technique or biliopancreatic diversion only when the laparoscopic procedure has failed. On the balance between risks and benefits, patients with more severe obesity ( BMI>50) are generally considered good candidates for Roux-en-Y bypass or biliopancreatic diversion, whereas adjustable gastric banding or sleeve gastrectomy may be more appropriate in milder degrees of obesity. On the balance between risks and benefits, patients with more severe obesity ( BMI>50) are generally considered good candidates for Roux-en-Y bypass or biliopancreatic diversion, whereas adjustable gastric banding or sleeve gastrectomy may be more appropriate in milder degrees of obesity.

22. Further findings… The effectiveness of obesity surgery has been traditionally measured only in terms of excess weight loss, for which data clearly indicate the effectiveness of all procedures. The effectiveness of obesity surgery has been traditionally measured only in terms of excess weight loss, for which data clearly indicate the effectiveness of all procedures. Today, research emphasis is more on the effect of surgery on obesity-related comorbidites, which can affect metabolic, cardiovascular, respiratory, gastrointestinal, musculoskeletal, and urological organ systems. Today, research emphasis is more on the effect of surgery on obesity-related comorbidites, which can affect metabolic, cardiovascular, respiratory, gastrointestinal, musculoskeletal, and urological organ systems. Additionally, the psychological benefits of weight loss are being investigated. New data indicate that at least some bariatric procedures exert their beneficial metabolic effects not only by weight loss but also through a change in hormone release (ghrelin, peptide YY, and glucagon-like peptide 1) from the gut. Additionally, the psychological benefits of weight loss are being investigated. New data indicate that at least some bariatric procedures exert their beneficial metabolic effects not only by weight loss but also through a change in hormone release (ghrelin, peptide YY, and glucagon-like peptide 1) from the gut. This finding corresponds to clinical observations that obesity in patients with diabetes is especially amenable to bariatric surgery. This finding corresponds to clinical observations that obesity in patients with diabetes is especially amenable to bariatric surgery.

23. Remember! As can be expected from other surgical disciplines, the results of surgery critically depend on the expertise of the surgeon and the multidisciplinary team. As can be expected from other surgical disciplines, the results of surgery critically depend on the expertise of the surgeon and the multidisciplinary team. Mortality in high-volume centers is lower than in lower-volume centers. Mortality in high-volume centers is lower than in lower-volume centers.

24. In conclusion There is good evidence to show that bariatric surgery is more effective than non-surgical approaches in the therapy of morbid obesity. There is good evidence to show that bariatric surgery is more effective than non-surgical approaches in the therapy of morbid obesity. However, no single operation is ideal for every morbidly obese patient, and all operations also entail some disadvantages. However, no single operation is ideal for every morbidly obese patient, and all operations also entail some disadvantages.

25. References: 1 Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA 2005; 294:1909-172 Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007; 357: 741-52.3 Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl) Med 2007; 357: 753-61.4 DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med 2007; 356: 2176-83.5 National Institutes of Health Consensus Development Panel. Gastrointestinal surgery for severe obesity. Obes Surg 1991; 1:257- 65.6 Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis JAMA 2004; 292:1724-377 Colquitt J, Clegg A, Sidhu M, Royle P. Surgery for morbid obesity. Cochrane Database Syst Rev 2003; 2: CD003641.8 O'Brien PE, Dixon JB, Laurie C, et al. Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: a randomized trial. Ann Intern Med 2006; 144: 625-33.9 Sauerland S, Angrisani L, Belachew M, et al. Obesity surgery: evidence-based guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc 2005; 19: 200-21.10 Black DW, Goldstein RB, Mason EE. Psychiatric diagnosis and weight loss following gastric surgery for obesity. Obes Surg 2003; 13: 746-51. 1 Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA 2005; 294:1909-172 Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007; 357: 741-52.3 Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl) Med 2007; 357: 753-61.4 DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med 2007; 356: 2176-83.5 National Institutes of Health Consensus Development Panel. Gastrointestinal surgery for severe obesity. Obes Surg 1991; 1:257- 65.6 Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis JAMA 2004; 292:1724-377 Colquitt J, Clegg A, Sidhu M, Royle P. Surgery for morbid obesity. Cochrane Database Syst Rev 2003; 2: CD003641.8 O'Brien PE, Dixon JB, Laurie C, et al. Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: a randomized trial. Ann Intern Med 2006; 144: 625-33.9 Sauerland S, Angrisani L, Belachew M, et al. Obesity surgery: evidence-based guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc 2005; 19: 200-21.10 Black DW, Goldstein RB, Mason EE. Psychiatric diagnosis and weight loss following gastric surgery for obesity. Obes Surg 2003; 13: 746-51.

26. References: 11 Puzziferri N, Austrheim-Smith IT, Wolfe BM, Wilson SE, Nguyen NT. Three-year follow-up of a prospective randomized trial comparing laparoscopic versus open gastric bypass. Ann Surg 2006; 243:181-88.12 Suter M, Giusti V, Worreth M, Heraief E, Calmes JM. Laparoscopic gastric banding: a prospective, randomized study comparing the Lapband and the SAGB: early results. Ann Surg 2005; 241: 55-62.13 Weiner RA, Korenkov M, Matzig E, Weiner S, Karcz WK. Initial clinical experience with telemetrically adjustable gastric banding. Surg Technol Int 2006; 15: 63-69.14 Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg 2004; 14: 1157-64.15 Moon Han S, Kim WW, Oh JH. Results of laparoscopic sleeve gastrectomy (LSG) at 1 year in morbidly obese Korean patients. Obes Surg 2005; 15:1469-75.16 De Luca M, Segato G, Busetto L, et al. Progress in implantable gastric stimulation: summary of results of the European multi- center study. Obes Surg 2004; 14 (suppl 1): S33-39.17 Brolin RE. Bariatric surgery and long-term control of morbid obesity. JAMA 2002; 288: 2793- 96.18 O'Brien PE, McPhail T, Chaston TB, Dixon jB. Systematic review of medium-term weight loss after bariatric operations. Obes Surg 2006; 16: 1032-40.19 Rubino F. Bariatric surgery: effects on glucose homeostasis. Curr Opin Clin Nutr Metab Care 2006; 9: 497-50720 Flum DR, Salem L, Elrod J A, Dellinger EP, Cheadle A, Chan L. Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. JAMA 2005; 294: 1903-08. 11 Puzziferri N, Austrheim-Smith IT, Wolfe BM, Wilson SE, Nguyen NT. Three-year follow-up of a prospective randomized trial comparing laparoscopic versus open gastric bypass. Ann Surg 2006; 243:181-88.12 Suter M, Giusti V, Worreth M, Heraief E, Calmes JM. Laparoscopic gastric banding: a prospective, randomized study comparing the Lapband and the SAGB: early results. Ann Surg 2005; 241: 55-62.13 Weiner RA, Korenkov M, Matzig E, Weiner S, Karcz WK. Initial clinical experience with telemetrically adjustable gastric banding. Surg Technol Int 2006; 15: 63-69.14 Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg 2004; 14: 1157-64.15 Moon Han S, Kim WW, Oh JH. Results of laparoscopic sleeve gastrectomy (LSG) at 1 year in morbidly obese Korean patients. Obes Surg 2005; 15:1469-75.16 De Luca M, Segato G, Busetto L, et al. Progress in implantable gastric stimulation: summary of results of the European multi- center study. Obes Surg 2004; 14 (suppl 1): S33-39.17 Brolin RE. Bariatric surgery and long-term control of morbid obesity. JAMA 2002; 288: 2793- 96.18 O'Brien PE, McPhail T, Chaston TB, Dixon jB. Systematic review of medium-term weight loss after bariatric operations. Obes Surg 2006; 16: 1032-40.19 Rubino F. Bariatric surgery: effects on glucose homeostasis. Curr Opin Clin Nutr Metab Care 2006; 9: 497-50720 Flum DR, Salem L, Elrod J A, Dellinger EP, Cheadle A, Chan L. Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. JAMA 2005; 294: 1903-08.