1. Bariatric Surgery Mr Peter O’Leary

2. History Greek  Baros = weight  Iatros = physician Kremen & Linner  1954 Jejuno-ileal Bypass Mason  1967 Gastric Bypass  Failure to gain weight post partial gastrectomy for peptic ulcer disease

3. Recognised as a general surgical sub-speciality by  American College of Surgeons  American Medical Association

4. Mrs. KG (48) Referred by Orthopaedics re Gastric bypass for:  Weight reduction prior to hip replacement (OA)  Improvement of mobility  Seeking procedure for 4 year Current statusWeight135kg Height1.75m BMI47

5. HxPC >9st until mid 20s Gained weight since the birth of her children Weight reduction measures  Weight watchers  Dieticians  Appetite suppressants  All effective short term

6. MedHx Osteoarthritis B/L hip Hypertension Hypercholestrolaemia Sleep apnoea Reflux and heart burn NIDDM

7. Family Hx  Nil of note Drug Hx  NKDA  Metformin  Atenolol SHx  Non-smoker  No alcholo  Shop assistant RoS  Nil of note

8. On Examination Looked well but obese Vitals normal MSS Fixed flexion R knee Joint line tender medially Crepitus + CVS, RS, Neuro - NAD

9. Pre-op Advice Advised aboutProcedure Possible complication Post-op recovery Endocrine assessment No pre-op consultation with Dietician No pre-op psychological evaluation

10. Indications BMI > 40 (> 35 with co-morbid conditions)  sleep apnea  cardiomyopathy  diabetes mellitus  musculoskeletal  body size severely impacting on function No medical or anaesthetic contraindications No previous major upper abdominal surgery No active drug or alcohol addiction history No major psychiatric history Well informed, motivated, and acceptable operative risks

11. Pre-op Considerations Endocrinologist  Pituitary  Thyroid  Adrenal Dietician  Eating behaviour modification  Post op diet adjustment, vitamin and mineral supplementation Psychological evaluation  Psychiatric co-morbidities  Change in relationship with food  Behaviour modification techniques

12. Please help…!

13. Bariatric surgery weight reduction surgery for morbidly obese 1.BMI >40 (basically, >100 pounds above ideal body weight). 2.BMI >35 with a medical problem related to morbid obesity.

14. Surgical options Stapling off of small gastric pouch (restrictive) roux-en-Y limb to gastric pouch

15. Mechanism of gastric by pass 1. Creates a small gastric reservoir 2. Causes dumping symptoms when a patient eats too much food or high calorie foods, the food is dumped into the roux-en-Y limb 3. Bypass of small bowel by roux-en-Y limb

16. Dose gastric by pass work? Weight loss 50% of excess weight

17. Postop Complications Early (1 to 6 weeks)  Postoperative bleeding  Anastomosis leak  Bowel perforation  Bowel obstruction  Wound infections Intermediate (7 to 12 weeks)  Prolonged vomiting Dietary indiscretions Bulimia Stricture at gastrojejunal anastomosis (4.6%)  Marginal ulcer  Dumping syndrome (50% after roux en y) Late (13 weeks to 12 months)  Cholelithiasis  Small bowel obstruction (adhesions)  Secondary hyperparathyroidism Leak after gastric bypass on upper gastrointestinal series

18. Long term eating habits Initially, the stomach tolerates 30 cc at one time 3 months, patients are ingesting ~1000 kcal in three to six meals per day  Dietary advice important at this stage Six months, should be on 3 meals a day Food aversions develop esp if prolonged vomiting associated with eating  Such patients often express "buyers remorse" and may request extensive investigations for problems with the gastric pouch Eating habits change compared to preoperative eating habits  Fresh fruits and vegetables are tolerated without a problem  Some patients have continuing food intolerances, especially to red meat, and become vegetarian

19. Changes post surgery Weight loss  Rapid in the first six months Averages 4 to 7 Kg per month  Slows 2 to 3 Kg after 6 months  Total weight loss peaks at 12 months  Weight regain 18-24 months post op Nutritional Deficiencies  Inadequate intake of nutrients  Alterations in the digestive anatomy lack of intrinsic factor – B12 def Lack of acid in new pouch (R en Y) – Poor absorption of iron Ca and Vit D absorption decreased after surgery – Secondary Hyperthyroidism Thiamine def due to recurrent vomiting Little evidence available on the amount of supplementation required

20. Cosmetic  After 12 months, patients seek info about plastic surgery to remove abdominal pannus  Insurance companies will not cover it - cosmetic  Exception if abdominal pannus becomes infected or excoriated  Case series suggested that delaying panniculectomy until after weight loss is safer and more effective Physical function  Fatigue improves, increased energy  Exercise habits improve increase in activities of daily living and recreational activities  Musculoskeletal and back pain improves or resolves in the majority of patients  Osteoarthritis improves to a lesser degree Dependent on the degree of underlying bone and cartilage damage  Sleep apnea improves

21. Psychological  Lethargy, depression, and other psychopathology  Food used for emotional reasons, pre-op  Grieve the loss of food  Several studies have shown increases in self-esteem, self- confidence, assertiveness, and expressiveness  Improvements seen in social interaction, sexual activity, and work performance Pregnancy  Greater fertility with weight loss  Surgery not associated with adverse perinatal outcomes  Pregnancy complications eg gestational diabetes, hypertension, and macrosomia  Period of rapid weight loss  Gastric band may need to be adjusted  nutritional deficiencies

22. "un poco con la cabeza de Maradona y otro poco con la mano de Dios"