BARIATRIC SURGERY
From the 34th Annual Phoenix Surgical Symposium sponsored by Banner Health and The Phoenix Surgical Society
J. Patrick O’Leary, MD, The Isidore Cohn Jr., MD, Professor and Chair, Department of Surgery, Louisiana State
University School of Medicine, New Orleans
| Introduction: bariatric surgery just recently accepted by mainstream medicine; obesity previously thought beautiful;
social and economic aspects of obesity may far surpass impact of disease as harbinger of other diseases; obesity
truly a disease; common misperceptions—obese patients simply lack willpower; obesity not disease; obesity end
result of gluttony and sloth; surgeons should have better things to do than be involved in treatment of obesity
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| Pathophysiology: many illnesses have acute exacerbations, making disease obvious (eg, diabetes); most critical cells
in body require source of glucose at all times; glucose reserve short-term; necessary to break down glycogen to
make glucose; glycogen not adequate store for body long term; components of energy expenditure—resting metabolic
rate uses ≈1500 kcal/day; thermogenic effect of exercise 750 kcal/day; thermogenic effect of food 250 kcal/
day; adaptive thermogenesis 250 kcal/day; total >2500 kcal; genetic factors clearly at base of serious obesity; 70%
to 80% of children of seriously obese parents also will be seriously obese; obesity cellular, metabolic, and infrequently
psychiatric; body mass index (BMI)—BMI 17 to 19 underweight, substantially increased risk for death;
BMI >25, overweight
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| Studies: study by speaker—25 patients; intravenous (IV) and oral glucose tolerance testing conducted, then intestinal
bypass performed; repeated tests at 3 mo, 6 mo, and 1 yr; 70% of patients had abnormal results, and 6% already
on insulin; 50% hypertriglyceridemic, 10% hypercholesterolemic, 46% hypertensive; 10% had congestive heart
failure; 10% had Pickwickian syndrome; stasis ulcers of lower extremity resolve with weight loss; German
study—late 1990s; looked at seriously obese people; identified insulin growth factor and activated it with protein
kinases and phosphorylation of particular ligand; showed decrease in adipocyte differentiation; if allowed to express
itself without phosphorylation, increased differentiation into adipocytes; small number of patients with this
expression; incidence of type 2 diabetes, 3 of 79 (all 3 had this expression); infrequently seen in nontype 2 diabetes;
futile cycle theory—when food consumed, each step in metabolic pathway generates energy, and each reverse or
futile cycle costs energy; adipocyte theory—question of whether hyperplasia or hypertrophy of adipocytes; biopsied
fat pad of infants and shown that hypertrophy present in obese infants with some hyperplasia
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| Conditions associated with severe obesity: cardiovascular disease, dyslipidemia (contributes to development of
cholelithiasis); diabetes mellitus (clear difference in how normal-sized individuals use insulin to drive glucose into
cell; as individual becomes more obese, more insulin needed to remain euglycemic); as weight lost, insulin sensitivity
improves; orthopedic problems (no durable long-term weight loss in this population other than with surgical
intervention); cancer (proven in gallbladder, breast, uterine, and colon; probable in pancreatic); estrogen absorbed
in fat; seriously obese women infertile and have amenorrheic cycles (related to increased baseline level of estrogen;
probable cause of increased incidence of uterine cancer); socioeconomic impact; psychosocial disadvantage
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| History of development of bariatric procedures: 2 forms; metabolic—affects metabolic mechanisms within body;
surgeons noted that when small intestine “short-circuited,” even normal-weight person lost weight; bypass, shunt,
or removal of parts of gastrointestinal (GI) tract; gastric restrictive—speaker describes as “cormorant” approach;
think of as “tying knot” around stomach
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 | Jejunoileal bypass (JIB): first procedure based on loss of small bowel surface area; stomach, duodenum, and first
14 in of jejunum taken and sewn into terminal ileum 4 in from ileocecal valve (remainder of bowel left intact
with its blood supply); small bowel bypass; many variations; ingested chyme remains; short exposure to bowel
and pancreatic juices and small bowel digestive enzymes, presents itself to colon where metabolized by bacteria;
initially unknown what happened to excluded bowel
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| Studies: Payne, DeWind, and Cummings (1957)—performed bypass on 19 patients, allowed patients to experience
malabsorptive state, and later put bypass back in continuity; completely reversible; no part of GI tract denervated
or removed; produced weight loss but also rehospitalizations (mostly for electrolyte imbalance); when continuity
restored, all patients regained original weight (or more); in 3 patients who did not have continuity restored (performed
JIB), one death from pulmonary embolism in late postoperative period; Varco and Linner (1952)—
performed various levels of resection of small intestine on dogs; placed jejunum in ileal position and ileum in jejunal
position; Linner also reported intestinal bypass performed on 360-lb woman with cardiac symptoms; noted
that another physician had performed 3 similar operations on patients in Sweden, and despite electrolyte abnormalities,
patients doing well and had lost weight; Dr. Linner’s patient lived 28 years and died of myocardial
event; operations uniformly produced substantial weight loss, but unexpected and unexplainable events occurred
(immune complex disease)
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| Mechanism: piece of small intestine becomes populated with own bacteria (primarily gram-negative and also
anaerobes); bacteria share antigen in bacterial wall with synovial lining of joints and with some structures in kidney;
translocation—occurs in small bowel; bacteria translocate and develop antigen-antibody response; synovium
shares as target site; nephrolithiasis—higher incidence in JIB patients; steatosis occurs due to shortened
bowel (fats in lumen of intestine steatified with calcium); calcium no longer available to bind with oxalate in
diet; more oxalate absorbed and secreted in kidney, where it complexes with calcium, causing nephrolithiasis
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| Further complications: renal failure due to immune complex disease and neglected stone disease; migratory arthralgias
explained by immune complex disease; iron-deficiency anemia due to rapid transit of iron through duodenum
(cannot be absorbed); weakness and lethargy of various etiologies, including immune complex disease;
complications seen in all patients; enterohepatic syndrome—previously considered idiopathic anomaly in liver
or due to malabsorption; actually due to toxins absorbed from overgrowth of bacteria in excluded limb of bowel;
toxins transported to liver, which suffers direct injury; also can produce lung injury; no occurrence of liver disease
or stone disease with enterectomy and small bowel resection; failure to thrive and flatulence; sudden
death—can occur in preoperative, immediate postoperative, and late postoperative periods; cardiac dysrhythmia;
usually seen in men (but can occur in women); usually occurs in patients with mild left ventricular hypertrophy
and no coronary artery disease
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| National Institutes of Health (NIH) Consensus Conference (1978): first ever held; discussed whether intestinal bypass
should be used in treatment of serious obesity; created American Society for Bariatic Surgery
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| Gastric restrictive procedures: gastric bypass—first performed for weight loss by Mason (1966 to 1970); high division
of stomach, leaving distal stomach in place, and Billroth II anastomosis; also used to treat duodenal ulcer;
procedure modifications—modified in 1971 with gastroplasty (failed); other modifications made and failed; modification
by Mason made anastomosis tighter (restricting emptying speed), but also failed; another modification of
small pouch (small aperture into small bowel) caused alkaline reflux gastritis; patient would lose weight transiently,
then regain; Roux limbs concept—suggested by John Alden in 1978; multiple variations of procedure (eg,
Roux-en-Y, long limb, divided stomach); can be done laparoscopically or via open surgery; in duodenal switch,
perform partial gastrectomy along greater curvature, placing jejunum 2 or 3 cm distal to pylorus (variant of biliopancreatic
bypass); Roux-en-Y gastric bypass (open or laparoscopic) gold standard—at present, gastroplasties
done on lesser curvature side (heavy musculature and does not distend); silastic ring used; gastric bypass produces
greater weight loss than any other procedure; Scopinaro—removed distal stomach; produced severe malabsorption
and weight loss; complications include pneumonia, deep venous thrombosis, leak, and bleeding; late complications
≈20%; better success with patients from northern Italy than those from southern Italy (attributed to diet);
malabsorptive procedures produce more complications but more weight loss
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| Complications of bariatric surgery and their management
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| Gastric band: pouch distended and lies caudal to band; obtain 2 views in patient who has nausea, vomiting, and
pain after ingestion of anything; herniation in caudal area common problem, requiring laparoscopic revisitation
(sometimes correctable laparoscopically); massive dilatation of esophagus—Sugerman, who withdrew from
trial of adjustable lap bands because of concern, believes that any obstruction of cardia of stomach may be associated
with esophageal distention; indicates band too tight; to avoid complication, use open surgery to insert
band, then over 6 wk gradually increase amount of fluid in balloon in band; all procedures can be done via open
surgery or laparoscopically; no differences between laparoscopic and open procedures, even for duodenal
switch; metabolic aberrations may result from procedures; solution supplementation (multivitamins and iron);
iron deficiency anemia difficult to address and best avoided; if performing malabsorptive procedure, supplement
starting on first day
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| JIB: complications—if patient has no complications, doing well, and producing stool 4 to 6 times daily, leave patient
alone; some recommend liver biopsy because progression to cirrhosis of liver silent; if liver function test
normal, no procedure needed; solution—if any other complication present, imperative that JIB be reversed; just
reversing JIB will cause patient to regain weight; defunctionalized loop of bowel needs to be put back in continuity
with large anastomosis; ≈50% will have what appears to be bowel obstruction in early postoperative period
(loop of bowel not yet conditioned to accept chyme); takes 6 wk to 6 mo for normal GI function; perform Roux-
en-Y gastric bypass in these patients; bring up bypassed limb of intestine, do large anastomosis, and wait; worthwhile
to insert feeding jejunostomy tube (can give elemental diet since patients unable to tolerate oral diet); warn
patients that in beginning, they will be unable to take large amounts of food
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| Vertical-banded gastroplasty: Mason’s procedure; complications—inadequate weight loss, mesh erosion (documented
by endoscopy), chronic vomiting (common), enlargement of pouch, and development of fistula (from upper
pouch to rest of stomach); solution—gastric diversion (speaker prefers Roux-en-Y gastric bypass); if patient presents
with sudden enlarged pouch 10 yr after procedure and had good control of weight for several years, do wedge
resection of cardia of stomach; correct mechanical problem if present; if not mechanical problem, do not repeat procedure
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| Silastic ring gastroplasty: complications—inadequate weight loss, ring erosion, vomiting, and ring angulation (can
be corrected laparoscopically); solution—wedge resection, diversion, and Roux-en-Y gastric bypass; if patient
previously experienced good weight loss, gastric bypass will maintain weight loss
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| Gastric banding: complications—band erosion, prolapse, inadequate weight loss, esophageal dilatation, and gastroesophageal
reflux disease (GERD); solution—correct mechanical problem if correctable; speaker recommends
removing band, stapling stomach, dividing it, and performing Roux-en-Y gastric bypass
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| Adjustable banding: complications—erosion (uncommon), prolapse (concentric or eccentric), inadequate weight
loss, reservoir migration (common) or flipping of reservoir (if not secured), esophageal dilatation, and GERD;
solution—correct mechanical problem; if reoperation needed, convert to Roux-en-Y gastric bypass
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| Roux-en-Y gastric bypass: complications—malnutrition (calcium, magnesium, and iron absorption substantially
decreased), inadequate or excessive weight loss, marginal ulceration, persistent nausea and vomiting, and pouchitis;
when procedure fairly new, concern about inflammatory disease in distal stomach, alkaline reflux gastritis,
and increased incidence of cancer; only 3 cancers described in patients who have had this procedure; solution—
if patient extremely ill, simply restore intestinal continuity; if patient well, perform biliopancreatic or duodenal
exclusion to produce weight loss
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| Biliopancreatic bypass: causes nearly all patients to have some problem, but also provides superb weight loss;
complications—excessive weight loss (incidence 6%-7%); malnutrition (global or component-specific [eg, iron
deficiency anemia, vitamins A and D]); body odor (cause unknown); solution—with excessive weight loss, add
another 50 to 150 cm to alimentary canal to get better absorption (does not correct trivalent cation absorption,
which occurs in duodenum); consider complete reversal, especially in very sick patient; can convert to Roux-en-
Y gastric bypass, but will have sizable gastric pouch (must be trimmed)
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| Generalizations: reversal of any bariatric procedure associated with weight regain and reoperation; any reoperation in
seriously obese individual associated with increased morbidity and mortality; operative mortality 0.6% (of 3000 patients
entered into Centers for Excellence, operative mortality 0.02%); if procedure does not work first time, it will not
work second time; some patients cannot be successfully treated surgically; after any GI procedure, all patients have at
least some GI symptoms in postoperative period
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Suggested Reading
Ali MR et al: Assessment of obesity-related comorbidities: a novel scheme for evaluating bariatric surgical patients.
J Am Coll Surg 202:70, 2006; Biertho L et al: Management of failed adjustable gastric banding. Surgery 137:33,
2005; Bowne WB et al: Laparoscopic gastric bypass is superior to adjustable gastric band in super morbidly obese
patients: A prospective, comparative analysis. Arch Surg 141:683, 2006; Carucci LR et al: Roux-en-Y gastric bypass
surgery for morbid obesity: evaluation of postoperative extraluminal leaks with upper gastrointestinal series. Radiology
238:119, 2006; Dhar NB et al: Jejunoileal bypass reversal: effect on renal function, metabolic parameters
and stone formation. J Urol 174:1844, 2005; El-Gamal H et al: Relationship of dyspnea to respiratory drive and pulmonary
function tests in obese patients before and after weight loss. Chest 128:3870, 2005; Gould JC et al: Laparoscopic
gastric bypass: risks vs. benefits up to two years following surgery in super-super obese patients. Surgery
140:524, 2006; Johnson JM et al: The long-term effects of gastric bypass on vitamin D metabolism. Ann Surg
243:701, 2006; Maggard MA et al: Meta-analysis: surgical treatment of obesity. Ann Intern Med 142:547, 2005;
Summary for patients in: Ann Intern Med 142:155, 2005; Mathurin P et al: The evolution of severe steatosis after
bariatric surgery is related to insulin resistance. Gastroenterology 130:1617, 2006; McCarty TM et al: Optimizing
outcomes in bariatric surgery: outpatient laparoscopic gastric bypass. Ann Surg 242:494, 2005; discussion, 242:498,
2005; Nelson WK et al: The malabsorptive very, very long limb Roux-en-Y gastric bypass for super obesity: results
in 257 patients. Surgery 140:517, 2006; Owens TM: Bariatric surgery risks, benefits, and care of the morbidly obese.
Nurs Clin North Am 41:249, 2006; Parikh MS et al: Objective comparison of complications resulting from laparoscopic
bariatric procedures. J Am Coll Surg 202:252, 2006; Prachand VN et al: Duodenal switch provides superior
weight loss in the super-obese (BMI > or =50 kg/m2) compared with gastric bypass. Ann Surg 244:611, 2006; Santry
HP et al: Trends in bariatric surgical procedures. JAMA 294:1909, 2005; Sheperd TM: Management of morbid obesity:
bariatric surgery in context. J Fam Pract Suppl:S3, 2005; Smoot TM et al: Gastric bypass surgery in the United
States, 1998-2002. Am J Public Health 96:1187, 2006; Suter M et al: Laparoscopic gastric banding: a prospective,
randomized study comparing the Lapband and the SAGB: early results. Ann Surg 241:55, 2005; Zingmond DS et al:
Hospitalization before and after gastric bypass surgery. JAMA 294:1918, 2005
Educational Objectives
| The goals of this program are to reduce complications from bariatric surgery and to improve the management of these
complications. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Describe the pathophysiology of obesity.
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| 2. Review the history of the development of bariatric procedures.
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| 3. Differentiate the various bariatric procedures.
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| 4. Detail specifics of the Roux-en-Y gastric bypass.
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| 5. Identify and manage complications associated with each bariatric procedure.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. O’Leary was recorded at the 34th Annual Phoenix Surgical Symposium, held January 25-28, 2006, in Scottsdale,
AZ, and sponsored by Banner Health and the Phoenix Surgical Society. The Audio-Digest Foundation thanks Dr.
O’Leary and the sponsors for their cooperation in the production of this program.
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