OBESITY SURGERY
From 6th Annual Surgery of the Foregut Symposium, sponsored by the Section of Minimally Invasive Surgery and the
Bariatric Institute at Cleveland Clinic Florida, in conjunction with the European Surgical Institute, the Federation of Latin
American Surgeons, and the Association of Latin American Endoscopic Surgeons
| PATIENT SELECTION IN BARIATRIC SURGERY —Scott Shikora, MD, Associate Professor of Surgery, Tufts
University, School of Medicine, and Surgical Director, Obesity Consult Center, Tufts-New England Medical Center,
Boston, MA
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| Guidelines for patient selection: 1991 consensus statement from National Institutes of Health (NIH)—body mass
index (BMI) ≥35 with comorbidities; failure of nonsurgical attempts at weight loss; no history of significant psychiatric
disorders; age—no age-limit recommendations in NIH consensus statement (insufficient data at time of
publication); need for updated guidelines—increased incidence of obesity; improved variety and safety of surgical
procedures (including laparoscopic techniques); increased surgical experience; improved understanding of importance
of comorbid conditions and how to mitigate them before surgery; multidisciplinary approach to patient
selection—mandated by some organizations, but not evidence-based
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| Behavioral considerations: relative contraindications—inability to understand, cope, or comply with restrictions,
guidelines, or follow-up; major psychiatric disorders (eg, psychosis, schizophrenia, borderline personality disorder),
including unstable or uncontrolled major depression; self-destructive lifestyle (eg, suicidality, active bulimia,
drug use); controversies and gaps in research—effect of behavioral screening on outcome; approach (eg, standardized
vs one-on-one testing); duration of perioperative behavioral intervention; potential for rehabilitation of patients
who do not meet behavioral criteria; red flags—abusive interactions with staff; missing ≥3 preoperative
appointments; excessive impatience (eg, willing to forgo or shorten preoperative process); smoking or excessive
drinking; weight gain during preoperative phase; history of failed bariatric procedure
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| Medical considerations: relative contraindications—severe comorbidities associated with unacceptably high operative
risk; end-stage disease; serious medical conditions unlikely to benefit from weight loss (eg, full-blown
AIDS, cirrhosis with portal hypertension)
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| Age: elderly patients—although data from other surgical specialties (eg, orthopedic, cardiac) have inconsistent conclusions,
and no consensus exists, most published reports consider surgery in older adults feasible, if they meet
other selection criteria; higher rates of morbidity and mortality considered acceptable; earlier recommendations
(for open bariatric surgery) included cutoff of 50 to 55 yr of age, but laparoscopic approach extends age limit; using
Medicare database, Flum et al (2005) found high mortality rate in patients ≥65 yr of age, but analysis criticized as
unrepresentative of older adults in general population; several case series of older adults undergoing bariatric surgery
show outcomes similar to those seen in younger patients; adolescents—increasing incidence, associated comorbidities,
and social ramifications demand effective therapy, but surgery controversial; problems include risk for
complications, including those related to growth and development, medicolegal issues, and lack of long-term data;
limited data from case series show good outcomes (medical and psychologic) and low rate of complications
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| Surgical considerations: patient history, operative reports, and results from radiographic studies may affect
choice of procedure; examples—patients with Crohn’s disease, previous surgery, disease, or irradiation of small
bowel, or transplantation better suited for laparoscopic adjustable gastric band (LAGB); patients with previous
LAGB or antireflux procedure may benefit from gastric bypass; patients with history of Roux-en-Y gastric bypass
(RYGBP), LAGB, or open antireflux procedure may require biliopancreatic diversion (BPD) with or without
duodenal switch; revisional surgery—although all bariatric procedures may fail, most failures caused by behavior,
not technique
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| CHOOSING THE RIGHT BARIATRIC OPERATION —Bruce Schirmer, MD, Stephen H. Watts Professor of Surgery,
University of Virginia Health System, Charlottesville
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| Introduction: no gold standard for bariatric surgery; choice of procedure affected by multiple factors
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| Patient preference: “top-10 list”—advertising; availability and wait-time; reputation of institution; reputation of
surgeon; personal research; recommendation of surgeon; location of hospital; experience of friends and family
members who have undergone bariatric procedures; recommendation of referring physician; insurance coverage
(often, most important factor)
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| Laparoscopic bias: referring physicians give high importance to laparoscopic approach for bariatric surgery,
largely due to belief that safety significantly improved, compared to open approach
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| Contraindications to surgery: failure to meet NIH criteria for patient selection; excess weight or BMI (varies
with surgeon’s experience); age (variable); severe comorbid conditions; previous abdominal or bariatric surgery;
significant psychiatric disorders; substance abuse; smoking
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| Revision surgery: considerations—anatomic status of previous surgery; likelihood of benefit; reason patient failed
previous surgery
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| Comparison of surgical techniques: RYGBP associated with better outcomes (improved weight loss; lower reoperation
rate) than vertical-banded gastroplasty (VBG), especially as weight increases; laparoscopy associated
with shorter recovery time and lower risk for incisional hernias and other complications, compared to open approach
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| Relative contraindications: gastric bypass—previous antireflux surgery (complicates surgery; consider malabsorptive
procedure); previous bilioenteric anastomosis; distal gastric disease or Crohn’s disease (consider gastric
banding); BPD or duodenal switch—previous surgery to shorten gastrointestinal (GI) tract; intestinal anastomoses;
perianal disease (resultant diarrhea likely intolerable); distal gastric resection; high likelihood of noncompliance
(follow-up critical); adjustable gastric banding—high likelihood of noncompliance; history of proximal gastric surgery
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| TECHNIQUE OF RYGBP, EEA OR LINEAR STAPLER, ANTECOLIC OR RETROCOLIC: DOES LENGTH OF
THE LIMB MATTER ?—Daniel M. Herron, MD, Associate Professor of Surgery, Chief, Section of Bariatric Surgery,
and Director, Laparoscopic Surgery Fellowship Program, Mount Sinai School of Medicine, New York, NY
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| Goals: gastrojejunal anastomoses should have low rates of leakage, bleeding, and stricture, be easy to perform and
teach, and be consistently reproducible
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| Circular stapler approach: advantages—familiar to general surgeons; relatively simple and reproducible; case
series (Wittgrove and Clark, 2000) had leak rate of 2.2%, stricture rate of 1.6%, and no esophageal injuries;
disadvantages—enlargement of port site required to admit head of stapler (patients complain of significant postoperative
pain); passage of stapler through abdominal wall associated with increased risk for infection
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| Hand-sewn 2-layer approach: advantages—technique avoids enlargement of port site and decreases infection
rate; case series (Higa, 2001) had no anastomotic leaks, operation time <60 min, and low rates of stenosis, bleeding,
and marginal ulcers
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| Linear stapler approach: series of 1240 cases (using 4-row and 6-row staplers) at Cleveland Clinic had leak rate
of ≈1%, bleeding rate of 2.3%, and stricture rate of ≈6%; technique also avoids port enlargement and infection associated
with circular stapler; other case series found use of linear stapler significantly decreased rate of infection at
left upper quadrant port site (compared to circular stapler)
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| Stapler size: retrospective review of surgeries using 21-mm or 25-mm staplers showed substantial decrease in stricture
rate (8.8% vs 26%) associated with larger stapler
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| Position of Roux limb: several large case studies found lower rates of internal hernia formation and small bowel
obstruction with antecolic, compared to retrocolic, positioning; creation of mesocolic tunnel responsible for
increased rates with retrocolic approach; no good comparative studies looking at rates of leakage or stricture formation
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| Length of Roux limb: as length of Roux limb increases, length of common channel (where absorption occurs) decreases,
leading to increased weight loss and risk for nutritional deficiencies; long limb (150 cm) associated with
greater weight loss than standard-length limb (75 cm) in patients with BMI \>50, but one study found differences
disappeared by postoperative year 4; very long limbs (those that bypass all but distal 75 cm of intestine) further increased
weight loss in super-obese patients (from 61% to 64% of excess weight), but had increased rates of deficiencies
in vitamins D and A, calcium, and albumin; longer Roux limbs may not benefit less obese patients
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| LONG-LIMB MALABSORPTIVE RYGBP —Robert E. Brolin, MD, Adjunct Professor of Surgery, University of
Pittsburgh School of Medicine, and Director of Bariatric Surgery, University Medical Center at Princeton, NJ
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| Malabsorptive procedures and weight loss: prospective comparative studies show gastric banding consistently
better than purely restrictive procedures (eg, VBG, gastric banding); food aversions associated with RYGBP partly
responsible for increased weight loss; observation that many super-obese patients did not lose as much weight as
hoped, led to creation of longer Roux limbs; limb length and malabsorption—study looked at caloric intake and
weight loss; patients with longer Roux limbs consistently had higher caloric intake but greater weight loss than
those with shorter Roux limbs; differences in malabsorption assumed to explain differences in outcomes
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| Distal RYGBP: malabsorption increased further by bypassing all but distal 75 cm of intestine; retrospective evaluation
compared 47 patients (mean weight, 450 lb; mean BMI, 60) to patients with shorter Roux limbs (lower
weights and BMIs); weight loss in short-limb group peaked at 18 mo and 56% of excess body weight (11% regain
by year 5); weight loss in long-limb (150 cm) group peaked at 24 mo and 61% excess body weight (10% regain by
year 5); weight loss in distal-bypass group greatest, peaked more slowly (36 mo), and regained least (maintained
60% excess weight loss); nutritional deficiencies—iron; vitamin B12 ; incidence of anemia doubled among patients
with distal bypass, but incidence of vitamin B12 deficiency decreased (unexplained); deficiencies in fat-soluble vitamins,
calcium, and protein likely to occur; inconsistent findings—some studies confirm increased weight loss
with longer Roux limbs; others show differences decrease with time or that measurable benefit occurs only in super-obese
patients
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| Conclusions: malabsorption important for weight loss among super-obese patients; benefit not seen in patients with
BMIs <50; high risk for metabolic complications associated with distal RYGBP limits use to patients committed to
long-term follow-up
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| BARIATRIC SURGERY IN THE ELDERLY —Dr. Herron
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| Background: consensus during 1980s limited bariatric surgery to patients ≤50 yr of age; rationale—comorbidities
associated with significantly shortened lifespan; benefit limited in elderly patients; many elderly obese patients
considered too sick to survive major surgery; changing demographics—25% of US population 60 to 69 yr of age
obese; increased life expectancy among non-obese individuals warrants weight loss, even among older adults
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| Mortality rates: Flum study (2005) showed high mortality rate among patients \>65 yr of age (Medicare population),
leading Medicare to limit bariatric surgery to certified centers of excellence; case series from individual hospitals
have different findings; Mt. Sinai experience—review of laparoscopic bariatric procedures performed
between 1999 and 2005 included 55 patients \>60 yr of age; comorbidities similar between older and younger bariatric
patients; type of surgery varied (RYGBP most common); relatively low rate of complications and no deaths
occurred in older group
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| Improvement in comorbidities: review (Western Pennsylvania Hospital and University of Massachusetts)
looked at 71 bariatric patients \>50 yr of age (all underwent laparoscopic RYGBP); diabetes resolved in 87% of patients;
hypertension resolved in 70% of patients; sleep apnea resolved in 86% of patients; note—findings similar to
those seen in younger patients
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| Weight loss: data from Western Pennsylvania Hospital show 60% to 70% excess weight loss at 1 and 2 yr after surgery
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| Complications: one sudden death occurred 2 wk after surgery; complication rates similar to those seen in younger
patients; small-bowel obstruction (7%); anastomotic ulcer (5%); anastomotic bleeding (4%); others (1%-2%)
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| Conclusions: bariatric surgery feasible in older patients; as with younger patients, careful selection, preoperative
evaluation, and postoperative care improve outcomes
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Suggested Reading
Adams TD et al: Long-term mortality after gastric bypass surgery. N Engl J Med 357:753, 2007; Belle SH et al:
Safety and efficacy of bariatric surgery: Longitudinal assessment of bariatric surgery. Surg Obes Relat Dis 3:116,
2007; Brolin RE et al: Malabsorptive gastric bypass in patients with superobesity. J Gastrointest Surg 6:195, 2002;
Brolin RE et al: Long-limb gastric bypass in the superobese. A prospective randomized study. Ann Surg 215:387,
1992; Dolan K et al: A comparison of laparoscopic adjustable gastric banding and biliopancreatic diversion in superobesity.
Obes Surg 14:165, 2004; Flum DR et al: Early mortality among Medicare beneficiaries undergoing bariatric
surgical procedures. JAMA 294:1903, 2005; Higa KD et al: Laparoscopic Roux-en-Y gastric bypass:
technique and 3-year follow-up. J Laparoendosc Adv Surg Tech A 11:377, 2001; MacLean LD et al: Long- or short-
limb gastric bypass? J Gastrointest Surg 5:525, 2001; Madan AK et al: Results of teenaged bariatric patients performed
in an adult program. J Laparoendosc Adv Surg Tech A 17:473, 2007; Papasavas PK et al: Laparoscopic
Roux-en-Y gastric bypass is a safe and effective operation for the treatment of morbid obesity in patients older than
55 years. Obes Surg 14:1056, 2004; Schirmer B, Jones DB: The American College of Surgeons Bariatric Surgery
Center Network: establishing standards. Bull Am Coll Surg 92:21, 2007; Sosa JL et al: Laparoscopic gastric bypass
beyond age 60. Obes Surg 14:1398, 2004; Wittgrove AC, Clark GW: Laparoscopic gastric bypass, Roux-en-Y –
500 patients: technique and results with 3-60 month follow-up. Obes Surg 10:233, 2000.
Educational Objectives
| The goal of this program is to improve outcomes of bariatric surgery. After hearing and assimilating this program, the
clinician will be better able to:
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 | 1. Carefully select patients for bariatric surgery, based on behavioral and medical factors, in addition to established
guidelines.
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| 2. List relative contraindications associated with bariatric procedures.
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| 3. Discuss the advantages and disadvantages of available techniques and approaches to Roux-en-Y gastric bypass
surgery.
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| 4. Identify patients who may benefit from malabsorptive surgery.
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| 5. Discuss the importance of age as a criterion for patient selection.
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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.
Acknowledgments
Drs. Shikora, Schirmer, Herron, and Brolin were recorded at 6th Annual Surgery of the Foregut Symposium, sponsored
by the Section of Minimally Invasive Surgery and the Bariatric Institute at Cleveland Clinic Florida, in conjunction
with the European Surgical Institute, the Federation of Latin American Surgeons, and the Association of Latin American
Endoscopic Surgeons, and held February 18-21, 2007, in Weston, FL. The Audio-Digest Foundation thanks the
speakers and the sponsors for their cooperation in the production of this program.
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