Indications for bariatric surgery
- BMI ≥ 40 without comorbid illness
- BMI 35-40 + at least one serious comorbidity, e.g.:
- T2DM
- OSA, OHS (obesity hypoventilation syndrome), Pickwickian syndrome (OSA+OHS)
- HTN, HLD
- NAFLD, NASH
- Pseudotumor cerebri
- GERD
- Asthma
- Impaired quality of life
- BMI > 30 and one of the following:
- Uncontrollable T2DM
- Metabolic syndrome
Contraindications to bariatric surgery
- Uncontrolled/untreated major depression, psychosis, eating disorders, drug/EtOH abuse
- Severe cardiac disease with prohibitive anesthetic risks
- Severe coagulopathy
- Inability to comply with nutritional requirements including life-long vitamin replacement
Types of bariatric surgery
| Anatomy | Weight loss | Pros/cons | |
| Roux-en-Y bypass | Small (30 cc) gastric pouch Roux (alimentary limb) 125-150 cm (any longer and common channel will shorten -> malnutrition Y (biliopancreatic limb) ~ 40 cm long |
70% of excess weight at 2 yrs |
Longer surgery (2.5 hrs vs 1.5 hrs for sleeve), more risk of leak due to anastomoses Proven cure for diabetes (preferred over sleeve if pt has high insulin requirement) |
| Sleeve gastrectomy |
Remove greater curvature; divide antrum 2-6 cm from pylorus Creates high pressure system (both sphincters intact) |
60% of excess weight at 2 yrs |
Lower risk of leak/shorter surgery if cannot tolerate longer lengths of general anesthesia; however a sleeve leak is harder to resolve due to high pressure system Can make mod/severe GERD worse due to high pressure system |
| Laparoscopic banding | Adjustable band placed around stomach, inflated/deflated via subcutaneous port | 50-60% of excess weight at 2 yrs |
Contraindications to Medical Weight Loss Medications
- Contrave- Uncontrolled HTN, history of seizures, dependence of opioid therapy, in conjunction with buproprion or other medications containing buproprion, in conjunction with MAOIs, bulimia, anorexia nervosa, or pregnancy
- Qsymia- Narrow-angled glaucoma, hyperthyroidism, pregnancy, or in conjunction with MAOIs
- Saxenda- personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type II, prior sensitivity to liraglutide, pregnancy
Laparoscopy
- Palmer's point - LUQ, 3 cm below costal margin and in midclavicular line
- Use in patients with prior abd surgery/suspected adhesions; generally described to have fewer adhesions in this area
- Ports
- Veress needle at Palmer's point, 12 mm port approximately 13 cm from the xiphoid, additional three 12 mm ports placed in LUQ, and 12 mm port in RUQ.
- Identify ligament of Treitz
- Divide jejunum approximately 40 cm distal to ligament of Treitz; divide mesentery
- Follow bowel for approximately 125 cm then create jejunojejunostomy. Close mesenteric defect
- Identify lesser curve and enter the retrogastric space just below the second vascular arcade, approximately 4 cm from the GE junction.
- Divide the stomach
- Insert EEA anvil in stomach
- Bring Roux limb up in antecolic/retrocolic antegastric fashion. Dock EEA stapler with anvil and fire to create gastrojejunostomy.
Post-operative management
- Post-op visits at 2 wks, 3 mo, 6 mo, annually
- Diet: 2 wks CLD pre-op, 2 wks CLD/full liquids post-op, then soft/purees
- Meds: PPI, Actigall (gallstone prophylaxis; rapid weight loss can promote gallstone formation)
- Can stop oral hyperglycemic meds after surgery; stop most HTN meds as well
Complications
- Internal hernia/Petersen's hernia - mesenteric defect created during division of jejunal limbs, allowing for potential internal herniation
- May present as bowel obstruction
- CT can show 'whirlpool' sign/swirling of mesentery, but can be negative in ~20% of cases