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Bariatric Surgery

Weight loss surgery

Reduces the size of the stomach with a device or by removing portion of the stomach or by resecting and re-routing the small intestine to a small stomach pouch

US National Institutes of Health (NIH) recommends this surgery

For people who have a body mass index (BMI) of at least 40

BMI of 35 and other serious co-existing medical conditions

BMI of 30-35 with significant comorbities

Surgical procedure types

1. Malabsorptive procedures
   • Biliopancreatic diversion
     • replaced by modification known as duodenal switch
     • part of stomach is resected and distal part of small intestine is connected to the pouch, bypassing duodenum and jejunum.
     • no restrictive diet
     • must take vitamin and dietary minerals above and beyond recommended daily allow
     • risk of serious illness, if this is not done
   • Jejunoilial bypass
     • procedure is no longer performed due to multiple complications
   • Endoluminal Sleeve
     • weight loss surgery without incisions or scarring
     • can be used before gastric bypass surgery or can be used as the only weight loss method
     • strict guidelines must be followed
       1. rigorous exercise program
       2. healthy diet
       3. behavior modification to change lifestyle habits
2. Restrictive procedures
   • Vertical banded gastroplasty
     • replaced by modification known as duodenal switch
     • essentially stomach stapling
     • part of stomach is permanently stapled to create a smaller stomach
   • Adjustable gastric band (lap band)
     • performed laproscopically
     • stomach is restricted by using a band that can be adjusted with saline
     • considered one of safest procedures performed today
   • Sleeve gastrectomy (gastric sleeve)
     • performed laproscopically
     • not reversible
     • stomach is reduced to about 15% of its normal size
     • most food items can be eaten in small amounts
     • very effective as first stage procedure for high BMI patients
     • limited results for patients with BMI 35-45.
     • appealing option for people with existing anemia, IBS, Chron's disease
   • Intragastric balloon (gastric balloon)
     • not yet approved by FDA for use in the United States
     • deflated balloon is placed in the stomach and can be filled to decrease the space of the stomach
     • balloon can only be left in for six months
     • can be used prior to another bariatric surgery
     • can be used on multiple occasions, if necessary
   • Gastric Plication (gastric imbrication or laproscopic greater curvature plication)
     • version of gastric sleeve or gastrectomy
     • a sleeve is created by suturing stomach tissue
     • preserves the natural nutrient absorption capabilities
     • reduces the volume of a patient's stomach
3. Mixed Procedures
   • Gastric bypass surgery
     • Roux-en-Y is the common form
     • considered the "gold standard" in the United States
   • Sleeve gastrectomy with duodenal switch
     • variation of biliopancreatic diversion
     • part of the stomach along the greater curve is resected
     • volume of stomach is reduced, restricting food intact
     • anatomically and functionally irreversible
   • Implantable gastric stimulation
     • currently being studied in the United States
     • device similar to a heart pacemaker is implanted
     • trying to determine electrical stimulation can modify the enteric nervous system of the stomach, which is interpreted by the brain to give a sense of being full
     • early evidence suggest that this is less effective than other forms of weight loss surgery
4. Revision surgery
   • surgical procedure performed on patients who have already had a type of bariatric surgery
   • performed due to failure or dysfunctional previous surgery
   • can be done laparoscopically or if there is extensive scarring, through an open surgery

Postsurgical diet

• clear liquid diet immediately after surgery
• continued until the gastrointestinal tract has recovered from surgery

Blended or pureed sugar-free diet for at least two weeks

• skimmed milk, cream of wheat, small amount of margarine, protein drinks, pureed fruit and mashed potatoes with gravy

Diet restrictions after recovery from surgery depend on the procedure performed

• daily multivitamin for life to compensate for reduced absorption or essential
• Nutrients
• high protein diet
• low fat diet
• low alcohol intake

Common problems after surgery

Gastric dumping syndrome (rapid gastric emptying)

• Foods bypass the stomach too rapidly and go into small intestine undigested
• Symptoms of early dumping can include:  nausea, vomiting, bloating, cramping, diarrhea, dizziness, fatigue
• Symptoms of late dumping can include:  weakness, sweating and dizziness
• May also suffer from hypoglycemia (low blood sugar) due to release of excessive amounts of insulin
• reatment:
  • avoid foods that cause it
  • have a balanced diet
  • eat several small meals a day low in carbohydrates
  • avoid simple sugars
  • drink liquids between meals
  • add fiber to diet as this slows gastric emptying and reduces insulin peaks
  • medications can be prescribed in severe cases
  • surgical intervention may be necessary

Infections

Pneumonia

Metobolic bone disease

• osteopenia
• secondary hyperparathyroidism
• due to decreased calcium absorption
• occurs because duodenum has been bypassed and this is where the highest concentration of calcium transporters is located

Gallstones

Kidney problems

• hyperoxaluria – excessive urinary excretion of oxalate
  • can lead to kidney stones
  • can lead to kidney failure
• rhabdomyolysis –  breakdown of skeletal muscle fibers, that leads to release of muscle fiber contents into the bloodstream
  • can lead to acute kidney injury and 

Nutritional derangements

• due to deficiencies of iron, vitamin B12, fat soluble vitamins, thiamine and folate

Seizures

• have been reported due to inappropriate insulin secretion secondary to islet cell hyperplasia