I E NT W I T H H IG H BM I

A PA T
M E T A BO L IC S Y N D RO ME
AND MAHA ASRAR
2020-031
BMI
 METABOLIC SYNDROME- WHO
DEFINITION
• Presence of any one of diabetes mellitus, impaired glucose tolerance, impaired fasting glucose or 
insulin resistance, AND two of the following:

• Blood pressure: ≥ 140/90 mmHg

• Dyslipidemia: triglycerides (TG): ≥ 1.695 mmol/L and high-density lipoprotein cholesterol (HDL-C) ≤

0.9 mmol/L (male), ≤ 1.0 mmol/L (female)

• Central obesity: waist:hip ratio > 0.90 (male); > 0.85 (female), or body mass index > 30 kg/m2

• Microalbuminuria: urinary albumin excretion ratio ≥ 20 µg/min or albumin:creatinine ratio ≥ 30 mg/g

RISK FACTORS
• AGE - RISK OF METABOLIC SYNDROME INCREASES WITH AGE.

• ETHNICITY

• OBESITY

• DIABETES- GESTATIONAL DIABETES OR IF FAMILY HISTORY OF TYPE 2 DIABETES

• OTHER DISEASES- NONALCOHOLIC FATTY LIVER DISEASE, POLYCYSTIC OVARY SYNDROME, CORONARY

HEART DISEASE OR SLEEP APNEA

• STRESS

• SEDENTARY LIFESTYLE
COMPLICATIONS
• ATHEROSCLEROSIS
• TYPE 2 DIABETES MELLITUS
• MI
• KIDNEY DISEASE
• STROKE
• NONALCOHOLIC FATTY LIVER DISEASE
• NEUROLOGICAL DISORDERS
PREVENTION/TREATMENT
• DIETARY, LIFESTYLE MODIFICATIONS

• PHARMACOLOGICAL

• SURGICAL
BARIATRIC SURGERY
INTRODUCTION
• BARIATRIC SURGERY, ALSO CALLED WEIGHT LOSS OR OBESITY SURGERY, IS THE SURGERY ON THE
STOMACH AND/OR INTESTINES TO HELP A PERSON WITH EXTREME OBESITY LOSE WEIGHT.

• REQUIRES A MULTIDISCIPLINARY TEAM (MDT) APPROACH FOR PATIENT SELECTION AND FOLLOW-UP

• DOES NOT CURE OBESITY BUT IS AN ADJUNCT TO HELP PEOPLE MANAGE THE PROBLEM MORE READILY
RATIONALE FOR SURGERY
• INCREASE LIFE EXPECTANCY

• DECREASE COMORBIDITIES

• DECREASE HEALTH-CARE COSTS TO THE SOCIETY

SELECTION CRITERIA
• BODY MASS INDEX >40MG/M2 OR BMI 35-39 KG/M2 WITH SERIOUS COMORBID DISEASE TREATED BY WEIGHT
LOSS
• MINIMUM OF 5 YEARS OBESITY
• FAILURE OF CONSERVATIVE TREATMENT
• NO ALCOHOLISM AND MAJOR UNTREATED PSYCHIATRIC ILLNESS
• AVOID, IF LIKELY, TO GET PREGNANT WITHIN TWO YEARS
• AGE LIMITS (18-55)
• ACCEPTABLE OPERATIVE RISK ON PREOPERATIVE ASSESSMENT
CONTRAINDICATIONS
• SUBSTANCE ABUSE, ALCOHOLISM OR MAJOR PSYCHOLOGICAL DISORDERS

• WOMEN WHO WANT TO BECOME PREGNANT WITHIN 18 MONTHS.

• HIGH RISK PATIENTS :

-AGES GREATER THAN 65
-BMI ≥50
-PRESENCE OF AT LEAST 2 OF 6 CARDIOPULMONARY OR VASCULAR CO-MORBIDITIES HTN, IHD, CHF, COPD, OBSTRUCTIVE SLEEP APNEA,
HISTORY OF DVT OR PE
OBESITY MULTIDISCIPLINARY TEAM
• SURGEON WITH A BARIATRIC TRAINING
• PHYSICIAN WITH A SPECIAL INTEREST IN OBESITY
• DIETICIAN
• SPECIAL BARIATRIC NURSE
• ANESTHETIST
• SKILLED THEATRE STAFF
• PSYCHIATRIST WITH INTEREST IN EATING DISORDERS
PRE-OP ASSESSMENT
• HISTORY (PREVIOUS SURGERIES & COMORBIDS LIFESTYLE)

• EXAMINATION (VITALS, BMI)

• PSYCHOLOGICAL SCREENING

• ANESTHESIOLOGY FITNESS

• CARDIAC SCREENING

• COAGULATION SCREENING (DVT VTE)

• GI SCREENING

• PULMONARY FUNCTION TESTS

INVESTIGATIONS
• CBC
• RFT AND LFT

• FASTING LIPID PROFILE

• FASTING GLUCOSE HBA1C

• VITAMIN A D AND E LEVELS

• TEST FOR H. PYLORI

• PTH LEVELS

• TEST FOR PREGNANCY

• RADIOLOGY- USG LIVER/GALLBLADDER, X-RAY ABDOMEN

ADDITIONAL LABS FOR BYPASS
PATIENTS
• MAGNESIUM

• CALCIUM

• PHOSPHATE

• FERRITIN

• B12 AND FOLATE

• ZINC, SELENIUM, COPPER

PRE-OP: PREPERATION
• LOW CARB DIET FOR 2 WEEK PRIOR TO SURGERY
• HIGH PROTEIN PRIOR TO SURGERY
• STRICT LIQUID DIET 2 DAY PRIOR TO SURGERY
• STOP NSAIDS, GOUT MEDICATIONS, GLUCOSAMINE, CHONDROITIN, VITAMIN E 7 DAYS BEFORE
SURGERY
• DVT PROPHYLAXIS AND MANAGEMENT OF COAGULATION DISORDERS
• CONTROL HYPERTENSION AND DIABETES
CURRENT SURGICAL OPTIONS
• RESTRICTIVE PROCEDURES: GASTRIC BANDING, SLEEVE GASTRECTOMY

• MALABSORBTIVE PROCEDURES: BILIOPANCREATIC DIVERSION-WITH OR WITHOUT

DUODENAL SWITCH

• MIXED OR COMBINATION PROCEDURES: ROUX-EN-Y GASTRIC BYPASS, MINI GASTRIC BYPASS

GASTRIC BANDING
GASTRIC BANDING
Disadvantages:
ADVANTAGES: • Bands can fail due to prolapse
• REVERSIBLE of the stomach
• LEAST RISKY • Bands can slip up or down or
• DOES NOT INVOLVE CUTTING ANY STOMACH OR erode into the stomach
BOWEL
• Continual band adjustment in
• EASY OPERATION TO PERFORM IN MOST PATIENTS
early post-op period
WHO HAVE A BMI <50KG/M2
• Revisional procedure might be
• 45-50% OF EXCESS WEIGHT LOST
indicated
• CAN BE INSERTED AS A DAY CASE PROCEDURE
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Disadvantages:
ADVANTAGES: • Careful post-op metabolic
• VERY EFFECTIVE follow up
• Riskier
• 65-75% EXCESS WEIGHT LOSS
• ALLEVIATES AND EVEN CURES TYPE
2 DIABETES IMMEDIATELY AND
INDEPENDENTLY OF WEIGHT LOSS
SLEEVE GASTRECTOMY
SLEEVE GASTRECTOMY
Disadvantages:
ADVANTAGES:
• Riskier than gastric banding
• LESS POST-OP MONITORING • Long staple line can leak
• Might need to be converted to
• REMOVES MOST OF THE gastric bypass later on
GHRELIN SECRETING AREA • Sleeve can expand requiring a
• 65% EXCESS WEIGHT LOSS resleeving procedure

• NO MALABSORPTION ISSUES
ONE ANASTOMOSIS GASTRIC BYPASS
SAGB/MGB
Disadvantages
ADVANTAGES
• Symptomatic (bile) reflux
• long-term risk of gastric and
• TECHNICAL SIMPLICITY esophageal cancers
• EASE OF REVISION AND
REVERSAL
BILIOPANCREATIC DIVERSION
BILIOPANCREATIC DIVERSION
ADVANTAGES:
• MOST EFFECTIVE WITH 75-85%
EXCESS WEIGHT LOSS
• GOOD FOR PATIENTS WITH VERY
HIGH BMI
• ALLEVIATES TYPE 2 DIABETES
Disadvantages:
• Highest perioperative
mortality
• Severe risk of many deficiency
syndromes
• Need for high protein intake
BARIATRIC SURGERY AND ITS EFFECT ON DM

• FOREGUT HYPOTHESIS: BYPASS OF A PROXIMAL DUODENUM AND JEJUNUM REDUCES

STIMULATED SECRETION OF ANTI-INCRETIN FACTORS WHICH NORMALLY INHIBIT
INSULIN SECRETION THUS ALLOWING THE UNOPPOSED EFFECTS ON INCRETIN TO
STIMULATE INSULIN SECRETION

• HINDGUT HYPOTHESIS: RAPID DELIVERY OF SMALL BOWEL CONTENT INTO DISTAL

JEJUNUM AND ILEUM EXAGGERATES STIMULATED INCRETIN (GLP-1, PPY) RELEASE
WHICH STIMULATES INSULIN SECRETION
RISKS/COMPLICATIONS
• GENERAL RISKS: BLEEDING, INFECTION, DVT (+/- PE), ACCIDENTAL BOWEL PERFORATION, PERIOPERATIVE MORTALITY

• RISKS OF SPECIFIC BARIATRIC PROCEDURES: INTERNAL HERNIATION (GASTRIC BYPASS AND BPD), STAPLE
LINE/ANASTOMOTIC LEAK (GASTRIC BYPASS, SLEEVE GASTRECTOMY AND BPD), BAND SLIPPAGE/EROSION, POUCH
DILATATION (GASTRIC BAND, GASTRIC BYPASS AND SLEEVE GASTRECTOMY)

• LONG-TERM RISKS: PROTEIN CALORIE MALNUTRITION, VITAMIN AND MICRONUTRIENT DEPLETION SYNDROMES,
WEIGHT REGAIN
CORRECTION OF DEFICIENCIES
• ALL PATIENTS OF MALABSORPTIVE PROCEDURES SHOULD TAKE A MULTIVITAMIN THAT CONTAINS
400MCG OF FOLATE 350 MCG OF B12 800 IU OF VITAMIN D

• MENSTRUATING WOMEN AND OTHER AT RISK FOR IRON DEFICIENCY SHOULD TAKE 320MG OF
FERROUS SULPHATE PER DAY.

• ADDITIONALLY THE DIET SHOULD INCLUDE 1500MG OF CALCIUM PER DAY

• IF VOMITING REPEATEDLY THIAMINE 50MG PER DAY