BARIATRIC AND METABOLIC SURGERY

Lt Col Syed Waheduzzaman

FCPS(Surgery), MS(Plastic Surgery)
 OVER WEIGHT AND OBESITY

Obesity is a medical condition in which excess body fat

has accumulated to the extent that it may have a negative
effect on health leading to reduced life expectancy and/or
increased health problems
 OVER WEIGHT AND OBESITY

Weight status BMI(Kg/m2

Normal 18.5-24.9
Overweight 25-29.9
Class 1 obesity 30-34.9
Class 2 obesity 35-39.9
Class 3 obesity >40
 CONDITION ASSOCIATED WITH SEVERE AND
COMPLEX OBESITY
Type 2 diabetes
Hypertension
Dyslipidaemia
Obstructive sleep apnoea(OSA)
Arthritis and functional impairment
Gastro oesophageal reflux disease
Non alcoholic fatty liver disease
Clinical depression
 BARIATRIC SURGERY
•  
Bariatric surgery is the branch of surgery involving
manipulation of the stomach and/or small bowel to aid weight
loss.

Severe and complex obesity

*When BMI is 35 and obesity related disease
*or BMI ≥ 40
 BENEFIT OF BARIATRIC SURGERY
• Leads to weight loss of 25-35% of body weight
• Most of the obesity related disease are improved
• Quality of life improves
• Life expectancy increase
• Lower incidence of both micro vascular and macro
vascular complication at 15 years
• Lower mortality after surgery within 3 years.
 METABOLIC SURGERY
• Metabolic surgery is defined as a set of gastrointestinal
operations used with the intent to treat
diabetes(diabetic surgery) and metabolic
dysfunctions(which include obesity)
• Surgery to treat Type2DM in patients with BMI above
35 should be considered “ metabolic/diabetic surgery”
not “bariatric surgery”
 ELIGIBILITY
• Adults with BMI > 50
• BMI > 40 when other intervention have not been
effective
• BMI >35 with onset of Type2DM in past 10 years
• Offer if BMI 30-34.9 with type2DM
• People of Asian origin with onset of type2 DM at a
lower BMI
 WHO CAN NOT HAVE OBESITY SURGERY
• Severe uncontrolled heart disease
• Uncontrolled psychiatric disorder
• Inability to follow instruction
• Drug abuse , cancer
 BARIATRIC MULTIDISCIPLINARY
TEAM
• Bariatric physician in
Primary(GP) or secondary
care(usually a
diabetologist)
• Dietitian
• Specialist nurse
• Mental health professional
• Bariatric surgeon
• Anaesthetist
• Radiologist
• Exercise therapist
• Other secondary care
specialist eg
respiratory/sleep medicine,
cardiology
 MULTIDISCIPLINARY ASSESSMENT
• Every patient should be assessed and managed by a
coherent and well functioning team of health care
professionals with a varied background and expertise
• Improved outcome are usually achieved in high volume,
specialized unites.
• Data collection and submission to national registries
are recommended to provide quality assurance and
long time outcome data
 COMMON OPERATIONS
• Gastric bypass 45%
• Sleeve gastrectomy 37%
• Gastric banding 10%
• Biliopancreatic diversion/duodonal switch 1.5%
 GASTRIC BANDING

• Gained popularity due to perioperative

safety, lack of nutritional complication,
relative ease and availability
• The pars flaccida technique(through the
window of lesser omentum is now
standard practice
• Works by reducing hunger probably
vagaly mediated.
 ROUX-EN-Y GASTRIC BYPASS
• Creates a short vertical lesser
curvature based gastric pouch
• Roux limb can be retro or anticolic
• Biliary limb is kept short to reduce
vitamin and mineral deficiency
• Mechanism of action is a
combination of restriction and mal
absorption of calories.
 SLEEVE GASTRECTOMY
• Less challenging to perform than
gastric bypass
• Lesser curvature based gastric tube is
constructed over a size 32-36 Fr
bougie
• Linear stapling device is used
• Staple line leak is the complication of
this surgery
 BILIOPANCREATIC DIVERSION
• Produces greater weight loss
than other procedures
• Associated with higher
nutritional complication rate
• Mechanism of action appears
to be mainly mal absorption of
calories
 DUODENAL SWITCH
• It is a variant of BPD
• A sleeve gastrectomy is followed by division
of duodenum just distal to pylorus, ileum is
divided with a linear stapler, followed by a
duodenoileostomy and ileoileostomy with
the objective to create a common channel
of 75-125 cm and alimentary channel of
100-250 cm.
• A high protein diet and regular vitamin and
mineral with life long monitoring and
patient commitment to avoid malnutrition .
 OTHER PROCEDURE
• Banded Roux-en-Y gastric by pass
• One anastomosis gastric bypass
• Single anastomosis duodenoileal bypass with sleeve
gastrectomy
• Sleeve gastrectomy and ileal transposition
 COMPLICATION
• Acute complications
1)Anastomotic leak and staple line dehiscence can be
rapidly fatal and require emergency laparotomy
2)Internal hernias developing after surgery eg gastric
bypass.
 COMPLICATION
Early Late

Gastric band Access port infection Band infection

DVT/PE Tubing leak
Slippage
Erosion into stomach
Band intolarance
Failure to lose weight/weight gain

Gastric bypass Anastomotic leak Internal hernia

Intra abdominal bleeding Chronic abdominal pain
Unspecified obstruction Malnutrition if long limb bypass
DVT/PE Anastomotic ulcer/stricture
Weight regain
Sleeve gastrectomy Anastomotic leak Gastro-oesophageal reflux
Intra abdominal bleeding Weight regain
DVT/PE
FOLLOW-UP
NUTRITIONAL REPLACEMENT
ROLE OF PLASTIC SURGERY IN BARIATRIC
SURGERY
COMMONLY PERFORMED BODY CONTOURING
PROCEDURE AFTER MASSIVE WEIGHT LOSS
• Panniculectomy
• Mastopexy
• Brachioplasty
• Lower body lift
• Thigh lift
• Upper body lift
LOWER BODY LIFT
LOWER BODY LIFT
PANNICULECTOMY
BRACHIOPLASTY
THANK YOU