Obesity, Bariatric and Metabolic Surgery: A Comprehensive Guide

Foreword by Kelvin D. Higa
Foreword by Michel Gagner
Preface
Acknowledgments
Contents
About the Editor
Associate Editor
Section Editors
Contributors
Obesity and Metabolic Syndrome
1 Introduction to Obesity
1.1 Definition of Obesity
1.2 Prevalence of Obesity
1.2.1 Worldwide
1.2.2 Obesity in the United Kingdom (UK)
1.2.3 Socioeconomics of Obesity
1.2.4 Effect of Ethnicity
1.3 Costs of Obesity
1.3.1 Individual Cost of Obesity
1.3.2 Population Cost
1.3.2.1 UK Costs
1.3.2.2 Worldwide Costs
1.4 Measurement of Obesity
1.4.1 BMI
1.4.2 Ideal Body Weight
1.4.3 Percent Excess Weight Loss and Percent Weight Loss
1.4.4 Waist Circumference and Waist-to-Hip Ratio
1.4.5 Waist and Hip Circumference Measurements
1.4.5.1 Waist Circumference
1.4.5.2 Hip Circumference
1.4.5.3 Waist-to-Hip Ratio
1.4.5.4 Skin Fold Thickness
1.4.5.5 Bioimpedance Analysis
1.5 Other Methods Used for Obesity Measurement
1.5.1 Dual Energy X-Ray Absorptiometry (DEXA)
1.5.2 Hydrometry (Dilution Method)
1.5.3 Hydrodensitometry - Underwater Weighing
1.5.4 Air Displacement Plethysmography
1.5.5 Computed Tomography or Magnetic Resonance Image
1.6 Importance of Assessing Abdominal Fat
1.7 Summary
1.8 Key Learning Points
1.9 Cross-References
References
2 Etiopathogenesis of Obesity
2.1 Introduction
2.2 Regulation of Energy Balance
2.2.1 Role of the Central Nervous System
2.3 Regulation of Food Intake
2.3.1 Short-Term Mechanisms
2.3.2 Long-Term Mechanisms
2.4 Regulation of Metabolism
2.5 Etiology of Obesity
2.5.1 Inherited Causes
2.5.2 Environmental Causes
2.5.2.1 Dietary Factors
2.5.2.2 Physical Activity
2.5.2.3 Other Factors
2.5.3 Endocrine Causes
2.5.4 Hypothalamic Obesity
2.5.5 Drugs
2.5.6 Pregnancy and Menopause
2.5.7 Eating Disorders and Psychological Causes
2.6 Key Learning Points
References
3 Gut-Derived Hormones and Energy Homeostasis
3.1 Hormones Secreted by the Enteroendocrine Cells
3.1.1 L-Cell Secretion
3.1.1.1 Peptide YY
3.1.1.2 Glucagon-Like-Peptide-1
3.1.1.3 Oxyntomodulin
3.1.1.4 P/D1-Type Cells and Ghrelin
3.2 Effect of Obesity on PYY, GLP-1 and OXM
3.3 The Effect of Diet Induced Weight Loss and Exercise on PYY, GLP-1 and OXM
3.4 Gut Hormone Cross-Talk and Combination Therapies
3.5 Key Learning Points
References
4 Why Sustained Dietary Weight Loss Is So Difficult
4.1 Introduction
4.1.1 Importance of Human Energy Homeostasis
4.2 The Weight Set-Point Theory
4.2.1 Evidence for a Weight Set-Point in Animals
4.2.2 Evidence for a Weight Set-Point in Humans
4.2.3 How Is the Weight Set-Point Defended?
4.2.4 What Determines an Individual´s Weight Set-Point?
4.2.4.1 Genetics
4.2.4.2 Epigenetics
4.2.4.3 Environment
4.2.4.4 History of Dieting
4.2.5 Why Does the Weight Set-Point Increases with the Western Diet?
4.2.5.1 Leptin Resistance
4.2.6 How Can the Weight Set-Point Be Reduced?
4.3 Summary
4.4 Key Learning Points
References
5 Obesity-Associated Comorbidities: Health Consequences
5.1 Introduction
5.2 Causes or Consequences of Obesity
5.2.1 Physiological Consequences of Excess Adipose Tissue
5.3 Characteristics of Obese Subjects
5.4 Psychological Illness and Obesity
5.4.1 Depression
5.4.2 Psychotic Illness
5.4.3 Psychological Effects of Dieting, Weight Loss, and Weight Gain
5.5 T2DM and Metabolic Syndrome
5.6 Hypertension and Obesity
5.7 Dyslipidemia
5.8 Cardiovascular Diseases
5.9 Obesity and Bladder/Urinary Tract
5.10 Obesity and the Male Reproductive System
5.11 Obesity and Female Reproductive System
5.11.1 Obesity in Pregnancy
5.12 Degenerative Arthritis
5.13 Biliary System
5.14 Esophageal Disorders
5.15 Nonalcoholic Fatty Liver Disease
5.16 Obstructive Sleep Apnea
5.17 Obesity and Cancer
5.18 Obesity and Thromboembolic Disease
5.19 Mortality
5.20 Key Learning Points
References
6 Medical Management of Obesity
6.1 Introduction
6.2 Aims of Treatment
6.3 The Team
6.4 The Principles of Treatment
6.5 Overview of Assessment and Treatment
6.6 Initial Assessment
6.6.1 Genetic Causes
6.6.2 Eating Disorders
6.6.3 Medical Conditions
6.6.4 Psychiatric Disorders
6.6.5 Medication
6.7 Treatment
6.7.1 Assessing Readiness to Change
6.7.2 Barriers to Weight Loss
6.7.3 Treatment of Eating Disorders
6.7.4 Lifestyle Modification
6.7.5 Weight Loss Drugs
6.8 Who and When to Refer for Bariatric Surgery
6.9 Obesity and Coronavirus Disease (COVID-19)
6.10 Summary
6.11 Key Learning Points
References
Introduction to Bariatric Surgery
7 Historical Perspectives of Bariatric Surgery
7.1 Introduction
7.2 Early Approaches: JejunoIleal Bypass
7.3 Gastric Bypass
7.4 Biliopancreatic Diversion
7.5 Duodenal Switch
7.6 Gastric Restrictive Procedures: Gastroplasty and Banding
7.7 Sleeve Gastrectomy
7.8 Gastric Plication
7.9 Mini-Gastric Bypass
7.10 Laparoscopic Surgery
7.11 Endoscopic Approaches
7.11.1 Intragastric Balloons
7.11.2 Endoscopic Sleeve Liner
7.11.3 Endoscopic Gastroplasty
7.11.4 Aspiration Therapy
7.12 Other Approaches
7.13 Summary
7.14 Key Learning Points
References
8 Evidence Base for Bariatric Surgery
8.1 Introduction
8.2 Outcomes of Surgery and Preoperative Expectations
8.2.1 Predictors of Outcomes
8.2.1.1 Types of Procedure
8.2.1.2 Other Predictors of Outcomes
8.2.2 Evidence Base for Bariatric Surgery in Class III Obese Patients with Type 2 Diabetes Mellitus
8.2.2.1 Randomized Controlled Trials
8.2.2.2 Long-Term Effect of Bariatric Surgery on Type 2 Diabetes Mellitus
8.2.3 Recommendations from International/National Consensus Statements on Bariatric Surgery in Patients with Type 2 Diabetes M...
8.2.4 Strategy for Managing Type 2 Diabetes Mellitus in the Severely Obese
8.3 Conclusion
References
9 Patient Selection in Bariatric Surgery
9.1 Introduction
9.2 Patient Selection Criteria
9.3 Contraindications to Surgery
9.3.1 Physiological Factors
9.3.1.1 Extremes of Age
Children and Adolescents
Elderly
9.3.1.2 Body Mass Index
9.3.2 Medical and Surgical Factors
9.3.2.1 Pharmacotherapy
9.3.2.2 Obstructive Sleep Apnea
9.3.2.3 Diabetes, Hypertension, and Cardiovascular Problems
9.3.2.4 Malignancy
9.3.2.5 Hiatus Hernia and Ventral Hernia
Hiatus Hernia
Ventral Hernia
9.3.2.6 Renal Failure
9.3.2.7 Nonalcoholic Fatty Liver Disease (NAFLD) and Nonalcoholic Steatohepatitis (NASH)
9.3.2.8 Organ Transplantation
9.3.2.9 Thromboembolic Risk
9.3.2.10 Previous Abdominal Surgery
9.3.2.11 Inflammatory Bowel Disease (IBD)
9.3.2.12 Immunosuppression
9.3.2.13 Vitamin-D Deficiency
9.3.3 Smoking
9.3.4 Functional Status and Mobility
9.3.5 Psychological Factors
9.3.5.1 Active Psychiatric Disease
9.3.5.2 Psychosocial Issues
9.3.5.3 Eating Disorders
9.3.5.4 Intelligence, Understanding, and Mental Capacity
9.3.5.5 Noncompliance
9.4 Summary
9.5 Key Learning Points
9.6 Cross-References
References
10 Procedure Selection in Bariatric Surgery
10.1 Introduction
10.2 Factors Affecting the Procedure Selection
10.2.1 Patient Factors
10.2.1.1 Reasons for Surgery
10.2.1.2 Comorbidities
10.2.1.3 Choice
10.2.2 Surgical Factors
10.2.3 Local/Regulatory Factors
10.3 Different Bariatric Procedures
10.3.1 Laparoscopic Adjustable Gastric Banding (LAGB)
10.3.2 Laparoscopic Sleeve Gastrectomy (LSG)
10.3.3 Laparoscopic Roux-En-Y Gastric Bypass (LRYGB)
10.3.4 Laparoscopic One-Anastomosis Gastric Bypass (OAGB) or Mini-Gastric Bypass
10.3.5 Laparoscopic Duodenal Switch (DS)
10.3.6 Laparoscopic Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy (SADI-S)
10.3.7 Endoscopic Bariatric Therapies (EBT)
10.4 Balancing Risks and Outcomes
10.5 Summary
References
Perioperative Assessment for Bariatric Surgery
11 Preoperative Medical Evaluation of the Bariatric Surgery Patient
11.1 Introduction
11.2 Initial Medical Assessment
11.2.1 Medical Causes of Obesity and Obesity-Associated Conditions
11.2.2 Preoperative Assessment
11.2.3 The Role of Investigations
11.2.4 The Bariatric Multidisciplinary Team (MDT)
11.2.5 Preoperative Enhanced Recovery After Bariatric Surgery (ERABS)
11.3 Management of Common Medical Conditions in the Patient Before Bariatric Surgery
11.3.1 Management of Cardiovascular Comorbidity
11.3.2 Respiratory Disease
11.3.3 Management of Thromboembolic Risk
11.3.4 Type 2 Diabetes Mellitus
11.3.5 Cholelithiasis
11.3.6 Management of Gastroesophageal Pathology
11.3.7 Medication
11.3.8 Pregnancy
11.3.9 Previous Surgery
11.4 COVID-19 and the Perioperative Management of the Bariatric Patient
11.5 Summary
11.6 Key Learning Points
11.7 Cross-References
References
12 Preoperative Dietary Evaluation Prior to Bariatric Surgery
12.1 Introduction
12.2 Weight and Dieting History
12.2.1 Diet History
12.2.2 Nutritional Assessment
12.2.3 Eating Disorders
12.3 Preparation for Bariatric and Metabolic Surgery
12.3.1 Preoperative Dietetic Counseling
12.3.2 Dietetic Input into the Multidisciplinary Team
12.3.3 Preoperative Diet
12.4 Revisional Surgery
12.4.1 Inadequate Weight Loss or Weight Regain
12.4.2 Malnutrition
12.5 Summary
12.6 Key Learning Points
12.7 Cross-References
References
13 Psychological Assessment of the Bariatric Surgery Patient
13.1 Rationale for Psychological Assessment in Bariatric Surgery
13.1.1 First-Generation Psychological Assessments: Identification of Contraindications
13.1.1.1 Empirical Evidence Regarding Psychological Contraindications
13.1.1.2 Consensus Evidence: Clinician´s View of Psychological Contraindications
13.1.2 Second-Generation Psychological Assessments: Psychological and Behavioral Readiness
13.1.3 Credentials of the Assessor
13.2 The Assessment Process and Content
13.2.1 Methods of Assessment
13.2.1.1 Semi-Structured Interviews
13.2.1.2 Key Areas Included in the Clinical Interview
Reasons for Seeking Surgery
The Patient´s Understanding and Knowledge of Their Role in Making Bariatric Surgery Effective
Expectations of Outcome
Weight and Dieting History
Eating Patterns
Current Eating Disorders
Eating Disorder History
Mental Health
Substance Misuse
Trauma and Abuse
Stability and Stressors
Psychological Impact of Weight, Including Stigma and Body Image
Relationships and Support
13.2.2 Psychological Assessment for Revisional Bariatric Surgery
13.3 Outcome of Assessments
13.4 Summary
13.5 Key Learning Points
13.6 Cross-References
References
14 Anaesthesia Considerations in the Obese Patient for Bariatric Surgery
14.1 Introduction
14.2 Bariatric Anesthesia in the UK
14.3 Preoperative Care
14.3.1 Cardiovascular Disease
14.3.1.1 Arterial Hypertension
14.3.1.2 Ischemic Heart Disease
14.3.1.3 Heart Failure
14.3.1.4 Cardiovascular Assessment
14.3.2 OSA and OHS
14.3.3 Fat Distribution
14.3.4 Airway
14.3.5 Preoperative Optimization
14.3.5.1 Smoking
14.3.5.2 T2DM
14.3.5.3 OSA
14.3.5.4 Coronavirus Disease (COVID-19)
14.3.5.5 Patients´ Expectations
14.3.5.6 Dignity
14.4 Perioperative Care
14.4.1 Induction of Anesthesia
14.4.2 Maintenance of Anesthesia
14.4.3 Analgesia and Antiemesis
14.4.4 Extubation
14.4.5 Recovery
14.5 Postoperative Care
14.5.1 Venous Thromboembolism (VTE) Prophylaxis
14.5.2 T2DM Postoperative Management
14.6 Summary
14.7 Key Learning Points
References
15 Preoperative Risk Scoring Systems in Bariatric Surgery
15.1 Introduction
15.2 Obesity Surgery Mortality Risk Score
15.2.1 Limitations of OSMRS
15.3 Bariatric Mortality Risk Classification System
15.3.1 Limitations of BMR Classification System
15.4 Edmonton Obesity Staging System
15.4.1 Limitations of EOSS
15.5 Metabolic Acuity Score
15.5.1 Limitations of the MAS
15.6 Nomogram for Predicting Surgical Complications in Bariatric Surgery Patients
15.7 American Society of Anesthesiologists Physical Status Classification System
15.7.1 Limitations of the ASA Classification
15.8 Cardiac Risk Assessment for Noncardiac Surgery
15.9 Longitudinal Assessment of Bariatric Surgery (LABS), National Bariatric Surgery Registry (NBSR), and Scandinavian Obesity...
15.10 Evaluation of Comorbidity Scoring Systems in Bariatric Surgery
15.11 Summary
References
16 Multidisciplinary Team in Bariatric Surgery: Structure and Role
16.1 Introduction
16.2 Obesity and the MDT
16.3 Members of the Multidisciplinary Team
16.4 Components for an Effective Bariatric MDT
16.5 Evidence Base for Multidisciplinary Team in Bariatric Surgery
16.6 Guidelines for MDT Use
16.7 Conclusion
16.8 Key Learning Points
References
17 Nursing and Physiotherapy Care of the Bariatric Surgery Patient
17.1 Introduction
17.2 Preparation for Surgery
17.2.1 What Does the Preparation Include?
17.2.2 Preoperative Care of the Patients Undergoing Bariatric Surgery
17.2.3 Intraoperative Care of the Patients Undergoing Bariatric Surgery
17.2.3.1 Teamwork
17.2.3.2 Patient Positioning
17.2.3.3 Prevention of Deep Vein Thrombosis in the Operation Theatre
17.2.3.4 Stapling Devices
17.2.3.5 Recommendations for Nursing Care of the Patient Undergoing Bariatric Surgery during the Coronavirus Disease (Covid-19...
17.3 Postoperative Care of the Patient Undergoing Bariatric Surgery
17.3.1 Pain Management
17.3.2 Respiration
17.3.3 Venous Thromboembolism
17.3.4 Detecting Early Postoperative Complications
17.3.4.1 Wound Infection
17.3.4.2 Nausea and Vomiting
17.3.4.3 Postoperative Hemorrhage
17.3.4.4 Anastomotic Leak
17.3.5 Intensive Care Input
17.3.6 Discharge
17.4 The physiotherapist´s Role in the Management of Patients Undergoing Bariatric Surgery
17.4.1 Triage/First Point of Contact/Preoperative Input
17.4.2 Physiotherapy Input Postoperatively
17.4.3 Physiotherapy Led Pre- and Postoperative Exercise Groups
17.4.4 The Digital Future
17.5 Summary
17.6 Key Learning Points
References
18 Peri-operative Management of the Bariatric Surgical Patient
18.1 Introduction
18.2 Physiological and Pathological Considerations in Patients with Obesity
18.2.1 Respiratory System
18.2.2 Cardiovascular System
18.2.3 Diabetes
18.2.4 Thrombosis
18.2.5 Pharmacological Considerations
18.3 Preoperative Evaluation
18.3.1 Airway Assessment
18.3.2 Respiratory Assessment
18.3.3 Cardiovascular Assessment
18.3.4 Diabetes Assessment and Management
18.3.5 Patient Optimization
18.3.6 Risk Prediction Models
18.3.7 Planning Postoperative Care
18.4 Intraoperative Care
18.4.1 Patient Preparation
18.4.2 Operating Theatre Equipment and Set-Up
18.4.3 Surgical Checklist and Staff Preparation
18.4.4 Anesthetic Induction and Patient Positioning
18.4.5 Intraoperative Phase
18.4.6 Recovery from Aesthesia
18.5 Postoperative Care
18.5.1 Immediate Post-operative Care
18.5.2 Analgesia and Antiemetics
18.5.3 Ward-Based Care
18.5.4 Thromboprophylaxis
18.5.5 Postoperative Diabetes Management
18.5.6 Identification of Complications
18.6 Summary
18.7 Key Learning Points
18.8 Cross-References
References
19 Enhanced Recovery After Bariatric Surgery
19.1 Introduction
19.2 Rationale and Pathophysiology of ERABS Interventions
19.2.1 Preoperative Comorbidities and Fitness
19.2.2 Surgical Stress and the Inflammatory Response to Injury
19.2.3 Insulin Resistance and the Metabolic Response
19.2.4 Fluid Balance and Postoperative Gastrointestinal Dysfunction: Nausea, Vomiting, and Postoperative Ileus
19.2.5 Surgery and Nociception
19.2.6 Postoperative Deconditioning
19.3 Enhanced Recovery After Bariatric Surgery Guidelines and Protocols
19.4 ERABS Recommendations
19.4.1 Preadmission Information, Education, and Counseling
19.4.2 Patient Evaluation and Optimization
19.4.2.1 Glycemic Control
19.4.2.2 Smoking and Alcohol Cessation
19.4.2.3 Preoperative Weight Loss
19.4.2.4 Prehabilitation
19.4.3 Preoperative Patient Preparation
19.4.3.1 Preoperative Diet, Fasting, and Carbohydrate Loading
19.4.3.2 Preanesthetic Medication
19.4.4 Perioperative Fluid Management and PONV Prophylaxis
19.4.5 Standardized Anesthetic Protocol
19.4.6 Perioperative Interventions
19.4.7 Postoperative Opioid-Sparing Multimodal Analgesia
19.4.8 Prevention of Postoperative Ileus, Early Postoperative Nutrition, and Ambulation
19.4.9 Thromboprophylaxis
19.4.10 Standardized Discharge and Follow-Up Criteria
19.5 Evidence Base Supporting ERABS
19.6 Limitations and Challenges of ERABS Protocols
19.7 Summary and Future Research
References
Laparoscopic Roux-en-Y Gastric Bypass (LRYGB): Mechanism of Action, Techniques, Complications, Outcomes, and Controversies
20 Laparoscopic Roux-en-Y Gastric Bypass: Mechanism of Action
20.1 Introduction
20.2 Mechanism of Action
20.2.1 Hypoabsorption
20.2.2 Caloric Restriction
20.2.3 Energy Expenditure
20.2.4 Changes in Eating Behavior
20.2.5 Enterohormones, Incretins, and Intestinal Adaptation
20.2.5.1 Enterohormones
GLP-1
GIP
PYY
Oxyntomodulin
CCK
Ghrelin
20.2.6 Adipose Tissue
20.2.6.1 Leptin
20.2.6.2 Adiponectin
20.2.7 Mechanisms of Diabetes Resolution
20.2.7.1 Foregut Hypothesis
20.2.7.2 Hindgut Hypothesis
20.2.8 Neuroendocrine Mechanism
20.2.8.1 Vagus Nerve
20.2.9 Bile Acids
20.2.10 GI Microflora
20.2.11 β(Beta)-Cell Changes
20.3 Summary
20.4 Key Learning Points
20.5 Cross-References
References
21 Laparoscopic Roux-en-Y Gastric Bypass: The Linear Technique
21.1 Introduction
21.2 Preprocedural Setup
21.3 Procedural Set-up
21.4 Laparoscopic Roux-en-Y Gastric Bypass
21.5 First Variation by Sanjay Agrawal
21.6 Jejuno-Jejunal Anastomosis with Closure of the JJA Mesenteric Window
21.7 Gastric Pouch Formation
21.8 Gastrojejunal Anastomosis and Leak Test
21.9 Second Variation by Yashwant Koak
21.9.1 Advantages and Disadvantages of Both Techniques
21.9.2 Pros and Cons of Linear Stapler Technique
References
22 Laparoscopic Roux-en-Y Gastric Bypass: Circular Stapler Technique with Transoral and Transabdominal Anvil Placement
22.1 Introduction
22.2 Patient Positioning and Port Placement
22.3 Jejuno-Jejunostomy
22.4 Gastric Pouch Creation
22.5 Transoral Technique
22.6 Transabdominal Placement
22.7 Advantages and Disadvantages
22.8 Postoperative Management
22.9 Conclusion
22.10 Key Learning Points
References
23 Laparoscopic Roux-en-Y Gastric Bypass: The Hand-Sewn Technique
23.1 Introduction
23.2 LRYGB-HS: Technical Pearls
23.2.1 Patient Selection
23.2.2 Positioning and Placement of Ports
23.2.3 Laparoscopic Assessment
23.2.4 The Formation of Roux Limb: Technical Tips
23.2.5 The Formation of Gastric Pouch
23.2.6 The Formation of Gastro-Jejunostomy: The Hand-Sewn Technique
23.3 Postoperative Care
23.4 The Outcome of LRYGB-HS Technique
23.5 Complications and Potential Difficulties
23.6 Summary
References
24 Laparoscopic Roux-en-Y Gastric Bypass: The Standardized Technique
24.1 Introduction
24.2 Preoperative Assessment
24.2.1 Nutritional Evaluation
24.2.2 Medical Evaluation
24.2.3 Psychological Evaluation
24.3 Operative Technique
24.3.1 Material List
24.3.2 Patient Positioning and Trocar Placement
24.3.3 Creation of the Gastric Pouch
24.3.4 Creation of the Gastrojejunostomy
24.3.5 Creation of the Jejuno-jejunostomy
24.3.6 Testing of the Gastrojejunostomy
24.3.7 Closure of Petersen´s Space and Mesenteric Gap During Entero-enterostomy
24.3.8 Completion
24.4 Advice for the Initial Cases
24.5 Postoperative Care
24.6 Conclusion
24.7 Key Learning Points
References
25 Laparoscopic Roux-en-Y Gastric Bypass: Complications - Diagnosis and Management
25.1 Introduction
25.2 Early Complications
25.2.1 Gastrointestinal Bleeding
25.2.1.1 Types of Gastrointestinal Bleeding
25.2.1.2 Symptoms and Presentation
25.2.1.3 Management
25.2.1.4 Immediate Steps
25.2.1.5 Prevention
25.2.2 Leak
25.2.2.1 Symptoms and Presentation
25.2.2.2 Diagnosis
Intraoperative Diagnosis
Postoperative Diagnosis
25.2.2.3 Management
25.2.2.4 Prevention
25.2.3 Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)
25.2.3.1 Signs and Presentation
25.2.3.2 Investigations and Management
25.2.3.3 Prevention
25.3 Late Complications
25.3.1 Ulcers and Fistulas
25.3.1.1 Symptoms and Presentation
25.3.1.2 Diagnosis
25.3.1.3 Management
25.3.1.4 Prevention
25.3.2 Gastrointestinal Obstruction
25.3.2.1 Symptoms and Presentation
25.3.2.2 Investigations
25.3.3 Internal Hernia
25.3.3.1 Management
25.3.3.2 Prevention
25.3.4 Port-Site Hernia
25.3.5 Stricture
25.3.6 Acute Gastric Dilatation (of the Gastric Remnant)
25.4 Long-Term Complications
25.4.1 Intussusception
25.4.2 Bezoars
25.5 Skin Complications
25.6 Nutritional, Metabolic, and Neurological Complications
25.6.1 Postprandial Hypoglycemia and Nesidioblastosis
25.6.2 Protein Malnutrition
25.6.3 Vitamins and Trace Elements
25.7 Neurologic and Musculoskeletal Complications
25.8 Cholelithiasis
25.9 Hockey Stick/Blind Limb/Candy Cane Syndrome and Other Causes of Postprandial Pain
25.10 Conclusion
References
26 Laparoscopic Roux-en-Y Gastric Bypass: Weight Loss Outcomes
26.1 Introduction
26.2 Weight Loss Outcomes
26.2.1 Comparison with Other Procedures
26.2.1.1 Comparison with Laparoscopic Adjustable Gastric Banding (LAGB)
26.2.1.2 Comparison with Laparoscopic Sleeve Gastrectomy (LSG)
26.2.1.3 Comparison with One-Anastomosis Gastric Bypass (OAGB)
26.2.1.4 Comparison with DS
26.3 Variables
26.3.1 Technical Variables
26.3.1.1 Pouch Size
26.3.1.2 Stoma Size
26.3.1.3 Anastomotic Technique
26.3.1.4 Limb Length
26.3.1.5 Banded Bypass
26.3.2 Patient Factors
26.4 Insufficient Weight Loss and Weight Regain
26.4.1 Pouch Dilatation
26.4.2 Stoma Resizing
26.4.3 Biliopancreatic Limb Prolongation
26.4.4 Conversion to Other Procedures
26.4.5 Gastro-Gastric Fistula
26.5 Summary
References
27 Laparoscopic Roux-en-Y Gastric Bypass: Comorbidity Outcomes
27.1 Introduction
27.2 Comorbidity Resolution After RYGB
27.2.1 Type 2 Diabetes Mellitus
27.2.2 Hypertension
27.2.3 Dyslipidemia
27.2.4 Obstructive Sleep Apnea
27.2.5 Osteoarthritis
27.2.6 Gastroesophageal Reflux Disease
27.2.7 Nonalcoholic Fatty Liver Disease
27.2.8 Infertility
27.3 Risks Associated with Pregnancy
27.4 Cancer Risk
27.5 Overall Mortality
27.6 Quality of Life
27.7 Cost Effectiveness
27.8 Summary
27.9 Key Learning Points
27.10 Cross-References
References
28 Laparoscopic Roux-en-Y Gastric Bypass: Current Controversies
28.1 Introduction
28.2 Mechanism of Action of the Gastric Bypass
28.3 Role of Open Gastric Bypass
28.4 Preferred Anastomotic Technique for the Gastrojejunostomy
28.5 Pouch Size and Surgical Outcomes
28.6 Optimal Limb Lengths
28.7 Closure of Potential Hernia Spaces: Retrocolic vs. Antecolic Roux
28.8 Gastric Bypass: The Current Scenario
28.9 Key Learning Points
References
29 Laparoscopic Roux-en-Y Gastric Bypass: Current Controversies in Limb Length Measurements
29.1 Introduction
29.2 Defining Limb Lengths
29.3 Roux Limb in RYGB
29.3.1 Roux Limb and Morbid Obesity
29.3.2 Roux Limb and Super Obesity
29.3.3 Why Increasing the Roux Length May Not Increase Weight Loss
29.4 The Common Channel in RYGB
29.5 The Biliopancreatic Limb
29.5.1 BPL and RYGB
29.5.2 BPD-DS
29.5.3 OAGB
29.5.4 Why a Longer BPL Leads to Better Weight Loss
29.6 Tall
29.7 Summary
29.8 Key Learning Points
References
30 Single Incision Laparoscopic Roux-en-Y Gastric Bypass
30.1 Introduction
30.2 Case Selection and Contraindication
30.3 Surgical Technique
30.3.1 Room Setup
30.3.2 Skin Incision and Port Placement
30.3.3 Gastric Pouch
30.3.4 Gastro-Jejunostomy
30.3.5 Jejuno-Jejunostomy
30.3.6 Mesenteric and Peterson Defect Closure
30.3.7 Liver Suspension Removal
30.3.8 Wound Closure
30.3.9 Surgical Results
30.4 Variations in Technique
30.4.1 Incision
30.4.2 Port Placement
30.4.3 Special Devices
30.4.4 Liver Retraction
30.4.5 Pouch Calibration
30.4.6 Pouch Creation
30.4.7 Limb Length
30.4.8 Leak Test and Drain
30.5 Complications
30.6 Technical Tips
30.7 Reoperation after SITU-LRYGB
References
Laparoscopic Sleeve Gastrectomy (LSG): Mechanism of Action, Technique, Complications, Outcomes, and Controversies
31 Laparoscopic Sleeve Gastrectomy: Mechanism of Action
31.1 Introduction
31.2 Debunking the ``Restrictive Theory´´ as the Main Mechanism of Action
31.3 Gastrointestinal (GI) Hormones
31.3.1 Ghrelin
31.3.2 Glucagon-Like Peptide 1 (GLP-1)
31.3.3 Peptide YY (PYY) and Oxyntomodulin
31.3.4 Glucose-Dependent Insulinotropic Polypeptide (GIP)
31.4 Other Hormones
31.4.1 Leptin
31.4.2 Adiponectin
31.5 Gut Microbiota
31.5.1 Bile Acids
31.6 Summary
31.7 Key Learning Points
References
32 Laparoscopic Sleeve Gastrectomy: The Technique
32.1 Introduction
32.2 Indications and Contraindications
32.3 Diagnosis and Management
32.3.1 Workup/Preoperative Evaluation
32.3.2 Preoperative Preparation
32.3.3 Operating Room Setup
32.3.4 Positioning of Patient
32.4 Operative Steps
32.4.1 Creating Pneumoperitoneum
32.4.2 Port Placement
32.4.3 Placement of Liver Retractor
32.4.4 Mobilization of Greater Curvature
32.4.5 Dissection Near Angle of His
32.4.6 Creation of Sleeve
32.4.7 Hemostasis and Reinforcement
32.4.8 Leak Test and Organ Retrieval
32.5 Postoperative Care
32.6 Complications
32.6.1 Hemorrhage
32.6.2 Leak
32.6.3 Stricture
32.6.4 Reflux
32.6.5 Nutritional Deficiency
32.7 Special Considerations
32.7.1 Banded LSG (BLSG)
32.8 Role of Antral Resection
32.9 Hiatal Hernia (HH) Repair
32.10 Staple Line Reinforcement (SLR) in LSG
32.11 Follow-Up
32.12 Summary
32.13 Key Learning Points
References
33 Laparoscopic Sleeve Gastrectomy: Early Complications
33.1 Evolution of Sleeve Gastrectomy (SG)
33.2 LSG Complications
33.3 Standard Perioperative Protocol
33.4 Intraoperative Complications
33.5 Diagnosis and Management of Post- LSG Complications
33.5.1 Diagnosis of Post-LSG Complications
33.5.1.1 Laboratory Parameters
33.5.1.2 Clinical Symptoms and Signs
33.5.1.3 Radiological Studies
33.5.1.4 Diagnostic Laparoscopy (DL)
33.5.2 Management of Post-LSG Complications
33.5.2.1 Early Post-LSG Complications
Leakage
Bleeding
Trocar-Site Hernia
Venous Thromboembolism (VTE) (Deep Venous Thrombosis and Pulmonary Embolism)
Post-LSG Mortality
33.6 Summary
References
34 Laparoscopic Sleeve Gastrectomy: Late (>30-Days) Complications - Diagnosis and Management
34.1 Introduction
34.2 Complications
34.2.1 Gastric Leaks
34.2.1.1 Pathogenesis
34.2.1.2 Classification of Leaks
Acute Leaks
Late and Chronic Leaks
34.2.1.3 Clinical Presentation and Diagnosis
34.2.1.4 Treatment
Endoscopic
Definitive Surgical Procedures
34.2.2 Stenosis
34.2.2.1 Clinical Features
34.2.2.2 Diagnosis
34.2.2.3 Treatment
Endoscopic Balloon Dilation and Stenting Are the Two Modalities Described with Varied Success Rates
34.2.3 GERD and Hiatal Hernia
34.2.3.1 How Does Obesity Cause GERD?
34.2.3.2 LSG and GERD
34.2.3.3 Clinical Presentation and Diagnosis
34.2.3.4 Treatment
34.2.3.5 Prevention
34.2.4 LSG and Barrett´s Esophagus
34.2.4.1 Diagnosis
34.2.4.2 Surveillance
34.2.4.3 Management
Nonsurgical Ablative Therapies
Surgical Therapies
34.2.4.4 Screening
34.2.4.5 Prevention
34.2.5 Port Site Hernia
34.3 Summary
34.4 Key Learning Points
References
35 Laparoscopic Sleeve Gastrectomy: Weight Loss Outcomes
35.1 Introduction
35.2 The Evolution of Laparoscopic Gastric Sleeve
35.3 Weight Loss Outcomes After LSG Performed During the First Decade of Its History (2000-2010)
35.4 Weight Loss Outcomes for the LSG Performed After 2010
35.5 Weight Loss Outcomes After Modified Surgical Techniques of LSG
35.5.1 LSG With or Without Antral Preservation
35.5.2 Banded Sleeve
35.6 Weight Loss Outcomes After LSG in Selected Categories of Patients
35.6.1 Low BMI Patients
35.6.2 High BMI Patients
35.6.3 Other Categories of High-Risk Patients
35.6.4 Severely Obese Adolescents and Children
35.6.5 Elderly Patients
35.6.6 Patients with Psychiatric Comorbidity
35.7 Weight Loss Outcomes After LSG as a Revisional Procedure
35.8 Summary
35.9 Key Learning Points
References
36 Laparoscopic Sleeve Gastrectomy: Comorbidity Outcomes
36.1 Introduction
36.2 Comorbidities in Bariatric/Metabolic Surgery
36.3 Comorbidity Outcomes
36.3.1 T2DM
36.3.2 Arterial Hypertension
36.3.3 Hyperlipidemia
36.3.4 OSA
36.3.5 NAFLD and NASH
36.3.6 Diseases of Bones and Joints
36.4 Risk of Cancers
36.5 Gastroesophageal Reflux
36.6 Long-Term Outcomes of Comorbidities
36.7 Summary
36.8 Key Learning Points
References
37 Laparoscopic Sleeve Gastrectomy: Current Controversies in Gastroesophageal Reflux
37.1 Introduction
37.2 Relationship Between Obesity and GERD
37.3 Preoperative Diagnostic Significance
37.3.1 Role of Preoperative Endoscopy
37.3.2 Difficulty of Diagnosing Hiatal Hernia
37.4 Sleeve Gastrectomy and Hiatal Hernia Repair
37.5 Sleeve Gastrectomy and Esophagitis
37.6 Sleeve Gastrectomy and Barrett´s Esophagus
37.7 Sleeve Gastrectomy and Esophageal Adenocarcinoma
37.8 Sleeve Gastrectomy and Changes in 24-Hour pH-Monitoring Results
37.9 Sleeve Gastrectomy and Changes in Combined pH-Impedance Results
37.10 Changes in Manometry Results
37.11 Prevention of GERD After Sleeve Gastrectomy: The Concept - Nissen Sleeve
37.12 Postgastrectomy Sleeve Follow-Up
37.13 Treatment of GERD After Sleeve
37.13.1 LINX Procedure
37.13.2 Lower Esophageal Sphincter Electrical Stimulation
37.13.3 Endoscopic Radiofrequency (Stretta)
37.14 Summary
References
38 Single-Incision Laparoscopic Sleeve Gastrectomy
38.1 Introduction
38.2 Technique
38.2.1 Material
38.2.2 Patient and Team Positioning
38.2.3 Technique
38.3 Postoperative Management
38.4 Specific SILS Based Complications and Management
38.5 Outcomes
38.6 Conclusions
38.7 Key Learning Points
References
Laparoscopic One Anastomosis Gastric Bypass (OAGB)/Mini Gastric Bypass (MGB): Mechanism of Action, Techniques, Complications, ...
Prelude to One Anastomosis Gastric Bypass Section
39 Laparoscopic OAGB/MGB: Mechanism of Action
39.1 Introduction
39.1.1 OAGB Is a Gastric Bypass
39.1.2 How Important Is Restriction for OAGB?
39.1.2.1 Role of Long Narrow Pouch
39.1.2.2 Banded Gastric Bypass
39.1.3 How Important Is Malabsorption for OAGB?
39.1.4 Hormonal Changes After OAGB
39.1.4.1 Incretin Effect
39.1.5 Gut Microbiota
39.1.6 Data from Animal Models
39.1.7 Future Studies
39.2 Summary
39.3 Key Learning Points
39.4 Cross-References
References
40 Laparoscopic One Anastomosis Gastric Bypass/Mini Gastric Bypass: MGB Technique
40.1 Introduction
40.2 History of Mini-Gastric Bypass
40.3 Technical Details in Performing Mini-Gastric Bypass
40.3.1 Patient Positioning
40.3.2 Ports
40.3.3 Constructing the Gastric Tube
40.3.4 Running the Bowel and Construction of the Gastrojejunostomy
40.4 Critical Factors in Use of the Staple-Gun in Mini-Gastric Bypass
40.4.1 How to Prevent Staple-Line Bleeds
40.4.2 Avoiding a Twist in the Pouch
40.4.3 Postoperative Period and Follow-Up
40.5 Complications and Management
40.5.1 Immediate Postoperative Complications
40.5.2 Leak
40.5.3 Management of Late Complications
40.5.3.1 Marginal Ulcer
40.5.3.2 Malnutrition: Hypoproteinemia
40.5.3.3 Internal Hernia
40.5.3.4 Dumping Syndrome
40.5.3.5 Diarrhea
40.5.3.6 Steatorrhea and Flatulence
40.5.3.7 Bile Reflux
40.5.3.8 Cholelithiasis
40.5.3.9 Weight Regain in Mini-Gastric Bypass
40.6 Reported Results of Mini-Gastric Bypass
40.6.1 Weight Loss
40.6.2 Comorbidity Resolution
40.7 Conclusion
40.8 Key Learning Points
References
41 Laparoscopic One Anastomosis Gastric Bypass (OAGB)/Mini Gastric Bypass (MGB): OAGB Technique
41.1 Introduction
41.2 Preoperative Preparation
41.3 The Standard OAGB Technique: Step-by-Step Description
41.3.1 Patient Positioning
41.3.2 First Things First: Pneumoperitoneum and Trocar Placement
41.3.3 Full SB Measurement and Designation of BPL and CCh Lengths: Degree of Hypo-absorption
41.3.4 SB Limb Lengths: Relevant Considerations
41.3.5 Omentum Transection
41.3.6 Supra-mesocolic Stage: Esophagogastric Junction (EGJ) (His Angle) Dissection
41.3.7 Gastric Reservoir Formation
41.3.8 Initial Part of the ``Anti-reflux Mechanism´´
41.3.9 Gastroenteric Anastomosis Conformation
41.3.10 Patency and Leak Test/Termination of the Operation
41.4 Postoperative Management
41.5 Summary
41.6 Key Learning Points
References
42 Laparoscopic One Anastomosis Gastric Bypass (OAGB) Mini Gastric Bypass (MGB) Early (30 Days) Complications - Diagnosis and ...
42.1 Introduction
42.2 Early Postoperative Complications with OAGB-MGB
42.2.1 Bleeding
42.2.2 Leak
42.2.3 Anastomotic Stenosis
42.2.4 Afferent Loop Syndrome
42.2.5 Remnant Stomach Obstruction
42.2.6 Respiratory Complications
42.2.7 DVT/ Pulmonary Embolism (PE)
42.3 Authors Single Center Experience
42.4 Conclusion
42.5 Key Learning Points
References
43 Laparoscopic One-Anastomosis Gastric Bypass/Mini Gastric Bypass: Managing Late Complications (>30 Days)
43.1 Introduction
43.2 Reflux After OAGB/MGB: Acid or Alkaline Reflux?
43.2.1 Reflux After OAGB: Diagnosis and Medical Treatment
43.2.2 Surgical Treatment
43.2.3 Bile Reflux: Potential Risk of Cancer?
43.3 Malnutrition and Excessive Weight Loss
43.4 Marginal Ulcers
43.4.1 Signs and Symptoms
43.4.2 Diagnosis
43.4.3 Management
43.4.4 Prevention
43.4.5 Petersen´s Hernia After OAGB/MGB
43.5 Insufficient Weight Loss and Weight Regain After OAGB/MGB
43.6 Summary
43.7 Key Learning Points
References
44 Laparoscopic One Anastomosis Gastric Bypass (OAGB)/ Mini Gastric Bypass (MGB): Weight Loss Outcomes
44.1 Introduction
44.2 Weight Loss Outcomes After OAGB as Primary Surgery
44.3 Weight Loss Outcomes After Revisional OAGB/MGB in Case of Failure of the First Procedure
44.3.1 AGB to OAGB/MGB
44.3.2 SG to OAGB/MGB
44.3.3 RYGB to OAGB/MGB
44.3.4 Gastric Pouch Resizing After OAGB/MGB
44.3.5 Other Revisional Procedures Following OAGB/MGB
44.4 Weight Loss Outcomes: Impact of Biliopancreatic Limb
44.5 Weight Loss Outcomes: OAGB Versus RYGB and OAGB Versus Sleeve
44.5.1 OAGB Versus RYGB
44.5.2 OAGB Versus Sleeve
44.6 Summary
44.7 Key Learning Points
References
45 Laparoscopic One Anastomosis Gastric Bypass (OAGB)/Mini Gastric Bypass (MGB): Co-morbidity Outcomes
45.1 Introduction
45.2 Metabolic Syndrome
45.3 Type 2 Diabetes Mellitus (T2DM)
45.3.1 OAGB-MGB and T2DM
45.3.2 OAGB-MGB Compared to LRYGB
45.3.3 OAGB-MGB Compared to LSG
45.4 Hypertension (HT)
45.5 Nonalcoholic Steatohepatitis/Nonalcoholic Fatty Liver Disease (NASH/NAFLD)
45.6 Obstructive Sleep Apnea (OSA)
45.7 Hyperlipidemia
45.8 Osteoarthritis
45.9 Gastro-Esophageal Reflux Disease (GERD)
45.9.1 LSG Versus OAGB-MGB
45.9.2 OAGB-MGB Versus LRYGB
45.9.3 Biliary Reflux and OAGB-MGB
45.10 OAGB-MGB in Patients with BMI 50 kg/m2
45.11 OAGB-MGB in Patients with BMI 35 kg/m2
45.12 Banded OAGB-MGB
45.13 Summary
45.14 Key Learning Points
References
46 Laparoscopic One Anastomosis Gastric Bypass/Mini Gastric Bypass: Bile Reflux and Carcinogenesis Risk
46.1 Introduction
46.2 Bile Reflux After OAGB and Risk of Carcinogenesis
46.3 Bile Reflux After OAGB
46.4 Summary
46.5 Key Learning Points
46.6 Cross-References
References
47 Laparoscopic One Anastomosis Gastric Bypass/Mini Gastric Bypass: Limb Length and Nutritional Issues
47.1 Introduction
47.2 Small Intestine Anatomy and Physiology
47.3 Limb Lengths in Bariatric Surgery: What Have We Learnt?
47.4 Fixed Versus Tailored Limb Length Model in OAGB/MGB
47.5 Effects of Limb Length on Efficacy and Malnutrition in OAGB/MGB: Review of Literature
47.6 Summary
47.7 Key Learning Points
References
Laparoscopic Adjustable Gastric Banding (LAGB): Mechanism of Action, Technique, Complications, Outcomes, and Controversies
48 Laparoscopic Adjustable Gastric Banding - Mechanism of Action
48.1 Introduction
48.2 The Gastric Band as a Restrictive Procedure
48.3 Effects of the Gastric Band on Hormones
48.4 Conclusion
References
49 Laparoscopic Adjustable Gastric Banding: The Technique
49.1 Introduction
49.2 Preoperative Preparation
49.3 Our Surgical Technique
49.3.1 Diaphragmatic Hiatus
49.3.2 Band Placement
49.3.3 Band Fixation
49.3.4 Port Placement
49.4 Special Circumstances
49.4.1 Portal Hypertension
49.4.2 Revision Procedures
49.5 Postoperative Care of Gastric Band Patients
49.5.1 Immediate Postoperative Care of Gastric Band Patients
49.5.2 Postoperative Follow-Up
49.5.3 Long-Term Management of Gastric Band Patients
49.6 Key Learning Points
References
50 Laparoscopic Adjustable Gastric Banding: Complications - Diagnosis and Management
50.1 Introduction
50.2 Classification of Complications
50.3 General Complications
50.3.1 Infection
50.3.2 Bleeding
50.3.3 Perforation of Viscus
50.3.4 Venous Thrombo-Embolism
50.4 Specific Complications
50.4.1 Band Erosion
50.4.2 Tight/Loose Band
50.4.3 Pouch Dilatation
50.4.4 Band Slippage
50.4.4.1 Anterior Slippage
50.4.4.2 Posterior Slippage
50.4.5 Esophageal Dilatation
50.4.6 Maladaptive Eating
50.4.7 Band Intolerance
50.4.8 Port Site Infection
50.4.9 Port Site Pain
50.4.10 Port Rotation
50.4.11 Band/Tubing Leaks, Disconnection, Migration
50.4.12 Weight Loss Failure/Weight Regain
50.4.13 Gastric Band Revision Surgery
50.5 Prevention of Band Complications
50.6 Summary
50.7 Cross-References
References
51 Laparoscopic Adjustable Gastric Banding: Outcomes
51.1 Introduction
51.2 Weight Loss Outcomes
51.2.1 Determinants of Effective Weight Loss Following LAGB
51.2.1.1 Meticulous Surgical Technique
51.2.1.2 Fluoroscopy-Guided Band Adjustments
51.2.1.3 Follow-up
51.3 Metabolic and Other Comorbidity Outcomes
51.3.1 Reemergence of Metabolic Complications
51.4 Patient Satisfaction and Quality of Life
51.5 Morbidity and Mortality
51.6 Future of Gastric Band
51.7 Summary
References
52 Laparoscopic Adjustable Gastric Band: Current Controversies
52.1 Introduction
52.2 The Role of LAGB
52.3 Technical Issues
52.3.1 Band Placement
52.3.2 Band Slippage
52.3.3 Hiatus Hernia
52.4 Preoperative Preparation
52.5 Long-Term Complications of Surgery
52.5.1 Band-Related Complications
52.5.2 Weight Regain
52.5.3 Band Removal and Revision
52.5.4 Port Complications
52.5.5 Pregnancy and LAGB
52.6 Summary
52.7 Key Learning Points
References
Revisional Bariatric Surgery
53 Revisional Surgery After Vertical Banded Gastroplasty
53.1 Introduction
53.2 Preoperative Patient Evaluation
53.3 Preoperative Patient Preparation
53.4 Choice of Procedure
53.4.1 Restoration of the VBG Anatomy
53.4.2 Reversal
53.4.3 Conversion to Another Bariatric Procedure
53.4.3.1 Technical Aspects of Conversion from VBG to RYGB
RYGB for Failed VBG: Results
53.5 Summary
53.6 Key Learning Points
References
54 Revisional Surgery After Laparoscopic Roux-en-Y Gastric Bypass
54.1 Introduction
54.2 Preoperative Evaluation
54.3 Restorative/Corrective Surgery
54.4 Augmentation
54.5 Conversion
54.6 Reversal
54.7 Algorithm for Revision Gastric Bypass: A Personal Approach
54.8 Summary
54.9 Key Learning Points
References
55 Revisional Surgery After Laparoscopic Sleeve Gastrectomy
55.1 Introduction
55.2 Patient Evaluation
55.3 Preoperative Workup
55.4 Reoperation for Weight Issues
55.5 Reoperation for Stenosis
55.6 Reoperation for Persisting Leaks
55.7 Reoperation for Hiatal Hernia with GERD
55.8 Techniques for Reoperation After Sleeve Gastrectomy
55.9 Conclusion
55.10 Key Learning Points
References
56 Revisional Surgery after Laparoscopic Adjustable Gastric Banding
56.1 Introduction
56.2 Preoperative Patient Evaluation
56.3 Techniques
56.3.1 Adjustable Banded Roux-en-Y Gastric Bypass
56.3.2 Laparoscopic Roux-en-Y Gastric Bypass
56.3.3 Laparoscopic Sleeve Gastrectomy
56.3.4 One Anastomosis Gastric Bypass
56.3.5 Laparoscopic Biliopancreatic Diversion with Duodenal Switch
56.4 Other Procedures
56.5 One or Two Steps?
56.6 Summary
56.7 Key Learning Points
References
57 Laparoscopic One Anastomosis Gastric Bypass/Mini Gastric Bypass: Revisional Surgery for Failure in Weight Loss and Metaboli...
57.1 Introduction
57.2 The OAGB Surgery
57.3 Weight Regain and Inadequate Weight Loss After Bariatric Surgery
57.4 Inadequate Weight Loss and Weight Regain After OAGB
57.5 Revisional Procedures Due to Inadequate Weight Loss or Weight Regain After OAGB: Technical Options
57.6 Summary
57.7 Key Learning Points
References
Other Operations for Obesity
58 Laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD-DS) Surgery
58.1 Introduction
58.2 Biliopancreatic Diversion (BPD)
58.3 BPD Versus BPD-DS
58.4 Patient Selection
58.5 Weight Loss
58.6 Remission of Comorbidities
58.7 Quality of Life (QoL)
58.8 BPD-DS as a Revisional Surgery
58.8.1 BPD-DS after SG
58.8.2 BPD-DS after RYGB
58.8.3 The Experts´ View of the Role of BPD-DS as a Revisional Surgery
58.9 Technical Tips and Operative Considerations
58.10 Inpatient Care and Complications
58.10.1 Operative Mortality
58.10.2 Staple Line/Anastomotic Leak
58.11 Outpatient Care and Complications
58.11.1 Vitamin and Micronutrient Deficiency
58.11.2 Protein Calorie Malnutrition
58.11.3 Small Bowel Obstruction
58.11.4 Chronic Diarrhea/Steatorrhea
58.11.5 Effect of BPD-DS on the Composition of Gut Microbiota
58.12 Single-Anastomosis Duodeno-Ileal Switch (SADI-S)
58.13 Summary
58.14 Key Learning Points
58.15 Cross-References
References
59 Laparoscopic Biliopancreatic Diversion (BPD) Surgery
59.1 Introduction
59.2 The Original Scopinaro´s BPD
59.2.1 Physiology
59.2.2 Pouch Size
59.2.3 Bowel Limb Length
59.3 BPD
59.3.1 Technical Steps of Laparoscopic BPD
59.3.2 Indication for Surgery
59.4 Results
59.4.1 Side Effects
59.4.2 Postoperative Complications
59.4.3 Nutritional Complications
59.4.3.1 Vitamins
59.4.3.2 Bone Metabolism
59.4.3.3 Anemia
59.4.3.4 Protein Malnutrition
59.4.4 Weight Loss
59.4.5 Resolution of Comorbidities
59.5 Summary
59.6 Key Learning Points
59.7 Cross-References
References
60 Laparoscopic Banded Bariatric Surgery
60.1 Introduction
60.2 Laparoscopic Banded Bariatric Surgeries
60.2.1 Laparoscopic BGBP
60.2.2 Laparoscopic Banded Sleeve Gastrectomy
60.2.3 Laparoscopic Banded One Anastomosis Gastric Bypass
60.3 Limitation in Reports on LBBS
60.4 Summary
60.5 Key Learning Points
60.6 Cross-References
References
61 Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) Surgery
61.1 Introduction
61.2 Surgical Technique
61.3 Postoperative Management
61.4 Lessons Learnt in SADI-s
61.5 Advantages and Drawbacks
61.5.1 Advantages Over Scopinaro´s Procedure
61.5.2 Advantages Over Duodenal Switch
61.5.3 Advantages Over Gastric Bypass
61.5.4 SADIS_After Failed Sleeve
61.6 Conclusions
61.7 Key Learning Points
61.8 Cross-References
References
62 Ileal Interposition with Sleeve Gastrectomy for Type 2 Diabetes Mellitus and Metabolic Syndrome
62.1 Duodenal Ileal Interposition with Sleeve Gastrectomy for Type-2 Diabetes Mellitus and Metabolic Syndrome
62.2 Introduction
62.3 Duodenal Ileal Interposition with Tailored Sleeve Gastrectomy (DII + SG)
62.3.1 Mechanisms of Action
62.3.2 Selection of Patients
62.3.3 Exclusion Criteria
62.4 Preoperative Evaluation
62.5 Procedure: Duodenal Ileal Interposition (Diverted) with Tailored Sleeve Gastrectomy
62.6 Postoperative Regimen
62.7 Results from Three Centers
62.8 Complications Encountered in These Three Centers
62.8.1 Postoperative Problems
62.8.1.1 During Hospital Stay
62.8.1.2 After Discharge
62.9 Nutritional Stability
62.10 Long-Term Results
62.11 Discussion
62.11.1 Advantages of Duodenal Ileal Interposition
62.11.2 Disadvantages
62.12 Future Trends
62.13 Summary
62.14 Jejunal Ileal Interposition with Sleeve Gastrectomy for Morbid Obesity (JII + SG)
62.14.1 Introduction
62.14.2 Mechanisms of Action
62.14.3 Selection of Patients
62.14.3.1 Inclusion Criteria and Indications
62.14.3.2 Exclusion Criteria
62.14.4 Preoperative Evaluation
62.14.5 Procedure
62.14.5.1 JII (Non-diverted) with SG
62.14.6 Postoperative Regimen
62.14.7 Efficacy of Procedure/Short and Mid-Term Outcomes
62.14.8 Complications
62.14.8.1 Postoperative Problems
62.14.8.2 Long-Term/Delayed Complications
62.14.9 Nutritional Stability
62.14.10 Long-Term Outcomes
62.14.11 Discussion
62.14.11.1 Advantages of Jejunal Ileal Interposition
62.14.11.2 Disadvantages
62.14.12 Summary and Future Trends
62.15 Key Learning Points
References
63 Single Anastomosis Sleeve Ileal (SASI) Bipartition
63.1 Introduction
63.2 Why Bipartition?
63.3 Why SASI Bipartition?
63.3.1 Mechanism of Action of SASI Bipartition and SG-TB
63.3.2 Advantages of SASI Bipartition
63.3.3 Disadvantages of SASI Bipartition
63.3.4 How to Do a Perfect SASI Bipartition?
63.3.5 SASI Bipartition Postoperative Complications
63.3.6 SASI Bipartition: Bariatric Outcomes
63.3.7 SASI Bipartition: Metabolic Outcomes
63.3.7.1 Glycemic Control
63.3.7.2 Hyperlipidemia and Obesity-Related Comorbidities
63.3.7.3 Nutritional Status After SASI Bipartition
63.3.8 SASI Bipartition and Reflux Esophagitis
63.4 Future of SASI Bipartition
63.5 Summary
63.6 Key Learning Points
References
64 Laparoscopic Greater Curvature Plication (LGCP)
64.1 Synonyms
64.2 Introduction
64.3 The LGCP Procedure
64.3.1 Indications
64.3.2 Contraindications
64.3.3 Patient Work-Up
64.3.4 Operating Team Position and Technical Aspects of the Operation
64.3.5 Surgical Technique
64.3.6 Leak Test
64.3.7 Postoperative Course
64.3.8 Complications
64.3.8.1 Intraoperative and Immediate Postoperative Complications
64.3.8.2 Long-Term Complications
Stomach Dilatation
64.3.9 Reversibility and Reoperations
64.3.10 Tips and Tricks
64.3.10.1 Dissection of the Greater Curvature
64.3.10.2 Angle of His Region
64.3.10.3 Suture Line
64.3.11 LGCP
64.3.12 Dietary Recommendations After LGCP
64.4 Summary
64.5 Key Learning Points
References
65 Laparoscopic Gastric Pacing
65.1 Introduction
65.2 Methods of Gastric Stimulation for the Treatment of Obesity
65.2.1 Gastric Pacing with Short Pulse Width and High Frequency Electric Current
65.2.2 Gastric Pacing with Long Pulse Width and Low Frequency Electric Current
65.2.3 Stimulation of Stomach Muscles during the Electrical Refractory Period
65.2.4 Closed-Loop Gastric Electrical Stimulation System
65.2.5 Surgical Technique of the Implantable Gastric Stimulator
65.2.6 Postoperative Management
65.2.7 Safety
65.3 Efficacy
65.4 Conclusions
65.5 Key Learning Points
References
66 Robotic-Assisted Bariatric Surgery
66.1 Background
66.2 Setting up the Operating Room for Robotic Bariatric Surgeries
66.2.1 Operating Room Configuration for Xi Version
66.3 Adjustable Gastric Banding (AGB)
66.3.1 SG
66.3.2 RYGB
66.3.3 BPD/DS
66.4 Revisional Bariatric Surgery
66.5 Summary
66.6 Key Learning Points
References
Endoscopic Approaches in Obesity and Bariatric Surgery
67 Endoscopic Sleeve Gastroplasty for Obesity
67.1 Introduction
67.2 History and Technique of the Endoscopic Sleeve Gastroplasty
67.2.1 Primary Endoscopic Sleeve Gastroplasty
67.2.2 Revisional Endoscopic Sleeve Gastroplasty
67.3 Potential Complications and Contraindications
67.4 Alternative Methods for Endoscopic Sleeve Gastroplasty
67.5 Key Learning Points
References
68 Intragastric Balloon Treatment for Obesity
68.1 Introduction
68.2 Indications and Contraindications to IGBs
68.3 The Management of IGB
68.4 Different Types of IGBs
68.4.1 FDA-Approved IGBs
68.4.1.1 Obalon Balloon System
68.4.1.2 Orbera Balloon
68.4.1.3 ReShape duo Integrated Dual Balloon System
68.4.2 Other Commercially Available IGBs
68.4.2.1 Spatz3 Adjustable Gastric Balloon
68.4.2.2 Elipse Intragastric Balloon
68.4.2.3 Medicone
68.4.2.4 Plenity
68.5 Summary
68.6 Key Learning Points
References
69 Newer Endoluminal Interventions for Obesity
69.1 Introduction
69.2 Clinically Tested Endoluminal Interventions
69.2.1 Primary Obesity Surgery Endolumenal (POSE) Procedure Using the Incisionless Operating Platform (USGI Medical Inc., San ...
69.2.2 Apollo OverStitch (Apollo Endosurgery Inc., Austin, Texas)
69.3 Devices in the Early Phase of Development
69.3.1 Gastric Aspiration Using the AspireAssist (Aspire Bariatrics Inc., King of Prussia, Pennsylvania)
69.3.2 TransPyloric Shuttle (TPS) (BAROnova Inc., Goleta, California)
69.3.3 Elipse Balloon
69.3.4 Duodenal Mucosal Resurfacing
69.3.5 Incisionless Magnetic Anastomosis System
69.4 Summary
69.5 Key Learning Points
References
70 Endoscopic Treatment of Complications After Bariatric Surgery
70.1 Introduction
70.2 Laparoscopic Adjustable Gastric Band (LAGB) Complications
70.2.1 LAGB Erosion and Slippage
70.3 Laparoscopic Roux-En-Y Gastric Bypass Complications
70.3.1 Food Impaction
70.3.2 Marginal Ulcers
70.3.3 Anastomotic Stricture
70.3.4 Choledocholithiasis
70.4 Banded Laparoscopic Roux-En-Y Gastric Bypass Complications
70.4.1 Ring Erosion
70.4.2 Ring Slippage/Intolerance/Stenosis
70.5 Gastric Fistula After RYGB and Sleeve Gastrectomy
70.6 Twisted Gastric Tube After SG
70.7 Secondary Treatment for Obesity
70.8 Summary
70.9 Key Learning Points
70.10 Cross-References
References
Metabolic Surgery
71 Concept of Metabolic Surgery
71.1 Introduction
71.2 Recognizing the Metabolic Benefits of Surgery
71.3 Evidence for Bariatric Surgery
71.4 Increasing Need for Metabolic Surgery
71.5 Advancing the Concept of ``Metabolic Surgery´´
71.6 Summary
71.7 Key Learning Points
71.8 Cross-References
References
72 Mechanisms of Action of Different Bariatric Surgical Procedures
72.1 Introduction
72.2 Mechanisms of Weight Loss
72.2.1 Malabsorption and Reduction of Stomach Size
72.2.2 Changes in Hunger and Satiety
72.2.3 Changes in Energy Expenditure
72.2.4 Changes in Food Preferences
72.3 Mechanisms of Improved Glucose Homeostasis After Bariatric Surgery
72.3.1 The ``Hindgut and Foregut´´ Theories
72.3.2 Bile Acids
72.3.3 Gut Microbiota
72.4 Conclusion
72.5 Key Learning Points
References
73 Glycemic Control and Reduction of Cardiorenal Risk Following Bariatric Surgery
73.1 Introduction
73.2 Weight Loss Following Bariatric Surgery
73.3 Glycemic Control Following Bariatric Surgery
73.4 Other Cardiorenal Risk Factors Following Bariatric Surgery
73.4.1 Changes in Lipid Metabolism
73.4.2 Changes in Blood Pressure
73.4.3 Changes in Inflammation
73.4.4 Changes in Chronic Kidney Disease
73.4.5 Other Factors
73.5 Summary
73.6 Key Learning Points
73.7 Cross-References
References
74 Resolution of Comorbidities Following Bariatric Surgery: Diabetes, Hypertension, Sleep Apnea, and Metabolic Syndrome
74.1 Introduction
74.2 T2DM
74.3 Hypertension
74.4 Sleep Apnea
74.5 Metabolic Syndrome
74.6 Mechanisms for Metabolic Improvements
74.7 Future Directions
74.8 Summary
74.9 Key Learning Points
References
75 Effect of Metabolic Surgery on Non-Alcoholic Steatohepatitis
75.1 Introduction
75.2 NAFLD Spectrum
75.3 Diagnosis
75.4 Impact of Bariatric Surgery on NAFLD
75.5 Nonalcoholic Steatohepatitis (NASH)
75.6 The Role of Bariatric Surgery in the Setting of Liver Transplantation for Complicated NAFLD
75.7 Summary
75.8 Key Learning Points
References
76 Multimodal Care for Diabetes Combining Pharmacotherapy and Metabolic Surgery
76.1 Introduction
76.2 Metabolic Surgery and Hard Outcomes
76.3 Relapse of Type 2 Diabetes after Metabolic Surgery
76.4 Mechanisms of Type 2 Diabetes Relapse after Metabolic Surgery
76.5 Clinical Implications of Maintaining Glycemic Control after Metabolic Surgery
76.6 Multimodal Approach
76.6.1 Adjunctive Pharmacotherapy Following Metabolic Surgery to Improve Diabetes Care
76.6.1.1 Adjunctive Antidiabetes Pharmacotherapy
Liraglutide
Dipeptidyl-Peptidase-4 Inhibitor
Semaglutide
SGLT-2 Inhibitors
Empagliflozin
76.6.1.2 Adjunctive Anti-Obesity Pharmacotherapy
Liraglutide
Semaglutide
Nonresponders to GLP-1 Agonists
Canagliflozin
Practical Considerations
76.7 Summary
76.8 Key Learning Points
References
77 Metabolic Surgery for Type 2 Diabetes Mellitus in Patients with BMI <35 kg/m2
77.1 Why Should We Address Low Body Mass Index Patients with Type 2 Diabetes?
77.2 Results of Metabolic Surgery over Glycemic Control in Patients with Type 2 Diabetes and BMI Below 35 kg/m2
77.2.1 Laparoscopic Adjustable Gastric Banding (LAGB)
77.2.2 Sleeve Gastrectomy (SG)
77.2.3 Roux-en-Y Gastric Bypass (RYGB)
77.2.4 Biliopancreatic Diversion (BPD)
77.3 Non-Glucocentric Endpoints
77.3.1 Renal Outcomes
77.3.2 Outcomes on Hypertension
77.3.3 Cardiovascular Events and Mortality
77.4 A Quick Note on Investigational Procedures
77.4.1 Ileal Transposition
77.4.2 Duodenal Jejunal Bypass
77.5 Summary
77.6 Key Learning Points
References
78 Mortality Following Metabolic and Bariatric Surgery
78.1 Introduction
78.2 Mortality in MBS
78.2.1 Early Mortality (0-90 Days)
78.2.2 One-Year Mortality
78.2.2.1 Randomized Versus Observational Studies
78.2.2.2 Procedure Choice
78.2.2.3 The Elderly
78.2.2.4 Extreme Obesity
78.2.2.5 Causes of 30-Day Mortality
78.3 Obesity as a Risk Factor
78.3.1 Cardiovascular Risk
78.3.2 Association with Cancers
78.4 Survival
78.5 Effect of Metabolic Surgery on T2DM Prevention
78.6 Effect of Metabolic Surgery on the Metabolic Syndrome
78.7 Additional Discussion Points
78.8 Summary
78.9 Key Learning Points
78.10 Cross-References
References
Training, Reporting, and Practice in Bariatric and Metabolic Surgery
79 Training in Bariatric Surgery
79.1 Introduction
79.2 Bariatric Surgery as Part of General Surgery
79.3 Training in Bariatric Surgery
79.3.1 Portfolio Development for Trainee Bariatric Surgeons
79.3.2 Training Framework and Learning Curves
79.3.3 Career Pathway for a Bariatric Surgeon
79.3.4 Fellowships in Bariatric Surgery
79.3.5 Training in Bariatric Endoscopy
79.4 Ways of Learning
79.4.1 Apprenticeship Model
79.4.2 Simulation
79.4.2.1 Dry Labs
Box Trainers
Virtual Reality
79.4.2.2 Wet Labs
Human Cadaveric Models
Animal Models
79.4.3 Assessment of Learning
79.4.3.1 Workplace-Based Assessments
79.4.3.2 Video-Based Assessment
79.5 Continued Professional Development
79.6 Summary
79.7 Key Learning Points
References
80 Digital Bariatric Surgery
80.1 Introduction
80.2 Healthcare Professionals
80.2.1 Training
80.2.1.1 Digitalization of Training
80.2.1.2 Global Training: Remote Mentoring
80.2.2 Formative Assessment
80.2.3 Operative Support
80.2.4 Integrated Operating Room Systems: Digital Surgery
80.2.5 Intelligent Operating Room: The Future Is Here
80.3 The Patient Pathway
80.3.1 Patient Referral and Initial Consultation
80.3.2 Electronic Health Records (EHR)
80.3.3 Mobile Applications
80.3.4 Informed Consent
80.3.5 The United Kingdom National Bariatric Surgery Register (NBSR)
80.3.6 Mixed Reality
80.3.7 Data Clinical Governance
80.4 Summary
80.5 Key Learning Points
References
81 Conceptualization to Publication in Bariatric and Metabolic Surgery
81.1 Introduction
81.2 Research Question
81.2.1 The Importance of Subject-Matter Knowledge
81.2.2 Finding a Gap in Knowledge
81.2.3 What Is the Nature of My Question?
81.2.4 Case Study: Laparoscopic Sleeve Gastrectomy vs. Roux-en-Y Gastric Bypass
81.2.5 Securing Funding
81.2.6 Navigating Through an Institutional Review Board
81.3 Data Sources
81.3.1 Using Existing Data
81.3.1.1 Published Literature
81.3.1.2 Public Data Sets
81.3.1.3 Electronic Medical Records
81.3.2 Creating Data
81.3.2.1 Cross-sectional Studies
81.3.2.2 Cohort Studies
81.3.2.3 Randomized Studies
81.3.2.4 Grant Drafting and Submission
81.4 Data Analysis
81.4.1 Descriptive Analysis
81.4.2 Predictive Analysis
81.4.3 Causal Inference Analysis
81.4.4 Meta-analysis
81.5 Components of a Manuscript
81.5.1 The Abstract
81.5.2 The Introduction
81.5.3 Materials and Methods
81.5.4 Results
81.5.5 Discussion
81.5.6 References
81.5.7 Miscellaneous Issues
81.6 Submitting a Manuscript for Consideration of Publication
81.6.1 The Title Page
81.6.2 The Manuscript
81.6.3 Selecting the Correct Journal
81.6.4 Ethics in Publishing
81.6.5 What to Expect After Submission
81.7 Navigating the Peer-Review Process
81.7.1 Why Do Manuscripts Get Rejected?
81.7.2 Manuscript Rejection
81.7.3 Psychologically Dealing with Rejection
81.7.4 Reviewer Selection
81.7.5 Rejection and Resubmission
81.7.6 Author Correspondence
81.7.7 Future Directions
81.8 Conclusions
81.9 Summary
81.10 Key Learning Points
References
82 Bariatric Data Management Reporting Worldwide
82.1 Introduction
82.2 Aims of a Clinical Data Registry
82.3 Registries for High-Quality Evidence: Observational Data Versus RCTs
82.4 Advantages of Using Registries
82.4.1 The Hawthorne Effect
82.5 Disadvantages of Registries
82.6 Current National Bariatric Surgery Registries
82.6.1 Metabolic and Bariatric Surgical Accreditation and Quality Improvement Project (MBSAQIP) Data Registry
82.6.2 Michigan Bariatric Surgery Collaborative
82.6.3 Scandinavian Obesity Surgery Registry (SOReg)
82.6.4 Italian Society of Obesity Surgery (SICOB) National Registry
82.6.5 National Bariatric Surgery Registry (NBSR-UK)
82.6.6 Australian Bariatric Surgery Registry
82.6.7 German Bariatric Surgery Registry (GBSR)
82.6.8 Dutch Society for Metabolic and Bariatric Surgery (DSMBS)
82.6.9 Israeli Bariatric Surgery Registry (IBSR)
82.7 International Registries: The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Global R...
82.8 Setting up a Clinical Registry and Sensitivities of Data Ownership
82.9 Designing the Registry
82.10 Minimum Datasets and Definition of a Bariatric ``Success´´
82.11 Data Preprocessing
82.12 Self-Reporting Versus Independent Reporting
82.13 Using the Registry: Strengths and Limitations
82.14 Device Monitoring and Relevance to Bariatric Surgery
82.15 Conclusion
82.16 Learning Points
References
83 Surgical Review Corporation (SRC) Center of Excellence Programs for Bariatric Surgery
83.1 Introduction
83.2 Program Methodology and Guiding Principles
83.2.1 Accreditation Requirements
83.3 Center of Excellence in Metabolic and Bariatric Surgery Accreditation Requirements
83.3.1 Master Surgeon in Metabolic and Bariatric Surgery Accreditation Requirements
83.3.2 Accreditation Process
83.4 Inspections
83.5 Outcomes Data
83.5.1 Data Collection and Entry
83.5.2 Compliance and Quality Improvement
83.5.3 The BOLD Study
83.5.4 The Future of BOLD
83.6 Benefits of an SRC Accreditation
83.6.1 CARE
83.7 The Evolution of Excellence: Global and Multispecialty Accreditation Programs Expansion
83.7.1 Expansion of Bariatric Accreditation Programs
83.7.2 Multispecialty Accreditation Programs Expansion
83.7.3 Network of Excellence Program
83.7.4 Global Expansion
83.7.5 Accreditation Program Endorsements
83.8 Summary
83.9 Key Learning Points
References
84 International Federation for Surgery of Obesity (IFSO) Center of Excellence Program for Bariatric Surgery
84.1 Introduction
84.2 History of the COE Program in the Region of IFSO-EC
84.3 Mission
84.4 Process of Application to COE Program
84.4.1 Surgeon´s Qualifications, Training, and Experience
84.4.2 Institutional Requirements
84.5 Procedure for the Final Accreditation as Center of Excellence
84.6 Current IFSO COE Participation
84.7 Current Database: IBAR Statistics
84.8 Conclusions
84.9 Key Learning Points
References
85 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)
85.1 Introduction
85.2 Levels of Designation
85.3 Onsite Visits
85.4 Discussion
85.5 Key Learning Points
References
86 Medicolegal Issues in Bariatric Surgery
86.1 Introduction
86.2 Bariatric Surgery and Litigation
86.2.1 Increasing Volume of Cases
86.2.2 Demographics of Bariatric Surgical Population
86.2.3 Access to Bariatric Surgery
86.2.4 Nature of Complications Following Bariatric Surgery
86.2.5 Evolution of Bariatric Surgical Procedures
86.3 Principles of Medical Law
86.3.1 Law Versus Ethics
86.3.2 Criminal Law
86.3.3 Civil Law
86.4 Medicolegal Literature in Bariatric Surgery
86.5 Avoiding Medicolegal Pitfalls
86.5.1 Appropriate Consenting
86.5.2 Change in Operating Surgeon
86.5.3 Consent in Children
86.5.4 Follow-Up
86.5.5 Emergency Presentation
86.6 Medicolegal Cases
86.6.1 Case Number 1
86.6.1.1 Medicolegal Analysis
Expert Review
86.6.1.2 Learning Points
86.6.2 Case Number 2
86.6.2.1 Medicolegal Analysis
Expert Review
86.6.2.2 Learning Points
86.6.3 Case Number 3
86.6.3.1 Medicolegal Analysis
Expert Review
86.6.3.2 Learning Points
86.6.4 Case Number 4
86.6.4.1 Medicolegal Analysis
Expert Review
86.6.4.2 Learning Points
86.7 Summary
86.8 Key Learning Points
References
Miscellaneous Topics
87 Nutritional Management After Bariatric Surgery
87.1 Introduction
87.2 Overview of Nutritional Management
87.3 Short-Term Nutritional Management
87.3.1 Staged Diet Progression
87.4 Long-Term Nutritional Management
87.4.1 Eating Behaviors After Surgery
87.4.2 Gastrointestinal Symptoms After Surgery
87.4.3 Disordered Eating
87.4.4 Weight Loss and Weight Regain
87.4.5 Alcohol
87.4.6 Exercise
87.4.7 Telogen Effluvium (Hair Loss)
87.5 Nutritional Considerations
87.5.1 Monitoring
87.5.2 Supplementation
87.5.3 Significant Nutrients to Be Monitored
87.5.3.1 Protein
87.5.3.2 Iron
87.5.3.3 Vitamin B12
87.5.3.4 Folate
87.5.3.5 Thiamine
87.5.3.6 Calcium and Vitamin D
87.5.3.7 Fat-Soluble Vitamins: A, E, and K
87.5.3.8 Zinc, Copper, and Selenium
87.5.4 Nutrition in Pregnancy
87.6 Lifelong Follow-Up
87.7 Summary
87.8 Key Learning Points
References
88 Management of Extreme Obesity (BMI > 60 kg/m2)
88.1 Introduction
88.2 Nomenclature
88.3 Prevalence
88.4 Assessment of the Extremely Obese Patient
88.5 Assessment of the Treatment Environment
88.6 The Specialist MDT
88.6.1 Bariatric Physician
88.6.2 Dietitian
88.6.3 Psychologist
88.6.4 Anesthetist
88.6.5 Surgeon
88.7 Surgical Options
88.7.1 Preoperative Weight Loss
88.7.2 Choice of Procedure
88.7.2.1 Staged Procedures
88.7.3 Review of Publications on Extreme Obesity Bariatric Surgery
88.7.3.1 Duodenal Switch
88.7.3.2 Laparoscopic Adjustable Gastric Band (LAGB)
88.7.3.3 Sleeve Gastrectomy
88.7.3.4 Laparoscopic Roux Y Gastric Bypass
88.7.3.5 Mini-Gastric Bypass
88.7.4 Technical Aspects
88.8 Specific Post-Discharge Issues for the Extreme Obese Patient
88.8.1 Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Prophylaxis
88.8.2 Mobilization/Occupational Therapy
88.8.3 Psychological Care
88.8.4 Enforcing Dietary Change
88.8.5 Redundant Skin/Personal Hygiene
88.9 Summary
88.10 Key Learning Points
88.11 Cross-References
References
89 Suboptimal Weight Loss After Bariatric Surgery: Mechanisms and Treatment Algorithms
89.1 Introduction
89.2 Definition of Weight Regain
89.3 Mechanisms of Weight Regain
89.3.1 Genetics
89.3.2 Gut Hormones
89.3.3 Physical Activity
89.3.4 Dietary Nonadherence
89.3.5 Maladaptive Eating Behaviors
89.3.6 Anatomical or Surgical Factors
89.3.7 Preoperative Risk Factors
89.4 Management Options
89.4.1 Prevention and Early Identification
89.4.2 Behavioral Therapy
89.4.3 Dietary
89.4.4 Pharmacotherapy
89.4.5 Surgical Intervention
89.4.6 Endoscopic Treatment
89.5 An Algorithm for Management of Weight Regain Following Bariatric Surgery
89.6 Summary
89.7 Key Learning Points
References
90 Respiratory Considerations and Effect of Bariatric Surgery in the Obese Patient
90.1 Introduction
90.2 Impact of Obesity on Respiratory Function
90.2.1 Altered Respiratory Mechanics
90.2.2 Respiratory Muscle Dysfunction
90.2.3 Increased Work and Energy Cost of Breathing
90.2.4 Spirometry and Lung Volumes
90.2.5 Gas Exchange
90.2.6 Ventilation and Perfusion
90.2.7 Ventilatory Responses
90.2.8 Inflammatory Responses
90.3 Respiratory Diseases Associated with Obesity
90.3.1 OSA
90.3.2 OHS
90.3.3 Asthma
90.3.4 Pulmonary Embolism
90.3.5 Pulmonary Hypertension
90.4 Preoperative Respiratory Considerations
90.4.1 Assessment
90.4.2 Treatment
90.5 Impact of Bariatric Surgery on Respiratory Comorbidities
90.6 Summary
90.7 Key Learning Points
References
91 Fertility, Pregnancy, and Bariatric Surgery
91.1 Introduction
91.2 Fertility
91.3 Contraception
91.4 Surgery-to-Conception Interval
91.5 Nutrition and Micronutrient Management Preconception and During Pregnancy
91.5.1 Preconception Phase
91.5.2 Pregnancy
91.5.3 Biochemical Monitoring During Pregnancy
91.6 Screening for (Gestational) Diabetes
91.7 Congenital Anomalies and Fetal Growth
91.8 Gestational Weight Gain
91.9 Surgical Complications
91.10 Is Sleeve Gastrectomy to Be Preferred in Women of Reproductive Age?
91.11 Perinatal Mental Health
91.12 Breastfeeding
91.13 Postpartum Weight Loss and Weight Retention and Regain
91.14 Long-Term Outcome in the Offspring
91.15 Summary of Clinical Care Management
91.16 Key Learning Points
References
92 Cancer, Obesity and Bariatric Surgery
92.1 Introduction
92.2 Mechanisms of Carcinogenesis in Obesity
92.2.1 Chronic Inflammation
92.2.1.1 Adipokines
Adiponectin
Leptin
92.2.1.2 Pro-Inflammatory Proteins
TNF-a and IL-6
C-Reactive Protein (CRP)
Vascular Endothelial Growth Factor (VEGF)
92.2.2 Insulin Resistance
92.2.2.1 Obesity Causes Insulin Resistance
92.2.2.2 Insulin Resistance Causes Cancer
92.2.3 Sex Steroids
92.2.4 Gut Microbiome
92.3 Clinical Association Between Obesity and Cancer
92.3.1 Breast
92.3.2 Endometrial
92.3.3 Ovarian
92.3.4 Esophagus: Adenocarcinoma
92.3.5 Gastric Cardia
92.3.6 Colorectal
92.3.7 Liver
92.3.8 Pancreatobiliary
92.3.9 Renal Cell
92.3.10 Meningioma
92.3.11 Thyroid
92.3.12 Multiple Myeloma
92.3.13 Prostate
92.3.14 Lung
92.4 Non-Surgical Weight Loss and Cancer
92.4.1 Hormone-Related Cancers
92.4.1.1 Breast Cancer
92.4.1.2 Endometrial Cancer
92.4.1.3 Ovarian Cancer
92.4.2 Gastrointestinal Cancers
92.4.2.1 Gastroesophageal Cancers
92.4.2.2 Colorectal Cancer
92.4.3 Hepatopancreatobiliary Cancers
92.4.4 Kidney Cancer
92.5 Bariatric Surgery and Cancer
92.5.1 Hormone-Related Cancers
92.5.1.1 Breast Cancer
92.5.1.2 Endometrial Cancer
92.5.1.3 Ovarian Cancer
92.5.2 Gastrointestinal Cancers
92.5.2.1 Gastroesophageal Cancer
92.5.2.2 Colorectal Cancer
92.5.3 Hepatopancreatobiliary Cancers
92.5.3.1 Liver Cancer
92.5.3.2 Gallbladder Cancer
92.5.3.3 Pancreatic Cancer
92.5.4 Kidney Cancer
92.6 Summary
92.7 Key Learning Points
References
93 Psychological Issues Before and After Bariatric Surgery
93.1 Introduction
93.1.1 Presurgical Issues
93.1.1.1 Influences on Eating Habits and Weight
93.1.1.2 The Impact of Dieting
93.1.1.3 The Impact of Health Conditions
93.1.1.4 The Impact of Ambivalence
93.1.1.5 The Physiological Impact of Repeated Dieting
93.1.2 Eating Disorders
93.1.3 Mental Health
93.1.4 Trauma
93.1.5 Working with Issues Before Surgery
93.2 Issues Following Weight Loss Surgery
93.2.1 Eating Behaviors
93.2.2 Emotional Eating
93.2.3 Weight Management: Loss and Regain
93.2.4 Managing Disclosure
93.2.5 Psychosocial Functioning
93.2.6 Impact on Relationships
93.2.7 Eating Disorders
93.2.7.1 Binge Eating
93.2.7.2 Postoperative Eating Avoidance
93.2.8 Perception of Self
93.2.9 Body Image and Excess Skin
93.2.10 Substance Misuse
93.2.10.1 Working with Issues after Surgery
93.3 Summary
93.4 Key Learning Points
References
94 Health-Related Quality of Life Before and After Bariatric Surgery
94.1 Introduction
94.2 What Is HRQoL?
94.3 How Can HRQoL Be Measured?
94.3.1 Unidimensional Measures of Health Status
94.3.1.1 Level of Functioning
94.3.1.2 Mood
94.3.1.3 Pain
94.3.1.4 Self-Esteem
94.3.1.5 Life Satisfaction
94.3.1.6 Eating Behavior
94.3.2 Multidimensional Measures of Health Status
94.3.2.1 Single-Item Scales
94.3.2.2 Composite Scales
94.4 Measuring HRQoL in the Context of Bariatric Surgery
94.5 The Impact of Bariatric Surgery on Quality of Life
94.5.1 The Impact of Health-Related Quality of Life
94.5.2 Broader Psychosocial Outcomes
94.5.3 Summary
94.6 Some Recommendations for Practice and Research
94.7 Conclusion
94.8 Key Learning Points
94.9 Cross-References
References
95 Social Aspects of Bariatric Surgery
95.1 Before Bariatric Surgery
95.1.1 Introduction: The Social Construction of Obesity
95.1.2 Consequences of the Stigma Attached to Obesity
95.1.2.1 Stigma of Obesity in Education
95.1.2.2 Stigma of Obesity in Employment
95.1.2.3 Stigma of Obesity in Personal Relationships
95.1.2.4 Stigma of Obesity in Healthcare Settings
95.2 After Bariatric Surgery
95.2.1 From Stigma to Judgment: The Social Risks of Bariatric Surgery
95.2.2 Qualitative Research as a Means of Understanding Patient Experiences
95.3 Recommendations for Practice
95.4 Summary
95.5 Key Learning Points
95.6 Cross-References
References
96 Bariatric Surgery Journey: A Patient´s Perspective
96.1 Introduction
96.2 Living with Obesity
96.3 Misconception About Obesity as a Life Style Problem Only
96.4 Preoperative Issues
96.4.1 Guilt
96.4.2 Shame/Embarrassment
96.4.3 Overconfidence Regarding Outcome
96.4.4 What Do They Expect from Surgery?
96.4.5 Reluctance to Acknowledge Psychological Issues
96.4.6 Anger
96.5 Surgery
96.5.1 Often-Kept Secret
96.5.2 Struggling to Follow Clinical Advice
96.6 Postsurgery Period
96.6.1 Unrealistically High Expectations of Weight Loss
96.6.2 Gastric Band Adjustments
96.7 Main Patient Complaints About Health Providers
96.7.1 Poor Communication
96.7.2 Attitudes
96.8 A Bariatric Health Care Provider as a Patient
96.8.1 Recommendations for Clinicians Based on Feedback Received from Patients
96.9 Honesty Is Vital, and Patients Must Be Well Informed
96.9.1 Diet
96.9.2 Vitamins and Blood Tests
96.9.3 Weight Loss
96.9.4 Excess Skin
96.9.5 Support Groups
96.9.6 Weight Regains
96.9.7 Gastric Bands
96.9.8 The Future
96.10 Summary
96.11 Key Learning Points
References
Special Topics
97 Management of Bariatric Emergencies by the General Surgeon
97.1 Introduction
97.2 Laparoscopic Gastric Band Emergencies
97.2.1 Gastric Pouch and Esophageal Dilatation
97.2.1.1 Presentation
97.2.1.2 Diagnosis
97.2.1.3 Management
97.2.2 Band erosion
97.2.2.1 Presentation
97.2.2.2 Diagnosis
97.2.2.3 Management
97.2.3 Band Slippage
97.2.3.1 Presentation
97.2.3.2 Diagnosis
97.2.3.3 Management
97.2.4 Infected Band
97.2.4.1 Presentation and Diagnosis
97.2.4.2 Management
97.2.5 Other Early Complications
97.2.5.1 Gastric/Esophageal Perforation
97.2.5.2 Tight Band
97.3 Laparoscopic Gastric Bypass Emergencies
97.3.1 Intraluminal Bleeding
97.3.1.1 Etiology
97.3.1.2 Presentation
97.3.1.3 Management
97.3.2 Extraluminal Bleeding
97.3.2.1 Etiology
97.3.2.2 Presentation
97.3.2.3 Management
97.3.3 Leaks
97.3.3.1 Presentation
97.3.3.2 Management
97.3.4 Abdominal Pain or Colic for More Than 4 Hours
97.3.5 Internal Hernias
97.3.5.1 Presentation and Diagnosis
97.3.5.2 Management
97.3.6 Acute Gastric Dilatation
97.3.7 Nausea and Vomiting for More Than 4 Hours
97.3.7.1 Presentation
97.3.7.2 Management
97.3.8 Marginal Ulceration
97.3.9 Retrograde Intussusception
97.3.10 Laparoscopic One-Anastomosis/Mini-gastric Bypass (OAGB/MGB)
97.4 Laparoscopic Sleeve Gastrectomy Emergencies
97.4.1 Intraluminal Bleeding
97.4.1.1 Etiology
97.4.1.2 Presentation
97.4.1.3 Management
97.4.2 Leak
97.4.2.1 Etiology
97.4.2.2 Presentation and Diagnosis
97.4.2.3 Management
97.4.3 Nausea and Vomiting for More Than 4 Hours
97.4.3.1 Etiology and Presentation
97.4.3.2 Management
97.5 Intragastric Balloon Emergencies
97.5.1 Nausea and Vomiting for More Than 4 Hours
97.5.1.1 Etiology and Presentation
97.5.1.2 Management
97.5.2 Balloon Leak and Obstruction
97.5.2.1 Etiology and Presentation
97.5.2.2 Management
97.5.3 Bacterial Overgrowth in the Balloon
97.5.3.1 Etiology and Presentation
97.5.3.2 Management
97.5.3.3 Stomach Perforation due to Intragastric Balloon
97.5.3.4 Spontaneous Balloon Hyperinflation
97.6 Conclusion
97.7 Key Learning Points
References
98 Gastroesophageal Reflux, Obesity, and Bariatric Surgery
98.1 Introduction
98.2 Pathophysiology of GERD Associated with Obesity
98.3 Bariatric Surgery and Gastroesophageal Reflux
98.3.1 Beneficial (Anti-Refluxogenic) Effects of Bariatric Surgery on GERD
98.3.1.1 Reduction and/or Repair of the Hiatal Hernia
98.3.1.2 Reduction in the Acid Exposure (Production) Due to Resection (All Surgeries with a Sleeve Gastrectomy Component)
98.3.1.3 Reduction in Acid Exposure Due to Exclusion (All Types of Bypasses)
98.3.1.4 Creation of a Low-Pressure System (All Types of Bypasses)
98.3.1.5 Mechanical Caudal Pull Effect (All Types of Bypasses)
98.3.2 Potential Refluxogenic Effects of Bariatric Surgery on GEJ
98.4 Evidence
98.4.1 Reflux After Laparoscopic Sleeve Gastrectomy (LSG/SG)
98.4.2 Reflux After OAGB
98.4.3 Reflux After LRYGB or RYGB
98.5 Approach to the Patient with Symptomatic Reflux After Bariatric Surgery
98.5.1 History Taking
98.5.2 Investigations
98.5.3 Management
98.5.3.1 Medical Management
98.5.3.2 Endoscopic Management
98.5.3.3 Surgical Management
98.5.4 Surveillance
98.6 Summary
98.7 Key Learning Points
References
99 Bariatric Surgery After Hiatal Surgery/Antireflux Surgery
99.1 Introduction
99.1.1 Antireflux Surgery
99.1.2 Surgery for Hiatus Hernia
99.1.3 Surgery for Achalasia Cardia
99.1.4 Mesh Use
99.1.5 Mobilization of Short Gastric Vessels
99.2 Bariatric Surgery and Gastroesophageal Reflux Disease
99.2.1 Laparoscopic Sleeve Gastrectomy (LSG) and GERD
99.2.2 Laparoscopic Roux-en Y Gastric Bypass (LRYGB) and GERD
99.2.3 Laparoscopic Adjustable Gastric Banding (LAGB) and GERD
99.2.4 One Anastomosis Gastric Bypass (OAGB) and GERD
99.3 Bariatric Surgery After Antireflux/Hiatal Surgery
99.3.1 What Is the Evidence?
99.4 The Authors´ Approach
99.4.1 Does the Patient Have GERD Symptoms?
99.4.2 What Antireflux Operation Did the Patient Have?
99.5 Intra-Operative Considerations
99.6 Summary
99.7 Key Learning Points
References
100 Abdominal Wall Hernia and Bariatric Surgery
100.1 Introduction
100.2 The Dilemma the Surgeon Faces with Hernia and Obesity
100.2.1 Problems with Ventral Hernia Repair in an Obese Patient
100.2.2 Open or Laparoscopic Ventral Hernia Repair?
100.2.3 Choice of Technique for Hernia Repair
100.2.3.1 Intraperitoneal on Lay Mesh Repair (IPOM)
100.2.3.2 Component Separation Techniques
100.2.3.3 Anatomical Repair
100.3 When Is the Right Time to Do a Ventral Hernia Repair?
100.3.1 Concomitant Bariatric Surgery with AWH Repair
100.3.1.1 Why Concomitant Surgery
100.3.1.2 Mesh or No Mesh?
100.3.2 Staged Procedures
100.3.2.1 Bariatric Surgery Followed by Hernia Repair
100.3.2.2 Ventral Hernia Repair Followed by Bariatric Surgery
100.4 Suggested Algorithm for Operative Repair
100.5 Summary
100.6 Key Learning Points
References
101 Gallstones and Bariatric Surgery
101.1 Introduction
101.1.1 Obesity and Cholelithiasis
101.2 Cholelithiasis after Bariatric Surgery
101.3 Cholecystectomy in Patients Undergoing Bariatric Surgery
101.3.1 Prophylactic Approach
101.3.2 Selective/Elective Approach
101.3.3 Deferred/Conventional Approach
101.4 Role of Ursodeoxycholic Acid in Bariatric Surgery
101.5 Management of Common Bile Duct Stones (Choledocholithiasis) After RYGB
101.6 Percutaneous Transhepatic Instrumentation of Common Bile Duct
101.7 Laparoscopically Assisted Trans-Enteric/Trans-Gastric Endoscopic (ERCP) Access, Using Specialized Endoscopes
101.8 Open/Laparoscopic Exploration of the Common Bile Duct/Choledochoduodenostomy
101.9 Conclusion
101.10 Key Learning Points
Reference
102 The Role of Primary Care in Bariatric Surgery
102.1 Introduction
102.2 Obesity Management in Primary Care
102.2.1 Diet
102.2.2 Physical Activity
102.2.3 Other Integrated Approaches
102.2.4 Drug Therapy
102.2.5 Surgery
102.3 Immediate Postoperative Care
102.4 Long-Term Care
102.4.1 Gastric Bypass and Sleeve Gastrectomy
102.4.2 Gastric Band
102.4.3 Biliopancreatic Diversion
102.5 Changes in Drug Therapy after Bariatric Surgery
102.6 Metabolic Complications after Bypass
102.7 Supplements
102.8 Diabetes Pharmacotherapy
102.9 Hypertension
102.10 Drugs Affecting Lipid Profile
102.11 Drugs for Gastric Hyperacidity
102.12 Other Effects of Weight Loss
102.13 Vitamin D Status
102.14 Re-Referral Criteria
102.15 Summary
References
103 Intensive Care and Obesity
103.1 Introduction
103.2 Medical Considerations
103.2.1 Airway
103.2.2 Ventilation
103.2.3 Cardiovascular Assessment
103.2.4 Sedation and Drug Dosing
103.2.5 Renal Assessment and Renal Replacement Therapy
103.2.6 Thromboembolic Prophylaxis
103.2.7 Nutrition
103.2.8 Resuscitation
103.3 Nursing Considerations
103.3.1 Staffing
103.3.2 Hygiene Needs and Skin Care
103.3.3 Privacy and Dignity
103.4 Equipment
103.5 Conclusion
103.6 Key Learning Points
References
104 Radiological Imaging in Bariatric Surgery
104.1 Introduction
104.2 Laparoscopic Adjustable Gastric Band (LAGB)
104.2.1 Early Complications in LAGB
104.2.2 Late Complications
104.2.2.1 Gastric Pouch Dilatation
104.2.2.2 Band Erosion
104.2.2.3 Other Complications
104.2.3 Gastric Band Fills
104.3 Roux-En-Y Gastric Bypass (RYGB)
104.3.1 Early Complications
104.3.1.1 Bleeding
104.3.1.2 Anastomotic Leak
104.3.1.3 Gastric Pouch Dilatation
104.3.1.4 Dilatation of the Gastric Remnant and Duodenum
104.3.1.5 Infection
104.3.1.6 Ischemia
104.3.2 Late Complications
104.3.2.1 Obstruction
104.3.2.2 Staple Line Dehiscence Leading to Gastro-Gastric Fistula
104.3.2.3 Gastrojejunal Marginal Erosion and Ulcers
104.4 One Anastomosis Gastric Bypass - Mini Gastric Bypass (OAGB-MGB)
104.5 Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S)
104.6 Laparoscopic Sleeve Gastrectomy (LSG)
104.7 Duodenal Switch
104.8 Summary
104.9 Key Learning Points
References
105 Adolescent Bariatric Surgery
105.1 Introduction
105.2 Definition
105.3 Prevalence
105.4 Why Is Adolescent Group So Special?
105.5 Rationale for Treatment of Obesity
105.6 Effect of Obesity on Individuals
105.7 Comorbidities
105.7.1 Cardiovascular
105.7.2 Metabolic
105.7.3 Endocrine
105.7.4 Respiratory
105.7.5 Renal
105.7.6 Hepatic
105.7.7 Orthopedic
105.7.8 Psychosocial
105.8 Treatment Options and Patient Selection
105.8.1 Lifestyle Modification
105.8.2 Patient Selection Guidelines
105.9 Preoperative Preparation
105.9.1 Role of MDT Members
105.9.1.1 Pediatrician
105.9.1.2 Dietitian
105.9.1.3 Psychologist
105.10 Surgery
105.10.1 AGB
105.10.2 VSG
105.10.3 RYGB
105.11 Psychological Impact of Surgery
105.12 Kidney Function
105.13 Role of Newer Surgical Interventions
105.13.1 Intragastric Balloons (IGBs)
105.14 Summary
105.15 Key Learning Points
References
106 Body Contouring Surgery: An Overview of Principles and Techniques
106.1 Introduction
106.2 Preoperative Assessment of the MWL Patient
106.2.1 Nutritional Considerations
106.2.2 Weight Loss and Weight Stability
106.2.3 Medical and Surgical History
106.2.4 Psychological Considerations
106.2.5 Multidisciplinary Team Approach
106.3 Techniques in Body Contouring Surgery
106.3.1 Contouring of the Trunk
106.3.1.1 Upper Body Lift
106.3.1.2 Female Upper Body Lift
106.3.1.3 Upper Body Lift in Males
106.3.1.4 Lower Body Lift
106.3.2 Brachioplasty
106.3.3 Medial Thigh Lift
106.3.4 Total Body Lift
106.4 Complications of Body Contouring Surgery
106.5 Funding
106.6 Summary
References
107 COVID-19, Obesity and Bariatric Surgery
107.1 Introduction
107.2 Effect of Obesity Upon COVID-19 Outcomes
107.3 Pathogenic Effects of Obesity Associated with COVID-19
107.4 Bariatric and Metabolic Surgery During COVID-19
107.5 Future Challenges
107.6 Summary
107.7 Key Learning Points
References
Index