Metabolic Disorder&Surgery

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World Health Organization defines obesity as a disease in which fat has accumulated to the extent that health is impaired. It is commonly measured by body mass index (BMI), which calculates the relationship of weight to height. An adult with a BMI of 30 or more is considered obese.

BMI Classifications kg/m2
Normal18.5 – 24.9
Overweight25 – 29.9
Class-I obesity30 – 34.9
Class-II obesity35 – 39.9
Class-III obesity (Morbid obesity)40 – 49.9
Class-IV obesity (Superobesity)50 – 59.9
Class-V obesity (Super-superobesity)>60

Which patients should be offered bariatric surgery?

Patients with BMI ≥40 kg/m2 could be considered surgical candidates; patients with less severe obesity (BMI ≥35 kg/m2) could be considered if they had high-risk comorbid conditions such as life-threatening cardiopulmonary problems (for example, severe sleep apnea, pickwickian syndrome, or obesity-related cardiomyopathy) or uncontrolled type 2 diabetes mellitus (T2DM). Other possible indications for patients with BMIs between 35 and 40 kg/m2 include obesity- induced physical problems interfering with lifestyle (for example, joint disease treatable but for the obesity, or body size problems precluding or severely interfering with employment, family function, and ambulation).

Which bariatric surgical procedure should be offered?

The best choice for any bariatric procedure (type of procedure and type of approach) depends on the individualized goals of therapy (e.g., weight loss and/or metabolic [glycemic] control), available local-regional expertise (surgeon and institution), patient preferences, and personalized risk stratification. Investigational procedures may be considered for selected patients based on available institutional review board (IRB) approved protocols, suitability for clinical targets and individual patient factors, and only after a careful assessment balancing the importance for innovation, patient safety, and demonstrated effectiveness

How should potential candidates for bariatric surgery be managed preoperatively?

TYPES OF BARIATRIC SURGERY

Various bariatric procedures are available for management of high-risk obese patients.

Currently, most bariatric procedures are being performed laparoscopically. This approach has the advantages of fewer wound complications, less postoperative pain, a briefer hospital stay, and more rapid postoperative recovery with comparable efficacy.

SLEEVE GASTRECTOMY

How it works?

A sleeve gastrectomy is a procedure that limits the amount of food you can eat by reducing the size of your stomach. Like other

metabolic surgeries, it also helps to establish a lower, healthier body fat set point by changing the signals between the stomach, brain, and liver.

  • The surgeon creates a small stomach “sleeve” using a stapling device. This sleeve will typically hold 100 mL to 150 mL and is about the size of a banana. The rest of the stomach is removed.
  • This procedure induces weight loss in part by restricting the amount of food (and therefore calories) that can be eaten without bypassing the intestines and absorbed.
  • Weight loss and improvement in parameters of metabolic syndrome are connected with the resection of the stomach and subsequent neurohormonal changes.

Advantages

  • Limits the amount of food that can be eaten at a meal.
  • Allows the body to adjust to its new, healthier set point.
  • Food passes through the digestive tract in the usual order, allowing vitamins and nutrients to be fully absorbed into the body.
  • No postoperative adjustments are required
  • In clinical studies patients lost an average of 66% of their excess weight.
  • Shown to help resolve high blood pressure, obstructive sleep apnea, and to help improve type 2 diabetes and high cholesterol.

Risks

The following are in addition to the general risks of surgery:

  • Complications due to stomach stapling, including separation of tissue that was stapled or stitched together and leaks from staple lines.
  • Gastric leakage (1-2%)
  • Ulcers
  • Dyspepsia
  • Esophageal dysmotility
  • Nonreversible since part of the stomach is removed
 Sleeve GastrectomyRoux en Y Gastric Bypass (RYGB)Mini Gastric Bypasst(MGB)          Transit Bipartition (TBP)
Mechanism of actionRestriction of intakeRestriction of intake + malabsorptionRestriction of intake + malabsorptionRestriction of intake + slight malabsorption
Risk of surgeryLow-mediumMediumMediumMedium
Weight loss rateRapidRapidRapidRapid
Excess weight loss rate (%EWL)EWL % S0-70 (in 12 months)EWL % 60-8S (in 12-18 months)EWL P 60-85 (in 12-18 months)EWL P 60-85 (in 12-18 months)
Duration of operation30 min60 min40 min120 min
Recovery time1 week1 week1 week1 week
Length of hospital stay2 days2 days2 days2 days
Change in the intestinesNo change1/3 of the intestine is unavailable1/3 of the intestine is unavailableNo change
Change in the stomach9/10 of the stomach is removedstomach is not removed, divided into 2 partsstomach is not removed, divided into 2 parts8/10 of the stomach is removed
Number of anastomosesNone212
New stomach volume100-150 cc15-20 cc50 cc200-300 cc
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