Bariatric surgery refers to a group of invasive procedures used to surgically reduce the size of the stomachStomachThe stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy to produce early satiety, decrease food intake (restrictive type) and/or alter digestionDigestionDigestion refers to the process of the mechanical and chemical breakdown of food into smaller particles, which can then be absorbed and utilized by the body.Digestion and Absorption, and artificially induce malabsorptionMalabsorptionGeneral term for a group of malnutrition syndromes caused by failure of normal intestinal absorption of nutrients.Malabsorption and Maldigestion of nutrients (malabsorptive type). The ultimate goal of bariatric surgery is drastic weight loss. Bariatric surgery is currently the only modality that provides significant long-term weight loss in morbidly obese individuals and cures or significantly improves obesity-related complications. The 2 modalities currently in wide use are the Roux-en-Y gastric bypassGastric bypassSurgical procedure in which the stomach is transected high on the body. The resulting small proximal gastric pouch is joined to any parts of the small intestine by an end-to-side surgical anastomosis, depending on the amounts of intestinal surface being bypasses. This procedure is used frequently in the treatment of morbid obesity by limiting the size of functional stomach, food intake, and food absorption.Gastroesophageal Reflux Disease (GERD) and sleeve gastrectomy.
Bariatric surgery is a group of invasive procedures that can be used to either surgically reduce the size of the stomachStomachThe stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy or reroute the intestines with the ultimate goal of drastic weight loss by restricting food intake or altering the absorptionAbsorptionAbsorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation.Digestion and Absorption of food.
Anatomy
It is important to review the anatomy of the stomachStomachThe stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy to more easily locate and recognize it within the abdominal cavity, as well as to promptly control bleeding during surgery.
Anatomical landmarks of the stomachStomachThe stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy:
Has 2 curvatures (lesser and greater)
Cardia:
Entrance of the stomachStomachThe stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy
Originates from the z-lineZ-lineEsophagus: Anatomy and creates the angle of His or angle of the cardiac orifice (angle between the fundusFundusThe superior portion of the body of the stomach above the level of the cardiac notch.Stomach: Anatomy and abdominal esophagusEsophagusThe esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus: Anatomy)
A crucial landmark in construction of the gastric pouch
FundusFundusThe superior portion of the body of the stomach above the level of the cardiac notch.Stomach: Anatomy: a dome-shaped region located at the highest point of the stomachStomachThe stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy
Body:
The main section of the stomachStomachThe stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy
Extends from the fundusFundusThe superior portion of the body of the stomach above the level of the cardiac notch.Stomach: Anatomy to the pylorusPylorusThe region between the sharp indentation at the lower third of the stomach (incisura angularis) and the junction of the pylorus with the duodenum. Pyloric antral glands contain mucus-secreting cells and gastrin-secreting endocrine cells (g cells).Stomach: Anatomy
Bordered by the lesser and greater curvatures
PylorusPylorusThe region between the sharp indentation at the lower third of the stomach (incisura angularis) and the junction of the pylorus with the duodenum. Pyloric antral glands contain mucus-secreting cells and gastrin-secreting endocrine cells (g cells).Stomach: Anatomy:
Connects to the duodenumDuodenumThe shortest and widest portion of the small intestine adjacent to the pylorus of the stomach. It is named for having the length equal to about the width of 12 fingers.Small Intestine: Anatomy
Contains the pyloric sphincter
Consists of a wide pyloric antrum and narrow pyloric canal
Left gastric arteryGastric arteryAny of several branches of the splenic artery distributed to the greater curvature of the stomach.Stomach: Anatomy: main supply to the gastric pouch in a gastric bypassGastric bypassSurgical procedure in which the stomach is transected high on the body. The resulting small proximal gastric pouch is joined to any parts of the small intestine by an end-to-side surgical anastomosis, depending on the amounts of intestinal surface being bypasses. This procedure is used frequently in the treatment of morbid obesity by limiting the size of functional stomach, food intake, and food absorption.Gastroesophageal Reflux Disease (GERD)
Right gastric arteryGastric arteryAny of several branches of the splenic artery distributed to the greater curvature of the stomach.Stomach: Anatomy
Right and left gastroepiploic (gastro-omental) arteriesArteriesArteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology
Splenic artery
Short gastric arteriesArteriesArteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology
Posterior gastric arteryGastric arteryAny of several branches of the splenic artery distributed to the greater curvature of the stomach.Stomach: Anatomy
Venous drainage:
Homonymous veinsVeinsVeins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins: Histology that accompany the arteriesArteriesArteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology
Right and left gastric veinsVeinsVeins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins: Histology drain into the portal veinPortal veinA short thick vein formed by union of the superior mesenteric vein and the splenic vein.Liver: Anatomy.
Left gastroepiploic vein drains into the splenic vein.
Right gastroepiploic vein drains into the superior mesenteric vein.
Innervation:
Parasympathetic innervation: anterior and posterior vagal trunk
Sympathetic innervation: greater splanchnic nerve and gastric branches from the celiac plexus
Bariatric surgery is a type of surgical management indicated in patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with morbid obesityObesityObesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity in whom lifestyle modifications (e.g., diet and exercise), psychotherapyPsychotherapyPsychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy, and pharmacotherapy have failed.
BMIBMIAn indicator of body density as determined by the relationship of body weight to body height. Bmi=weight (kg)/height squared (m2). Bmi correlates with body fat (adipose tissue). Their relationship varies with age and gender. For adults, bmi falls into these categories: below 18. 5 (underweight); 18. 5-24. 9 (normal); 25. 0-29. 9 (overweight); 30. 0 and above (obese).Obesity > 40 kg/m2
BMIBMIAn indicator of body density as determined by the relationship of body weight to body height. Bmi=weight (kg)/height squared (m2). Bmi correlates with body fat (adipose tissue). Their relationship varies with age and gender. For adults, bmi falls into these categories: below 18. 5 (underweight); 18. 5-24. 9 (normal); 25. 0-29. 9 (overweight); 30. 0 and above (obese).Obesity > 35 kg/m2 with complications of obesityObesityObesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity (e.g., diabetesDiabetesDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus mellitus, hypertensionHypertensionHypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, obstructive sleep apneaSleep apneaRepeated cessation of breathing for > 10 seconds during sleep and results in sleep interruption, fatigue, and daytime sleepiness.Obstructive Sleep Apnea)
Previous failure of diet therapy
Psychiatric stability without alcohol use or the consumption of illicit drugsIllicit DrugsDrugs that are manufactured, obtained, or sold illegally. They include prescription drugs obtained or sold without prescription and non-prescription drugs. Illicit drugs are widely distributed, tend to be grossly impure and may cause unexpected toxicity.Delirium
PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship who are aware of the implications of surgery and the dietary changes that are required
PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship who are motivated
Underlying medical problems are not contraindicationsContraindicationsA condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks).Noninvasive Ventilation for surgery.
ContraindicationsContraindicationsA condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks).Noninvasive Ventilation
Relative:
PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship > 65 years of age
Children and adolescents (surgery is delayed until they have reached maximal pubertal growth)
Underlying medical conditions (e.g., cardiac or respiratory diseases)
Pre-existing GERDGERDGastroesophageal reflux disease (GERD) occurs when the stomach acid frequently flows back into the esophagus. This backwash (acid reflux) can irritate the lining of the esophagus, causing symptoms such as retrosternal burning pain (heartburn). Gastroesophageal Reflux Disease (GERD) for gastric sleeve (but not for gastric bypassGastric bypassSurgical procedure in which the stomach is transected high on the body. The resulting small proximal gastric pouch is joined to any parts of the small intestine by an end-to-side surgical anastomosis, depending on the amounts of intestinal surface being bypasses. This procedure is used frequently in the treatment of morbid obesity by limiting the size of functional stomach, food intake, and food absorption.Gastroesophageal Reflux Disease (GERD))
Absolute:
Inability to ambulate
Prader-Willi syndromePrader-Willi syndromePrader-Willi syndrome (PWS) is a rare autosomal neurodevelopmental genetic disorders mapped to a specific region of chromosome 15 attributed to genomic imprinting. A paternally derived chromosome 15 with this deletion results in 15q11-13 paternal deletion syndrome, or PWS.Prader-Willi Syndrome and Angelman Syndrome
Prior fasting/bowel rest (nil per os, nothing by mouth) for 8 hours
Explanation of the procedure to the patient and obtaining informed consentInformed consentInformed consent is a medicolegal term describing the documented conversation between a patient and their physician wherein the physician discloses all relevant and necessary information to a patient who is competent to make an informed and voluntary decision regarding their care. Competency, disclosure, and voluntariness are the key elements upon which IC is based.Informed Consent
Laboratory workup:
CBC: platelet count > 50,000
PTT and PT within acceptable ranges
Renal function: serum creatinine and BUN within acceptable ranges
AnticoagulantsAnticoagulantsAnticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants are withheld before the procedure.
Deep vein thrombosisThrombosisFormation and development of a thrombus or blood clot in the blood vessel.Epidemic Typhus (DVTDVTDeep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis) prophylaxisProphylaxisCephalosporins:
EnoxaparinEnoxaparinLow-molecular-weight fragment of heparin, having a 4-enopyranosuronate sodium structure at the non-reducing end of the chain. It is prepared by depolymerization of the benzylic ester of porcine mucosal heparin. Therapeutically, it is used as an antithrombotic agent.Anticoagulants
Antibiotic prophylaxisProphylaxisCephalosporins: 1st-generation cephalosporinsCephalosporinsCephalosporins are a group of bactericidal beta-lactam antibiotics (similar to penicillins) that exert their effects by preventing bacteria from producing their cell walls, ultimately leading to cell death. Cephalosporins are categorized by generation and all drug names begin with “cef-” or “ceph-.” Cephalosporins (cefazolinCefazolinA semisynthetic cephalosporin analog with broad-spectrum antibiotic action due to inhibition of bacterial cell wall synthesis. It attains high serum levels and is excreted quickly via the urine.Cephalosporins)
ECGECGAn electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Electrocardiogram (ECG)
AnesthesiaAnesthesiaA state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures.Anesthesiology: History and Basic Concepts: The procedure is usually performed under general anesthesiaGeneral anesthesiaProcedure in which patients are induced into an unconscious state through use of various medications so that they do not feel pain during surgery.Anesthesiology: History and Basic Concepts.
Types and steps of the procedures
Roux-en-Y gastric-bypass technique:
Gastric bypassGastric bypassSurgical procedure in which the stomach is transected high on the body. The resulting small proximal gastric pouch is joined to any parts of the small intestine by an end-to-side surgical anastomosis, depending on the amounts of intestinal surface being bypasses. This procedure is used frequently in the treatment of morbid obesity by limiting the size of functional stomach, food intake, and food absorption.Gastroesophageal Reflux Disease (GERD) is both restrictive (reduces the size of the stomachStomachThe stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy) and malabsorptive (reroutes the intestines to alter food absorptionAbsorptionAbsorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation.Digestion and Absorption). A laparoscopic approach is generally preferred because of shorter recovery and hospital stay.
The 20–30-mL gastric pouch is fashioned based on the lesser curvatureLesser curvatureStomach: Anatomy of the stomachStomachThe stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy, providing the restrictive component.
The Roux limb is brought up to the gastric pouch by any of the following paths:
Antecolic/antegastric
Retrocolic/retrogastric (shortest path)
Retrocolic/antegastric
The Roux limb is anastomosed with the gastric pouch using non-absorbable sutures or staples.
Peterson’s defect (space between the limbs of the small intestineSmall intestineThe small intestine is the longest part of the GI tract, extending from the pyloric orifice of the stomach to the ileocecal junction. The small intestine is the major organ responsible for chemical digestion and absorption of nutrients. It is divided into 3 segments: the duodenum, the jejunum, and the ileum. Small Intestine: Anatomy, the transverse mesocolon, and the retroperitoneum)
Intermesenteric defect (space within the mesenteric pouch)
Defect in the transverse mesocolon
Roux-en-Y gastric bypass
Image by Lecturio.
Gastric sleeve technique:
The goal is to create a smaller, tube-shaped stomachStomachThe stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy along the lesser curvatureLesser curvatureStomach: Anatomy with a volume of approximately 60–100 mL. This procedure is most commonly performed laparoscopically.
The phrenoesophageal ligament and gastroesophageal fat pad are divided to expose the left diaphragmDiaphragmThe diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force.Diaphragm: Anatomy.
The greater curvatureGreater curvatureStomach: Anatomy of the stomachStomachThe stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy is released and an elasticElasticConnective Tissue: Histology bougie (a long plastic tube used to calibrate the size of the sleeve) is inserted.
A linear cutting stapler is moved parallel to the lesser curve of the stomachStomachThe stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy, starting at the antrum and progressing towards the fundusFundusThe superior portion of the body of the stomach above the level of the cardiac notch.Stomach: Anatomy, while being careful to not impinge on the incisura.
At the fundusFundusThe superior portion of the body of the stomach above the level of the cardiac notch.Stomach: Anatomy, the linear stapler is moved medially to the angle of His, and the greater curvatureGreater curvatureStomach: Anatomy is completely resected to create the gastric sleeve.
The remnant stomachStomachThe stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy is then removed.
Gastric sleeve
Image by Lecturio.
Post-operative carePost-operative careAfter any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care
Observation in the recovery roomRecovery roomHospital unit providing continuous monitoring of the patient following anesthesia.Postoperative Care for 6 hours and later in the wards
Same-day discharge is possible.
Special diet plan with small frequent meals to avoid vomitingVomitingThe forcible expulsion of the contents of the stomach through the mouth.Hypokalemia, food intolerance, and dumping syndrome
Careful follow-up of patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship by a multidisciplinary team is necessary:
Monitoring of weight loss
Vigilance for malnutritionMalnutritionMalnutrition is a clinical state caused by an imbalance or deficiency of calories and/or micronutrients and macronutrients. The 2 main manifestations of acute severe malnutrition are marasmus (total caloric insufficiency) and kwashiorkor (protein malnutrition with characteristic edema).Malnutrition in children in resource-limited countries and vitamin deficiencies
Plastic surgery: Aesthetic procedures may be indicated to remove excess skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions from the abdomen, thighs, and arms after drastic weight loss.
PrognosisPrognosisA prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations.Non-Hodgkin Lymphomas:
Greatest extent of weight loss occurs during the 1st postoperative year.
Gastric bypassGastric bypassSurgical procedure in which the stomach is transected high on the body. The resulting small proximal gastric pouch is joined to any parts of the small intestine by an end-to-side surgical anastomosis, depending on the amounts of intestinal surface being bypasses. This procedure is used frequently in the treatment of morbid obesity by limiting the size of functional stomach, food intake, and food absorption.Gastroesophageal Reflux Disease (GERD) provides slightly better-maintained weight loss at 5 years than the gastric sleeve.
Best means to cure obesity-related complications: improves or cures type 2 diabetesDiabetesDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus, hypertensionHypertensionHypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, and hyperlipidemia
Significant number of patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship develop gallstonesGallstonesCholelithiasis (gallstones) is the presence of stones in the gallbladder. Most gallstones are cholesterol stones, while the rest are composed of bilirubin (pigment stones) and other mixed components. Patients are commonly asymptomatic but may present with biliary colic (intermittent pain in the right upper quadrant).Cholelithiasis secondary to rapid weight loss:
If symptomatic, cholecystectomyCholecystectomyCholecystectomy is a surgical procedure performed with the goal of resecting and extracting the gallbladder. It is one of the most common abdominal surgeries performed in the Western world. Cholecystectomy is performed for symptomatic cholelithiasis, cholecystitis, gallbladder polyps > 0.5 cm, porcelain gallbladder, choledocholithiasis and gallstone pancreatitis, and rarely, for gallbladder cancer. Cholecystectomy is indicated
Some surgeons advocate prophylactic cholecystectomyCholecystectomyCholecystectomy is a surgical procedure performed with the goal of resecting and extracting the gallbladder. It is one of the most common abdominal surgeries performed in the Western world. Cholecystectomy is performed for symptomatic cholelithiasis, cholecystitis, gallbladder polyps > 0.5 cm, porcelain gallbladder, choledocholithiasis and gallstone pancreatitis, and rarely, for gallbladder cancer. Cholecystectomy at the time of bariatric surgery.
Complications
Bariatric surgery, like any invasive procedure, has inherent risks and complications.
Roux-en-Y gastric bypassGastric bypassSurgical procedure in which the stomach is transected high on the body. The resulting small proximal gastric pouch is joined to any parts of the small intestine by an end-to-side surgical anastomosis, depending on the amounts of intestinal surface being bypasses. This procedure is used frequently in the treatment of morbid obesity by limiting the size of functional stomach, food intake, and food absorption.Gastroesophageal Reflux Disease (GERD)
Anastomotic leak:
May lead to intra-abdominal abscessAbscessAccumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection.Chronic Granulomatous Disease, peritonitisPeritonitisInflammation of the peritoneum lining the abdominal cavity as the result of infectious, autoimmune, or chemical processes. Primary peritonitis is due to infection of the peritoneal cavity via hematogenous or lymphatic spread and without intra-abdominal source. Secondary peritonitis arises from the abdominal cavity itself through rupture or abscess of intra-abdominal organs.Penetrating Abdominal Injury, and sepsisSepsisSystemic inflammatory response syndrome with a proven or suspected infectious etiology. When sepsis is associated with organ dysfunction distant from the site of infection, it is called severe sepsis. When sepsis is accompanied by hypotension despite adequate fluid infusion, it is called septic shock.Sepsis and Septic Shock
Marginal ulcers: form at the GI anastomosis usually on the intestinal side, as a result of unopposed exposure to gastric acidGastric acidHydrochloric acid present in gastric juice.Gastroesophageal Reflux Disease (GERD)
Gastro-gastric fistulaFistulaAbnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body.Anal Fistula: fistulaFistulaAbnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body.Anal Fistula formation between the gastric pouch and gastric remnant
Nutritional deficiencies:
Result from exclusion of the large portion of the stomachStomachThe stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy and inadequate absorptionAbsorptionAbsorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation.Digestion and Absorption due to intestinal bypass
Common deficiencies: vitamin B12Vitamin B12A cobalt-containing coordination compound produced by intestinal microorganisms and found also in soil and water. Higher plants do not concentrate vitamin B 12 from the soil and so are a poor source of the substance as compared with animal tissues. Intrinsic factor is important for the assimilation of vitamin B 12.Folate and Vitamin B12, folateFolateFolate and vitamin B12 are 2 of the most clinically important water-soluble vitamins. Deficiencies can present with megaloblastic anemia, GI symptoms, neuropsychiatric symptoms, and adverse pregnancy complications, including neural tube defects. Folate and Vitamin B12, ironIronA metallic element with atomic symbol fe, atomic number 26, and atomic weight 55. 85. It is an essential constituent of hemoglobins; cytochromes; and iron-binding proteins. It plays a role in cellular redox reactions and in the transport of oxygen.Trace Elements, zincZincA metallic element of atomic number 30 and atomic weight 65. 38. It is a necessary trace element in the diet, forming an essential part of many enzymes, and playing an important role in protein synthesis and in cell division. Zinc deficiency is associated with anemia, short stature, hypogonadism, impaired wound healing, and geophagia. It is known by the symbol zn.Trace Elements, copperCopperA heavy metal trace element with the atomic symbol cu, atomic number 29, and atomic weight 63. 55.Trace Elements, calciumCalciumA basic element found in nearly all tissues. It is a member of the alkaline earth family of metals with the atomic symbol ca, atomic number 20, and atomic weight 40. Calcium is the most abundant mineral in the body and combines with phosphorus to form calcium phosphate in the bones and teeth. It is essential for the normal functioning of nerves and muscles and plays a role in blood coagulation (as factor IV) and in many enzymatic processes.Electrolytes, vitamin DVitamin DA vitamin that includes both cholecalciferols and ergocalciferols, which have the common effect of preventing or curing rickets in animals. It can also be viewed as a hormone since it can be formed in skin by action of ultraviolet rays upon the precursors, 7-dehydrocholesterol and ergosterol, and acts on vitamin D receptors to regulate calcium in opposition to parathyroid hormone.Fat-soluble Vitamins and their Deficiencies
Dumping syndrome:
Caused by rapid movement of large amounts of food from a small stomachStomachThe stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy into the intestine
Usually associated with foods rich in simple sugars and starches
Presents as bloatingBloatingConstipation, abdominal discomfort, and diarrheaDiarrheaDiarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
Can also be associated with tachycardiaTachycardiaAbnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia.Sepsis in Children and hypotensionHypotensionHypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension due to massive fluid influx into the intestinal lumen
Gastric sleeve
Gastroesophageal reflux: due to increased pressure within a narrow, tubular stomachStomachThe stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy
Lyo, V., Husain, F.A. (2021). Roux-en-Y gastric bypass and sleeve gastrectomy. In Delaney, Conor P. et al. (Ed.), Netter’s Surgical Anatomy and Approaches. http://dx.doi.org/10.1016/B978-0-323-67346-4.00010-4