Bariatric Surgery

Obesity is becoming a major health problem in the United States. Today,

more than 1 in every 3 people in the United States is obese. Obese
patients are at increased risk of developing illnesses as well as death.
orbidly obese patients have been shown to have a 1! times red"ction
in life e#pectancy. Obesity is meas"red in terms of a person$s %ody ass
&nde# '%&(, which is calc"lated from a person$s height and weight. )
normal person wo"ld have a %& between !* and !+. orbid obesity is
defined as a %& of over ,*, and "s"ally correlates to act"al body weight
e#ceeding ideal body weight by 1** lbs ',+.+ kg(.
Anatomy and Physiology
&n order to "nderstand how bariatric s"rgery res"lts in weight
loss, it is necessary to "nderstand how food is digested '-ig"re
1(
1. )fter swallowing, food enters the stomach, which acts to
hold the food and then allow small amo"nts of the food
to pass f"rther into the digestive tract. The vol"me of the
stomach is "s"ally between .** / 1*** cc '!* / 3* o0.(
!. &n the first part of the small bowel 'd"oden"m(, food
comes into contact with bile, secreted by the liver as well
as en0ymes from the pancreas. These secretions help in
the digestion and absorption of food. The small bowel is
where most of the absorption of food occ"rs and may
reach a length of . / 1 meters 'over !* feet(. The
pro#imal 'closest to the mo"th( two/fifths of the small
bowel is called the jej"n"m and the distal 'farthest from
the mo"th( three/fifths is called the ile"m
ost bariatric proced"res work by two methods / a restrictive
component and a malabsorptive component
1. 2estrictive component / a portion of the stomach may be
removed or bypassed so as to red"ce the vol"me of the
stomach. Th"s, only a limited amo"nt of food can be
eaten prior to getting f"ll
!. alabsorptive component / %ile and pancreatic
secretions, which are necessary for digestion of food, are
directed away from the food. These secretions reach the
food several yards down the length of the small bowel,
th"s delaying and ca"sing incomplete digestion and
absorption of the food
-ig"re 1 / )natomy of the gastrointestinal
'stomach and bowel( tract. 3ote that digestive
j"ices from the pancreas and liver enter the
small bowel at the d"oden"m. The pro#imal
!4+ of the small bowel is called the jej"n"m.
The distal 34+ is called the ile"m. The small
bowel empties into the colon 'large bowel(. 5
S. %rett

6roblems 2elated to orbid Obesity / obese patients have a higher risk
of developing many diseases
7eart and blood vessels / hypertension, coronary artery disease,
heart fail"re an varicose veins
7ormonal / diabetes, abnormal menstr"al periods, infertility,
abnormal hair growth
6"lmonary / obstr"ctive sleep apnea 'loss of breathing(,
hypoventilation 'decreased breathing( syndrome, asthma
)rthritis / "s"ally of the knees and hips and chronic back pain
8astrointestinal / heartb"rn, fatty liver, gallstones, hernias
Urological / "rinary incontinence 'loss of "rine(
6sychological / chronic depression, an#iety and s"bstance ab"se
9ancer / increased incidence of cancer of the "ter"s, colon,
breast and prostate
:eath / there is a 1! time red"ction in life e#pectancy seen in
morbidly obese patients
History and Examination
6atients seek help for their obesity for either cosmetic reasons or
beca"se they s"ffer from one or more associated illnesses and
have been told that their illness wo"ld improve by loss of weight
;very person who is considered for bariatric s"rgery needs to be
thoro"ghly eval"ated. %ariatric s"rgery involves a long/term
commitment beca"se the patient has to make long term changes
in physical and dietary habits
;ating and physical habits of the patient are reviewed. ost
patients have already tried diet or e#ercise programs
The %ody ass &nde# '%&( is "s"ally calc"lated < Other
associated illnesses are eval"ated as necessary
) bariatric team may have a psychologist or co"nselor who
eval"ates the patient for depression or an#iety. %ariatric teams
fre="ently have s"pport gro"ps of patients to help "nderstand
lifestyle changes patients may have to make
6atients also need to meet with a dietician to disc"ss
postoperative dietary changes
Testing
The following blood tests may be taken since they may change
after s"rgery
1. 7emoglobin / this gives a meas"re of the red blood cells
in the blood
!. ;lectrolyte levels / This is a meas"re of the vario"s salts
in the blood s"ch as sodi"m, potassi"m and especially
calci"m
3. 8l"cose / This is a meas"re of the s"gar in the blood
,. 9holesterol and triglyceride levels / indicators of the fat
content in the blood
+. -at sol"ble vitamins '>itamins ),:,; and ?(
.. &ron and folic acid levels
1. Thyroid and cortisone levels
These tests are associated with obesity or may be changed after
bariatric s"rgery
1. 7eart work "p incl"ding an electrocardiogram ';?8,
heart tracing( and4or a stress test to see if the patient$s
heart is able to withstand an operation
!. 6"lmonary -"nction Testing '6-T( may be obtained
beca"se some patients may need added assistance on a
ventilator 'breathing machine( after s"rgery
3. ) bone density scan is sometimes performed before
s"rgery to check bone calci"m which may be low after
s"rgery
,. Other tests may be obtained to check o"t some of the
illnesses associated with obesity
Indications for surgery
%ariatric s"rgery is indicated for patients who are morbidly
obese, %& greater than ,*, or for patients with a %& greater
than 3+ if they have associated medical problems
6atients with a %ody ass &nde# of less than 3+ are "s"ally
treated with a weight red"ction diet, a program of increased
physical activity, approved weight loss medication and
co"nseling to modify behavior
2emember that this s"rgery is one of choice and great care
sho"ld be taken before "ndergoing bariatric s"rgery
Surgical procedures
There are several operations for morbid obesity. ost
proced"res are carried o"t "nder general anesthesia thro"gh a
midline 'along the center line( abdominal incision
) cholecystectomy (removal of gallbladder is fre="ently
incl"ded as part of the proced"re d"e to the high risk of gallstone
disease in obese patients
Some of the proced"res are@
1. >ertical %anded 8astroplasty '-ig"re !( / this is a
restrictive type of proced"re. -ood intake is red"ced
beca"se the stomach is smaller. ) vertical '"p and down(
po"ch is constr"cted "sing the "pper part of the stomach
"s"ally by "sing a s"rgical stapler. The po"ch "s"ally
allows only 1 /! o0 of food to enter the stomach. This
po"ch may be s"rro"nded by cloth mesh to prevent the
stomach from distending
-ig"re ! / >ertical banded
gastroplasty. See te#t. 5 S. %rett
!. 2o"#/en/A 8astric %ypass '-ig"re 3( / this is a
combination of a restrictive and malabsorptive proced"re
o The "pper portion of the stomach is freed and a row of
staples is placed hori0ontally 'from side to side( a few
centimeters '1/! inches( below the esophag"s / stomach
j"nction. The gastric po"ch meas"res also abo"t 1 /! o0
b"t, "nlike the previo"s proced"re, the stomach po"ch is
totally separated from the rest of the stomach
o The small bowel is divided appro#imately .* cm. '!,
inches( beyond the stomach. The distal loop is bro"ght
"p and attached to the stomach po"ch. This forms the
food channel
o The pro#imal loop contains secretions of bile and the
pancreas and is called the biliopancreatic channel. This
channel is attached to the side of the food channel
appro#imately .* cm distal to the attachment of the
stomach and small bowel forming a A shaped
arrangement of the bowel
o &n this proced"re food intake is restricted beca"se of the
small stomach po"ch and there is poor absorption of
food beca"se the bile and pancreatic secretions do not
come into contact with food "ntil abo"t 1!* cm beyond
the stomach
-ig"re 3 / 2o"#/en/A 8astric %ypass.
See te#t. 5 S. %rett
3. %iliopancreatic %ypass '-ig"re ,( / this proced"re also
has the restrictive and malabsorptive components
o Staples are "sed to create a po"ch of the pro#imal
stomach of appro#imately !** ml '. o0(. The distal
stomach is then removed from the body
o The small bowel is then divided at appro#imately !+* cm
pro#imal to the ileocecal valve, which is at the end of the
small bowel
o The distal loop of the bowel is then attached to the
stomach po"ch to form the food channel
o The pro#imal loop of this bowel 'biliopancreatic channel(
is then attached to the side of the food channel at
appro#imately +* cm '!* inches( from the ileocecal valve
o This proced"re is similar to the 2o"#/en/A b"t with a
longer bypass of the bile and pancreatic secretions. The
food and biliopancreatic secretions only mi# for the last
+* cm of the small bowel
-ig"re , / %iliopancreatic %ypass. See
te#t. 5 S. %rett
,. :"odenal Switch '-ig"re +( / this is a variation of the
biliopancreatic bypass
o Stapling vertically along the length of the stomach
creates a narrow t"be of the stomach, of appro#imately
1** ml vol"me
o The d"oden"m 'the first part of the small bowel( is
divided j"st beyond the stomach
o Similar to the biliopancreatic bypass, the small bowel is
divided to form a pro#imal biliopancreatic channel and a
distal food channel. The food channel is attached to the
stomach/d"odenal t"be. The biliopancreatic channel is
then attached to the side of the food channel at
appro#imately +* cm from the ileocecal valve
-ig"re + / :"odenal Switch. See te#t. 5
S. %rett
+. Baparoscopic S"rgery / bariatric s"rgery can be
performed laparoscopically
o ) laparoscope is a long t"be with lenses at one end that
are connected by fiber optics to a small television
camera at the other. The fiber optics also carries light
into the abdomen from a special light so"rce. This
system allows the s"rgeon to see and operate within the
abdomen. Several small incisions '1 cm( are made on
the abdomen to introd"ce instr"ments 'and(. %oth the
vertical banded gastroplasty and the 2o"#/en/A gastric
bypass can be performed laparoscopically
o )nother proced"re that is performed laparoscopically is
gastric banding. &n this proced"re an inflatable band is
wrapped aro"nd the pro#imal stomach. ) reservoir p"mp
containing saline for this band is b"ried j"st "nder the
skin of the abdomen. The band may be inflated to
different degrees. The inflated band restricts food intake
into the stomach '-ig"re .(
-ig"re . / 8astric %anding. See te#t.
5 S. %rett
!omplications
Several complications altho"gh possible with any s"rgery are
more prevalent in obese patients d"e fre="ently to poor heart
and l"ng f"nction. These are myocardial infarction 'heart attack(
or heart fail"re and p"lmonary complications s"ch as respiratory
fail"re re="iring ventilator s"pport, p"lmonary embol"s 'blood
clot from legs or pelvis going to the l"ngs(, l"ng collapse
'atelectasis( or pne"monia
9omplications specific to bariatric s"rgery incl"de
1. %owel leaks that may give rise to abscesses 'p"s( that
may need reoperation to repair
!. Co"nd dehiscence 'separation of the wo"nd e#posing
the bowel(
3. &nj"ry to the spleen
,. Ulcers forming at the attachment of the small bowel to
the stomach. &f antacids are not effective, 'a( the s"rgery
may have to be redone
+. Obstr"ction of the stomach at the point it joins the small
bowel may re="ire dilation
.. 6oor absorption of iron, folate, vitamins %1!, ), :, ; and
calci"m may be seen if not these are not given after
s"rgery
1. 8allstones and decreased liver f"nction may be seen
d"e to poor absorption of bile salts
D. Boose skin from loss of fat "nder the skin may re="ire
plastic s"rgery to e#cise the loose skin
E. ;#cessive weight loss despite vitamin and mineral
s"pplements may re="ire a reversal of the bypass
Postoperative !are
&mmediate postoperative care
1. 6atients stay in the hospital for + /1 days for recovery of
bowel f"nction
!. ) t"be is placed thro"gh the nose and into the stomach
to drain the stomach po"ch
3. One or more drains may be placed in the abdomen.
These are removed as the drainage decreases and the
bowel regains f"nction
,. S"t"res or staples in the abdominal incision "s"ally are
removed aro"nd 1* days
+. Some s"rgeons obtain an F / ray dye swallowing st"dy
to see if there is ade="ate emptying of the stomach
po"ch prior to starting a diet. :iet is "s"ally started with
li="ids and slowly advanced to solid food. ) dietician may
be cons"lted to advise a patient of the proper diet. &t is
important to remember that the amo"nt of food that a
patient can eat is m"ch more limited
Bong term care
1. 6atients may e#perience diarrhea with flat"lence
'passing gas( d"e to partially digested food for a few
months
!. 6atients may need to increase the n"mber of meals a
day d"e to the small si0e of each meal. 6atients notice a
="ick loss of weight over the first si# months, followed by
a slower loss of weight over the ne#t 1! to 1D months. %y
abo"t two years the weight stabili0es
3. any patients notice that associated illnesses improve
after a few months with the weight loss
,. &t is important is to check for anemia 'low blood iron( and
deficiency of vitamins and minerals, which can occ"r
from s"rgery. "ltivitamins and iron s"pplements may be
needed to make "p for their poor absorption
+. -ollow "p visits may incl"de blood tests s"gar and
cholesterol, which "s"ally fall after s"rgery
.. There may be e#cessive loose skin hanging from the
abdomen d"e to loss of fat "nder the skin. This may
re="ire a plastic s"rgery 't"mmy t"ck( to trim away the
e#cess skin
9opyright5 !*** Ao"rS"rgery.9om )ll 2ights 2eserved