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Surgery_Schwartz. outcomes (heart attack and stroke) in patients treated with these medications have yet to be published, except in the case of liraglutide.43 Figure 27-4 shows a comparison of weight loss outcomes for these medications. The median percentages of participants who had a weight loss of at least 5% or 10% with each of five medications approved for long-term weight man-agement are from a meta-analysis by Khera et al.48In summary, medications approved for long-term obesity treatment, when used as an adjunct to lifestyle intervention, lead to greater mean weight loss and an increased likelihood of achieving clinically meaningful 1-year weight loss compared to placebo.42 Yet weight loss medications are underutilized, likely due to several factors. First, patients are often disappointed by moderate weight loss. Second, there are requirements to pay a substantial portion of costs, which may lead to short-term rather than longer-term use. Third, there remain concerns about medi-cation safety.


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Surgery_Schwartz. weight loss. Second, there are requirements to pay a substantial portion of costs, which may lead to short-term rather than longer-term use. Third, there remain concerns about medi-cation safety. Finally, weight regain is common after termina-tion of drug treatment, which is discouraging to both patients and their providers.22,42Barriers to TreatmentOnly a small fraction of patients for whom these medical treat-ments or bariatric surgery are indicated actually pursue and receive them. Past studies have estimated that 1% or fewer of those people with severe obesity who could consider bariatric surgery ever do so. Barriers to general obesity care include the slow recognition among providers that obesity requires long-term management, inadequate physician training in nutrition and obesity, limited reimbursement for the full range of treat-ments, lack of more effective and accessible lifestyle programs, and limited referrals of patients with severe obesity to expe-rienced surgeons.22 Lack


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Surgery_Schwartz. reimbursement for the full range of treat-ments, lack of more effective and accessible lifestyle programs, and limited referrals of patients with severe obesity to expe-rienced surgeons.22 Lack of knowledge about the more recent outcomes of bariatric surgery may also play a contributing role.CANDIDATES FOR BARIATRIC SURGERYIndicationsThere has been significant procedure evolution over the last several years indicating an ongoing major shift in bariatric procedures both in the United States and worldwide13 (Fig. 27-5). According to a 2016 report from the American Society of Metabolic and Bariatric Surgery (ASMBS), the two most common procedures in the United States are RYGB and SG, accounting for approximately 25% to 30% and 50% to 60%, respectively, of annual cases.49,50 The utilization of LAGB has declined dramatically to under 10% of cases, and the malabsorptive procedure BPD with or without DS is utilized in less than 1% to 2% of cases (see Fig. 27-2). All of these procedures were


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Surgery_Schwartz. LAGB has declined dramatically to under 10% of cases, and the malabsorptive procedure BPD with or without DS is utilized in less than 1% to 2% of cases (see Fig. 27-2). All of these procedures were defined by the Centers for Medicare & Medicaid Services (CMS) as standard approved procedures, noting that SG coverage is based on the discretion of regional carriers throughout the United States.The indications for performing bariatric surgery in class II and class III obesity still remain as described in the National Institutes of Health (NIH) Consensus Conference of 1991, and a summary of the broad selection criteria are shown in Table 27-2.51 In 2016, the second Diabetes Surgery Summit (DSS-II) published guidelines indicating that metabolic surgery 2should also be considered for patients with T2DM and BMI of 30 to 34.9 kg/m2 (class I obesity) if blood sugar is inadequately controlled despite optimal medication treatment.16 In addition, these guidelines recommended that the BMI


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Surgery_Schwartz. with T2DM and BMI of 30 to 34.9 kg/m2 (class I obesity) if blood sugar is inadequately controlled despite optimal medication treatment.16 In addition, these guidelines recommended that the BMI threshold for metabolic surgery (surgery for diabetes as the indication) should be reduced by 2.5 kg/m2 for Asian populations at risk.The NIH criteria for bariatric surgery do not set guidelines or limits for age, and surgical practice varies widely. The pediatric obesity epidemic is both increasing and also driving the adult epidemic, and a growing proportion of younger patients are potentially eligible for bariatric surgery. For young patients, there are concerns about assent to surgery and compliance with and adherence to postoperative lifestyle changes, but there are also some emerging data that suggest intervening earlier in the disease process may lead to improved reversal of comorbid conditions compared to adults.52 In addition, there is a longer period of postoperative benefit in terms


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Surgery_Schwartz. suggest intervening earlier in the disease process may lead to improved reversal of comorbid conditions compared to adults.52 In addition, there is a longer period of postoperative benefit in terms of improved quality of life and prevention of or reduction in the emotional, social, and physical consequences of obesity (see “Bariatric Procedures in Adolescents”). Alternatively, older patients are more likely to have more numerous and debilitating comorbid conditions and thus have an immediate benefit in quality of life but not necessarily enhanced longevity. There is also some concern that recovery from potential complications is impaired in patients over the age of 65. Most studies in older patients have focused on RYGB and older restrictive procedures with limited follow-up. The results of more recent studies in older patients are generally equivocal in terms of any increased risk of morbidity and mortality or any difference in weight outcomes compared to younger adults.53-55 One


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Surgery_Schwartz. of more recent studies in older patients are generally equivocal in terms of any increased risk of morbidity and mortality or any difference in weight outcomes compared to younger adults.53-55 One study has shown that the older patient population, especially those few patients older than age 70 undergoing bariatric surgery, did have an increased risk of mortality and morbidity after RYGB.56 Also, a 2016 study from the Utah Obesity group found that RYGB is protective against mortality even for older patients and also reduces the age-related increase in mortality observed in severely obese individuals not undergoing surgery.57ContraindicationsMedical issues that preclude patients from being good surgi-cal candidates include American Society of Anesthesiologists (ASA) class IV disease of a nature that makes surgical therapy extraordinarily high risk. Psychological instability or the inabil-ity to understand the implications of the proposed operation and what changes will result from it


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Surgery_Schwartz. nature that makes surgical therapy extraordinarily high risk. Psychological instability or the inabil-ity to understand the implications of the proposed operation and what changes will result from it in terms of the patient’s life-style are also contraindications. Known and documented active drug or alcohol addiction is a contraindication to surgery (see Table 27-2). Tobacco use should be completely avoided by bar-iatric patients at all times, and smoking cessation should occur 6 weeks prior to surgery. After surgery smoking increases risks of poor wound healing, anastomotic ulcers, and impaired health.58 A poorly controlled eating disorder, especially bulimia, is also a contraindication to surgery. Nonambulatory status is a relative contraindication to surgery and is associated with increased sur-gical risk,59 especially if the obesity is so severe that the patient cannot normally do self-care or would not likely be able to do so after surgery. In addition to excessive morbidity,


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Surgery_Schwartz. sur-gical risk,59 especially if the obesity is so severe that the patient cannot normally do self-care or would not likely be able to do so after surgery. In addition to excessive morbidity, the placement of these individuals in care facilities postoperatively for recovery is often impossible due to their size and limitations of physical ability. Finally, lack of sufficient social support or an extremely poor or unsupportive home environment can be contraindications to surgical care, since such environmental factors are important to optimize outcomes once discharged from the hospital.Brunicardi_Ch27_p1167-p1218.indd 117323/02/19 2:20 PM 1174SPECIFIC CONSIDERATIONSPART IIABCDEFGHFigure 27-5. Bariatric surgery procedure evolution. A. Horizontal gastroplasty; B. vertical banded gastroplasty; C. Roux-en-Y gastric bypass; D. transected Roux-en-Y gastric bypass; E. laparoscopic adjustable gastric band; F. biliopancreatic diversion; G. biliopancreatic diversion with duodenal switch; H.


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Surgery_Schwartz. C. Roux-en-Y gastric bypass; D. transected Roux-en-Y gastric bypass; E. laparoscopic adjustable gastric band; F. biliopancreatic diversion; G. biliopancreatic diversion with duodenal switch; H. vertical sleeve gastrectomy. (Modified with permission from Arterburn DE, Courcoulas AP: Bariatric surgery for obesity and metabolic conditions in adults, BMJ. 2014 Aug 27;349:g3961.)Brunicardi_Ch27_p1167-p1218.indd 117423/02/19 2:20 PM 1175THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 27Table 27-2Patient selection criteria for bariatric surgeryFACTORCRITERIAWeight (adults)BMI ≥40 kg/m2 with no comorbid conditionsBMI ≥35 kg/m2 with obesity-associated comorbidityWeight loss historyFailure of previous nonsurgical attempts at weight reduction, including nonprofessional programsCommitmentExpectation that patient will adhere to postoperative careFollow-up visits with physician(s) and team membersRecommended medical management, including use of dietary supplementsInstructions regarding any


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Surgery_Schwartz. that patient will adhere to postoperative careFollow-up visits with physician(s) and team membersRecommended medical management, including use of dietary supplementsInstructions regarding any recommended procedures or testsContraindications/exclusionsProhibitive surgical risk, ASA IVReversible endocrine or other disorders that can cause obesityCurrent drug or alcohol misuseUncontrolled, severe psychiatric illnessUncontrolled, severe bulimiaLack of comprehension of risks, benefits, expected outcomes, alternatives, and lifestyle changesData from Mechanick JI, Youdim A, Jones DB, et al: Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery, Obesity (Silver Spring). 2013 Mar;21 Suppl 1:S1-S27.MECHANISM OF ACTION OF BARIATRIC AND METABOLIC SURGERYOverviewThere


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Surgery_Schwartz. The Obesity Society, and American Society for Metabolic & Bariatric Surgery, Obesity (Silver Spring). 2013 Mar;21 Suppl 1:S1-S27.MECHANISM OF ACTION OF BARIATRIC AND METABOLIC SURGERYOverviewThere is not yet a clear understanding as to how various bariatric procedures exert their effects on weight loss, metabolism, and glycemic control. Much effort is currently being devoted to gaining a better understanding of these specific mechanisms. A review of what is known from published animal and human studies about mechanisms related the three most common surgical proce-dures is shown in Fig. 27-6.17 A few interim, summary statements can be drawn from this available data. First, neither LRYGB nor SG can be thought of as primarily “restrictive procedures,” and there are changes in behavior and physiology that likely help to maintain the new reduced body weight that are not observed after nonsurgically induced weight loss. LAGB appears to be more dependent on gastric restriction as both the


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Surgery_Schwartz. physiology that likely help to maintain the new reduced body weight that are not observed after nonsurgically induced weight loss. LAGB appears to be more dependent on gastric restriction as both the behavioral changes and changes in gut hormone secretion are much less dramatic. Second, both LRYGB and SG are associated with metabolic improvements that are different from those that are caused by weight loss alone, and these mechanisms remain under current active study. For LAGB, the metabolic effects are mostly due to the impact of the resulting weight loss. This growing understanding of the physiol-ogy of these procedures points away from the older, classic 3anatomic classifications of “restrictive” versus “malabsorptive” procedures. This new conceptual approach has important implica-tions for future studies of how bariatric surgery exerts its effects. Earlier hypotheses for the mechanism of action of LRYGB have been classified into either the “foregut hypothesis” or “hindgut


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Surgery_Schwartz. for future studies of how bariatric surgery exerts its effects. Earlier hypotheses for the mechanism of action of LRYGB have been classified into either the “foregut hypothesis” or “hindgut hypothesis.”60 The foregut hypothesis states that improvements after LRYGB come from the bypassing of the upper small intestine that results in the reduction of nutrient-dependent hormonal actions that would normally impair glucose tolerance.61 The hindgut hypothesis states instead that the key events are the result of more rapid delivery of nutrients to the distal small intestine causing effects such as increased GLP-1/PYY secretion and the ileal brake.62 Now, the more recently recognized and common metabolic effects of SG and LRYGB may indicate directions for study away from this foregut/hindgut distinction, as the SG does not bypass the foregut or induce nutrients further down in the intestine.Mechanisms of Bariatric Surgery (Weight Loss)Certainly, one component mechanism by which RYGB pro-duces


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Surgery_Schwartz. as the SG does not bypass the foregut or induce nutrients further down in the intestine.Mechanisms of Bariatric Surgery (Weight Loss)Certainly, one component mechanism by which RYGB pro-duces weight loss is related to reduced caloric intake and malab-sorption brought about by a smaller gastric volume and bypass of the proximal small bowel, so weight loss following LAGB and SG may be explained, at least in part and early on, by gas-tric restriction63 and resulting reduced food intake. Aside from anatomic changes induced by surgery, there are also changes in physiology that may affect food preferences and energy expen-diture. Gastric emptying and insulin sensitivity increases follow-ing RYGB and SG.63 Functional magnetic resonance imaging has demonstrated a decreased neuronal activation of the food reward-related centers in response to high-calorie foods follow-ing RYGB.64 Neural signaling may be altered and stretch sensi-tive vagal endings in the new pouch and Roux limb, resulting in a


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Surgery_Schwartz. food reward-related centers in response to high-calorie foods follow-ing RYGB.64 Neural signaling may be altered and stretch sensi-tive vagal endings in the new pouch and Roux limb, resulting in a feeling of early satiety.65 Hormonal changes are also evi-dent, and in a number of studies looking at the effect of RYGB on ghrelin levels, results are conflicting. Changes in intestinal microbiota is another area of active study.66 Individuals with obesity have different gut flora compared to nonobese subjects. The Firmicutes (mainly Lactobacillus and Clostridium species) to Bacteroidetes ratio (Bacteroides or Prevotella species) is elevated in obese subjects. Following gastric bypass, the Fir-micutes group decrease while Bacteroides/Prevotella increase at 3 and 6 months intervals.67 Bacteria transplant provides some of the benefits of gastric bypass surgery without the surgery.68 It has also been shown that administering oral lactobacillus post-RYGB leads to increased weight loss; this


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Surgery_Schwartz. transplant provides some of the benefits of gastric bypass surgery without the surgery.68 It has also been shown that administering oral lactobacillus post-RYGB leads to increased weight loss; this indicates benefits of changing gut microbiota to induce weight loss.69Serum bile acid levels also increase following gastric bypass.70 Gastric bypass diverts undiluted bile acids to the distal bowel. Bile acids activate protein-coupled receptor TGR5 pres-ent in L cells responsible for GLP-1 secretion. They also activate FXR (farsenoid-X receptor) in the jejunum, which regulates lipid and glucose metabolism.71 Furthermore, bile acids lead to rapid clearance of triglycerides.72 Bariatric surgery alters bile acid enterohepatic circulation in favor of weight loss and resolution of nonalcoholic steatohepatitis (NASH).73 Ryan et al demonstrated in a study on mice that the therapeutic value of SG is not limited to mechanical restriction but to an increase in circulating bile acids and associated


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Surgery_Schwartz. (NASH).73 Ryan et al demonstrated in a study on mice that the therapeutic value of SG is not limited to mechanical restriction but to an increase in circulating bile acids and associated changes to gut microbiota.74 Hollanda et al studied two cohorts of patients: those who lost more than 50% of their excess weight compared to those who did not. This group suggested that ghrelin and GLP-1 may be mediators of success-ful weight loss as those levels increased, while PYY and GLP-2, Brunicardi_Ch27_p1167-p1218.indd 117523/02/19 2:20 PM 1176SPECIFIC CONSIDERATIONSPART IILRYGBLAGBSGLipidElevated HDLReduced triglyceridesReduced total cholesterol, LDLElevated HDLReduction in triglycerides not as dramatic as LRYGB or SGElevated HDLReduced triglyceridesGlucose homeostasisImproved fasting blood glucose and insulin sensitivity, prior to weight lossImprovements are slower and not as dramatic as after SG or LRYGBImproved fasting blood glucose and insulin sensitivity, prior to weight lossRole of


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Surgery_Schwartz. and insulin sensitivity, prior to weight lossImprovements are slower and not as dramatic as after SG or LRYGBImproved fasting blood glucose and insulin sensitivity, prior to weight lossRole of gastric restrictionHas not yet been directly testedFailure of band leads to less gastric restriction and less weight lossGastric restriction is not the critical factor preventing hyperphagiaGastric emptyingFew published studiesNo overall change in gastric emptying rate; Emptying rate of proximal pouch created by band is enhancedMost papers show increaseEnergy expenditureControversialNot reportedUnchanged, but only reported in one studyLeptinCirculating leptin levels lower than expected for body weightChanges to leptin sensitivity not testedPlasma leptin reduced, as expected for body weight; Changes to leptin sensitivity not testedCirculating leptin levels lower than expected for body weight; Body weight changes not driven by changes to leptin sensitivityGhrelinReduced total ghrelin;


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Surgery_Schwartz. Changes to leptin sensitivity not testedCirculating leptin levels lower than expected for body weight; Body weight changes not driven by changes to leptin sensitivityGhrelinReduced total ghrelin; Controversial, but no change in acyl-ghrelin levelsIncreased circulating ghrelinReduced total ghrelin; Contro-versial, but no change in acyl-ghrelin levelsCCKNo changeNo changeNot measuredGLP=1 (postprandial)Weight loss-independent postprandial increaseIncreased circulating GLP-1 but much less than RYGB or SGWeight loss-independent increase comparable to LRYGBPYY (postprandial)Increased postprandial PYY levels; Reduced body weight loss in PYY knockout miceNo changeIncreased postprandial PYY levels, comparable to levels after LRYGBBile acidsIncreased plasma bile acidsNot reportedIncreased plasma bile acidsDiet changeDecreased fat intake, more fruits and vegetablesDecrease bread intake and increase in caloric liquids; Greater fat intake and fewer fruits/vegetables than RYGBDecreased fat intake,


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Surgery_Schwartz. acidsDiet changeDecreased fat intake, more fruits and vegetablesDecrease bread intake and increase in caloric liquids; Greater fat intake and fewer fruits/vegetables than RYGBDecreased fat intake, similar to LRYGBFood IntoleranceSome dumping syndrome, usually well-tolerated More persistent and problematic than LRYGB; Mainly vomitingLittle or noneFigure 27-6. Mechanisms of effect: comparison of LRYGB, LAGB, and SG. (Reproduced with permission from Stefater MA, Wilson-Pérez HE, Chambers AP, et al: All bariatric surgeries are not created equal: insights from mechanistic comparisons, Endocr Rev. 2012 Aug;33(4):595-622.)Brunicardi_Ch27_p1167-p1218.indd 117623/02/19 2:20 PM 1177THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 27gut mass and hypertrophy (citrulline), and the bile acid effect on fibroblast growth factor-19 (FGF-19) appear to have no effect on weight loss.75 In summary, there exists a complex relationship between dietary changes, bile flow changes, altered hormonal milieu and the


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Surgery_Schwartz. growth factor-19 (FGF-19) appear to have no effect on weight loss.75 In summary, there exists a complex relationship between dietary changes, bile flow changes, altered hormonal milieu and the gut microbiota that is not yet completely well characterized as it relates to weight loss after bariatric surgery.Mechanisms of Metabolic Surgery (Diabetes Improvement)Understanding the basic mechanism(s) of diabetes improvement following bariatric surgery is an important area of intensive study. Recently published data on worldwide trends in diabetes indicate that the number of adults with diabetes has increased from 108 million in 1980 to 422 million in 2014,76 the major-ity with T2DM. In the United States, diabetes is the number two cause of hospitalizations in adults age 18 years or older, accounting for approximately 11% of all hospital admissions. With no medical cure, the natural course of diabetes is charac-terized by progressive β-cell failure and development of micro-vascular and


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Surgery_Schwartz. accounting for approximately 11% of all hospital admissions. With no medical cure, the natural course of diabetes is charac-terized by progressive β-cell failure and development of micro-vascular and macrovascular complications, leading to renal failure, blindness, amputation, and death due to cardiovascular disease (CVD). Bariatric surgery has been renamed metabolic surgery for T2DM treatment and has emerged as an effective tool for control of hyperglycemia.77-86More than 20 years ago Pories et al found that bariatric surgery rapidly normalized blood glucose levels in people with obesity and T2DM, and 10 years later the majority remained dis-ease free.87 He suggested that caloric restriction played a role but that there were likely other factors such as proximal intestinal nutrient exclusion, rapid distal gut nutrient delivery, and the role of gut hormones that would require further investigation. The findings of T2DM improvement and remission after bariatric surgery have now been


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Surgery_Schwartz. rapid distal gut nutrient delivery, and the role of gut hormones that would require further investigation. The findings of T2DM improvement and remission after bariatric surgery have now been widely replicated by others, and there is evidence that bariatric surgery prevents or delays incident cases of T2DM. Much work has been done to investigate these spe-cific physiological mechanisms underlying the beneficial gly-cemic effects of bariatric surgery, but they remain incompletely understood. Candidate hypotheses include changes in bile acid metabolism, nutrient sensing and glucose utilization, intestinal adaptation, incretins, possible anti-incretin(s), and the intestinal microbiome. These physiologic and molecular changes lead to reduced hepatic glucose production, increased glucose uptake in tissues, improved insulin sensitivity, and enhanced β-cell func-tion. A schematic of these potential mechanisms of improved glycemic control is shown in Fig. 27-7.It is likely that several of


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Surgery_Schwartz. in tissues, improved insulin sensitivity, and enhanced β-cell func-tion. A schematic of these potential mechanisms of improved glycemic control is shown in Fig. 27-7.It is likely that several of these individual factors, acting together and with different impact based on the specific surgical pro-cedure, are responsible for postoperative glycemic improvement. Work in this area is actively ongoing, and genomic, metabolomic, and gut microbiome studies will likely enhance the understanding of these changes. This may potentially lead to identifying novel pathways and potential therapeutic targets to replace bariatric pro-cedures by equally effective, but less invasive, new treatments for obesity-related T2DM. In other words, understanding mechanisms of glycemic improvement after bariatric surgery may allow for the development of treatments to “bypass the bypass.”88PREOPERATIVE ISSUESPreoperative PreparationPatient selection for surgery should be based on a multidisci-plinary team


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Surgery_Schwartz. surgery may allow for the development of treatments to “bypass the bypass.”88PREOPERATIVE ISSUESPreoperative PreparationPatient selection for surgery should be based on a multidisci-plinary team approach. All patients should undergo preoperative evaluation for obesity-related comorbidities and causes of obe-sity, with special attention directed to factors that could affect candidacy for bariatric surgery89 (Table 27-3).The preoperative assessment of the patient for bariatric surgery must include input from the nutritionist as an important independent evaluation. Careful assessment of the patient’s eat-ing habits, knowledge, self-awareness, and insight are important. An estimation of the patient’s motivation to change eating habits is important. The nutritionist should have at least one assessment session with the patient and an educational session preoperatively once the decision to proceed with surgery has been determined. The operation to be performed requires specific nutritional


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Surgery_Schwartz. session with the patient and an educational session preoperatively once the decision to proceed with surgery has been determined. The operation to be performed requires specific nutritional counseling and education. Psychological assessment is required by most programs and many insurance carriers with a goal of identifying potential contraindications to surgical intervention, such as poorly controlled psychiatric illness or active substance abuse, and identifying strategies to help with long-term weight management.90 There are published recommendations regarding the content of a mental health evaluation for bariatric surgery,91-93 but no consensus guidelines have been published. These evalua-tions are carried out by interview and questionnaires, which rely on clinical interviews including tests of personality or psycho-pathological conditions.94 More comprehensive evaluations also assess bariatric surgery knowledge, weight history, lifestyle hab-its, and potential barriers.91,92


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Surgery_Schwartz. tests of personality or psycho-pathological conditions.94 More comprehensive evaluations also assess bariatric surgery knowledge, weight history, lifestyle hab-its, and potential barriers.91,92 Psychological assessment in clinical practice may be inaccurate compared to independent evaluations for research purposes, as patients present themselves in the most favorable light in order to gain access to surgery.95Obstructive sleep apnea (OSA) is prevalent in over 90% of bariatric surgery candidates with approximately one-third undiagnosed.96-101 The Epworth Sleepiness Scale, a standard set of questions evaluating daytime sleepiness, is often used as a screening tool for OSA.38 As OSA is associated with increased risk of mortality102 (and in bariatric surgery patients, with adverse outcomes),59 routine preoperative screening with polysomnog-raphy should be considered.103 In addition, standard preopera-tive management of obese patients with OSA using continuous positive airway pressure


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Surgery_Schwartz. routine preoperative screening with polysomnog-raphy should be considered.103 In addition, standard preopera-tive management of obese patients with OSA using continuous positive airway pressure (CPAP) is recommended.104 Asthma and hypoventilation syndrome of obesity are other significant pulmonary diseases often requiring preoperative management. Hypoventilation syndrome of obesity is defined as resting arte-rial partial pressure of oxygen less than 55 mmHg and partial pressure of carbon dioxide greater than 47 mmHg, with accom-panying pulmonary hypertension and polycythemia. Pulmonary consultation is indicated for patients with hypoventilation syn-drome. Postoperative intensive care unit hospitalization, rarely used after bariatric surgery, may be indicated for these patients.Preoperative weight loss can reduce liver volume/size and may help improve the technical aspects of surgery in those people with extreme central obesity and an enlarged liver, and it is sometimes utilized as a


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Surgery_Schwartz. weight loss can reduce liver volume/size and may help improve the technical aspects of surgery in those people with extreme central obesity and an enlarged liver, and it is sometimes utilized as a practice-specific recommendation or requirement. Ten percent total body weight loss (TBWL) with energy-restricted diets has been associated with a reduction in hepatic volume,105 variable perceived and measured improved facility in operative technique,106,107 variable effects on short-term108-112 complication rates, and weight loss. Cirrhosis113 has been associated with poor outcomes following bariatric surgery, including progression to liver transplantation.114Preoperative glycemic control should be optimized using diet, physical activity, and medications, as needed. Reasonable targets for preoperative glycemic control include a hemoglo-bin A1c value of 6.5% to 7.0% or less, a fasting blood glucose Brunicardi_Ch27_p1167-p1218.indd 117723/02/19 2:20 PM 1178SPECIFIC


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Surgery_Schwartz. targets for preoperative glycemic control include a hemoglo-bin A1c value of 6.5% to 7.0% or less, a fasting blood glucose Brunicardi_Ch27_p1167-p1218.indd 117723/02/19 2:20 PM 1178SPECIFIC CONSIDERATIONSPART IIlevel of ≤110 mg/dL, and a 2-hour postprandial blood glucose concentration of ≤140 mg/dL.115 More liberal preoperative targets with higher A1c should be considered in patients with advanced comorbid conditions or long-standing diabetes where lower targets are not attainable. For patients with active GERD on medication, a preoperative screening upper endoscopy to rule out Barrett’s esophagus and to rule out intrinsic lesions of the stomach or duodenum is recommended. This is especially true for patients planning LRYGB, where the distal stomach and duodenum will be precluded from easy inspection postop-eratively. In addition, the presence of Barrett’s esophagus is a contraindication to SG, which is a reflux-inducing operation. The presence of a hiatal hernia detected on


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Surgery_Schwartz. from easy inspection postop-eratively. In addition, the presence of Barrett’s esophagus is a contraindication to SG, which is a reflux-inducing operation. The presence of a hiatal hernia detected on preoperative esoph-agogastroduodenoscopy will alert the surgeon for the need to perform intraoperative repair.Patients with a history of DVT or cor pulmonale should undergo a diagnostic evaluation for DVT. A prophylactic vena caval filter may present a greater risk than benefit in patients A Immediate impact of surgeryB Potential mediators/mechanismsC Effect on glucose homeostasisCaloric restritctionImproved ˜-cell function/functional ˜-cell massAltered bile acid/ FGF-19 signalingReduced hepatic and pancreatic triglyceridesRYGBRYGBSGReduced hepatic glucose productionIncreased glucose utilizationIncreased glucose effectivenessImproved insulin sensitivityAltered microbiomeReduced glucotoxicityWeight lossAltered GI nutrient-sensingAltered gut hormonesAltered neural signalingRapid emptying of


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Surgery_Schwartz. glucose effectivenessImproved insulin sensitivityAltered microbiomeReduced glucotoxicityWeight lossAltered GI nutrient-sensingAltered gut hormonesAltered neural signalingRapid emptying of nutrients into the small intestineIntestinal adaptation/Reprogramming of intestinal glucoseRYGBSGEnhanced nutrient/bile delivery to the mid/distal jejunum and ileumRYGBSGSGExclusion of the duodenum and proximal jejunum and ileumRYGBRemoval of the stomach fundusSGFigure 27-7. Schematic of potential mechanisms of improved glycemic control after LRYGB and SG. A. Immediate effects of RYGB and SG due to anatomical changes. B. Potential mediators/mechanisms involved. Cross talk occurs among these factors. C. Effects on glucose homeostasis. (Reproduced with permission from Batterham RL, Cummings DE: Mechanisms of Diabetes Improvement Following Bariatric/Metabolic Surgery, Diabetes Care. 2016 Jun;39(6):893-901.)Brunicardi_Ch27_p1167-p1218.indd 117823/02/19 2:20 PM 1179THE SURGICAL MANAGEMENT OF


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Surgery_Schwartz. of Diabetes Improvement Following Bariatric/Metabolic Surgery, Diabetes Care. 2016 Jun;39(6):893-901.)Brunicardi_Ch27_p1167-p1218.indd 117823/02/19 2:20 PM 1179THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 27with a history of prior pulmonary embolism (PE) or DVT given the risks of filter-related complications including thrombosis. The overall risk of venous thromboembolism (VTE) after sur-gery is 0.42%, and over 70% of these events occur after hospital discharge, most within 30 days after surgery.116 The risk of VTE is greater in patients undergoing RYGB than in those undergoing LAGB and is more frequent following open surgery. Patients with a VTE event tend to be male, older, and have higher BMIs; they are also more likely to have a history of VTE.116 The risk of VTE is greater in patients with an inferior vena cava filter (hazard ratio [HR] 7.66, 95% CI 4.55–12.91),116 and there is evidence suggest-ing that prophylactic inferior vena caval (IVC) filter placement before bariatric


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Surgery_Schwartz. with an inferior vena cava filter (hazard ratio [HR] 7.66, 95% CI 4.55–12.91),116 and there is evidence suggest-ing that prophylactic inferior vena caval (IVC) filter placement before bariatric surgery does not prevent PE and may lead to addi-tional morbidity, which may outweigh its use.117,118Candidates for bariatric surgery should avoid pregnancy preoperatively and for 12 to 18 months postoperatively and Table 27-3Preoperative checklist for bariatric surgery• Complete for History & Physical (H&P) (obesity-related comorbidities, causes of obesity, weight/BMI, weight loss history, commitment, and exclusions related to surgical risk)• Routine labs (including fasting blood glucose and lipid panel, kidney function, liver profile, lipid profile, urine analysis, prothrombin time/INR, blood type, CBC)• Nutrient screening with iron studies, B12 and folic acid (RBC folate, homocysteine, methylmalonic acid optional), and 25-vitamin D (vitamins A and E optional); consider more extensive testing


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Surgery_Schwartz. CBC)• Nutrient screening with iron studies, B12 and folic acid (RBC folate, homocysteine, methylmalonic acid optional), and 25-vitamin D (vitamins A and E optional); consider more extensive testing in patients undergoing malabsorptive procedures based on symptoms and risks• Cardiopulmonary evaluation with sleep apnea screening (ECG, CXR, echocardiography if cardiac disease or pulmonary hypertension suspected; DVT evaluation if clinically indicated)• GI evaluation (H pylori screening in high-prevalence areas; gallbladder evaluation and upper endoscopy if clinically indicated)• Endocrine evaluation (A1c with suspected or diagnosed prediabetes or diabetes); TSH with symptoms or increased risk of thyroid disease; androgens with PCOS suspicion (total/bioavailable testosterone, DHEAS, D4-androstenedione); screening for Cushing’s syndrome if clinically suspected (1 mg overnight dexamethasone test, 24-hour urinary free cortisol, 11 PM salivary cortisol)• Clinical nutrition evaluation by


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Surgery_Schwartz. screening for Cushing’s syndrome if clinically suspected (1 mg overnight dexamethasone test, 24-hour urinary free cortisol, 11 PM salivary cortisol)• Clinical nutrition evaluation by registered dietician• Psychosocial-behavioral evaluation• Document medical necessity for bariatric surgery• Informed consent• Provide relevant financial information• Continue efforts for preoperative weight loss• Optimize glycemic control• Pregnancy counseling• Smoking cessation counseling• Verify cancer screening by primary care physicianReproduced with permission from Mechanick JI, Youdim A, Jones DB, et al: Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery, Obesity (Silver Spring). 2013 Mar;21 Suppl 1:S1-S27.women who become pregnant after bariatric surgery should be


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Surgery_Schwartz. The Obesity Society, and American Society for Metabolic & Bariatric Surgery, Obesity (Silver Spring). 2013 Mar;21 Suppl 1:S1-S27.women who become pregnant after bariatric surgery should be counseled and monitored for appropriate weight gain, nutri-tional supplementation, and for fetal health.119 All women of reproductive age should be counseled on contraceptive choices following bariatric surgery as utilization, absorption, and effec-tiveness are inconsistent.120,121 Patients should be provided with educational materials and access to preoperative educational sessions. Multimedia tools for patient education and consent show promise for improving understanding.122-124 There should be a thorough and dynamic consent discussion regarding the risks and benefits, procedural options, and the need for long-term follow-up and vitamin supplementation (including costs required to maintain appropriate follow-up). Consent should include the experience of the surgeon with the specific proce-dure


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Surgery_Schwartz. for long-term follow-up and vitamin supplementation (including costs required to maintain appropriate follow-up). Consent should include the experience of the surgeon with the specific proce-dure and whether the program participates in national quality improvement initiatives and certification.Anesthesiology IssuesTwo major challenges that face the anesthesiologist when per-forming a general anesthetic for the severely obese patient are vascular access and airway management. Fiberoptic laryngos-copy is often used for the most difficult class IV or even class III airways should standard laryngoscopy be determined to provide an inadequate view. Videotelescopic intubation systems are suc-cessfully used as well. Significant preoxygenation for 3 minutes or longer prior to intubation is used for the severely obese patient to provide a longer safe duration for intubation should difficul-ties be encountered. However, desaturation must be immediately addressed with reestablishment of


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Surgery_Schwartz. used for the severely obese patient to provide a longer safe duration for intubation should difficul-ties be encountered. However, desaturation must be immediately addressed with reestablishment of oxygenated ventilation because this patient group does not tolerate any prolonged desaturation without potential adverse cardiopulmonary consequences.The anesthesiologist must also manage alterations in car-diopulmonary function from the use of a pneumoperitoneum during laparoscopic bariatric procedures. These include the effects of carbon dioxide absorption on required minute venti-lation, the potential for bradyarrhythmias, and the potential for decreased systemic pH with longer procedures in patients with preexisting cardiopulmonary disease. Arterial monitoring of the latter group of patients may be necessary by the anesthesiology team, and a radial arterial line is standard for such patients.125 Drug pharmacokinetics differ in severely obese patients as well. Changes in volume of


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Surgery_Schwartz. may be necessary by the anesthesiology team, and a radial arterial line is standard for such patients.125 Drug pharmacokinetics differ in severely obese patients as well. Changes in volume of distribution include smaller-than-normal fraction of total body water, greater adipose tissue content, altered protein binding, and increased blood volume. Possible changes in renal function and hepatic function must be consid-ered when administering drugs. Specific anesthetic drug meta-bolic alterations in the severely obese include a larger volume distribution of thiopentone, resulting in a prolonged effect of the drug. Calculation of the dosage should be done by lean body weight. Benzodiazepines also exhibit a prolonged elimination phase, causing prolongation of their effects. Increased pseudo-cholinesterase activity is present in the severely obese patient, requiring increased dosages of pancuronium. Enflurane metab-olism is increased over the average-sized person, requiring a lower dosage of


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Surgery_Schwartz. activity is present in the severely obese patient, requiring increased dosages of pancuronium. Enflurane metab-olism is increased over the average-sized person, requiring a lower dosage of this agent.Enhanced Recovery After SurgeryEnhanced recovery after surgery (ERAS) protocols have been initiated in bariatric surgery and have demonstrated promise to decrease surgical morbidity. Additionally, a recent meta-analy-sis has identified a significant decrease in length of stay (stan-dard mean difference = −2.40 [−33.89, −0.89], P = 0.002).126 In 2016, the ERAS Society published evidence-based guidelines Brunicardi_Ch27_p1167-p1218.indd 117923/02/19 2:20 PM 1180SPECIFIC CONSIDERATIONSPART IIfor perioperative care in bariatric surgery.127 The guidelines include recommendations in preoperative, intraoperative, and postoperative care. These include shorter acting and lower absorption anesthetic agents and opioid minimization as impor-tant intraoperative recommendations.Special Equipment


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Surgery_Schwartz. intraoperative, and postoperative care. These include shorter acting and lower absorption anesthetic agents and opioid minimization as impor-tant intraoperative recommendations.Special Equipment and InfrastructureThe special needs of the bariatric patient and program extend from the entry to the hospital and clinic, to the operating room, and throughout the inpatient and outpatient experience. The program needs infrastructure and support at all levels including support staff, physicians and surgeons, administrators, program directors, psychologists, and nutritionists. The physical plant needs to include extra-wide doorways, special seating, a scale that weighs up to 800 lb (363 kg), larger patient gowns, large blood pressure cuffs, and floor-mounted toilets. In the operat-ing room, the table must accommodate 600 to 800 lb (272 to 363 kg) and must position in steep reverse Trendelenburg posi-tion. Larger lower extremity compression devices, extra padding, safety belts, and a footboard


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Surgery_Schwartz. must accommodate 600 to 800 lb (272 to 363 kg) and must position in steep reverse Trendelenburg posi-tion. Larger lower extremity compression devices, extra padding, safety belts, and a footboard are required. An angled (30° or 45°) telescope, extra-long graspers and staplers, and a liver retractor system are all standard equipment. Staff sensitivity training for the care of the obese as well as regular education about the com-plications of bariatric surgery are program requirements.BARIATRIC SURGICAL PROCEDURESVBG shown in Figs. 27-1 and 27-5, although still listed as one of the approved operations for the surgical treatment of severe obesity based on the NIH Consensus Conference of 1991,51 is not currently performed due to poor long-term weight loss and technical complications, so it is of historic interest only, and the surgical technique will not be described here.8 The other procedures described in this section will be articulated using a laparoscopic approach as that is the


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Surgery_Schwartz. is of historic interest only, and the surgical technique will not be described here.8 The other procedures described in this section will be articulated using a laparoscopic approach as that is the dominant method. RYGB, BPD, and DS may still be performed by some surgeons using an open approach, but this has now become the exception. In this text LRYGB will refer specifically to RYGB performed by the laparoscopic approach, while RYGB will indicate proce-dures performed by the open approach or by both approaches as is the case for many studies of outcomes. Minimization of the morbidity of the open incision, especially incisional hernias and wound complications, as well as earlier hospital discharge and lower 30-day complication rates have all been clearly shown to favor using a laparoscopic approach when feasible.128-130 Lapa-roscopy begins with the safe creation of a pneumoperitoneum, often a difficult step in the bariatric patient. A tracheostomy hook can be inserted through a


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Surgery_Schwartz. approach when feasible.128-130 Lapa-roscopy begins with the safe creation of a pneumoperitoneum, often a difficult step in the bariatric patient. A tracheostomy hook can be inserted through a trocar-sized incision to elevate the fascia in the left subcostal region to facilitate the insertion of a Veress needle into an appropriate location for pneumoperi-toneum creation. The use of a Hasson approach for creating a pneumoperitoneum in the bariatric population may be limited by the thick body wall. In the patient with an extremely thick body wall, extra-long trocar ports can be used for laparoscopic surgery. The pneumoperitoneum pressure that is used when per-forming bariatric surgical procedures is generally in the 15 to 18 mmHg range. A high-flow insufflator is mandatory to main-tain the pneumoperitoneum for adequate and safe visualization.When an open surgical approach is used for any of these procedures, an upper midline incision with table mounted retrac-tors is the most commonly


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Surgery_Schwartz. pneumoperitoneum for adequate and safe visualization.When an open surgical approach is used for any of these procedures, an upper midline incision with table mounted retrac-tors is the most commonly used approach. The robotic approach to bariatric procedures is also now utilized with purported Figure 27-8. Configuration of laparoscopic gastric bypass. (Reprinted with permission from Cleveland Clinic Center for Medi-cal Art & Photography © 2005-2009. All Rights Reserved.)advantages of reduction of the use of the open technique, improved surgical, length of stay, cost outcomes, and potentially improving ergonomics and resultant surgeon fatigue and injury. A meta-analysis involving 27 studies and over 25,000 patients concluded that there were no significant differences between robotic bariatric surgery and laparoscopic bariatric surgery with respect to overall complications, length of stay, reoperation, conversion, and mortality.131 Another study utilizing Univer-sity Consortium data


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Surgery_Schwartz. surgery and laparoscopic bariatric surgery with respect to overall complications, length of stay, reoperation, conversion, and mortality.131 Another study utilizing Univer-sity Consortium data demonstrated no difference in hospital mortality, major complications, readmissions, or length of stay between the robotic and laparoscopic approach.132 In both stud-ies, robotic surgery did increase significantly operative time and hospital costs (>20%) compared to laparoscopic approaches. As yet, larger prospective cohort studies and/or randomized trials have not yet been published, so the role of this technique is still to be defined and further studies are needed.133,134Laparoscopic Roux-en-Y Gastric BypassBackground and Patient Selection. Figure 27-8 depicts the configuration of the LRYGB. It is an appropriate operation for consideration for most patients eligible for bariatric surgery. Relative contraindications specifically for LRYGB include pre-vious gastric surgery, previous antireflux


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Surgery_Schwartz. an appropriate operation for consideration for most patients eligible for bariatric surgery. Relative contraindications specifically for LRYGB include pre-vious gastric surgery, previous antireflux surgery, severe iron deficiency anemia, distal gastric or duodenal lesions that require ongoing future surveillance, and Barrett’s esophagus with severe Brunicardi_Ch27_p1167-p1218.indd 118023/02/19 2:20 PM 1181THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 275mm5mm12mm12mm5mm5mmFigure 27-9. Port scheme for laparoscopic gastric bypass. (Reprinted with permission from Cleveland Clinic Center for Medi-cal Art & Photography © 2005-2009. All Rights Reserved.)dysplasia. The major feature of the operation is a proximal gas-tric pouch of small size (<20 mL) that is totally separated from the distal residual stomach. A Roux limb of proximal jejunum is brought up and anastomosed to the pouch. The pathway of that limb can be anterior to the colon and stomach, posterior to both, or posterior to the


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Surgery_Schwartz. residual stomach. A Roux limb of proximal jejunum is brought up and anastomosed to the pouch. The pathway of that limb can be anterior to the colon and stomach, posterior to both, or posterior to the colon and anterior to the stomach. The length of the biliopancreatic limb from the ligament of Treitz to the distal enteroenterostomy is 20 to 50 cm, and the length of the Roux limb is 75 to 150 cm.Creating the proximal gastric pouch by totally dividing it from the distal stomach is superior to simply stapling and par-titioning the stomach, since the latter is associated with a high incidence of staple line breakdown.135 The size of the proximal gastric pouch must be small to create adequate restriction and should be based on the lesser curvature of the stomach to pre-vent dilation over time. Length of the Roux limb was associated with higher short-term weight loss for longer length limbs,136 but this difference becomes less meaningful on long-term follow-up and has not been demonstrated


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Surgery_Schwartz. Length of the Roux limb was associated with higher short-term weight loss for longer length limbs,136 but this difference becomes less meaningful on long-term follow-up and has not been demonstrated in more recent studies.137 Gastric pouch size and caliber of the gastrojejunostomy have not, in any studies, been shown to be related to weight loss. The gas-trojejunal anastomosis can be constructed in a variety of ways, including hand sewn techniques and linear and circular staplers. Smaller diameter circular staplers are associated with a higher incidence of postoperative stenosis, and linear stapling is asso-ciated with a lower incidence of stenosis compared to circular stapling.138,139Technique. The operation generally is performed using five ports plus a liver retractor as shown in Fig. 27-9. Both the sur-geon, who stands on the patient’s right, and the first assistant, who stands on the patient’s left, have two ports for instruments. The telescope requires a port, usually in the


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Surgery_Schwartz. 27-9. Both the sur-geon, who stands on the patient’s right, and the first assistant, who stands on the patient’s left, have two ports for instruments. The telescope requires a port, usually in the supraumbilical region. The assistant’s ports are in the left subcostal and flank areas, while the surgeon may have both ports in the right upper quadrant or one on each side of the camera. Division of the proximal jejunum at 40 to 50 cm distal to the ligament of Tre-itz is performed with the linear stapler, using a vascular stapler cartridge. Further division of the mesentery at that location is performed either with the stapler or harmonic scalpel, such that adequate mobilization of the Roux limb is achieved. A Pen-rose drain or a marking suture is placed on the proximal Roux limb for identification and facilitation of advancement to the Figure 27-10. Creating Roux limb during laparoscopic gastric bypass.gastric pouch (Fig. 27-10). The length of the Roux limb (usually 100–150 cm) to be


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Surgery_Schwartz. and facilitation of advancement to the Figure 27-10. Creating Roux limb during laparoscopic gastric bypass.gastric pouch (Fig. 27-10). The length of the Roux limb (usually 100–150 cm) to be created is measured. A jejunojejunostomy is then created to the proximal end of the biliopancreatic limb at the previously determined location along the Roux limb. A side-to-side stapled anastomosis is performed (Fig. 27-11). Either singleor double-fired staple technique (the latter using a stapler Brunicardi_Ch27_p1167-p1218.indd 118123/02/19 2:20 PM 1182SPECIFIC CONSIDERATIONSPART IIFigure 27-12. Passage of Roux limb. (Reprinted with permission from Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All Rights Reserved.)321Figure 27-13. Creation of gastric pouch for laparoscopic Roux-en-Y gastric bypass. (Reprinted with permission from Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All Rights Reserved.)Figure 27-11. Enteroenterostomy of lapa-roscopic


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Surgery_Schwartz. Roux-en-Y gastric bypass. (Reprinted with permission from Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All Rights Reserved.)Figure 27-11. Enteroenterostomy of lapa-roscopic Roux-en-Y gastric bypass.fired in each direction) is used. The stapler defect is optimally closed with sutures but can be closed with a stapler if great care is taken not to narrow the lumen of the alimentary tract at this location. Once the stapler defect is closed, the mesenteric defect is then also closed with running permanent suture.Passage of the Roux limb toward the stomach is now per-formed. If an antecolic route is to be used, the end of the Roux limb is brought up so as to confirm its ability to reach the stom-ach (Fig. 27-12). If a retrocolic route is to be used, a defect is made in the transverse colon mesentery just to the left and slightly above the ligament of Treitz. The proximal end of the Roux limb is placed into the retrogastric space. The left lobe of the liver is now


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Surgery_Schwartz. the transverse colon mesentery just to the left and slightly above the ligament of Treitz. The proximal end of the Roux limb is placed into the retrogastric space. The left lobe of the liver is now retracted using any one of several retractor types. The patient is moved to a reverse Trendelenburg posi-tion. The harmonic scalpel divides the peritoneum in the area of the angle of His, and then it is used to open an area along the lesser curvature of the stomach approximately 3 cm down from the gastroesophageal junction. Another approach for creating access to the lesser curvature of the stomach is to use a white or gray load (vascular load) of the stapler and divide the lesser curvature vessels up to the surface of the stomach. Then a blue load of the stapler is fired one time transversely from the lesser curvature side partially across the stomach, followed by mul-tiple subsequent firings of the stapler upward in the direction of the angle of His, to completely separate the proximal


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Surgery_Schwartz. from the lesser curvature side partially across the stomach, followed by mul-tiple subsequent firings of the stapler upward in the direction of the angle of His, to completely separate the proximal gastric pouch from the remainder of the stomach (Fig. 27-13). Option-ally, use of an Ewald tube passed by the anesthesiologist and maneuvered to lie against the lesser curvature of the proximal stomach can help calibrate the pouch size.Once the pouch is created, the Roux limb is brought up to the proximal gastric pouch. For the linear stapled anastomosis, the proximal end of the Roux limb is aligned with the distal gastric pouch end, and the sides of the organs are sutured together to maintain their side-by-side position. A stapler is introduced through a gastrotomy and an enterotomy for the two legs of the stapler, and the anastomosis is created (Fig. 27-14). The stapler defect is closed with sutures and often reinforced with a second Brunicardi_Ch27_p1167-p1218.indd 118223/02/19


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Surgery_Schwartz. two legs of the stapler, and the anastomosis is created (Fig. 27-14). The stapler defect is closed with sutures and often reinforced with a second Brunicardi_Ch27_p1167-p1218.indd 118223/02/19 2:21 PM 1183THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 27Figure 27-14. Gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass. (Reprinted with permission from Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All Rights Reserved.)Figure 27-15. Oral passage of EEA circular stapler to create gastrojejunostomy for laparoscopic Roux-en-Y gastric bypass. (Reprinted with permission from Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All Rights Reserved.)step of the operation involves suture closure of all mesenteric defects using permanent suture.Alternatively, a completely hand-sewn gastrojejunostomy can be created using two layers of absorbable suture to anasto-mose an approximately 1-cm gastrotomy and enterotomy. The circular anastomosis technique is


Surgery_Schwartz

Surgery_Schwartz. a completely hand-sewn gastrojejunostomy can be created using two layers of absorbable suture to anasto-mose an approximately 1-cm gastrotomy and enterotomy. The circular anastomosis technique is another approach to complete the gastrojejunostomy and is also a particularly useful technique for “salvage” anastomosis if the gastric pouch is very small and/or high. This is done through placement of the anvil of the sta-pler through the anterior wall of the proximal gastric pouch. This is accomplished by pulling the anvil transorally via an endoscopically placed guidewire (Fig. 27-15), making a gas-trotomy in the pouch that is later closed, or making a gastrotomy in the lower stomach before completing gastric division to cre-ate the pouch, allowing the anvil to be placed into the lumen of the stomach and then be brought through the anterior stomach in an area that is subsequently included in the proximal gastric pouch (Fig. 27-16).Procedure-Specific Complications. Mortality after LRYGB is


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Surgery_Schwartz. stomach and then be brought through the anterior stomach in an area that is subsequently included in the proximal gastric pouch (Fig. 27-16).Procedure-Specific Complications. Mortality after LRYGB is now consistently less than 0.5% in most large reported series. Data from several national data sets/studies find a mortal-ity rate of approximately 0.3%, 0.14%, and 0.2% at 30 days overall.59,140 Overall morbidity after LRYGB has also been low. In the Longitudinal Assessment of Bariatric Surgery (LABS) study, a composite endpoint including death, deep-vein throm-bosis or venous thromboembolism, reintervention, or failure to be discharged by 30 days after surgery occurred in 4.8% of those who had undergone LRYGB.59 In the national database of the ASMBS, morbidity alone was 14.87% for 30,864 gas-tric bypass procedures.141 Complications that do occur after LRYGB include a 0.3% incidence of anastomotic leak,142 0.33% layer of sutures. The gastrojejunostomy may be tested for secu-rity by using


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Surgery_Schwartz. bypass procedures.141 Complications that do occur after LRYGB include a 0.3% incidence of anastomotic leak,142 0.33% layer of sutures. The gastrojejunostomy may be tested for secu-rity by using either methylene blue injected under pressure through the Ewald tube or a flexible upper endoscopy intraop-eratively to test for air leakage from the anastomosis. The final Brunicardi_Ch27_p1167-p1218.indd 118323/02/19 2:21 PM 1184SPECIFIC CONSIDERATIONSPART IIFigure 27-16. Transgastric passage of circular EEA stapler to create gastrojejunostomy for laparoscopic Roux-en-Y gastric bypass. (Reproduced with permission from Schauer PR, Schirmer BD, Brethauer S: Minimally Invasive Bariatric Surgery. New York, NY: Springer; 2007.)Figure 27-17. Obstruction of contrast at enteroenterostomy with small bowel obstruction from internal hernia after laparoscopic Roux-en-Y gastric bypass.incidence of venous thromboembolism,143 a 3% to 5% incidence of wound infections or problems,140 a 3% to 15% incidence


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Surgery_Schwartz. obstruction from internal hernia after laparoscopic Roux-en-Y gastric bypass.incidence of venous thromboembolism,143 a 3% to 5% incidence of wound infections or problems,140 a 3% to 15% incidence of marginal ulcers,144 an approximately 7% incidence of bowel obstruction,145 a 4% incidence of postoperative transfusion,146 and a 1% to 19% incidence of anastomotic stenosis,139 based on the type of anastomosis created. Postoperative nutritional complications after LRYGB include a 66% incidence of iron deficiency, a 5% incidence of iron deficiency anemia, a 50% incidence of vitamin B12 deficiency,147 and an at least 15% incidence of vitamin D deficiency,148 which usually is pres-ent preoperatively. Both early and late dumping occur in an unspecified number of postoperative cases, as the symptoms are difficult to document and overlap with other problems such as hypoglycemia.Several complications that are specific to LRYGB must be emphasized. One of the most important is small bowel


Surgery_Schwartz

Surgery_Schwartz. symptoms are difficult to document and overlap with other problems such as hypoglycemia.Several complications that are specific to LRYGB must be emphasized. One of the most important is small bowel obstruction. This complication must be treated differently than in the average general surgery patient, whose complication is usually from adhesions and often will resolve with conserva-tive, nonoperative therapy. Patients who have had LRYGB who present with obstructive symptoms generally require surgical therapy on an emergent basis. This is because the etiology of the bowel obstruction after LRYGB is often an internal hernia from inadequate or nonclosure of the mesenteric defects by the sur-geon at the time of operation. Thus, treatment for these patients differs from most patients with small bowel obstruction. One of the most important points of this chapter is to emphasize to gen-eral surgeons to be aware of the need to emergently operate on patients after LRYGB who present with small


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Surgery_Schwartz. bowel obstruction. One of the most important points of this chapter is to emphasize to gen-eral surgeons to be aware of the need to emergently operate on patients after LRYGB who present with small bowel obstruc-tion. Currently, centers that perform small bowel transplantation are seeing patient referral for that procedure after small bowel obstruction after LRYGB, where patients developed infarction of most of the bowel from an internal hernia and have short gut syndrome.149 Other patients, for whom surgery is delayed and the bowel infarcts, do not survive. When the surgeon does encounter bowel obstruction after LRYGB, he or she can expect to see proximally dilated bowel. Cutoff of passage of contrast on CT scan at the enteroenterostomy is particularly suggestive of this diagnosis (Fig. 27-17). The surgical treatment of this particular problem can, if addressed early in the course of the obstruction, be treated laparoscopically. The surgeon must place a trocar for the telescope low


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Surgery_Schwartz. 27-17). The surgical treatment of this particular problem can, if addressed early in the course of the obstruction, be treated laparoscopically. The surgeon must place a trocar for the telescope low enough in the abdomen to ade-quately survey most of the small intestine. The cecum and ter-minal ileum are identified, and the bowel is followed retrograde from the terminal ileum to determine the anatomy. Often much of the small bowel is herniated through a mesenteric defect, and only this technique allows the surgeon to reliably identify the bowel and decompress it appropriately. If the bowel is viable, 4Brunicardi_Ch27_p1167-p1218.indd 118423/02/19 2:21 PM 1185THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 27suturing the mesenteric defect is all that is needed for treatment. It should be emphasized that either an antecolic or retrocolic placement of the Roux limb can result in this complication, as internal hernias can arise from either approach.Marginal ulcers are another complication


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Surgery_Schwartz. that either an antecolic or retrocolic placement of the Roux limb can result in this complication, as internal hernias can arise from either approach.Marginal ulcers are another complication relatively specific to LRYGB. The patient presents with pain in the epigastric region that is not altered by eating. Diagnosis is by endoscopy. Treatment is medical with proton pump inhibitors, which are effective in 90% of cases. Only those with a gastrogastric fistula to the distal stomach, severe stenosis of the lumen of the gastrojejunostomy, or acute perforation require surgical therapy. Treatment of a perforated marginal ulcer is a laparoscopic Graham patch. Stenosis of the gastrojejunostomy has been reduced by the use of the linear stapling technique.138 Stenosis symptoms usually appear from 6 to 12 weeks postoperatively, but less commonly can occur later. Diagnosis is by upper endoscopy. Treatment is circumferential balloon dilatation. Resolution normally occurs with one to two treatments.


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Surgery_Schwartz. 12 weeks postoperatively, but less commonly can occur later. Diagnosis is by upper endoscopy. Treatment is circumferential balloon dilatation. Resolution normally occurs with one to two treatments. Less than 10% of patients require reoperation, and those are almost always associated with concurrent marginal ulcers.150In the immediate postoperative period, anastomotic leak is the single serious complication after RYGB, either open or laparoscopic. Careful vigilance and a high index of suspicion for this problem are important since its presentation may be insidi-ous and the patient’s demise, if untreated, may be sudden and complete. Tachycardia, tachypnea, fever, and oliguria are the most common symptoms that should arouse suspicion for this problem. The treatment is surgical, except in rare circumstances where a drain is already in place, no hemodynamic or clinical deterioration is present, and the leak is contained.151 Usual surgi-cal treatment involves repair as feasible, drainage,


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Surgery_Schwartz. circumstances where a drain is already in place, no hemodynamic or clinical deterioration is present, and the leak is contained.151 Usual surgi-cal treatment involves repair as feasible, drainage, and creation of a reliable feeding access through a distal Stamm gastrostomy.In the first few hours or day after surgery, hematemesis indicates bleeding from the gastrojejunostomy unless proven otherwise. The dangers to the patient include aspiration, life-threatening hemorrhage, or more commonly intraluminal hematoma of the Roux limb and enteroenterostomy, which then causes an obstruction of the biliopancreatic limb leading to distal gastric staple line rupture.152 In fact, any obstructive symptoms in the first few weeks after surgery or any signs of obstruction of the biliopancreatic limb on postoperative swallow studies due to stenosis of the enteroenterostomy require imme-diate surgical intervention to prevent rupture of the distal gastric staple line. Some reports show that percutaneous


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Surgery_Schwartz. swallow studies due to stenosis of the enteroenterostomy require imme-diate surgical intervention to prevent rupture of the distal gastric staple line. Some reports show that percutaneous decompres-sion of the distal stomach can help to ameliorate the problem,153 but operative therapy to decompress the stomach and treat the obstruction is first-line therapy.Laparoscopic Sleeve GastrectomyBackground and Patient Selection. SG was originally introduced as the first of a two-stage operative treatment for patients with super obesity (BMI >60 kg/m2).154,155 Its currently utilization is as a primary single-stage operation, but the pos-sibility of a second-stage treatment remains, especially for the super obese patients, depending on the effectiveness of it as the primary operation. In addition, patients who have longstanding severe GERD may not be good candidates for SG as GERD is worsened by the anatomical configuration of the SG. Barrett’s esophagus is also a contraindication for


Surgery_Schwartz

Surgery_Schwartz. patients who have longstanding severe GERD may not be good candidates for SG as GERD is worsened by the anatomical configuration of the SG. Barrett’s esophagus is also a contraindication for performing SG, since the potential for future esophageal dysplasia and the need for an available intact stomach for esophageal reconstruction outweigh the potential advantages of the procedure.Figure 27-18. Port scheme for laparoscopic sleeve gastrectomy.Technique. The patient is positioned supine, with foot sup-port to allow reverse Trendelenburg positioning. The surgeon stands to the patient’s right along with the camera driver, while the assistant stands to the patient’s left. Port placement may vary, but a recommended port placement schema is shown in Fig. 27-18. The 15-mm port, helpful for removal of the stomach, is located in either the camera (just to the patient’s left of the umbilicus) or surgeon’s right hand (right upper quadrant near the midline) location. The other of these ports is a


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Surgery_Schwartz. of the stomach, is located in either the camera (just to the patient’s left of the umbilicus) or surgeon’s right hand (right upper quadrant near the midline) location. The other of these ports is a 12-mm port. The assistant has two 5-mm ports available in the left upper quadrant laterally, and the surgeon’s left-hand port is a 5-mm port more lateral and superior in the right upper quadrant. A liver retractor is placed in the epigastric region.The operation begins by devascularizing the greater curva-ture of the stomach, beginning 3 to 5 cm proximal to the pylorus. The division of all vessels adjacent to the greater curvature is continued up to the left crus of the diaphragm. A complete mobilization of the fundus in this area and division of posterior fibrous attachments to the antrum and body of the stomach are then performed such that the stomach is attached solely by the lesser curvature blood supply and the pyloric and esophageal regions. Stapled division of the stomach now


Surgery_Schwartz

Surgery_Schwartz. and body of the stomach are then performed such that the stomach is attached solely by the lesser curvature blood supply and the pyloric and esophageal regions. Stapled division of the stomach now follows. The first firing of the stapler occurs from the point of devascularization of the greater curvature at an angle pointing toward a point about 2 cm lateral to the incisura. The antrum of the stomach is at its thickest here, and so it is important to be certain the stapler load used is sufficiently large enough to allow good approximation and closure of the divided stomach. Two staple firings are performed, which takes the gastric division to past the incisura. After the first staple firing, some surgeons will engage the anesthesiologist to pass a 32to 40-French bougie and position it along the lesser curvature of the stomach. This bougie then serves as a guide for further gastric division. Alter-natively, some surgeons will insert the endoscope instead of the bougie as a guide for


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Surgery_Schwartz. the lesser curvature of the stomach. This bougie then serves as a guide for further gastric division. Alter-natively, some surgeons will insert the endoscope instead of the bougie as a guide for gastric division. It can also be used to test for air leaks, bleeding, or obstruction as it is withdrawn after gastric division. Dividing the stomach adjacent to the bougie or endoscope will produce the desired diameter of the gastric sleeve. It is most important not to narrow the stomach lumen at the incisura. During the second and third firing of the stapler to divide the stomach, it is critical to confirm by visualization of both the anterior and posterior surfaces of the stomach that the incisura area is not narrowed. By the third firing of the stapler, usually the angle of the gastric division is now pointed directly toward the angle of His, parallel to the bougie (Fig. 27-19). Brunicardi_Ch27_p1167-p1218.indd 118523/02/19 2:21 PM 1186SPECIFIC CONSIDERATIONSPART IIFigure


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Surgery_Schwartz. division is now pointed directly toward the angle of His, parallel to the bougie (Fig. 27-19). Brunicardi_Ch27_p1167-p1218.indd 118523/02/19 2:21 PM 1186SPECIFIC CONSIDERATIONSPART IIFigure 27-20. Completed sleeve gastrectomy. (Reprinted with permission from Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All Rights Reserved.)Figure 27-19. Performing sleeve gastrectomy. (Reprinted with permission from Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All Rights Reserved.)At this point, changing staple loads to lower staple height is advisable.Once the stomach is completely divided up to the angle of His, the staple line is inspected for hemostasis and integ-rity. Some surgeons will reinforce the staple line with a but-tress material, while others will invaginate the staple line with a running serosa to serosa suture. Some surgeons will exchange the bougie at this point for a 32-French Ewald tube and per-form a methylene blue leak test.


Surgery_Schwartz

Surgery_Schwartz. others will invaginate the staple line with a running serosa to serosa suture. Some surgeons will exchange the bougie at this point for a 32-French Ewald tube and per-form a methylene blue leak test. Alternatively, if an endoscope is used, it is withdrawn with insufflation, and the staple line is inspected for air leaks while submerged in saline. The speci-men is removed through the 15-mm trocar site, usually with only slight enlargement of the site. Figure 27-20 shows the com-pleted operation. Controversy still exists as to the optimal size of the bougie used during the procedure and the relative utility of methods used to oversew or reinforce the staple line.Procedure-Specific Complications. The major factor unique to SG is that it creates a high-pressure gastric tube. This increased intraluminal pressure places the staple line at risk for leakage and increased risk for GERD. As noted previ-ously, controversy exists about both bougie size and staple line reinforcement/oversew as


Surgery_Schwartz

Surgery_Schwartz. intraluminal pressure places the staple line at risk for leakage and increased risk for GERD. As noted previ-ously, controversy exists about both bougie size and staple line reinforcement/oversew as they relate to clinical outcomes. One summary of the literature shows that the stenosis rate is lower if a 40-French bougie is used, and the leak rate may also be lower without compromising weight loss.156 However, individual insti-tutional experiences with smaller-sized bougies have shown the potential for good weight loss and no increased incidence of stenosis.157 Another controversial area is that of staple line rein-forcement with staple buttressing material or reinforcement with oversewing.158 The overall bleeding rate for the staple line after SG is generally cited as about 2% in collected series.159 There have been no studies that have shown a definitive decrease in this bleeding rate with the use of buttress materials; however, a panel of experts has voiced support for a decreased


Surgery_Schwartz

Surgery_Schwartz. series.159 There have been no studies that have shown a definitive decrease in this bleeding rate with the use of buttress materials; however, a panel of experts has voiced support for a decreased incidence of bleeding from the staple line if buttress material is used.158 One meta-analysis did show that there is evidence to suggest buttress materials may decrease the staple line leak rate.160 Other prospective randomized studies have failed to show a benefit of buttress materials for leak prevention.161 A more recent study of over 180,000 SG procedures in the Metabolic and Bariat-ric Surgery Accreditation and Quality Improvement Program (MBSAQIP) national database showed that staple line rein-forcement cases were associated with higher leak rates (0.96% vs. 0.65%, odds ratio [OR] 1.20 95% CI 1.00–1.43) and lower bleeding rates (0.75% vs. 1.00%, OR 0.74 95% CI 0.63–0.86) compared to no reinforcement, at the patient level.162 At this time, there is no preponderance of data to support


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Surgery_Schwartz. CI 1.00–1.43) and lower bleeding rates (0.75% vs. 1.00%, OR 0.74 95% CI 0.63–0.86) compared to no reinforcement, at the patient level.162 At this time, there is no preponderance of data to support one approach as being superior to others for both staple line bleeding or leak rates. Given this state of the literature, a surgeon should con-sider the risks, benefits, and costs of these surgical techniques and utilize those that, in their hands, minimize morbidity while maximizing clinical outcomes.If there is a relative obstruction or stenosis of the sleeve, which most often occurs at the incisura because of narrowing there during formation of the sleeve, pressure above the level of the obstruction will be even more elevated and create an increased risk for staple line leak. Leaks of the proximal staple line are the most frequent type seen after SG and often are felt to be related to increased intraluminal pressure distally. They may also be related to stapling too close to the angle of


Surgery_Schwartz

Surgery_Schwartz. staple line are the most frequent type seen after SG and often are felt to be related to increased intraluminal pressure distally. They may also be related to stapling too close to the angle of His, with resultant instability of the tissue directly adjacent to the esophagus in this area. It is important not to staple too close to the angle of His during the final stapling division portion of the stomach so as to not further weaken the staple line in this area. Proximal staple line leaks may also present as late leaks, 6 weeks to months following the procedure. Late leaks are rare Brunicardi_Ch27_p1167-p1218.indd 118623/02/19 2:21 PM 1187THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 27Figure 27-21. Laparoscopic adjustable band overall scheme. (Reprinted with permission from Cleveland Clinic Center for Medi-cal Art & Photography © 2005-2009. All Rights Reserved.)following other bariatric procedures, but are seen with SG, and index of suspicion should remain high.Distal staple line leaks


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Surgery_Schwartz. Center for Medi-cal Art & Photography © 2005-2009. All Rights Reserved.)following other bariatric procedures, but are seen with SG, and index of suspicion should remain high.Distal staple line leaks are different from proximal staple line leaks and are usually associated with earlier presentation and related to mechanical failure of the staple line to securely approximate the thicker distal gastric tissue. These leaks are more amenable to successful repair with a reoperation, whereas proximal leaks may not improve with oversewing at a reopera-tion unless the mechanics of the relative distal obstruction and high intraluminal pressure of the sleeve are also treated. Endo-scopic intervention to dilate stenotic areas as well may be bene-ficial in the setting of a stenosis with or without a proximal leak. Care must be taken by the endoscopist to not excessively dilate the tract beyond the original size of the bougie used. Another factor that may influence stenosis at the incisura is that


Surgery_Schwartz

Surgery_Schwartz. leak. Care must be taken by the endoscopist to not excessively dilate the tract beyond the original size of the bougie used. Another factor that may influence stenosis at the incisura is that there may be a relative twisting of the stomach at this location, with the antrum being partially twisted away from the upper por-tion of the sleeve. Endoscopic treatment can help straighten and markedly alleviate the obstruction in such cases. Thus, relatively early endoscopic intervention is appropriate in the patient with a stenosis at the incisura. One study has shown that endoscopic dilation is usually successful in treating stenosis after SG, with a mean of 1.6 dilatations being done an average of 48 days postoperatively.163The patient with the proximal gastric staple line leak because of mechanical factors may experience persistence of the leak for months. Nonsurgical treatment with drainage and stenting can be used initially. Some now advocate for conver-sion of the patient with a


Surgery_Schwartz

Surgery_Schwartz. mechanical factors may experience persistence of the leak for months. Nonsurgical treatment with drainage and stenting can be used initially. Some now advocate for conver-sion of the patient with a longstanding leak after SG to a RYGB to provide a low-pressure anastomosis above the site of the ste-nosis.164,165 Similarly, persistent stenosis of the sleeve despite conservative therapy and endoscopic dilatation also is an indica-tion for conversion to RYGB.Laparoscopic Adjustable Gastric BandingBackground and Patient Selection. LAGB involves place-ment of an inflatable silicone ring around the proximal stom-ach. The band is attached to a reservoir system that allows adjustment of the tightness of the band. This reservoir system is accessed through a subcutaneously placed port, similar in concept to ports used for chemotherapy via central venous catheters. Figure 27-21 shows the LAGB apparatus in place. Patients who have had previous upper gastric surgery, such as a Nissen


Surgery_Schwartz

Surgery_Schwartz. similar in concept to ports used for chemotherapy via central venous catheters. Figure 27-21 shows the LAGB apparatus in place. Patients who have had previous upper gastric surgery, such as a Nissen fundoplication, and those with severe GERD are rela-tively poor candidates for LAGB due to altered proximal gastric anatomy interfering with proper band placement or worsening of GERD symptoms. Two major types of bands have been used for this procedure. The original Lap-Band has been used most frequently. The Swedish Band, remarketed as the Realize Band in the United States, is slightly wider and larger in circumfer-ence than the Lap-Band but is no longer being manufactured. The port systems have differences as to profile and methods of attachment to the fascia.Technique. Port placement for LAGB has varied among sur-geons. Usually some combination of two ports for the surgeon’s hands, one or two for the assistant, a port for the telescope, and a liver retractor site are needed. With the


Surgery_Schwartz

Surgery_Schwartz. LAGB has varied among sur-geons. Usually some combination of two ports for the surgeon’s hands, one or two for the assistant, a port for the telescope, and a liver retractor site are needed. With the patient placed in reverse Trendelenburg position, the procedure begins with division of the peritoneum at the angle of His and then division of the gas-trohepatic ligament in its avascular area (the pars flaccida) to expose the base of the right crus of the diaphragm. If a hia-tal hernia is present, it must be repaired at this point, using a Figure 27-22. Grasper being passed through under stomach to grasp tubing during placement. (Reprinted with permission from Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All Rights Reserved.)standard posterior esophageal dissection to expose the crura and perform suture repair. A grasper is inserted along the base of the anterior surface of the diaphragmatic crura, from right to left, emerging at the angle of His in the area of the


Surgery_Schwartz

Surgery_Schwartz. the crura and perform suture repair. A grasper is inserted along the base of the anterior surface of the diaphragmatic crura, from right to left, emerging at the angle of His in the area of the divided peri-toneum (Fig. 27-22). The device is then used to pull the band Brunicardi_Ch27_p1167-p1218.indd 118723/02/19 2:21 PM 1188SPECIFIC CONSIDERATIONSPART IIABunderneath the posterior surface of the gastroesophageal junc-tion. This technique, by passing the band through some fibrous tissue in this plane, serves to anchor the band more securely posteriorly. During the initial years of band placement, a ret-rogastric location of the posterior half of the band in the free space of the lesser sac caused an unacceptably high incidence of slippage and prolapse of the band. The adoption of the pars flaccida technique decreased the incidence of such slippage.166Once the band is passed around the proximal stomach, it is locked into its ring configuration through its own self-locking mechanism.


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Surgery_Schwartz. flaccida technique decreased the incidence of such slippage.166Once the band is passed around the proximal stomach, it is locked into its ring configuration through its own self-locking mechanism. This involves the tubing end being passed through the orifice of the buckle for the Lap-Band and the suture on the end of the flanged end of the band site being passed through for the Realize Band. Once the band is securely locked in place, the buckle portion of the band is located on the lesser curvature of the stomach (Fig. 27-23A,B). Now the anterior surface of the fundus and proximal stomach is imbricated over the band using several sutures (Fig. 27-24). The tubing of the band system is brought out through the desired site for placement of the port portion of the system. Usually this is a trocar site near the upper abdomen or xiphoid region to place the port most superficially such that it can be palpated postoperatively. The port is secured Figure 27-23. A. Lap-Band in place around


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Surgery_Schwartz. a trocar site near the upper abdomen or xiphoid region to place the port most superficially such that it can be palpated postoperatively. The port is secured Figure 27-23. A. Lap-Band in place around stomach. (Reprinted with permission from Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All Rights Reserved.) B. RealizeT (Swedish) Band around stomach.to the anterior abdominal wall fascia. Access to the port for subsequent addition of fluid to the band system is percutane-ously achieved using a Huber or noncutting type needle. The band is initially placed empty of fluid, except priming, in most circumstances.Procedure-Specific Complications. The complications that may occur after LAGB include gastric prolapse, band slippage, band erosion, and port and tubing complications. In addition, failure to lose clinically significant weight is more common fol-lowing this procedure compared to others. Acute gastric pro-lapse is the most common emergent complication that


Surgery_Schwartz

Surgery_Schwartz. In addition, failure to lose clinically significant weight is more common fol-lowing this procedure compared to others. Acute gastric pro-lapse is the most common emergent complication that requires reoperation after LAGB. Acute, severe pain with immediate dysphagia, vomiting, and inability to take oral food or liquid is the typical presentation. Vomiting may predispose or exac-erbate this problem. Either anterior or posterior prolapse may occur.167 The initial evaluation for prolapse involves obtaining a plain film radiograph. If the band is in a horizontal position instead of its normal oblique position, prolapse must be strongly suspected. Initial treatment for an acute or chronic prolapse is to remove all the fluid from the system. This often allows reduc-tion of the prolapse and resolution of symptoms. If symptoms do not resolve after this, an upper gastrointestinal (UGI) series Brunicardi_Ch27_p1167-p1218.indd 118823/02/19 2:21 PM 1189THE SURGICAL MANAGEMENT OF


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Surgery_Schwartz. and resolution of symptoms. If symptoms do not resolve after this, an upper gastrointestinal (UGI) series Brunicardi_Ch27_p1167-p1218.indd 118823/02/19 2:21 PM 1189THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 27Figure 27-24. Stomach imbricated over band.is indicated, and if prolapse persists, then reoperation laparo-scopically to reduce the prolapse and resuture the band in place is indicated. Chronic gastric prolapse is more subtle. The band retains its normal oblique angle, but there is symmetric dilation of the gastric pouch above the band. These are initially managed with fluid removal and monitoring of symptoms. Follow-up evaluation can be performed in 4 to 8 weeks, and if the chronic prolapse resolves on UGI, slow refilling of the band may begin.Band erosion is uncommon, reported in 1% to 2% of most series. The patient usually develops either a port site infection or systemic fever and a low-grade abdominal inflammatory sepsis. Endoscopy can be diagnostic, visualizing the white


Surgery_Schwartz

Surgery_Schwartz. 1% to 2% of most series. The patient usually develops either a port site infection or systemic fever and a low-grade abdominal inflammatory sepsis. Endoscopy can be diagnostic, visualizing the white band mate-rial within the stomach. The presence of otherwise unexplained free air on computed tomography (CT) scan should alert the surgeon to this diagnosis as well. Laparoscopic removal of the band is indicated, with repair of the gastric perforation. Often the perforation is already sealed by an inflammatory process, but if not, appropriate management of a gastric perforation must be followed.167Port and tubing problems occur in at least 5% to 15% of patients undergoing LAGB. These require revision of the port/tubing system due to perforation, leaking, or kinking of the tub-ing or turning of the port such that access to the surface of the port for adding fluid is precluded. Usually a procedure under local anesthesia is all that is required to repair or realign the tub-ing or port. The


Surgery_Schwartz

Surgery_Schwartz. of the port such that access to the surface of the port for adding fluid is precluded. Usually a procedure under local anesthesia is all that is required to repair or realign the tub-ing or port. The incidence of band removal for patient dissatisfac-tion or lack of weight loss has been difficult to assess completely, but this number is increasing annually. Angrisani et al168 reported a 40.9% incidence of band removal after 10-year follow-up. In the Longitudinal Assessment of Bariatric Surgery (LABS) study, 18 subsequent reoperations occurred for every 100 participants with LAGB who were followed up for 3 years.169 Overall, these numbers are expected to increase as follow-up increases.Biliopancreatic Diversion and Duodenal SwitchBackground and Patient Selection. BPD was first described by, and remains championed by, Scopinaro in Italy.9 The operation, which is shown in Fig. 27-25, involves resection of the distal half to two-thirds of the stomach and creation of an alimentary tract of


Surgery_Schwartz

Surgery_Schwartz. and remains championed by, Scopinaro in Italy.9 The operation, which is shown in Fig. 27-25, involves resection of the distal half to two-thirds of the stomach and creation of an alimentary tract of the most distal 200 cm of ileum, which is anastomosed to the stomach. The biliopancreatic limb is anastomosed to the alimentary tract at approximately 100 cm proximal to the ileocecal valve. This operation is limited in its utilization due to both technical difficulty and the significant percentage of nutritional complications that arise postoperatively.One early problem with BPD was the development of a high incidence of marginal ulcers postoperatively. Hess and Figure 27-25. Diagram of biliopancreatic diversion. (Reprinted with permission from Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All Rights Reserved.)Brunicardi_Ch27_p1167-p1218.indd 118923/02/19 2:21 PM 1190SPECIFIC CONSIDERATIONSPART IIHess10 and Marceau and colleagues170 separately described the


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Surgery_Schwartz. Photography © 2005-2009. All Rights Reserved.)Brunicardi_Ch27_p1167-p1218.indd 118923/02/19 2:21 PM 1190SPECIFIC CONSIDERATIONSPART IIHess10 and Marceau and colleagues170 separately described the adaptation of the DS operation, originally proposed by DeMeester and colleagues171 for treatment of bile reflux gastri-tis, to replace the gastric portion of the BPD. This procedure was originally called BPD with DS. For ease of description, it is now simply called the duodenal switch (DS) (Fig. 27-26). Currently, BPD and DS represent together less than 1% to 2% of bariatric operations performed in the United States. Patients who undergo either BPD or DS must be prepared for the consequences of a malabsorptive operation. Frequent and large-quantity bowel movement after any large amount of oral intake is common. Also, patients must agree to close follow-up and a large number of vitamin and mineral supplements to avoid nutritional prob-lems. Given the increased incidence of postoperative


Surgery_Schwartz

Surgery_Schwartz. intake is common. Also, patients must agree to close follow-up and a large number of vitamin and mineral supplements to avoid nutritional prob-lems. Given the increased incidence of postoperative nutritional and other complications, BPD and DS usually are recommended only for patients who have higher BMIs or for patients who have failed another operation for weight loss or metabolic control. Contraindications to the procedure include geographic distance from the surgeon, lack of financial means to afford supplements, and preexisting calcium, iron, or other nutrient deficiencies.Technique. The technique for BPD and DS is the same for the open and the laparoscopic approach, and they are very techni-cally challenging operations.172 The BPD operation begins with performance of a distal subtotal gastrectomy with a residual 200-mL gastric pouch. The terminal ileum is identified and divided 250 cm proximal to the ileocecal valve. The distal end of that divided ileum is then anastomosed to


Surgery_Schwartz

Surgery_Schwartz. gastrectomy with a residual 200-mL gastric pouch. The terminal ileum is identified and divided 250 cm proximal to the ileocecal valve. The distal end of that divided ileum is then anastomosed to the stom-ach, creating a 2to 3-cm stoma. The proximal end of the ileum is then anastomosed side-to-side to the terminal ileum Figure 27-26. Diagram of duodenal switch. (Reprinted with permission from Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All Rights Reserved.)approximately 100 cm proximal to the ileocecal valve. Prophy-lactic cholecystectomy is performed due to the high incidence of gallstone formation with the malabsorption of bile salts.The DS procedure differs from the BPD procedure only in the proximal gut portion of the operation. Instead of a distal gas-trectomy, resection of all the stomach except for a narrow lesser curvature tube of the stomach (SG) is performed. The diam-eter of this tube is calibrated with a bougie of 32to 40-French size. The duodenum


Surgery_Schwartz

Surgery_Schwartz. resection of all the stomach except for a narrow lesser curvature tube of the stomach (SG) is performed. The diam-eter of this tube is calibrated with a bougie of 32to 40-French size. The duodenum is them divided in its first portion, leaving an approximately 2-cm length of duodenum intact beyond the pylorus. This end of the duodenum is then anastomosed to the distal 250 cm of ileum. This anastomosis is often done in an end-to-end fashion with a circular stapler. This is the most dif-ficult portion of the DS procedure, and leak rates are slightly higher than with other anastomoses. The distal bowel configura-tion and cholecystectomy are similar to BPD.Procedure-Specific Complications. Complications that occur after BPD include those seen after RYGB, where intestinal anastomoses and gastric division create potential problems with bleeding and leakage. Scopinaro and col-leagues173 reported GI obstruction in 1.2%, wound infections in 1.2%, and marginal ulcers in 2.8% of patients.


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Surgery_Schwartz. gastric division create potential problems with bleeding and leakage. Scopinaro and col-leagues173 reported GI obstruction in 1.2%, wound infections in 1.2%, and marginal ulcers in 2.8% of patients. However, others found the incidence of marginal ulcer to be higher after BPD, leading to the adoption of the DS. Preservation of the pylorus reduces the incidence of dumping (poorly quantitated in most series) after BPD. The duodenoileostomy of DS also has a very low rate of stomal ulcer, unlike the gastroileostomy of BPD.Nutritional complications are by far the most frequent and concerning after both of these operations, particularly on long-term follow-up. Scopinaro and colleagues173 reported a protein malnutrition rate of 7%, iron deficiency anemia rate of less than 5%, and bone demineralization at 5 years of 53%. Other prob-lems that may arise include alopecia from inadequate protein absorption, night blindness from a lack of vitamin A, and gall-stones if the gallbladder is not