Bariatric surgery sequelae

Diseases

Overview

Introduction

Excess weight is responsible for an estimated 500,000 deaths per year in the US.[1] In England and Scotland, an estimated 23% of all deaths are attributed to overweight or obesity.[2] The incidence of class III obesity (body mass index [BMI] of 40 or above) is increasing at a rapid rate, and this has resulted in an increase in bariatric operations worldwide. Bariatric surgery (also referred to as metabolic surgery) has been shown to substantially lower all-cause mortality rates among adults with obesity, compared with nonsurgical obesity management.[3] Studies demonstrate that children and adolescents with class III obesity benefit from weight loss surgery.[4] The mechanism of action of bariatric surgery for obesity is not fully understood but is believed to include gastric volume restriction, malabsorption, and hormonal changes.[5][6]

Recommendations for the BMI threshold for bariatric surgery differ among guidelines.[7] [8] [9] [10] The American Society of Metabolic and Bariatric Surgery and the International Federation for the Surgery of Obesity and Metabolic Disorders recommend bariatric surgery for individuals who have a BMI of ≥35 kg/m², regardless of comorbidities, or for individuals with a BMI between 30.0 and 34.9 kg/m² who do not achieve durable weight loss and management of comorbidities despite optimal nonsurgical therapy.[8] Bariatric surgery is also a treatment option for patients with type 2 diabetes and a BMI >30 kg/m² who do not achieve durable weight loss and management of comorbidities despite optimal nonsurgical therapy.[8] [11] In Asian individuals the BMI threshold is lower due to differences in body composition and cardiometabolic risk.[11]

After bariatric surgery, patients may present to clinics, emergency departments, or a hospital other than the one where they had the operation. Thus, knowledge of common complications is necessary.[12] The abdomen with central adiposity may be difficult to examine and can mask typical signs of sepsis. Careful attention to vital signs, examination findings, and any deviation from expected postoperative course is essential.

Types of surgical procedures

The most commonly performed operations include:[8]

Roux-en-Y gastric bypass
Sleeve gastrectomy.

Although these may be performed through open or laparoscopic techniques, the majority of bariatric surgery is performed laparoscopically.[8] [10]

Other operations include:[13]

Emerging operations

One-anastomosis gastric bypass
Single anastomosis duodeno-ileostomy with sleeve

Less common operations

Adjustable gastric banding, e.g., the Lap-Band

Biliopancreatic diversion with or without duodenal switch.

Bariatric surgery requires specialist anesthetic expertise.[14]

Assessing and preparing patients for surgery

Preparation for surgery includes preoperative weight loss, glycemic control, and medication reconciliation. Enhanced Recovery After Surgery (ERAS) pathways have been developed for bariatric surgery in order to standardize these perioperative interventions.[15] [16] One aspect of ERAS and patient preparation is the shared decision-making regarding the need and choice of surgery. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) risk-benefit calculator estimates a patient's chance of postoperative complications, remission of weight-related comorbidities, and postoperative weight change, and may be useful to provide a context for preoperative discussion.[17] MBSAQIP: MBSAQIP Bariatric Surgical Risk/Benefit Calculator

Expected weight loss

Weight loss after bariatric surgery is difficult to predict, as it may be affected by predisposing genetic factors, preoperative weight, and adherence to planned postoperative diet and activity level.[18][19] Postsurgical weight loss is typically measured as percentage of initial excess body weight lost, with excess weight calculated as initial body weight minus ideal body weight. One systematic review of bariatric surgery reported long-term (2 years or more) excess weight loss of 49% for adjustable gastric band, 63% for gastric bypass, and 73% for biliopancreatic diversion with duodenal switch.[20] Following sleeve gastrectomy, mean percentage excess weight loss of 58.4%, 59.5%, 56.6%, 56.4%, and 62.5% has been reported at 5, 6, 7, 8, and 11 years, respectively.[21] The MBSAQIP risk-benefit calculator can provide guidance for postoperative weight loss expectations.[17] MBSAQIP: MBSAQIP Bariatric Surgical Risk/Benefit Calculator

In addition to weight loss, bariatric surgery has a profound impact on the resolution of type 2 diabetes mellitus and other obesity related illness, more so than can be achieved by medical measures.[20] [22][23][24][25]

Gastric bypass: description

Roux-en-Y gastric bypass has historically been the most common bariatric operation worldwide. Although it lost much of its pre-eminence to the adjustable gastric band in the 2000s and more recently to the sleeve gastrectomy, it is now the second most common type of bariatric surgery.[26] [27] One large meta-analysis of randomized trials reported a mortality rate of <0.1% for gastric bypass.[28]

Bypass may be performed through either laparoscopic technique or open surgical technique. The laparoscopic technique uses 5 to 7 abdominal access incisions 5 mm to 15 mm in length, whereas the open technique generally requires a vertical midline incision. The laparoscopic approach involves less postoperative pain, faster recovery, and fewer wound-related complications.[29]
A surgical stapler is used to divide the stomach into 2 sections. The upper section is typically referred to as the gastric pouch and is 15 mL to 30 mL in volume, based on the lesser curvature of the stomach (right side). It excludes the gastric fundus.
Using a stapler that both staples and divides tissue, the jejunum is transected 20 cm to 100 cm from its origin at the ligament of Treitz. The proximal end is connected 75 cm to 150 cm "downstream" from the distal segment - or "Roux limb." The Roux limb is connected to the gastric pouch, thus creating a Y-shaped intestinal anatomy.
The distal stomach is completely excluded from the alimentary path. Its secretions, along with those from the liver and pancreas, drain through the biliopancreatic limb (20 cm to 100 cm long).
Food passes from the esophagus into the gastric pouch, before passing through the proximal anastomosis to enter the Roux limb or alimentary limb (75 cm to 150 cm long). At the distal anastomosis, the ingested food joins the digestive secretions in the common channel (150 cm to 400 cm long).
Weight loss and metabolic improvements result through several different mechanisms including gastric volume restriction, mild malabsorption, and hormonal effects.[5][6]
The gastric remnant and biliopancreatic limb are inaccessible during standard upper endoscopy or colonoscopy, and endoscopic retrograde cholangiopancreatography cannot be performed.
Roux-en-Y gastric bypass diagram
Copyright ©2008 Daniel M. Herron, MD; used with permission

Images

Roux-en-Y gastric bypass diagram
Plain radiographic view of an obstruction at the distal anastomosis. No air bubble is visible in the bypassed stomach (gastric remnant)
CT of the abdomen in the same patient reveals a tremendously dilated gastric remnant. With CT guidance, a dilated remnant is easily accessed percutaneously
Ischemic small bowel entrapped within a distal mesenteric hernia
Sleeve gastrectomy
Laparoscopic adjustable gastric band
Upper GI series in patient with adjustable gastric band in normal position. The dashed line is superimposed over the band to emphasize the normal angulation of the band, with the left side angled upward approximately 20-40 degrees from the horizontal. Note the very small pouch between the band and the diaphragm
Biliopancreatic diversion with duodenal switch (BPD-DS)

Citations

Key Articles

National Institute for Health and Care Excellence (NICE). Obesity: identification, assessment and management. Jul 2023 [internet publication].[Full Text]
Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) indications for metabolic and bariatric surgery. Obes Surg. 2023 Jan;33(1):3-14.[Abstract][Full Text]
Di Lorenzo N, Antoniou SA, Batterham RL, et al. Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP. Surg Endosc. 2020 Jun;34(6):2332-58.[Abstract][Full Text]
Parrott J, Frank L, Rabena R, et al. American Society for Metabolic and Bariatric Surgery integrated health nutritional guidelines for the surgical weight loss patient 2016 update: micronutrients. Surg Obes Relat Dis. 2017 May;13(5):727-41.[Abstract]

Other Online Resources

MBSAQIP: MBSAQIP Bariatric Surgical Risk/Benefit Calculator

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