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Please cite this article in press as: Tsai AY-C, Osborne A, Bariatric surgery, Surgery (2017), http://dx.doi.org/10.1016/j.mpsur.2017.09.002
OESOPHAGUS AND STOMACH
Please cite this article in press as: Tsai AY-C, Osborne A, Bariatric surgery, Surgery (2017), http://dx.doi.org/10.1016/j.mpsur.2017.09.002
OESOPHAGUS AND STOMACH
Table 1 Figure 3
Please cite this article in press as: Tsai AY-C, Osborne A, Bariatric surgery, Surgery (2017), http://dx.doi.org/10.1016/j.mpsur.2017.09.002
OESOPHAGUS AND STOMACH
associated with improvement in comorbidities and a low (hunger) hormone has been shown in obese individuals to be
complication rate. The mechanism of action is thought to be due significantly less suppressed after eating compared to normal
to neurohumoral changes similar to those seen following gastric weight individuals. The published data on ghrelin in RYGB have
bypass. shown variable changes (inconclusive); however, the recent
Complications of sleeve gastrectomy include staple-line STAMPEDE trial showed greater suppression of acylated (active)
bleeding, leak, and late stricture or torsion of the sleeve. ghrelin 2 years after surgery. Changes in taste include food
Gastroesophageal reflux symptoms are common in the long term. preferences with high-calorie foods becoming less appealing and
A perceived benefit of the sleeve is that if there is weight regain less consumed. This was demonstrated using functional MRI,
afterwards, it is still possible to convert to another bariatric which showed that activation of brain reward systems during
operation such as gastric bypass or duodenal switch. evaluation of the appeal of high-calorie food was less after gastric
bypass than gastric banding. Energy expenditure also increases
Bilio-pancreatic diversion with duodenal switch after surgery and research into mechanisms is ongoing.
Scopinaro first introduced the bilio-pancreatic diversion (BPD) in Bile acids synthesis occurs in the liver and allows digestion of
1979.10 It was designed as a safer technique to the jejunoileal dietary fats and oils. In RYGB, as the bile pass down the bili-
bypass performed from the 1950se1970s. It had significant opancreatic limb, bypassing the intestinal Roux limb, it directly
nutritional and metabolic complications and therefore was progresses into the alimentary limb without dilution. The higher
modified to include a duodenal switch (DS) in an attempt to concentration of bile acids in the distal intestinal tract has been
eliminate them. BPD-DS is technically challenging and usually shown to enhance release of GLP-1 and PYY.
considered as a planned second stage or rescue operation (duo- The physiological changes after bariatric surgery involve
denoileostomy/ileo-ileostomy). The gastrocolic ligament from multiple mechanisms with complex gut-brain signalling,
the distal antrum to proximal duodenum is divided. The dissec- anatomical and hormonal effects. Understanding of such mech-
tion of the duodenum ends at the point where the anterior anisms will aid the development of non-surgical intervention in
pancreatic tissue joins the duodenal wall. A linear stapler is used the treatment and prevention of obesity and metabolic syndrome
to transect the duodenum. The common limb is measured 50 associated.
e100 cm from the ileocaecal valve and the alimentary limb is
therefore variable in length (about 200e300 cm). The ileum is Mini-gastric bypass and evidence-based practice
divided at the point of measurement and the duodenoileostomy There are numerous bariatric procedures including modification
is performed as an end-to-end anastomosis with a circular sta- of the commonly performed operations, such as banded RYGB,
pler. The biliopancreatic limb is joined to the common limb by a mini-gastric bypass and endoscopic procedures such as
side-to-side ileo-ileostomy. intragastric balloons and endoscopic sleeve gastroplasty.
The BPD-DS is a combination procedure that is both hormonal Mini-gastric bypass (MGB), also known as one anastomosis
and malabsorptive. It produces effective weight loss in patients gastric bypass was first described by Rutledge.18 The technique
with a BMI > 50 and may be superior to RYGB in achieving was developed with the aim of providing a technically simpler
weight loss.16 Dorman and colleagues compared 190 patients option that might have a shorter learning curve and operative
who underwent primary BPD-DS between 2005 and 2010 to 139 time with equivocal or even improved outcomes. The uptake of
RYGB patients.16 They found no difference between percentage this innovative technique has been much slower due to concerns
total weight loss between the two groups and significantly higher including symptomatic biliary reflux causing gastritis or oeso-
improvements in type 2 diabetes, hypertension and hyper- phagitis, marginal ulcers and anxiety over managing anastomotic
lipidaemia in the BPD-DS group. leaks due to a potential high volume of biliary and pancreatic
Patients having BPD-DS require rigorous life-long medical and secretions. Furthermore, many surgeons are anxious about any
nutritional follow up as long term nutritional and vitamin de- possible increased risk of Barretts oesophagus and gastric or
ficiencies occur at a significant rate.17 oesophageal cancer associated with biliary reflux in MGB. Long-
term outcomes over two decades may still not provide the evi-
Mechanisms underlying weight loss surgery dence for or against this debate and this will only be possible
Bariatric operations are traditionally classified as either restric- with high quality research.
tive or malabsorptive; however, studies have shown that the Large series of over 1000 patients have shown that MGB is a
effects on gut hormones, microbiota, bile salts and food prefer- safe and effective operation in the short term. Lee et al. showed
ences are responsible for the weight loss and improvement in that laparoscopic MGB is associated with lower mean BMI at 5-
diabetes and cardiovascular diseases. year follow up compared to LRYGB as well as shorter surgical
Studies have shown reduced hunger, increased satiety and time with a reduced incidence of postoperative bowel obstruc-
change in bile salts after RYGB, associated with exaggerated re- tion.19 In the largest published series of 2410 patients with 6-year
sponses of anorexigenic intestinal hormones such as glucagon- follow up, Rutledge found the complication rate of dyspepsia and
like polypeptide-1 (GLP-1) and peptide YY (PYY); these gut ulcers was 5.6% and the leak rate was 1.08%; the average
hormone changes are absent after gastric band surgery. The level operative time was 37.5 minutes and the median length of stay
of the gut hormone is found to be directly related to the degree of was 1 day.18 It remains unclear why with such promising results
weight loss with the highest levels found in patients with the MGB has remained less popular.
most weight lost. Blocking the release of these hormone results in According to the IDEAL framework,20 once a technique is
food intake after the surgery returning to preoperative levels (in developed and the outcome described, high-quality randomized
ad libitum meal model). Ghrelin, the only known orexigenic trials should be the default option to test it against the current
Please cite this article in press as: Tsai AY-C, Osborne A, Bariatric surgery, Surgery (2017), http://dx.doi.org/10.1016/j.mpsur.2017.09.002
OESOPHAGUS AND STOMACH
standard unless the advance is clear and substantial. The trial heart strain. The recognition and treatment of sleep apnoea is
design of the latest British RCT By-Band was published in 2014 to important especially in the postoperative period as the effect of
compare the clinical and cost-effectiveness including accept- surgery and anaesthesia can result in pulmonary complications.
ability of gastric band versus RYGB. Already a sleeve gastrec- Obesity Surgery-Mortality Risk score (OS-MRS) is an estab-
tomy arm has been added to reflect change in practice. How can lished and validated tool to assess the risk of surgery in gastric
we help RCTs keep up with evolving technology and ensure re- bypass. It assigns one point to each of five preoperative values
sults remain relevant? Choosing the right operation for the right including male sex, age 45, BMI 50, presence of hyperten-
patient remains a debate. Unlike gastrointestinal cancer surgeries sion and known risk of deep vein thrombosis and pulmonary
where there are fewer surgical options for one disease, Bariatric embolism. A risk group (score 0e1) is considered as lowest
surgeons are spoiled for choice. risk, B (2e3) intermediate and C (4e5) high risk. The mor-
tality rate among the three classes is: A, 0.31%, B, 1.9%, C,
Establishing a bariatric service 7.56%. OS-MRS is a useful clinical tool for choosing the appro-
priate bariatric procedure, and provides a rough guide in the
Multidisciplinary service
attempt of downgrading risk.
A bariatric programme is multidisciplinary and requires sub-
stantial commitment from the surgeons and from the institute. Hospital infrastructure
The team includes surgeons, dietitians, psychologists, anaesthe- BOMSS published its professional standards for facilities per-
tists, critical care physicians, endocrinologists, respiratory phy- forming bariatric surgery in March 2013, which are summarized
sicians, and specialized nursing staff. Professional bodies (Box 2).
including the International Federation for Surgery of Obesity and
Metabolic Disorders, American Society for Bariatric Surgery and Surgical training in bariatric surgery
American College of Surgeons and British Obesity & Metabolic Bariatric surgery is now possibly the most common gastrointes-
Surgery Society (BOMSS) have set up Safety, Quality, and tinal operation in the USA and this has led to a significant in-
Excellence guidelines and accreditation scheme to ensure the crease in the number of bariatric programmes. A risk of this is
best standards of patient care. that many surgeons might enter into bariatric practice without
The establishment of a bariatric surgery programme requires sufficient training and experience or work in institutions without
commitment and investment of the hospital. It is important to sufficient infrastructure to provide the necessary multidisci-
create an obesity-friendly environment from the waiting area in plinary structure to the overall care.
an outpatient clinic to the operating theatre and postoperative The current professional standards to accredit bariatric sur-
recovery ward. The weight capacity of furniture including geons and institutes in the UK and USA are based on case volume
chairs, benches, examination couches and beds must be and hospital infrastructure and staffing requirements for the
adequate in supporting the patient safely. Bariatric patients often multidisciplinary team. These requirements are established upon
require diagnostic investigations such as gastroscopy, upper GI the strong evidence of improved patient outcomes under the care
contrast studies and CT scanning during the hospital stay or as of high volume surgeons and high volume centres and the
emergency. The bariatric surgeon should be familiar with the assumption that volume of cases directly reflects a surgeons
weight and size limit of the equipment at the hospital before competency. A bariatric training programme needs to meet the
putting patients through surgery as this may set an upper weight increasing clinical demand whilst maintaining patient safety.
limit to the patient selection. Some older hospital buildings were
not structurally designed to cater for bariatric patients and Learning curve
therefore the load-bearing capacity of the floor and the fire- The understanding of learning curve forms the foundation of
escape staircase and equipment should be reassessed. training development. A learning curve is defined as the number
of procedures that a surgeon needs to perform to reach a plateau
Preoperative and perioperative care in operating time, conversion rates, complications and mortality.
Because of the multiple comorbidities and associated mortality Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most
with severe obesity, careful screening is crucial before the commonly performed operation and has received the most
operation. Preoperative assessment should begin with a thor- attention.
ough medical and dietary history. As the major cause of death in In 2002, Oliak and colleagues analysed the first 225 consecutive
obese patients is related to cardiovascular diseases such as LRYGB operations performed by one laparoscopic surgeon and
myocardial infarction, congestive heart failure and stroke, opti- showed that most of the reduction in operative time occurred over
mization including stabilization of blood pressure, echocardio- the first 75 patients.21 Studies have shown that during the early
gram of the ventricular function, and deep vein thrombosis phase of training there is increased mortality and morbidity. Flum
prophylaxis should be carried out. and Dellinger (2004) evaluated 30-day mortality of 3328 patients
Pulmonary function is commonly compromised in the who underwent obesity procedures over a 15-year study period.
morbidly obese due to heavy chest wall and increased intra- When the mortality was considered in a multivariable logistic
abdominal pressure. Obstructive sleep apnoea is a result of regression analysis, only surgical inexperience and patients
increased upper airway pressures during sleep, which is exac- comorbidities were associated with increased 30-day mortality.22
erbated by the fat in the neck and reduced neck mobility. This The odds ratio of patient death within 30 days of hospital
leads to an episodic fall in oxygen saturation and rise in CO2 level discharge was 4.7 times higher within the surgeons first 19 pro-
which may in turn cause pulmonary vasoconstriction and right cedures than later. One of the main objectives of bariatric surgery
Please cite this article in press as: Tsai AY-C, Osborne A, Bariatric surgery, Surgery (2017), http://dx.doi.org/10.1016/j.mpsur.2017.09.002
OESOPHAGUS AND STOMACH
Staffing
C Patients must have access to full range of specialist professionals REFERENCES
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Please cite this article in press as: Tsai AY-C, Osborne A, Bariatric surgery, Surgery (2017), http://dx.doi.org/10.1016/j.mpsur.2017.09.002