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Surgery_Schwartz_7702 | Surgery_Schwartz | pouch was also altered from transverse to vertical using the upper lesser curvature at this time (Fig. 27-1).In 1980, Mason5 first performed the vertical banded gastroplasty (VBG), which was a restrictive procedure using a stapled proximal gastric pouch of the upper lesser curvature of the stomach with a restrictive band for its outlet to the rest of the stomach. This operation produced excellent initial weight loss (50% of excess weight or more) with low mor-bidity and mortality. It rapidly became the most commonly performed bariatric operation in the United States during the 1980s. However, by the early 1990s, it became clear that patients who underwent VBG modified their diets to high-calorie soft foods and liquids and some regained weight.6 A significant incidence of stenosis at the cuff and staple line Introduction1167History / 1167State of the Field / 1169The Disease of Obesity1169Overview / 1169U.S. Prevalence of Obesity / 1170Causes of Obesity / 1170Concurrent Medical and | Surgery_Schwartz. pouch was also altered from transverse to vertical using the upper lesser curvature at this time (Fig. 27-1).In 1980, Mason5 first performed the vertical banded gastroplasty (VBG), which was a restrictive procedure using a stapled proximal gastric pouch of the upper lesser curvature of the stomach with a restrictive band for its outlet to the rest of the stomach. This operation produced excellent initial weight loss (50% of excess weight or more) with low mor-bidity and mortality. It rapidly became the most commonly performed bariatric operation in the United States during the 1980s. However, by the early 1990s, it became clear that patients who underwent VBG modified their diets to high-calorie soft foods and liquids and some regained weight.6 A significant incidence of stenosis at the cuff and staple line Introduction1167History / 1167State of the Field / 1169The Disease of Obesity1169Overview / 1169U.S. Prevalence of Obesity / 1170Causes of Obesity / 1170Concurrent Medical and |
Surgery_Schwartz_7703 | Surgery_Schwartz | cuff and staple line Introduction1167History / 1167State of the Field / 1169The Disease of Obesity1169Overview / 1169U.S. Prevalence of Obesity / 1170Causes of Obesity / 1170Concurrent Medical and Social Problems / 1170Medical Management of Obesity1171Lifestyle Intervention / 1171Pharmacotherapy / 1172Barriers to Treatment / 1173Candidates for Bariatric Surgery1173Indications / 1173Contraindications / 1173Mechanism of Action of Bariatric and Metabolic Surgery1175Overview / 1175Mechanisms of Bariatric Surgery (Weight Loss) / 1175Mechanisms of Metabolic Surgery (Diabetes Improvement) / 1177Preoperative Issues1177Preoperative Preparation / 1177Anesthesiology Issues / 1179Enhanced Recovery After Surgery / 1179Special Equipment and Infrastructure / 1180Bariatric Surgical Procedures1180Laparoscopic Roux-en-Y Gastric Bypass / 1180Laparoscopic Sleeve Gastrectomy / 1185Laparoscopic Adjustable Gastric Banding / 1187Biliopancreatic Diversion and Duodenal Switch / 1189Investigational | Surgery_Schwartz. cuff and staple line Introduction1167History / 1167State of the Field / 1169The Disease of Obesity1169Overview / 1169U.S. Prevalence of Obesity / 1170Causes of Obesity / 1170Concurrent Medical and Social Problems / 1170Medical Management of Obesity1171Lifestyle Intervention / 1171Pharmacotherapy / 1172Barriers to Treatment / 1173Candidates for Bariatric Surgery1173Indications / 1173Contraindications / 1173Mechanism of Action of Bariatric and Metabolic Surgery1175Overview / 1175Mechanisms of Bariatric Surgery (Weight Loss) / 1175Mechanisms of Metabolic Surgery (Diabetes Improvement) / 1177Preoperative Issues1177Preoperative Preparation / 1177Anesthesiology Issues / 1179Enhanced Recovery After Surgery / 1179Special Equipment and Infrastructure / 1180Bariatric Surgical Procedures1180Laparoscopic Roux-en-Y Gastric Bypass / 1180Laparoscopic Sleeve Gastrectomy / 1185Laparoscopic Adjustable Gastric Banding / 1187Biliopancreatic Diversion and Duodenal Switch / 1189Investigational |
Surgery_Schwartz_7704 | Surgery_Schwartz | Roux-en-Y Gastric Bypass / 1180Laparoscopic Sleeve Gastrectomy / 1185Laparoscopic Adjustable Gastric Banding / 1187Biliopancreatic Diversion and Duodenal Switch / 1189Investigational Bariatric Procedures / 1190Follow-Up and Postoperative Care1191Results of Bariatric Surgery1192Short-Term Outcomes / 1192Effectiveness of Bariatric Surgery Compared to Nonsurgical Treatment / 1193Longer-Term Studies / 1193Other Studies / 1198Comparisons Between Procedures / 1199Resolution of Specific Comorbid Conditions / 1199Results of Surgery for Diabetes (Metabolic Surgery) / 1200Complications of Bariatric Surgery1203Surgical Complications / 1203Nonsurgical Complications / 1204Reoperative (Revision and Conversion) Bariatric Surgery1205Introduction / 1205Principles and Preoperative Evaluation / 1205Treatment for Insufficient Weight Loss or Weight Regain / 1206Treatment of Surgical Complications / 1206Special Issues in Bariatric Surgery1207Bariatric Procedures in Adolescents / 1207Cost | Surgery_Schwartz. Roux-en-Y Gastric Bypass / 1180Laparoscopic Sleeve Gastrectomy / 1185Laparoscopic Adjustable Gastric Banding / 1187Biliopancreatic Diversion and Duodenal Switch / 1189Investigational Bariatric Procedures / 1190Follow-Up and Postoperative Care1191Results of Bariatric Surgery1192Short-Term Outcomes / 1192Effectiveness of Bariatric Surgery Compared to Nonsurgical Treatment / 1193Longer-Term Studies / 1193Other Studies / 1198Comparisons Between Procedures / 1199Resolution of Specific Comorbid Conditions / 1199Results of Surgery for Diabetes (Metabolic Surgery) / 1200Complications of Bariatric Surgery1203Surgical Complications / 1203Nonsurgical Complications / 1204Reoperative (Revision and Conversion) Bariatric Surgery1205Introduction / 1205Principles and Preoperative Evaluation / 1205Treatment for Insufficient Weight Loss or Weight Regain / 1206Treatment of Surgical Complications / 1206Special Issues in Bariatric Surgery1207Bariatric Procedures in Adolescents / 1207Cost |
Surgery_Schwartz_7705 | Surgery_Schwartz | / 1205Treatment for Insufficient Weight Loss or Weight Regain / 1206Treatment of Surgical Complications / 1206Special Issues in Bariatric Surgery1207Bariatric Procedures in Adolescents / 1207Cost Effectiveness / 1207Quality Assurance / 1207Plastic Surgery After Weight Loss / 1208Future Important Questions1209Brunicardi_Ch27_p1167-p1218.indd 116723/02/19 2:20 PM 1168JejunoilealBypassGastricBypassHorizontalGastroplastyAdjustable GastricBandingVertical BandedGastroplastyRoux-en-Y gastricBypassBPD with DuodenalSwitchBiliopancreaticDiversionSleeveGastrectomyMalabsorptiveRestrictiveBoth50s60s70s80s90sdisruptions was also problematic.7 Long-term weight loss was poor,8 and by the 1990s in the United States, Roux-en-Y gastric bypass (RYGB) became the procedure of choice for bariatric surgery.In the meantime, in Italy Scopinaro had developed and pop-ularized the biliopancreatic diversion (BPD) in the early 1980s.9 This procedure was also modified to include duodenal switch (DS),10 the only | Surgery_Schwartz. / 1205Treatment for Insufficient Weight Loss or Weight Regain / 1206Treatment of Surgical Complications / 1206Special Issues in Bariatric Surgery1207Bariatric Procedures in Adolescents / 1207Cost Effectiveness / 1207Quality Assurance / 1207Plastic Surgery After Weight Loss / 1208Future Important Questions1209Brunicardi_Ch27_p1167-p1218.indd 116723/02/19 2:20 PM 1168JejunoilealBypassGastricBypassHorizontalGastroplastyAdjustable GastricBandingVertical BandedGastroplastyRoux-en-Y gastricBypassBPD with DuodenalSwitchBiliopancreaticDiversionSleeveGastrectomyMalabsorptiveRestrictiveBoth50s60s70s80s90sdisruptions was also problematic.7 Long-term weight loss was poor,8 and by the 1990s in the United States, Roux-en-Y gastric bypass (RYGB) became the procedure of choice for bariatric surgery.In the meantime, in Italy Scopinaro had developed and pop-ularized the biliopancreatic diversion (BPD) in the early 1980s.9 This procedure was also modified to include duodenal switch (DS),10 the only |
Surgery_Schwartz_7706 | Surgery_Schwartz | the meantime, in Italy Scopinaro had developed and pop-ularized the biliopancreatic diversion (BPD) in the early 1980s.9 This procedure was also modified to include duodenal switch (DS),10 the only major malabsorptive operation currently in use.The laparoscopic approach to bariatric surgery became available in the 1990s, and Belachew performed the first laparo-scopic adjustable gastric banding (LAGB) operation in 1994.11 Wittgrove and Clark performed the first laparoscopic RYGB the same year.12 LAGB was commonly performed in Europe and Australia during the late 1990s, and in 2001 it was approved for use in the United States. Sleeve gastrectomy (SG) as a primary bariatric operation has grown rapidly in use since 2008.Figure 27-1. History of bariatric surgery. (Reproduced with permission from Arterburn DE, Courcoulas AP: Bariatric surgery for obesity and metabolic condi-tions in adults, BMJ. 2014 Aug 27;349:g3961.)Key Points1 Sixty-five percent of the world’s population live in | Surgery_Schwartz. the meantime, in Italy Scopinaro had developed and pop-ularized the biliopancreatic diversion (BPD) in the early 1980s.9 This procedure was also modified to include duodenal switch (DS),10 the only major malabsorptive operation currently in use.The laparoscopic approach to bariatric surgery became available in the 1990s, and Belachew performed the first laparo-scopic adjustable gastric banding (LAGB) operation in 1994.11 Wittgrove and Clark performed the first laparoscopic RYGB the same year.12 LAGB was commonly performed in Europe and Australia during the late 1990s, and in 2001 it was approved for use in the United States. Sleeve gastrectomy (SG) as a primary bariatric operation has grown rapidly in use since 2008.Figure 27-1. History of bariatric surgery. (Reproduced with permission from Arterburn DE, Courcoulas AP: Bariatric surgery for obesity and metabolic condi-tions in adults, BMJ. 2014 Aug 27;349:g3961.)Key Points1 Sixty-five percent of the world’s population live in |
Surgery_Schwartz_7707 | Surgery_Schwartz | from Arterburn DE, Courcoulas AP: Bariatric surgery for obesity and metabolic condi-tions in adults, BMJ. 2014 Aug 27;349:g3961.)Key Points1 Sixty-five percent of the world’s population live in countries where overweight and obesity are linked to more deaths than underweight and malnutrition. Obesity is the second leading cause of preventable death in adults in the United States.2 There is an ongoing major shift in procedure utilization with the sleeve gastrectomy and Roux-en-Y gastric bypass being the two most common procedures, worldwide.3 The former classification of bariatric operations as either “restrictive” or “malabsorptive” is being replaced by knowl-edge from investigation into the more basic physiologic and metabolic mechanisms responsible for the effects of bariatric surgery.4 Patients who develop a bowel obstruction after laparoscopic gastric bypass require surgical and not conservative therapy due to the high incidence of internal hernias and the potential for bowel | Surgery_Schwartz. from Arterburn DE, Courcoulas AP: Bariatric surgery for obesity and metabolic condi-tions in adults, BMJ. 2014 Aug 27;349:g3961.)Key Points1 Sixty-five percent of the world’s population live in countries where overweight and obesity are linked to more deaths than underweight and malnutrition. Obesity is the second leading cause of preventable death in adults in the United States.2 There is an ongoing major shift in procedure utilization with the sleeve gastrectomy and Roux-en-Y gastric bypass being the two most common procedures, worldwide.3 The former classification of bariatric operations as either “restrictive” or “malabsorptive” is being replaced by knowl-edge from investigation into the more basic physiologic and metabolic mechanisms responsible for the effects of bariatric surgery.4 Patients who develop a bowel obstruction after laparoscopic gastric bypass require surgical and not conservative therapy due to the high incidence of internal hernias and the potential for bowel |
Surgery_Schwartz_7708 | Surgery_Schwartz | who develop a bowel obstruction after laparoscopic gastric bypass require surgical and not conservative therapy due to the high incidence of internal hernias and the potential for bowel infarction.5 Malabsorptive operations are highly effective in producing durable weight loss and metabolic improvements but have higher surgical complication rates and considerable nutri-tional side effects. Patients undergoing such procedures require complete follow-up and appropriate nutritional supplements.6 Large, longer-term observational studies of bariatric surgery have shown durable weight loss, diabetes remission, lipid improvements, and improved survival with bariatric surgery. Still unclear are specific preand postoperative predictors of those outcomes, long-term complications, microvascular and macrovascular events, mental health outcomes, and costs.7 High quality data have clearly established that bariatric pro-cedures are more effective than medical or lifestyle interven-tions for inducing | Surgery_Schwartz. who develop a bowel obstruction after laparoscopic gastric bypass require surgical and not conservative therapy due to the high incidence of internal hernias and the potential for bowel infarction.5 Malabsorptive operations are highly effective in producing durable weight loss and metabolic improvements but have higher surgical complication rates and considerable nutri-tional side effects. Patients undergoing such procedures require complete follow-up and appropriate nutritional supplements.6 Large, longer-term observational studies of bariatric surgery have shown durable weight loss, diabetes remission, lipid improvements, and improved survival with bariatric surgery. Still unclear are specific preand postoperative predictors of those outcomes, long-term complications, microvascular and macrovascular events, mental health outcomes, and costs.7 High quality data have clearly established that bariatric pro-cedures are more effective than medical or lifestyle interven-tions for inducing |
Surgery_Schwartz_7709 | Surgery_Schwartz | events, mental health outcomes, and costs.7 High quality data have clearly established that bariatric pro-cedures are more effective than medical or lifestyle interven-tions for inducing weight loss and initial remission of type 2 diabetes, even in less obese patients. Randomized clinical trials showed greater weight loss and type 2 diabetes mellitus remission following bariatric surgery compared with nonsur-gical treatments.8 The incidence of complications after bariatric surgery varies from 4% to over 25% and depends on the duration of follow-up, the definition of complication used, the type of bariatric procedure performed, and individual patient characteristics.9 Emerging areas in bariatric surgery include the use of inter-mediate weight loss devices, adolescent bariatric surgery, and the increase in the need for revision and conversion bar-iatric procedures.Brunicardi_Ch27_p1167-p1218.indd 116823/02/19 2:20 PM 1169THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 2780p < | Surgery_Schwartz. events, mental health outcomes, and costs.7 High quality data have clearly established that bariatric pro-cedures are more effective than medical or lifestyle interven-tions for inducing weight loss and initial remission of type 2 diabetes, even in less obese patients. Randomized clinical trials showed greater weight loss and type 2 diabetes mellitus remission following bariatric surgery compared with nonsur-gical treatments.8 The incidence of complications after bariatric surgery varies from 4% to over 25% and depends on the duration of follow-up, the definition of complication used, the type of bariatric procedure performed, and individual patient characteristics.9 Emerging areas in bariatric surgery include the use of inter-mediate weight loss devices, adolescent bariatric surgery, and the increase in the need for revision and conversion bar-iatric procedures.Brunicardi_Ch27_p1167-p1218.indd 116823/02/19 2:20 PM 1169THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 2780p < |
Surgery_Schwartz_7710 | Surgery_Schwartz | surgery, and the increase in the need for revision and conversion bar-iatric procedures.Brunicardi_Ch27_p1167-p1218.indd 116823/02/19 2:20 PM 1169THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 2780p < 0.0017060Relative Procedure Utilization (%)504030201002006200720082009Year of Procedure2010201120122013Adjustable Gastric BandingRoux-en-Y Gastric BypassSleeve GastrectomyDuodenal SwitchFigure 27-2. Changes in bariatric procedure utilization. (Reproduced with permission from Reames BN, Finks JF, Bacal D, et al: Changes in bariatric surgery procedure use in Michigan, 2006-2013, JAMA. 2014 Sep 3;312(9):959-961.)State of the FieldThere has been an ongoing major shift in bariatric procedures both in the United States and worldwide13 with the rapid adop-tion of the laparoscopic sleeve gastrectomy and the simultane-ous decreasing utilization of the laparoscopic adjustable gastric banding procedure (Fig. 27-2). International trends in the utiliza-tion of bariatric surgical procedures have also | Surgery_Schwartz. surgery, and the increase in the need for revision and conversion bar-iatric procedures.Brunicardi_Ch27_p1167-p1218.indd 116823/02/19 2:20 PM 1169THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 2780p < 0.0017060Relative Procedure Utilization (%)504030201002006200720082009Year of Procedure2010201120122013Adjustable Gastric BandingRoux-en-Y Gastric BypassSleeve GastrectomyDuodenal SwitchFigure 27-2. Changes in bariatric procedure utilization. (Reproduced with permission from Reames BN, Finks JF, Bacal D, et al: Changes in bariatric surgery procedure use in Michigan, 2006-2013, JAMA. 2014 Sep 3;312(9):959-961.)State of the FieldThere has been an ongoing major shift in bariatric procedures both in the United States and worldwide13 with the rapid adop-tion of the laparoscopic sleeve gastrectomy and the simultane-ous decreasing utilization of the laparoscopic adjustable gastric banding procedure (Fig. 27-2). International trends in the utiliza-tion of bariatric surgical procedures have also |
Surgery_Schwartz_7711 | Surgery_Schwartz | and the simultane-ous decreasing utilization of the laparoscopic adjustable gastric banding procedure (Fig. 27-2). International trends in the utiliza-tion of bariatric surgical procedures have also been published. These show that the total number of bariatric surgical procedures performed in 2014 was 579,517. The three most commonly per-formed procedures in the world were SG at 46%, followed by RYGB (40%), and LAGB (7%). The annual percentage changes from 2013 show an increased utilization of SG and a decreased use of RYGB in the United States, Canada, Europe, and Asia and Pacific countries. In Central and South America, however, the use of SG decreased, and RYGB was most commonly used.14Extension of the indication from bariatric surgery for weight loss to metabolic surgery to treat type 2 diabetes (T2DM) even in patients with less than severe obesity has been another more recent development, driven by the availability of more level 1 data.15,16Also, considerable effort is now being | Surgery_Schwartz. and the simultane-ous decreasing utilization of the laparoscopic adjustable gastric banding procedure (Fig. 27-2). International trends in the utiliza-tion of bariatric surgical procedures have also been published. These show that the total number of bariatric surgical procedures performed in 2014 was 579,517. The three most commonly per-formed procedures in the world were SG at 46%, followed by RYGB (40%), and LAGB (7%). The annual percentage changes from 2013 show an increased utilization of SG and a decreased use of RYGB in the United States, Canada, Europe, and Asia and Pacific countries. In Central and South America, however, the use of SG decreased, and RYGB was most commonly used.14Extension of the indication from bariatric surgery for weight loss to metabolic surgery to treat type 2 diabetes (T2DM) even in patients with less than severe obesity has been another more recent development, driven by the availability of more level 1 data.15,16Also, considerable effort is now being |
Surgery_Schwartz_7712 | Surgery_Schwartz | 2 diabetes (T2DM) even in patients with less than severe obesity has been another more recent development, driven by the availability of more level 1 data.15,16Also, considerable effort is now being devoted to the study of the basic physiologic mechanisms underlying weight loss and, perhaps more importantly, the resolution of comorbid medical problems associated with obesity. Despite the classic “restric-tive” and “malabsorptive” anatomic conceptualizations of bar-iatric surgical procedures (see Fig. 27-1), there is much ongoing research in animal and human models towards understanding the specific underlying mechanisms of action, which may be more physiologic in nature.17 Some of the potential candidates for the mechanisms of action of bariatric procedures include alterations in ghrelin, leptin, glucagon-like peptide-1 (GLP-1), cholecystokinin, peptide YY (PYY), gut microbiota, and bile acids. In the future, bariatric procedures will not be described by anatomic surgical similarities | Surgery_Schwartz. 2 diabetes (T2DM) even in patients with less than severe obesity has been another more recent development, driven by the availability of more level 1 data.15,16Also, considerable effort is now being devoted to the study of the basic physiologic mechanisms underlying weight loss and, perhaps more importantly, the resolution of comorbid medical problems associated with obesity. Despite the classic “restric-tive” and “malabsorptive” anatomic conceptualizations of bar-iatric surgical procedures (see Fig. 27-1), there is much ongoing research in animal and human models towards understanding the specific underlying mechanisms of action, which may be more physiologic in nature.17 Some of the potential candidates for the mechanisms of action of bariatric procedures include alterations in ghrelin, leptin, glucagon-like peptide-1 (GLP-1), cholecystokinin, peptide YY (PYY), gut microbiota, and bile acids. In the future, bariatric procedures will not be described by anatomic surgical similarities |
Surgery_Schwartz_7713 | Surgery_Schwartz | leptin, glucagon-like peptide-1 (GLP-1), cholecystokinin, peptide YY (PYY), gut microbiota, and bile acids. In the future, bariatric procedures will not be described by anatomic surgical similarities but by how they affect key physiological variables, which will provide greater mechanistic insight into how the procedures actually work.THE DISEASE OF OBESITYOverviewWorldwide obesity has more than doubled since 1980. In 2014, 39% of adults age 18 years and over (38% of men and 40% of women) were overweight, and 13% of the world’s adult population (11% of men and 15% of women) were obese. In 2014, an estimated 41 million children under the age of 5 years were overweight or obese.18 Overweight and obesity are now on the rise in lowand middle-income countries, particularly in urban settings. Currently, 65% of the world’s population live in countries where overweight and obesity are linked to more deaths than underweight and malnutrition. Obesity is the second leading cause of preventable | Surgery_Schwartz. leptin, glucagon-like peptide-1 (GLP-1), cholecystokinin, peptide YY (PYY), gut microbiota, and bile acids. In the future, bariatric procedures will not be described by anatomic surgical similarities but by how they affect key physiological variables, which will provide greater mechanistic insight into how the procedures actually work.THE DISEASE OF OBESITYOverviewWorldwide obesity has more than doubled since 1980. In 2014, 39% of adults age 18 years and over (38% of men and 40% of women) were overweight, and 13% of the world’s adult population (11% of men and 15% of women) were obese. In 2014, an estimated 41 million children under the age of 5 years were overweight or obese.18 Overweight and obesity are now on the rise in lowand middle-income countries, particularly in urban settings. Currently, 65% of the world’s population live in countries where overweight and obesity are linked to more deaths than underweight and malnutrition. Obesity is the second leading cause of preventable |
Surgery_Schwartz_7714 | Surgery_Schwartz | Currently, 65% of the world’s population live in countries where overweight and obesity are linked to more deaths than underweight and malnutrition. Obesity is the second leading cause of preventable death in adults in the United States, after tobacco use.19The degrees of obesity are defined by body mass index (BMI = weight [kg]/height [m]2), which correlates body weight with height. The World Health Organization international clas-sification of overweight and obesity is shown in Table 27-1. It should be noted that for Asian populations, classifications remain the same as the international classification, but the pub-lic health action points for interventions are set at a lower BMI threshold. For children, age needs to be considered when defin-ing overweight and obesity, so for children age 5 to 19 years, 1Table 27-1The international classification of adult overweight and obesity according to body mass index (BMI)CLASSIFICATIONBMI (kg/m2)PRINCIPAL CUTOFF POINTSADDITIONAL CUTOFF | Surgery_Schwartz. Currently, 65% of the world’s population live in countries where overweight and obesity are linked to more deaths than underweight and malnutrition. Obesity is the second leading cause of preventable death in adults in the United States, after tobacco use.19The degrees of obesity are defined by body mass index (BMI = weight [kg]/height [m]2), which correlates body weight with height. The World Health Organization international clas-sification of overweight and obesity is shown in Table 27-1. It should be noted that for Asian populations, classifications remain the same as the international classification, but the pub-lic health action points for interventions are set at a lower BMI threshold. For children, age needs to be considered when defin-ing overweight and obesity, so for children age 5 to 19 years, 1Table 27-1The international classification of adult overweight and obesity according to body mass index (BMI)CLASSIFICATIONBMI (kg/m2)PRINCIPAL CUTOFF POINTSADDITIONAL CUTOFF |
Surgery_Schwartz_7715 | Surgery_Schwartz | age 5 to 19 years, 1Table 27-1The international classification of adult overweight and obesity according to body mass index (BMI)CLASSIFICATIONBMI (kg/m2)PRINCIPAL CUTOFF POINTSADDITIONAL CUTOFF POINTSaNormal range 18.50–24.99 18.50–22.9923.00–24.99Overweight≥25.00≥25.00 Preobese 25.00–29.99 25.00–27.4927.50–29.99 Obese≥30.00≥30.00 Obese class I 30.00–34.99 30.00–32.4932.50–34.99 Obese class II 35.00–39.99 35.00–37.4937.50–39.99 Obese class III≥40.00≥40.00aFor Asian populations, classifications remain the same as the international classification, but public health action points for interventions are set at 23, 27.5, 32.5, and 37.5 kg/m.2Data from WHO, 1995, WHO, 2000 and WHO 2004.Brunicardi_Ch27_p1167-p1218.indd 116923/02/19 2:20 PM 1170SPECIFIC CONSIDERATIONSPART IIoverweight is BMI-for-age greater than 1 standard deviation above the World Health Organization (WHO) growth reference median, and obesity is greater than 2 standard deviations above the WHO growth reference | Surgery_Schwartz. age 5 to 19 years, 1Table 27-1The international classification of adult overweight and obesity according to body mass index (BMI)CLASSIFICATIONBMI (kg/m2)PRINCIPAL CUTOFF POINTSADDITIONAL CUTOFF POINTSaNormal range 18.50–24.99 18.50–22.9923.00–24.99Overweight≥25.00≥25.00 Preobese 25.00–29.99 25.00–27.4927.50–29.99 Obese≥30.00≥30.00 Obese class I 30.00–34.99 30.00–32.4932.50–34.99 Obese class II 35.00–39.99 35.00–37.4937.50–39.99 Obese class III≥40.00≥40.00aFor Asian populations, classifications remain the same as the international classification, but public health action points for interventions are set at 23, 27.5, 32.5, and 37.5 kg/m.2Data from WHO, 1995, WHO, 2000 and WHO 2004.Brunicardi_Ch27_p1167-p1218.indd 116923/02/19 2:20 PM 1170SPECIFIC CONSIDERATIONSPART IIoverweight is BMI-for-age greater than 1 standard deviation above the World Health Organization (WHO) growth reference median, and obesity is greater than 2 standard deviations above the WHO growth reference |
Surgery_Schwartz_7716 | Surgery_Schwartz | is BMI-for-age greater than 1 standard deviation above the World Health Organization (WHO) growth reference median, and obesity is greater than 2 standard deviations above the WHO growth reference median.The fundamental cause of obesity and overweight is an energy imbalance between calories consumed and calories expended. Globally, there has been an increased intake of energy-dense foods that are high in fat and a decrease in physi-cal inactivity due to the increasingly sedentary nature of many forms of work, changing modes of transportation, and increas-ing urbanization. These changes in dietary and physical activ-ity patterns are the result of both societal and environmental changes associated with development. There is also a dearth of supportive policies to counteract these forces in sectors such as health, agriculture, transport, urban planning, environment, food processing, marketing, and education. Obesity as a disease was recognized by the American Medical Association in 2013. | Surgery_Schwartz. is BMI-for-age greater than 1 standard deviation above the World Health Organization (WHO) growth reference median, and obesity is greater than 2 standard deviations above the WHO growth reference median.The fundamental cause of obesity and overweight is an energy imbalance between calories consumed and calories expended. Globally, there has been an increased intake of energy-dense foods that are high in fat and a decrease in physi-cal inactivity due to the increasingly sedentary nature of many forms of work, changing modes of transportation, and increas-ing urbanization. These changes in dietary and physical activ-ity patterns are the result of both societal and environmental changes associated with development. There is also a dearth of supportive policies to counteract these forces in sectors such as health, agriculture, transport, urban planning, environment, food processing, marketing, and education. Obesity as a disease was recognized by the American Medical Association in 2013. |
Surgery_Schwartz_7717 | Surgery_Schwartz | such as health, agriculture, transport, urban planning, environment, food processing, marketing, and education. Obesity as a disease was recognized by the American Medical Association in 2013. It is multifactorial in its etiology, and the components of the disease likely include a combination of both environmental and genetic factors.U.S. Prevalence of ObesityAccording to the 2013–2014 National Health and Nutrition Examination Survey (NHANES) data, in the United States the overall age-adjusted prevalence of obesity was 37.7% (95% confidence interval [CI], 35.8–39.7%); among men, it was 35.0% (95% CI, 32.8–37.3%); and among women, it was 40.4% (95% CI, 37.6–43.3%). The corresponding prevalence of class III obesity overall was 7.7% (95% CI, 6.2–9.3%); among men, it was 5.5% (95% CI, 4.0–7.2%); and among women, it was 9.9% (95% CI, 7.5–12.3%). Changes over the decade from 2005 through 2014, adjusted for age, race, smoking status, and education, showed significantly increas-ing trends | Surgery_Schwartz. such as health, agriculture, transport, urban planning, environment, food processing, marketing, and education. Obesity as a disease was recognized by the American Medical Association in 2013. It is multifactorial in its etiology, and the components of the disease likely include a combination of both environmental and genetic factors.U.S. Prevalence of ObesityAccording to the 2013–2014 National Health and Nutrition Examination Survey (NHANES) data, in the United States the overall age-adjusted prevalence of obesity was 37.7% (95% confidence interval [CI], 35.8–39.7%); among men, it was 35.0% (95% CI, 32.8–37.3%); and among women, it was 40.4% (95% CI, 37.6–43.3%). The corresponding prevalence of class III obesity overall was 7.7% (95% CI, 6.2–9.3%); among men, it was 5.5% (95% CI, 4.0–7.2%); and among women, it was 9.9% (95% CI, 7.5–12.3%). Changes over the decade from 2005 through 2014, adjusted for age, race, smoking status, and education, showed significantly increas-ing trends |
Surgery_Schwartz_7718 | Surgery_Schwartz | and among women, it was 9.9% (95% CI, 7.5–12.3%). Changes over the decade from 2005 through 2014, adjusted for age, race, smoking status, and education, showed significantly increas-ing trends among women for overall obesity and for class III obesity, but not among men.20For children in the United States, obesity is defined as a BMI at or above the sex-specific 95th percentile, and extreme obesity is defined as a BMI at or above 120% of the sexspecific 95th percentile on the U.S. Centers for Disease Control and Prevention (CDC) BMI-for-age growth charts. In the most recent NHANES study of U.S. children and adolescents age 2 to 19 years, the prevalence of obesity from 2011 to 2014 was 17.0%, and extreme obesity was 5.8%.21Causes of ObesityBoth genetic and environmental factors contribute to the devel-opment of obesity. Not everyone exposed to the prevailing envi-ronment becomes obese, suggesting that genetic mechanisms are operating at the individual level. Estimates vary, but twin, | Surgery_Schwartz. and among women, it was 9.9% (95% CI, 7.5–12.3%). Changes over the decade from 2005 through 2014, adjusted for age, race, smoking status, and education, showed significantly increas-ing trends among women for overall obesity and for class III obesity, but not among men.20For children in the United States, obesity is defined as a BMI at or above the sex-specific 95th percentile, and extreme obesity is defined as a BMI at or above 120% of the sexspecific 95th percentile on the U.S. Centers for Disease Control and Prevention (CDC) BMI-for-age growth charts. In the most recent NHANES study of U.S. children and adolescents age 2 to 19 years, the prevalence of obesity from 2011 to 2014 was 17.0%, and extreme obesity was 5.8%.21Causes of ObesityBoth genetic and environmental factors contribute to the devel-opment of obesity. Not everyone exposed to the prevailing envi-ronment becomes obese, suggesting that genetic mechanisms are operating at the individual level. Estimates vary, but twin, |
Surgery_Schwartz_7719 | Surgery_Schwartz | to the devel-opment of obesity. Not everyone exposed to the prevailing envi-ronment becomes obese, suggesting that genetic mechanisms are operating at the individual level. Estimates vary, but twin, family, and adoption studies show that the rate of heritability of BMI is high, ranging from 40% to 70%.22,23 Eleven rare and monogenic forms of obesity are now recognized, including a deficiency of the leptin and melanocortin-4 receptors, which are expressed in the hypothalamus and are involved in regulating energy homeostasis.24 Heterozygous mutations in the melano-cortin-4 receptor gene are currently the most common cause of monogenic obesity, causative in 2% to 5% of children with severe obesity.Genes and environment interact in a complex process that regulates energy balance and weight. Reducing food intake or increasing physical activity leads to a negative energy bal-ance and a cascade of compensatory adaptive mechanisms that preserve vital functions and are associated with | Surgery_Schwartz. to the devel-opment of obesity. Not everyone exposed to the prevailing envi-ronment becomes obese, suggesting that genetic mechanisms are operating at the individual level. Estimates vary, but twin, family, and adoption studies show that the rate of heritability of BMI is high, ranging from 40% to 70%.22,23 Eleven rare and monogenic forms of obesity are now recognized, including a deficiency of the leptin and melanocortin-4 receptors, which are expressed in the hypothalamus and are involved in regulating energy homeostasis.24 Heterozygous mutations in the melano-cortin-4 receptor gene are currently the most common cause of monogenic obesity, causative in 2% to 5% of children with severe obesity.Genes and environment interact in a complex process that regulates energy balance and weight. Reducing food intake or increasing physical activity leads to a negative energy bal-ance and a cascade of compensatory adaptive mechanisms that preserve vital functions and are associated with |
Surgery_Schwartz_7720 | Surgery_Schwartz | Reducing food intake or increasing physical activity leads to a negative energy bal-ance and a cascade of compensatory adaptive mechanisms that preserve vital functions and are associated with reductions in resting energy expenditure, food preoccupation, and many other changes that depend on the amount and duration of caloric restriction. There is also a counterregulatory increase in appetite and food intake that limits the degree of expected weight loss that is associated with interventions such as exercise programs.22Individuals with obesity have excessive adipose cells, both in size and number. The number of such cells often is deter-mined early in life; adult-onset obesity is largely a product of increase in adipose cell size. Weight gain results from increase in both adipose cell size and number. Adipose tissue may be deposited in large quantities in the subcutaneous layer of the abdominal wall or the viscera. Generally, males tend to have central visceral fat distribution, | Surgery_Schwartz. Reducing food intake or increasing physical activity leads to a negative energy bal-ance and a cascade of compensatory adaptive mechanisms that preserve vital functions and are associated with reductions in resting energy expenditure, food preoccupation, and many other changes that depend on the amount and duration of caloric restriction. There is also a counterregulatory increase in appetite and food intake that limits the degree of expected weight loss that is associated with interventions such as exercise programs.22Individuals with obesity have excessive adipose cells, both in size and number. The number of such cells often is deter-mined early in life; adult-onset obesity is largely a product of increase in adipose cell size. Weight gain results from increase in both adipose cell size and number. Adipose tissue may be deposited in large quantities in the subcutaneous layer of the abdominal wall or the viscera. Generally, males tend to have central visceral fat distribution, |
Surgery_Schwartz_7721 | Surgery_Schwartz | size and number. Adipose tissue may be deposited in large quantities in the subcutaneous layer of the abdominal wall or the viscera. Generally, males tend to have central visceral fat distribution, whereas females more often have a peripheral fat distribution. Central or visceral fat distri-bution is associated with metabolic diseases such as diabetes, hypertension, and the metabolic syndrome.Concurrent Medical and Social ProblemsRaised BMI is a major risk factor for diseases such as cardio-vascular disease (mainly heart disease and stroke), which were the leading cause of death in 2012, diabetes, osteoarthritis, some cancers (including endometrial, breast, ovarian, prostate, liver, gallbladder, kidney, and colon).18 The risk for these conditions increases with increases in BMI. Childhood obesity is asso-ciated with a higher chance of obesity, premature death, and disability in adulthood. In addition to increased future risks, children with obesity experience sleep apnea, increased | Surgery_Schwartz. size and number. Adipose tissue may be deposited in large quantities in the subcutaneous layer of the abdominal wall or the viscera. Generally, males tend to have central visceral fat distribution, whereas females more often have a peripheral fat distribution. Central or visceral fat distri-bution is associated with metabolic diseases such as diabetes, hypertension, and the metabolic syndrome.Concurrent Medical and Social ProblemsRaised BMI is a major risk factor for diseases such as cardio-vascular disease (mainly heart disease and stroke), which were the leading cause of death in 2012, diabetes, osteoarthritis, some cancers (including endometrial, breast, ovarian, prostate, liver, gallbladder, kidney, and colon).18 The risk for these conditions increases with increases in BMI. Childhood obesity is asso-ciated with a higher chance of obesity, premature death, and disability in adulthood. In addition to increased future risks, children with obesity experience sleep apnea, increased |
Surgery_Schwartz_7722 | Surgery_Schwartz | obesity is asso-ciated with a higher chance of obesity, premature death, and disability in adulthood. In addition to increased future risks, children with obesity experience sleep apnea, increased risk of fractures, hypertension, early markers of cardiovascular disease, insulin resistance, and psychological effects.The severely obese patient typically presents with multiple chronic and weight-related problems or comorbidities/comorbid conditions. These include degenerative joint disease, low back pain, hypertension, obstructive sleep apnea, gastroesophageal reflux disease (GERD), cholelithiasis, T2DM, dyslipidemia, asthma, hypoventilation syndrome of obesity, right-sided heart failure, migraine headaches, pseudotumor cerebri, venous stasis ulcers, deep venous thrombosis (DVT), fungal skin rashes, skin abscesses, stress urinary incontinence, infertility, dysmenorrhea, depression, and large abdominal wall hernias.There are anatomical, metabolic, and physiological effects of obesity | Surgery_Schwartz. obesity is asso-ciated with a higher chance of obesity, premature death, and disability in adulthood. In addition to increased future risks, children with obesity experience sleep apnea, increased risk of fractures, hypertension, early markers of cardiovascular disease, insulin resistance, and psychological effects.The severely obese patient typically presents with multiple chronic and weight-related problems or comorbidities/comorbid conditions. These include degenerative joint disease, low back pain, hypertension, obstructive sleep apnea, gastroesophageal reflux disease (GERD), cholelithiasis, T2DM, dyslipidemia, asthma, hypoventilation syndrome of obesity, right-sided heart failure, migraine headaches, pseudotumor cerebri, venous stasis ulcers, deep venous thrombosis (DVT), fungal skin rashes, skin abscesses, stress urinary incontinence, infertility, dysmenorrhea, depression, and large abdominal wall hernias.There are anatomical, metabolic, and physiological effects of obesity |
Surgery_Schwartz_7723 | Surgery_Schwartz | skin rashes, skin abscesses, stress urinary incontinence, infertility, dysmenorrhea, depression, and large abdominal wall hernias.There are anatomical, metabolic, and physiological effects of obesity through which this excess adiposity leads to disease risk factors and chronic diseases themselves (Fig. 27-3).22 Subcu-taneous adipose tissue holds most of the stored lipid at a variety of anatomical sites while visceral adipose tissue is a smaller storage compartment with omental and mesenteric fat mechanistically linked to some of the metabolic disturbances and adverse con-sequences outcomes associated with obesity.25,26 Adipose tissue surrounds and compresses the renal parenchyma and may contrib-ute to the hypertension frequently observed in patients who are obese.27 Obesity is frequently accompanied by an increase in pha-ryngeal soft tissues, which can lead to obstructive sleep apnea.28 Excess adiposity also imposes a significant mechanical load on joints, making it a risk factor for | Surgery_Schwartz. skin rashes, skin abscesses, stress urinary incontinence, infertility, dysmenorrhea, depression, and large abdominal wall hernias.There are anatomical, metabolic, and physiological effects of obesity through which this excess adiposity leads to disease risk factors and chronic diseases themselves (Fig. 27-3).22 Subcu-taneous adipose tissue holds most of the stored lipid at a variety of anatomical sites while visceral adipose tissue is a smaller storage compartment with omental and mesenteric fat mechanistically linked to some of the metabolic disturbances and adverse con-sequences outcomes associated with obesity.25,26 Adipose tissue surrounds and compresses the renal parenchyma and may contrib-ute to the hypertension frequently observed in patients who are obese.27 Obesity is frequently accompanied by an increase in pha-ryngeal soft tissues, which can lead to obstructive sleep apnea.28 Excess adiposity also imposes a significant mechanical load on joints, making it a risk factor for |
Surgery_Schwartz_7724 | Surgery_Schwartz | accompanied by an increase in pha-ryngeal soft tissues, which can lead to obstructive sleep apnea.28 Excess adiposity also imposes a significant mechanical load on joints, making it a risk factor for the development of osteoarthri-tis.29 An increase in intraabdominal pressure likely accounts for the elevated risks of gastroesophageal reflux disease (GERD), Barrett’s esophagus, and esophageal adenocarcinoma among those with obesity.30 Chronic overactivity of the sympathetic ner-vous system is present in some patients with obesity and may contribute to pathophysiological processes, including high blood pressure.27 Obesity is also associated with an increased preva-lence of mood, anxiety, and other psychiatric disorders, especially Brunicardi_Ch27_p1167-p1218.indd 117023/02/19 2:20 PM 1171THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 27ä Adiposity˜ Lipid production˜ Activity ofthe sympatheticnervous system˜ Activity of therenin–angiotensin–aldosterone systemMechanical stress˜ Adipokine | Surgery_Schwartz. accompanied by an increase in pha-ryngeal soft tissues, which can lead to obstructive sleep apnea.28 Excess adiposity also imposes a significant mechanical load on joints, making it a risk factor for the development of osteoarthri-tis.29 An increase in intraabdominal pressure likely accounts for the elevated risks of gastroesophageal reflux disease (GERD), Barrett’s esophagus, and esophageal adenocarcinoma among those with obesity.30 Chronic overactivity of the sympathetic ner-vous system is present in some patients with obesity and may contribute to pathophysiological processes, including high blood pressure.27 Obesity is also associated with an increased preva-lence of mood, anxiety, and other psychiatric disorders, especially Brunicardi_Ch27_p1167-p1218.indd 117023/02/19 2:20 PM 1171THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 27ä Adiposity˜ Lipid production˜ Activity ofthe sympatheticnervous system˜ Activity of therenin–angiotensin–aldosterone systemMechanical stress˜ Adipokine |
Surgery_Schwartz_7725 | Surgery_Schwartz | SURGICAL MANAGEMENT OF OBESITYCHAPTER 27ä Adiposity˜ Lipid production˜ Activity ofthe sympatheticnervous system˜ Activity of therenin–angiotensin–aldosterone systemMechanical stress˜ Adipokine synthesis˜ Adipose tissuemacrophages and otherinflammatory cells˜ Proinflammatorycytokines˜ Pharyngealsoft tissue˜ Mechanicalload on joints˜ Intraabdominalpressure˜ InsulinType 2 diabetesNonalcoholicfatty liver diseaseSteatohepatitisCirrhosisCoronaryartery diseaseObstructivesleep apneaOsteoarthritisGastroesophagealreflux diseaseBarrett’s esophagusEsophagealadenocarcinomaCongestive heart failureStrokeChronic kidney diseaseImpaired insulinsignaling and˜ insulin resistanceLipotoxicityDyslipidemiaSystemic andpulmonaryhypertensionRenalcompressionHydrolysis oftriglyceridesRelease offree fatty acidsFigure 27-3. Pathways through which obesity leads to major risk factors and common chronic diseases. Common chronic diseases are shown in red boxes. The dashed arrows indicate an indirect association. | Surgery_Schwartz. SURGICAL MANAGEMENT OF OBESITYCHAPTER 27ä Adiposity˜ Lipid production˜ Activity ofthe sympatheticnervous system˜ Activity of therenin–angiotensin–aldosterone systemMechanical stress˜ Adipokine synthesis˜ Adipose tissuemacrophages and otherinflammatory cells˜ Proinflammatorycytokines˜ Pharyngealsoft tissue˜ Mechanicalload on joints˜ Intraabdominalpressure˜ InsulinType 2 diabetesNonalcoholicfatty liver diseaseSteatohepatitisCirrhosisCoronaryartery diseaseObstructivesleep apneaOsteoarthritisGastroesophagealreflux diseaseBarrett’s esophagusEsophagealadenocarcinomaCongestive heart failureStrokeChronic kidney diseaseImpaired insulinsignaling and˜ insulin resistanceLipotoxicityDyslipidemiaSystemic andpulmonaryhypertensionRenalcompressionHydrolysis oftriglyceridesRelease offree fatty acidsFigure 27-3. Pathways through which obesity leads to major risk factors and common chronic diseases. Common chronic diseases are shown in red boxes. The dashed arrows indicate an indirect association. |
Surgery_Schwartz_7726 | Surgery_Schwartz | 27-3. Pathways through which obesity leads to major risk factors and common chronic diseases. Common chronic diseases are shown in red boxes. The dashed arrows indicate an indirect association. (Reproduced with permission from Heymsfield SB, Wadden TA: Mechanisms, Pathophysiology, and Management of Obesity, N Engl J Med. 2017 Jan 19;376(3):254-266.)among persons with severe obesity and in those seeking bariatric surgery.31-33 Decreased quality of life also results due to severe obesity. Most patients seeking surgical treatment of severe obe-sity do so because of the medical issues they face from comorbid conditions or the decreased quality of life they are experiencing as a result of severe obesity.MEDICAL MANAGEMENT OF OBESITYTreatments should be aligned with the severity of obesity, asso-ciated comorbid conditions, and the individual’s functional limitations. There are guidelines available to evaluate an indi-vidual’s health risks and potential treatment options.34,35 Three main | Surgery_Schwartz. 27-3. Pathways through which obesity leads to major risk factors and common chronic diseases. Common chronic diseases are shown in red boxes. The dashed arrows indicate an indirect association. (Reproduced with permission from Heymsfield SB, Wadden TA: Mechanisms, Pathophysiology, and Management of Obesity, N Engl J Med. 2017 Jan 19;376(3):254-266.)among persons with severe obesity and in those seeking bariatric surgery.31-33 Decreased quality of life also results due to severe obesity. Most patients seeking surgical treatment of severe obe-sity do so because of the medical issues they face from comorbid conditions or the decreased quality of life they are experiencing as a result of severe obesity.MEDICAL MANAGEMENT OF OBESITYTreatments should be aligned with the severity of obesity, asso-ciated comorbid conditions, and the individual’s functional limitations. There are guidelines available to evaluate an indi-vidual’s health risks and potential treatment options.34,35 Three main |
Surgery_Schwartz_7727 | Surgery_Schwartz | asso-ciated comorbid conditions, and the individual’s functional limitations. There are guidelines available to evaluate an indi-vidual’s health risks and potential treatment options.34,35 Three main treatment options exist with sufficient evidence-based support: lifestyle intervention, pharmacotherapy, and bariatric surgery.Lifestyle InterventionLifestyle interventions designed to modify eating behaviors and physical activity are the first option for weight manage-ment, given their low cost and low risk.35 Behavioral therapy, the core of any lifestyle intervention, provides patients with techniques for adopting dietary and activity recommendations. Among these recommendations are regular recording of food intake, physical activity, and weight. Patients review their progress approximately weekly with a trained interventionist Brunicardi_Ch27_p1167-p1218.indd 117123/02/19 2:20 PM 1172SPECIFIC CONSIDERATIONSPART II01020304050Percentage of | Surgery_Schwartz. asso-ciated comorbid conditions, and the individual’s functional limitations. There are guidelines available to evaluate an indi-vidual’s health risks and potential treatment options.34,35 Three main treatment options exist with sufficient evidence-based support: lifestyle intervention, pharmacotherapy, and bariatric surgery.Lifestyle InterventionLifestyle interventions designed to modify eating behaviors and physical activity are the first option for weight manage-ment, given their low cost and low risk.35 Behavioral therapy, the core of any lifestyle intervention, provides patients with techniques for adopting dietary and activity recommendations. Among these recommendations are regular recording of food intake, physical activity, and weight. Patients review their progress approximately weekly with a trained interventionist Brunicardi_Ch27_p1167-p1218.indd 117123/02/19 2:20 PM 1172SPECIFIC CONSIDERATIONSPART II01020304050Percentage of |
Surgery_Schwartz_7728 | Surgery_Schwartz | Patients review their progress approximately weekly with a trained interventionist Brunicardi_Ch27_p1167-p1218.indd 117123/02/19 2:20 PM 1172SPECIFIC CONSIDERATIONSPART II01020304050Percentage of Participants6070809010010%5%High-lntensityLifestyleInterventionPharmacotherapyInterventionLook AHEADDPPTeixeira, et aI.PlaceboOrlistatLorcaserinLiraglutidePhentermine-topiramateNaltrexone-bupropionFigure 27-4. 22Percent weight loss at 1 year with intensive lifestyle interventions or pharmacotherapy combined with lower level lifestyle. Shown are the percentages of participants in randomized, controlled trials who had weight loss of at least 5% or at least 10% of their initial weight at 1 year after intensive lifestyle intervention or pharmacotherapy that typically was combined with lower-intensity lifestyle. Percentages shown are cumulative; the percentage of participants who lost at least 5% of their initial weight includes the percentage who lost at least 10%. Additional data on the | Surgery_Schwartz. Patients review their progress approximately weekly with a trained interventionist Brunicardi_Ch27_p1167-p1218.indd 117123/02/19 2:20 PM 1172SPECIFIC CONSIDERATIONSPART II01020304050Percentage of Participants6070809010010%5%High-lntensityLifestyleInterventionPharmacotherapyInterventionLook AHEADDPPTeixeira, et aI.PlaceboOrlistatLorcaserinLiraglutidePhentermine-topiramateNaltrexone-bupropionFigure 27-4. 22Percent weight loss at 1 year with intensive lifestyle interventions or pharmacotherapy combined with lower level lifestyle. Shown are the percentages of participants in randomized, controlled trials who had weight loss of at least 5% or at least 10% of their initial weight at 1 year after intensive lifestyle intervention or pharmacotherapy that typically was combined with lower-intensity lifestyle. Percentages shown are cumulative; the percentage of participants who lost at least 5% of their initial weight includes the percentage who lost at least 10%. Additional data on the |
Surgery_Schwartz_7729 | Surgery_Schwartz | lifestyle. Percentages shown are cumulative; the percentage of participants who lost at least 5% of their initial weight includes the percentage who lost at least 10%. Additional data on the percentage of participants with weight loss at 1 year of at least 15% of their initial weight were available for the Look AHEAD36 study (16%), the DPP39 trial (11%), liraglutide40 (14%), phentermine–topiramate (32%), and naltrexone–bupropion (14%). (Reproduced with permis-sion from Heymsfield SB, Wadden TA: Mechanisms, Pathophysiology, and Management of Obesity, N Engl J Med. 2017 Jan 19;376(3):254-266.)who provides support and encouragement, help setting goals, and problem-solving instructions.35 This type of comprehen-sive program results in a mean weight loss of 5% to 8%, and approximately 60% to 65% of patients lose 5% or more of initial weight. The Look AHEAD study randomized 5145 adults with obesity to either an intensive lifestyle intervention (ILI) or to a diabetes support group and | Surgery_Schwartz. lifestyle. Percentages shown are cumulative; the percentage of participants who lost at least 5% of their initial weight includes the percentage who lost at least 10%. Additional data on the percentage of participants with weight loss at 1 year of at least 15% of their initial weight were available for the Look AHEAD36 study (16%), the DPP39 trial (11%), liraglutide40 (14%), phentermine–topiramate (32%), and naltrexone–bupropion (14%). (Reproduced with permis-sion from Heymsfield SB, Wadden TA: Mechanisms, Pathophysiology, and Management of Obesity, N Engl J Med. 2017 Jan 19;376(3):254-266.)who provides support and encouragement, help setting goals, and problem-solving instructions.35 This type of comprehen-sive program results in a mean weight loss of 5% to 8%, and approximately 60% to 65% of patients lose 5% or more of initial weight. The Look AHEAD study randomized 5145 adults with obesity to either an intensive lifestyle intervention (ILI) or to a diabetes support group and |
Surgery_Schwartz_7730 | Surgery_Schwartz | to 65% of patients lose 5% or more of initial weight. The Look AHEAD study randomized 5145 adults with obesity to either an intensive lifestyle intervention (ILI) or to a diabetes support group and education group (DSE) to assess the impact on weight loss, T2DM, and cardiovascular outcomes. At 1 year, the intensive intervention group lost an average of 8.6% initial weight compared to 0.7% in the support and educa-tion group. As shown in Fig. 27-4, 68% of participants in the Look AHEAD study lost at least 5% of their initial weight, and 37% of these participants lost at least 10%. Also at 1 year, par-ticipants undergoing the more intensive program experienced improved cardiovascular risk factors and glycemic control.36At 4 years, participants in the intensive intervention group experienced more weight loss (−6.15% ILI compared to −0.88% DSE), better glycemic control, fitness, and an improvement in cardiovascular risk factors.37 Nevertheless, the beneficial clinical effects of the | Surgery_Schwartz. to 65% of patients lose 5% or more of initial weight. The Look AHEAD study randomized 5145 adults with obesity to either an intensive lifestyle intervention (ILI) or to a diabetes support group and education group (DSE) to assess the impact on weight loss, T2DM, and cardiovascular outcomes. At 1 year, the intensive intervention group lost an average of 8.6% initial weight compared to 0.7% in the support and educa-tion group. As shown in Fig. 27-4, 68% of participants in the Look AHEAD study lost at least 5% of their initial weight, and 37% of these participants lost at least 10%. Also at 1 year, par-ticipants undergoing the more intensive program experienced improved cardiovascular risk factors and glycemic control.36At 4 years, participants in the intensive intervention group experienced more weight loss (−6.15% ILI compared to −0.88% DSE), better glycemic control, fitness, and an improvement in cardiovascular risk factors.37 Nevertheless, the beneficial clinical effects of the |
Surgery_Schwartz_7731 | Surgery_Schwartz | more weight loss (−6.15% ILI compared to −0.88% DSE), better glycemic control, fitness, and an improvement in cardiovascular risk factors.37 Nevertheless, the beneficial clinical effects of the improved weight loss achieved with intensive lifestyle intervention did not reduce morbidity and mortality associated with cardiovascular disease after 9.6 years when the Look AHEAD study was stopped due to futility for that primary endpoint.38 Figure 27-4 shows a comparison of several lifestyle intervention trials (Look AHEAD, the Diabetes Prevention Program [DPP] trial,39 and the trial reported by Teixeira et al40) for >5% and >10% weight loss outcomes. These trials, specifically, were selected because they were judged to be good quality by the Guidelines (2013) for the Management of Overweight and Obesity in Adults and because the trial data were reported as categorical weight loss. Categorical weight loss data from the DPP trial were provided by the DPP Research Group to the authors of the | Surgery_Schwartz. more weight loss (−6.15% ILI compared to −0.88% DSE), better glycemic control, fitness, and an improvement in cardiovascular risk factors.37 Nevertheless, the beneficial clinical effects of the improved weight loss achieved with intensive lifestyle intervention did not reduce morbidity and mortality associated with cardiovascular disease after 9.6 years when the Look AHEAD study was stopped due to futility for that primary endpoint.38 Figure 27-4 shows a comparison of several lifestyle intervention trials (Look AHEAD, the Diabetes Prevention Program [DPP] trial,39 and the trial reported by Teixeira et al40) for >5% and >10% weight loss outcomes. These trials, specifically, were selected because they were judged to be good quality by the Guidelines (2013) for the Management of Overweight and Obesity in Adults and because the trial data were reported as categorical weight loss. Categorical weight loss data from the DPP trial were provided by the DPP Research Group to the authors of the |
Surgery_Schwartz_7732 | Surgery_Schwartz | Obesity in Adults and because the trial data were reported as categorical weight loss. Categorical weight loss data from the DPP trial were provided by the DPP Research Group to the authors of the review.22In summary, multidisciplinary lifestyle intervention and weight-management programs are viable and potentially cost-effective treatment options in overweight or obese patients with or without T2DM. Such approaches, however, often fail to achieve durable weight loss of more than 5% to 10%, so they are not effective enough for the severely obese. Importantly, lifestyle and medical approaches do not appear to improve car-diovascular outcomes in studies so far. Thus, further research is needed to evaluate the role for current medical and lifestyle therapeutic regimens for obesity and T2DM, including compari-sons to surgical interventions. Certainly, and at the very least, these approaches are important adjuncts to bariatric surgery.PharmacotherapyMedications may be considered as an | Surgery_Schwartz. Obesity in Adults and because the trial data were reported as categorical weight loss. Categorical weight loss data from the DPP trial were provided by the DPP Research Group to the authors of the review.22In summary, multidisciplinary lifestyle intervention and weight-management programs are viable and potentially cost-effective treatment options in overweight or obese patients with or without T2DM. Such approaches, however, often fail to achieve durable weight loss of more than 5% to 10%, so they are not effective enough for the severely obese. Importantly, lifestyle and medical approaches do not appear to improve car-diovascular outcomes in studies so far. Thus, further research is needed to evaluate the role for current medical and lifestyle therapeutic regimens for obesity and T2DM, including compari-sons to surgical interventions. Certainly, and at the very least, these approaches are important adjuncts to bariatric surgery.PharmacotherapyMedications may be considered as an |
Surgery_Schwartz_7733 | Surgery_Schwartz | including compari-sons to surgical interventions. Certainly, and at the very least, these approaches are important adjuncts to bariatric surgery.PharmacotherapyMedications may be considered as an adjunct to lifestyle modi-fication in adults who have a BMI of 30 or higher or a BMI of 27 to 29 with at least one obesity-related condition.41 Phar-macotherapy and lifestyle intervention together lead to addi-tive weight losses and should be used together and may also be helpful in facilitating the maintenance of reduced weight.34,41,42 Phentermine, the most widely prescribed weight-management medication in the United States, is a sympathomimetic amine that was approved by the FDA in 1959 for short-term use of fewer than 3 months long.41 There are now five newer FDA-approved medications for long-term weight management that include three single drugs and two combination drugs. In 1-year pivotal trials, total weight losses for the three single therapies (orlistat, lorcaserin, and liraglutide), | Surgery_Schwartz. including compari-sons to surgical interventions. Certainly, and at the very least, these approaches are important adjuncts to bariatric surgery.PharmacotherapyMedications may be considered as an adjunct to lifestyle modi-fication in adults who have a BMI of 30 or higher or a BMI of 27 to 29 with at least one obesity-related condition.41 Phar-macotherapy and lifestyle intervention together lead to addi-tive weight losses and should be used together and may also be helpful in facilitating the maintenance of reduced weight.34,41,42 Phentermine, the most widely prescribed weight-management medication in the United States, is a sympathomimetic amine that was approved by the FDA in 1959 for short-term use of fewer than 3 months long.41 There are now five newer FDA-approved medications for long-term weight management that include three single drugs and two combination drugs. In 1-year pivotal trials, total weight losses for the three single therapies (orlistat, lorcaserin, and liraglutide), |
Surgery_Schwartz_7734 | Surgery_Schwartz | weight management that include three single drugs and two combination drugs. In 1-year pivotal trials, total weight losses for the three single therapies (orlistat, lorcaserin, and liraglutide), the effects of which are mediated by different mechanisms, ranged from 5.8% to 8.8% of initial body weight.41,43-45 The two combination medications (phentermine–topiramate and naltrexone–bupropion) include drugs that act on neural weight-loss mechanisms.46,47 In 1-year pivotal trials, total weight loss for these combination drugs ranged from 6.4% to 9.8% of initial body weight.These medications, when prescribed with lifestyle inter-ventions, produce additional weight loss relative to placebo ranging from approximately 3% of initial weight for orlistat and lorcaserin to 9% for the higher-dose phentermine plus topi-ramate–extended release at 1 year. The proportion of patients achieving clinically meaningful (at least 5%) weight loss ranges from 37% to 47% for lorcaserin, 35% to 73% for orlistat, | Surgery_Schwartz. weight management that include three single drugs and two combination drugs. In 1-year pivotal trials, total weight losses for the three single therapies (orlistat, lorcaserin, and liraglutide), the effects of which are mediated by different mechanisms, ranged from 5.8% to 8.8% of initial body weight.41,43-45 The two combination medications (phentermine–topiramate and naltrexone–bupropion) include drugs that act on neural weight-loss mechanisms.46,47 In 1-year pivotal trials, total weight loss for these combination drugs ranged from 6.4% to 9.8% of initial body weight.These medications, when prescribed with lifestyle inter-ventions, produce additional weight loss relative to placebo ranging from approximately 3% of initial weight for orlistat and lorcaserin to 9% for the higher-dose phentermine plus topi-ramate–extended release at 1 year. The proportion of patients achieving clinically meaningful (at least 5%) weight loss ranges from 37% to 47% for lorcaserin, 35% to 73% for orlistat, |
Surgery_Schwartz_7735 | Surgery_Schwartz | plus topi-ramate–extended release at 1 year. The proportion of patients achieving clinically meaningful (at least 5%) weight loss ranges from 37% to 47% for lorcaserin, 35% to 73% for orlistat, and 67% to 70% for higher-dose phentermine plus topiramate–extended release. All three of these medications produce greater improvements in cardiometabolic risk factors than placebo, Brunicardi_Ch27_p1167-p1218.indd 117223/02/19 2:20 PM 1173THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 27but none has been shown to reduce cardiovascular morbid-ity or mortality. There is limited data for the long-term safety and efficacy of these medications, and some of these drugs may increase heart rate43 or attenuate expected blood pressure reductions.47 In addition, completed trials of hard cardiovascular disease 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 | Surgery_Schwartz. plus topi-ramate–extended release at 1 year. The proportion of patients achieving clinically meaningful (at least 5%) weight loss ranges from 37% to 47% for lorcaserin, 35% to 73% for orlistat, and 67% to 70% for higher-dose phentermine plus topiramate–extended release. All three of these medications produce greater improvements in cardiometabolic risk factors than placebo, Brunicardi_Ch27_p1167-p1218.indd 117223/02/19 2:20 PM 1173THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 27but none has been shown to reduce cardiovascular morbid-ity or mortality. There is limited data for the long-term safety and efficacy of these medications, and some of these drugs may increase heart rate43 or attenuate expected blood pressure reductions.47 In addition, completed trials of hard cardiovascular disease 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 |
Surgery_Schwartz_7736 | 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. | 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. |
Surgery_Schwartz_7737 | 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 | 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 |
Surgery_Schwartz_7738 | 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 | 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 |
Surgery_Schwartz_7739 | 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 | 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 |
Surgery_Schwartz_7740 | 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 | 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 |
Surgery_Schwartz_7741 | 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 | 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 |
Surgery_Schwartz_7742 | 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 | 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 |
Surgery_Schwartz_7743 | 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, | 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, |
Surgery_Schwartz_7744 | 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. | 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. |
Surgery_Schwartz_7745 | 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 | 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 |
Surgery_Schwartz_7746 | 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 | 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 |
Surgery_Schwartz_7747 | 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 | 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 |
Surgery_Schwartz_7748 | 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 | 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 |
Surgery_Schwartz_7749 | 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 | 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 |
Surgery_Schwartz_7750 | 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 | 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 |
Surgery_Schwartz_7751 | 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 | 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 |
Surgery_Schwartz_7752 | 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 | 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 |
Surgery_Schwartz_7753 | 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 | 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 |
Surgery_Schwartz_7754 | 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; | 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; |
Surgery_Schwartz_7755 | 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, | 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, |
Surgery_Schwartz_7756 | 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 | 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 |
Surgery_Schwartz_7757 | 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 | 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 |
Surgery_Schwartz_7758 | 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 | 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 |
Surgery_Schwartz_7759 | 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 | 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 |
Surgery_Schwartz_7760 | 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 | 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 |
Surgery_Schwartz_7761 | 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 | 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 |
Surgery_Schwartz_7762 | 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 | 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 |
Surgery_Schwartz_7763 | 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 | 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 |
Surgery_Schwartz_7764 | 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 | 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 |
Surgery_Schwartz_7765 | 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 | 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 |
Surgery_Schwartz_7766 | 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 | 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 |
Surgery_Schwartz_7767 | 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 | 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 |
Surgery_Schwartz_7768 | 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 | 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 |
Surgery_Schwartz_7769 | 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 | 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 |
Surgery_Schwartz_7770 | 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 | 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 |
Surgery_Schwartz_7771 | 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 | 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 |
Surgery_Schwartz_7772 | 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 | 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 |
Surgery_Schwartz_7773 | 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 | 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 |
Surgery_Schwartz_7774 | 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 | 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 |
Surgery_Schwartz_7775 | 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 | 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 |
Surgery_Schwartz_7776 | 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 | 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 |
Surgery_Schwartz_7777 | 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 | 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 |
Surgery_Schwartz_7778 | 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 | 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 |
Surgery_Schwartz_7779 | 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 | 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 |
Surgery_Schwartz_7780 | 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 | 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 |
Surgery_Schwartz_7781 | 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 | 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 |
Surgery_Schwartz_7782 | 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 | 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 |
Surgery_Schwartz_7783 | 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 | 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 |
Surgery_Schwartz_7784 | 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 | 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 |
Surgery_Schwartz_7785 | 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 | 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 |
Surgery_Schwartz_7786 | 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 | 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 |
Surgery_Schwartz_7787 | 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 | 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 |
Surgery_Schwartz_7788 | 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 | 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 |
Surgery_Schwartz_7789 | 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 | 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 |
Surgery_Schwartz_7790 | 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 | 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 |
Surgery_Schwartz_7791 | 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 | 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 |
Surgery_Schwartz_7792 | 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. 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_7793 | 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 | 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 |
Surgery_Schwartz_7794 | 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 | 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 |
Surgery_Schwartz_7795 | 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 | 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 |
Surgery_Schwartz_7796 | 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. 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_7797 | 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 | 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 |
Surgery_Schwartz_7798 | 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 | 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 |
Surgery_Schwartz_7799 | 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 | 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 |
Surgery_Schwartz_7800 | 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. | 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. |
Surgery_Schwartz_7801 | 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, | 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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