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HISTORY OF BARIATRIC SURGERY

The original bariatric surgical procedure was the jejunocolic bypass, followed shortly thereafter by the jejunoileal bypass. This approach was introduced in 1954 and consisted of 14 inches (35.6 cm) of jejunum connected to 4 inches (10.2 cm) of ileum as either an end-to-end or an end-to-side anastomosis, which bypassed most of the small intestine. This procedure resulted in substantial weight loss but with an unacceptably high risk of unanticipated early and late complications, including life-threatening hepatic failure and cirrhosis, renal failure, oxalate nephropathy, immune complex disease, and multiple nutritional deficiencies. Because of these complications, the jejunoileal bypass procedure is no longer performed. The original bariatric surgical procedure was the jejunocolic bypass, followed shortly thereafter by the jejunoileal bypass. This approach was introduced in 1954 and consisted of 14 inches (35.6 cm) of jejunum connected to 4 inches (10.2 cm) of ileum as either an end-to-end or an end-to-side anastomosis, which bypassed most of the small intestine. This procedure resulted in substantial weight loss but with an unacceptably high risk of unanticipated early and late complications, including life-threatening hepatic failure and cirrhosis, renal failure, oxalate nephropathy, immune complex disease, and multiple nutritional deficiencies. Because of these complications, the jejunoileal bypass procedure is no longer performed

 

In the late 1970s, the gastric bypass was developed on them basis of information gathered from gastrectomy procedures and then modified to a Roux-en-Y anastomosis. This procedure was found to have equivalent weight loss to the jejunoileal bypass but with a much lower risk of complications.

At present, there are three broad categories of bariatric procedures:

  • Purely gastric restriction,
  • Gastric restriction with some malabsorption, as represented by the Roux-en-Y

gastric bypass (RYGB), and

  • Gastric restriction with significant intestinal malabsorption.

 

Currently, RYGB procedures account for >80% of bariatric operations, although the proportion is changing with the advent of the laparoscopic Sleeve gastrectomy procedure. The majority of patients (80%) are female, from a higher socioeconomic class, privately insured, and between 40 and 64 years of age 

 

INDICATIONS FOR BARIATRIC SURGERY

 

  • Patients with BMI>40
  • Patient  with less severeobesity (BMI >35 kg/m2) could be considered if they had high risk

comorbid conditions such as life-threatening cardiopulmonary problems (for example, severe sleep apnea, pickwickian syndrome, or obesity-related cardiomyopathy) or uncontrolled.

type 2 diabetes mellitus (T2DM)

  • Other indications for patients with BMIs between 35 and 40 kg/m2 include obesity induced physical problems interfering with lifestyle (for example, joint disease treatable but for the obesity, or body size problems precluding or severely interfering with employment, family function, and ambulation).

 

 

UNSUITABLE PATIENTS FOR BARIATRIC SURGERY

  • Extremely high operative risk (such as severe congestive heart failure or unstable angina)
  • Active substance abuser, or
  • Patient with a major psychopathologic condition

 

TYPES OF BARIATRIC SURGERY

 

  

 

RISKS

 Operative mo rtality risk is 0.1-0.3% upto 1 month. The 30 day readmission rate is 4%.

 

 

BENEFITS OF BARIATRIC SURGERY

 

The purpose of bariatric surgery is to induce substantial, clinically important weight loss that is sufficient to reduce obesity related medical complications to acceptable levels.

 

Effects of bariatric surgery on obesity-related Comorbidities

 

Comorbidity                           Preoperative incidence (%)           Remission >2 years postoperatively             (%) Reference

 

T2DM, IFG, or IGT                               34                                              85                                                           103

 

Hypertension                                         26                                             66                                                            104

 

Hypertriglyceridemia

and low HDL

cholesterol                                             40                                             85                                                            105

 

Sleep apnea                                           22 (in men)                               40                                                            106

                                                             01 (in women)

 

Obesity hypoventilation

Syndrome                                              12                                             76                                                             107

  

HDL, high-density lipoprotein; IFG, impaired fasting glucose; IGT, impaired glucose tolerance; T2DM, type 2 diabetes mellitus.

 

Adapted from Greenway

  • Foregut bypass leads to improvement in the physiologic responses of gut hormones involved in glucose regulation and appetite control, including ghrelin, glucagon-like peptide-1 (GLP-1), and peptide YY.
  • Mechanical improvements include less weight bearing on joints, enhanced lung compliance, and decreased fatty tissue around the neck, which relieves obstruction to breathing and sleep apnea.
  • Fluid and hemodynamic changes that lower the blood pressure after bariatric surgery include diuresis, natriuresis, and decreases in total body water, blood volume, and indices of sympathetic activity.
  • Other clinical benefits include improvements in T2DM, obesity-related cardiomyopathy, cardiac function, lipid
  • Profile, respiratory function, disordered sleep, degenerative joint disease, obesity-related infections, mobility, venous stasis, non-alcoholic fatty liver disease (NAFLD), asthma, polycystic ovary syndrome (PCOS), infertility, and complications of pregnancy.
  • Most bariatric surgery patients also experience considerable improvements in psychosocial status and quality of life postoperatively.