B56. Morbid obesity, and bariatric surgery

Page created on October 11, 2021. Last updated on October 20, 2021 at 13:57

Morbid obesity

For information on obesity, see the corresponding pathology 1 topic.

Bariatric surgery

Introduction

Bariatric surgery is weight-loss surgery, that is, those surgical procedures aimed at causing weight loss. It must be combined with lifestyle modification.

Patients must meet the following criteria:

  • Persons with BMI > 40 OR persons with BMI 35 – 40 and a comorbidity:
    • Type 2 diabetes
    • Obstructive sleep apnoea
    • Hypertension
    • Obesity-hypoventilation syndrome
    • Nonalcoholic steatohepatitis
    • Impaired quality of life
    • Etc.
  • Failed dietary therapy
  • Psychiatrically stable without alcohol dependence or illegal drug use
  • Age 16 – 65

Preoperative assessment

Preoperative assessment is comprehensive and should be performed by a multidisciplinary team. The person’s psychology and cognitive abilities should be assessed for any psychiatric disorders and to determine whether the patient is able and willing to make the necessary lifestyle changes. Any newly diagnosed significant psychiatric disorders should be treated ahead of surgery.

A dietician should be involved to make nutritional plans for the patient before, during, and after bariatric surgery. A thorough medical assessment must be made to assess for any comorbidities which may contraindicate the surgery.

Patients should participate in lifestyle change programs before surgery to demonstrate their commitment to them. Pregnancy is discouraged for the first 2 years after surgery, so patients of childbearing should be encouraged to use birth control.

Obesity leads to physiological changes that impact perioperative anaesthesia, and so getting anaesthesia on board for evaluation is important.

Surgeries

Bariatric surgeries have a volume-restrictive and nutrient-malabsorptive effect, which is what drives the weight loss.

The possible bariatric surgeries include:

  • Sleeve gastrectomy
  • Roux-en-Y gastric bypass
  • Gastric banding
  • (Intragastric balloon)

Sleeve gastrectomy is a partial gastrectomy in which the majority of the greater curvature of the stomach is removed.

Roux-en-Y gastric bypass involves removal of most of the stomach and the proximal duodenum, followed by gastrojejunostomy to connect the remaining stomach to the jejunum. You can read more about it in the topic about malignant stomach tumours, as the same procedure is used there.

Gastric banding refers to applying a band to the epigastric part of the stomach, which narrows it. It’s a much smaller procedure than bypass or sleeve, and is applied laparsoscopically. It’s a commonly used procedure nowadays due to its less invasive nature and reversibility.

Another option is an intragastric balloon. This balloon is placed in the stomach endoscopically and filled with 400 – 700 mL of saline. It occupies volume in the stomach, thereby promoting satiety. The balloon must be removed after six months, and so intragastric balloon is not a permanent solution. This method was not covered in the lecture.


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