Minimally Invasive

Bariatric and
Metabolic Surgery

Principles and
Technical Aspects

Marcello Lucchese
Nicola Scopinaro
Editors

123
Minimally Invasive Bariatric
and Metabolic Surgery
Marcello Lucchese • Nicola Scopinaro
Editors

Minimally Invasive
Bariatric and Metabolic
Surgery
Principles and Technical Aspects
Editors
Marcello Lucchese Nicola Scopinaro
General and Emergency Surgery Department of Surgery
Bariatric Surgery University of Genoa Medical School
Careggi University Hospital Genoa
Florence Italy
Italy

ISBN 978-3-319-15355-1 ISBN 978-3-319-15356-8 (eBook)

DOI 10.1007/978-3-319-15356-8

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Preface

Obesity affects millions of people worldwide with a negative impact on qual-

ity and duration of their lives.
This condition represents a major issue in terms of public health due to the
cost of the many comorbidities often associated. Moreover, obesity has a
multifactorial background, thus its treatment needs a multifactorial environ-
ment with several specialists involved in the course of evaluation, treatment,
and follow-up of the patients.
Nevertheless, the role of the bariatric surgeon is still central in identifying
a therapeutic strategy upon the suggestions provided by the multidisciplinary
team. In fact, when asked to treat a condition of severe obesity, a surgeon can-
not act directly on the primary cause of the obesity itself. This means that
different techniques are still available to the surgeon’s choice and that the best
treatment for obese patients is to “tailor” a specific procedure according to
the patient’s expectations, the degree of overweight, the presence and type of
comorbidities, and the expected postoperative compliance.
Therefore, the bariatric surgeon needs to know all the possible medical
problems linked to obesity together with their implications and solutions.
A sudden innovation took place in the last years since it was observed that
bariatric surgery could improve some metabolic conditions such as type 2
diabetes and metabolic syndrome, hypertension, impaired fertility, and sleep
apnea, sometimes before achieving a significant weight loss.
Consequently, the aim of bariatric surgery was upgraded from just a
weight loss surgery to a metabolic surgery suitable to manipulate all the pos-
sible hormonal and metabolic changes that can be responsible for the
improvement of the abovementioned comorbidities. Therefore, bariatric sur-
geons started to be called more and more often to address a solution for some
chronic diseases, sometimes not directly linked to the excess of weight.
On the one hand, this book frames out the evolution of bariatric surgery
beyond the principles of surgical treatment, providing an overall picture of
the evolution and treatment of medical, endocrine, and psychological aspects
that must be considered in the multidisciplinary approach to the obese
patients. On the other hand, the book provides some important technical prin-
ciples addressed to both bariatric and general surgeons. In fact, even surgeons
not directly involved in bariatrics will be called more and more often to treat
patients who previously had a bariatric procedure.
The knowledge of bariatric techniques and their consequences would dra-
matically help in their work.

v
vi Preface

The present book is also addressed to all the health professionals and stu-
dents who want to know more about the surgical treatment of obesity, and we
hope that this will help to understand the real impact of this severe illness on
patients’ lives.
Finally, a special thanks to all the colleagues who contributed to realize the
present book, investing a precious part of their time in building up this
project.

Florence, Italy Marcello Lucchese

Genoa, Italy Nicola Scopinaro
Contents

Part I Obesity

1 Historical Background: From the Past to Present . . . . . . . . . . 3

John B. Dixon and T. Rice
2 Incidence and Prevalence of Obesity . . . . . . . . . . . . . . . . . . . . . 11
Luca Busetto and Stefania Maggi
3 The Pathophysiology of Obesity . . . . . . . . . . . . . . . . . . . . . . . . . 17
Geltrude Mingrone and Marco Castagneto
4 Obesity-Related Comorbidities. . . . . . . . . . . . . . . . . . . . . . . . . . 25
Paola Fierabracci, Anna Tamberi, and Ferruccio Santini
5 Hypogonadism and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Mario Maggi, Annamaria Morelli, Micaela Luconi,
Francesco Lotti, Marcello Lucchese, Enrico Facchiano,
and Giovanni Corona
6 Microbiota Organ and Bariatric Surgery . . . . . . . . . . . . . . . . . 43
Nicola Basso, Giovanni Casella, Emanuele Soricelli,
Geltrude Mingrone, and Adriano Redler

Part II Surgery of Obesity

7 The “Bariatric Multidisciplinary Center”. . . . . . . . . . . . . . . . . 59

John Melissas
8 Metabolic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Henry Buchwald
9 Diabetes Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Francesco Rubino
10 The Role of Laparoscopy in Bariatric Surgery . . . . . . . . . . . . . 99
Marcello Lucchese, Alessandro Sturiale,
Giovanni Quartararo, and Enrico Facchiano

vii
viii Contents

11 Anesthesia in Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 109

Jay B. Brodsky
12 Fast-Track in Bariatric Surgery: Safety, Quality,
Teaching Aspects, Logistics and Cost-Efficacy
in 8,000 Consecutive Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Hjortur Gislason, H.J. Jacobsen, A. Bergland, E. Aghajani,
B.J. Nergard, B.G. Leifsson, and J. Hedenbro

Part III Surgical Treatment

13 Indications for Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . 133

Marcello Lucchese, Giovanni Quartararo, Lucia Godini,
Alessandro Sturiale, and Enrico Facchiano
14 Endoscopic Treatment: Intragastric Balloon . . . . . . . . . . . . . . 145
Alfredo Genco, Roberta Maselli,
Massimiliano Cipriano, Emanuele Soricelli,
Giovanni Casella, and Adriano Redler
15 Endoscopic Treatment: New Technologies . . . . . . . . . . . . . . . . 153
Nicola Di Lorenzo and Francesco Maria Carrano
16 Adjustable Gastric Banding . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Karl A. Miller
17 Laparoscopic Sleeve Gastrectomy . . . . . . . . . . . . . . . . . . . . . . . 175
Giovanni Casella, Emanuele Soricelli, Alfredo Genco,
Adriano Redler, and Nicola Basso
18 Laparoscopic Gastric Plication. . . . . . . . . . . . . . . . . . . . . . . . . . 187
Martin Fried
19 Laparoscopic Roux-en-Y Gastric Bypass:
Technical Aspects, Clinical Management,
and Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Kelvin D. Higa
20 Laparoscopic Biliopancreatic Diversion . . . . . . . . . . . . . . . . . . 209
Nicola Scopinaro
21 Laparoscopic Duodenal Switch . . . . . . . . . . . . . . . . . . . . . . . . . 227
Antonio Iannelli and Francesco Martini
22 Revisional Surgery: Gastric Banding Failure . . . . . . . . . . . . . . 237
Jacques M. Himpens
23 Revisional or Conversion Procedures
for Roux-en-Y Gastric Bypass Failure. . . . . . . . . . . . . . . . . . . . 251
Luigi Angrisani, Antonella Santonicola, Giampaolo Formisano,
Ariola Hasani, and Michele Lorenzo
24 Revisional Surgery: Biliopancreatic Diversion Failure . . . . . . 257
Valerio Ceriani, Ferdinando Pinna, Tiziana Lodi,
and Paolo Gaffuri
Contents ix

25 Internal Hernia After Bariatric Procedures . . . . . . . . . . . . . . . 267

Enrico Facchiano, Giovanni Quartararo,
Alessandro Sturiale, and Marcello Lucchese
26 Emergencies in Bariatric Surgery: Highlights
for the General Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Carlo Bergamini, Giovanni Alemanno,
Enrico Facchiano, and Marcello Lucchese

Part IV Outcomes

27 Nutritional Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

Giovanni Camerini
28 Long-Term Follow-Up After Bariatric Surgery . . . . . . . . . . . . 303
Konstantinos Spaniolas and Walter J. Pories
 Part I
Obesity
 Historical Background:
From the Past to Present 1
John B. Dixon and T. Rice

Obesity and conditions associated with it have thousand years have been found through many
been detailed for centuries, to the extent that little areas of Europe. Perhaps the most famous of
appears to be new, yet we are still struggling to these is an Austrian figurine the “Venus of
answer the most basic questions. This chapter Willendorf”. During the hunter-gatherer era
will deal with some of the key questions and humans were typically lean, and the overweight
challenges that present today from a historical and obese state, with greater energy storage, may
perspective to examine just how far we have have represented a survival benefit during times
come, and will conclude with an historical over- of scarcity. However, since humans adopted agri-
view of bariatric-metabolic surgery. cultural practices and moved to settled societies,
history has consistently portrayed obesity as a
threat to health and moral substance, while at
The big questions times also representing wealth and status.
Is obesity a disease?
How much is known about the extent of
obesity complications? 1.1 Is Obesity a Disease?
What is the cause? And who is to blame?
How are obese people perceived? On June 18, 2013, the American Medical
How should obesity be managed? Association (AMA) adopted a policy that recog-
nises obesity as a disease that requires a range of
medical interventions to advance treatment and
Evidence of human obesity can be traced back prevention. The debate continues as many health
35,000 years to the time of the first human popu- care providers, professional organisations, and
lation in Europe. Statues in ivory, limestone, and payors, take a philosophical approach that it is not
terracotta of obese humans dating back 23–25 a disease, and yet it would be difficult to find or
design any definition of “disease” that could
exclude obesity. Ancient Egyptians were thought
J.B. Dixon (*) • T. Rice, MD to have perceived obesity as a disease, as stone
Clinical Obesity Research Laboratory, reliefs showed sporadic obese individuals, often
Baker IDI Heart and Diabetes Institute, on walls portraying illness. The Aztecs believed
St Kilda Road Central, PO Box 6492, obesity was supernatural, a misfortune of the
Melbourne, VIC 8008, Australia
e-mail: [email protected]; Gods. Hippocrates (460–377 BCE), who cor-
[email protected] rectly acknowledged the energy balance equation,

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 3

Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_1,
© Springer International Publishing Switzerland 2015
4 J.B. Dixon and T. Rice

recognised obesity as associated with death and a sugary taste of urine were often indolent, over-
infertility. “Corpulence is not only a disease itself, weight individuals who consumed excessive
but a harbinger of others” – Hippocrates. Galen sweet and fatty foods, and recommended physi-
of Pergamon (AD 129–217), the Greek physician, cal work as a cure.
surgeon, and philosopher, argued that excessive Obesity has been repeatedly associated with
corpulence harmed the actions or functions of the both male and female infertility, for example,
body and thus was a disease. He considered obe- in Persian physician-philosopher Avicenna’s
sity as a disease of size or quantity and declared (980–1037) renowned Canon medicinae.
that ridding the patient of excessive fat would pro- Descriptions of women with reduced or absent
vide the “cure”. By the sixteenth and seventeenth menstruation, together with masculine features
century, accounts of obesity and its comorbidity and poor fertility, may be found in biblical
were detailed and widely available for practitio- records, works of Hippocrates, and throughout
ners. Girolamo Mercuriale, writing in 1587, history in all global regions and ethnicities.
believed that when obesity only impacted upon Interestingly, the durability of the phenotype may
the body’s appearance, it was simply a symptom, suggest that the robust masculine features and
but when it impacted upon the proper function of reduced fertility provided survival advantage
the body, it became a disease. under stressful circumstances, so polycystic
ovary syndrome may actually not have been con-
sidered a “disease” state in times gone by.
Disease The common theory regarding the underlying
“A pathological condition with signs and pathophysiology of obesity during the sixteenth
symptoms” and seventeenth centuries was that excess fat
“An abnormal or harmful condition” caused tightness or constriction within the body,
“Impairment of function” impeding the flow of blood, humours, and vital
“A pathological condition resulting from heat. The observations that obesity was associ-
various causes, such as infection, genetic ated with asthma, cardiac events, and obstructive
defect, or environmental stress” sleep apnoea were actually quite consistent with
this prevailing theory. Avicenna’s Canon beauti-
fully describes asthma, sudden death, and cardio-
vascular disease as complications of obesity.
1.2 Obesity-Related “Severe obesity restricts movement and causes
Complications: Comorbidity breathlessness … breathing passages are
obstructed and flow of air hindered leading to
Perhaps in deference to a rigid denial of obesity nasty temperament …. On the whole these peo-
as a disease, we have been driven to address the ple are at risk of sudden death … because their
complications of obesity as comorbidities rather veins are small and compressed. They are vulner-
than accept the reality of a common origin of able to stroke, hemiplegia ….”
these issues. Generally, we regard disorders of French physician Jean Fernel (1497–1555) also
regulation as causing complications, sometimes provided a graphic account of the dangers of over-
even without proof of specific causality, for consumption. “The vessels were overburdened
example, the disorders associated with diabetes, with excrements which could not be sufficiently
hypertension, dyslipidaemia, renal dysfunction, evacuated. Everything inside the body became
neurological degeneration, and alcoholism. Yet compressed and tight. The pathways in the body
historically, obesity was clearly described in were narrowed or obstructed and the body was no
terms of its associated complications. longer permeable and sufficiently ventilated.
The earliest recognition of type 2 diabetes was When the compression in the body reached a max-
credited to Hindu physicians Sushrut and Charak imum, the innate heat could be extinguished or
(500–400 BCE). They observed that people with vessels could rupture, leading to sudden death”.
1 Historical Background: From the Past to Present 5

Giovanni Argenterio (1566), in a commentary physicians’ dire warnings about the conse-
on Galen, warned “that people with ‘too much quences of obesity were being promulgated,
fat’ had shorter lives. Since most of their blood at least in part, in order to provide scientific
was transformed into fat, the body was robbed of justification for the accepted social values of
its necessary nutrition and the fat also pressed on diligence and temperance.
the vessels and suffocated the vital heat”. Yet the pejorative views of obesity as being
Sleep disturbances were also well recognised representative of a lack of self-control and
before the first medical description of sleep “impure spirit” were not universal, nor were they
apnoea was made by Sidney Burwell and col- applied uniformly across the spectrum of over-
leagues (1956), and the Dickens Pickwickian weight and obesity. Art indicates that at times
club papers (1837). Gosky (1658) described the throughout history, moderate degrees of corpu-
obese as “‘slow, lazy, and idle’, they tired quickly lence were considered desirable, particularly
or even developed an irresistibly strong propen- among women, and so they chose to over-consume
sity to fall asleep”. to obtain a more succulent beautiful body. It
seemed that only severe, highly visible obesity,
often associated with signs of illness such as
1.3 How Is Obesity Viewed by shortness of breath and impaired mobility, were
Society? What Is the Cause? viewed as problematic. Indeed, even to the current
Who Is to Blame? day, there are tribes and nations in Africa that
deliberately overfeed young women prior to mar-
Excess has historically dominated causal aspects riage, in preparation for childbearing, and to
of obesity. Hippocrates proposed that health con- enhance beauty and the appearance of wealth.
sisted of balancing the body’s four humours, and More widely however, obesity was associ-
obesity is caused by a surplus of the humours. ated with illness, impurity, decay, and putrefac-
Galen’s writings On the Power of Foods (AD tion. As a result of the consumption of excessive
180) suggested that digested food was converted food, the humours were thought to be over-bur-
to blood, and the more food consumed, the more dened and the innate heat weakened, much like
blood is produced and the more obese a person a fire being smothered, and the fat itself accu-
becomes. This view had not changed in the sev- mulated and stagnated in the vessels and cavi-
enteenth century, when obesity was being ties of the body. Until the eighteenth century,
described as being due to abundant oily blood, fat was not understood to be a biological fuel
derived from excessive food. By the early eigh- source that could be “burnt off”, but was rather
teenth century, Hossauer distinguished “obesitas seen as a functional excrement, which could
haereditaria”, a form with a familial susceptibil- only be excreted with great difficulty. Those
ity, from obesity acquired through an over- with excessive fat in their body were well
indulgent lifestyle. advised to seek help from physicians to get rid
Weakness of character, sloth, and gluttony of superfluous fat before there was any manifest
have often dominated the Christian views of harm.
obesity. Obese people were commonly labelled Linked with the character judgements made
as lazy, due to their reduced ability to move and about the obese, there was a clear perspective that
function freely, without suffering shortness of fat people failed to address their issue, ignored
breath. Mercuriale, writing in 1587, described their sickness until too late, and were difficult to
that obesity impaired intellectual function, espe- treat, with therapies having reduced effect.
cially when obesity was not innate but acquired This context appears to be the basis for many
through gluttony. He felt the Lacedaemonians physicians’ attitudes and beliefs today. The con-
had been justified in condemning those who cept that obesity may be more than simply an
were fat as having little intelligence and cour- individual responsibility and should instead be
age. By the eighteenth century, it appears that considered a broader societal and public health
6 J.B. Dixon and T. Rice

issue appears to be limited to the last century and of obesity. Banting had overcome obesity with
especially recent decades, and is still a conten- the help of physician William Harvey through,
tious view in the present day. among other measures, eliminating bread, butter,
milk, sugar, beer, and potatoes from his diet.
The health (hot) spa, healthy lifestyle, heavy
1.4 Therapy for Obesity sweating, healthy diet, and vegetarian approaches
have continued to be mainstays of therapy up to
Historical therapies for obesity have been the present day. Many still feel that this method-
designed to address the specific cause, and in ology forms the only morally appropriate therapy
many ways closely parallel today’s dominant today.
treatment options, involving changes to diet,
sweating, hard work, and exercise. Soranus of
Ephesus wrote about the treatment of obesity in 1.5 Complementary, Traditional,
the second century AD, with his work trans- and Drug Therapies
lated and expanded by Caelius Aurelianus in
the fifth century. These prominent physicians It seems logical to target obesity, a chronic dis-
described the need to both limit food intake and ease resulting from dysfunctional energy regula-
reduce the stored fat, by means of perspiration. tion, with drug therapy. However, the road to
Physical activity (including “passive exercise” delivering effective drug therapy has been littered
such as riding in a chariot, or reading poetry with disappointment, failure, and drug withdraw-
aloud) and heat treatments (hot baths, mas- als. This has been attributed to unacceptable side
sages) were recommended to induce sweating. effects and difficulty targeting key central energy
Soranus and Caelius also advocated keeping balance pathways. Central energy balance path-
the obese patient awake, in order to exhaust ways contain redundant protective elements com-
their bodies and generate more heat. While mon to other essential processes of living
these measures were dubious in light of today’s including control of blood pressure, oxygen satu-
understanding, their dietary plan actually reso- ration, temperature, blood glucose, and electro-
nates quite closely with today’s very low energy lytes, so their manipulation has been challenging.
diet protocols, incorporating intermittent peri- As already mentioned, treatments were histori-
ods of significant food restriction, with a return cally aimed at enhancing the excretion of excess
to a more stable diet in between, and complete fat through the urine, faeces, and sweat, so were
avoidance of fatty foods. predominantly laxatives, diuretics, and stimulants
By the fifteenth and sixteenth centuries, dietary that increased body temperature and promoted
manipulations were taking more questionable sweating. Soranus of Ephesus again seems to be
turns, with physicians prescribing dietary compo- the forefather of the use of laxatives and purga-
nents known to stimulate the innate heat, such as tives. Many of the traditional medicine streams
spicy and sour foods. Foods with diuretic proper- including Chinese Traditional Medicine and
ties were also heavily prescribed. Perhaps, one of Ayurvedic Medicine also include such agents. One
the first comprehensive weight management pro- example is Brindleberry (Garcinia cambogia,
grams followed the successful self-treatment of hydroxycitric acid), which has featured in the culi-
the Scottish physician, George Cheyne (1671– nary and medicine traditions of Asian countries
1743), who used major changes to his diet, hot for centuries, as an agent to sour food, control
foods, hot baths (springs), and physical activity to appetite, and prevent the accumulation of excess
alter his excessive weight. fat. Despite Garcinia and its active components
William Banting’s “Letter on Corpulence showing no efficacy for weight management in
Addressed to the Public”, with four editions pub- modern clinical trials, it is still widely available
lished in the 1860s, described the first widely- today and publicised as a natural therapy for
circulated low-carbohydrate diet for the treatment weight loss, touted as a stimulant of fat-burning.
1 Historical Background: From the Past to Present 7

Interestingly, one of the only pharmacothera- and 1970s, but were still being used and abused
pies available to treat obesity today, orlistat in various forms until the 1990s (Obetrol, which
(Xenical), could actually be considered as falling was later rebranded as Adderall, is one notable
into this category of “fat excretion enhancers”. Its example). The amphetamines and several more
action as a lipase inhibitor prevents the absorption contemporary sympathomimetics acted primarily
of ingested fat, resulting in the excretion of dietary through appetite suppression, effectively target-
fat in the faeces. Of course, we now understand ing the noradrenaline and serotonin systems.
that it is not the excretion of internal fat stores that Unfortunately, most of these agents have now
brings about weight loss, as was thought in the been withdrawn due to neurological and cardio-
seventeenth century, but rather the prevention of vascular side effects, including fenfluramine
fat absorption from the diet. While its effects are (developed in 1973), dexfenfluramine (mid-
modest (average 5 % weight loss) and side effects 1990s), the fen-phen combination of fenflura-
are unfavourable, in today’s environment of rigor- mine and phentermine, Ephedra (ma huang,
ous drug approval it is one of the few options con- a Traditional Chinese Medicine), and most
sidered to be sufficiently safe and effective. recently sibutramine (approved 1997), which was
The seventeenth-century Tibetan medical trea- available until 2010. Phentermine is still avail-
tise The Blue Beryl, written by Sangye Gyamtso, able for short-term use as a single therapy, and
included such measures as massaging the body has most recently been approved in the USA in
vigorously with pea flour, and consuming gullet, combination with topiramate (Qsymia) for the
hair, and flesh of a wolf. Odd as this remedy treatment of chronic severe obesity.
sounds, it is actually not so far removed from the The few modern drug therapies available are
use of porcine thyroid extracts, which began in the moderately effective, generally allowing 2–10 %
1890s, in response to much more scientifically of body weight loss, but have never had major
sound observation and reasoning. Given that uptake or been able to be used continuously, as
hypothyroid patients who received the extract would be needed to treat a chronic condition, due
began to lose weight as their other symptoms to the side effects. Further complicating the mat-
improved, it seemed a logical extension to try the ter, as a result of past disappointments such as
same therapy in obese patients. While later recog- those described above, it is extraordinarily diffi-
nised to be dangerous in euthyroid individuals, cult to get new preparations approved. The litera-
this line of hormonal manipulation to effect ture throughout the twentieth century was
weight loss has continued, with growth hormone continually optimistic and promoted the long list
and more recently human chorionic gonadotropin of potential targets that would change the game
also being tried as effective obesity therapies, but in the future. This approach continues today, yet
found wanting. The discoveries of leptin and history would suggest the current optimism is
ghrelin also initially brought great hopes of find- misplaced, but for a set of critical observations
ing “the cause of obesity” and effective therapies, regarding bariatric-metabolic surgery.
yet these failed to lead to any useful treatments.
Many of the more recent therapies have tar-
geted the reduction of hunger, increased early 1.6 Bariatric-Metabolic Surgery
satiation and satiety, and increased energy expen-
diture. In the 1930s, dinitrophenol, an uncoupler By last century, with sound scientific reasoning,
of oxidative phosphorylation, was introduced as obesity was well understood and the solutions
an obesity treatment. Its toxic side effects (includ- seemed obvious, but treatments continually
ing sometimes fatal hyperthermia, neuropathy, failed. However, one therapeutic modality,
and cataracts) saw it banned by the FDA in 1938 bariatric-metabolic surgery, bucked the trend and
however. Amphetamines then became the drugs is now helping to advance our understanding of
of choice for a multitude of “diet pills” which the whole disease of obesity. Bariatric surgery
reached the height of their popularity in the 1960s started in the early 1950s, with various intestinal
8 J.B. Dixon and T. Rice

bypass procedures, and has been gradually evolv- The extraordinary observation that bariatric sur-
ing since. Surgery has evolved largely through an gical interventions not only worked but the effect
extraordinary group of committed surgeons was durable was perhaps the greatest moment in
whose innovation and determination has gener- the “history of obesity”, certainly for the manage-
ated so much more than the range of safe and ment of obesity. But it was an observation that was
effective procedures that we have today. This largely missed; it was well ahead of its time, and it
surgical innovation preceded knowledge of the challenged the most fundamental societal attitudes
key hormones and mechanistic pathways known and beliefs about obesity. Gastro-intestinal proce-
to be critical in the regulation of human energy dures, some with very simple changes, could trans-
balance, yet still effectively acted upon them. form the severely obese ill person into a leaner
Surgery, perhaps naively, targeted “restriction” of healthier functional individual who never looked
intake with gastric procedures and “reduced back. Was it curing the sloth and gluttony, strength-
absorption” with diversionary procedures. ening the intellect and the character, and providing
Edward Mason, known as the father of obesity courage? Or was it effectively treating a disease of
surgery, provided enormous impetus to modern disordered regulation of energy balance? Bariatric
bariatric surgery in 1967 with the loop gastric surgery demonstrated for the first time that there
bypass, and later developed and championed the was an effective therapy in humans, but it would
vertical banded gastroplasty. These were impor- take almost 50 years before the critical questions of
tant nutritional and metabolic departures from just how it worked would adequately be scientifi-
intestinal bypass procedures which had proved cally addressed. The process of investigation was
problematic. Nicola Scopinaro, using insights actually the reverse of the familiar steps used in
into intestinal physiology, developed the bilio- developing most novel therapies – “This surgery
pancreatic diversion which provided selective clearly works in humans, but we need definitive
and limited intestinal malabsorption that when proof so let’s see if it works in rodents”. The proce-
combined with partial gastric resection was dures do work, and this model is now providing
extraordinarily successful for weight loss, dys- mechanistic insights. We are now starting to under-
lipidaemia, and type 2 diabetes. Numerous ver- stand the mechanisms involved in bariatric surgery,
sions of the gastric bypass and gastroplasties and by extension some of the processes involved in
dominated bariatric surgery until the early 1990s. the development and treatment of obesity-related
Fixed gastric bands had never been popular, but metabolic disease.
then two surgeons recognised the importance of
stomal adjustability – Dag Hallberg, in trying to
optimise the restriction of vertical banded gastro- It’s not a disease
plasty, and Ivor Kuzmak, in modifying fixed Comorbidity not complications
banding. The adjustable gastric band was devel- Weakness of character
oped during the early general laparoscopic sur- Personal responsibility–Poor choices
gery era and heralded the revolution of Personal rather than a public health issue
laparoscopic bariatric surgery. Within a short The correct therapy is obvious
period Wittgrove and Clarke were performing
laparoscopic Roux-en-Y gastric bypass and it
was clear that laparoscopic surgery was the way Today, the challenge of obesity and the diseases
forward in bariatric surgery. The major advances that it causes such as type 2 diabetes has never
in bariatric surgery over the last decade have been greater. Despite important insights provided
been related to standardisation and quality con- through bariatric-metabolic surgery, population
trol, major reductions in operative morbidity and perceptions regarding the cause, who is to blame,
mortality, the publication of credible high quality and solutions for management have changed little
research and monitoring through national and in thousands of years. To tackle this epidemic we
international registries (Fig. 1.1). need to change these perceptions and embrace the
1 Historical Background: From the Past to Present 9

Bariatric Surgery Timeline

1967 1993 1995
1954 1978 Lap Adj. 2002
Gastric Lap Lap SG
I-Bypass Bypass BPD Gastric RYGB
Band

1950 1960 1970 1980 1990 2000 2010

Intestinal bypass

Biliopancreatic Diversion

BPD–Duodenal Switch

Gastric Bypass

Horizontal

Vertical

Vertical banded gastroplasty

Gastric Band Non Adjustable

Adjustable gastric band

I-Bypass = Intestinal bypass
BPD = Biliopancreatic Diversion Sleeve Gastrectomy
RYGB = Roux-en-Y gastric bypass
SG = Sleeve Gastrectomy
Gastric Pilcation

Fig. 1.1 Bariatric surgery timeline

epidemic as a whole-of-society/environmental Suggested Reading

issue, with victims that have an incurable chronic
1. Azziz R, Dumesic DA, Goodarzi MO. Polycystic
disease that reduces the length and quality of life. ovary syndrome: an ancient disorder? Fertil Steril.
The problem is obvious; the solutions are not. 2011;95:1544–8.
There have been no serendipitous moments or 2. Bray G. Chapter 1. History of obesity. In: Williams G,
paradigm shifts that have changed our societal Frühbeck G, editors. Obesity: science to practice.
Chichester: Wiley; 2009.
focus and perceptions about obesity – which is in 3. Dossey L. Gluttony and obesity. Explore (NY). 2010;
fact a serious disease. Findings regarding the 6:1–6.
genetic and epigenetic aspects of obesity and met- 4. Haslam D. Obesity: a medical history. Obes Rev.
abolic programming, our current understanding 2007;8 Suppl 1:31–6.
5. Papavramidou N, Christopoulou-Aletra H. Management
central control of energy balance and defence of of obesity in the writings of Soranus of Ephesus and
body weight (fat), and the evidence that bariatric Caelius Aurelianus. Obes Surg. 2008;18:763–5.
surgery provides a durable weight change should 6. Park RJ. Historical reflections on diet, exercise, and
have changed these societal perceptions and driven obesity: the recurring need to “put words into action”.
Can Bull Med Hist. 2011;28:383–401.
a fundamental change in our search for solutions. 7. Stolberg M. ‘Abhorreas pinguedinem’: fat and obesity
The future will depend on understanding and in early modern medicine (c. 1500-1750). Stud Hist
exploring the facts, rather than beliefs, and design- Philos Biol Biomed Sci. 2012;43:370–8.
ing solutions that work rather than holding on to
solutions that should work, but never will.
 Incidence and Prevalence
of Obesity 2
Luca Busetto and Stefania Maggi

2.1 Introduction 2.2 Definition of Overweight

and Obesity
In the recent years, obesity has received consider-
able attention as a major health problem world- According to the World Health Organization,
wide. Obesity is now the most prevalent form of overweight and obesity are defined as an abnor-
malnutrition in the industrialized countries and it mal or excessive fat accumulation that presents a
is rapidly becoming highly prevalent also in the risk to health. A crude population measure of
developing world. The relevance of obesity as a overweight and obesity is the body mass index
risk factor for several medical conditions and (BMI), a person’s weight (in kilograms) divided
diseases is well known. Obesity is linked to vari- by the square of his height (in metres). BMI (kg/m2)
ous disabling and/or life-threatening conditions, is used in epidemiology and in clinical practice to
such as heart disease, diabetes, hypertension, define underweight, normal weight, overweight
stroke, certain cancers, osteoarthritis, respiratory (pre-obesity), and obesity [3]. However, the use
abnormalities, gastro-esophageal reflux disease of BMI as a proxy for adiposity, the true determi-
(GERD), and liver disease (nonalcoholic fatty nant of the obese state, has been criticized, given
liver disease, cirrhosis, and hepatocellular carci- that body weight is the sum of individual organs
noma). Therefore, obesity epidemic was numbered and tissues and therefore it includes adipose tis-
as one of the major contributors to the global bur- sue, skeletal muscle mass, and organs mass.
den of disease and disability [1]. According to Moreover, BMI does not convey any information
some predicting models, the rapidly increasing on fat distribution (e.g., visceral fat accumulation
prevalence of obesity and related comorbidities and fatty infiltrations in individual organs) that is
can reverse in some countries the current prevail- now considered an important determinant of met-
ing trend of increasing life expectancy [2]. abolic and cardio-vascular risk [4]. On the other
hand, current reference methods for the direct
measurement of fat mass (underwater-weighing;
L. Busetto (*) total body densitometry) or total and regional
Department of Medicine, University of Padova, adipose tissue volumes (CT or MRI) are costly
Via Giustiniani, 2, Padova 35128, Italy
and not applicable in large epidemiologic investi-
e-mail: [email protected]
gations or in routine clinical practice.
S. Maggi
On a population level, a strong positive corre-
CNR, Neuroscience Institute, Aging Branch, Padova,
Via Giustiniani, 2, Padova 35128, Italy lation between BMI and overall body fat content
e-mail: [email protected] has been extensively reported [5]. However, this

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 11

Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_2,
© Springer International Publishing Switzerland 2015
12 L. Busetto and S. Maggi

Table 2.1 Classification of weight category by BMI surveys or population studies, where weight and
BMI (kg/m2) BMI (kg/m2) cut-off height are measured or self-reported [9].
general points for Asian According to WHO database, 34.5 % of the
Classification cut-off points populations world adults (age ≥ 20 years) were overweight
Underweight <18.5 <18.5
and 11 % were obese in 2008 [9]. This means that
Normal range 18.5–24.9 18.5–22.9
in the world there were more than 1.4 billion
Pre-obese 25.0–29.9 23.0–27.4
overweight adults in 2008. Of these over 200 mil-
Obese class I 30.0–34.9 27.5–32.4
lion men and nearly 300 million women were
Obese class II 35.0–39.9 32.5–37.4
Obese class III ≥40.0 ≥37.5
obese [9]. The prevalence of overweight and obe-
sity was higher in women than in men (over-
Source: Adapted from WHO [3, 8]
weight: 35.1 vs. 33.8 %; obesity 14.0 vs. 10.0 %)
[9]. Prevalence of obesity varies greatly across
can mask significant variations in the relationship the WHO regions. Obesity is much more preva-
between BMI and adiposity on an individual lent in the Americas (29.7 % in women and
level. For instance, the body fat content of a 23.5 % in men), in the WHO region of Europe
healthy subject with a normal BMI value has (23.1 % in women and 20.4 % in men), and in the
been demonstrated to vary from 8 to 38 % in men Eastern Mediterranean region (24.5 % in women
and from 30 to 44 % in women [6]. This large and 13.0 % in men). Prevalence of obesity are
variability implies that an individual subject may lower in the WHO regions of Africa (11.1 % in
have a BMI corresponding to an obese state both women and 5.3 % in men), Western Pacific
having a low fat-free mass and a substantial fat (6.8 % in women and 5.1 % in men), and South
accumulation or having a large skeletal muscle East Asia (3.7 % in women and 1.7 % in men). In
mass and normal fat mass. This latter condition all WHO regions women were more likely to be
typically occurs in athletes, in which high BMI obese than men, and in the WHO regions for
may simply reflect increased muscle mass, which Africa, Eastern Mediterranean, and South East
does not have anything to do with obesity and Asia, women had roughly double the obesity
associated diseases. Even at an epidemiological prevalence of men [9]. At a national level, the
level, the poor performance of BMI as a marker nations with the higher prevalence of overweight/
adiposity is emphasized by the large differences obesity are represented by Pacific Islands (Nauru,
in percentage body fat observed between men Cook Islands, Tonga, Samoa, Palau, Kiribati),
and women having the same BMI level, with where the prevalence stands over 80 %. High-
women having a higher percentage of body fat income Arabic Kingdoms in the Persian Gulf
than men [7]. Ethnical factors also play a role. A region (Kuwait, Qatar, United Arab Emirates,
BMI of 20–25 kg/m2, which is considered normal Saudi Arabia, and Bahrain) had overweight prev-
and healthy in a Caucasian subject, correspond to alence between 70 and 80 % and represents the
an elevated body fat content and is associated to second group of nations with the highest preva-
an increased disease risk in people belonging to lence in the world. The only world three nations
other ethnic groups, and particularly in Asian with a prevalence of overweight in 2008 lower
subjects. This observation prompted the WHO to than 10 % were represented by very poor low-
adopt different cut-off points for overweight and income states (Bangladesh, Ethiopia, and Nepal)
obesity in people of Asian origin (Table 2.1) [8]. [9]. Besides ethnic factors, the economic levels
play a crucial role in determining overweight/
obesity prevalence worldwide. Indeed, the preva-
2.3 Prevalence of Obesity lence rates increase with income level of coun-
Worldwide tries up to upper middle-income levels. The
prevalence of overweight in high and upper
The prevalence of obesity around the world is middle-income countries was more than double
monitored by the WHO through the Global that of low- and lower middle-income countries.
Database on BMI, which gathered data from For obesity, the difference is more than triple
2 Incidence and Prevalence of Obesity 13

Czech republic
Slovenia
Malta
United Kingdom
Russia
Hungary
Lithuania
Slovakia
Ireland
Bosina
Spain
Luxembourg
Belarus
Poland
Serbia
Latvia
Iceland
Montenegro
Portugal
Bulgaria
Germany
Croatia
Albania
Moldova
Macedonia
Ukraine
Finland
Norway
Belgium
Estonia
Austria
Romania
Greece
Italy
Sweden
Netherlands
Denmark
France
Switzerland

0 5 10 15 20 25 30

Fig. 2.1 The prevalence (%) of obesity in adults in European nations, according to WHO database 2008 [9]

from lower middle-income countries to upper obesity varies greatly across the European coun-
middle-income countries [9]. tries, with countries having obesity figures closer
The USA has a high prevalence of overweight to the US values and countries having much
and obesity. The more recent US data are from lower figures. The prevalence of obesity in
the National Health and Nutrition Examination European nations ranked according to the WHO
Survey, 2011–2012 [10]. According to this sur- levels in 2008 [9] is represented in Fig. 2.1.
vey, more than one-third (34.9 %) of adults were In Italy, prevalence of overweight according to
obese. Prevalence of obesity was higher among WHO database was 49.2 % in 2008, and preva-
middle-aged adults (39.5 %) than among younger lence of obesity was 17.2 % [9]. These estimates
(30.3 %) or older (35.4 %) adults. The overall are largely based on data collected by the
prevalence of obesity did not differ between men Cardiovascular Epidemiologic Observatory of
and women. However, large racial differences the Italian Health Institute (Istituto Superiore di
were observed. The prevalence of obesity was Sanità – Progetto Cuore). A more detailed analy-
higher among non-Hispanic black (47.8 %), sis of this database demonstrated an overweight
Hispanic (42.5 %), and non-Hispanic white prevalence of 50 % in men and 34 % in women.
(32.6 %) adults than among non-Hispanic Asian In the same sample, the prevalence of obesity
adults (10.8 %). Among non-Hispanic black was 17 % in men and 21 % in women [11].
adults, 56.6 % of women were obese compared Overweight and obesity prevalence was higher in
with 37.1 % of men [10]. the southern regions of Italy, where 19 % of men
In 2008, the general prevalence of obesity in and 30 % of women were obese, and 52 % of men
the WHO region for Europe was lower (21.9 %) and 35 % of women are overweight [11].
than the prevalence observed in the US (31.8 %) Alarming prevalence of obesity has been
[9]. However, the prevalence of overweight and observed also in children and adolescents in
14 L. Busetto and S. Maggi

several countries worldwide. A study comparing increase in prevalence has been observed for the
data from large nationwide surveys, has shown most severe forms of obesity: whereas the gen-
that the combined prevalence of obesity and eral prevalence of obesity (BMI >30 kg/m2) dou-
overweight in children was high in the USA bled in the last 15 years of the twentieth century
(25 %), moderate in Russia (16 %), and low in in the USA, the prevalence of morbid obesity
China (7 %) [12]. In 2011–2012, the prevalence (BMI >40 kg/m2) had a fourfold increase and the
of obesity in the USA was 16.9 % in subjects 2- prevalence of super-obesity (BMI >50 kg/m2)
to 19-year-olds [13]. In Italy, 22.2 % of children had a sixfold increase [17]. However, these secu-
in primary school were overweight and 10.6 % lar trends on the prevalence of obesity must be
had obesity in 2012 [14]. Alarming data have considered with caution: a continuous variable,
been observed in the southern regions of Italy such as body weight, is used to classify dichoto-
where more than 40 % of 6–10-year-old children mous variables such as obesity and overweight.
were overweight or obese [14]. A high percent- This could imply that an average modest weight
age of obese children and adolescents nowadays gain might lead to a relevant increase in the inci-
present complications that, until a decade ago, dence of overweight and obesity. However, in the
characterized only adulthood: insulin resistance, USA it has been reported that the average increase
type 2 diabetes, dyslipidemia, nonalcoholic fatty of BMI has been very relevant, changing from
liver disease, metabolic syndrome, and hyperten- 25.6 kg/m2 in 1976–1980 to 27.9 kg/m2 in 1999–
sion [15]. These complications are associated in 2004 in men, and from 25.3 to 28.7 kg/m2 in
children and adolescents to cardiovascular events, women [18]. The increase in the prevalence of
cancer, and premature death as in adult [15]. obesity has been observed worldwide and most
Obese children are also at higher risk of preco- countries had rising trends of obesity. Only 2 of
cious puberty, polycystic ovary syndrome, sleep the 28 countries in the Global database on BMI
apnea, orthopedic complications, and psycholog- showed a falling trend in the prevalence of obe-
ical and social disturbances [16]. Finally, obese sity in men (Denmark and Saudi Arabia), and 5
children have a higher probability of becoming of the 28 countries showed a falling trend in the
obese adults, thus fueling current epidemic of prevalence of obesity in women (Denmark,
obesity and related diseases [16]. Ireland, Saudi Arabia, Finland, and Spain) [9].
This discouraging global picture of the “obesity
epidemic” may be partially ameliorated by the fact
2.4 Incidence and Time Trends that recent data seem to suggest a stabilization of
prevalence after years and years of progressive
The prevalence of obesity has increased steadily increment in some industrialized countries with
in the past 30 years, configuring an unprece- high prevalence of overweight and obesity. In the
dented “epidemic” for a non-communicable dis- USA, there was no significant change in obesity
ease. The worldwide prevalence of obesity had prevalence in the total adult population between
nearly doubled since 1980 (10 % of men and 2003–2004 and 2011–2012 (+2.8 percentage
14 % of women were obese in 2008, compared points) [13]. A significant increase in prevalence
with 5 % for men and 8 % for women in 1980) was observed only among adults aged 60 years
[9]. In the early 1960s, the prevalence of obesity and older (+4.4 percentage points) [13].
in the USA was 11 % among men and 16 % Obesity trends in children and adolescents seem
among women, and it changed relatively little to parallel trends of overweight and obesity in
until 1980. Data from NHANES II (between adults. Previous studies indicate that in many
1976 and 1980) and NHANES III (between 1988 developed countries children obesity has reached
and 1994) demonstrate that the prevalence rates levels similar to those in the USA and that obesity
of obesity increased considerably, to about 21 % prevalence is rapidly increasing in developing
in men and 26 % in women. By 2003–2004 the countries (e.g., in Brasil, has tripled from 1970
prevalence had increased further to almost 32 % (4 %) to 1990 (14 %)). On the other hand, more
in men and 34 % in women [10]. An even greater recent trend seems to stabilize in the US children
2 Incidence and Prevalence of Obesity 15

and this might be due to the aggressive campaign 2. Olshansky SJ, Passaro DJ, Hershow RC, et al. A poten-
tial decline in life expectancy in the United States in the
against obesity and unhealthy dietary patterns.
21st century. N Engl J Med. 2005;352:1138–45.
Among American children and adolescents aged 3. WHO. Obesity: preventing and managing the global
2–19 years, there was no significant change in obe- epidemic. Report of a WHO consultation. World
sity prevalence between 2003–2004 and 2011– Health Organ Tech Rep Ser. 2000;894:1–253.
4. Müller MJ, Lagerpusch M, Enderle J, et al. Beyond
2012 overall (−0.2 percentage points) [13], but
the body mass index: tracking body composition in
there was a significant decrease in obesity preva- the pathogenesis of obesity and the metabolic syn-
lence among 2–5-year-old American children (−5.5 drome. Obes Rev. 2012;13:6–13.
percentage points) [13]. Data from other countries 5. Okorodudu DO, Jumean MF, Montori VM, et al.
Diagnostic performance of body mass index to iden-
also have shown a decline or stabilization of obe-
tify obesity as defined by body adiposity: a systematic
sity levels in children. In Germany, a significant review and meta-analysis. Int J Obes (Lond). 2010;
decline in overweight or obesity in children aged 34:791–9.
4–7 years and a stabilization in children from 8 to 6. Thomas EL, Frost G, Taylor-Robinson SD, Bell JD.
Excess body fat in obese and normal-weight subjects.
16 years of age have been observed between 2004
Nutr Res Rev. 2012;25:150–61.
and 2008 [13]. Results of an Italian survey on prev- 7. Karastergiou K, Smith SR, Greenberg A. Sex differ-
alence of overweight and obesity in primary school ences in human adipose tissues – the biology of pear
children demonstrated a trend to stabilization in shape. Biol Sex Differ. 2012;3:13.
8. WHO. Appropriate body-mass index for Asian popu-
prevalence in the very recent years [14].
lations and its implications for policy and intervention
strategies. Lancet. 2004;363:157–63.
Conclusion 9. World Health Organization. Obesity. 2008. [Accessed
The prevalence of obesity has increased dra- 7 Apr 2014]. Available at: http://www.who.int/topics/
obesity/en/.
matically in the last decades in both adults and
10. Ogden CL, Carroll BK, Flegal KM. Prevalence of
children, with evidence of possible recent sta- obesity among adults: United States, 2011-2012.
bilization in some industrialized countries. NCHS Data Brief. 2013;131:1–8.
Nevertheless, the prevalence rates continue to 11. Progetto Cuore. Istituto Superiore di Sanità. 2014.
[Accessed 7 Apr 2014]. Available at: http://www.
be greater than one third of the population and
cuore.iss.it/eng/.
the obesity epidemic is still escalating in the 12. Wang Y. Cross-national comparison of childhood
developing world. The reduction of the preva- obesity: the epidemic and the relationship between
lence rate of obesity is a public health priority. obesity and socioeconomic status. Int J Epidemiol.
2001;30:1129–36.
Obesity is the result of a complex interaction
13. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence
between the environment, genetic predisposi- of childhood and adult obesity in the United States,
tion, and human behavior. It is associated with 2011-2012. JAMA. 2014;311:806–14.
an increased risk of numerous chronic dis- 14. Okkio alla Salute. Ministero dell’Istruzione,
dell’Università e della Ricerca. 2014. [Accessed 7 Apr
eases, disability, and death. In addition, the
2014]. Available at: http://www.okkioallasalute.iss.it/.
obesity epidemic represents a heavy burden 15. Weiss R, Dziura J, Burgert TS, et al. Obesity and the
on the economy with its massive health care metabolic syndrome in children and adolescents.
costs. The problem of overweight and obesity N Engl J Med. 2004;350:2362–74.
16. Han JC, Lawlor DA, Kimm SYS. Childhood obesity.
has therefore emerged as one of the most
Lancet. 2010;375:1737–48.
pressing global issues that we will continue to 17. Sturm R. Increases in clinically severe obesity in the
face during the next several decades. United States, 1986-2000. Arch Intern Med. 2003;163:
2146–8.
18. Finucane MM, Stevens GA, Cowan MJ, et al.
National, regional, and global trends in body-mass
References index since 1980: systematic analysis of health exam-
ination surveys and epidemiological studies with 960
1. Peeters A, Backholer K. Is the health burden associ- country-years and 9.1 million participants. Lancet.
ated with obesity changing? Am J Epidemiol. 2012; 2011;377:557–67.
176:840–5.
 The Pathophysiology of Obesity
3
Geltrude Mingrone and Marco Castagneto

The New York Times announced in June 2013 that priately, of the adipose organ [2]: the fat cells
millions of Americans contracted a disease [1]. enlarge and can also proliferate by differentiation
This was not caused by any peculiar pathogen, of precursors. However, there is a very remark-
but occurred because the American Medical able variability among individuals of the meta-
Association had declared obesity a “multimeta- bolic response to the increased energy intake in
bolic and hormonal disease state”. In spite of this, relation to environmental, life style, genetic, and
the debate on whether and/or when this statement neuro-hormonal factors which should be taken
applies will likely continue also because many into consideration and will be discussed in this
more millions of people worldwide are facing the chapter.
same problem. Perhaps, when we will have
achieved a better understanding of the etiology
and pathophysiology of obesity, it will be possi- 3.2 Physiology of Caloric Intake
ble to answer this question. and Energy Expenditure

The basic physiological mechanisms that regu-

3.1 Etiology late the energy balance in the central nervous sys-
tem (CNS) derive from the afferent signals from
The simplest explanation of the mechanisms the periphery? regarding satiety and adiposity,
which lead to weight gain and to obesity is that of which trigger efferent neuro-hormonal activation
a caloric intake in excess of energy expenditure aimed at reducing appetite and maintaining
used for thermogenesis, body functions, and energy balance [3, 4].
physical activity (Fig. 3.1). The calories in excess Afferent signals derive from the gastrointes-
of requirements are then stored as triglycerides in tinal tract, including pancreas and liver, in the
the fat cells of the adipose tissue or, more appro- form of autonomic stimulation by physical and
chemical food ingestion [5]. Even more impor-
G. Mingrone, MD, PhD (*) tantly, a series of hormones are released by the
Department of Internal Medicine, Catholic gut which assist in nutrient digestion and absorp-
University, Largo A. Gemelli 8, Rome 00168, Italy
tion and regulate through the vagus satiety feel-
e-mail: [email protected]
ing. Among them there are cholecystokinine
M. Castagneto, MD
(CCK) which stimulates exocrine pancreas func-
Department of Surgery, Catholic University,
Largo A. Gemelli 8, Rome 00168, Italy tion, peptide YY (PYY) which increases energy
e-mail: [email protected] expenditure and slows gastric emptying as well

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 17

Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_3,
© Springer International Publishing Switzerland 2015
18 G. Mingrone and M. Castagneto

Fig. 3.1 Partitioning of EE components

daily energy expenditure
(EE). Resting energy REE TEF PA
expenditure (REE)
represents 65 % of daily
EE, thermic effect of food
(TEF) or food thermogen-
esis 10 %, and physical
activity (PA) the remaining
25 %
25 %

65 %

10 %

as it is done by glucagon-like peptide 1 (GLP1) [12]. The former is prevalent in mammals and
which, in addition, has a potent effect on endo- is made of round adipocytes containing a large
crine pancreatic function [6, 7]. Finally, insulin, fat droplet which displaces the small nucleus to
glucagon and amylin, beside their effects on car- the periphery. The brown adipocyte is smaller
bohydrates metabolism, act on the hypothalamus with many small fat accumulations and is rich
stimulating satiety. On the contrary, ghrelin, a of mitochondria which are responsible for the
potent orexigenic peptide, secreted by the fundus darker appearance. Thermogenesis is the primary
of the stomach when empty, is suppressed by food function of this type of adipose tissue and, in fact,
ingestion. The other type of afferent signals regu- contrary to the white one, it contains uncoupling
lating food intake, comes from the adipose tissue proteins which prevent storage of energy in the
which is not only a fat storage compartment but, ATP molecules. It is also highly vascularized and
as it has been progressively recognized, plays an innervated by sympathetic fibers. On the other
active role in maintaining energy balance. In fact, hand, the white adipose tissue, which is widely
the adipose organ produces a number of media- prevailing in the adult, beside adipocyte, contains
tors with important physiological functions and macrophages, fibroblasts, leukocytes, and endo-
impacts in the development of diseases linked to thelial cells which are responsible for the secre-
obesity [8–10]. tion of additional mediators to those peculiar of
More than 50 adipose tissue hormones and adipose tissue. The most well known adipokines
cytokines have been described including acute are leptin, adiponectin, tumor necrosis factor α
phase proteins, complement-like factors and (TNFα), interleukin 6 (IL6), and resistin.
adhesion molecules. These so-called adipo- Leptin is a peptide with a central function in
kines are involved in the regulation of satiety, the regulation of body weight through limita-
energy balance, lipid and glucose metabolism, tion of food intake and enhancement of energy
and inflammation [11]. There are two types of expenditure. Being produced by adipocytes,
adipose tissues, the “white” and the “brown” its blood level is directly proportional to the fat
3 The Pathophysiology of Obesity 19

mass. In turn, leptin binds to the leptin recep- frontal cortex with the ventromedial prefron-
tor in the hypothalamus with the activation of tal cortex and the nucleus striatum (Fig. 3.2).
anorexigenic response. Leptin and its receptor Relevant information, in particular sight and
are regulated by separate genes whose muta- smell, reaches the brain as external cues acting
tion leads to endocrine abnormalities including on the amygdala and insula; interoceptive infor-
obesity similar to the one observed in the ob/ob mation from the gut is sensed by the insula, while
mice, deficient in leptin, and in the db/db mice circulating peptides and nutrients are sensed by
that have a deficit of leptin receptors [13]. The the hypothalamus and brainstem, as well as by
relative interplay between leptin production and the ventral tegmental area and the substantia
leptin receptor expression may partly explain the nigra. The amygdala encodes the current incen-
so-called leptin resistance phenomenon which is tive value of food cues, while the insula con-
commonly observed in patients who are obese in veys sensory features of foods and its activity is
the face of high circulating levels of leptin [14]. modulated by hunger. The cognitive control over
Another very interesting action of leptin, beside appetite regions, either to enhance or to suppress
the regulation of appetite and of energy expen- appetite, is mediated mainly via the frontal lobes.
diture, is a direct stimulation of T lymphocytes Fasting increases activation of the hypothalamus,
with increased inflammatory cytokines produc- insula, and striatum, while meal consumption
tion such as TNFα and IL6. increases activation of the prefrontal cortex. A
Adiponectin is a cytokine-like molecule that recent review [17] has highlighted how obesity is
interacts with its specific receptor on the cell consistently associated with heightened or abnor-
membrane of the central nervous system, of the mal responses to visual food cues in a distributed
muscles and of the liver. The action of the adipo- network of brain regions involved in reward/
nectin is antithetic to leptin being reduced in obe- motivation and emotion/memory and how a pro-
sity, increasing glucose and fatty acids uptake longed long-term exposure to highly palatable,
and reducing production of TNFα and IL6 and of high-calorie foods may cause decreased reward
other inflammatory mediators [15]. area activation following food intake. By using a
Resistin is a protein which is secreted mainly positron emission tomography (PET) approach,
by adipocytes and macrophages, and owes its Del Parigi et al. [18] found that obese individu-
name to its enhancing effect on insulin resistance. als showed a greater activation in the midbrain
This might be due, at least partially, to the and middle-dorsal insula that are areas involved
increased hepatic glucose production and to the in the cerebral reward response, and a lesser acti-
impaired glucose uptake and glycogen synthesis vation in the posterior cingulate cortex, which
effect. In addition, it displays an inflammatory is associated with awareness state. PET studies
action especially on smooth muscle cells through demonstrated that obese adults show a lower post-
stimulation of the immune system [16]. prandial activation of the cognitive control areas
than lean individuals. EEG studies described the
temporal evolution of the brain responses to face
3.3 Central Regulation of Energy and food pictures, highlighted differences in rest-
Homeostasis and Efferent ing state cortical networks among underweight,
Signaling normal-weight, and overweight/obese subjects
and changes in responses of the obese subjects
The central nervous system is the site where con- with respect to the normal-weight individuals.
verge afferent nervous and hormonal signals so In the arcuate nucleus, there are two types of
far described, providing information on satiety neurons [19]: the first with anorexigenic and the
and adiposity and where effector neuro-chemical second with orexigenic effects. The first type pro-
signals are activated in order to maintain the duces pro-opiomelanocortin peptide which inter-
energy balance. acting with the ventromedial as well as the other
The appetite brain network includes the hypothalamic nuclei reduces food intake and
insula, the amygdala/hippocampus, the orbito- increases energy expenditure. On the contrary,
20 G. Mingrone and M. Castagneto

Fig. 3.2 Appetite Brain Prefrontal cortex

Network. Information from Anterior cingulate cortex
the prefrontal cortex and
the anterior cingulated
cortex arrive to the insula, Sensation Interoception
which receives also (taste, olfaction, vision) (hunger, nausea)
afferences relative to food
sensations like taste,
olfaction and vision, and Insula
interoceptive sensation,
such as hunger. Efferences
from the insula reach the
amigdala and hippocampus
and the orbital frontal
Amigdala Orbital frontal
cortex and the striatum. cortex
The latter has also hippocampus
afferences from the
substantia nigra that reach
also the orbital frontal
cortex and the striatum. Striatum
Finally, the hypothalamus
sends information to the
substantia nigra, the orbital Dopamine
Substantia nigra
frontal cortex, and the
striatum. In red are
highlightened the
inhibitory actions

Hypotalamus

5HT or serotonin
the orexigenic neurons synthesize PYY and
aguti-related peptide which increase food intake Insulin
and reduce energy consumption (Fig. 3.3). The
hypothalamus receives sensory satiety signals NPY/
from the peripheral organs through the vagal AGRP mRNA transcription POMC
complex in the hindbrain and also directly from Leptin
the blood carrying nutrients and peptides from
the digestive system as well as from the adipose
tissue. Finally, additional signal are acquired
from limbic and cortical areas regarding cogni-
tive and reward response to food intake [4].

3.4 Pathophysiology of Obesity

Voracious feeding Inhibits food
and weight gain intake
3.4.1 Environmental and Genetic
Factors Fig. 3.3 Stimulatory effects are indicated by solid lines
and inhibitory effects by dashed lines. 5-hydroxy-
Regardless of whether obesity is a condition tryptamine or serotonine as well as leptin stimulates pro-
opiomelanocortin (POMC) neurons and inhibits the
or a disease, it arises from multiple etiologic
neuropetide Y(NPY)/agouti related protein neurons.
determinants, either inherited or acquired. In par- Insulin does the contrary. Therefore, insulin stimulates
ticular, the strict interplay of environmental and appetite while serotonin and leptin do the opposite
3 The Pathophysiology of Obesity 21

genetic factors is strongly correlated to obesity lean subjects lend support to this standpoint [25].
development. Environment contributes provid- As a consequence, the energy in excess is stored
ing and advertising easy access to calorie-dense as fat in the adipose organ which, beside subcuta-
and palatable food, facilitating sedentary lifestyle, neous tissue, includes the visceral and pelvic fat
while increasing prevalence of mental distress or and also the peri-muscular, peri-vascular, and
illness either by itself or because of related medi- peri-osteal areas. As mentioned before, the adi-
cations [20]. It represents an important determi- pocyte responds to fat accumulation with enlarge-
nant of the obesity epidemics especially in the ment and also with proliferation thus representing
western countries. Environmental factors act on the core pathology of obesity [25]. The patho-
individual genetic background which animal as physiology, on the other hand, encompasses the
well as human family studies have shown to be a inappropriate secretion of hormones and media-
major determinant of obesity. Indeed, weight is a tors associated with the central feedback satiety
highly inheritable trait although greatly polymor- signaling as well as the numerous cytokines pro-
phic and polygenic. More than 40 genes have been duced by fat cells. As illustrated before, the adi-
so far linked to obesity which, interacting with the pose tissue, especially when it is expanded,
environment, may result in its relevant phenotypic represents a major component of the endocrine
expression [21]. At the present time, however, car- and reticuloendothelial system.
rying obesity genes have little recognizable effect In fact, in addition to the adipokines specifi-
and, therefore, should be considered as more of cally produced by the expanded fat cells, mac-
a risk factor than a determinant [22]. Thus, an rophages and T and B lymphocytes also increase
epigenetic component in the pathophysiology of and secrete inflammatory cytokines such as
obesity should be taken into consideration. In fact, TNFα, IL1, IL6, and acute phase proteins [26].
recent works have shown how genome mutations, The inflammatory action of adipose tissue spreads
that do not involve changes in DNA sequence, to other organs, like the liver, the pancreas or like
could explain how environmental conditions, like the vascular system, contributing to the well-
maternal food intake during pregnancy and over- known clinical manifestations of obesity. Among
feeding during infancy have an impact on obesity them hypertension, atherogenesis, atherosclero-
susceptibility [23, 24]. However, there are some sis, fatty liver dysfunction (non-alcoholic fatty
monogenic obesity syndromes with well charac- liver disease, NAFLD, and non-alcoholic steato-
terized single locus mutations especially in the hepatitis, NASH), insulin resistance, and type 2
pediatric population. Among them it should be diabetes mellitus are the commonest [27].
mentioned the Prader-Willis syndrome (in which From the metabolic point of view, it should be
seven genes of paternal origin are deleted), the underlined that the excessive burden of fat, which
Bordet-Biedl syndrome, the leptin deficiency syn- is stored in the adipocytes as triglycerides, impli-
drome, and other rare diseases all associated with cates increased circulating free fatty acid levels
complex neurological abnormalities. which in turn are responsible for the lipotoxicity
effect at organ level like the liver and the pan-
creas [28]. The latter occurs especially on the
3.4.2 Obesity as Derangement β-cells which progressively go into exhaustion.
of Central Regulation
of Energy Balance
3.4.3 Clinical Correlates of Obesity
When the fine neuro-hormonal control of food
intake and energy expenditure, which takes place 3.4.3.1 Impaired Glucose Tolerance
predominantly at the CNS level, fails then altera- and Type 2 Diabetes Mellitus
tions in neuro-chemical signaling ensues that This is one of the most common co-morbidities
affect the adiposity and satiety feedback mecha- of obesity which affects over 80 % of diabetic
nism. Animal and human studies on obese and patients. The basic pathophysiological mecha-
22 G. Mingrone and M. Castagneto

nism of this disease is strictly related to the 3.4.5 Obesity and Cancer
increased insulin resistance requiring enhanced
insulin secretion with eventual β-cell exhaustion Epidemiological studies [35] have shown that
[29]. There are many causative factors of insulin obesity is associated with increased rates of
resistance even though not all of them are fully cancers affecting breast, endometrium, esopha-
understood. However, the chronic low grade gus, colon, and kidney. It is estimated that in the
inflammation state of obesity, which is caused by obese population, the risk is 1.5–3.5 folds higher
the enhanced production of cytokines and other respect to the lean subjects. Multiple factors can
mediators, are a major determinant of insulin explain the association between obesity and can-
resistance. For instance, TNFα activates intracel- cer depending on the type of tumor, the age, and
lular kinases which inhibit insulin receptors the sex of the subject. Possible mechanisms of
making them less responsive to insulin signaling carcinogenesis include hyperinsulinemia and
[30]. Another mechanism of insulin resistance is high level of insulin-like growth factor as well as
the previously reported excessive level of circu- sex hormones. Also the chronic adipokine-medi-
lating free fatty acids which, in addition to the ated inflammation state with the ensuing oxida-
mentioned lipotoxicity effect, by accumulating tive stress plays a role [36].
in the muscle cells and hepatocytes impair insu-
lin sensitivity probably through the impairment Conclusions
of the insulin signaling cascade [31, 32]. Finally, The homeostatic neuro-hormonal mechanisms
the gastrointestinal microbiota, which is differ- which maintain a correct balance between
ent in lean or obese subjects, may play a role also energy intake and energy expenditure may
in decreasing insulin sensitivity by modifying become disrupted for genetic and environ-
intestinal immunologic and permeability milieu mental factors in the obese population. The
with the resulting additional energy absorption excessive accumulation of fat in the enlarged
and translocation of inflammatory bacterial adipocytes triggers the production of inflam-
products [33]. matory factors which progressively lead to
serious comorbidities and eventually a reduced
life expectancy.
3.4.4 Cardiovascular Disease

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 Obesity-Related Comorbidities
4
Paola Fierabracci, Anna Tamberi,
and Ferruccio Santini

4.1 Introduction 4.2 The Metabolic Syndrome

(MetS)
Obesity contributes to the development of many
diseases that increase the risk of mortality and The metabolic syndrome is defined by a cluster
worsen the quality of life. Recent studies indicate of interconnected biochemical and clinical
that, relative to the normal weight category, the parameters associated with visceral obesity,
main contribution to excess mortality in obesity which increase the risk of mortality for all causes.
comes from higher levels of BMI, while over- The main factors that contribute to the syndrome
weight (defined as a BMI of 25– < 30 kg/m2) are insulin resistance, dyslipidemia, endothelial
appears associated with significantly lower all- dysfunction, elevated blood pressure, a hyperco-
cause mortality [1]. However, BMI does not take agulable and inflammatory state. Several defini-
into account body composition and body distri- tions of MetS have been proposed (Table 4.1)
bution and it has been clearly established that the [1–6], many of them being focused on insulin
preferential accumulation of fat in the upper body resistance. The ATPIII and IDF definitions
and visceral districts is more harmful because it employ measures that are readily available to
is associated with an increased risk of developing physicians, thus facilitating their clinical applica-
diabetes, dyslipidemia, hypertension, and cardio- tion, although discrepancies may arise when the
vascular disease. The main obesity-related definition is applied to different ethnic groups
comorbidities are depicted in Fig. 4.1. [7]. In particular, the risk of type 2 diabetes mel-
litus (T2DM) increases at much lower levels of
obesity in Asians compared to Europeans.
Therefore, a new set of criteria with ethnic/racial
specific cutoffs has been recently proposed [8].

4.2.1 Visceral Obesity

P. Fierabracci • A. Tamberi • F. Santini (*)
Obesity Center at the Endocrinology Unit, The white adipose tissue (WAT) includes white
University Hospital of Pisa, Via Paradisa 2, adipocytes and stromal vascular cells (preadipo-
Pisa 56100, Italy cytes, endothelial cells, pericytes, and various
e-mail: [email protected];
[email protected]; immune cells) [9]. In lean subjects, most WAT is
[email protected] localized at subcutaneous sites while only minor

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 25

Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_4,
© Springer International Publishing Switzerland 2015
26 P. Fierabracci et al.

Cardiovascular disease Psychiatric disorders:

- Major Depression
obesity cardiomyopathy - Binge Eating Disorder
- Night Eating Syndrome

Cancer:
- Endometrium Respiratory disfunctions:
- Oesophagus - Obesity hypoventilation
- Thyroid? syndrome
- Breast (postmenopausal) -Obstructive sleep apnoea
- Colorectum syndrome
- Pancreas
- Kidney
Metabolic syndrome:
- Central Obesity
Endocrine dysfunctions: - Insulin resistance and type 2
- Abnormalities of GH/IGF1 Diabetes
axis - Hypertension
- Hyperthyrotropinemia - Dyslipidemia
- Hypovitaminosis D - Non alcoholic fatty liver disease
- Infertility, anovulation, (NAFLD)
polycystic ovary syndrome
- Hypotestosteronemia
Osteoarthritis

Chronic venous insufficiency Hyperuricemia gout

Fig. 4.1 Main obesity-related comorbidities

adipose tissue depots are associated with internal the insulin resistant, proinflammatory, pro-
organs including the omental, mesenteric, epi- thrombotic, and pro-hypertensive state of the
ploic, retroperitoneal, and intrathoracic fat. A metabolic syndrome.
gender-related difference in fat deposition has
been described, prior to and during the develop-
ment of obesity. Women have generally higher 4.2.2 Insulin Resistance and Type 2
adiposity than men. Furthermore, women accu- Diabetes
mulate more in subcutaneous sites whereas men
accumulate more fat within the central area. In Insulin resistance is a pathophysiological condi-
response to a positive energy balance, when tion in which peripheral tissues such as the adi-
physiological fat depots cannot further expand, pose tissue, the muscle, and the liver are less
fat accumulation may occur at undesired sites sensitive to insulin action. Therefore, pancreatic
such as the liver, the heart, the skeletal muscle, beta cells have to secrete more insulin to over-
and the pancreas. Ectopic fat deposition is pre- come the hyperglycemia of insulin-resistant indi-
dictive of insulin resistance and related metabolic viduals. The resulting hyperinsulinemia may
abnormalities referred to as the metabolic syn- compensate for insulin resistance to some bio-
drome. The adipose tissue is an endocrine organ logical actions of the hormone (e.g., maintenance
producing adipokines, like adiponectin and of normoglycemia) but it may cause an overex-
leptin, and inflammatory cytokines such as inter- pression of insulin activity in normally sensitive
leukin (IL-6) and tumor necrosis factor (TNF)-α. tissues. The clinical manifestations of MetS are
Ectopic/visceral obesity is associated with the result of some insulin actions associated with
hypoxic, inflamed, and dysfunctional adipose tis- a resistance to other actions [10]. In the long
sue that modifies its secretion thus contributing to term, the inability by pancreatic beta cells to
 4

Table 4.1 Criteria for the diagnosis of metabolic syndrome

WHO (1998) [2] EGIR (1999) [3] ATPIII (2001) [4] AACE (2003) [5] IDF (2005) [6]
Insulin resistance IGT, IFG, T2DM, or lowered Plasma insulin >75th None, but any three of the IGT or IFG plus any of the None
insulin sensitivitya plus any percentile plus any two of following five features following based on the
two of the following the following clinical judgment
Hyperglycemia Male and female Male and female Male and female Male and female Male and female
IGT, IFG, or T2DM IGT or IFG (but not >110 mg/dl (includes IGT or IFG (but not ≥100 mg/dl (includes
diabetes) diabetes) diabetes) diabetes)
Obesity Male Female Male Female Male Female Male and Female Male and Female
Obesity-Related Comorbidities

Waist-to-hip Waist-to-hip Waist circumf. Waist Waist Waist BMI ≥ 25 kg/m2 Increased waist

.
ratio >90 ratio >0.85 ≥ 94 cm circumf. ≥ circumf. ≥ circumf. ≥ circumference (population
and/or: 80 cm 102 cm 88 cm specific) plus any two of
BMI > 30 kg/m2 the following
Dyslipidemia Male and female Male and female Male and female Male and female Male and female
Triglycerides ≥ 150 mg/dl Triglycerides ≥ 150 mg/dl Triglycerides ≥ 150 mg/dl Triglycerides ≥ 150 mg/dl Triglycerides ≥ 150 mg/dl
or receiving treatment
and/or: and HDL cholesterol: and HDL cholesterol: and HDL cholesterol:
Male Female HDL Male Female Male Female Male Female
cholesterol
<39 mg/dl
<35 mg/dl <39 mg/dl <40 mg/dl <50 mg/dl <40 mg/dl <50 mg/dl <40 mg/dl <50 mg/l
Hypertension Male and female Male and female Male and female Male and female Male and female
≥140/90 mmHg ≥140/90 mmHg or on ≥130/85 mmHg ≥130/85 mmHg Systolic ≥130 mm Hg or
hypertension treatment Diastolic ≥85 mm Hg or
on hypertension treatment
Others Male and female
Microalbuminuria:
Urinary excretion rate
of >20 mg/min or:
Albumin:creatinine
ratio of >30 mg/g.
a
Insulin sensitivity measured under hyperinsulinemic euglycemic conditions, glucose uptake below lowest quartile for background population under investigation
BMI body mass index, IFG impaired fasting glucose, IGT impaired glucose tolerance, T2DM type 2 diabetes mellitus
27
28 P. Fierabracci et al.

produce sufficient hormone to correct insulin leading to increased sodium reabsorption at

resistance may lead to hyperglycemia and type 2 kidney level [17]. Furthermore, adipose tissue
diabetes [11]. produces aldosterone in response to AT II [18]
The action of insulin is expressed through and adipocytes can be considered a renin-
binding to specific receptors that determine the angiotensin-aldosterone miniature.
activation of a cascade involved in the control of
cell metabolism, including the synthesis of gly-
cogen, triglycerides (TG), and proteins, as well 4.3 The Obesity
as other biological responses specific of each Cardiomyopathy
cell-type. Insulin resistance may occur at multi-
ple levels, including desensitization of the insulin The obese status is associated with a spectrum
receptors, inhibition of the signaling cascade and of cardiovascular disorders ranging from a
effects on gene transcription. Insulin resistance is hyperdynamic circulation with subclinical myo-
not necessarily associated with obesity, but cardial structural changes to overt heart failure.
appears with abnormal fat distribution (i.e., vis- Occurrence of obesity cardiomyopathy as a dis-
ceral fat accumulation) [12]. tinct entity has been proposed. Obesity cardio-
myopathy may result from a complex interaction
between functional, metabolic, and toxic factors,
4.2.3 Dyslipidemia including an expansion of the blood volume,
insulin resistance, activation of the sympathetic
The “atherogenic dyslipidemia” is characterized nervous system, and cardiac lipotoxicity.
by an increase of lipoproteins containing apoli- Study performed by ultrasonic tissue charac-
poprotein B (apoB), elevated fasting and post- terization in a series of severely obese healthy
prandial triglycerides, with the preponderance of subjects showed early myocardial structural and
small dense lipoprotein and low levels of high functional alterations that were almost com-
density lipoprotein cholesterol (HDL-C). This pletely normalized after weight loss achieved by
pattern appears to be heritable, but several nonge- bariatric surgery [19, 20].
netic factors, such as abdominal adiposity, influ-
ence the expression of this phenotype. Insulin
resistance may lead to atherogenic dyslipidemia 4.4 The Nonalcoholic Fatty Liver
by several mechanisms, including increased Disease (NAFLD)
lipolysis with excessive delivery of free fatty
acids to the liver that uses them as substrate for Increasing evidence suggests that NAFLD rep-
the synthesis of TG [13, 14]. resents the hepatic component of the metabolic
syndrome and the most common cause of abnor-
mal liver tests in the adult population of Western
4.2.4 Hypertension countries. NAFLD is a consequence of visceral
fat accumulation and is defined by a lipid accu-
Essential hypertension is a common feature of mulation >5 % in hepatic tissue in the absence
the metabolic syndrome [15]. Current evidence of chronic alcohol consumption [21]. NAFLD is
suggests that visceral obesity is characterized by characterized by a wide spectrum of liver dam-
an activation of the renin-angiotensin system age ranging from simple steatosis to advanced
(RAS), resulting in increased expression of fibrosis and to cryptogenic cirrhosis through
angiotensinogen, angiotensin II (AT II), and AT1 steatohepatitis (NASH), and, ultimately, to hepa-
receptor, which, in concert, contribute to the tocellular carcinoma [22, 23]. The prevalence
development of hypertension [16]. In addition, and severity of NAFLD increases with incre-
insulin resistance and hyperinsulinemia lead to ments of body mass index. NAFLD is usually
activation of the sympathetic nervous system, asymptomatic, and hepatomegaly can be the
4 Obesity-Related Comorbidities 29

only objective sign. No combination of clinical patients than in the general population [29] with
or biochemical abnormalities can accurately dif- visceral obesity being more strictly associated to
ferentiate the spectrum of NAFLD, and only liver OSAS; the accumulation of adipose tissue in the
biopsy can establish the diagnosis. Whole hepatic neck and in the pharyngeal structures is one of
enlargement is proportional to the severity of the the main mechanisms involved in this associa-
metabolic syndrome, and various imaging meth- tion. Noteworthy, OSAS itself may predispose
odologies can be used for the estimation of liver individuals to worsening obesity because of sleep
volume. Recently, an ultrasound technique has deprivation, daytime somnolence, and disrupted
been introduced, which measures the hepatic left metabolism [30]. Sleep fragmentation and
lobe volume (HLLV) [24, 25]. HLLV was tightly chronic intermittent hypoxia are likely to play a
correlated to intra-abdominal fat and an excellent prevalent role in causing the increased morbidity
indicator of visceral adiposity, clustering with and mortality in comparison with simple obesity
the parameters defining the metabolic syndrome. [31], and OSAS is indeed associated [32] with an
Furthermore, after weight loss achieved by gas- increased prevalence of metabolic syndrome,
tric banding, reduction of the HLLV was the best hypertension, insulin resistance and T2DM, and
single predictor of improvement of various car- cardiovascular illness, such as transient ischemic
diometabolic risk factors. attacks, stroke, cardiac arhythmias, myocardial
infarction, and pulmonary hypertension [33, 34].

4.5 Respiratory Dysfunctions

4.6 Psychiatric Disorders
Obesity hypoventilation syndrome (OHS) and
obstructive sleep apnea syndrome (OSAS) are Major depression, binge eating disorder (BED),
the main pulmonary dysfunctions associated with and night eating syndrome (NES) are commonly
obesity [26]. Fat accumulation in the upper site of associated with obesity. Current evidence sug-
the body leads to reduction in chest wall compli- gests that there is a temporal association
ance and respiratory muscle performance, with between obesity and depression, which would
consequent hypoxemia and progressively wors- make obesity a risk factor for the development
ening disability. OHS is defined as the combined of the disease. However, a temporal depression
presence of obesity and awake arterial hypercap- to obesity relationship has also been observed,
nia (PaCO2 >45 mmHg) in the absence of other which may be due to eating and sleeping distur-
causes of hypoventilation. bances as well as the use of antidepressant med-
OSAS is characterized by repetitive upper air- ications [35].
way occlusion episodes leading to apnea with Early-onset obesity is associated with the devel-
arousal being required to reestablish airway opment of eating disorders, body-dysmorphic
patency. OSAS affects up to 7 % of the adult disorders, and low self-esteem. In a recent study
male population, and its prevalence increases including 280 obese subjects, patients with early
with age. The apnea/hypopnea index (AHI) that onset obesity displayed a higher burden of depres-
indicates the frequency of the apnea/hypopnea sive spectrum symptomatology than patients who
episodes per hour of sleep, is commonly used to developed obesity only during adulthood [36].
quantify the severity of OSAS. The pathophysi- BED, defined as the ingestion of large amount
ology of OSAS is mainly based on the imbalance of food in a short period of time (>2H) accompa-
between the collapsing forces of the upper airway nied by a sense of loss of control over eating, is
during inspiration and the counteracting forces of another psychiatric disorder independently asso-
the upper airway dilating muscles [27]. Obesity ciated with obesity and depression. Its prevalence
and male gender are the most important risk fac- increases with severity of the obese state. NES is
tors for sleep apnea [28]. The OSAS prevalence characterized by evening hyperphagia, meaning
is 12- to 30-fold higher among morbidly obese that at least 25 % of the daily caloric intake is
30 P. Fierabracci et al.

consumed after the last evening meal or that two The main pathogenic mechanisms include BMI,
or more nocturnal eating episodes occur per excess weight, particularly visceral fat accumula-
week. NES is more common among obese per- tion, diet, and lifestyle factors. Furthemore, bio-
sons although it is not exclusive to them [37]. logical mechanisms appear to be involved, such
About one in five obese subjects assessed for eli- as hyperinsulinemia and insulin resistance, the
gibility for bariatric surgery present with mood activities of IGFs and IGF binding proteins, sex
and/or personality disorders [38, 39]. A careful hormones and SHBG, low-grade inflammation,
psychological and/or psychiatric assessment and changes in adipose tissue production of adipo-
treatment should always be provided to establish kines and vascular growth factors, oxidative
the eligibility for bariatric surgery, to improve the stress, endocrine disruptors, and alterations in
postoperative outcome and to reduce the risk of immune function.
complications. The Swedish Obese Subjects (SOS) study,
reporting the long-term effects of bariatric sur-
gery on morbidity and mortality in a follow-up
4.7 Osteoarthritis period longer than 10 years, showed a significant
reduction in cancer incidence in association with
Osteoarthritis (OA) is the most important muscu- substantial weight loss [43].
loskeletal disease associated with obesity [40]. It
is a disabling degenerative joint disorder charac-
terized by pain, limitation of mobility, and an 4.9 Endocrine Dysfunctions
overall negative impact on quality of life. The
incidence and progression of OA in obese sub- 4.9.1 The Thyroid
jects is increased both in weight-bearing and
non-weight-bearing joints. Weight loss contrib- The relationships between serum thyroid hor-
ute to improve symptoms and to delay the pro- mones, body weight, and feeding have been
gression of joint disease. The pathogenesis of extensively investigated. A reciprocal interaction
obesity-related OA is multifactorial: Both between the hypothalamus-pituitary-thyroid axis
mechanical factors as well as metabolic factors and the adipose tissue is required for the proper
appear to be involved, including the low-grade homeostasis of energy balance. In both lean and
inflammatory state associated with obesity and obese subjects, thyroid hormone and TSH levels
the abnormal expression of adypokines. Weight are strongly influenced by the individual nutri-
loss may improve both pain and joint function, tional status [44]. Fasting is characterized by a
and osteoarthritis should be considered when reduction of T3 in the bloodstream, while the
assessing the indications of obese candidates to production rate of the hormone is significantly
bariatric surgery. increased during overfeeding, thus explaining
increased serum levels of T3 observed in some
obese cohorts compared to controls. A slight ele-
4.8 Cancer vation of serum TSH has been described in obese
subjects. However, these changes are usually
The International Agency for Research into within the normal range and current evidence
Cancer and the World Cancer Research Fund suggests that they may represent an adaptive
(WCRF) [41] have reported a strong association response of the hypothalamus-pituitary-thyroid
of obesity with the endometrial, esophageal ade- axis to weight gain. The increased rate of thyroid
nocarcinoma, colorectal, postmenopausal breast, hormone disposal occurring in obese individuals
prostate, and renal cancers, whereas other types would be the primary event promoting an activa-
of malignancies such as leukemia, non-Hodgkin’s tion of the hypothalamus-pituitary-thyroid axis,
lymphoma, multiple myeloma, malignant mela- aimed at maintaining serum thyroid hormones
noma, and thyroid tumors are less frequent [42]. within the euthyroid range. While thyroid
4 Obesity-Related Comorbidities 31

hormone replacement therapy is required if obe- reflect the combined effects of integrated GH
sity is associated with subclinical or overt hypo- secretion and tissue responsiveness to GH. Low
thyroidism, no specific intervention is required serum IGF-1 concentrations have been consis-
for minor TSH changes, not related to a specific tently reported in severe obesity [50–53].
thyroid disease. In a large series of severely obese Improvement of GH/IGF-1 activity after weight
subjects evaluated before bariatric surgery [45], loss [54] suggests a reversible defect of this axis,
thyroid disease was by far the most frequent strictly related to body weight.
among endocrine diseases, including primary A recent study [55] performed in obese
hypothyroidism, non-autoimmune nodular dis- women demonstrated that the extent of IGF-1
ease, and thyroid cancer. Although these preva- deficiency is proportional to increased BMI; after
lence rates did not substantially differ from those laparoscopic adjustable gastric banding a sponta-
observed in a comparable population of normal neous raise of serum IGF-1 occurred, propor-
weight subjects, we suggest that routine screen- tional to the extent of weight reduction. Overall,
ing for thyroid dysfunction should be always per- these observations indicate that, beside age, body
formed during the preoperative evaluation of weight is a major determinant of serum IGF-1
bariatric patients. levels in obesity.

4.9.2 Vitamin D 4.9.4 The Adrenal Gland

An inverse relationship between obesity and The abdominal fenotype of obesity with associ-
serum 25-OH vitamin D has been consistently ated metabolic and cardiovascular alterations
reported, and vitamin D deficiency leading to may resemble hypercortisolism, thus providing
secondary hyperparathyroidism is a common the basis for a role of glucocorticoids on the
finding in obese candidates to bariatric surgery. development of human obesity [56, 57]. In obese
Putative pathogenic mechanisms of vitamin defi- individuals, daily variations of serum adrenocor-
ciency in obese individuals include: poor sunlight ticotropin hormone (ACTH) and cortisol are usu-
exposure, reduced 25-OH vitamin D synthesis at ally maintained. At variance, dynamic studies
hepatic level, diminished vitamin D bioavalaibil- suggest the presence of a hyperresponsiveness of
ity due to increased uptake by the adipose tissue, the hypothalamic–pituitary–adrenocortical
and inadequate dietary intake. In some studies, (HPA) axis to various stimuli [58]. Density of the
hypovitaminosis D has been linked with obesity- glucocorticoid receptor in the visceral adipose
related comorbidities such as hypertension and tissue appears to be higher than in peripheral sub-
type 2 diabetes mellitus [46]. cutaneous fat [59], suggesting a pathogenic role
of cortisol in the development of abdominal
obesity.
4.9.3 The GH/IGF I Axis Stress adaptation requires a series of responses
that include an activation of the HPA axis [60,
Obesity is associated with abnormalities of the 61]. Abdominal obesity and its metabolic comor-
growth hormone/insulin-like growth factor-1 bidities are significantly associated with stress-
(GH/IGF-1) axis. Both GH secretion rate and related conditions such as adverse life events,
burst frequency are reduced in obese as com- psychological disturbances, and psychosocial
pared to lean subjects [47]. Furthermore, mor- distress [62–68]. Chronic hyperactivation of the
bidly obese patients show reduced GH secretion HPA axis due to the inability to cope with long-
after pharmacological stimulation, with serum term environmental adverse events has been
peak GH levels frequently comparable to those advocated among the mechanisms leading to
found in adult patients with organic GH defi- abdominal obesity in susceptible individuals
ciency [48, 49]. Serum concentrations of IGF-1 [69, 70].
32 P. Fierabracci et al.

Cushing’s syndrome has been detected in 4. Expert Panel on Detection, Evaluation, and Treatment
of High Blood Cholesterol in Adults. Executive
0.8 % obese subjects candidates to bariatric sur-
Summary of The Third Report of The National
gery, a prevalence greater than that reported in Cholesterol Education Program (NCEP) Expert Panel
the general population. Considering the possible on Detection, Evaluation, And Treatment of High
lack of distinguishable features of hypercorti- Blood Cholesterol In Adults (Adult Treatment Panel
III). JAMA. 2001;285:2486–97.
solism in obese patients, we believe that screen-
5. Einhorn D, Reaven GM, Cobin RH, Ford E, Ganda
ing of Cushing’s disease by a simple overnight OP, Handelsman Y, Hellman R, Jellinger PS, Kendall
1 mg dexamethasone test may be performed to D, Krauss RM, Neufeld ND, Petak SM, Rodbard HW,
avoid improper bariatric surgery [44]. Seibel JA, Smith DA, Wilson PW. American College
of Endocrinology position statement on the insulin
resistance syndrome. Endocr Pract. 2003;9:237–52.
6. International Diabetes Federation: The IDF consensus
4.9.5 The Gonads worldwide definition of the metabolic syndrome.
http://www.idf.org/metabolic-syndrome.
7. Ritchie SA, Connell JM. The link between abdominal
Fertility can be negatively affected by obesity in
obesity, metabolic syndrome and cardiovascular dis-
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Cleeman JI, Donato KA, Fruchart JC, James WP,
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Loria CM, Smith Jr SC, International Diabetes
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reproductive technologies and pregnancy have Prevention, Hational Heart, Lung, and Blood Institute,
been reported. The main factors implicated in American Heart Association, World Heart Federation;
International Atherosclerosis Society, International
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Association for the Study of Obesity. Harmonizing
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 Hypogonadism and Obesity
5
Mario Maggi, Annamaria Morelli, Micaela Luconi,
Francesco Lotti, Marcello Lucchese,
Enrico Facchiano, and Giovanni Corona

5.1 Introduction evidence, however, obesity is still one of today’s

most blatantly visible – yet most neglected –
Obesity is a complex condition virtually affect- public health problems. A great amount of evi-
ing all ages and socioeconomic groups [1, 2]. dence has documented that obesity represents an
Excess body weight is a crucial risk factor for important risk factor also for male hypogonadism
mortality and morbidity not only for cardiovas- [2–6]. The specific pathogenetic mechanisms
cular diseases but also for type 2 diabetes melli- involved in this phenomenon are complex and
tus (T2DM), cancer, and musculoskeletal not completely understood. Evidence indicates
disorders which cause nearly three million that T deficiency induces increased adiposity
deaths every year worldwide [1, 2]. Despite this and, at the same time, increased adiposity
induces hypogonadism [2–6]. In line with these
data, few randomized clinical studies (RCTs)
have documented a possible improvement of fat
M. Maggi • F. Lotti mass and metabolic control in men with obese
Sexual Medicine and Andrology Unit, T2DM and metabolic syndrome (MetS) [7, 8].
Department of Experimental, On the other hand, weight loss is able to increase
Clinical and Biomedical Sciences “Mario Serio”,
University of Florence, Florence, Italy
testosterone (T) levels in men [6]. All the afore-
mentioned issues will be better analyzed in the
A. Morelli
Anatomy and Histology Unit, Department of
following sections.
Experimental and Clinical Medicine “Mario Serio”,
University of Florence, Florence, Italy
M. Luconi 5.2 Definition of Male
Endocrinology Unit, Department of Experimental, Hypogonadism
Clinical and Biomedical Sciences “Mario Serio”,
University of Florence, Florence, Italy
Male hypogonadism is defined as the failure of
M. Lucchese • E. Facchiano the testes to produce sperm, sex steroids
Bariatric and Metabolic Surgery Unit,
University of Florence, Florence, Italy
(T being the most abundant), or both, because of
a central (pituitary/hypothalamus) or peripheral
G. Corona (*)
Endocrinology Unit, Medical Department, Azienda
(testicular) deficiency [3–5]. The latter condi-
Usl, Maggiore-Bellaria Hospital, Bologna, Italy tion is termed primary (hypergonadotropic)
e-mail: [email protected] hypogonadism, while the former is known as

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 35

Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_5,
© Springer International Publishing Switzerland 2015
36 M. Maggi et al.

secondary (hypogonadotropic, HH) hypogonad- severe, ranging from an almost complete femi-
ism. This classical dichotomic nosography in nine body shape to various defects in viriliza-
hypo- and hypergonadotropic hypogonadism tion [3–5]. In the case of a peri-pubertal
retains a practical utility for treatment purpose. appearance of hypogonadism (early onset hypo-
In fact, while hypogonadal patients with hypo- gonadism, EOH), because of central (e.g., pitu-
thalamic or pituitary diseases can be success- itary tumors, as germinoma) or peripheral
fully treated with either gonadotropin/ defects (e.g., Klinefelter’s syndrome), there
gonadotropin releasing hormone (GnRH) or T, might be a slowing or delaying in puberty pro-
for those affected by primary testicular failure, gression, with a eunuchoidal phenotype, includ-
only T substitution can be considered. However, ing scant body hair, high-pitched voice,
the aforementioned classification of hypogo- microorchidism, and prostate hypoplasia. Late
nadism does not take into consideration onset hypogonadism (LOH) is the most frequent
T-deficiency related symptoms. It is well known form of T deficiency and indicates a form of
that both primary and secondary hypogonadism, syndromic male hypogonadism with a clinical
if not treated, are characterized by symptoms exordium in young adulthood or later on [3–5].
and signs of dramatically different severity, In the latter condition, hypogonadal symptoms
depending on the age of onset. We have pro- will be relatively mild, insidious, and difficult to
vided our classification based on time of symp- recognize, but often bothersome and frustrating,
tom onset, as reported in Fig. 5.1 [9]. In the case such as weakness and fatigue, reduced libido
of very early onset hypogonadism (VEOH), i.e., and erectile dysfunction, mood symptoms, low
during early fetal life, symptoms can be very bone mineral density, mild anemia, all of which

HCG Gonadotropins
Full
LOH 1/
Kallmann syndrome
GPR54 -; GnRHR-

male
100

Klinefelter 1/
Morris syndrome (CAIS)
Masculinization

syndromer 1,000
Incidence

1/
10,000

1/
Full
VEOH EOH LOH 100,000
female
–1 0 10 30 100
Age (years)

Fig. 5.1 Classification of male hypogonadism as a func- (e.g., complete androgen insensitivity or Morris’
tion of age of onset and patient’s phenotype. Schematic Syndrome, blue ellipsis) or impaired secretion or activity
prevalence in male population is also shown. Size of ellip- of GnRH (e.g., Kallmann’s syndrome or mutation in
sis reflects on abscissa (log scale): age of onset and on GPR54 and GnRH receptor, red ellipsis). EOH early onset
ordinates (log scale): incidence (right axis) or female to hypogonadism (i.e., peri-pubertal onset, such as in
male phenotype (left axis, arbitrary unit). VEOH: very Klinefelter’s syndrome, green ellipsis). LOH late onset
early onset hypogonadism, i.e., starting during fetal life hypogonadism, i.e., in adulthood or aging (brown ellipsis)
for absence of testosterone formation or activity (Adapted from Ref. [9])
5 Hypogonadism and Obesity 37

Table 5.1 More and less specific clinical symptoms and signs associated with hypogonadism
Symptoms Clinical signs
More specific Sexual Increased body fat, body mass index
Reduced sexual desire (libido) Very small (especially <5 ml) or shrinking
Erectile dysfunction testes
Decreased spontaneous erections Decreased prostate size
Physical
Decreased vigorous activity
Difficulty walking >1 km
Inability to bend
Psychological
Sadness
Loss of energy
Fatigue
Less specific Sexual Loss of body (axillary and pubic) hair, reduced
Decreased frequency of intercourse shaving
Decreased autoeroticism Gynecomastia
Delayed ejaculation
Physical
Hot flushes, sweats
Decreased energy, motivation, initiative,
and self-confidence
Reduced muscle bulk and strength
Diminished physical or work performance
Psychological
Poor concentration and memory
Sleep disturbance, increased sleepiness

can contribute to decreasing the overall quality 5.4 LOH and Obesity, Clinical
of life ([3–5, 10], see also Table 5.1). Evidence

The association between LOH, obesity, MetS,

5.3 Definition of Late Onset insulin resistance, and T2DM is well known [5–7,
Hypogonadism 11–14]. Accordingly, in two independent meta-
analyses of the available evidence, we reported
Different T thresholds have been proposed for the that subjects with MetS and T2DM have signifi-
biochemical definition of low T [3–5]. According cantly reduced T levels (about 3 nmol/l lower) [15,
to major international guidelines, T substitution 16]. Zumoff et al. [17] and ourselves [18] previ-
has to be offered to symptomatic individuals ously showed that SHBG-bound and unbound tes-
when circulating total T is below 8 nmol/L tosterone levels decreased in obese males in
(231 ng/dL). In addition, there is also general proportion to the degree of their obesity, even after
agreement that a total T level above 12 nmol/L adjustment for obesity-related conditions (see also
(346 ng/dL) does not require substitution. When Fig. 5.2). In addition, data from morbidly obese
total T is repetitively >8 and <12 nmol/L, in the men indicate that LH levels and pulse amplitude
presence of typical hypogonadal symptoms (as were attenuated when compared to normal weight
listed before), a T treatment trial might be con- controls [19, 20]. These observations support the
sidered [3–5]. In addition, it should be recog- concept of a true obesity-associated HH. The spe-
nized that a pathological valuate of T must be cific pathogenetic mechanisms linking LOH with
confirmed in a second sample before prescribing insulin resistance, MetS, and T2DM appear to be
T replacement therapy (TRT) [3–5]. complex and often multi-directional (see Fig. 5.3).
38 M. Maggi et al.

0.40
a 18 b
Adj r = –0.184
Adj r = –0.290
0.35 p < 0.0001
p < 0.0001
16
Total-T nmol/L

c–free T mmol/L
0.30
14

0.25
12

10 0.20

8 0.15

c 9 d 0.75
Adj r = –0.189 p = 0.836 at ANOVA
c-biovailable T mmol/L

9 p < 0.0001 0.70

7 Log10 [LH] U/L 0.65

6 0.60

5 0.55

4 0.50
< 25 25–29.9 30–34.9 ≥35 < 25 25–29.9 30–34.9 ≥35
BMI kg/m2

Fig. 5.2 Testosterone (T; panels a–c) and luteinizing derived from a consecutive non-selected series of men
hormone (LH, panel d) levels as a function of obesity (mean age = 51.3 ± 13.3 years) attending our Sexual Medicine
classification. T testosterone, c-free-T and c-bioavailable- & Andrology Clinic for sexual dysfunction between 2000
T = calculated free and bioavailable testosterone according to and 2013 (unpublished). The inset indicates the age adjusted
Vermeulen formula. BMI body mass index. Data are data. BMI was considered as a continuous value
expressed as mean [95 % confidence interval]. Data are

↓ GnRH

Estrogens
Adipokines

Morbidities:
Pituitary
Fig. 5.3 Proposed • MetS
interactions between
increased visceral fat • T2DM
and hypogonadism. MetS LH, FSH
metabolic syndrome, • obesity
T2DM type 2 diabetes
mellitus, LH luteinizing Testosterone
Adipokines
hormone, FSH follicle
stimulating hormone,
GnRH gonadotropin-
releasing hormone, T Spermatogenesis
testosterone
Testis
5 Hypogonadism and Obesity 39

Obesity is characterized by a relative abundance of hormonal alterations also correlated with glucose
estrogens since P450 aromatase is highly expressed intolerance severity. Since the pituitary gonado-
by fat tissue. The increased amount of estrogen tropins are positively controlled by GnRH and a
levels, might, in turn, have a negative effect on reduced content of GnRH neurons was demon-
both the hypothalamus and the pituitary, leading to strated in the hypothalamus from HFD rabbits
decreased LH secretion [6, 7]. Accordingly, it has [24], the role of HFD-related alterations in the
been reported that the use of the aromatase inhibi- hypothalamic area in determining the documented
tor letrozole can restore T levels and increase LH dysfunctions of the gonadotropic axis have been
levels in severely obese hypogonadal men [21]. In extensively investigated. A close association of
line with this view, we now show that body weight MetS – and in particular the related altered glu-
loss, obtained either through lifestyle or bariatric cose and lipid metabolism – has been identified
intervention, is associated to a fall in estrogen lev- with peculiar hypothalamic alterations, including
els and with a rise in gonadotropins and T [6]. increased expression of the glucose transporter 4
However, other fat-associated factors, besides (GLUT4) and inflammation. Indeed, HFD deter-
estrogens, have been proposed as a link between mined a low-grade inflammation in the hypothala-
obesity and reproductive axis disorders: a series of mus, significantly inducing microglial activation
adipokines and among them, the most extensively and interleukin-6 (IL-6) expression. Interestingly,
studied are leptin, ghrelin, and adiponectin ([22] all these hypothalamic derangements were, in
see also Fig. 5.3). turn, associated with LH and FSH reduction, and
occurred in the preoptic area of the hypothalamus,
lining the third ventricle, where GnRH neurons
5.5 LOH and Obesity: reside. Accordingly, the same hypothalamic area
Experimental Studies was characterized by a reduced immunopositivity
not only for GnRH [24], but also for Kisspeptin-1
The contribution of the different metabolic receptor (KISS1R; 23), which along with its natu-
derangements on the related condition of HH has ral ligand kisspeptin represents the most charac-
been recently investigated in an animal model of terized system mediating, at central level, the
high fat diet (HFD)-induced MetS [23]. The effects of a range of metabolic inputs known to
model, established in adult male rabbits fed a regulate GnRH secretion [31, 32]. However, a not
HFD for 3 months, has been largely characterized fully clarified issue is whether metabolic altera-
by our group [24–30] and recapitulates the human tions act directly on GnRH neurons or are medi-
phenotype, including visceral obesity, hyperten- ated by other integrating factors. Indeed, recent
sion, dyslipidemia, and glucose intolerance. findings demonstrated that a subpopulation of
Moreover, as in humans, HFD rabbits exhibit an GnRH neurons projects dendrites in regions out-
overt HH, with low plasma levels of testosterone, side the blood–brain barrier, where they may
luteinizing hormone (LH), and follicle-stimulat- directly sense molecules circulating in the blood-
ing hormone (FSH), and reduced androgen- stream [33]. Hence, the range of factors that are
dependent organ weight. In this experimental integrated by GnRH neurons for the control of the
model, sex hormone imbalance was associated GnRH/gonadotropin secretion could be extended.
with MetS severity, since T decreased and estro- Using a well characterized cellular model, we
gen increased as a function of the number of MetS identified a direct inhibitory action of increasing
components [23]. Also, gonadotropin plasma lev- glucose concentrations on human fetal GnRH-
els were negatively associated with MetS and, secreting neurons, the FNC-B4 cells [34–37],
among MetS factors, hyperglycemia and hyper- thus opening new mechanistic insights into the
cholesterolemia resulted as being the major deter- direct metabolic control of GnRH release [38].
minants for the negative association with LH FNC-B4 cells express glucose transporters
levels, while the dyslipidemic component (high (GLUT1, GLUT3, and GLUT4) and may respond
cholesterol and triglycerides) appeared to be asso- to changes in glucose concentrations. Exposing
ciated with FSH reduction [23]. Moreover, FNC-B4 cells to high glucose significantly
40 M. Maggi et al.

reduced the expression not only of GnRH but also International, multicenter, Post-Authorization
of genes relevant for GnRH neuron function, such Surveillance Study (IPASS) on long-acting-
as KISS1R and leptin receptor. Even if obtained intramuscular T undecanoate conducted on 1,493
in vitro, these findings support the idea of a direct, hypogonadal men showed that after 9–12 months
deleterious contribution of hyperglycemia on waist circumference decreased from 100 to
human GnRH neurons, thus improving our under- 96 cm and blood pressure and lipid parameters
standing about the pathogenic mechanisms link- were altered in a favorable and significant man-
ing HH to metabolic disorders. Overall, in vitro ner [40]. Another more recent open-label, single-
and in vivo experimental studies indicate that center, cumulative, prospective registry study of
metabolic derangements may activate proinflam- 255 hypogonadal men (aged 33–69 years)
matory pathways within the hypothalamus, thus showed that normalizing serum T to normal
compromising a key brain area involved in the physiological levels produced consistent loss of
control of reproduction. In agreement with this body weight, waist circumference, and BMI over
possibility, in vivo treatment with obeticholic the full 5 years of the study [41]. Despite this evi-
acid, a drug that ameliorates glucose metabolism dence, unfortunately, only few RCTs have evalu-
in the rabbit MetS model [24, 29], not only ated the impact of TRT in patients with MetS and
reverted all the HFD-induced hypothalamic alter- T2DM. By meta-analyzing available evidence,
ations – including GLUT4 induction and inflam- we found that TRT was associated with a signifi-
matory response – but also increased GnRH cant reduction of fasting glycemia, HOMA index,
mRNA expression [23]. triglyceride levels, and waist circumference in
patients with MetS [8]. Accordingly, an improve-
ment of fasting glycemia, HbA1c, and triglycer-
5.6 Testosterone Therapy ide levels was observed in subjects with T2DM
and Obesity [8]. Hence, TRT and lifestyle modifications can
also be combined, and this is strongly recom-
In obese individuals, several studies have demon- mended in LOH obese individuals. However, this
strated that intense lifestyle intervention, along strategy has been tested only in two placebo-
with nutritional counseling and physical activity, RCTs (92 and 93). By meta-analyzing the results
is able to reduce weight loss and to conjointly of these studies, we report here that the combina-
raise T levels. A recent meta-analysis, in fact, tion of TRT and lifestyle modifications is able to
showed that weight loss is associated with an improve waist line, HOMA index, and lipid pro-
increase of bound and unbound T levels, along file (reducing triglycerides and increasing HDL
with gonadotropin levels, and that the final effect cholesterol levels) when compared to both pla-
is directly related to the amount of body mass cebo and lifestyle modifications alone [42].
index (BMI) reduction [6]. Accordingly, the
analysis of longitudinal data of the European Conclusions
Male Aging Study demonstrated that weight loss Several clinical and experimental data have
was associated with a proportional increase – and documented a strong inverse relationship
weight gain with a proportional decrease – in between obesity and testosterone levels. The
total T and sex hormone binding globulin [39]. underlying pathogenetic mechanisms appear
Based on this evidence, lifestyle modifications to be complex and often multi-directional.
should be strongly encouraged in hypogonadal According to the current guidelines [5],
subjects with obesity, T2DM, and MetS. intense lifestyle intervention, along with nutri-
Unfortunately, diet and behavioral therapies tional counseling and physical activity should
often ultimately fail. Several uncontrolled studies be the first approach to obese individuals with
have shown that T replacement therapy (TRT) hypogonadism. However, since diet and
could improve body composition and reduced fat behavioral therapies often fail, TRT and life-
mass (see Ref. [4, 5, 7, 8] for review). The style modifications can also be combined. In
5 Hypogonadism and Obesity 41

fact, several uncontrolled studies have shown 11. Wu FC, Tajar A, Pye SR, Silman AJ, Finn JD, O’Neill
that TRT could improve body composition TW, Bartfai G, Casanueva F, Forti G, Giwercman A,
Huhtaniemi IT, Kula K, Punab M, Boonen S,
and reduced fat mass. Conversely, only lim- Vanderschueren D, European Male Aging Study
ited RCTs are available. Longer and larger Group. Hypothalamic-pituitary-testicular axis disrup-
studies are advisable to better clarify the role tions in older men are differentially linked to age and
of TRT in obese men. modifiable risk factors: the European Male Aging
Study. J Clin Endocrinol Metab. 2008;93:2737–45.
12. Corona G, Mannucci E, Lotti F, Fisher AD, Bandini
E, Balercia G, Forti G, Maggi M. Pulse pressure, an
index of arterial stiffness, is associated with androgen
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 Microbiota Organ and Bariatric
Surgery 6
Nicola Basso, Giovanni Casella, Emanuele Soricelli,
Geltrude Mingrone, and Adriano Redler

The gastrointestinal tract is known to be a weighs up to 2 kg. One-third of our gut microbiota
complex and finely balanced ecosystem. It is one is common to most people, two-thirds are spe-
of the largest interfaces between the outside cific for each individual being a sort of identity
world and the human internal environment. card. This separate ecosystem contributes sub-
The human gut hosts 100 trillion (10014) stantial beneficial functions to the host: digestion
microorganisms, encompassing hundreds of phy- of otherwise indigestible plant polysaccharides,
lotypes composed of approximately 1,100 preva- development of the mucosal and systemic
lent species, with approximately 160 such species immune system, and control of the regeneration
per individual. Density of bacterial cells in the of the intestinal epithelium. The definition
colon is estimated to be 1012 per ml, making it “microbiota organ” (Fig. 6.1) seems to be appro-
one of the most densely populated microbial hab- priate [1, 2].
itats on Earth. In its entirety, the microflora is Different species and quantities of bacteria are
estimated to contain 150-fold more genes than found at different points along the digestive tract.
our own host genomes and this bacterial genome The stomach pH is deadly for most microbes, the
(microbiome) contributes a broad range of bio- acid-resistant Lactobacillus and Streptococcus are
chemical and metabolic functions that the host predominant and account for 102–3/ml. In the duo-
could not otherwise perform. Microbiota, in total, denum and jejunum up to 104–5 bacteria/ml
(Lactobacillus, Escherichia coli, Enterococcus
N. Basso (*) faecalis) can be found despite the toxicity of bile
Department of Surgical Sciences, and pancreatic secretions. The number of bacteria
“Sapienza” University of Rome, rises in the ileum (107 bacteria/ml) and in the colon
Via Napoli, 51, Rome 00184, Italy
(1012 bacteria/ml). The large intestine contains the
e-mail: [email protected]
largest number of bacteria, and is characterized by
G. Casella • E. Soricelli • A. Redler
a complex and dense microbial community mainly
Department of Surgical Sciences,
“Sapienza” University of Rome, made up of anaerobic species [3].
Vle Regina Elena, 324, Rome 00161, Italy Three bacterial divisions, the Firmicutes
e-mail: [email protected]; (Gram-positive), Bacteroidetes (Gram-negative),
[email protected]; [email protected]
and Actinobacteria (Gram-positive) dominate the
G. Mingrone adult human gut microbiota. The Firmicutes is
Department of Internal Medicine,
the largest bacterial phylum (60 %) and contains
Catholic University, Largo A. Gemelli 8,
Rome 00168, Italy more than 200 genera, including Lactobacillus,
e-mail: [email protected] Mycoplasma, Bacillus, and Clostridium; the

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 43

Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_6,
© Springer International Publishing Switzerland 2015
44 N. Basso et al.

Fig. 6.1 The microbiota organ

Bacteroidetes (20 %) include about 20 genera; ration, from birth to adulthood. From the third
the Actinobacteria (Gram-positive) are frequently day, the composition of the intestinal flora is
missed by RNA gene sequencing and can be directly dependent on how the infant is fed: in
detected only by fluorescent in situ hybridization breastfed babies, compared to infant formulas
(FISH). It is worth noting that human species and nourished babies, gut microbiota is dominated by
murine species have similar microbiota composi- Bifidus bacteria. Breast milk is rich in oligosac-
tion [4]. charides, fermented in the distal gut and promot-
Newborn babies are germ free. The develop- ing the growth of beneficial microbes as
ment of the gut microbiota starts at birth and its bifidobacteria. At the age of 4 years, the gut
composition changes substantially at three stages microbiota in host individuals has fully matured.
in life: from birth to weaning; from weaning to Transformation to the adult-type microbiota is
attaining a “normal” diet; during old age. Sterile triggered by multiple host and external factors.
inside the uterus, the newborn’s digestive tract is Carnivore microbiomes are enriched in protein
quickly colonized by microorganisms from the degradation genes, while herbivore microbiomes
mother (vagina, feces, skin, breast, etc.) and from are enriched in genes necessary to break down
the environment in which the delivery takes starch, thus, a Prevotella-type community is asso-
place. Nutrition is a driving factor in shaping gut ciated with fiber intake and a Bacteroides-type
microbiota composition and its functional matu- community with high protein intake.
6 Microbiota Organ and Bariatric Surgery 45

After transformation to the adult type and or quantitative imbalance in the intestinal flora, in
until the seventh decade, the gut microbiota their metabolic activities or changes in their local
remains remarkably constant. However, the inter distribution leads to a condition known as dysbio-
phyla numerical proportions may have important sis where microbial imbalance exerts adverse
fluctuations around an individual core of stable effects on the host. A pivotal role of gut microbi-
colonizers. Microbes in the human gut undergo ota has been evidenced in the development of gas-
selective pressure from the host as well as from trointestinal diseases, such as Clostridium difficile
microbial competitors. This typically leads to a infection (CDI), other inflammatory bowel dis-
homeostasis of the ecosystem in which some spe- eases, and colorectal cancer [10, 11].
cies occur in high and others in low abundance Recent studies have highlighted a role for gut
(the “long-tail” effect), with some low abundance microbiota dysbiosis in the genesis of obesity
species, like methanogens, performing special- and of the metabolic syndrome. There are a num-
ized functions beneficial to the host [5, 6]. ber of linking arguments: dysbiosis occurs in dia-
betic and obese versus lean individuals; some
components of the gut microbiota (e.g., lipopoly-
6.1 Functions of Microbiota saccharides, LPS) play a harmful role in obesity
and diabetes; the diet takes part in the modulation
The gut microbiota has multiple functions of the gut microbiome and microbiota composi-
related not only to the gastro-intestinal system tion/function in obesity and metabolic syndrome
but also to the central and autonomic nervous [12–20].
system, the immune system. Alterations of the In obese subjects (human and murine), the gut
microbiota may lead to anxiety and depressive microbiota has a higher proportion of the phylum
status: a significant correlation between gut Firmicutes and a lower proportion of the phylum
inflammatory status and anxiety traits has been Bacteroidetes, the reverse occurs in lean subjects
documented [7, 8]. [15, 16]. A direct relationship between
Although the most abundant molecular func- Bacteroidetes abundance and body weight has
tions generally trace back to the most dominant been demonstrated.
species, some of them may be contributed to pri- Gnotobiology, which is the selective coloniza-
marily by low-abundance genera. Because of this tion of germ-free animals, has given insight into
factor and of additional ones such as the elevated the role covered by the commensal microbiota in
number of species, the numerical variations a series of patho-physiological mechanisms, such
induced by host and external factors, the multiple as obesity, insulin resistance, and diabetes.
functions, investigations on microbiota are diffi- The host-bacterial association possesses a
cult and necessitate specific and sophisticated beneficial mutuality enhancing the host digestive
methods to answer specific questions: nucleic and metabolic efficiency and ensuring a stable
acid studies (which are they?), metatranscrip- metabolic supply for the microorganisms.
tomics, metaproteomics, metabolomics (what are In fact, germ-free mice show a less body fat
they doing?), and metagenomics. The study of content than conventional raised mice. High-fat
“clusters” of functionally related groups is of Western-type diet in conventional mice induces
help in elucidating microbiota’s role [5, 9]. obesity and insulin resistance. When given the
same diet, germ-free mice are resistant to obesity
and to insulin resistance. The effect is FIAF
6.2 Microbiota and Obesity (fasting-induced adipose factor) dependent
(Fig. 6.2) [12, 17].
The gut microbiota is highly vulnerable to changes Colonization of germ-free mice with conven-
in the gut microenvironment. Under normal con- tional microbiota leads to a 60 % increase in the
ditions, commensal microbes and their hosts body fat that likely depends on the greater capacity
enjoy a symbiotic relationship. A qualitative and/ to extract energy from food which, otherwise,
46 N. Basso et al.

Fig. 6.2 Germ-free mice are resistant to obesity and to insulin resistance. The effect is fasting-induced adipose factor
(FIAF) dependent [12, 15, 46]

would be only partially utilized, together with an flora derived from obese rather than from lean
increased insulin resistance [12, 13]. donors (Fig. 6.4) [14].
In fact, the microbiota metabolizes complex Furthermore, germ-free mice “humanized” by
carbohydrates present in the fibers, which could microbiota from human donors become sensible
not be otherwise digested, to oligo- and mono- to western-type high-fat diet (Fig. 6.5) [22].
saccharides, which in turn are fermented to short- In addition, obese mice have an inversion of
chain fatty acids, including butyrate, propionate, the proportional intestinal content of
and acetate. Short-chain fatty acids are absorbed Bacteroidetes and Firmicutes with a net reduc-
in the colon, where butyrate provides energy for tion of the former and an increase of the latter
colonic epithelial cells. Through the portal circu- [15, 16]. Interestingly, germ-free animals show a
lation acetate and propionate reach the liver and decreased lipogenic-related gene expression
peripheral organs, where they become substrates which can contribute to their leaner shape [13].
for gluconeogenesis and de novo lipogenesis,
thus determining the accumulation of triglycer-
ides in the liver [12, 18, 21] (Fig. 6.3). 6.3 Microbiota and Metabolic
Besides representing an energy source, short- Syndrome
chain fatty acids modulate intestinal gene expres-
sion by inhibiting the enzyme histone deacetylase High-fat diet induces significant changes in the
and regulate energy metabolism through composition of the gut microbiota by decreasing
G-protein-coupled receptors (GPCRs), such as the population of bifidobacteria. Decreased bifi-
GPR41 or GPR43 [17, 18]. dobacteria determine loosening of the tight junc-
The effect of increasing body weight is tions between cells thus being responsible for
enhanced if germ-free mice are colonized with increased gut permeability to a major component
6 Microbiota Organ and Bariatric Surgery 47

Fig. 6.3 In obese

individuals, the microbiota
is capable of extracting
extra energy from the food
by fermenting, otherwise
indigestible, carbohydrates
to mono saccharides and to
short-chain fatty acids
(SCFA) thus increasing fat
storage [12, 21]. FIAF:
fasting-induced adipose
factor; LPL: Lipoprotein
Lipase (from Cani and
Delzenne [21] modified)

Fig. 6.4 Germ-free mice colonized with microbiota derived from obese donors gain more weight than germ-free mice
colonized from lean donors [14]
48 N. Basso et al.

Fig. 6.5 Germ-free mice

“humanized” by micro-
biota from human donors
become sensible to
western-type high-fat diet
[22]

Fig. 6.6 Microbiota modulation is responsible for increased gut permeability to lipopolysaccharides (LPS), thus
inducing endotoxiemia, low-grade inflammation and metabolic syndrome (From Cani and Delzenne [21] modified)

of the outer membrane of Gram-negative bacteria, signaling [18], ensuing low-grade inflammation
the LPS (Fig. 6.6), an endotoxin that possesses (metabolic endotoxemia), diminished insulin sen-
pro-inflammatory actions and blunts insulin sitivity and, finally, metabolic syndrome.
6 Microbiota Organ and Bariatric Surgery 49

Table 6.1 From high-fat Energy Obesity

diet to the metabolic harvesting
syndrome [14] High Metabolic
fat Microbiota
dysbiosis syndrome
diet Low grade
Gut
inflam-
permeability
mation [LPS]

Correlation between LPS endotoxemia and fast- be associated with increased primary bile
ing insulinemia, glycemia, and triglycerides has acids in the blind loop and secondary bile
been demonstrated in type 2 diabetic patients [23]. acids further down in the gastrointestinal tract,
The two driving factors of the metabolic syn- both of which have antimicrobial properties.
drome, energy harvest and gut permeability, are • Antimicrobial prophylaxis for patients under-
dependent on gut microbiota dysbiosis [14] going bariatric surgical procedures determines
(Table 6.1). an acute although transient effect on microbi-
ota composition.
• Time spent masticating: in all procedures with
6.4 Microbiota and Surgery a restrictive component, increased chewing
time produces larger quantities of saliva and
Bariatric surgery results in weight loss, reduced promotes gastric secretion and motility.
adiposity, and improved glucose metabolism, not • Food choices and preferences: after bariatric
simply attributable to decreased caloric intake or surgery diet changes in terms of quantity and
absorption. Gut microbiota share some of these quality. From soft diet in the first weeks, the
effects. patients switch gradually to a regular diet but
Surgery induces changes in environmental and with foods different from those consumed
systemic factors, as well as in the anatomy of the before surgery.
digestive tract, all of which might have an effect The mechanisms linking rearrangement of the
on the composition of the gut microbiota [24]. gastrointestinal tract to the metabolic outcomes
• Acid production: the diminished acid secre- are largely unknown, a role for microbiota has
tion, because of gastric resection (sleeve gas- been advocated.
trectomy [SG], bilio-pancreatic diversion Very few studies report the effect of bariatric
[BPD]) or gastric bypass [GBP]), determines surgery on the microbiota composition. To date
marked changes in the intestinal pH that affect only four studies in humans and five studies in
genus and species relative proportions of the animals have been reported (Table 6.2).
intestinal flora rather than the overall cell In 2009, Zhang et al. were the first to report on
number. Achlorhydria is associated with an the effect of GBP on gut microbiota in man [26].
increased number of Gram-positive bacteria They examined microbial 16S rRNA genes from
and with modifications of microbiota ecology PCR amplicons by using the pyrosequencing tech-
in the lower gastrointestinal tract: microbial nology to compare the microbial community struc-
community composition and short-chain fatty tures of nine individuals, three normal weight, three
acid production [25]. morbidly obese, and three post-GBP. In normal-
• Food transit time: in SG and in GBP the food weight and in obese individual Firmicutes were
reaches rapidly in the small intestine stimulat- dominant, in GBP patients Firmicutes were signifi-
ing the secretion of entero-hormones (PYY, cantly decreased with a proportional increase of
GLP-1). In malabsorption operations, portions Gammaproteobacteria. Most importantly, in obese
of the small bowel are bypassed and undi- subjects, the population number of Archaea hydro-
gested food reaches the colon. gen utilizing H+ extracted from indigestible polysac-
• Entero-hepatic cycle: in operations with Roux charides and thus increasing energy uptake, was
limb (GBP, BPD) the bile acids follow a dif- higher than in normal weight subjects and in sub-
ferent route from that of food. GBP seems to jects with GBP (Fig. 6.7).
50 N. Basso et al.

These results suggest that microbiota play a the weight loss was positively correlated to the
significant role in the genesis of the GBP-induced amount of Bifidobacterium population.
EWL. However, the work has an important bias: More recently, these data have been confirmed
the three studied groups were composed of sepa- by Graessler in six obese patients submitted to
rate subjects without longitudinal preoperative GBP [28].
and postoperative assessments. Li et al. showed a substantial higher concen-
In 2010, Furet confronted the microbiota pro- tration of gut Proteobacteria, especially
files in the feces of morbidly obese patients Enterobacter hormaechei, and a proportionate
before, 3, and 6 months after GBP and associated lower concentration of Firmicutes and
these data to body composition, metabolic data, Bacteroidetes in rats after GBP in comparison
and inflammatory markers [27]. He confirmed the with sham-operated rats [29, 30]. In a similar
augmented Firmicutes/Bacteroidetes ratio in study in man, Kong et al. investigated the gut
obese patients; at 3 and 6 months post-GBP this microbiota from fecal samples and adipose tissue
ratio diminished in direct relationship to patient’s samples in severely obese individuals, before and
weight loss (body weight, BMI, body fat mass, after GBP 31]. Early after surgery a remarkable
and serum leptin concentrations). A significant 37 % increase in gut bacteria belonging to the
negative relationship between the amount of phylum Proteobacteria occurred. The researchers
Faecalibacterium prausnitzii and metabolic and also found a significant association between gut
inflammatory parameters was found. Furthermore, microbiota composition and adipose tissue gene
expression (including metabolic and inflamma-
tory genes) as well as clinical phenotype – as
Table 6.2 Literature overview on bariatric surgery and
microbiota substantial proportion of which were indepen-
dent from changes in caloric intake.
Type of
Author Year Subjects N surgery In a recent intriguing study, Liou et al. demon-
Zhang et al. [26] 2009 Humans 9 GBP strated that the implantation by gastric gavage of
Furet et al. [27] 2010 Humans 43 GBP gut microbiota from GBP-operated mice into germ-
Graessler et al. 2013 Humans 6 GBP free mice, triggered decreased host weight and
[28] adiposity [32]. GBP was associated with increased
Kong et al. [31] 2013 Humans 15 GBP populations of Proteobacteria (Escherichia) and
Li et al. [29] 2011 Rats GBP Verrucomicrobia (Akkermansia), and a reduction
Li et al. [31] 2011 Rats GBP in Firmicutes compared to sham surgery or to food
Liuo et al. [32] 2013 Mice GBP restriction. Mice that underwent GBP extracted
Osto et al. [44] 2013 Rats GBP significantly less energy from the diet than mice
Ryan et al. [33] 2014 Mice SG
that underwent sham surgery or calorie-restricted

1014
Copies of 16S rDNA per gram stool

1013 Bacteria
1012 Archaea (+ energy utilization)
1011 Methan obacteriales (+ energy extraction)
1010
109
108
Fig. 6.7 Obese subjects 107
(ob) had a higher number 106
of hydrogen utilizing 105
Archaea than normal 104
weight subjects (nw) and 103
subjects with Roux-en-Y 102
gastric bypass (gb) (From 101
Zhang et al. [26] modified) nw1 nw2 nw3 ob1 ob2 ob3 gb1 gb2 gb3
6 Microbiota Organ and Bariatric Surgery 51

mice. This effect may have been mediated by opens new exciting perspectives in the treatment
gut restructuring and by changes in the intestinal of obesity and related diseases.
microbiota (Fig. 6.8). The relationship between bariatric surgery
Most important, germ-free mice on HFD, and gut microbiota has been investigated taking
when colonized with microbiota from GBP mice, into account one type of procedure, GBP. Only
had a significant weight loss and exhibited a recently a study concerns the effects of SG on
trend toward lower fasting insulin levels. In mice bile acids circulation and associated changes
colonized with microbiota from sham surgery to gut microbiota [33]. After SG, in HFD mice
animals no effect was apparent. These data indi- the increase of circulating bile acids was asso-
cate that the decreased host adiposity is transmis- ciated to a substantial reduction of the relative
sible through the GBP altered microbiota and abundance of Bacteroides and to an increase
that it plays an active role in weight loss and in the relative abundance of Lactobacillus and
metabolic status [32]. Lactococcus and of Enterobacteriaceae (genus
The possibility of transplantation of the bene- Escherichia coli). Concomitantly decrease in
ficial effects of GBP on weight and metabolism adiposity and improvement in glucose toler-
through the gut microbiota as reported by Liou ance occurred. These effects were dependent on

Fig. 6.8 Microbiota altered by Roux-en-Y gastric bypass, when transferred to intact germ-free animals, induced in the
host phenotypic and metabolic changes mimicking the effects of surgery in the operated subject [32]
52 N. Basso et al.

host. At present, only inulin and trans-galacto-

oligosaccharides are used as prebiotics having as
main target two bacterial genera, Lactobacilli
and Bifidobacteria. Cani demonstrated that
Bifidobacteria are capable of lowering LPS lev-
els by reducing intestinal permeability and thus
preventing the low-grade inflammation. Inulin
treatment in high-fat-fed diabetic mice restored
Bifidobacteria levels, diminished body weight,
normalized low-grade inflammation, improved
glucose-tolerance, and glucose-induced insulin
secretion. These effects were mediated via a
GLP-1- and PYY-dependent pathway (Fig. 6.10).
Use of prebiotics to modify gut microbiota to
favor the beneficial bifidobacteria was hypothe-
sized [36–39] (Fig. 6.10).
In a RCT by Woodard, daily use of probiotics
Fig. 6.9 The effects of sleeve gastrectomy on metabo- (Lactobacillus) in patients submitted to GBP, at 6
lism and microbiota are mediated by Farsenoid-X recep- months post-op, determined significant reduction
tors (FXR) in bacterial overgrowth (measured with H2 breath
levels), greater although not significant percent
Farsenoid-X receptor (FXR) signaling molecule. of excess weight loss (EWL), and significantly
While microbiota is modified and modifies bile higher postoperative vitamin B12 levels when
acids, FXR represents a link both to microbiota compared to the control group [40].
changes and to surgery benefits [33] (Fig. 6.9).

6.6 Fecal Transplant in Clinics

6.5 Probiotics and Prebiotics
In the fourth century in China, the use of
Manipulation of the gut microbiota to prevent human fecal suspension by mouth for patients
obesity and/or to control the glycemic metabo- with severe diarrhea has been described.
lism has been investigated in animals and humans Recent literature reports the implantation of
using prebiotics and probiotics. microbiota from human feces by naso-gastric
According to the 2001 FAO/WHO definition, tube, colonoscopy, or enema in the therapy of
probiotics are “live micro-organisms which, recurrent Clostridium difficile infection (CDI),
when administered in adequate amounts, confer a after failed antibiotic therapy. A total of 317
health benefit on the host” [34]. The rationale for patients were treated with a 93 % resolution
the use of probiotics for the treatment of gut rate. In 2013, in a RCT reported by Van Noon
microbiota-related diseases is the restoration of in the NEMJ, fecal transplant (FT) was con-
intestinal homeostasis by beneficial microbes. fronted to vancomycin therapy in CDI patients
Probiotics are Lactobacilli and Bifidobacteria, [41]. Cured patients were 94 % in the FT
but also yeasts such as Saccharomyces boulardii, group and 31 % in the vancomycin group. In
Streptococci, and nonpathogenic strains of another study, CDI resolution was stable at 17
Escherichia coli [35]. months follow-up in 91 % of patients and the
Prebiotics (mostly oligosaccharides) are non- host gut microbiota was similar to the donor
digestible but fermentable food ingredients that microbiota at 24 months follow-up [42]. In
selectively stimulate the growth or activity of one 2013, the FDA accepted FT as an investigational
or more gut microbes beneficial to the human therapy.
6 Microbiota Organ and Bariatric Surgery 53

Fig. 6.10 Prebiotics act by increasing Bifidobacterium et al. [45]). eCB endocannabinoid, GLP-1 glucagon-like
population, decreasing gut permeability and modulating peptide 1, GLP-2 glucagon-like peptide 2, LPS lipopoly-
gut peptides endogenous production (From Delzenne saccharides, ZO-1 zonula occludens 1, PYY Peptide YY

More interesting for the purpose of this chapter Gut microbiota can be modulated by pro- and
is the 2010 work by Vrieze. A double-blind RCT prebiotics and by FT.
was conducted on 18 obese patients with the meta- The therapeutic value of FT deserves
bolic syndrome [43]. Nine patients received FT investigation.
from lean donors and nine patients received their More conclusive studies in the experimental
own feces (control). After 6 weeks, in the FT from animal and especially in man are needed.
lean donors group fasting triglycerides levels were
markedly reduced and peripheral and hepatic insu- Conclusions
lin sensitivity was markedly improved; no effect While there are only few firm data on the rela-
was apparent in the control group. Although the tionship between microbiota and the obesity
beneficial effects remitted after 12 weeks, it is not and metabolic syndrome problem, it is
known whether repeated FT would be beneficial. undoubtable that the “microbiota organ,” rich
of more than three million genes deserves a
greater attention.
6.7 Summary A tremendous lack of data limits our cur-
rent knowledge of the complexity of gut
Gut microbiota composition and its metabolites microbiota-host interactions and the exact
are different in obese and lean individuals. mechanisms linking dietary habits, gut micro-
Gut microbiota plays a central role in energy biota, and metabolic disorders.
harvesting and storage and in the pathogenesis of Investigations centered on the relationship
low-grade inflammation and hence in the genesis between bariatric surgery and gut microbiota
of obesity and of the metabolic syndrome. are very scarce, do not encompass the differ-
Bariatric surgery (GBP and SG) determines ent bariatric procedures, and need systematic
significant changes in the composition of gut controlled human studies to confirm the clini-
microbiota. The exact significance of these cal relevance of the observed laboratory data.
changes remains to be determined. However, experimental and clinical stud-
The beneficial effects of gut microbiota can be ies, although in a very preliminary manner,
transferred from lean to obese subjects. indicate that bariatric surgery affects gut
54 N. Basso et al.

microbiota both in the experimental and in the 12. Backhed F, Ding H, Wang T, et al. The gut microbiota
clinical setup determining microbiota changes as an environmental factor that regulates fat storage.
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14. Turnbaugh PJ, Ley RE, Mahowald MA, et al. An
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microbiota control metabolic endotoxemia-induced erties: consequences for host health in the context of
inflammation in high-fat diet-induced obesity and dia- obesity and metabolic syndrome. Microb Cell Fact.
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 Part II
Surgery of Obesity
 The “Bariatric Multidisciplinary
Center” 7
John Melissas

Obesity (BMI ≥30 kg/m2) is a worldwide epi- period 1995–2008 with higher level in women
demic that currently affects 500 million adults and models predict a tripling of SO prevalence
and 40–50 million children, according to the for English women by the year 2030 [7].
World Health Organization (WHO), becoming
one of the leading causes of death and disability
in Europe and worldwide [1–3]. 7.1 Obesity Burden and Cost
In the USA, the age-adjusted prevalence of
obesity was 35.5 % among adult men and 35.8 % Obesity is a gateway to ill health and excess
among adult women in 2009–2010, with the weight has proven to drastically elevate a per-
prevalence of obesity in children and adolescents son’s risk of developing debilitating diseases,
being 16.9 % [4]. such as diabetes, hypertension, dyslipidemia,
The prevalence of obesity has tripled since the sleep apnea, vascular occlusion, nonalcoholic
1980s in many European countries, with over- steatohepatitis, cancer, infertility, and pregnancy
weight and obesity affecting 50 % of the popula- complications [4, 8, 9].
tion [1–3]. Overall, obesity reduces life-expectancy, quality
More alarming is the rapidly growing preva- of life and is a major cause of disability being
lence of severe obesity (SO) (BMI ≥ 40 kg/m2 or extremely costly for the health system worldwide
BMI ≥ 35 kg/m2 with manifest of serious co- [4, 8–10]. Estimated direct costs for obesity and
morbidities) which is increasing faster than obe- related co-morbidities treatment exceed 5 % of the
sity in adults and in children [5]. total health care costs in both the USA and Europe
In Sweden, young adult men exhibited a five- [7, 8, 11]. Additionally, obesity-related indirect
fold increase in moderate obesity over the 30-year costs from work absence, reduction of productivity,
period ending in 2005, whereas SO increases ten- etc. may exceed the direct medical costs [12]. Both
fold and is projected to affect 4 % of the adult direct and indirect expenditures correlate with the
Swedish population by the year 2020 [6]. Studies degree of obesity. As BMI increases, the number
in the UK showed that adult SO doubled in the and severity of metabolic derangements increase in
adults and children [9, 13]. The impact of obesity in
women in reproductive age is of particular concern,
J. Melissas because of the association between maternal pre-
Bariatric Unit, Heraklion University Hospital,
pregnancy obesity with serious pregnancy compli-
University of Crete, 164 Erythreas Street,
Heraklion, Crete 71409, Greece cations, greater fetal adiposity, and development of
e-mail: [email protected] childhood obesity in the offspring [9].

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 59

Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_7,
© Springer International Publishing Switzerland 2015
60 J. Melissas

In the USA, annual direct costs are three times these savings would triple if 25 % of eligible SO
higher for SO workers than for obese workers patients were subjected to surgical intervention.
and more than ten times higher than for over- That estimate does not include additional economic
weight employees. Absence from work is benefits associated with decrease in work absence
estimated to be 5.9 more days/year in SO workers and increase in workers’ productivity [11].
compared to men with normal weight. Reduced
productivity estimated in American SO work-
force is equivalent to 1 month lost productivity 7.3 Multidisciplinary Obesity
per year [10, 14]. Approach
Obviously, weight management is going to
play a major role in reducing both morbidity and Since obesity is a complex condition where bio-
mortality and health care costs in Europe and logical, psychological, and social factors inter-
worldwide [4, 9, 11, 13]. fere to lead to excess body weight, its management
cannot focus only on weight reduction. The
improvement of body composition with fat-free
7.2 Bariatric Surgery mass maintenance, co-morbidities management,
and quality of life improvement are also included
Bariatric surgery is now recognized as the only in treatment terms. [8, 17, 18]
effective treatment for severe obese (SO) patients Therefore, comprehensive obesity manage-
with long-term sustained weight-loss and post- ment by either conservative or surgical method is
operative resolution or significant improvement “by definition” a multidisciplinary effort and
in the obesity co-morbidities, being an interval should be undertaken by a team of different pro-
part of the comprehensive management of SO fessionals able to tackle with the different aspects
patients [4, 9, 15]. Current evidence points to of obesity and its related disorders [4, 8, 17, 18].
major benefits in terms of prevention of type 2 Bariatric surgery has rapidly evolved into met-
diabetes, important gains regarding cardiovascu- abolic surgery. Type 2 diabetes, a primarily medi-
lar risk and cancer reduction and suggests lon- cal disease which evolved into a condition where
gevity [4, 9, 16]. surgeons may play a more active role in the dia-
Bariatric operations are preventive as well betic patient management, is an excellent exam-
as therapeutic. Weight-loss achieved post- ple. Bariatric-metabolic procedures can now be
operatively may forestall or stop development of utilized to treat metabolic conditions even with-
a significant number of obesity co-morbidities [4, out direct relation to weight-loss [19]. This is fur-
15, 16]. It is notable, particularly for its economic ther emphasizing the need of a holistic
significance, that bariatric surgery can obviate interdisciplinary approach for the management of
the need for other major procedures, such as kid- the disorders that fall into the bariatric-metabolic
ney, heart and liver transplantation, hip replace- surgery field [4, 19, 20].
ment, and cancer surgery [9]. Early intervention The interdisciplinary guidelines and meta-
in any disease process provides greater likelihood bolic and bariatric surgery have been described in
of achieving partial or total remission and this is detail [4, 21–23]. It is remarkable to mention that
of great importance, when considering bariatric for a given patient, the risk-benefit ratio requires
surgery at the younger age group and in those an experienced multidisciplinary bariatric team
with BMI 30–35 kg/m2 [9]. to be carefully evaluated. The team providing
Heath care system benefits from bariatric sur- such assessment should consist of the following
gery are enormous. A study from England sug- specialists with experience in the management of
gested that if only 5 % of the eligible patients were the bariatric patient:
to have bariatric surgery, the net saving for the Physician
NHS over 3 years would be nearly 400 million GB Surgeon
pounds. Additionally, the authors estimate that Anesthetist
7 The “Bariatric Multidisciplinary Center” 61

Psychologist or psychiatrist 7.5 Surgeon’s Training

Nutritionist and/or dietician
Nurse practitioner/social worker The need for adequate training of the bariatric
Additional consultation with endocrinologist, surgeon, particularly for those entering the field,
cardiologist, respiratory physician, ICU expert, has long before been recognized by the
interventional gastroenterologist, radiologist, and International Federation for the Surgery of
other specialists would be obtained as indicated Obesity and related Metabolic Disorders (IFSO)
[4, 23]. [25] and the American Society for Metabolic and
Bariatric Surgery (ASMBS) [26].
Surgeons with comprehensive training are
7.4 Safety and Efficacy able to manage morbidly obese and super-obese
of Surgical Intervention patients with low morbidity and mortality and
outcome results similar to those reported by
Bariatric surgery needs to be safe and effective experienced surgeons.
[24, 25]. This highly demanding challenging In a study by Kothori et al. [27], following
therapy necessitates the appropriate training and completion of an advanced laparoscopic fellow-
experience from the surgeon’s part. It is vital that ship, a surgeon was evaluated for 125 consecu-
beyond the optimal therapeutic knowledge, the tive patients. He performed gastric bypasses with
surgeon should also have the technical skills in mean operative time of 123 min, mean hospital
the open and/or the laparoscopic surgery. Apart stay of 2.2 days, anastomotic leak in 2.6 %, and
from performing meticulous pre- and post- intestinal obstruction in 0.6 % during the imme-
operative care, the surgeon has to be committed diate post-operative period. The authors con-
to long-term patient follow-up [23, 24]. cluded that after a full training in bariatric
Additionally, institutional commitment to the laparoscopic surgery, results were similar and
excellent multidisciplinary care of the SO patient comparable to those published in the literature.
who has an exceptional surgical and anesthetic Re-operative bariatric surgery is an even more
risk is essential to ensure safe and effective per- complex and demanding field. This type of sur-
formance of bariatric surgery. The ancillary ser- gery requires years of experience, more detailed
vices including specialized nursing staff, preoperative patients’ evaluation and should be
dieticians, exercise advisors, and multidisci- practiced preferably by surgeons with extensive
plinary medical team are extremely valuable and experience and in institutions with all the neces-
necessary [23, 24]. sary facilities, equipment and multidisciplinary
Medical and surgical facilities, such as operat- expertise [23].
ing room tables, surgical instruments, furniture,
and radiology equipment capable of handling
morbidly obese patients are “sine qua non” 7.6 Surgeon-Institution Volume
resources for any institution that seeks to treat
bariatric patients [4, 23, 24]. The relation between volume of patients man-
Several parameters can be associated with aged per year and mortality for most procedures
extended hospital stay, higher complication rate is well-known [28]. In a study of 474,108 patients
and increased mortality after bariatric surgery. subjected to eight cardiovascular operations or
Advanced age, male gender, high BMI, inade- cancer resections, the surgeon’s volume was
quate training, and inexperienced surgeon may inversely related to the operative mortality for all
contribute to poor outcome of the surgical inter- eight procedures [29].
vention. Although the first three parameters can- In another study, 197 surgeons who performed
not be changed, the effort should focus on 19,174 gastric bypass operations were evaluated
continuous improvement of the bariatric sur- in terms of relation between volume of surgeries
geon’s training and experience [23, 24]. with the incidence of complications and mortality.
62 J. Melissas

The reported mortality rates were 1.3 % for sur- high-risk with underlying medical conditions,
geons performing 1–5 procedures over a 5-year patients with serious psychological problems and
period, 0.5 % for those performing 6–99 proce- patients for revisional bariatric surgery, creates
dures, 0.3 % for those with 200–499 and 0.2 % further difficulties to advise a common barrage of
for those performing ≥500 bariatric operations tests [31].
over 5 years. Similar results in favor of those sur- However, all efforts should be made for the
geons with higher volume were found when com- optimum control of all underlined medical condi-
plications rates were assessed [30]. tions and for the reduction of surgical risk and
Therefore, it is obvious that surgeons and complications [32, 33].
institution should undertake the management of
a minimum number of bariatric patients per
year, to optimize the results of treatment 7.8 Post-operative Care
offered. and Follow-up

The post-operative follow-up consists of office

7.7 Pre-operative Evaluation visits at 1st, 3rd, 6th, 9th, 12th, 18th, and 24th
month as common practice. Annual follow-up
The pre-operative evaluation of the bariatric visits are recommended after the first 2 post-
patient covers a complete history, including pre- operative years. Additional visits depending on
vious weight-loss attempts and results. Obviously, the patient’s condition and the existence of co-
the selection of patients for bariatric and meta- morbidities should be considered necessary [24].
bolic surgery should follow the universally The patient is not only evaluated by the bariat-
accepted indications, described by International ric surgeon, but also by the entire multidisci-
Organizations, such as EASO, IFSO, IFSO-EC plinary bariatric team. These office visits include
[4, 21, 22]. A complete physical examination history and clinical examination, laboratory tests
should follow to assess surgical risk and guide in as required, and consultations by experts depend-
planning the appropriate pre-operative investiga- ing on the procedure performed. Recording the
tions and consultations. outcome of existing co-morbidities, measuring
Extra attention should be given to the presence weight, waist and hip parameters and offering
of serious obesity co-morbidities, and at this stage dietary advices, behavioral modification tech-
the value of the multidisciplinary bariatric team is niques, encouraging participation in exercise pro-
extremely important [4, 23, 24]. Conditions, such grams and support groups are included in the
as type 2 diabetes, sleep apnea syndrome, hyper- long-term follow-up [4, 8, 9, 24, 25].
tension, gastro-esophageal reflux disease, chronic
anemia, previous deep venous thrombosis or pul-
monary embolism and serious psychological 7.9 The Center of Excellence
disorders should be diagnosed and controlled. (COE) Concept
The addition to the standard multidisciplinary
bariatric team of ICU specialist, endocrinologist, Experience in the USA and Europe has shown
respiratory physician, hematologist, and gastroen- that the combination of a good surgeon operating
terologist is both required and necessary, depend- in a good, well-equipped institution can ensure
ing on the presence of certain co-morbidities in safe and effective management of the bariatric
each patient [23, 24, 31]. patient. Excellence in the surgical management of
It is extremely difficult to recommend stan- severely obese patients should be associated with
dard pre-operative laboratory teams. The fact that permanent weight-loss, good quality of life, low
potential bariatric patients may belong to differ- short- and long-term complications, amelioration
ent categories, such as low-risk obese patients, of obesity co-morbidities in the vast majority of
7 The “Bariatric Multidisciplinary Center” 63

patients and all those goals to be achieved with Table 7.1 Surgeon’s requirements
low morbidity and mortality [23, 34, 35]. 1. Appropriate certification to perform general surgery
When a bariatric center can prove that it has 2. Training and experience in gastrointestinal surgery
the necessary multilevel resources to undertake 3. Successful completion of a training course in
the management of severely obese patients with bariatric surgery
outstanding results, it can be accredited as a 4. Testimonials by mentors (proctors) of satisfactory
bariatric surgical ability
Center of Excellence (COE) in Bariatric and
5. Careful maintenance of a database of all bariatric
Metabolic Surgery [23, 24, 36]. cases, including outcomes
The evaluation of centers is carried out by 6. Commitment to postoperative life-time follow-up
independent bodies and the COE designation is of the patients
administered by a professional organization such 7. Have performed at least 25 bariatric cases per year
as IFSO or the American College of Surgeons (50 cases are required when adjustable gastric
banding is most commonly utilized)
(ACS) or the ASMBS.
8. Be able to perform revisional surgery
The philosophy of COE accreditation is sim-
9. Attend bariatric meetings regularly and subscribe to
ple: A well-trained and competent surgeon oper- at least one bariatric journal
ating in a well-equipped and serviced institution 10. Perform at least 25 bariatric cases per year
with sufficient volume of patients, would be including a number of revisional cases among them
able to offer safe and efficient management of (50 cases are required when adjustable gastric
banding is most commonly utilized)
patients with metabolic disorders. Efficacious
11. Be involved in the training and the accreditation of
treatment of the bariatric/metabolic diseases less-experienced bariatric surgeons
would be beneficial to patients and health care 12. Follow-up for at least 75 % of the operated patients
systems.

7.10 The COE Program in Europe, 7.11 The European Accreditation

Middle East, and Africa Council

In Europe, the establishment of a Center of EAC-BS examines the institutional facilities and
Excellence program under the guidance of the the surgeon’s qualifications and experience in
European Chapter of IFSO (IFSO-EC) was appro- order to ensure that they offer safe and efficient
priate and indicated [24, 35]. In May 2008, during management to severely obese and patients with
the General Assembly of IFSO-EC in Capri, the other metabolic disorders. EAC-BS utilizes the
concept of a COE program was unanimously requirements set by IFSO [23] for surgeons [7]
endorsed by the representatives of all the European and institutions (Table 7.2) in order to accept
National Bariatric Societies. Thus, the European them for participation in the COE program.
Accreditation Council for Bariatric Surgery The management offered to the patients by the
(EAC-BS) was formed. Leading bariatric surgeons participating institutions and surgeons (Table 7.1)
from the area of Europe, Middle East, and Africa is carefully observing patients’ outcome which is
are participating in the organization, either as mem- recorded in the International Bariatric Registry
bers of the Scientific Board or the Review (IBARTM).
Committee [35]. In August 2009, during the General Indexes of excellence, such as intra- and post-
Council meeting in Paris, the COE program was operative complications, re-admissions, long-
endorsed by IFSO. Institutions and surgeons fulfill- term complications, mortality, excess weight loss
ing the IFSO requirements (Tables 7.1 and 7.2) for and co-morbidities outcome, are evaluated for
safe and effective management of the morbidly each participating center.
obese patients could now apply (www.EAC-BS. Finally, a site visit by experienced auditor will
com) for participation to the COE program [36]. follow to verify the reported patients’ data and
64 J. Melissas

Table 7.2 Institution’s requirements reviewers will then submit their opinion to the
1. Ensure that surgeons performing bariatric surgery Scientific Board, the final decision-making body.
have the appropriate certification, training, and If everything is in order, EAC-BS will suggest to
experience. IFSO-EC that the center/surgeon is good enough
2. Provide ancillary services such as specialized
to receive the COE designation (Table 7.3).
nursing care, dietary instruction, counseling, and
psychological assistance if and when needed
3. Have readily available consultants in cardiology,
pulmonology, psychiatry, and rehabilitation with 7.12 Results of IFSO-EC Center
previous experience in treating bariatric surgery of Excellence Program
patients
4. Have trained anesthesiologists with experience in
treating bariatric surgery patients The program is evolving in a very satisfactory
5. Ensure that a recovery room capable of providing way. Seventy-two institutions and 118 surgeons
critical care to morbidly obese patients and an from 22 countries from the region of Europe,
intensive care unit with similar capacity are available Middle East, and Africa are participating.
6. Ensure that radiology department facilities can Since January 2010, data from more than
perform emergency chest x-rays with portable
machinery, abdominal ultrasonography, and upper
22,881 bariatric patients have been entered in the
GI series IBAR. In 84.4 % of them, the applied treatment
7. Ensure that blood tests can be performed on a 24-h was a primary bariatric procedure, in 5.9 % a
basis two-stage procedure and in 9.7 % a re-do for fail-
8. Ensure that blood bank facilities are available and ure of the original operation.
blood transfusion can be carried out at any time From the primary procedures, 55.18 % were
9. Have comprehensive and full in-house consultative
gastric bypass, 24.68 % sleeve gastrectomy,
services required for the care of the bariatric
surgical patients, including critical care services 11.52 % band, 0.50 % gastric plication, 1.15 %
10. Have the complete line of necessary equipment, mini gastric bypass, 0.86 % biliopancreatic diver-
instruments, items of furniture, wheel chairs, operating sion (Scopinaro), 2.05 % biliopancreatic diver-
room tables, beds, radiology facilities such as CT sion (duodenal switch), 0.02 % gastroplasty, and
scan, lifts, and other facilities specially designed and
suitable for morbidly and super obese patients
4.04 % “other” bariatric procedure.
11. Have a written informed consent process that Early (≤30 days) post-operative mortality was
informs each patient of the surgical procedure, the as low as 0.07 % for all procedures including the
risk for complications and mortality rate, alternative re-operations. Mortality for primary procedures
treatments, the possibility of failure to lose weight was 0.04 %, for 2-stage 0.30 % and for re-do pro-
and his/her right to refuse treatment
cedures 0.14 %.
12. Maintain details of the treatment and outcome of
each patient in a digital database. Re-admissions for complications in the early
13. Have experienced interventional radiologists (≤30 days) post-operative period was 1.69 %
available to take over the non-surgical management among all operated patients with primary proce-
of possible anastomotic leaks and strictures dures, and for the late (≥30 days) post-operative
14. Performs at least 50 bariatric surgical cases per year period 2.26 %. For the 2-stage and the re-do
including revisional cases. The peri-operative care
and the surgical procedures have to be standardized
procedures the incidence of re-admissions for
for each surgeon. early complications was 1.28 and 4.24 % and
15. Provides life-time follow-up for the majority and for late complications 2.22 and 3.42 %,
not less than 75 % of all bariatric surgical patients. respectively.
Patients’ data should be available on request by Weight-loss as assessed by % EWL and %
EAC-BS authorities.
EBL for patients subjected to primary bariatric
procedures at 12th post-operative month was
examine the institutional equipment, facilities, 68.81 and 70.83 %, respectively. At 24th
resources and services. The auditor will construct post-operative month, it was 70.83 and 78.71 %,
a detailed report which is then forwarded to two respectively. Cure or significant improvement of
Review Committee members for evaluation. Both obesity co-morbidities were observed in 79.4 %
7 The “Bariatric Multidisciplinary Center” 65

Table 7.3 COE evaluation procedure

Application
Institution and surgeon(s)

↓
Scientific board

↓
Accepted as program
participants

↓
Access to an internet-operated database (International Bariatric Registry-IBARTM) is provided to
the provisional program participants.
All procedures and patients’ outcome will be prospectively entered in the database.

↓
Monitor:
Morbidity
Mortality
Outcome

As soon as sufficient number of operated patients’ data is accumulated in the IBARTM to permit evaluation
of patients’ outcome:

Site visit and auditor’s

report to

↓
↓

1st reviewer 2nd reviewer

↓ ↓

Scientific board
(decision) –
approval as COE

for diabetes, 77.2 % for hypertension, 84.6 % for In conclusion, IFSO-EC COE program, admin-
osteo-articular diseases, 93.6 % for sleep apnea istered in this geographic region by EAC-BS,
syndrome, and 80.8 % for dyslipidemia. offered significant incentives for safe and effective
66 J. Melissas

multidisciplinary management of morbidly obese 14. Durden ED, Huse D, Ben-Joseph R, et al. Economic
costs of obesity to self-insured employers. J Occup
patients in participating provisional and designated
Environ Med. 2010;52:991–7.
Center of Excellence institutions. 15. Sjöström L. Review of the key results from the
Swedish Obese Subject trial-a prospective controlled
intervention study of bariatric surgery. J Intern Med.
2013;273:219–34.
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2006;2:497–503.
 Metabolic Surgery
8
Henry Buchwald

Metabolic surgery [is] the operative manipulation sequelae of operations for gastric ulcer dis-
of a normal organ or organ system to achieve a bio- ease (René Mengy), gastric bypass for obe-
logical result for a potential health gain (Buchwald
and Varco, 1978). sity (Edward E. Mason), jejunoileal bypass in
patients with morbid obesity (H. William Scott),
The above definition is from the foreword to partial ileal bypass for hyperlipidemia manage-
our 1978 text titled Metabolic Surgery [1]. This ment (Henry Buchwald and Richard L. Varco),
concept of metabolic surgery is a broad interpre- metabolic consequences of pancreatectomy
tation of the role of the surgeon in medicine’s (Ward O. Griffin, Jr), metabolic surgical sig-
battle against disease and the capability of sur- nificance of the spleen (Earl N. Metz, G. James
gery to contribute to proactive health care. Cerilli, Robert M. Zollinger), portal diversion for
The discipline of surgery had its roots in inci- inborn errors of metabolism (Charles W. Putman,
sional surgery, for example, the draining of boils Thomas E. Starzl), ablation of normal endocrine
in the days of the sixteenth-century guild of glands as treatment of benign and malignant
barber-surgeons. It rapidly became a craft, almost disease (Edward L. Kaplan), transplantation in
exclusively, of extirpative procedures. Radical metabolic disease (Arthur J. Matas, Richard
and then ultraradical cancer resections exempli- L. Simmons, Robert J. Desnick), functional neu-
fied this era. As surgical techniques matured and rosurgery (Donlin N. Long), and pulsing electro-
prosthetic materials and devices became avail- magnetic fields (C. Andrew L. Bassett).
able, reconstructive surgery was born and came Today, 25 years later, we could more than
to fruition in cardiac, orthopedic, and transplan- double the number of chapters on metabolic sur-
tation surgery. At present, we have firmly entered gery to include indirect and direct vagal nerve
the realm of metabolic surgery, more by a realiza- electronic stimulation for type 2 diabetes [2,
tion of past and current accomplishments than by 3], duodenal stimulation for type 2 diabetes [4],
a dramatic evolution. perirenal sympathetic nerve ablation for type 2
The 11 chapters written by prominent sur- diabetes [5], pancreas transplantation and islet
geons in our 1978 book talked of results and cell autotransplantation for type 2 diabetes [6,
7], carotid body procedures for hypertension
[8], deep brain stimulation for refractory depres-
H. Buchwald, MD, PhD sion [9], unilateral cervical vagal stimulation
Department of Surgery, University of Minnesota,
for refractory depression [10], central nervous
420 Delaware Street SE, MMC 290,
Minneapolis, MN 55455, USA stimulation for epilepsy [11], intrathecal implant-
e-mail: [email protected] able pump infusions for pain and spasticity [12],

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 69

Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_8,
© Springer International Publishing Switzerland 2015
70 H. Buchwald

implantable pump insulin infusion for type 2 out weight loss, in particular type 2 diabetes. This
diabetes [13], and the myriad of bariatric sur- chapter will, therefore, discuss the old and newly
gery procedures that have been introduced into proposed mechanisms of action for these proce-
the field since 1978 and are discussed in this dures, the specific neurologic networks and hor-
volume (for example laparoscopic adjustable mones involved, the energy metabolism of
gastric banding, sleeve gastrectomy, biliopan- obesity, the involvement of inflammation, and the
creatic diversion, duodenal switch, gastric plica- present and future outcomes for this acquired
tion), as well as the experimental approaches to knowledge.
bariatrics and type 2 diabetes management (e.g.,
direct hypothalamic stimulation or ablation [14],
truncal vagotomy [15], electronic gastric stimula- 8.1 Mechanisms of Action
tion [16], duodeno-jejunal bypass [17, 18], ileal
transposition [19–21], endoluminal sleeves [22]). Traditionally, the weight loss achieved by bariat-
All of these procedures, and more, are exam- ric surgery has been attributed to either a restric-
ples of metabolic surgery and in their entirety tion of food intake or malabsorption of
encompass this field. Let it be emphasized, there- unrestricted oral consumption. This simplistic
fore, that bariatric surgery has not transitioned approach, of course, ignores the minimal weight
into being metabolic surgery but that bariatric loss success achieved by electronic stimulation
surgery and its offshoots are all, and have always procedures [2, 3, 16] that employ no overt restric-
been, part of the discipline of metabolic surgery. tion of eating or of absorption. In the final analy-
Awareness of this concept by bariatric surgeons sis, at the level of caloric absorption from the
was greatly enhanced by the prescient work of intestinal tract, all the common bariatric surgery
Scopinaro and Pories, who about 20 years ago procedures are restrictive. This principle is illus-
showed normalization of blood glucose values trated in Fig. 8.1a of the steps in ostensibly
after biliopancreatic diversion [23] and gastric restrictive bariatric surgery and in Fig. 8.1b of the
bypass [24]. A 2004 meta-analysis clearly steps in ostensibly malabsorptive bariatric sur-
emphasized that bariatric operations were also gery. Caloric intake can be restricted by the inhi-
metabolic surgery by resolving or mitigating type bition of eating caused by a gastric balloon, a
2 diabetes, hyperlipidemia, and hypertension, gastric band, a sleeve gastrectomy, or a gastric
generally as a function of percentage excess bypass. Caloric intake can be equally restricted
weight loss (Table 8.1) [25]. by the insufficient intestinal absorptive surface
This volume is primarily concerned with the available in the so-called malabsorptive proce-
metabolic surgery procedures of bariatric sur- dures. Since the bariatric surgery operations,
gery, which, in turn, have given rise to metabolic even those with the ultrashort common channels
operations specifically designed to mitigate cer- of a biliopancreatic diversion or duodenal switch,
tain of the comorbidities of obesity, with or with- extremely rarely cause excessive weight loss,

Table 8.1 Summary findings Ref. [25]

Gastric Gastroplasty Gastric Biliopancreatic division/
banding (%) (%) bypass (%) duodenal switch (%) Total (%)
% excess weight loss −47.45 −68.17 −61.56 −70.12 −61.23
Resolution type 47.9 71.6 83.7 98.9 76.8
2 diabetes
Resolution 58.9 73.6 96.9 99.1 79.3
hyperlipidemia
Resolution 43.2 69.0 67.5 83.4 61.7
hypertension
Buchwald et al. [25]
8 Metabolic Surgery 71

a Unrestricted
Intake

Unrestricted
Absorption to Tmax

Restrictive Element
LAGB, RYGB, VBG, SG, GI

Restricted Intake

Absorption Limited
By Intake

Negative Caloric State for BMI Demand Activation

Neurohormonal Mechanisms
For Utilization Body Stores
Cannibalism of Body Fat and Lean Tissues

Activation
Weight Loss Neurohormonal Mechanisms
For Compensation and Preservation
New Weight Set Point Where Caloric Intake Body Stores
In Equilibrium With Demand

b Unrestricted
Intake

Unrestricted
Absorption to Tmax

Malabsorptive Element
RYGB, BD, DS

Unrestricted Intake

Limited Absorption

Negative Caloric State for BMI Demand Activation

Neurohormonal Mechanisms
For Utilization Body Stores
Cannibalism of Body Fat and Lean Tissues
Activation
Weight Loss Neurohormonal Mechanisms
For Compensation and Preservation
New Weight Set Point Where Caloric Intake Body Stores
In Equilibrium With Demand

Fig. 8.1 Traditional explanatory mechanisms for bariat- Roux-en-Y gastric bypass, VBG vertical banded gastro-
ric operations: (a) Restrictive, (b) malabsorptive. Key: plasty, SG sleeve gastrectomy, GI gastric imbrication,
LAGB laparoscopic adjustable gastric band, RYGB BPD biliopancreatic diversion, DS duodenal switch
72 H. Buchwald

there must be a brake effect in body metabolism enzymes, and inhibition of peristalsis [30];
not explainable by the old mechanisms of action afferent sympathetic fibers are traceable to cere-
concepts. Further, there are many nonobese, even bral pain receptors. Roux-en-Y gastric bypass,
lean, individuals who have undergone gastric or biliopancreatic diversion/duodenal switch, and
massive intestinal resections for various reasons certain of the other metabolic/bariatric proce-
and who subsequently maintained their body dures, can be expected to induce a sympathetic
weight. It is time, therefore, in order to under- neurologic response.
stand the changes we are eliciting by metabolic There is also an intrinsic nerve syncytium, pri-
bariatric surgery, that we acknowledge that we do marily in the submucosal layer of the intestinal
restrict the ability to eat and that we do restrict tract, extending from the esophagus to the anus
body caloric intake, but that we must look to [31] (Fig. 8.2). Surely, this network is altered by
more sophisticated explanations for the true many of the metabolic/bariatric operations, for
mechanisms of action of these procedures. We example, Roux-en-Y gastric bypass, biliopancre-
need to investigate the complex neurohormonal atic diversion/duodenal switch, and ileal transpo-
networks that control weight, certain weight- sition. The density of the submucosal neural
related diseases, and the disease of obesity itself. fibers has been demonstrated to be an indicator of
type 2 diabetes severity [32]. Finally, with respect
to the participation of intestinal neurogenic path-
8.1.1 Neural Networks ways in the mechanisms of action of the meta-
bolic/bariatric operations, there exists the high
There exists vigorous parasympathetic and sym- fundic gastric pacemaker [33], which is discon-
pathetic innervation to the intestinal tract. Old nected by a Roux-en-Y gastric bypass and bilio-
and extensive teaching of vagal nerve function pancreatic diversion, and totally extirpated by
concentrated on efferent stimulation of acid/ sleeve gastrectomy and duodenal switch.
pepsinogen secretion by the stomach, control
of bile production and gallbladder function, and
output of pancreatic exocrine enzymes [26, 27]. 8.1.2 Gut and Fat Derived
However, only 10–20 % of vagal fibers are effer- Hormones
ent; 80 % or more are afferent. We know that
these afferent connections go to the brain, pri- Complementing the neural network in influenc-
marily to the hypothalamus and medulla oblon- ing weight and obesity control mechanisms, as
gata [28]. These fibers are intimately associated well as intimately involved in the obesity comor-
with hypothalamic functional centers related to bidity of type 2 diabetes, are the gut and the
hunger, appetite (post-hunger satisfaction eat- fat derived hormones. Over the course of time,
ing behavior), and satiety [29]. Prosthetic gastric more and more individual intestinally and fat
volume restrictors, gastric imbrication, adjust- secreted hormones have and are being identified.
able gastric bands, Roux-en-Y gastric bypass, Currently, there are about 100 of these unique
biliopancreatic diversion/duodenal switch, and peptides and they each have one or several
simple sleeve gastrectomy, as well as the experi- functions [34]. Due to the concentrated efforts
mental procedures of gastric and vagal stimula- of dedicated investigators, the role and signifi-
tion, duodeno-jejunal bypass, and endoluminal cance of specific gut hormones in the respon-
sleeves, all influence vagal, in particular afferent sible mechanisms for the metabolic/bariatric
vagal, nerve function. procedures have been emphasized. Over time,
Sympathetic gut innervation is primarily the popularity of these individual hormones has
mediated via the celiac plexus. Efferent sympa- risen and fallen, and possibly risen again. The
thetic fibers are involved in glucose production true importance of each documented hormone
and release, inhibition of gastrointestinal in obesity and type 2 diabetes is as yet not pre-
8 Metabolic Surgery 73

Fig. 8.2 Vagal and sympathetic innervation of the stomach and intestine; intestinal wall nerve syncytium (Reprinted
from Netter [31], with permission from Elsevier)
74 H. Buchwald

cise. It is also likely that mechanisms of action decreasing appetite and promoting weight loss
are never dependent on a single hormone but [49–53]. PYY (3-36) also inhibits pentagastrine-
rather on a mosaic of hormonal interactions. It stimulated gastric acid secretion [54] and the
is, therefore, pertinent to review the actions and cephalic phase of pancreatic exocrine secretion
properties of certain of the better understood [55, 56].
hormones. Primary interest by metabolic/bar- Both GLP-1 and PYY are secreted in increas-
iatric surgeons on hormonal mechanisms has ing amounts as a function of the caloric content
focused on glucagon-like peptide-1 (GLP-1), of ingested food [57]. Other influencing factors
peptide YY (PYY), leptin, ghrelin, and glucose- include the intestinal site of stimulation [58–60],
dependent insulinotropic peptide (formerly gas- bile acids [61], central neural and vagal mecha-
tric inhibitory peptide) (GIP). nisms [62–64], and other hormones (vasoactive
GLP-1 and PYY are both elaborated by the intestinal peptide [65], gastrin [66]). Leptin forms
L-cells of the intestinal mucosa and seem to a triad with GLP-1 and PYY in weight regulating
work in concert, eliciting the same metabolic mechanisms, possibly providing for an autoregu-
responses or augmenting the actions of the other. latory feedback loop. Leptin stimulates GLP-1
Their gastrointestinal properties include the secretion and GLP-1 suppresses leptin levels [67].
reduction of hunger and an increase in the sensa- Leptin, a peptide hormone synthesized and
tion of satiety, resulting from stimulation of the released by adipocytes, has been implicated, by
arcuate nucleus of the hypothalamus [35–37]. its action on mediobasal hypothalamic recep-
They are also responsible for the “ileal brake” tors, in maintaining a body weight set point
effect of delayed gastric emptying, delayed [68–70]. When fat mass falls, plasma leptin lev-
mouth-to-cecum transit time, and decreased jeju- els fall as well, stimulating appetite and sup-
nal wave pressure [38–40]. Regarding pancreatic pressing energy expenditure; when fat mass
endocrine function, GLP-1 and PYY contribute increases, plasma leptin levels increase, sup-
significantly to the incretin effect, defined as the pressing appetite and increasing energy expen-
concentration of insulin release by oral glucose diture [71–73]. Thus, apart from its reciprocal
stimulation that exceeds the insulin concentra- autoregulation mechanism with GLP-1, leptin’s
tion elicited by the same amount of intravenous specific hypothalamic effect on suppressing eat-
glucose [41]. The influence of GLP-1 on pancre- ing is parallel to that of GLP-1. Leptin’s rela-
atic endocrine function is direct and appears to tionship to obesity, however, is far from clear
be more powerful than that of PYY. GLP-1 stim- cut. Much of the leptin physiologic data were
ulates glucose-dependent insulin secretion, pre- derived from rodent models and have not been
insulin gene expression, β-cell proliferation and equivalently substantiated in humans. Obese
antiapoptotic pathways, and inhibits glucagon individuals generally have a high, not low, cir-
release [42, 43]. It has been shown that GLP-1 culating concentration of leptin [73] and are
secretion is reduced in patients with type 2 dia- stated to be leptin-resistant [71]. It is apparent,
betes [44, 45], which may be responsible for the therefore, that the normal leptin feedback con-
hyperglycemia of this disease [46]. The PYY trol in obese humans is flawed.
effect on insulin secretion is indirect by inhibit- In addition to its action on the circulatory sys-
ing the action of gastrin-stimulating peptide and tem, lung surfactant activity, bone, reproduction,
gastrin-releasing peptide [47, 48]. and areas of the brain not involved in weight reg-
It is interesting that PYY exhibits two active ulation, leptin is an inflammatory marker
circulating forms: PYY (1-36) and PYY (3-36). responding specifically to adipose-derived cyto-
PYY (1-36) increases appetite and promotes kines [74–77]. Increases in leptin levels in
weight gain, and is not the PYY hormone that response to overeating may, therefore, play a role
interests metabolic/bariatric surgeons. PYY in inflammation-related diseases, including not
(3-36) is the form cited in metabolic mechanisms only obesity but diabetes, hypertension, and
literature and is responsible for centrally cardiovascular disease.
8 Metabolic Surgery 75

Ghrelin is a peptide hormone produced by P/ 8.2 Energy Metabolism

D1 cells in the fundus of the stomach and the of Obesity
episilon cells of the pancreas [78]. There are ghre-
lin receptors in the pituitary, stomach, intestine, Having defined metabolic surgery, we should
pancreas, thymus, gonads, and heart [79]. Some now more closely examine the energy metabo-
of ghrelin’s actions may be due to its potent stim- lism of obesity, the primary working domain of
ulation of growth hormone secretion from the metabolic/bariatric surgery. Past knowledge of
anterior pituitary [80]. Most interestingly, ghrelin obesity causation and mechanisms of action
selectively reduces mechanosensitivity of upper focused on genetics and energy balance [94, 95].
gastrointestinal vagal afferents [81]. Ghrelin’s The genetics of obesity is not truly a subject to be
actions are in opposition to those of leptin: it covered under metabolic surgery or metabolics;
increases hunger and eating [82, 83]. Circulating however, energy balance is appropriately consid-
ghrelin levels are the highest before a meal and at ered under metabolic mechanisms.
their lowest thereafter [84]. Intravenously admin- Total body metabolic processes in kinetic
istered ghrelin increases food intake in a dose- terms can be defined as total energy expenditure
dependent manner [85]. However, plasma ghrelin (TEE), which is equal to the basal metabolic rate
levels in the obese are lower than in lean individ- (BMR), the energy of activity expenditure, the
uals [86], suggesting that ghrelin does not con- thermal effect of food (TEF), and adaptive ther-
tribute to obesity. An exception is Prader–Willi mogenesis (AT). The BMR is the lowest level of
Syndrome where ghrelin levels are high [87, 88]. energy needed to maintain life (e.g., autonomic
Ghrelin appears to be an anti-inflammatory hor- cardiorespiratory functions). The TEF is the body
mone in opposition to the cytokine properties of heat produced and the AT is the fluctuation in
leptin [89, 90]. TEF produced by environmental temperature and
GIP, secreted by the K-cells of the duode- humidity [95]. The homeostatic responses to
num, along with GLP-1, is an incretin hormone increased food intake in normal individuals
[91]. In the past, it was believed that GIP neu- essentially is an attempt to resist weight gain;
tralized and inhibited stomach acid, decreased whereas, in obese individuals these mechanisms
gastric transit time, and retarded intestinal motil- appear to be blunted resulting in a decrease in the
ity; however, recent information attributes these TEF and a subsequent decrease in the TEE [96].
actions to secretin and not to physiologic levels The nature of energy metabolism after meta-
of GIP. Thus, GIP is really not a gastric inhibi- bolic/bariatric surgery has not been extensively
tory hormone. It is now believed that the primary studied and is not well understood. The preopera-
function of GIP is to induce insulin secretion via tive TEE of patients undergoing gastric bypass
glucose hyperosmolarity in the duodenum [92]. can vary from normal to hypermetabolic. In the
Hence, a name change to glucose-dependent former, there appears to be no change postopera-
insulinotropic peptide, allowing for retention tively; in the latter, normalization of TEE seems
of the acronym “GIP.” Type 2 diabetics are not to occur postoperatively [97]. Further, preserva-
responsive to GIP administration and have lower tion of energy economy is reciprocal to the degree
postprandial levels of GIP secretion compared to of weight loss [98]. After gastric bypass, both
nondiabetics [93]. TEE and resting energy expenditure are decreased
As our knowledge base evolves, other hor- by about 25 % [99].
mones will arouse interest and controversy with
respect to their effects on normal body weight,
obesity, type 2 diabetes, and other comorbidities 8.3 Inflammation
of obesity. At present, attention is being paid to
pancreatic polypeptide, cholecystokinin, oxynto- Currently, underlying causative mechanisms for
modulin, and adipose-derived adiponectin and obesity and type 2 diabetes are often focused on
resistin. the state of inflammation. An increase in energy
76 H. Buchwald

(caloric) intake over energy expenditure leads to bidities. Metabolic/bariatric surgery today
an increase in the size of the adipocytes. Once the resolves upwards of 75 % of morbid obesity
adipocyte volume exceeds 1 μl of lipid, the num- and super obesity, and does likewise for the
ber of fat cells increases. The ensuing leptin obesity comorbidities. Our surgical tools, in
response in non-obese individuals reduces hun- contrast to unifocal pharmaceuticals, are more
ger and downregulates caloric intake. In the complex and multifaceted in what they engen-
obese, with a blunted leptin response [71], the der in the neurohormonal mechanisms of the
unchecked caloric load overtaxes the adipocytes’ diseases of the metabolic syndrome. We are,
ability to grow larger or increase in number however, learning to unravel the consequences
resulting in a state of inflammation at the cellular of our operations, what metabolic param-
level and ectopic fat storage in internal organs, eters they influence, and what hormonal and
including the liver and muscle [76]. In addition, inflammatory processes they alter. With this
the consumption of high volumes of fructose, knowledge, we can eventually not only learn
absent in our ancestral diets, has been suggested how our current procedures actually work but
to cause leptin resistance and elevated triglycer- how to modify them and plan future proce-
ides, which result in weight gain [72, 100, 101] dures based on sound insights and experimen-
and a state of generalized inflammation. tal data. In addition, our gained understanding
The inflammation rationale carries over to may allow us to help in the development of
obesity-induced type 2 diabetes. The increased nonsurgical therapies. Over 200,000 new
fat cell mass results in an increase in free fatty patients receive metabolic/bariatric operations
acids, which, in turn, reduce glucose utilization annually. These individuals need to become
by the liver and peripheral tissues, thereby our co-investigators in human basic science
reducing insulin clearance by the liver and research. We must view metabolic surgery not
increasing insulin delivery to the periphery, as a compilation of operations but as a means
resulting in peripheral insulin resistance. to unravel the etiology of obesity and, in par-
Adipocyte-secreted cytokines contribute to the ticular, its comorbidity type 2 diabetes. In the
inflammatory state as well. The reactive oxygen final analysis, metabolic surgery is cognitive
species engendered by the inflammatory process surgery.
are then responsible for endothelial damage,
impaired beta cell function and, in general, play
a cardinal role in the long-term complications of References
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 Diabetes Surgery
9
Francesco Rubino

9.1 Introduction role [3–9]. These physiologic mechanisms pro-

vide a rational target for the design of new surgi-
Bariatric surgery was originally designed to cal techniques, gastrointestinal devices and for
induce weight-reduction in morbidly obese novel pharmaceuticals.
patients. Benefits of bariatric surgery, however, The broad implications for the care of diabetes
extend well beyond weight loss and include dra- and the fascinating mechanisms of action of bar-
matic improvement of type 2 diabetes, hyperten- iatric surgery have attracted the interest of physi-
sion, dyslipidaemia and reduction of overall cians, scientists and policy makers. This has
mortality. Studies in rodents and humans have transformed, over the past decade, an underap-
shown that the anti-diabetes effects of certain bar- preciated surgical specialty, practised by only a
iatric procedures are not just secondary to weight few, dedicated and passionate surgeons into one
loss and result from a variety of neuroendocrine of the fastest growing areas of twenty-first-
and metabolic mechanisms, which are direct con- century medicine.
sequence of changes in gastrointestinal (GI) anat- As a result of an intense, multidisciplinary
omy [1]. This knowledge provides a rationale for research effort over the past 10-years, a substan-
the use of gastrointestinal surgery as both, a treat- tial body of level-1 evidence has now accumu-
ment of type 2 diabetes and a tool to elucidate the lated showing that surgical treatment of type 2
elusive pathophysiology of this disease [2]. diabetes controls hyperglycaemia and improves
The exact molecular mechanism of action of quality of life more than lifestyle modifications
surgery on diabetes remains unknown, but and available drugs [10–13]. Several professional
changes in intestinal glucose metabolism, gut organizations already recommend consideration
hormones, bile acids (BAs), microbiota and of surgery in the management of obese type 2
nutrient sensing have been suggested to play a diabetes [14], and it is plausible that a surgical or
interventional approach to this disease will
become increasingly popular in the years to
F. Rubino, MD
come.
Bariatric and Metabolic Surgery,
The James Black Centre, King’s College London, The implementation of a surgical approach to
Denmark Hill Campus, 125 Coldharbour Lane, type 2 diabetes, however, poses numerous
London SE5 9NU, UK challenges. Consistent with the goals of improv-
King’s College Hospital, London, UK ing glycaemic and metabolic control, not merely
Catholic University of Rome, Rome, Italy weight loss, a surgical approach to type 2 diabetes
e-mail: [email protected] requires the development of a new model of care

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 81

Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_9,
© Springer International Publishing Switzerland 2015
82 F. Rubino

distinct from traditional bariatric surgery. Surgical and biliopancreatic diversion [19–24]. Elegant
treatment of T2DM in fact cannot be based on the reports by Pories and colleagues in the early
weight-centric model of bariatric surgery and 1990s provided detailed descriptions of the clini-
requires disease-based criteria for surgical indica- cal remission of hyperglycaemia after gastric
tion, diagnostics and outcome measures. The shift bypass surgery [22, 23], emphasizing both the
in the primary aim of treatment, from obesity to magnitude and the rapidity of this effect.
type 2 diabetes, also has ramifications for the defi- Scopinaro and co-workers reported resolution of
nition of research priorities and for health care hyperglycaemia and discontinuation of diabetes
policies. For all the aforementioned reasons, “dia- medication in over 90 % of diabetic patients
betes surgery” needs to be considered as a new undergoing biliopancreatic diversion [24].
surgical discipline, contiguous but distinct from Although clinical observations of post-surgery
traditional bariatric surgery [15]. remission of hyperglycaemia were consistently
Despite the challenges ahead, diabetes surgery reported for more than half a century, such
has the potential to revolutionize diabetes care at remarkable phenomenon remained substantially
large and change the way we look at this disease. unknown to the rest of the scientific community.
This chapter presents an overview of this new Even after the advent of electronic consultation
discipline, from historical aspects to future of medical literature, diabetes experts were
directions. largely unaware that a surgical operation on the
alimentary tract could exert such a profound
effect on the disease.
9.2 History of Diabetes Surgery: Many factors have likely acted as a barrier for
From Heretical Suggestion the dissemination of this knowledge and for the
to Accepted Treatment consideration of surgery as a diabetes treatment.
Option First, segmentation of medical specialties and
lack of interdisciplinary communication, an
In 1925, a case report in The Lancet documented increasing phenomenon in twentieth-century
rapid resolution of diabetes as a serendipitous medicine, may have played a role. Also, the
observation in a patient with peptic ulcer days observation of resolution of hyperglycaemia
after gastrectomy and gastrojejunostomy [16]. challenged the traditional teaching that diabetes
The author asked: “what can we account for the is an invariably chronic and progressive disease
apparent improvement (of diabetes)? The glycos- and things that cannot be explained are often
uria was absent after the operation in spite of a looked with skepticism in medicine. On the other
diet containing a fair amount of carbohydrate”. hand, the prevailing view that obesity leads to
Several other clinical observations of dramatic diabetes and that weight loss improves hypergly-
improvement of diabetes after partial or total gas- caemia provided a straightforward explanation
trectomies were reported throughout the first half for the effect of bariatric surgery in morbidly
of the twentieth century [17, 18]. With the advent obese patients; in this context, the improvement
of bariatric surgery for morbid obesity in the late of diabetes after gastrointestinal surgery could
1950s, similar modifications of GI anatomy not be seen as an incongruous observation to
started to be performed in subjects with morbid inspire new hypothesis. Furthermore, as an
obesity, a population with high prevalence of implicitly organ-focused intervention, surgery
type 2 diabetes; as a result, reports of surgically could not be seen as a rational solution for a sys-
induced control of type 2 diabetes became temic disease such as diabetes. Perhaps most
increasingly common [19, 20]. Dramatic importantly, for most of the twentieth-century,
improvements or even resolution of diabetes the gastrointestinal tract was regarded as merely
symptoms were observed with almost all types of a tube for digestion and absorption of nutrients;
bariatric operations, including vertical banded this means that the surgical control of diabetes by
gastroplasty, jejuno-ileal bypass, gastric bypass gastrointestinal surgery could only be interpreted
9 Diabetes Surgery 83

as an indirect result of restriction of energy published in the Annals of Surgery in 2002 [2],
intake. we presented data from the medical literature
My personal interest for the subject started in documenting efficacy of gastrointestinal surgery,
July 1999. I was spending an afternoon in the particularly gastric bypass and biliopancreatic
library of Mount Sinai Medical Center in diversion, in both obese and non-obese diabetic
New York researching on matters of surgical subjects. Accordingly, we suggested that GI sur-
anatomy and technique to see if it was possible to gery could be a legitimate intervention to inten-
simplify some procedures and facilitate a laparo- tionally treat diabetes (“diabetes surgery”) and
scopic approach. Accidentally, I came across a that the GI tract could be an ideal target for inter-
table in a paper that summarized results of ventions of curative intent [2].
1-month postoperative laboratory tests after bil- Unable to test the hypothesis in humans, I
iopancreatic diversion. The vast majority of turned to animal experiments to investigate
patients had normal plasma glucose levels despite whether a rearrangement of gastrointestinal anat-
many of them were reported to be diabetic prior omy could per se improve diabetes. Experiments
to surgery. Although metabolic outcomes were using a modified version of human gastric bypass
not the scope of my research, I was puzzled by (duodenal-jejunal bypass – DJB) in Goto-
the idea that patients with diabetes could have Kakizaki rats, a non-obese model of type 2 diabe-
normal glucose levels without using glucose- tes provided the first experimental evidence that
lowering drugs: how could such a radical and gastrointestinal surgery can directly improve type
rapid effect be explained by weight loss alone? 2 diabetes by weight-independent mechanisms
Given the role of the GI tract in the regulation of [1]. Clinical case-reports and case-series showing
glucose insulin secretion through the so-called improvement of diabetes by a variety of gastroin-
entero-pancreatic axis, I hypothesized that the testinal operations in non-obese individuals
anti-diabetic effect of bariatric surgery may result provided further support for the weight-indepen-
from neuroendocrine and/or metabolic mecha- dent effects of surgery [25, 26].
nisms secondary to the anatomic rearrangement The idea of diabetes surgery gained accep-
of GI anatomy. I thought that if this were true, tance particularly after a landmark 2007 interna-
there would be two important implications: first, tional consensus conference in Rome (the
gastrointestinal surgery could be used to inten- “Diabetes Surgery Summit” [DSS]), where a
tionally treat diabetes (“diabetes surgery”), not group of leading international scholars discussed
only in the morbidly obese. Second, the gastroin- available evidence and recommended, for the
testinal tract could represent a valuable target for first time, consideration of gastrointestinal sur-
other forms of intervention and possibly even gery for type 2 diabetes including in selected
harbour mechanisms of disease in diabetes [2]. patients with moderate obesity (BMI 30–35)
With the visionary support of my mentor at [27]. After the Rome’s DSS, the concept of “met-
the time, Dr. Michel Gagner, we submitted a pro- abolic surgery” has rapidly emerged to more
tocol for a randomized clinical trial (RCT) com- broadly indicate a surgical approach aimed at
paring Roux-en-Y gastric bypass versus medical treating diabetes and obesity. The DSS also
therapy for patients with BMI <35 kg/m2. Perhaps encouraged further clinical and mechanistic
ahead of its time, this protocol did not receive the research in metabolic surgery and was instrumen-
approval of the Institutional IRB. Frustrated, but tal in attracting physicians, as well as clinical and
conscious that offering a surgical approach to basic scientists to this emerging discipline. This
diabetes for non-morbidly obese patients was, in has contributed to raising standards of research
fact, “unthinkable” for the knowledge of the time, and practice and to a phenomenal growth in
and indeed also concerning for a number of rea- knowledge that has perhaps no parallel in any
sonable objections, we decided to share the idea other field of surgery.
with other researchers and to pursue other forms Over the past few years, research by several
of investigation. In a review/hypothesis paper independent investigators has corroborated the
84 F. Rubino

finding that gastrointestinal surgery can directly 9.3 Mechanisms of Action

improve diabetes [28–30] suggesting that a of Gastrointestinal
variety of GI mechanisms, including changes in Operations on Glucose
gut hormones, bile acids, gut microbiota, Metabolism: The Physiologic
duodenal-jejunal nutrient sensing and intestinal Rational for Diabetes Surgery
glucose uptake can play a role in the control of
diabetes and obesity by gastrointestinal surgery 9.3.1 Effects of Surgery
[3–9]. Furthermore, there has also been a sub- on Pathophysiologic Aspects
stantial improvement of the quality and level of of Type 2 Diabetes
clinical evidence in this field. At the time of this
writing, there are at least eight reports in the Examining the mechanisms by which surgery
literature from randomized clinical trials, all can improve diabetes may help understand the
consistently showing that bariatric procedures physiology and pathophysiology of diabetes and
can improve diabetes more than drugs and life- inform the choice of surgical procedure for the
style interventions at least 1- to 3-years after treatment of T2DM as well as the design of new
surgery [10–13, 31–34]. A number of well-con- operations, devices and pharmaceutical thera-
ducted case-control studies have also docu- pies. The pathophysiology of T2DM is character-
mented that surgery can reduce cardiovascular ized by a combination of insulin resistance and
disease (CVD) and death associated with diabe- inadequate insulin secretion; treatments of cura-
tes [35–37]. tive intent would need to address both defects.
This growing body of evidence has led several Gastrointestinal (GI) bypass procedures can
professional organizations to recognize the role improve both insulin sensitivity and insulin pro-
of surgery in diabetes. In 2009, the American duction [39–42] suggesting that interventions on
Diabetes Association introduced surgery for the the GI tract represent a rational and physiologic
first time in its “Standards of Medical Care for approach for diabetes treatment [43]. In particu-
Diabetes” [38]. In 2011, a landmark position lar, Roux-en-Y gastric bypass (RYGB) restores
statement by the interventional Diabetes first-phase insulin response and results in hyper
Federation [14], an umbrella organization repre- secretion of C-peptide and insulin following
senting over 200 national diabetes societies, rec- nutrient ingestion suggesting enhancement of
ommended that surgical treatment be considered beta-cell function [40–43]. Increased beta-cell
in the management algorithm of diabetes care mass has also been hypothesized following
and emphasized the need to go beyond weight- reports of nesidioblastosis complicating RYGB
centric criteria for surgical indication. Many sur- [44], observations of increased PDX1 levels [45]
gical organizations (i.e. ASMBS, IFSO) and and prevention of beta-cell loss after experimen-
diabetes organizations (IDF) today recommend tal duodenal-jejunal bypass in rodents [46], and
that surgery be considered for patients with type increased beta-cell mass after RYGB in pigs [47].
2 diabetes that is difficult to control by medical
therapies or when associated with conditions that
increase risks of cardiovascular disease. In 2014, 9.3.2 Role of Gut Hormones
the question is no longer if surgery should be
considered a diabetes treatment but when it 9.3.2.1 Ghrelin
should be offered and who are the patients for Ghrelin is a hormone chiefly synthesized by the
whom access to this form of treatment should be gastric antrum and fundus and involved in regula-
prioritized. tion of both hunger and glucose homeostasis
Clearly, in little more than a decade, diabetes [48]. With sleeve gastrectomy (SG), RYGB and
surgery has progressed from a sort of heretical BPD-duodenal switch (which includes a SG),
suggestion to an accepted treatment option in ghrelin-synthesizing cells of the gastric fundus
selected patients. are either resected or excluded from nutrient
9 Diabetes Surgery 85

contact, whereas the fundus remains intact after nutrients to the distal bowel due the anatomic
traditional BPD (Scopinaro’s procedure) and lap- shortcut imposed by gastrointestinal bypass pro-
aroscopic adjustable gastric banding (LAGB). cedures may enhance secretion of GLP-1 by local
Ghrelin levels decrease maximally after SG. After L-cells [65]. The hindgut hypothesis is often pre-
RYGB and BPD, ghrelin levels tend to decrease sented as alternative to the “foregut” or “proxi-
but the changes are not as consistent as after SG mal” bowel hypothesis, which postulates that the
[49–52]. In contrast with the effects of other exclusion of the duodenum and proximal jeju-
operations, ghrelin levels are most commonly num may prevent secretion of a putative signal
increased after LAGB [53–56]. that promotes insulin resistance and type 2 diabe-
tes [2, 3]. It is likely that the two mechanisms
9.3.2.2 PYY (enhancement of distal bowel physiology and
PYY is a 36-amino acid compound released from reduction of proximal signals from the excluded
L-type endocrine cells in the lower intestine. It bowel) are not mutually exclusive.
exists in two forms: PYY1–36 (total) and PYY3– The “hindgut hypothesis”, however, has been
36 (active), with the latter being the most com- recently called into question by a number of
mon circulating form [22]. PYY acts on the observations. First, the hypothesis would not
arcuate nucleus inhibiting appetite and promot- explain why similar changes in postprandial
ing weight loss [57]. Physiologically, PYY levels GLP-1 response occur after sleeve gastrectomy
increase immediately after meals – a response without shortcut for nutrients. Recent experi-
that is blunted in obese patients. Following diver- ments in rodents show, in fact, that isolated duo-
sionary procedures (i.e. RYGB, BPD) and to denal bypass without gastric restriction/resection
some extent after sleeve gastrectomy, postpran- (DJB) does not cause the same postprandial
dial PYY response is increased, possibly contrib- increase of GLP-1 seen after RYGB or sleeve
uting to early satiety and overall restriction of gastrectomy, suggesting that changes in GLP-1
food intake [58–60]. observed after the latter operations may be related
to disruption of the physiologic gastric phase of
9.3.2.3 Glucagon-Like Peptide 1 (GLP1) nutrient passage rather than to the bypass of the
GLP1 is an incretin hormone released together small bowel [66]. Furthermore, evidence from
with GLP 2, oxyntomodulin and PYY from intes- both human and animal studies show that block-
tinal L-cells, which are more common in the age of GLP-1 action only modestly reduces the
ileum and colon. GLP-1 potentiates glucose- effect of surgery on glucose tolerance and diabe-
stimulated insulin secretion, inhibits glucagon tes control. In fact, the effect of RYGB on glu-
release and suppresses gastric emptying (“ileal cose metabolism is not substantially reduced in
brake”) [61]. Following gastrointestinal bypass genetic mice models with attenuated GLP-1
procedures and sleeve gastrectomy, a postpran- secretion, in GLP-1-receptor deficient mice and
dial rise in GLP1 is observed almost immediately after administration of GLP-1-receptor antago-
after surgery and this effect is sustained over time nist exendin-9,39 in human subjects [67, 68].
[62, 63] whereas no changes in plasma GLP-1 Altogether, these findings question the hindgut
are seen after LAGB [64]. Given the role of hypothesis as the primary mechanism for the
GLP-1 in the control of insulin secretion as well improvement of diabetes after surgery.
as gastric emptying and energy intake, the
changes in GLP-1 response could plausibly play 9.3.2.4 Leptin
a role both in weight-reduction and improvement Leptin is primarily an adipocyte-derived hor-
of hyperglycaemia after RYGB and SG. mone, but is also produced by the stomach.
The exact mechanism that causes such a Circulating leptin levels contribute to the regula-
change in GLP1 concentrations is unclear. Two tion of appetite and energy homeostasis. The role
hypotheses have been suggested. The hindgut of gastric leptin, however, has remained unclear.
hypothesis”, holds that a faster presentation of A recent study in rodents suggests that
86 F. Rubino

endoluminal leptin could activate a neuroendo- after surgery [73] In an interesting animal study
crine response through the jejunal leptin recep- by Kaplan and colleagues [5], RYGB led to a
tor – PI3K to lower glucose levels. In fact, rapid and sustained increase in the relative abun-
enhanced activation of this jejunal leptin signal- dance of certain microbes (Escherichia and
ing was found to play a role in the rapid antidia- Akkermansia) throughout the GI tract, indepen-
betic effect of DJB [69]. dent of weight loss and calorie restriction.
Transfer of these organisms into non-operated
germ-free mice led to a decrease in weight and
9.3.3 Role of Bile Acids (BAs) body fat mass. Altogether, these findings demon-
strate that gastrointestinal surgery can dramatic
The role of BAs in physiology is not limited to alter the composition of intestinal microbiota,
their contribution to digestion/absorption of which may play a role in the improvement of
nutrients. In fact, BAs have also hormonal activ- metabolism.
ity; through the interaction with specific recep-
tors, they contribute to the regulation of various
metabolic pathways. BAs act through FXR 9.3.5 Role of Changes in Intestinal
receptors, which in turn regulate lipid and glu- Glucose Metabolism
cose metabolism [70]. Through these receptors in and Nutrient Sensing
brown adipose tissue, BAs can also attenuate
diet-induced obesity [71]. BAs can also activate Lipid and glucose sensing in the jejunum can
the G protein-coupled receptor TGR5, through activate a gut–brain–liver response that reduces
which they can influence insulin sensitivity. hepatic glucose production, thus exerting a
TGR5 receptors are also present in the L-cells of glucose-lowering effect. This mechanism does
the distal bowel. not require insulin and is enhanced after DJB [6].
Procedures involving exclusion of the proxi- Enhanced nutrient sensing appears to play a role
mal bowel alter the physiologic mix of bile and in the rapid improvement of hyperglycaemia in
nutrients, leading to presentation of undiluted bile insulin-deficient rodent models after DJB [6].
acids to the distal intestine. This may result in an A recent study in rodents has also implicated
increase of circulating levels of BAs and also re-programming of intestinal glucose metabo-
stimulate local L-cells via TGR5, possibly con- lism in the glucose-lowering effects of RYGB. In
tributing to enhanced GLP-1 response. Serum bile particular, increased glucose metabolism is
acid (BA) levels increase following RYGB. An observed in the Roux-limb of rodents undergoing
increase in bile acid levels, however, is also seen RYGB [7].
after sleeve gastrectomy and recent experiments
implicate bile acid–FXR signaling in the improve-
ment of glucose homeostasis after SG [72]. 9.3.6 Surgical Anatomy and Anti-
diabetes Effect

9.3.4 Role of Intestinal Flora While all procedures result in variable degree of
(Microbiota) improvement of T2DM, meta-analysis of obser-
vational studies and results of randomized clini-
The intestinal flora contributes to carbohydrate cal trials suggest that procedures involving
metabolism and energy production. Obese sub- intestinal rerouting, like BPD and RYGB, have
jects have different gut flora compared to lean the greatest effect on diabetes [34, 74] and that
subjects. In particular, Firmicutes to Bacteroidetes longer intestinal bypass (such as in BPD) is asso-
ratio is elevated in the obese subjects. Following ciated with greater rates of remission of hyper-
gastric bypass, the Firmicutes group decrease glycaemia [11]. Studies in rodents [66] also show
while Bacteroides increase at 3 and 6 months that while both gastric and intestinal mechanisms
9 Diabetes Surgery 87

may contribute to improved glucose tolerance, protein extracts from the duodenum and/or jeju-
intestinal mechanisms seem to play a major role num of diabetic rodents and humans induced
in the improvement of glucose tolerance. insulin resistance in cell-based assays and in nor-
mal rats [75]. This observation supports the
hypothesis that the proximal small bowel of sub-
9.3.7 The Anti-incretin Theory jects with type 2 diabetes may produce diabeto-
genic factor(s), consistent with one of the
This theory [2, 43] provides a coherent theoreti- predictions made by the anti-incretin theory.
cal model that could explain observations of
physiologic response to nutrient ingestion as well
as effects of gastrointestinal bypass surgery. 9.4 Current Clinical Evidence:
According to the anti-incretin theory, nutrient The Clinical Rational
passage through the GI-tract physiologically acti- for Diabetes Surgery
vates negative feedback mechanisms (anti-
incretins) to balance the short- and long-term 9.4.1 Durability of Glycaemic
effects of incretins (GLP-1, GIP) thus preventing Control After GI Surgery
postprandial hyperinsulinaemic hypoglycaemia
and proliferative disorders of the beta-cell. An Long-term control of glycaemia and normal lev-
excess of anti-incretin signals, possibly stimu- els of glycosylated haemoglobin have been
lated by specific macronutrient composition of observed in obese diabetic patients for up to 15
modern diet or chemical additives, could cause years follow-up. According to a meta-analysis
insulin resistance, reduced insulin secretion and involving 22,094 patients with T2DM, procedure-
β-cell depletion, leading to T2DM. Conversely, specific rates of disease remission (defined as
reduction of nutrient stimuli on the gut through persistent normoglycaemia without diabetes
the exclusion of large portions of the upper small medications) were 48 % for LAGB, 68 % for
bowel from nutrient transit (i.e. RYGB, duodenal- VBG, 84 % for RYGB and 98 % for BPD [76].
jejunal bypass, biliopancreatic diversion) could However, most of the studies involved in this
reduce excess anti-incretin and restore appropri- meta-analysis were retrospective in nature and
ate incretins/anti-incretins balance, thus explain- with relatively short-follow-up (1- to 3-year). A
ing improvement and remission of T2DM large multicenter, prospective observational
(“foregut hypothesis” or “proximal intestine study – the Swedish Obese Subjects (SOS)
hypothesis”) [43]. study – [77] compared bariatric surgery (LAGB
The anti-incretin theory may explain the supe- n = 156, VBG n = 451, RYGB n = 34) versus a
rior control of diabetes by diversionary proce- control group of well-matched obese patients
dures but also the efficacy of procedures that do managed conservatively. At 2 years, 72 % of dia-
not include duodenal exclusion such as, for betic subjects in the surgical group achieved
instance, sleeve gastrectomy. In fact, any reduc- remission of T2DM compared to 21 % in the
tion of food stimulation on the proximal gastroin- medically treated arm. A recently published fol-
testinal tract, whether due to diet, mechanical low-up analysis from this study looking at gly-
gastric restriction (banding), anatomical exclu- caemic control 15 years after surgery shows that
sion (i.e. RYGB, BPD, DJB) or accelerated tran- remission was sustained in the majority of
sit (i.e. sleeve gastrectomy) may reduce patients who had short duration of diabetes
production of anti-incretin (diabetogenic) signals (<3 years) and substantially declined in those
thereby improving glucose homeostasis. with longer duration of disease at baseline [77]. It
The anti-incretin theory needs further experi- must be noted, however, that approximately 95 %
mental verification; however, a number of recent of patients in the SOS study underwent gastric
studies provide preliminary, supporting evidence. restrictive procedures rather than potentially
For instance, in a study by Salinari and co-workers, more effective procedures such as RYGB or BPD.
88 F. Rubino

Laparoscopic sleeve gastrectomy (LSG) has of either RYGB or sleeve gastrectomy (LSG) in
gained considerable popularity in recent years, 150 patients with BMI 27–43 kg/m2. The propor-
owing to a relatively easy surgical procedure and tion of patients who reached the primary end
a remarkable efficacy in inducing both weight point was 12 % in the medical-therapy group ver-
loss and control of co-morbid disease. A system- sus 42 % in the gastric-bypass group and 37 % in
atic review by Gill et al. of 27 studies involving the sleeve-gastrectomy group. Significantly, all
673 patients (mean follow-up 13.1 months) who patients in the RYGB group who achieved the
underwent sleeve gastrectomy has reported a primary end point did so without any medication
overall T2DM resolution rate of 66.2 % in obese whereas patients in the sleeve-gastrectomy group
subjects and improved glycaemic control in required the use of one or more glucose-lowering
26.9 % [78]. A study specifically looking at drugs. A recent update of the STAMPEDE trial
5-year durability of glycaemic control in diabetic with 3-year follow-up data confirmed better gly-
patients undergoing bariatric surgery showed an caemic control and quality of life after surgery
overall recurrence of T2DM after initial remis- versus medical therapy and a greater reduction of
sion in 19 % and that recurrence was associated diabetes medication usage after RYGB than after
with longer duration of T2DM [79]. Analysis by sleeve gastrectomy [34]. In the last 2 years, four
procedures showed that RYGB resulted in more other RCTs were published comparing RYGB
durable glycaemic control compared to either SG [13], LAGB or both [31–33] versus medical ther-
or LAGB [79]. apy and lifestyle interventions. Consisting with
previous trials, surgical treatment by any of these
interventions resulted in better control of glycae-
9.4.2 Surgery Versus Medical mia and reduction of CV risk factors [13].
Therapy and Lifestyle
Intervention
9.4.3 Surgical Control of Diabetes
The efficacy of surgical vs medical treatment of in Patients with BMI
T2DM in morbidly obese patients has been com- <35 kg/m2
pared in several randomized controlled trials. In a
study by Mingrone et al. [11] 60 patients aged While the benefits of metabolic surgery in mor-
30–60 years, with duration of diabetes ≥5 years bidly obese patients are clearly established, there
and a HbA1c level of 7.0 % or more were ran- is now increasing evidence for similar, salutary
domly assigned to receive conventional medical effects of gastrointestinal surgery on type 2 dia-
therapy or undergo either gastric bypass or bilio- betes in patients with BMI <35 kg/m2 using both
pancreatic diversion. The primary end point of traditional bariatric operations and novel GI pro-
the study was the rate of diabetes remission at 2 cedures. Cohen and co-workers first used DJB to
years (defined as a fasting glucose level of treat diabetes in low BMI patients with favour-
<100 mg/dL [5.6 mmol/L] and a HbA1c level of able short-term results [25]. De Paula et al. [80]
<6.5 % in the absence of pharmacologic therapy). have reported remission of diabetes in 65.2 % of
Diabetes remission occurred in no patients in the patients with BMI 21–29 following laparoscopic
medical-therapy group versus 75 % in the gastric- ileal interposition associated to a duodenal
bypass group and 95 % in the biliopancreatic- bypass and sleeve gastrectomy. The long-term
diversion group. A similar randomized clinical metabolic sequelae and safety of these novel pro-
trial by Schauer et al. [12] (STAMPEDE Trial) cedures, however, remains to be evaluated and
used glycated haemoglobin level of 6.0 % or less therefore they should still be considered experi-
(with or without diabetes medications) a 12 mental in humans.
months after randomization as primary end point The effect of traditional bariatric procedures
and compared intensive medical therapy and life- in low-BMI patients has also been investigated in
style modification vs surgical therapy by means recent years.
9 Diabetes Surgery 89

Scopinaro and co-workers [81] reported on achieved T2DM remission (defined as FBG
the effects of BPD on Type 2 DM in 30 patients <126 mg/dL and HbA1c <6.2 % on no diabetes
(12 of whom on insulin preoperatively) with BMI medications), in contrast to only 13 % of the
25–35 kg/m2. BMI progressively decreased, sta- conventional-therapy group. In this study, remis-
bilizing around 25 since the fourth month postop- sion of diabetes was predicted predominantly by
eratively. One year after BPD, mean HbA1c was greater weight loss in surgical patients at 2 years
6.3 % ±0.8, with 25 patients (83 %) controlled (20.7 vs. 1.7 %). A recent RCT from Australia
(HbA1c ≤7 %) on free diet, without antidiabetic also documented better diabetes control after
drugs, and the remaining showing improved gly- LAGB than medical/lifestyle therapy in patients
caemic control. with BMI <30 kg/m2.
Lee et al. [82] reported on the effect of loop Lee et al. [82] randomized 60 patients (BMI
gastric bypass, (“mini” – gastric bypass), for 25–35 kg/m2, mean HbA1c level-10 %) to either
T2DM in a prospective study involving 44 RYGB or LSG; the remission rate for T2DM
patients with BMI <35 kg/m2 (range 28.3– (defined as fasting plasma glucose levels less
33.7 kg/m2) versus 166 patients with BMI >35 kg/ than 126 mg/dL in addition to HbA1c values less
m2 (4 years follow-up). In this study, 77 % of than 6.5 % without the use of oral hypoglycae-
patients with BMI <35 kg/m2 and 92 % of those mics or insulin) was 93 % for patients who under-
with BMI >35 kg/m2 achieved the American went RYGB compared to 47 % for those who
Diabetes Association target goals of HbA1C underwent sleeve gastrectomy. The STAMPEDE
<7.0 %, LDL <100 mg/dL and triglycerides trial, compared advanced medical therapy and
<150 mg/dL. surgical therapy (RYGB or LSG) in 150 patients
Demaria et al. [83] have reported more con- with BMI 27–43 kg/m2 (of whom 34 % had BMI
servative albeit impressive figures for early post- <35 kg/m2) [12]. The 3-year postoperative fol-
operative outcomes of metabolic surgery to treat low-up analysis of this study recently published
diabetes in 235 patients with BMI <35 kg/m2 in the New England Journal of Medicine showed
from sites participating in the ASMBS bariatric no differences in the effect of surgery between
surgery center of excellence program in the patients with BMI above or below 35 kg/m2 [34].
USA. According the Bariatric Outcomes
Longitudinal Database (BOLD), 55.2 % of 9.4.3.1 Predictors of Diabetes
patients after gastric bypass and 27.5 % of Remission of T2DM
patients after gastric banding were reported to From a surgical perspective, the choice of proce-
have discontinued medications to treat diabetes dure is an important determinant of outcome.
within 6–12 months of surgery for an overall There is an increasing gradient of efficacy from
medication cessation rate of 39.1 %. LAGB to RYGB and BPD. Although some obser-
The durability of diabetes control after RYGB vational studies have suggested similar remission
in patients with BMI <35 kg/m2 has been investi- rates after SG and RYGB [85], the recently pub-
gated by Cohen and co-workers in a recent stud- lished RCTs by Lee et al. [74] and Schauer et al.
ies published in Diabetes Care. The authors [12, 34] confirm the superior efficacy of
documented sustained >80 % remission 5-year RYGB. Although BPD appears to have the most
postoperatively in 60 patients with T2DM and profound effect on diabetes remission in both
BMI 26–34 [84]. obese and non-obese patients, it is not widely
Patients with T2DM and BMI <35 kg/m2 have favoured due to the greater surgical risk associ-
also been included in several RCTs comparing ated with it. Other factors that have been posi-
surgery versus medical therapy. Dixon et al. [10] tively co-related with diabetes remission are
assigned 60 patients with BMI 30–40 kg/m2 to percentage of excess weight loss (%EWL),
receive conventional medical/behavioral therapy younger age, lower pre-op HbA1c and shorter
or LAGB plus conventional therapy. Two years duration of diabetes (less than 5 years) [79].
after surgery, 73 % of post-LAGB patients Severity of diabetes, as judged by pre-operative
90 F. Rubino

insulin usage has also been noted to be a signifi- [35]. This survival benefit has previously also
cant factor. Schauer et al. [86] have reported a been reported by Adams et al. in a large retrospec-
diabetes remission rate of 97 % in diet controlled, tive cohort study [37] where 8,000 patients who
87 % in oral agent treated and 62 % in insulin had undergone gastric bypass surgery were com-
treated subjects in their case series study. pared for long-term mortality with age-, sex- and
C-peptide >3 ng/mL has been identified as an BMI-matched control subjects who had applied
important predictor of diabetes resolution after for driver’s licences (Utah, USA). The analysis
SG in non-morbidly obese diabetic subjects in reported an adjusted long-term all-cause mortality
one study [87]. In contrast to other published reduction of 40 % in the surgical group, with spe-
data; age, sex, baseline BMI, duration of diabetes cific mortality reductions in the operated group of
and weight changes were not significant predic- 56 % for coronary artery disease, 92 % for diabe-
tors of diabetes remission at 2 years or of tes and 60 % for cancer when compared with
improvement in glycaemia at 1 and 3 months in matched controls. Other studies have demon-
the recently published RCT by Mingrone et al. strated major improvements in health-related
[11]. Future RCTs comparing medical versus quality of life following bariatric surgery using
surgical strategies for management of Type 2 DM both generic and obesity-specific quality-of-life
will hopefully help clarify which factors best pre- instruments.
dict remission following surgery and guide
patient selection particularly among the less 9.4.3.3 Diabetes Surgery
obese. in the Treatment Algorithm
for Type 2 Diabetes
9.4.3.2 Non-glycaemic Benefits The management of patients with obesity and
of Metabolic Surgery T2DM is both complex and challenging. It is
Several studies have demonstrated that the bene- clearly evident from several experimental and
fits of metabolic surgery extend beyond ameliora- observational studies and more recently from
tion of hyperglycaemia and include improvement randomized controlled trials that diabetes surgery
of other cardiovascular risk factors such as dys- offers superior results both in terms of efficacy
lipidaemia and hypertension. In addition, there is and durability of glycaemic control when com-
reduced cancer incidence in surgically treated pared to lifestyle modifications and pharmaco-
obese females [88, 89]. The meta-analysis by therapy. There is now also a significant body of
Buchwald et al. [76] showed marked decrease in evidence indicating that patients with BMI less
levels of total cholesterol, LDL cholesterol and than 35 kg/m2 can also respond favourably to dia-
triglycerides after bariatric procedures. betes surgery in the short-term. The SOS study
Approximately 70 % of patients experienced an also shows that surgery can have a favourable
improvement in hyperlipidaemia, whereas hyper- influence on long-term complications of diabetes
tension improved or resolved in 79 % of patients. and mortality, although this needs to be con-
In the SOS study, the 2- and 10-year recovery firmed in RCTs.
rates from hypertriglyceridaemia, low levels of Given the level of clinical evidence, several
high-density lipoprotein cholesterol, hypertension organizations now recommend using surgery for
and hyperuricaemia were more favourable in the the treatment of T2DM, especially in patients
surgery group than in the medically managed con- that do not adequately respond to conventional
trol group, whereas recovery from hypercholes- therapies or in presence of surgery-responsive
terolaemia did not differ between the groups [90]. co-morbidities (i.e. hypertension, dyslipidaemia)
Furthermore, follow-up of participants in the SOS that increase CV risk. Accordingly, the
study after an average of 11 years found that bar- International Diabetes Federation (IDF) recom-
iatric surgery was associated with a 29 % reduc- mends prioritization for bariatric surgery in mor-
tion in all-cause mortality after adjusting for sex, bidly obese patients (BMI >35 kg/m2) with Type
age and risk factors in this severely obese group 2 diabetes and considers eligible for surgical
9 Diabetes Surgery 91

treatment patients with BMI >30 kg/m2 if HbA1c defining aspects since they determine what spe-
is higher than 7.5 % despite fully optimized con- cific set of technical and clinical skills the spe-
ventional therapy, especially if weight is increas- cialist surgeon needs to learn. Defining the exact
ing, or in presence of other weight responsive meaning of diabetes/metabolic surgery and using
co-morbidities not achieving targets on conven- the proper terminology is neither a mere seman-
tional therapies [14]. According to the IDF, in tic issue nor a mere academic exercise. A clear
Asians and some other ethnicities of increased definition indeed is the first step to frame the
risk, BMI action points may be reduced by boundaries of this emerging field and has impor-
2.5 kg/m2 [14]. The American Diabetes tant conceptual and practical ramifications.
Association recommends that bariatric surgery We have suggested that gastrointestinal meta-
be considered as a treatment option for Type 2 bolic surgery should be defined and characterized
diabetes when the patient’s BMI exceeds 35 kg/ by its intent to treat diabetes and obesity from the
m2 [38]. At the time of this writing, the National perspective of a metabolic illness as opposed to
Institute for Health and Care Excellence (NICE) traditional bariatric surgery intended as a mere
in the UK has proposed a draft document to rec- weight-reduction therapy [15]. The transition
ommend surgical treatment of type 2 diabetes in from bariatric to metabolic and diabetes surgery
all patients with BMI >30 kg/m2 and diabetes implies changes in every aspect of clinical prac-
duration <10 years. tice, including the selection of surgical candi-
dates, the prioritization of access to surgery, the
definition of success of treatment, pre-operative
9.5 Definition of “Metabolic” diagnostics, post-operative outcome measures,
and “Diabetes Surgery”: follow-up and care team composition [15].
What’s in a Name? In fact, among patients who seek traditional
bariatric surgery, females are over-represented
In spite of the rapidly increasing popularity, the and diabetes is less prevalent than expected for a
concept and practice of metabolic and diabetes severely obese population. Reported female/male
surgery have not been clearly defined. Buchwald ratio ranges between 3:1 and 4:1 and prevalence
and Varco first proposed the term metabolic sur- of diabetes is as low as 18–33 %. This reflects
gery as “the operative manipulation of a normal differences in the way individuals of different
organ or organ system to achieve a biological genders conceptualize the risks of obesity against
result for a potential health gain” [91]. the risks and benefits of surgery. Diabetes and
Gastrectomies and vagotomies for peptic ulcer other metabolic diseases instead are likely to be
disease, portal diversion for glycogen storage perceived equally as a medical problem by both
disease and partial ileal bypass for hyperlipidae- genders and the focus on metabolic dysfunction
mia were cited as examples. More recently, the rather than weight as the primary reason to seek
term metabolic surgery has been used instead to surgical treatment may encourage more patients
indicate a yet-investigational approach to non- with long-standing disease, complex medical
obese diabetics or a set of novel experimental regimen or concerns about cardiovascular risk to
procedures such as ileal interposition and seek surgical care.
duodenal-jejunal bypass. The definitions above We recently conducted a study [15] to compare
have historical interest but are not consistent with demographics and peri-operative outcomes of two
the principles that usually guide the definition of cohorts of patients undergoing surgery at two dis-
other surgical disciplines. In fact, surgical spe- tinct surgical units within the same tertiary care
cialties are distinguished by the target organ- medical center: the Gastrointestinal Metabolic
system (i.e. “digestive” or “GI surgery”) or by the and Diabetes Surgery Center whose model of
disease or disease-group that one intends to treat clinical practice was shaped around the stated aim
(i.e. endocrine surgery, surgical oncology etc). to surgically treat diabetes and metabolic disease
Organ-systems and disease groups are indeed and the section of Bariatric Surgery, a traditional
92 F. Rubino

Table 9.1 Differences between bariatric and metabolic surgery

Bariatric surgery Metabolic surgery
Purpose Weight loss Glycaemic/metabolic control; CV risk
reduction
Indication criteria BMI centric Uncontrolled type 2 diabetes, metabolic
syndrome, NASH, Increased CV risk
Operations Traditional (RYGB, SG, BPD, LAGB) Traditional (RYGB, SG, BPD, LAGB)
Investigational (DJB, IT endoscopic
duodenal sleeve)
Measures of outcome Weight loss (excess weight loss) Glycaemic control, blood pressure, lipid
control, CV risk reduction, weight loss
Presumed mechanisms of Restriction to food intake/malabsorption Several, complex, neuroendocrine
action
Modified from Rubino and Cummings [92]
RYGB Roux-en-Y gastric bypass, SG sleeve gastrectomy, BPD biliopancreatic diversion, LAGB laparoscopic adjustable
gastric banding, DJB duodenal jejunal bypass, IT ileal interposition

practice of weight loss surgery. Only patients with are used with the primary intent to treat diabetes
BMI levels within the accepted criteria for con- and metabolic disease. This definition is descrip-
ventional bariatric surgery were included to rule tive of the target organ-system (the GI tract) and of
out BMI as a confounding. The results showed the disease-group (obesity, diabetes, metabolic
that the patient population of metabolic surgery is syndrome), independent on type of procedures and
characterized by older age, greater prevalence of patient’s BMI. This definition is not based on the
male patients and significantly higher prevalence assumption of whether the site of surgery is normal
of all metabolic conditions examined, including or pathologic, yet it is consistent with the evidence
type 2 diabetes, hypertension and dyslipidaemia. that gastrointestinal operations engage mecha-
The severity of diabetes was greater in metabolic nisms of action that are metabolic in nature.
surgery patients as shown by higher fasting gly- According to such definition, standard proce-
caemia, HBA1c and greater proportion of insulin dures traditionally utilized in bariatric surgery
users prior to surgery. At baseline, metabolic sur- (i.e. Roux-en-Y gastric bypass, sleeve gastrec-
gery patients also had a greater prevalence of tomy, biliopancreatic diversion, gastric banding,
established cardiovascular disease (i.e. ischaemic etc) should be considered “metabolic” rather than
heart disease, congestive heart failure, cardiac “bariatric” surgery when used with the primary
arrhythmia) compared to bariatric surgery pat- intent to treat metabolic illnesses even in mor-
ents. Consistent with previous studies, the patient bidly obese patients (BMI >35). When the pri-
population in the bariatric surgery cohort was mary intent of surgery (or the reason why a
characterized by a preponderance of young female patient is seeking surgical treatment) is specifi-
subjects with a relatively low prevalence of diabe- cally the treatment of diabetes, there are suffi-
tes and cardiovascular disease. cient ramifications for clinical practice (impact
The results of this study show that offering sur- on patients’ expectations, need for specific out-
gery to treat diabetes rather than as a mere weight- come measures, involvement of appropriate mul-
reduction therapy changes demographics and tidisciplinary teams and support systems, etc.) to
clinical characteristics of surgical candidates. This indicate the approach as “diabetes surgery”. The
support consideration of metabolic/diabetes sur- name bariatric surgery should only be retained, in
gery as a novel practice distinct from traditional our opinion, for those cases where surgery is
bariatric surgery. Based on these results we pro- sought with the primary intent to address physi-
posed a practical definition of gastrointestinal met- cal complications of excess weight. Table 9.1
abolic surgery (or metabolic surgery) as a broad shows differences between metabolic/diabetes
surgical specialty where gastrointestinal operations surgery and bariatric surgery.
9 Diabetes Surgery 93

9.6 Diabetes Surgery: Current diabetic patients, including the less obese.
Priorities and Future Furthermore, mechanistic studies aimed at
Directions using gastrointestinal surgery to elucidate the
role of the gut in glucose homeostasis may
The development of proper diabetes surgery possibly uncover new targets and molecules
implies a number of transformative changes to for future less invasive therapeutic approaches
the model of care of traditional bariatric surgery. of curative intent.
Traditional bariatric surgery practice in fact does
not include accurate diagnostics measures of dia-
betes, evaluation of residual pancreatic function
or careful screening for micro- and macrovascu- References
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els are not a mandatory routine test in most 1. Rubino F, Marescaux J. The effect of duodenal-jejunal
exclusion in a non-obese animal model of type 2 dia-
centers of excellence for bariatric surgery. This betes: a new perspective for an old disease. Ann Surg.
traditional practice is largely responsible for our 2004;239(1):1–11.
current inability to accurately predict outcomes 2. Rubino F, Gagner M. Potential of surgery for curing type
of bariatric surgery on diabetes based on preop- 2 diabetes mellitus. Ann Surg. 2002;236(5):554–9.
3. Thaler JP, Cummings DE. Minireview: hormonal and
erative patients’ characteristics. metabolic mechanisms of diabetes remission after gastro-
Appropriate therapeutic strategies should also intestinal surgery. Endocrinology. 2009;150(6):2518–25.
be developed to optimize diabetes and metabolic 4. Pournaras DJ, Glicksman C, Vincent RP, Kuganolipava
control. For instance, preoperative medical/ S, Alaghband-Zadeh J, Mahon D, Bekker JH, Ghatei
MA, Bloom SR, Walters JR, Welbourn R, le Roux
dietary interventions should be considered when CW. The role of bile after Roux-en-Y gastric bypass
appropriate to improve preoperative glycaemic in promoting weight loss and improving glycaemic
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therapy after surgery should be tailored to com- 5. Liou AP, Paziuk M, Luevano Jr JM, Machineni S,
Turnbaugh PJ, Kaplan LM. Conserved shifts in the gut
plement mechanisms of action of specific opera- microbiota due to gastric bypass reduce host weight
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Finally, development of appropriate disease- idly lower glucose concentrations in uncontrolled dia-
based criteria for selection of surgical candidates betes. Nat Med. 2012;18:950–5.
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be implemented, including measures of risks- Kucharczyk J, Bonab AA, Fischman AJ, Yarmush
ML, Stylopoulos N. Reprogramming of intestinal glu-
stratification, predicting factors of success and cose metabolism and glycemic control in rats after
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B, Foretz M, Leclerc J, Duchampt A, Zitoun C,
Conclusion Thorens B, Magnan C, Mithieux G, Andreelli
The novel field of diabetes surgery has F. Intestinal gluconeogenesis is a key factor for early
emerged from a surgical discipline initially metabolic changes after gastric bypass but not after
focused primarily on weight loss. Surgery gastric lap-band in mice. Cell Metab. 2008;8:201–11.
9. Jiao J, Bae EJ, Bandyopadhyay G, Oliver J, Marathe
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pharmaceutical interventions. It is envisaged inputs in Zucker fa/fa rats. Diabetes. 2013;62(4):1074–
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that ongoing RCTs and future studies will 10. Dixon JB, O’Brien PE, Playfair J, Chapman L,
help identify the best candidates for surgical Schachter LM, Skinner S, Proietto J, Bailey M,
treatment among the vast population of Anderson M. Adjustable gastric banding and conven-
94 F. Rubino

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 The Role of Laparoscopy
in Bariatric Surgery 10
Marcello Lucchese, Alessandro Sturiale,
Giovanni Quartararo, and Enrico Facchiano

In 1902, Georg Kelling (Dresden, Saxony) appendectomy to the American Journal of

performed the first laparoscopic procedure in Obstetrics and Gynecology, which was rejected
dogs, and in 1910, Hans Christian Jacobaeus as unacceptable for publication on the ground
(Sweden) reported the first laparoscopic opera- that the technique reported on was “unethical”.
tion in humans. In the ensuing several decades, His paper was finally published in the Journal of
numerous individuals refined and popularized Endoscopy. Prior to 1990, the only specialty
the approach further for laparoscopy. The intro- performing laparoscopy on a widespread basis
duction of computer chip television camera was was gynecology, mostly for relatively short,
a seminal event in the field of laparoscopy. The simple procedures. Laparoscopy in general sur-
first publication on diagnostic laparoscopy by gery began in 1985 with the first laparoscopic
Raoul Palmer, appeared in the early 1950s, fol- cholecystectomy performed by Erich Muhe and
lowed by the publication of Frangenheim and submitted to the Congress of the German
Semm. Hans Lindermann and Kurt Semm prac- Society of Surgery. The following year, Mouret
tised CO2 hysteroscopy during the mid-seven- presented the clip of his procedure at Dubois in
ties. In 1981, Semm, from the Universitats Paris [1] and only afterwards it was also per-
Frauenklinik, Kiel, Germany, performed the formed in the United States [2]. As result of
first laparoscopic appendectomy. Following his these first experiences, laparoscopy spread
lecture on laparoscopic appendectomy, the pres- widely—thanks to the innovation in the techno-
ident of the German Surgical Society wrote to logical field too. This condition led to the appli-
the Board of Directors of the German cation of the new approach to other surgical
Gynecological Society suggesting suspension procedures, such as gastrointestinal and bariat-
of Semm from medical practice. Subsequently, ric surgery, with variable success depending on
Semm submitted a paper on laparoscopic the technique. In fact, 38 years after the first
bariatric procedure, which was a jejuno-ileal
bypass, performed to treat morbid obesity by
M. Lucchese (*) • A. Sturiale • G. Quartararo
E. Facchiano
Kremen in 1954 [3], Broadbent [4] and Catona
Department of Surgery, Bariatric and Metabolic [5], who placed a nonadjustable gastric band,
Surgery Unit, Azienda Sanitaria Firenze, Santa Maria performed the first laparoscopic bariatric sur-
Nuova Hospital, Piazza Santa Maria Nuova, 1, gery in 1992–1993. Belachew et al. and Forsell
Florence 50122, Italy
e-mail: [email protected]; [email protected];
et al. were the first to perform a laparoscopic
[email protected]; adjustable gastric banding. These laparoscopic
[email protected] roots of bariatric banding may explain the early

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 99

Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_10,
© Springer International Publishing Switzerland 2015
100 M. Lucchese et al.

prevalence of laparoscopic adjustable gastric skills. To solve this limitation, a new training
banding in Europe. In 1994, Wittgrove et al. per- curriculum comprising five steps has been
formed the first laparoscopic gastric bypass in proposed:
the United States, initiating preference for lapa- • Knowledge-based learning about the
roscopic gastric bypass that has come to domi- procedures.
nate the country’s operative selection in the first • Divide the process into tasks by identifying
decade of the twenty-first century. Also in 1994, the most challenging parts.
Hess performed a laparoscopic vertical banded • Laboratory environment training, identifying,
gastroplasty. In 1991, the National Institutes of and/or developing different training models.
Health Conference statement on gastrointestinal • Transfer the acquired skills to the real envi-
surgery for severe obesity stated that bariatric ronment showing the acquired technique.
surgery is the only therapy which let the morbid • Granting privileges for operating room prac-
obese patients to reach a stable and satisfactory tices [7].
weight loss [6]. Hence, bariatric surgery, which An evolution of laparoscopy is the application
had a great expansion in the middle of 1900s, of a single-incision laparoscopy (SIL) in bariatric
reached higher levels with the introduction of surgery. Several authors have reported their own
laparoscopy because it was proved to be safe experience showing that it is a feasible technique
and feasible. Nowadays, laparoscopy is consid- in groups of highly selected patients. The selec-
ered the “gold standard” for the surgical treat- tion is based on the type of intervention which
ment of morbid obesity. Many different types of should be not complex and on body habitus.
operations can be performed: vertical banded Patients with tall trunk are more difficult because
gastroplasty (VBG), adjustable gastric banding of the distance between the epigastric zone and
(AGB), laparoscopic Roux-en-Y Gatric bypass ombelicus that should be not more than 22–25 cm.
(LRYGB), sleeve gastrectomy (SG), and bilio- The potential advantages include less postopera-
pancreatic diversion (BPD). LRYGB is the pro- tive pain, better cosmetic result, and satisfaction
cedure mostly performed [7]. It is demonstrated of the patient. Some authors report an increase of
that a team of bariatric surgery recently built up incisional hernia rate due to the longer fascial
is associated with a doubled or tripled complica- incision. Furthermore, these patients often
tions rate due to the learning curve. In fact, the undergo plastic surgery after the achievement
LRYGB is a challenging procedure because of and maintenance of ideal weight whereby the
visceral fat, liver size, and thickness of the desired esthetic result is reached in a second
abdominal wall. For this reason, the surgeon phase [9].
must be technically proficient. Some authors The further innovation in the minimally invasive
believe that a total number of procedures rang- surgical techniques development led to the applica-
ing from 75 to 120 are necessary to obtain a tion of the robot in bariatric surgery, trying to over-
postoperative complications rate similar to that come the limits of standard laparoscopy. The
reported in literature. The American Society for robotic approach is safe and feasible in all types of
Metabolic and Bariatric Surgery (ASMBS) bariatric surgery with a postoperative complica-
asserts that to be a proficient surgeon it is needed tions rate, including anastomotic leakage, very low
to certify 100 bariatric procedures, whose half and only slightly different from the conventional
as first operator, with a good outcome, starting laparoscopy [10]. Robotic bariatric surgery has a
from the residency supervised by an experi- shorter learning curve; in fact, it is believed that 20
enced surgeon. This kind of skills standardiza- cases are enough to overcome the basic learning
tion is not well established in the European phase. The robot could be useful in patients with
countries where the achievement of such a train- difficult anatomy or in cases of revisional surgery
ing program is more difficult [8]. The difficulty after restrictive procedures where the surgeon may
for the training resident to perform LRYGB find difficult dissection and reconstruction. At pres-
comes from the required advanced laparoscopic ent time, there is no scientific evidence about the
10 The Role of Laparoscopy in Bariatric Surgery 101

superiority of the robot-assisted technique on the • UGI endoscopy: It is an essential tool in the pre-
conventional laparoscopy whereby the exact role of operative workup because it allows to identify
the robotic approach should be defined more pre- some pathological conditions such as
cisely in larger studies, also evaluating the high Helicobacter pylori-related gastritis, ulcers,
costs [10, 11]. polyps, or tumors. The surgical treatment pro-
posed to the patient may be delayed or modified
according to the type of finding [14]. In case of
10.1 Preoperative Workup polypoid lesions, LRYGB is contraindicated
because it does not allow the periodic endo-
It consists of all investigations that a morbid scopic exploration of the abandoned stomach.
obese patient must preoperatively perform to In case of gastritis or ulcerative lesions, the
establish whether the procedure chosen by the appropriate medical therapy is started and only
multidisciplinary equipe is safe and feasible. after endoscopic demonstration of a complete
• Blood exams: Routine preoperative blood resolution, surgery can be performed. In a recent
exams including hormonal screening tests and study, the esophageal capsule endoscopy (ECE)
to the lipid concentrations dosage. was evaluated as an alternative to the standard
• Abdominal ultrasound: The guidelines of the esophago-gastro-duodenoscopy (EGD). The
ASMBS suggest to perform the preoperative best advantage of this technique is the noninva-
abdominal ultrasound only in patients with sive approach thus reducing the cardiopulmo-
symptoms related to biliary disease and abnor- nary complications rate, which is about 0.6 %
mal liver function tests. On the opposite, The and related to the conscious sedation. On the
Society of American Gastrointestinal and other hand, the main limit is the difficulty to
Endoscopic Surgeons in their guidelines of evaluate the stomach and duodenum. Further
2008 assess that it is appropriate to perform studies are needed to determine and define the
abdominal ultrasound as a preoperative screen- role of this method as a preoperative tool [15].
ing. Ultrasound findings may be various as the • 24-h pH monitoring: It is the procedure that
fatty liver, gallstones, and hepatomegaly but allows to diagnose gastro-esophageal reflux
their evidence does not add much value to the disease (GERD). It is more accurate if associ-
preoperative workup because it does not ated with impedentiometry. Some authors
change the surgical choice. Hence, it may state include this investigation in the preoperative
that the performance of abdominal ultrasound workup of patients who have to undergo a
is recommended as a preoperative screening SG. This attitude in based on the evidence that
only in symptomatic patients whereas the rou- the SG seems to increase GERD symptoms
tinary use is not recommended [12]. [16], whereas LRYGB seems to improve
• Barium radiography: Preoperative routine use them. However, the effects of SG on GERD
is controversial. Angrisani assesses that this remain controversial. The literature can be
radiological examination is the standard pro- divided in two categories: those who show an
cedure before gastric banding. Ghassemian increase of GERD prevalence after SG and
does not consider it as part of his protocol for those who demonstrate a reduction of GERD
preoperative LRYGB whereas Bova argues prevalence. The pathogenetic mechanisms
that it is necessary only in patients with upper proposed are different. The increase in GERD
gastro-intestinal (UGI) pathology such as pre- prevalence may be explained by lower esoph-
vious gastric surgery. However, the reported ageal sphincter (LES) hypotension, blunting
data are often not comparable because they of angle of His, decrease in gastric compli-
describe different types of operations. For this ance and emptying, and decrease in plasma
reason, further prospectical studies are needed ghrelin. On the other hand, the reduction of
to establish if the preoperative radiological GERD prevalence might be explained by
screening may be useful [13]. decrease in abdominal obesity, decrease in
102 M. Lucchese et al.

acid production and wall tension, increase in mortality if compared to patients with BMI
long-term gastric compliance and gastric <50 kg/m2. In fact, the Longitudinal Assessment
emptying. Anyway, the studies supporting of Bariatric Surgery Consortium has recently
both categories are rather heterogeneous and demonstrated a high probability of adverse out-
difficult to compare each other because of dif- come in patients with BMI >55 kg/m2 with an
ferent factors such as variable method of increase in the conversion rate, complications,
GERD evaluation, length of follow-up, and and hospital stay [19]. Hence, this condition
surgical technique. Hence, it cannot be cer- causes more anesthetic and surgical problems.
tainly state to introduce this investigation in The technical difficulties are due to the consid-
the preoperative workup [17]. It could be used erable thickness of the abdominal wall that hin-
only in symptomatic patients or with esopha- ders the movements of laparoscopic instruments,
gitis [16]. It would be desirable to perform the massive presence of intra-abdominal adi-
further studies where the preoperative and pose tissue with short mesentery and hepato-
postoperative GERD is evaluated through a megaly with fragile liver [20]. The surgery of
standardized technique such as the 24-h pH these patients is so challenging that the
monitoring and analyzing the effects of the International Federation for the Surgery of
sleeve on GERD symptoms [17]. Obesity and Metabolic Disorders suggests to
• Esophageal manometry: It is a technique that avoid these patients during the first period of
studies the esophageal motor activity. It must surgeon’s practice [19]. Therefore, preoperative
be included in the preoperative workup of all weight loss is used to reduce the conversion rate
patients who undergo VLB because it is a and improve the outcome [21]—thanks to the
valuable instrument to predict the outcome of significant reduction of the volume of the liver
these patients correlated to the long-term fol- left lobe and visceral adipose tissue.
low-up esophageal dilatation. There is only a The first attempt to gain preoperative weight
small percentage of patients with normal pre- loss is based on a conservative therapy such as
operative manometry who develop postopera- the diet. In case of diet failure, the placement of
tive GERD symptoms and esophageal an intragastric balloon is useful [20].
dilatation due to the band fill being too tight. • Diet: It is demonstrated in literature that a pre-
The treatment is to enlarge the band allowing operative very low calory diet (VLCD) fol-
the esophagus to recover in a few weeks. VLB lowed for a period ranging from 3 to 6 weeks
has been shown to have beneficial effect on before the operation reduces the operative risk
GERD symptoms, in fact, the symptoms dis- and improves the postoperative outcome
appear in the short-term follow-up with a nor- These diets are usually based on industrial liq-
malization of the values of LES pressure and uid preparations that are poorly accepted by
24-h pH monitoring. This investigation may the patients [22, 23]. The efficacy of preopera-
be useful even in the prognostic evaluation of tive VLCD based on homemade ingredients to
GERD symptoms in patients who will undergo achieve weight loss was recently reported. It is
a SG. On the other hand, there is no scientific associated with a good patient’s satisfaction,
evidence to support the routinary use of this cost reduction, and few secondary effects such
investigation in the preoperative workup for as nausea and diarrhea [22].
patients who will undergo an LRYGB [18]. • Intragastric balloon (IB): It is widely demon-
strated in literature that the positioning of the
IB is not effective to obtain a permanent
10.2 Preoperative Weight Loss weight loss [19]. Although it could even reach
a weight loss of 32 % of the excess weight at
Super obesity (BMI >50 kg/m2) and super- the time of the removal, which usually occurs
super-obesity (BMI >60 kg/m2) are associated 6 months after about 40-50 % of the patients
with an increase in early and late morbidity and regain the weight lost in 12 months [21].
 10 The Role of Laparoscopy in Bariatric Surgery 103

Therefore, IB may be considered as a “bridge between the open and closed technique about
therapy” to surgery reducing operative time vascular and visceral lesions incidence, and
and overall risk of adverse outcome [19]. that the open technique is associated with a
reduction of failed entry. Among the closed
technique, the use of optical trocar is the safest
10.3 Operating Room because Veress needle is associated with an
increase of the incidence of failed entry, extra-
The operating room must be adequate to perform peritoneal insufflation, and omental lesions.
laparoscopic surgery. The total weight capacity of These results may certainly be affected by the
the operating table has to allow the placement of heterogeneity of the studies, whereby further
super-obese patient in anti-Trendelemburg posi- randomized controlled trials are needed [24].
tion. The multidisciplinary equipe is fundamental In morbidly obese patients, the optical trocar
during the operative time as much as in the preop- is generally used because it is demonstrated to
erative evaluation. In fact, a group of well-trained be safe, effective, and a rapid technique. On
nurses and anesthesiologist dedicated to follow the other hand, the open technique is time-
the entire pathway of the patients from the preop- consuming and more difficult because of the
erative investigations to intraoperative and post- thickness of the abdominal wall and subcuta-
operative management have the same importance neous fat. The vascular damages are certainly
of the surgeon for a good outcome. more likely in case of midline trocar insertion
because it is pushed directly against the spine
and major vessels. For this reason, it is better
10.4 Surgical Strategies to introduce the optical trocar into the left
upper quadrant just below the ribs thus pre-
In the field of laparoscopic bariatric surgery, the venting the collapse of the abdominal wall on
surgeon has different options during the operation: the viscera. It is the fundamental to understand
• Laparoscopic access: Many different methods the phases of the correct introduction through
of laparoscopic access are reported in litera- the abdominal wall to achieve a good safety
ture. These include the closed technique, level of the procedure [25]. However, some
which has two options, and the open tech- authors state that the midline insertion of the
nique. The first variant of the closed technique device appears to be a safe procedure [26].
is based on the insertion of the Verres needle • Drain placement: The placement of routine
1 into the peritoneal cavity, gas insufflations, abdominal drainage during bariatric sur-
insertion of the first trocar and then the intro- gery is widely used and the basic purpose is
duction of the other trocars under direct view. the early detection of a leak so that it can be
The second variant, instead, consists in the converted into a controlled fistula avoiding
introduction of an optical trocar into the peri- re-intervention. Several randomized trials and
2 toneal cavity followed by gas insufflation and systematic reviews showed that the system-
subsequent insertion of the other trocars under atic use of abdominal drainage is associated
visual control. The open technique is based on with an increase of postoperative morbidity,
the opening of the peritoneal cavity, insertion costs, and length of hospital stay in different
3
of a blunt trocar, gas insufflation, and then types of abdominal surgery. The placement
introduction of the other trocars under optical of abdominal drainage alone is often not suf-
control. The potential advantages of the latter ficient to make the diagnosis of anastomotic
technique are the prevention of vascular and leak because neither the quantity nor the qual-
visceral lesions, gas embolism, and preperito- ity of the drainage allow to do certain diag-
neal insufflation. There is no consensus about nosis, whereby further investigations such as
the best approach. In a recent review, it has UGI contrast or CT scan are needed in clini-
been observed that there are no differences cally stable patients [27]. The drain does not
 104 M. Lucchese et al.

frequently allow a conservative treatment accuracy and it even helps to identify bleeding
because it is placed near the gastro-jejunal sites and to test the anastomotic patency [28].
anastomosis and it does not drain any jejuno- The availability of the endoscopist, as member
jejunal anastomotic leak. It has been observed of the multidisciplinary team, in the operating
that the drainage does not significantly reduce room to perform this procedure is fundamental.
the incidence of re-interventions in patients For this reason too, this type of surgery should
with confirmed anastomotic leak; in fact, the be performed only in specialized centers. A
post-re-intervention morbidity and mortal- possible complication of IE is related to an
ity rate are similar to that of patients without excessive air pressure during the procedure that
drainage [28]. In some cases, even further may increase the risk of bleeding or leak,
radiological investigations fail to demonstrate whereby it must be gently performed by skilled
the anastomotic leakage [29]. For these rea- endoscopists. From the recent published stud-
sons, the clinical signs are the most sensi- ies, it may state that the intraoperative endos-
tive marker to assess postoperative outcome. copy is a safe and effective method to evaluate
Laparoscopy significantly reduced the surgical the patency of the gastro-jejunal anastomosis
insult, whereby the presence of one or more of [33–35], but further randomized trials are
persistent tachycardia, temperature higher than needed to evaluate whether it is useful and cost-
38.5°C, reduced diuresis and poor control of effective because the incidence of postopera-
abdominal pain, must alert the surgeon to per- tive leaks in patients with intraoperative
form investigations or reintervention [27, 30, negative test is seldom reported.
31]. The ASMBS states there is no high level • Staple-line reinforcement (SLR): Although the
of evidence to support the routine use of drain- importance of staple-line reinforcement in
age to prevent GI leakage [32]. bariatric surgery has been documented, its real
• Intraoperative testing of anastomotic leakage: advantage remains controversial. There are
It is a method that allows to evaluate the anasto- three options of reinforcement: oversewing
motic integrity during the intervention in the staple line, application of fibrin glue seal-
patients who undergo LRYGB. There are two ant, and incorporation of buttressing materi-
options: the simplest procedure is the infusion als. The latter has been developed to increase
1) of methylene blue through an orogastric tube. the strength of the staple line by increasing the
In this way it is possible to evaluate both the thickness of the wall. It is preloaded in the
gastro-jejunal and jejuno-jejunal anastomosis. staple gun and incorporated into the staple line
Some authors believe that this method has on firing. Many different products are avail-
some drawbacks including the staining of the able such as permanent and non-permanent
operative field in case of leak, making more dif- bovine pericardial strips or synthetic bioad-
ficult the further test after surgical repair, and sorbable materials [36]. These types of
the possible difficulty to blindly introduce the staple-line reinforcement were used in both
orogastric tube [33]. In our experience, the lat- SG and LRYGB. The major postoperative
ter does not represent a difficulty because it is complications after SG are the staple-line
employed the same tube used to calibrate the bleeding and the leakage which is the most
gastric pouch and it is placed at peri-anastomotic life-threatening complication. It has an inci-
level under optic control. The other reported dence of 2.7 % and occurs mainly in the high-
method is the intraoperative endoscopy (IE) est part of the suture just below the
2) with hydro-pneumatic test. The advantages gastro-esophageal junction. The pathophysi-
offered by this technique are the possibility of a ology of the leakage may be related to differ-
direct visualization of the lumen and the anas- ent factors such as reduced blood supply,
tomosis guiding the surgeon to identify the pos- mainly at the angle of His, stapler device
sible leak. It may be repeated after surgical failure, inadequate technique, postoperative
repair without modifying its diagnostic high intragastric pressure due to gastroparesis.
 10 The Role of Laparoscopy in Bariatric Surgery 105

The real advantages of the SLR for SG are not conventional approach means to perform cho-
clear. Some authors believe that there are no lecystectomy during LRYGB only in patients
differences in the outcome between the groups with symptomatic stones according to the
with and without SLR. This is in contrast with guidelines for the treatment of gallstone disease
results of another meta-analysis, which dem- [42]. Another possible fourth approach is to
onstrates a reduction of leakage in SLR delay the cholecystectomy after LRYGB only
patients group. Another prospective random- 3) in patients who become symptomatic after
ized study, however, shows that there is no dif- weight loss. In this case, the intervention can be
ference in the incidence of leaks or bleeding in easier and has a lower perioperative morbidity
the two groups, but a higher incidence of post- [41]. Although the incidence of gallstones
operative stenosis in the SLR group [37]. increases after bariatric surgery, only almost
There is no evidence about the best practice the 40 % of these patients become symptomatic
regarding SLR in LRYGB too. Some authors [43, 44]. This finding could support the latter
report a reduction of bleeding with subse- approach. For those patients who do not
quently decrease of endo-clips application undergo simultaneous cholecystectomy, it has
[38] and reduction of leak [39] if the bovine been shown that pharmacological prevention
pericardial strips are used. A multicenter ran- with ursodeoxycholic acid (UDCA) is effective
domized trial, instead, report the preliminary in decreasing the biliary cholesterol saturation,
results that fibrin glue does not have adverse but a low compliance to the therapy was also
effects, it is not time-consuming and may be detected. Hence, although there are controver-
effective to prevent leaks and internal hernias sial opinions, it may be stated that a cholecys-
in morbidly obese patients [40]. tectomy performed during LRYGB is safe and
• Timing to perform cholecistectomy during bar- feasible, usually using the same trocars, some-
iatric surgery: Most of the studies aim to estab- times introducing the sixth. It is associated with
lish the indications to perform a cholecystectomy an increased operative time and in some series
in patients who undergo LRYGB or other bar- increased hospitalization time without increas-
iatric procedures. There are three possible ing the intervention-related complications rate
approaches: prophylactic, selective, or conven- [43]. The prophylactic approach seems to be an
tional cholecystectomy [41, 42]. The prophy- overtreatment because the risk of symptomatic
1) lactic cholecystectomy means to perform this gallstone disease requiring operation is low
intervention during LRYGB, regardless for the [44]. The selective approach reduces potential
presence or absence of preoperative biliary future gallstone-related morbidity, the need of
stones. The reason for this approach is the evi- readmission for further surgery thus reducing
dence that the rapid postoperative weight loss is costs [41]. Instead, the conventional approach
associated with an increase of the gallstone for- shows, regardless for the UDCA administra-
mation incidence if compared with the normal tion, that the majority of patients who develop
population. A percentage between 28 and 36 % stones remain asymptomatic, whereby they
of the patients after LRYGB develop stones don’t need surgical treatment. For this reason,
within 3 years. The pathophysiology of this the risks to perform a simultaneous cholecys-
process lies in an increased hepatic secretion of tectomy might be unwarranted [42].
cholesterol causing a cholesterol supersatura-
tion of the bile [43]. The selective approach,
2)
instead, consists to perform cholecystectomy 10.5 Revisional Surgery
during LRYGB in asymptomatic patients with
preoperative or intraoperative finding of chole- With the increase of the bariatric procedures
lithiasis. This approach is based on the higher worldwide, it has gradually emerged a new group
probability to have symptoms in patients with of surgeries known as revisional surgery and the
stones compared to those without stones. The number of patients which require this type of
106 M. Lucchese et al.

operations is progressively raised. It consists of re- 10.6 Laparoscopy Versus Open

intervention in patients who have undergone Technique
previous bariatric surgery. The revisional surgery
can be classified into two categories: conversion The introduction of the laparoscopy has widely
surgery that converts an initial procedure into proved its advantages over the open approach in
another, such as converting an AGB into an various types of surgery. The same advantages
LRYGB; and the return surgery that restores the are found in bariatric surgery with the difference
initial anatomy of the patient [45]. There are sev- that the morbid obese patients have more risks
eral conditions requiring revisional surgery, such than non-obese patients for cardiopulmonary
as intractable marginal ulcer, severe gastro- complications, infections, and wound-related
esophageal reflux, gastro-gastric fistula, severe complications [48, 49].
nutritional or metabolic disorders, problems with
the band including slippage, tubing leakage, Advantages
esophageal motor problems, and at last inadequate • Reduction of the surgical insult with a conse-
weight loss or weight regain. Revisional bariatric quent concentrations decrease of the mediators
surgery is complex and technically demanding. of the hypermetabolic stress response, such as
There are several publications showing that revi- catecholamines, cortisol, cytokines, and other
sional laparoscopic surgery is safe and feasible acute-phase reactants. This condition deter-
without prejudicing the subsequent weight loss, mines a reduction in energy expenditure, pul-
but it should be performed in high-volume centers monary and renal workload, and myocardial O2
by experienced surgeons. The complication rate demand that contributes to perioperative mor-
ranges from 0 to 39 % with a conversion rate bidity through unclear process, and a reduction
between 0 and 47.6 %. The laparoscopic approach of cell-mediated immunity impairment related
showed a progressive significant reduction of to a fewer postoperative infections [48].
S
minor complications and it seems to be superior if • Reduction of the postoperative ileum with a
compared to the open technique even if the pri- faster bowel function recovery and reduced
mary procedure was performed in open way. hospitalization time [48].
However, the advantages of this surgery are greater • Reduction of pulmonary alterations that
than the risks in most of the patients [46] with results in less reduction of oxygen saturation
perioperative outcomes very similar to those of and total lung capacity, with fewer pulmonary
primary procedures [47]. For these reasons, the complications [48].
evaluation of patients who have an inadequate • Reduction of wound-related complications
weight loss or weight regain is complex and such as seroma, hematoma, infection, dehis-
requires a multidisciplinary team. First, psychiat- cence, and incisional hernias [48]. A recent
ric and nutritional disorders must be excluded and meta-analysis showed a reduction of the risk
then anatomical problems which can be treated of wound infection and incisional hernia,
endoscopically or surgically must be evaluated. In respectively, of 79 and 89 % compared to open
case of LRYGB as primary procedure, the main surgery [49].
cause of inadequate weight loss or weight regain is • Although the data are conflicting and in some
the dilation of the gastric pouch or of the gastro- cases difficult to compare each other, the rate
jejunal anastomosis. In this condition, the endo- of reinterventions, anastomotic leak, and all-
scopic procedures have conflicting results, but the cause mortality are similar to the open sur-
introduction of new devices may change the future gery. However, all-cause mortality is low in
scenario. The surgical approach has the best both type of surgery [49].
results. On the other hand, in case of vomiting with • The outcome of weight loss at 12 months was
feeding difficulties, the main cause can be an anas- the same as that of the open surgery [49].
tomotic stenosis that can be successfully treated by • Reduction of postoperative adhesions that
endoscopic treatment [45]. makes less difficult further surgery.
10 The Role of Laparoscopy in Bariatric Surgery 107

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respiratory and cardiovascular systems [50].
10. Cirocchi R, Boselli C, Santoro A, Guarino S, Covarelli
Morbid obese patients have a baseline intrab- P, Renzi C, et al. Current status of robotic bariatric
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24. Ahmad G, O’Flynn H, Duffy JM, Phillips K, Watson linear stapler to reduce extraluminal bleeding during
A. Laparoscopic entry techniques. Cochrane Database laparoscopic gastric bypass: prospective randomized
Syst Rev. 2012;(2):CD006583. clinical trial. Obes Surg. 2004;14(9):1198–202.
25. Berch BR, Torquati A, Lutfi RE, Richards WO. 39. Shikora SA. The use of staple-line reinforcement dur-
Experience with the optical access trocar for safe and ing laparoscopic gastric bypass. Obes Surg. 2004;
rapid entry in the performance of laparoscopic gastric 14(10):1313–20.
bypass. Surg Endosc. 2006;20(8):1238–41. 40. Silecchia G, Boru CE, Mouiel J, Rossi M, Anselmino
26. Sabeti N, Tarnoff M, Kim J, Shikora S. Primary mid- M, Tacchino RM, et al. Clinical evaluation of fibrin
line peritoneal access with optical trocar is safe and glue in the prevention of anastomotic leak and internal
effective in morbidly obese patients. Surg Obes Relat hernia after laparoscopic gastric bypass: preliminary
Dis. 2009;5(5):610–4. results of a prospective, randomized multicenter trial.
27. Kavuturu S, Rogers AM, Haluck RS. Routine drain Obes Surg. 2006;16(2):125–31.
placement in Roux-en-Y gastric bypass: an expanded 41. Tucker ON, Fajnwaks P, Szomstein S, Rosenthal
retrospective comparative study of 755 patients and RJ. Is concomitant cholecystectomy necessary in
review of the literature. Obes Surg. 2012;22(1):177–81. obese patients undergoing laparoscopic gastric bypass
28. Lee S, Carmody B, Wolfe L, Demaria E, Kellum JM, surgery? Surg Endosc. 2008;22(11):2450–4.
Sugerman H, et al. Effect of location and speed of diag- 42. Quesada BM, Kohan G, Roff HE, Canullan CM,
nosis on anastomotic leak outcomes in 3828 gastric Chiappetta Porras LT. Management of gallstones and
bypass cases. J Gastrointest Surg. 2007;11(6):708–13. gallbladder disease in patients undergoing gastric
29. Gonzalez R, Sarr MG, Smith CD, Baghai M, Kendrick bypass. World J Gastroenterol. 2010;16(17):2075–9.
M, Szomstein S, et al. Diagnosis and contemporary 43. Hamad GG, Ikramuddin S, Gourash WF, Schauer
management of anastomotic leaks after gastric bypass PR. Elective cholecystectomy during laparoscopic
for obesity. J Am Coll Surg. 2007;204(1):47–55. Roux-en-Y gastric bypass: is it worth the wait? Obes
30. Liscia G, Scaringi S, Facchiano E, Quartararo G, Surg. 2003;13(1):76–81.
Lucchese M. The role of drainage after Roux-en-Y 44. Taylor J, Leitman IM, Horowitz M. Is routine chole-
gastric bypass for morbid obesity: a systematic cystectomy necessary at the time of Roux-en-Y gas-
review. Surg Obes Relat Dis. 2014;10(1):171–6. tric bypass? Obes Surg. 2006;16(6):759–61.
31. Quartararo G, Facchiano E, Scaringi S, Liscia G, 45. Ferraz AA, de Siqueira LT, Nunes FE, de Araujo JGJ,
Lucchese M. Upper gastrointestinal series after Roux- Campos JM, de Barros-Correia TX, et al. Revision
en-Y gastric bypass for morbid obesity: Effectiveness surgery for treatment of weight regain after Roux-
in leakage detection. A systematic review of the litera- en-Y gastric bypass. Obes Surg. 2014;24(1):2–8.
ture. Obes Surg. 2014;24(7):1096–101. 46. Shimizu H, Annaberdyev S, Motamarry I, Kroh M,
32. ASMBS Clinical Issues Committee. ASMBS guide- Schauer PR, Brethauer SA. Revisional bariatric sur-
line on the prevention and detection of gastrointestinal gery for unsuccessful weight loss and complications.
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and surgical exploration. Surg Obes Relat Dis. 47. Stefanidis D, Malireddy K, Kuwada T, Phillips R,
2009;5(3):293–6. Zoog E, Gersin KS. Revisional bariatric surgery: peri-
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laparoscopic Roux-en-Y gastric bypass: leak test and dure. Surg Endosc. 2013;27(12):4504–10.
beyond. Surg Laparosc Endosc Percutan Tech. 48. Schauer PR, Ikramuddin S. Laparoscopic surgery for
2010;20(6):424–7. morbid obesity. Surg Clin North Am. 2001;81(5):
34. Cingi A, Yavuz Y. Intraoperative endoscopic assess- 1145–79.
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tomosis in laparoscopic Roux Y gastric bypass 2005;241(2):219–26.
surgery. Obes Surg. 2011;21(10):1592–6. 51. Gaszynski T, Szewczyk T. The influence of laparo-
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tive randomized clinical study comparing two 2014;9(1):83–8.
 Anesthesia in Bariatric Surgery
11
Jay B. Brodsky

11.1 Preoperative Considerations Most obese patients, especially younger

ones without serious medical co-morbidities
11.1.1 Preoperative History scheduled for elective bariatric procedures, do
and Physical Examination not require an expensive and complex preoper-
ative workup [1]. A comprehensive metabolic
A thorough preoperative past medical history and panel, a chest radiograph, and perhaps an EKG
physical examination are always important. in older patients are usually all that need to be
Special attention should be directed at identify- routinely obtained. Any patient who has had
ing potential intraoperative airway management previous bariatric surgery should be evaluated
problems. A high Mallampati score (III or IV), for metabolic changes that can include protein,
large neck circumference, poor dentition, limited vitamin, iron, and calcium deficiencies. Patients
mouth opening, and reduced range of head and with MetS, with sleep-disordered breathing
neck motion should all be evaluated. problems, and with other significant cardiovas-
Besides the anatomic and mechanical prob- cular conditions are of special concern, and
lems often present, extreme obesity is associated when present may indicate the need for further
with many potentially serious medical conditions diagnostic evaluation and perhaps consultation
(Table 11.1). Medical co-morbidities must be with a cardiologist, endocrinologist, or sleep
recognized, and when possible optimized before physician.
elective bariatric surgery. Of particular concern The most common sleep-disordered breath-
are patients with the metabolic syndrome (MetS). ing condition is obstructive sleep apnea (OSA).
Although definitions of the constituents of MetS Patients maintain a normal PaCO2 during the
vary by degree, the presence of central or vis- day but have CO2 retention, sleep disturbances,
ceral obesity, dyslipidemia, hypertension, and intermittent airway obstruction with hypox-
diabetes or insulin resistance are always present emia, and cardiac arrhythmias at night. OSA
(Table 11.2). is characterized by frequent episodes of apnea
(>10 s cessation of airflow despite continuous
respiratory effort against a closed airway) and
hypopnea (50 % reduction in airflow or reduc-
J.B. Brodsky, MD tion associated with a decrease of oxyhemo-
Department of Anesthesiology, Perioperative
globin saturation (SpO2) >4 %). OSA is very
and Pain Medicine, Stanford University School
of Medicine, Stanford, CA 94305, USA common in obesity and has been reported to be
e-mail: [email protected] present in as many as 70 % of morbidly obese

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 109
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_11,
© Springer International Publishing Switzerland 2015
110 J.B. Brodsky

Table 11.1 Pathophysiology and diseases associated Table 11.2 Metabolic Syndrome (MetS)
with obesity
1. Abnormal glucose metabolism (must be present)
1. Cardiovascular system (a) Diabetes mellitus
(a) Hypertension (both systemic and pulmonary) (b) Impaired glucose tolerance
(b) Atherosclerosis and hyperlipidemia (c) Impaired fasting glucose insulin resistance
(c) Congestive heart failure Plus at least two of the following
(d) Coronary artery disease 2. Hypertension (blood pressure >140/90 mmHg)
(e) Peripheral vascular disease and chronic venous 3. Dyslipidemia:
insufficiency (d) Triglycerides ≥1.695 mmol l−1
2. Respiratory system (e) High-density lipoprotein cholesterol
(a) Dyspnea (restrictive lung disease) (i) ≤0.9 mmol l−1 (male)
(b) Altered sleep disorders (obstructive sleep apnea, (ii) ≤1.0 mmol l−1 (female)
obesity hypoventilation syndrome)
4. Central obesity: large waist; waist:hip ratio
(c) Pulmonary embolism
(iii) >0.90 (male)
3. Gastrointestinal system
(iv) >0.85 (female)
(a) Hepatic steatosis and abnormal liver function
5. Microalbuminuria
tests
(f) Urinary albumin excretion ratio ≥2 min−1
(b) Cholelithiasis
(g) Albumin:creatinine ratio 30 mg g−1
(c) Abdominal, inguinal, and hiatal hernias
(d) Higher incidence of gall bladder cancer (females) Metabolic syndrome: World Health Organization (WHO)
definition (1999)
(e) Higher incidence of colon cancer (males)
Patients with the metabolic syndrome have a much greater
4. Reproductive system incidence of serious medical problems than do patients of
(a) Female infertility, disrupted menstruation, and similar weight
ovulation
(b) Urinary incontinence
(c) Gestational diabetes (BMI > 40 kg/m2) patients undergoing bariatric
(d) Higher incidence of cervical, endometrial, surgery [2]. OSA is associated with many poten-
ovarian, and breast cancer tially serious conditions including systemic
(e) Higher incidence of prostate cancer and pulmonary hypertension, coronary artery
5. Endocrine system
disease, congestive heart failure, and stroke.
(a) Type 2 diabetes mellitus
Polysomnography (PSG) will give a definitive
(b) Disorders of plasma cortisol and growth hormone
diagnosis of OSA; however, preoperative test-
(c) Decreased levels of testosterone and increased
levels of estradiol and estrogen in men ing has not been shown to be cost effective or
6. Musculoskeletal system to actually improve operative outcomes in bar-
(a) Osteoarthritis (hips, knees) iatric patients. In the absence of a PSG diag-
(b) Hyperuricemia and gout nosis, we use the STOP-BANG questionnaire
(c) Rhabdomyolysis to identify patients with OSA [3] (Table 11.3).
(d) Spinal column problems Many of the anatomic and pathophysiologic
7. Dermatologic system consequences that are associated with OSA can
(a) Acanthosis nigricans be reduced or corrected by applying nasal con-
(b) Fungal skin infections tinuous positive airway pressure (CPAP) or bi-
8. Psychiatric level positive airway pressure (BiPAP) devices,
(a) Depression but only if the treatment is instituted weeks or
(b) Low self-esteem
months before surgery. Unfortunately, many
(c) Impaired body image
OSA patients do not use their prescribed CPAP
Increasing obesity is associated with pathophysiologic masks. Those patients who do have their own
changes in all organ systems and with many associated
medical co-morbidities. These conditions should be devices should be instructed to bring them to
sought during the preoperative evaluation and should be the hospital on the day of surgery for use during
optimized before surgery when possible their recovery.
11 Anesthesia in Bariatric Surgery 111

Table 11.3 STOP-BANG Questionnaire for Identifying Diabetic medications (e.g., insulin, oral hypo-
Patients with Obstructive Sleep Apnea (OSA)
glycemics) are also withheld on the day of sur-
SNORE: Do you snore loudly? (snoring gery. Prophylaxis, with an antibiotic against
can be heard through closed wound infection and with heparin to prevent deep
door)
venous thrombosis, is usually given at the sur-
TIRED: Do you feel tired, sleepy,
fatigued, during daytime? geon’s request. An anti-sialogogue (e.g., atro-
OBSERVED: Has anyone seen you stop pine, glycopyrrolate) can also be administered if
breathing during sleep? a fiber-optic tracheal intubation is planned.
BLOOD Do you have, or are you being
PRESSURE: treated, for high blood pressure?
BMI: Is your BMI >35 kg/m2?
11.2 Intraoperative
AGE: Are you older than 50?
Considerations
NECK Is your neck circumference
CIRCUMFERENCE: >40 cm?
GENDER: Are you a male? 11.2.1 Positioning
Modified from: Chung and Elsaid [34]
This questionnaire is used to identify patients with OSA Extremely obese patients have a marked reduc-
who have not undergone diagnostic polysomnography. If tion in lung volume, which is further exaggerated
the answer to any three of these questions is “yes”, then a when they lie flat. Once a patient is moved onto
presumptive diagnosis of OSA can be made. If the answer
to five or more is “yes,” a more “definitive” diagnosis of
the operating room table, they should be posi-
OSA can be made tioned with pillows, blankets, or a commercial
“elevation” device so that their head, upper body,
and shoulders are in the head elevated laryngos-
11.1.2 Premedication copy position (HELP). In this position the
patient’s ears should be level with their sternum.
As a rule sedative premedication should be When compared to MO patients placed in the
avoided, especially for patients with OSA. We conventional “sniff” intubating position, HELP
occasionally give small amounts of an anxiolytic facilitates gas exchange while improving visual
(e.g., midazolam) for very anxious patients. We exposure during direct laryngoscopy (DL) [4].
usually continue most medications for chronic The position of the operating room table influ-
hypertension. The exception are angiotensin- ences the size of the surgical workspace in obese
converting enzyme (ACE) inhibitors (e.g., lisino- patients (BMI > 35 kg/m2) undergoing laparos-
pril, captopril, losartan), which are stopped for copy. In one study the operating room table was
the day of surgery. These drugs can cause pro- placed, in random order, in five different posi-
found hypotension following induction of gen- tions: (1) table horizontal with the legs flat, i.e.,
eral anesthesia. The preoperative administration supine position, (2) table in 20° reverse
of a beta-blocker remains controversial, and it we Trendelenburg (RT) with the legs flat, (3) table in
do routinely use them. 20° RT with the legs flexed 45° upward at the
MO patients were once considered at risk for hips, i.e., beach chair position, (4) table horizon-
gastric acid aspiration because of their increased tal with the legs flexed 45° upward at the hips,
intra-abdominal pressure and a high incidence and (5) table in 20° Trendelenburg with the legs
of gastro-esophageal reflux disease (GERD). flat. This study found that the mean inflated intra-
Recent studies and clinical experience have not abdominal volume in the supine position was
demonstrated a need for routine aspiration pro- about 3.2 l, and that volume increased by 900 ml
phylaxis. For patients with severe GERD and in both the Trendelenburg position or when the
for those who have previously undergone gas- legs were flexed at the hips with RT. Intra-
tric banding procedures, an H2-receptor antago- abdominal volume decreased by 230 ml in the RT
nist (e.g., ranitidine, famitidine) is given position. The conclusion was that the
preoperatively. Trendelenburg position was best for lower
112 J.B. Brodsky

abdominal surgery, and RT combined with leg electroencephalography (EEG) depth of anes-
flexion at the hips gave the largest workspace for thesia monitor, especially to titrate down the
upper abdominal surgery [5]. They noted that concentration of inhalational and intravenous
although the Trendelenburg position increased anesthetics toward the end of surgery prior to
intra-abdominal space, it should not be used dur- emergence [6].
ing bariatric surgery because ventilation of the The anesthesiologist is responsible for proper
MO patient could be significantly compromised placement of gastric tubes, used to decompress
in this position. the stomach, to size the gastric pouch, and to test
All pressure points must be carefully padded for anastomotic leaks. Any foreign body in the
to prevent pressure sores, neurologic injury, and esophagus (gastric tube, temperature probe, TEE
rhabdomyolysis (RML), each of which occurs probe) must be completely withdrawn before the
more frequently in obese surgical patients. The gastric pouch is stapled.
patient’s neck, arms, and legs should also be sup-
ported to avoid stretch injuries and subsequent
peripheral nerve damage. 11.2.3 Fluid Management

Intraoperative fluid requirements in obese

11.2.2 Physiologic Monitoring patients are usually greater than for normal-
weight patients undergoing similar laparo-
Standard physiologic monitors (EKG, noninva- scopic procedures. Obese patients receiving
sive blood pressure cuff, pulse oximetry, end- several liters of intravenous crystalloid had a
tidal capnography, and temperature probe) are faster recovery and fewer complications after
always applied. laparoscopic cholecystectomy than those with
An indwelling urinary catheter is impor- restrictive fluid replacement [7]. There are few
tant in order to monitor urine output. There is studies of fluid replacement in MO patients.
normally a transient decrease in urine produc- Liberal amounts of intra-operative intravenous
tion during laparoscopy, with return of nor- fluid may reduce the incidence of postopera-
mal kidney function following release of the tive nausea and vomiting (PONV) in bariatric
pneumo-peritoneum. patients [8]. Generous amounts of intravenous
An arterial line is usually unnecessary for con- fluid should also be given intraoperatively to
tinuous blood pressure monitoring, except in reduce the risk of RML and postoperative renal
patients with significant hypertension or other failure [9].
cardiovascular conditions. When intraoperative
blood tests are planned, an indwelling arterial
line allows frequent sampling for blood gas anal- 11.2.4 Temperature Maintenance
ysis and for intermittent serum glucose monitor-
ing. Central venous or pulmonary artery lines and All anesthetized patients lose heat and become
trans-esophageal echocardiography (TEE) are poikilothermic during surgery. Even though adi-
seldom indicated, except in patients with signifi- pose tissue is a thermal insulator, heat loss is
cant cardiopulmonary disease or to guide fluid increased during laparoscopy in obese patients
resuscitation. A central venous line may be nec- due to the cool, dry CO2 that is used for the
essary when peripheral venous access is limited. pneumo-peritoneum and when cold irrigating flu-
Ultrasonography greatly increases the success ids are used. Forced-air heating blankets are
rate of internal jugular vein cannulation in obese always applied, and warmed intravenous and irri-
patients. gating fluid are occasionally needed. Attempts to
A nerve stimulator is very important to minimize heat loss using heated and humidified
assess the degree of neuromuscular block- gas for the pneumo-peritoneum have not been
ade. Many anesthesiologists routinely use an successful [10].
11 Anesthesia in Bariatric Surgery 113

11.3 Anesthetic Drug subjects and these formulae can result in inap-
Administration propriate overdosing of heavier patients. TBW
is capped at 150 kg in some models, but TCI
11.3.1 Pharmacologic Principles infusions in bariatic patients are almost always
inaccurate and can be potentially dangerous
Increases in cardiac output (CO), lean body [13]. Intraoperative drug dosing is best guided
weight (LBW), adipose tissue, extracellular fluid by monitoring clinical end points such as heart
volume, liver and kidney abnormalities, and rate and blood pressure, degree of sedation, and
changes in plasma protein binding all occur with degree of neuromuscular blockade.
increasing obesity. Each of these parameters can We prefer using succinylcholine for muscle
alter the pharmacology of the agents used during relaxation for laryngoscopy and tracheal intuba-
anesthesia. Drug dosing based on actual or total tion because of its rapid onset and its short dura-
body weight (TBW) is valid for normal-weight tion of action. Pseudocholinesterase levels and
patients, but must be strictly avoided in obese extracellular fluid space both increase in obesity,
patients. and unlike other drugs the dose of succinylcho-
LBW (muscles, bones, tendons, ligaments, line in obese patients is based on actual or TBW
body water) is equal to TBW minus the weight (1.0 mg/kg), which reflects these changes [14].
of body fat. In normal males, LBW is about Rocuronium can also be used for DL and tra-
80 % TBW and in normal females 75 % of cheal intubation if the reversal agent sugamma-
TBW. There is an overall increase in LBW with dex is available. Sugammadex can immediately
obesity, mainly due to an increase in total body reverse paralysis by rocuronium or vecuronium
water. However, whereas adipose tissue increases if and when airway intubation difficulties are
proportionally with increasing weight, the per- encountered. At this time sugammadex is not
centage of lean body tissue per kilogram of TBW released for clinical use in the United States. For
decreases. Since metabolic activity in the body maintenance of muscle paralysis, there appears
mainly occurs in lean tissues, LBW is a more to be no advantage between any of the non-
practical scalar for drug dosing in every patient, depolarizing muscle relaxants (e.g., atracurium,
but especially those with extreme obesity. As a vecuronium, rocuronium) in bariatric patients.
general guideline for MO patients, simply add- The initial dose of these neuromuscular agents
ing 20–30 % to the patient’s ideal body weight should be based on IBW or LBW and the degree
(IBW) will give a value for LBW that can be used of motor blockade during surgery carefully mon-
for dosing drugs. IBW, for both men and women, itored with a nerve stimulator. Paralysis must be
can be estimated by multiplying patient’s height completely reversed before the patient’s trachea
in meters squared by 22 [11]. is extubated.
Opioids, but especially long-acting agents
(e.g., morphine, hydromorphone, demerol)
11.3.2 Intravenous Drugs should be kept to a minimum due to their respi-
ratory depressive effects. We use an intravenous
The dosing of lipid soluble intravenous anesthetic infusion of the ultrashort acting opioid remifent-
induction agents (thiopental, propofol) should be anil during bariatric surgery to supplement inha-
based on LBW [12]. Anesthetic induction and lational anesthesia. Toward the completion of
maintenance using total intravenous anesthesia the procedure, usually at the time the trocars are
(TIVA) with target-controlled infusions (TCI) removed and after the wounds are infiltrated with
have improved the accuracy of drug delivery for local anesthetic, we discontinue the inhalational
normal-weight patients. However, due to the lack agent but continue the remifentanil. Once surgery
of pharmacokinetic/pharmacodynamic parame- is complete, the remifentanil infusion is stopped.
ters specific to the MO population, the algorithms The patient will usually emerge from anesthesia
used by TCI devices are derived from normal and be fully awake within 2–3 min.
114 J.B. Brodsky

11.3.3 Choice of Inhalational of an endotracheal tube [18]. The UK Society

Anesthetic of Bariatric Anaesthetists recommended that an
endotracheal tube always be the default airway
Desflurane is the least lipid soluble inhaled anes- in obese surgical patients [19].
thetic, and some have recommended its use for MO patients have limited oxygen stores due
obese patients based on the belief that slower to their reduced lung volume. Their hemoglobin
release from fat of the more lipid soluble anes- will desaturate rapidly once they are made apneic
thetics (isoflurane, sevoflurane) will prolong for tracheal intubation. A secure airway must be
emergence from anesthesia [15]. Although lower established quickly. The safe apnea period (SAP),
blood flow to adipose tissue may limit the initial i.e., the time from onset of paralysis to a SpO2 of
delivery of volatile agents to fat, anesthetic con- 90–92 %, is only about 2–3 min in MO patients
centrations in the highly perfused brain and lungs compared to 8–10 min in a normal-weight patient
rapidly decrease once any agent is discontinued. [20]. To “unload” the diaphragm and maximize
In MO patients, there are no significant clinical functional residual capacity, the OR table should
differences in recovery time with any of the inha- be placed in a 20°–30° RT position before induc-
lational anesthetics [16]. tion of anesthesia [21]. Application of positive-
end expiratory pressure and/or noninvasive
positive-pressure ventilation during pre-oxygen-
11.4 Airway and Ventilatory ation prior to intubation decreases atelectasis and
Management increases the SAP in MO patients.

11.4.1 Securing the Airway

11.4.2 Tracheal Intubation
Ventilation by bag and mask can be difficult in
obese patients due to their heavy chest wall and A high Mallampati airway score (III or IV) com-
reduced pulmonary compliance. The presence bined with large neck circumference (>60 cm)
of a high Mallampati score (III or IV) and OSA are the most reliable predictors for potential dif-
with upper airway obstruction are additional risk ficulty with conventional DL [22]. Increasing
factors for difficulty with mask ventilation [17]. BMI itself is not a risk factor for failed tracheal
Besides the potential of hypoventilation during intubation. The most important strategy for suc-
ineffective mask ventilation, gastric insufflation cess with DL is to pre-oxygenate the patient until
can occur which will increase the risk of regur- their end-tidal oxygen concentration is >90 %,
gitation and pulmonary aspiration. For effec- while placing the patient in the HELP (which
tive mask/bag ventilation two people are often significantly improves view with direct laryn-
needed, one to apply and maintain a tight mask goscopy), and tilting the OR table to RT (which
fit while keeping the airway open and one to bag- increases SAP) (Fig. 11.1). A longer SAP pro-
ventilate the patient. vides the laryngoscopist with additional time to
Despite the popularity of supra-glottic airways secure the airway before hypoxemia develops.
for all types of surgery including laparoscopy, An assistant, who is experienced with airway
these devices should be avoided in MO patients. management, should always be immediately
An endotracheal tube protects against acid aspi- available to help.
ration, and allows for controlled or assisted If difficulty with intubation is encountered, an
positive-pressure ventilation. A major audit LMA can serve as a temporary bridge until an
of airway complications during and after gen- endotracheal tube can be successfully placed
eral anesthesia recently reported a several-fold [23]. Intubation aids, including a short laryngo-
increased risk of pulmonary problems, especially scope handle and different laryngoscope blades,
acid aspiration, in obese patients anesthetized a gum elastic bougie, a video-laryngoscope,
with a laryngeal mask airway (LMA) instead and equipment for emergency crico-thyrotomy
11 Anesthesia in Bariatric Surgery 115

Fig. 11.1 The ideal position for induction of general elevated laryngoscopy position (HELP). The operating
anesthesia in a morbidly obese patient is shown. The room table should be tilted 20°–30° in reverse
patient should be positioned with pillows, blankets, and/or Trendelenburg (RT). HELP improves visual exposure dur-
elevation devices so that the head, upper body, and shoul- ing direct laryngoscopy, while RT maximizes lung vol-
ders raised so that an imaginary horizontal line can con- umes increasing the safe apnea period.
nect the patient’s ears with their sternum, the head

and trans-tracheal jet ventilation, should always ventilation have been recommended to minimize
be available. peak airway pressure and potential lung injury, but
Historically, an awake fiber-optic bron- there is no evidence that these practices are actu-
choscopy has been used for MO patients when ally beneficial [25].
a difficult intubation was anticipated. Video- Peak ventilatory pressure increases with the
laryngoscopes have generally replaced the laparoscopic pneumo-peritoneum, and lowering
bronchoscope in anticipated situations, and also tidal volume even further, increasing respiratory
when unanticipated difficulty is encountered dur- rate, and adding positive end-expiratory pressure
ing conventional DL [24]. In some institutions, (PEEP) and/or alveolar recruitment maneuvers
a video-laryngoscope, rather than direct rigid can maintain satisfactory oxygenation and help
laryngoscopy, is now used for the first intubation maximize the surgical workspace [26]. However,
attempt for all MO patients. end-tidal CO2 levels, which normally increase at
the start of the pneumo-peritoneum will increase
even further during small tidal volume ventila-
11.4.3 Mechanical Ventilation tion, and this will result in permissive hypercap-
nia and respiratory acidosis.
MO patients should never be allowed to breathe The pneumo-peritoneum can cause cephalad
spontaneously during laparoscopy, so ventila- displacement of the diaphragm causing the tip of
tion should always be controlled during bariat- the endotracheal tube to enter the right bronchus.
ric surgery. Following successful intubation, we Tube displacement during laparoscopy should
mechanically ventilate our patients with a FiO2 of always be considered in the differential diagnosis
0.5–1.0 and a tidal volume of 10 ml/kg (IBW). Even of hypoxemia and marked increase in peak inspi-
smaller tidal volumes and/or pressure-controlled ratory pressure during surgery.
116 J.B. Brodsky

11.5 Postoperative the patient has poorly controlled diabetes. A

Considerations 5-HT3 antagonist (e.g., odonsatron, granisitron)
is also given during surgery. Administering sev-
11.5.1 Admission to the PACU eral different antiemetic agents can reduce, but
not eliminate the development of PONV. Liberal
As with tracheal intubation at the start of the amounts of intravenous crystalloid fluid replace-
case, careful attention to the airway is also essen- ment may also help reduce the incidence of
tial during emergence from anesthesia. The vast PONV after laparoscopy.
majority of bariatric patients can have their endo-
tracheal tube removed in the operating room
immediately following the completion of sur- 11.5.4 Postoperative Analgesia
gery. If hemodynamically stable, the airway
should be extubated with the patient’s head and At the completion of the laparoscopic procedure,
upper body elevated. The patient should then be the surgeon infiltrates local anesthetic into the
transferred to the PACU and recovered in the trocar sites. Incisional wound pain in the immedi-
same position. Postoperative mechanical ventila- ate recovery period should be less than would be
tion is seldom needed, and ICU admission is rare expected after a laparotomy. However, many
following laparoscopic surgery. patients do complain of mild to moderate general
discomfort, probably from peritoneal irritation
and/or distention from the pneumo-peritoneum.
11.5.2 Management of OSA Opioid analgesia should be kept to a minimum
and use of non-opioid adjuncts should be insti-
For patients with severe OSA, we insert a nasal tuted early. Alpha-2 agonists (e.g., clonidine,
trumpet prior to tracheal extubation in order to dexmedetomidine) reduce analgesic require-
avoid upper airway obstruction immediately fol- ments with no respiratory depressant effects, and
lowing removal of the endotracheal tube. Patients can be used as an alternative or as a supplement
who use nasal CPAP or BiPAP at home should to opioids [29]. Nonsteroidal anti-inflammatory
bring their devices to the hospital to be used in (NSAIDs) drugs are helpful initially, but should
the PACU if there is any sign of airway obstruc- be discontinued within a day or two to avoid the
tion. There is no evidence that CPAP causes potential complication of gastric ulceration.
anastomotic leaks from a distended gastric pouch Additional analgesic strategies include low-dose
following bariatric surgery [27]. A commercially ketamine, intravenous lidocaine or acetamino-
available Boussignac mask helps maintain satis- phen, and/or continuous infusion of local anes-
factory SpO2 levels in patients who do not have thetics, either intraperitoneally or at the wound
their own CPAP equipment [28]. sites [30]. The goal of any of multimodal analge-
sic technique is to reduce or completely eliminate
the use of opioids. Small doses of short-acting
11.5.3 Postoperative Nausea opioids (fentanyl) are used for intravenous
and Vomiting patient-controlled analgesia (PCA). A baseline
opioid infusion should be avoided in bariatric
Obesity is not a risk factor for PONV. However, patients, and the fentanyl administered only as
many patients undergoing bariatric procedures needed by patient control.
do have multiple risk factors (e.g., female, receiv-
ing opioids, emetogenic surgery). We always
start multimodal drug prophylaxis for PONV 11.5.5 Complications
during the procedure. Dexamethasone (4–8 mg)
is a very effective antiemetic agent, and it is rou- Thrombo-embolism can present in the PACU and
tinely included in our therapeutic regimen, unless is a major cause of postoperative mortality. MO
11 Anesthesia in Bariatric Surgery 117

patients are at risk for venous thrombosis because Conclusion

of their greater blood volume, relative polycythe- The incidence of obesity in the population
mia, high fatty acid levels, hyper-cholesterolemia is rising throughout the world, and increas-
and diabetes. Preoperative anticoagulation is ing numbers of obese patients are presenting
always indicated and a vena caval umbrella is for weight-loss procedures. Absolute weight,
sometimes placed in older and very high-risk per se, does not increase anesthetic risk for
patients. Early ambulation must be encouraged. these patients. There are no differences in out-
To achieve this, the anesthetic technique should comes between MO and super-MO patients
allow the patient to recover quickly and be able to undergoing bariatric operations under similar
get out of bed on the same day shortly after sur- anesthetic management [32]. Fast-track lapa-
gery. Many bariatric procedures, including gas- roscopic bariatric surgery can be safely per-
tric banding and gastric bypass operations, are formed, even in the outpatient setting, as long
currently performed in out-patient ambulatory as the anesthesiologist is aware of the special
surgical centers. The most common presentation needs of obese patients and is prepared to
of a pulmonary embolism in the PACU is tachy- meet those challenges [33].
cardia, hypertension, and hypoxemia. Patients
can also experience increased anxiety, dyspnea,
and a “feeling of doom.” These signs and symp- References
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rane or desflurane. J Clin Anesth. 2005;17:413–9.
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2004;240:892–9.
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neum is not indicated: a prospective randomized trial. tion. Anesth Analg. 2002;94:737–40.
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ideal body weight – a new formula. Obes Surg. tion in morbidly obese patients. Eur J Anaesthesiol.
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 Fast-Track in Bariatric Surgery:
Safety, Quality, Teaching Aspects, 12
Logistics and Cost-Efficacy in 8,000
Consecutive Cases

Hjortur Gislason, H.J. Jacobsen, A. Bergland,

E. Aghajani, B.J. Nergard, B.G. Leifsson,
and J. Hedenbro

12.1 Introduction and length of hospital stay. The term now refers
to a multimodal package of techniques, which
In the last decades, there has been continuous aim to decrease post-surgical organ dysfunction,
development in surgical and anaesthesia tech- improve post-operative recovery and reduce
niques with a shift towards less invasive and less complications. This includes enhanced recovery
traumatic treatment. Many of the standard modal- after surgery (ERAS); ERAS protocols are aimed
ities in abdominal surgery like routine use of at improving surgical recovery and implement
nasogastric tubes, drains and urine catheters have several evidence-based perioperative care inter-
been shown to be unnecessary or even harmful. ventions [2, 3]. Another and no less important
Minimally invasive surgery and, especially, the issue for patient safety is the teaching and train-
use of laparoscopic technique have been proved ing aspects of new surgeons as well as of the
as safe and associated with enhanced recovery. whole surgical team [4–8]. The use of short-
The term “fast-track surgery” originally described acting opioids and lower dose of propofol only in
by Kehlet [1] dealt primarily with patients’ pain the induction of anaesthesia are useful to ensure
quicker emergence from anaesthesia [9, 10].
Results can be improved by making a medical
H. Gislason (*) • H.J. Jacobsen • E. Aghajani audit and standardizing all aspects of the treat-
B.J. Nergard • B.G. Leifsson ment process. Continuously entering own data to
Department of Surgery, Aleris Hospital, a database increases awareness of the results.
Aleris Obesity, Fredrik-Stangs gate 11-13,
Oslo 0264, Norway
In times of limited economic resources, most
countries have a limited health budget but a large
Aleris Obesity Skåne, Skåne, Sweden
e-mail: [email protected]
number of patients needing our treatment
[11–16]. It is our obligation to secure a good use
A. Bergland
Department of Anaesthesia, Aleris Hospital,
of these resources by treating as many patients as
Aleris Obesity, Fredrik-Stangs gate 11-13, possible for a low cost and with high quality.
Oslo 0264, Norway Good logistics are also a key element in order
Aleris Obesity Skåne, Skåne, Sweden to streamline the work and secure maximal use of
J. Hedenbro
the resources, improve patient quality and obtain
Department of Surgery, Aleris Hospital, good long-term results. Economical awareness is
Aleris Obesity, Fredrik-Stangs gate 11-13, especially important and easily incorporated in
Oslo 0264, Norway the treatment process without compromising
Aleris Obesity Skåne, Lund-Kristianstad, Sweden patient safety and quality.

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 119
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_12,
© Springer International Publishing Switzerland 2015
120 H. Gislason et al.

Fig. 12.1 Factors

involved in ERAS/ Fast track principles
fast-track surgery (From
Jacobsen et al. [17], with
• Minimal invasive technique • Standardized anestesia
permission)
• Standardized surgery • Multimodal paintreatment
• Experienced surgeons (opeoid/non-opeoid)
• Consistent treatment team • Local anestesia
• Antiemetics

• Reduced surgical
Stress response

• Reduced morbidity

Exclusion of additional Post operative management:

interventions:
• Walking test within 2 hrs
• Gastric tube • Free oral fluid
• Urine catheter • Enhanced mobilization
• Central vein catheter
• Arterial cannula
• Drainage

Outcome of treatment is measured by hospital bariatric surgery based on “fast-track” methodology

stay, rate of readmissions and complications, with focus on quality, cost-efficiency and training
economical aspects and long-term results on of new bariatric surgeons.
weight and comorbidity.

12.3 Materials and Methods

12.2 Our Practical
Implementation Aleris Hospital in Oslo, Norway, and Aleris
Obesity Skåne, Sweden, are two surgical pri-
Experienced surgeons, well beyond their learning vate practice units specializing in bariatric sur-
curves, initiated a high-volume bariatric surgery gery. The treatment protocol was started and
programme in 2005. Clinical pathways were developed in Oslo in 2005–2008 [10, 17].
established and time recordings from all parts of Evidence-based elements of “fast-track” sur-
the treatment as well as clinical outcome were pro- gery with minimal invasive technique were
spectively registered. With time, we have imple- implemented in the programme from the begin-
mented our approach to four different hospitals. In ning (Fig. 12.1). Both units used the same treat-
order to provide good-quality treatment for high ment protocol and a joint database, and all
volumes of patients, a separate department was operations were performed in a standardized
deemed necessary, so that no interference occurred manner using the same rotating team of sur-
from the emergency room patients or other type of geons. All 8,000 consecutive LRYGBs per-
surgery. The nursing staffs were offered good con- formed in the two hospitals between September
ditions in order to avoid shifts in personnel. 2005 and February 2014 were included in
We present a cohort study with 8,000 consecu- the study. Indications for surgery were the same
tive LRYGB using a standardized programme for as those generally accepted as good standard
12 Fast-track Roux-en-Y Gastric Bypass: Logistics and ERAS 121

Table 12.1 Enhanced recovery after surgery (ERAS) protocol

Pre-operative preparation Screening by phone: criteria for surgery? Medical records collected
A 1-day course on education and information by the multidisciplinary team
Initiation of patient contribution: physical activities, diet, stop smoking
Day of operation Clear oral fluid up to 2 h before surgery, no solid food for 8 h
Shower with antiseptic sponge 2 h before surgery, empty urinary bladder
Single-dose cefuroxime (1.5 g iv) or 800 mg Bactrim® orally 2 h before surgery
No thrombosis prophylactics unless history of thrombo-embolic diseases, or APC
resistance in family history
During operation 8 mg i.v. dexamethasone at induction of anaesthesia
Standardized anaesthesia
Local anaesthetics in wounds
In the recovery room Observation (telemetry, oxygen saturation), pain medication and antiemetics when
needed
Free oral fluid (amount recorded )
Walking test (20 m) after 2 h and arrival to the ward
At the ward – day of surgery Standard multimodal analgesia and anti-emetic
Intensive mobilization; out of bed every h, using the PEP whistle, “keep the patient
busy”
5,000 IU low molecular heparin 6 h after surgery
If tachycardia, more pain than expected or not getting out of bed the surgeon
notified
Day after surgery Shower and changing the bandages
Group meeting with the dietician (liquid and pure diet for 5 weeks)
Going through pre-operative blood test and administering the supplements
Discharge meeting with the surgeon emphasizing “early sign of complication” and
the importance of early contact by phone
Patients living within 90 min from hospital discharged home, the others to the
neighbouring hotel for 1–4 days
After discharge Phone call 1 and 7 days and 3 weeks after discharge
Self-administration of low molecular heparin s.c. for 10 days
Omeprazole 40 mg daily for 3 months

for bariatric surgery in the European day of surgery was scheduled, usually 5–6 weeks
Guidelines [18]. later (Table 12.1).
We developed a “length of hospital stay pre-
diction system” based on comorbidity, BMI, psy-
12.4 Pre-operative Preparation chosocial status and distance of residence from
and Organization the hospital [17]. The ambition was to close the
ward during most weekends, and this was facili-
At first contact, a screening phone call is made tated by identifying and scheduling patients with
providing medical history, and the previous med- anticipated longer hospital stay to the beginning
ical records are collected. The patients attended a of the week. Initially, patients were offered 3-day
mandatory full-day course with information and post-operative hospital care, but in 2008 this was
education in group sessions held by a surgeon, reduced to 2 days and in 2009 patients were
anaesthesiologist, nurse, dietician and physio- planned to be discharged on the first post-
therapist. The patient was fully informed about operative day. Patients living more than 1 hour of
the fast-track set-up and what will happen on the transport from the hospital were encouraged to
day of surgery. Weight loss of 5 % and change in stay near the hospital until 5 days after surgery.
lifestyle and eating habits were strongly encour- The ward and one operating theatre were
aged prior to surgery. At the end of the day of the booked for 4 days at a time; the frequency of
first visit, patients were evaluated for indication “bariatric weeks” depended on the number of
for surgery, type of operation was decided and patients cleared for surgery. The ward is usually
122 H. Gislason et al.

closed on Friday evenings but remained open Table 12.2 Safe surgery, teaching aspects and quality
control
during the weekend only due to emergency cases
or prolonged hospital stay. All members of the Continuous medical education
team of all staff
Standardization
Research and development
12.5 Logistics and Fast-Track projects for all categories
Principles Surgeon Two surgeons procedure
Five-step training 1. Assisting in 50 operations
Medical audit for the patient flow was made. All programme for new 2. Starting operation and
surgeon operating for 45 min with
elements of the treatment procedures before, dur- strict hands-on guidance
ing and after surgery were thoroughly standard- (two of six operations that
ized. The team in the operating theatre consisted day)
of two surgeons, one senior bariatric surgeon and 3. When technically sufficient
and good progression within
the other a surgeon skilled in laparoscopy but in 45 min, the trainee is allowed
training for bariatric surgery. There were also two to complete the operation, but
operating nurses, one anaesthesiologist and one not exceeding 60 min
anaesthetist nurse. The time recordings were con- 4. The trainee is performing 100
more operations still with
tinuously registered in a database. The whole hands-on guidance
treatment was based on teamwork and all co- 5. The trainee becomes expert
workers were primed on their role to get a stream- surgeon and starts performing
lined logistics and avoid unnecessary waiting. An surgery with a trainee
important principle at the operating theatre was Early sign of Immediate re-operation
complication
“parallel working”, many staff members working
Recordings of If complication within 30 days,
with the patient at the same time, washing and operation video recording of the operation
covering abdomen before the patient was intu- examined in order to learn and
bated, reflecting the fact that the “busy time in the improve
process is the turnover-time”. Continuous database Individual surgeon’s
recordings complication rate can be
Standardization of the procedure makes the followed
surgery safer, as it is performed precisely the
same way by all surgeons of the team. Most
authors agree that the experience and skill of the
individual surgeon is the most important single 12.6 Surgical Procedure
factor for patient safety and good outcome [4–8].
Thus, training programmes for new surgeons are The surgical procedure was meticulously stan-
of great importance in order to avoid painful dardized and the time used for different parts of
learning curves. Technical training in intracorpo- the operation was recorded (Fig. 12.2). The pur-
real suturing and use of staplers needs numerous pose was to enhance technical improvements and
repetitions under guidance (Table 12.2). shorten the surgical time. This also helps the
All the instruments used for each operation anaesthesiologist to monitor the anaesthesia
were pre-packed into three standardized pack- according to the progress of the surgery and to
ages. One package contained the reusable surgical time the termination of the anaesthesia.
tools, packed and sterilized at our hospital. The The surgical procedure has been described in
other two packages were custom made for our detail previously [17, 19]. The patient was placed
purposes by surgical tools suppliers: one contain- in a supine, split-leg, reversed Trendelenburg
ing staplers and troacars (Ethicon Endo-Surgery position. Five ports were used: two 5-mm and
or Covidien) and the other containing all other two 12-mm ports for instruments and one 10-mm
single-use items for one operation (Mölnlycke port for the camera. A 45° scope and intra-
Health Care AB, Gothenburg, Sweden). abdominal pressure at 18 mmHg were used.
12 Fast-track Roux-en-Y Gastric Bypass: Logistics and ERAS 123

Logistics of laparoscopic Roux-en- Y gastric bypass (RYGBP)

One day One procedure One operation

Preparing operating room

Start of surgery
Arrival
5:15 min
Start of anestesia 27 %
5:09 min
Start of surgery
Gastric pouch completed

32 %
39 min

First anastomosis

26 %
End of surgery
1:18 min
Second anastomosis
End of anestesia
15 %
3:37 min
To recovery End of surgery
Preparation or
11 min

Six RYGBP 65:19 min 39 min

Fig. 12.2 Logistic of the treatment process from when a 2010. Non-operative time is mean time (minutes: sec-
patient walks into the operating theatre until next patient onds). The operating time is referred as median (From
arrives for 261 patients operated during second half of Jacobsen et al. [17], with permission)

In brief, a small gastric pouch (15 ml) was created 12.7 Anaesthesia
with the bowel in an antecolic and antegastric
position. The gastroenteric (GE) anastomosis and The patient walked into the OR after receiving a
the enteroenteric (EE) anastomosis were stapled peripheral venous cannula and IV antibiotic pro-
linearly and the staple holes handsewn. The phylaxis with single dose of cefuroxim 1.5 g. The
bowel was approximated to the gastric pouch as anaesthetic method has been described in detail
an omega loop, subsequently divided by stapling [10, 17]. In brief, induction of anaesthesia was
between the two anastomoses. The last step was performed in semi-reversed Trendelenburg posi-
to test the integrity of the GE anastomosis by tion, using fentanyl and target controlled infusion
inflation with methylene blue–dyed saline via a of propofol and remifentanyl based on the
nasogastric tube. The nasogastric tube was patient’s ideal weight. Muscle relaxation was
inserted and removed during the period of anaes- facilitated with a small dose of vecuronium. After
thesia. Until June 2010, LRYGBs were per- tracheal intubation, propofol was substituted
formed without closing the mesenteric defects, with desflurane to ensure rapid recovery from
but since July 2010 the mesenteric defects were anaesthesia after the surgery.
stapled as described previously [20].
During the period from 2007 to 2013, five
skilled laparoscopic surgeons went through a 12.8 Post-operative Care
specific training programme in bariatric surgery. (Table 12.1)
In order to minimize the negative consequences
of the learning curve, the training programme The patients were observed post-operatively and
was strictly organized in five steps as shown in monitored at the recovery unit for approximately
Table 12.2. 2 h. Within the first 2 h, the patients were
124 H. Gislason et al.

mobilized out of bed and were allowed to drink 12.10 Data Collection and Statistics
freely. The patients were encouraged to drink at
least 1 L of water until the next day. Data were prospectively collected and registered
Post-operative pain was controlled with in our database (FileMaker 11), which is a part of
paracetamol, parecoxib and oxycodone at fixed our routine patient record system. The surgeons
intervals. Post-operatively, 1,000 mL Ringer’s filled in data regarding the operation and post-
acetate was prescribed as IV fluid until the next operative care, as well as primary data concern-
morning. ing patient characteristics and discharge status.
If the patient had more pain than expected, The anaesthesia personnel registered the time
experienced tachycardia or was not able to move consumption for different tasks in the operation
out of bed, the surgeon and/or anaesthesiologist theatre and turnover time between operations.
were consulted. Threshold for early re- The theatre procedure was divided in six different
laparoscopy was low in order to reduce the con- parts for this purpose (Fig. 12.2).
sequences of a possible complication. All data regarding weight loss, metabolic sta-
At the ward, observation and mobilization tus and post-operative changes in comorbidity as
were continued. Patients were instructed to get well as complications were registered continu-
out of bed at least once every hour, drinking small ously. All patient contacts with personnel from
sips and blowing the PEP whistle. Early the day the obesity team were recorded and relevant
after surgery patients took a shower and got new information registered in the database. All
bandages. They also attended a group meeting patients operated in Sweden had their data
with the dietician to discuss fluid and pureed entered into the database of the Scandinavian
food, and with the surgeon for instruction about Obesity Surgery Registry (SOReg) that covers
possible complications and how to react. After >98 % of bariatric surgery in Sweden. This
discharge the patients had open access for read- enabled us to make frequent comparisons with
mission to the hospital and were carefully other specialist centres.
instructed to contact the ward or surgeon in case Proportions are referred to as numbers (%).
of any adverse events. The patient also had the All continuous data are presented as median
telephone numbers of the surgeon on call at any (range) unless otherwise stated. Differences were
time, of the ward and the outpatient clinic. estimated by Student’s t test, with a p-value <0.05
A questionnaire was sent to all the patients 4 being regarded as significant. Weight loss was
weeks after surgery in order to evaluate patient expressed as percentage excess BMI loss
satisfaction. This questionnaire consisted of (%EBMIL).
questions about the patient’s perception of the
different parts of the treatment process.
12.11 Results

12.9 Follow-Up Routines During the period September 2005–February

2014, 8,000 patients were admitted at our units
Our patients also entered a 5-year interdisciplin- for bariatric surgery. Primary LRYGB was per-
ary follow-up programme. This includes live- formed successfully in all cases and no conver-
style courses consisting of a group of 16–18 sions to open surgery were needed. In 97.8 % of
patients at 3 months, 1 and 3 years. Metabolic the patients, the data collection was complete.
follow-up is done twice a year in the first 3 years Eighty-one patients (1 %) were lost from our
and then once a year, most often in co-operation follow-up system with no data available at 1
with their general practitioner. Abdominal prob- month or more after surgery; 7,639 (95.5 %)
lems that could be related to the obesity surgery were primary operations and 359 (4.5 %) opera-
are a part of the treatment package and taken care tions were revisional procedures, where most of
of by the surgeons of the team. the latter had previously undergone open VBG or
12 Fast-track Roux-en-Y Gastric Bypass: Logistics and ERAS 125

gastric banding; 78 % were females, with median severe peritonitis due to late leakage that mani-
age 41.9 years (17–77) and mean BMI 42.8 fested itself on the fifth and on the seventh post-
(28.7–81.1). operative day, respectively. One patient died due
to aspiration at intubation secondary to bowel
obstruction. Thus, the mortality rate within 30
12.12 Complications days was 0.04 % (3/8,000).

Total complications rate (<30 days) was 2.3 %;

126 patients (1.6 %) had reoperation within 30 12.13 Fast-Track Principles
days. Of these, 69 (0.9 %) had gastrointestinal (Table 12.3)
leakage, 50 (0.63 %) were re-operated and 19
were conservatively treated. Fifty-nine patients Time consumption in all parts of the procedure
(0.7 %) had clinically significant bleeding, was gradually reduced from 102 min in 2005–
defined as bleeding requiring either re-operation, 2007 to 49 min in 2011–2013 (p < 0.001). This
blood transfusion, endoscopic intervention or includes non-surgical time consumption in the
haemoglobin <8.5 g/100 mL. Twenty-seven operation theatre was reduced from 43 min in
(0.34 %) of these patients had an early re- 2005–2006 to 13 min in 2011–2013 (p < 0.001).
operation; two (0.03 %) had endoscopic treat- The surgical time was reduced from median 59
ment. Seventeen (0.21 %) received blood (40–96) to 36 (22–144) min in the same period
transfusions only, and 13 patients were observed (p < 0.001) and the turnover time from 13 to
without any intervention. 7 min (p < 0.001).
Twenty-eight patients (0.35 %) were re- Figure 12.2 illustrates the logistics and time
operated due to bowel obstruction. There were 21 consumption during all stages of the operation
negative laparoscopies (0.3 %). Thus, 21 (16.7 %) including the turnover time between operations
of the 126 reoperations failed to demonstrate any during the second half of 2010 (261 procedures).
suspected complication. The median hospital stay was 1.7 (1–110) days
Nine patients (0.1 %) were admitted to the for the total patient material. From 2005 to 2007
intensive care unit (ICU) with serious complica- compared to 2011–2013, the hospital stay was
tions. Three of those patients died; two due to reduced from 3.1 (2–110) to 1.3 (1–13) days

Table 12.3 Results and progression in the fast-track programme

First part of Last part of
study period study period
2005–2007 2011–2013
N = 425 N = 4618
Logistics One procedure Total time 102 49 (p < 0.001)
(minutes) Operation time 59 (40–96) 36 (22–144) (p < 0.001)
Non-operation time 43 13 (p < 0.001)
Time between 13 7 (p = 0.04)
procedures
Economics Number of patients 3.7 (2–5) 7.3 (5–8) 100 % increase in
operated from 8 am to production with
4 pm 7 % increase in
staff
ERAS Complication rate 1.4 % 2.6 % (p = 0.20). Include
(<30 days) five learning curves
ERAS Readmission rate 1.3 % 2.6 % (p = 0.20)
(days)
ERAS Hospital stay (days) 3.1 (2–110) 1.3 (1–56) (p < 0.001)
126 H. Gislason et al.

Table 12.4 Factors to ascertain economy surgical time for the five trainees for the first and
1. Well-organized teamwork – logistics last 100 complete operations decreased from
2. Risk and discharge classification of patients median 60 to median 43 min (p < 0.001).
3. High volume of patients and the ward closed at most In Table 12.3, the main results of the fast-track
weekends programme are summarized.
4. Surgical procedure without excessive use of staplers,
use of multiple use instruments
5. Short hospital stay
6. Low readmission and complication rate
12.14 Discussion

By implementing a fast-track protocol with con-

(p < 0.001) (Table 12.3). A total of 160 (2.0 %) tinuous recording and analysis of results, we have
patients were readmitted during the first 30 days, been able to improve our results step by step.
most often because of dehydration or constipation. We have managed to double the volume of
The average excess BMI loss after 18 months patients treated with relatively small increases in
was 81, and 73.1 % at the observed median fol- total hospital costs, perfoming 1,600–1,900
low-up time of 43 months (range 4–96) after bypasses per year with the same staff during the
surgery. last 4 years at the two units. Time consumption
Data on hospital satisfaction were obtained for the total procedure was reduced from 102 min
from 706 patients during 2008–2010. The evalua- to 49 min (p < 0.001), comparing the first and last
tion showed that 95 % of the respondents were well 3 years. With only 7 min turnover time between
or very well satisfied (score 5 or 6 on a scale of the patients, total time for one patient has been
1–6) with the treatment and stay at the ward. reduced to 56 min, enabling us to perform 6–8
Further, 99 % expressed that they would recom- operations in a single operating theatre during
mend our facility to others for the same treatment. ordinary daytime.
The cost to keep the ward open for 5 days was We were able to keep the complication rate
approximately 31.000 EUR (250.000 NOK) and more or less constantly low throughout this
for the weekends 12.500 EUR (100.000 NOK). 8-year period, but at the same time five surgeons
Personnel costs represent almost half of the total were trained into fully qualified senior bariatric
cost. Out of 83 treatment weeks in our two units, surgeons. By using ERAS protocols, we were
wards were closed during weekends in 62 (75 %). gradually able to reduce scheduled hospital stay
In 2007, nine nurses were required per ward to from 3 to 1 day, without increasing the readmis-
cover day, evening and night shift. From 2010 sions significantly (constant around 2 %).
this number was increased to ten nurses and We used pre-operative ASA score to guide
remained constant. In comparison with 2007, in patient selection; patients with an ASA score
2010 we treated 100 % more patients with only greater than 3 were not included in the fast-track
7 % increase of personnel on the wards, and no protocol. However, only very few patients scor-
change in personnel in the operating theatres. ing ASA 4 were excluded. We found, as others
Table 12.4 outlines the distribution of the cost of have shown, that pre-operative education and
the treatment process other than salaries. preparation of patients are vital steps in order to
During the study period five surgeons were secure successful fast-track programme [9, 21].
educated in bariatric surgery. After assisting on Patient demographics in our study are compara-
50 operations, trainees were successively allowed ble with other European studies, both regarding
to perform more parts of the surgery (Table 12.2). BMI and comorbidities [7, 22, 23].
In 2010, they performed 427 cases as chief sur- Our early complication rate at 2.3 % is accept-
geons with only 11 (2.6 %) major complications, able and comparable with good results from
5 (1.2 %) of which required re-operation. The other high-volume units [7, 22–24]. A protocol
12 Fast-track Roux-en-Y Gastric Bypass: Logistics and ERAS 127

for enhanced recovery makes the post-operative tubes, abdominal drainage, perioperative bowel
management easier. Our re-operations rate was clearance or enforced bed rest. On the contrary,
1.6 %, but some of the leaks and bleedings could by mobilizing our patients within 2 h, using no
probably have been treated conservatively. urine catheter and allowing them to drink fluids
However, by performing an early re-operation, freely, we were able to reduce the use of intrave-
usually without prior radiological examination, nous fluids and we have noticed considerable
prolonged hospital stay can be avoided. Also, reduction in the use of pain and anti-emetic medi-
due to an aggressive attitude to early re-opera- cation. Arterial cannulas for intra-operative blood
tion, only nine patients (0.1 %) needed ward in pressure recordings or central vein catheters were
the ICU. Still, three of these patients died rarely used.
(0.04 %), two due to late leakage and delay in The hospital stay in our study was reduced
treatment. In order to prevent such deleterious throughout the study period and mean hospital
outcome, thorough information to the patient is stay was 1.7 days. Several studies have evaluated
very important. In case of acute adverse events, ERAS protocols in bariatric surgery and demon-
hospital ward or surgeon on call should be con- strated similar reductions in post-operative hos-
tacted immediately and early readmission and pital stay without increase in perioperative
treatment secured. morbidity [10, 17, 26–28].
In many hospitals, long delays between opera- We had a high follow-up rate (98.6 %) on
tions, i.e. turnover time, is a barrier, keeping the weight loss and early and serious complications.
production at a low volume. Our time recording The average excess BMI loss was 73.1 %
system was an important control tool in order to observed median 43 months (range 4–96) after
increase and maintain a high efficacy in our surgery. This is acceptable but long-term data are
clinic. Issues that created delays in our logistics still not available.
were identified and corrected at early stages. In Salaries for the physicians and staff represent
our setting, the surgeons were highly involved in 49 % of our total costs. Only a fraction of these
the turnover process by getting the next patient costs are volume dependent. High production
ready for operation. volume, as in our centre, is therefore cost effec-
We found our education programme for new tive. From 2007 to 2010, we managed to double
bariatric surgeons to be useful. In our fast-track the number of procedures per bariatric surgical
system, the surgery should not take more than 1 week, by increasing the staff of ward nurses by
hour. In order to measure the trainee’s progres- only 7 % and without increasing the staff at the
sion, we found it useful to record the four differ- operating theatre. We also find our “discharge
ent parts of the operation (Fig. 12.2). The classification” to be a useful logistics tool for
operating time for our five trainees declined sig- increasing the likelihood of being able to close
nificantly from their first to their last 100 cases the ward in most (75 %) of the weekends. Of
(p < 0.001). Further, the complication rate was costs other than salaries, stapler devices make up
not increased during their learning curves. a very significant part (Fig. 12.3). It is therefore
Recently, many studies have demonstrated crucial to optimize their use, e.g. with reusable
that multimodal evidence-based care within the instruments.
fast-track methodology and implementation of In order to spread knowledge of our methods,
clinical pathways significantly enhances post- we have had numerous courses demonstrating
operative recovery and reduces morbidity. It our fast-track model for colleagues from other
should therefore be more widely adopted [7, 9, countries, and we organize an annual meeting
22–25]. Our study supports this conclusion. We dedicated to bariatric surgery. This kind of
found no need for traditional surgical approaches approach and experience may also be transferred
such as the use of post-operative nasogastric to other types of standardized surgery.
128 H. Gislason et al.

Fig. 12.3 Pie chart of Staplers

distribution of costs other 6%
than salaries. Analysis of 8% Other disposable material
one full fiscal year at one
centre
10 % Pharmaceutics

2% Week-end and ICU extra costs

3%
59 % External services
12 %
Lease of ward and office space

Other costs

Conclusion 6. Shikora SA, Kim JJ, Tarnoff ME, et al. Laparoscopic

By establishing a dedicated treatment team, Roux-en-Y gastric bypass: results and learning curve
of a high-volume academic program. Arch Surg.
implementing fast-track methodology and fol- 2005;140(4):362–7.
lowing closely our results, we were able to 7. Sommer T, Larsen JF, Raundahl U. Eliminating learn-
increase the production volumes, reduce costs, ing curve- related morbidity in fast track laparoscopic
and at the same time train new bariatric sur- Roux-en-Y gastric bypass. J Laparoendosc Adv Surg
Tech A. 2011;21(4):307–12.
geons without new learning curves and with- 8. Ballantyne GH, Ewing D, Capella RF, et al. The learn-
out compromising the safety or quality for the ing curve measured by operating times for laparoscopic
patients. and open gastric bypass: roles of surgeon’s experience,
institutional experience, body mass index and fellow-
ship training. Obes Surg. 2005;15(2):172–82.
9. Kehlet H, Wilmore DW. Evidence-based surgical care
Conflict of Interest All contributing authors declare that and the evolution of fast-track surgery. Ann Surg.
they have no conflicts of interest. 2008;248(2):189–98.
10. Bergland A, Gislason H, Raeder J. Fast-track surgery
for bariatric laparoscopic gastric bypass with focus on
anaesthesia and peri- operative care. Experience with
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 Part III
Surgical Treatment
 Indications for Bariatric Surgery
13
Marcello Lucchese, Giovanni Quartararo,
Lucia Godini, Alessandro Sturiale,
and Enrico Facchiano

13.1 Introduction than anything else, since there is a wide disparity

in the proportions of different types of operations
Early bariatric surgeries took place in the 1950s performed between centres and countries [3].
and initially consisted of the intestinal bypass
procedure, aimed to induce an iatrogenic malab-
sorption resulting in weight loss. 13.2 Actual Indications
In 1991 the National Institute of Health pro-
posed the first guidelines for the practice of bar- Bariatric surgery is indicated in patient in the age
iatric surgery, eventually creating new guidelines from 18 to 60 years having:
expanding indications and procedures [1]. 1. BMI ≥40 kg/m2
Indications for bariatric surgery have been 2. BMI ≥35 kg/m2 with co-morbidities that can
analysed and accepted by different scientific soci- improve with weight loss (diabetes, hyperten-
eties over years, including the last revision pub- sion, OSAS, severe joint disease, severe psy-
lished by the European Chapter of International chological problems secondary to obesity,
Federation for the Surgery of Obesity in 2014 [2]. etc.) [2]
On the other hand, there are no precise recom-
mendations concerning the type of procedure
based on patient characteristics. This choice 13.3 Type 2 Diabetes
seems to be related to surgeon experience more
Bariatric surgery in these years took an impor-
tant role in diabetes treatment. Medical thera-
peutic options targeting primarily glucose
M. Lucchese (*) • G. Quartararo control, in fact, have very limited success in con-
A. Sturiale • E. Facchiano
Department of Surgery, Bariatric and Metabolic
trolling blood glucose levels amongst the
Surgery Unit, Azienda Sanitaria Firenze, Santa Maria severely obese, with many of these patients not
Nuova Hospital, Piazza Santa Maria Nuova, 1, achieving targets [4].
Florence 50122, Italy Bariatric surgery has demonstrated to be
e-mail: [email protected]; [email protected];
[email protected]; [email protected]
effective in long-term control of type 2 diabetes.
RYGBP seems to be the best operation when
Lucia Godini
Department of Neuroscience, Psychology, Drug
obesity is associated with type 2 diabetes, even
Research and Child Health, University of Florence, though some studies have shown that even pure
Largo Brambilla, 3, Florence 50134, Italy restrictive procedures can be effective [5].
Symptoms mimic those of a brain tumor, but no tumor is present. Pseudotumor cerebri can
occur in children and adults, but it's most common in women of childbearing age who are obese.
The pressure inside your skull (intracranial pressure) increases for no obvious reason.
M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 133
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_13,
© Springer International Publishing Switzerland 2015
134 M. Lucchese et al.

The problem of long-term recovery from type Guidelines on Metabolic and Bariatric Surgery
2 diabetes after bariatric surgery has been exten- have been published on behalf of IFSO-EC and
sively treated elsewhere in this volume. EASO [2], and we report their considerations:
It is also underlined that bariatric surgery can
be considered in genetic syndromes, such as
13.4 Young Obese Prader–Willi syndrome, only after careful con-
sideration of an expert medical, paediatric and
Bariatric surgery in adolescents and child can surgical team [2, 8, 9].
be actually considered only in specialised cen- In adolescent patients, the RYGB ensures the
tres and after a careful multidisciplinary evalu- best weight maintenance but it requires an adher-
ation [2]. ence to the follow-up, such a commitment is not
According to the recent update of the ASMBS always guaranteed in such subjects [10]. On the
paediatric committee best practice guidelines, the other hand, SG procedure seems to prove to be a
selection criteria for adolescents being consid- viable option for the treatment of adolescent
ered for a bariatric procedure should include a obesity, achieving both weight loss variations
BMI of >35 kg/m2 with major co-morbidities (i.e. and resolution of co-morbidities comparable to
type 2 diabetes mellitus, moderate-to-severe the RYGB procedure without malabsorptive
sleep apnoea, pseudotumour cerebri or severe risks [2].
NASH) or a BMI >40 kg/m2 with other co- Despite single differences in recommenda-
morbidities (e.g. hypertension, insulin resistance, tions guidelines, we can conclude that bariatric
glucose intolerance, substantially impaired qual- surgery in adolescents and children should be
ity of life or activities of daily living, dyslipid- performed only in centres of excellence with
emia, sleep apnoea with apnoea–hypopnea index extensive experience in bariatric surgery for
>5) [6, 7]. adults. A multidisciplinary approach to these
patients, including paediatric specialists, is
mandatory.
An adolescent with severe obesity bar-
iatric surgery can be considered if he/she:
13.5 Elderly Obese
1. Has a BMI >40 kg/m2 (or 99.5th percen-
tile for respective age) and at least one
In the elderly obese (>65yy), bariatric surgery did
co-morbidity
not necessarily show to be effective in signifi-
2. Has followed at least 6 months of organ-
cantly prolonging the average mean of life [2, 11].
ised weight-reducing attempts in a spe-
Benefits of bariatric surgery in the senior
cialised centre
obese patient are still being evaluated. Even if
3. Shows skeletal and developmental
postoperative risks in the over 60 obese are
maturity
potentially higher, the advantages of recovered
4. Is capable to commit to comprehensive
mobility, the increased independence and the
medical and psychological follow-up
improved control of co-morbidity may lead to a
5. Is willing to participate in a post-
better quality of life [12, 13].
operative multidisciplinary treatment
The proof of favourable risk–benefit of bar-
programme in a unit with specialist pae-
iatric surgery in elderly is lacking so far. Several
diatric support (nursing, anaesthesia,
recent studies proposed sleeve gastrectomy as
psychology, post-operative care)
the procedure of choice in elderly obese since it
could obtain advantage in terms of quality of
life from weight loss for the low complication
For what concerns European guide- rate and the absence of malabsorptive compo-
lines, recently the Interdisciplinary European nent [14].
13 Indications for Bariatric Surgery 135

Age seems to be a prognostic factor for in obese patients will result in implementation
weight loss and co-morbidities remission as of overall health and quality of life.
well the degree of obesity, patient motivation In a recent meta-analysis, it has been demon-
and the presence of uncompensated binge- strated that body weight loss significantly
eating disorder. Further studies are needed to increases testosterone levels in obese patients.
identify predictive factors of outcome after bar- Moreover, testosterone recovery seems to be
iatric surgery, in particular regarding physical directly correlated with the weight loss.
activity and psychiatric disorders [15, 16]. The Testosterone rise induced by lifestyle interven-
identification of predictive factors of success tions was only modest, probably reflecting the
will help to develop interventions targeting spe- relatively modest results of the targeted diet and
cific needs of patients. physical activity on body weight loss. The testos-
As for young obese, in the elderly obese terone increase would be more important after
patients, an accurate multidisciplinary evaluation surgical-induced weight loss (9.8 % with diet vs.
is mandatory in order to evaluate the risk–benefit 32 % with surgery) [20].
ratio before possible bariatric surgery. As a matter of fact, male hypogonadism could
represent a new co-morbidity to consider when
evaluating patients for bariatric surgery, and so it
13.6 Novel Indications could become a new possible criterion for patients
with BMI ≥35 [19].
In the last decade, we are assisting to a novel More studies, based on randomised trials,
dynamic revaluation of the historical selection are needed to confirm the role of testosterone of
criteria for bariatric surgery. This is not just for glycaemic metabolic control after bariatric
the higher incidence of obesity worldwide but for surgery.
the evidence of new obesity-related pathological
conditions and co-morbidities. FL
The necessity of evaluating new obesity- 13.6.2 NALFD
steatosis » nonalcoholic steatohepatitis » fibrosis » cirrhosis » liver failure
related metabolic disorders that may potentially
beneficiate of a surgically induced weight loss is Morbid obesity is strongly associated with nonal-
getting evidence in literature. coholic fatty liver disease (NAFLD), which is
one of the most common causes of chronic liver
disease worldwide [22].
13.6.1 Hypogonadism NAFLD includes a broad spectrum of liver tis-
sue alterations, which range from steatosis (pure
Hypogonadism and sub-fertility can be fre- fatty liver) through nonalcoholic steatohepatitis
quently associated to obesity and metabolic (NASH) to fibrosis, cirrhosis and liver failure. In
syndrome. Hypogonadal state has demon- the severely obese, the fatty liver and its stages
strated to induce a worsening of co-morbidities often have progressed to NASH or cirrhosis even
such as cardiovascular disorders and type II before contemplating therapy [23].
diabetes [17]. In particular the correlation Weight loss should be a primary therapy for
between testosterone low level and peripheral NAFLD. However, evidence supporting inten-
insulin resistance could lead to presume an tional weight loss as a therapy for NAFLD is
important role of testosterone on the glycaemic limited [24].
metabolic improvement after bariatric surgery Since insulin resistance causes abnormal
[18, 19]. As recently reported in literature, deposition of triglycerides in the liver, the link
alterations in sex hormones, testosterone in between metabolic syndrome and NALFD is
male obese patients, can improve drastically clear. By the way bariatric surgery could improve
after weight [15, 18, 20, 21]. Obviously, treat- NALFD, ameliorating also other factors like
ment of impaired fertility and poor sexual life weight loss, inflammation, dyslipidaemia and
136 M. Lucchese et al.

intestinal hormones. These are the reasons bariat- clinical conditions warranting prioritisation in
ric surgery has to be considered a potential treat- the 35–40 BMI class [4].
ment of NALFD [22, 25]. Recently ASMBS stated that the BMI alone is
The NAFLD guideline does not formally a poor index of adiposity and risk. Underlining
recommend bariatric surgery for the treatment the limitation of the 35 BMI cut-off, the ASMBS
of NASH because beyond potential benefits, concluded that bariatric surgery shouldn’t be
there is an important lack of scientific evidence denied to patient with BMI >30 < 35 kg/m2 or
that could demonstrate any recommendation >27.5 kg/m2 for at-risk ethnicities who do not
to support or reject bariatric surgery to treat achieve substantial and durable weight and co-
NASH patients [26, 27]. morbidity improvement [35, 36].
On the other hand, it is important to note that In conclusion, as clearly stated in the recent
bariatric surgery is not contraindicated in NASH position statement of IFSO, the access to bariat-
patients without cirrhosis [28, 29]. ric surgery should not be denied to patient with
The promising results in literature about class I obesity associated with significant obesity-
metabolic surgical treatment of liver steatosis related co-morbidities simply on the basis of
should encourage to design new randomised BMI level [37].
clinical trials in order to assess the therapeutic
effect of bariatric surgery with long follow-up
periods. 13.7 Contraindications
for Bariatric Surgery

13.6.3 Class I Obesity Mean contraindications are regarding psychiatric

(not stabilised) disorders, behavioural eating dis-
Class I obesity (BMI >30 < 35 kg/m2) has been orders (such as bulimia and binge-eating disor-
demonstrated to have a co-morbidity burden, in der), addictions (alcoholism, toxicomania) and
particular type II diabetes, similar than class II or uncontrolled progressive severe chronic disease
III obesity; even class I obesity is associated
with lower mortality rate than higher obesity
class [30].
In the Consensus Conference Statement on 1. Absence of a period of identifiable med-
Bariatric Surgery for morbid obesity published ical management
10 years ago, Buchwald already proposed the 2. Patient who is unable to participate in
possibility in extending the benefits of bariatric prolonged medical follow-up
surgery to patients with class I obesity who 3. Non-stabilised psychotic disorders, severe
have a condition that can be cured or markedly depression and personality and eating dis-
improved by substantial and sustained weight orders, unless specifically advised by a
loss [31]. Since 2004 a considerable number of psychiatrist experienced in obesity
trials, meta-analysis and observational studies 4. Alcohol abuse and/or drug dependencies
have been published about possible extension 5. Diseases threatening life in the short
of the NIH recommendation of 1991 [1, term
32–34]. 6. Patients who are unable to care for
In 2009 the American Diabetes Association themselves and have no long-term fam-
considered the current evidence insufficient to ily or social support that will warrant
recommend surgery to BMI >30 with type II dia- such care
betes. Recently the International Diabetes Specific exclusion criteria for bariatric
Federation suggested that patients with type II surgery in the treatment of T2DM are as
diabetes with class I obesity could be candidate follows:
to surgery if they fall in the same metabolic and
13 Indications for Bariatric Surgery 137

reduced number of transient lower oesopha-

1. Secondary diabetes ? geal relaxation (TLESR) after LAGB. However,
2. Antibodies positive (anti-GAD or ICA) a significant worsening of reflux symptoms and
or C-peptide <1 ng/ml or unresponsive de novo esophagitis has been demonstrated
to mixed meal challenge during long-term follow-up [38, 45]. Outcomes
in terms of GERD after LSG are contradictory
[46].
(cancer, cirrhosis, inflammatory bowel disease, Symptomatic GERD complicates sleeve gas-
etc.). trectomy up to 25 % of cases according to the
Here we report the schematic contraindica- literature [47, 48].
tions to bariatric surgery of the Interdisciplinary In fact despite the initial high incidence of de
European Guidelines on Metabolic and Bariatric novo GERD symptoms or worsening of GERD
Surgery [2]. after LSG, many studies demonstrate a decrease
Fried et al. [2] of GERD on long-term follow-up. Possible
causes are the weight loss and the “Angle of His”
restorations [38, 49, 50].
13.8 Co-morbidities That Could Some technical precautions could avoid the
Influence the Choice worsening of GERD or creation of de novo
of Bariatric Procedure GERD symptoms after LSG: avoiding large
pouch, strictures that could decreased the acid
13.8.1 GERD clearance, the lesion of lower oesophageal
sphincter and antrum narrowing [38, 49, 50].
Gastroesophageal reflux disease (GERD) is one The presence of GERD symptoms could be
most common disease worldwide. Obesity has actually considered only a relative contraindica-
demonstrated to increase the severity and the tion to sleeve gastrectomy and gastric banding in
incidence of GERD due to several factors such as morbidly obese patients [51, 52].
augmented intra-abdominal pressure, increased Even in the absence of large RCT, RYGBP
hiatal hernia incidence, oesophageal dismotility could be the procedure of choice in case of symp-
disorders and lower oesophageal sphincter tomatic GERD [14, 43] As suggested by many
decreased pressure [38, 39]. Roux-en-Y gastric authors, a preoperative oesophageal manometry
bypass (RYGB) is considered an anti-reflux sys- and pH-metry should be performed in patients
tem, and there is accordance in literature about candidate to LSG [38, 39].
GERD remission after RYGB. In fact RYGB has Further prospective studies are needed to clar-
been proposed by many authors as a good choice ify the role of GERD in the selection for bariatric
for redo surgery in case of failed anti-reflux oper- operations.
ations [40–42].
Studies in literature are inconsisted regarding
the possible effect of laparoscopic adjustable gas- 13.8.2 Osteoporosis
tric banding (LAGB) or laparoscopic sleeve gas-
trectomy (LSG) on patients with preoperative Several studies demonstrate a significant worsen-
existing GERD. There is not a clear evidence of ing of bone density after bariatric surgery, in par-
worsening of GERD after LAGB because of the ticular in postmenopausal women.
difficulty of distinguishing recurrent GERD and As calcium absorption happens in the duode-
symptoms indicating a complication of the band- num and proximal jejunum, performing proce-
ing [43, 44]. dures with the bypass of duodenum or with a
Some series demonstrated an initial GERD malabsorptive component in patients with pre-
remission after surgery probably due to the existing osteoporosis could not be recommended
weight loss, reduced intra-gastric pressure and [53, 54].
138 M. Lucchese et al.

13.8.3 Familiarity for Upper be performed. On the other hand, it should be

GI Cancer considered that the bypass of duodenum and
proximal part of jejunum represents weight-
In these cases, preoperative endoscopy is man- independent factor of insulin sensibilisation
datory. In case of direct familiarity with upper [14, 61, 62].
GI cancer, procedures that consist of the exclu-
sion of part of the stomach are not recom-
mended. If LAGB or SG is not suitable for a 13.9 Psychological
patient with upper GI cancer familiarity, it is and Psychiatric Aspects
possible to perform RYGBP with subtotal gas- in the Choice of the Type
trectomy [55, 56]. of Bariatric Surgery

Patients candidate for bariatric surgery show

13.8.4 Suspected Low Adherence frequently high rates of current and lifetime
to the Follow-Up psychiatric axis I pathologies, with rates of up
to 70 %. Mood disorders, anxiety disorders and
In case of high suspicion of low adherence to the binge-eating disorder (BED) are the most preva-
follow-up after bariatric surgery, a SG should be lent psychiatric diseases found in these patients
recommended, avoiding the procedures that can [63]. Pre-bariatric surgery individuals display
require a strict follow-up (malabsorptive or also several other bad eating habits such as
LAGB) [14, 57, 58]. However, the exclusion of sweet eating, snack eating, food craving and
these patients from bariatric surgery programmes nighttime eating and have significantly increased
should be evaluated. odds of alcohol use and personality disorders
[64] and lower levels of self-esteem and quality
of life [65].
13.8.5 Systemic Disease Requiring Although the presence of depression, anxiety
Chronic Drug and eating pathologies has been demonstrated in
Somministration (IBD, candidates for bariatric surgery, its impact on the
Neurological Syndromes, short- and long-term weight loss outcome is still
Transplant Patient, IRC) unclear [63].
Some studies support no influence of pre-
When a morbid obese patient is affected by surgical co-morbidity on post-operative weight
systemic diseases, it should be recommended loss [66, 67], whereas others show a negative
to perform a pure restrictive procedure [3, impact of preoperative depression, phobic anxi-
59, 60]. ety, interpersonal sensitivity and binge eating
(BE) [68–71] with a higher risk for poorer post-
surgery outcome and increased rates of compli-
13.8.6 Type I Diabetes cations. Legembauer et al. [71] found that in
bariatric surgery patients, depressive disorders at
There isn’t too much literature about obesity sur- baseline and within one’s lifetime represented a
gery and type I diabetes. After bariatric surgery, negative predictive value for the percentage of
patients with type I diabetes demonstrate a sig- BMI lost in the long term, 4 years after the opera-
nificant improvement in terms of quality of life, tion. Brolin et al. [72] assessed different eating
with an improvement of glycaemic control and patterns and weight loss after bariatric surgery
reduction of overall doses of insulin. and found that the snack-eating patients had
In case of malabsorptive procedure, there are lesser weight loss and that Roux-en-Y gastric
risks of impaired or inadequate drugs absorp- bypass (RYGBP) patients are not in the habit of
tion; this is why a restrictive procedure should consuming sweets [72].
13 Indications for Bariatric Surgery 139

A multidisciplinary approach has been recom- (bilio-pancreatic diversion), comparing the dif-
mended by the major national and international ferent outcomes in terms of weight loss efficacy
bariatric surgical societies (Società Italiana di and psychological effects [78]. The results have
Chirurgia dell’Obesità (SICOB), American showed that all the three types of operation sig-
Society for Metabolic and Bariatric Surgery nificantly improved psychopathology and eating
(ASMBS)) to investigate psychiatric disorders disordered behaviours [78].
and/or abnormal psychological profiles, patient Unfortunately, psychological conditions
motivation and post-operative management. appear to improve in most, although not in all,
A multidisciplinary treatment, where psychologi- individuals. Despite some findings supporting
cal support, physical education and diet are avail- that BE behaviour is stricken out by gastric
able, allows a decrease of preoperative weight restrictive surgeries, many patients keep on, even
surgical risks and improves postoperative adher- if less seriously, to have maladaptive and psycho-
ence to a long-term follow-up programmes [73]. logically distressing eating patterns post-surgery
To date, no indications are available for the [79]. In patients continuing to have BE and BED
choice of a specific surgery procedure, on the after the surgery, weight loss outcomes are worse
basis of the pathological eating behaviour compared with individuals who never had these
assessed before the operation. behaviours or who were remitted [79].
A study reported that the laparoscopic adjust- This position was confirmed by another
able gastric band (LAGB) was less successful in research, reporting that the post-operative loss of
patients with binge-eating disorder or sweet- control over eating (LOC) appeared to obstruct
eating behaviour [74]. Bad eating habits such as the rate of weight loss, especially as the time
sweet eating, binge eating and nighttime eating since the surgery passed. For this, post-operative
are often present before bariatric surgery. They LOC over eating may represent a useful index of
may persist after surgery and unfortunately are limited post-surgical improvements and a clinical
hidden by patients [75, 76]. These findings sug- focus in post-surgical care [80]. Supervising path-
gest that subjects with a pathological eating ological eating patterns soon after the surgery and
behaviour might be candidates for a different bar- for several years thereafter, particularly amongst
iatric procedure different from LAGB [74]. those who engaged in BE prior to surgery, may
According this, another research sustained help to detect patients who can benefit from addi-
that, considering the mechanisms of action of tional treatment for their binge eating [81].
LAGB and Roux-en-Y gastric bypass (RYBP), Drug treatment post-surgery and, in addition,
the second one could be a better choice than gas- non-pharmacological cognitive–behavioural
tric banding for patients with poor control over treatments for BE and BED, in individual or
their eating [77]. group context, represent valid alternatives [79].
They have demonstrated positive results in the
treatment of BE and should be accounted for
13.9.1 Psychological Profile After bariatric surgery candidates to improve the out-
the Surgery comes [82].
These data suggest the importance to identify
After the weight loss surgery, affective disorders, individuals at high risk to develop or to maintain
anxiety, eating behaviours and other symptoms psychiatric symptoms after the surgery and to
of psychopathology seem to decrease signifi- follow them post-operatively driving them step
cantly in most individuals. Researchers found by step to the therapeutic approach. The coopera-
that after the surgery, patients substantially dis- tion amongst the specialists, with the aim to
play changed eating behaviour and meal patterns, develop appropriate interventions, facilitates the
achieving a relevant weight loss [57] A recent weight loss outcomes and a long-term successful
study has investigated three different bariatric management of the patient in the most profitable
surgery procedures, LAGB, RYGB and BPD timing [83].
140 M. Lucchese et al.

Conclusion 6. Michalsky M, Reichard K, Inge T, Pratt J, Lenders

When we perform a bariatric surgical proce- C. ASMBS pediatric committee best practice guide-
lines. Surg Obes Relat Dis. 2012;8(1):1–7.
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permitting to discover year by year new path- GL, Inge TH, et al. Best practice updates for pedi-
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13 Indications for Bariatric Surgery 143

76. Nugent C, Bai C, Elariny H, Gopalakrishnan P, 80. White MA, Kalarchian MA, Masheb RM, Marcus
Quigley C, Garone Jr M, et al. Metabolic syndrome MD, Grilo CM. Loss of control over eating predicts
after laparoscopic bariatric surgery. Obes Surg. outcomes in bariatric surgery patients: a prospec-
2008;18(10):1278–86. tive, 24-month follow-up study. J Clin Psychiatry.
77. Apovian CM, Huskey KW, Chiodi S, Hess DT, 2010;71(2):175–84.
Schneider BE, Blackburn GL, et al. Patient factors 81. Busetto L, Segato G, De Luca M, De Marchi F, Foletto
associated with undergoing laparoscopic adjust- M, Vianello M, et al. Weight loss and postoperative
able gastric banding vs Roux-en-Y gastric bypass complications in morbidly obese patients with binge
for weight loss. J Am Coll Surg. 2013;217(6): eating disorder treated by laparoscopic adjustable
1118–25. gastric banding. Obes Surg. 2005;15(2):195–201.
78. Castellini G, Godini L, Amedei SG, Faravelli C, 82. Vaidya V. Psychosocial aspects of obesity. Adv
Lucchese M, Ricca V. Psychological effects and out- Psychosom Med. 2006;27:73–85.
come predictors of three bariatric surgery interven- 83. Meany G, Conceicao E, Mitchell JE. Binge eat-
tions: a 1-year follow-up study. Eat Weight Disord. ing, binge eating disorder and loss of control eating:
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the literature. Int J Eat Disord. 2007;40(4):349–59. bolic surgery. J Visc Surg. 2010;147(5 Suppl):e1–3.
 Endoscopic Treatment:
Intragastric Balloon 14
Alfredo Genco, Roberta Maselli,
Massimiliano Cipriano, Emanuele Soricelli,
Giovanni Casella, and Adriano Redler

14.1 Introduction the other hand, a chance to reduce the surgical

and anaesthesiologic complications deriving
At the present time there is no medical cure for from bariatric surgery.
obesity and, despite the numerous dietary treat- In 1986, Pasulka et al. demonstrated how a
ments, the natural course of the disease is charac- small preoperative weight loss (10–20 %)
terized by an ongoing, sometimes unstoppable, reduced surgical complications [2] resulting from
weight gain. There are now one billion over- bariatric surgery. Consequently, over the last few
weight or obese persons worldwide. The indica- years, the interest of operating in the sector has
tions inherent to surgical treatment are far from turned to devices able to help patients to maintain
acceptable to patients. Bariatric surgery has been diet programmes, making diet more ‘aggressive’
shown to lead to a greater incidence of intra- and and effective, and thus leading to greater control
post-operative complications, directly correlated of the comorbidities in view of radical surgical
to the numerous diseases resulting from obesity treatment.
[1]. Only some of these patients, however, One of these remedies is the intragastric
express the desire or are able to undergo a surgi- balloon.
cal operation. In this context, the intragastric bal- The first intragastric balloon was launched in
loon can play a very clear role in interrupting the the market 30 years ago. From that date, several
ongoing and inexorable weight gain in patients intragastric prosthesis have been presented and
with first-degree obesity and in achieving posi- used worldwide. The concept first saw the light in
tive control or resolution or improving of the rel- 1921 when Davies observed that patients with
evant comorbidities. In super-obese patients, bezoars (partially digested agglomerates of hairs
where there are numerous comorbidities, the or vegetable fibres), often complained of post-
weight loss obtained with the BIB® represents, on prandial fullness, nausea and vomiting. This led
to the idea of contriving a device that would imi-
tate an intragastric bezoar by partially filling the
A. Genco (*) • R. Maselli • M. Cipriano
stomach [3].
E. Soricelli • G. Casella • A. Redler
Department of Surgical Sciences, All the balloons used in the past showed poor
Sapienza, University of Rome, results and complications but with the introduc-
Viale del Policlinico 155, Rome 00161, Italy tion of the BioEnterics® Intragastric Balloon
e-mail: [email protected]; roberta.maselli.
(BIB®, Allergan Inc., Irvine, CA, USA), a new
[email protected]; [email protected]; lelesori@
hotmail.com; [email protected]; adriano. chapter in the history of intragastric balloons is
[email protected] being written (Fig. 14.1).

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 145
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_14,
© Springer International Publishing Switzerland 2015
146 A. Genco et al.

Fig. 14.1 BIB intragastric balloon (BIB®, Allergan Inc., Irvine, CA, USA) (left); device placed in the stomach (right)

Prosthesis,ATIIP) (Districlass Medical, France),

placed by a combined endoscopic surgical
procedure, filled with air and attached to the
abdominal wall [5]. It is currently used in few
centres (Fig. 14.3).
The Obalon® Gastric Balloon (OBG)
(ObalonTherapeutics, Inc., San Diego, CA, USA)
is a non-surgical and fully repeatable and revers-
ible weight loss device. Compared with other
commercially available intragastric balloons, the
Obalon is totally swallowable and does not need
endoscopy for its placement. Up to three devices
can be placed together [6] (Fig. 14.4).

14.2 Intragastric Balloon:

Mechanism of Action
Fig. 14.2 Heliosphere intragastric ballooon (Helioscopie,
Vienne, France) The efficacy of the device in inducing weight loss
is due not to a placebo effect but to the character-
istics which make it effective ‘in itself’. How it
On the market there are, nowadays, other actually works chiefly depends on its
types of intragastric balloons, including the characteristics:
‘Heliosphere bag’ (Helioscopie, Vienne, France) • Its weight (if it is filled with liquid), which
[4], a balloon filled with air and inducing a minor stimulates the baroceptors at the gastric wall
discomfort compared to that induced by liquid- level. These, through the brain–gut axis, stim-
filled balloon, which has been proved to be effec- ulate the satiety centre located at hypotha-
tive in treating short-term obesity (Fig. 14.2). lamic level.
It should also be mentioned the Endogast • Delayed gastric emptying: an ultrasonographic
(Adjustable Totally Implantable Intragastric study highlighted the fact that in patients with-
14 Endoscopic Treatment: Intragastric Balloon 147

a b

Fig. 14.3 Endogast (Adjustable Totally Implanted Intragastric Prosthesis, ATIIP) (Districlass Medical, France).
(a) Schematic illustration of the device, (b) the device

a b c

Fig. 14.4 The Obalon® Gastric Balloon (ObalonTherapeutics, Inc., San Diego, CA, USA) as it appears deflated (a), (b) the
inflation system gauge to remotely inflate the device, (c) inflated device

out the balloon, food could already be visual- observed, followed by a gradual reduction
ized in the antrum 32 min after the consumption until the basal levels reached after removal.
of a solid meal. Thirty days after BIB®
placement in the same patients, this study visu-
alized food after 300 min. 14.2.1 Indications
• Reduction of the unoccupied gastric volume by
about 750 cm3 due to the presence of the device. The balloon system is indicated for temporary
• Discomfort: the overall disorders (nausea, pre- use associated with a specific diet treatment in
cocious sense of satiety, vomiting, epigastric patients with a history of obesity (at least 5 years),
pain) suffered during the first 24–30 h post- after numerous failures of the dietary treatment
placement and if the patient fails to adhere to only.
the prescribed dietary regime. The balloon is indicated in patients with:
II class
• Hormonal mechanisms: during treatment with • <35 BMI with obese-related comorbidities
the BIB® in the first 3 months a significant whose resolution or improvement requires
increase in the plasmatic ghrelin levels was mandatory weight loss
148 A. Genco et al.

III class
• >35 BMI, as a pre-surgery role in patients 14.2.3 Post-placement
with comorbidities, before any other type of Pharmacological Treatment
surgery, or in patients who refuse surgery
Due to the secondary effects deriving from the
presence of the balloon (nausea, regurgitation or
14.2.2 Placement and Removal vomiting, cramp-like epigastric pains) and from
Technique the almost total impossibility of eating during the
first 24–36 h, all patients must receive support
Balloon placement and removal can be performed treatment consisting in the infusion of electro-
in conscious sedation with diazepam or mid- lytic solutions, proton pump inhibitors, antispas-
azolam, in unconscious sedation with propofol modic and antiemetic drugs.
or with orotracheal intubation. Before placement,
a diagnostic oesophago-gastro-duodenoscopy is
performed. 14.2.4 Discharge
The BIB balloon is then positioned with the
valve under the cardia and is filled, under endo- Before discharge the patient is made aware of the
scopic vision, with 500–700 ml of physiological importance of optimum hydration and of ongoing
solution and 10 ml vital staining solution (methy- urine checks (if methylene blue has been used),
lene blue). The connection catheter is removed in order to diagnose in time the premature rupture
and the valve checked for possible leaks. The of the balloon or a possible valve leak in a case a
mean duration of the procedure is 12 min. BIB has been placed.
Balloon removal is carried out after 6 months. On the first day, the patient receives a liquid
The removal procedure should be preceded by a diet only. From the second and up to the sixth or
72-h, no-‘roughage’ diet and by a 24-h semi- seventh day, a semi-liquid diet is followed.
liquid diet. The procedure foresees a gastroscopy
to see the balloon and subsequently deflate it with
a specific device. The BIB® is removed with a 14.2.5 Follow-Up
dedicated ‘grasper’ when completely deflated.
Stomach observation is necessary to exclude pos- The dietetic regime from the seventh day is a
sible mucosal lesions. daily intake of 1,000–1,200 kcal consumed over
The Endogast is placed by a combined endo- three main meals and two snacks. This dietetic
scopic surgical procedure, filled with air and regime is maintained until removal of the device.
attached to the abdominal wall. The device is When there are signs (e.g. blue urine for the BIB)
connected to a subcutaneous system to adjust the or symptoms indicating a possible complication,
volume of air. an immediate clinical evaluation of the patient is
For the Obalon, the patient swallows a capsule essential. Decubital ulcers or gastrectasia indi-
attached to a micro-catheter (the balloon is inside cates the need to remove the balloon.
this gelatin capsule). Once in the stomach, veri- All the patients are informed of the increased
fied by fluoroscopy and by the inflation system chance of balloon rupture if it remains in the gas-
gauge, the balloon is remotely inflated with gas tric cavity for longer than the prescribed period.
(nitrogen). After the inflation the micro-catheter At the end of the treatment, the device will, in
is detached and removed, leaving the balloon in any case, be removed. The following alternatives
the stomach. are then evaluated: (a) starting the patient of on a
After a 3-month treatment period, all the bal- ‘maintenance’ diet programme; (b) subjecting
loons are retrieved by an upper GI endoscopy, him/her to the consensual placement of a second
using standard, commercially available endo- balloon (multiple treatment); or (c) performing
scopic tools. the previously planned bariatric surgery.
14 Endoscopic Treatment: Intragastric Balloon 149

14.3 Results group, weight loss from baseline was 5.5 kg and
BMI loss was 2.0 kg/m2. These results demon-
14.3.1 Early Secondary Effects strate that intragastric balloon combined with
dietary instructions induces significantly higher
In our experience with the BIB, the secondary weight loss than simple dietary therapy in the
post-placement effects were the following: nausea first 6 months of treatment and persists at
for 24–36 h in 87 % of the patients; vomiting 12 months of follow-up [7].
(a mean two episodes) in 51 %; slight epigastral- Regarding the Heliosphere treatment, in a
gia in 61 %, regressed with antispasmodic drugs; recent published study of 84 patients, the efficacy
increased intestinal meteorism in 36 %; diarrhea in terms of EWL was 33.2 % at 6 months. The
(5–6 episodes/day) in 5 %; and halitosis in 12 % . only study existing at the moment on the Endogast
For the Heliosphere, nausea and vomit were is a report on 57 patients who reached an EWL of
present in 7.4 % of the patients during the first 39.2 % at 1-year follow-up.
week. To our knowledge only a pilot feasibility study
has been published on the Obalon results [6],
showing a significant weight loss induced by the
14.3.2 Weight Loss balloon.

From March 1998 to May 2013, our case histo-

ries recorded 1,596 placements of BIB® in 1,503 14.3.3 Long-Term Results
patients (461 males/842 females). The mean age
was 36.5 (19–69); mean BMI 38.9 (27.7–56.5); It is difficult to consider the long-term efficacy of
mean EW percentage 59.2 (34–117.6). At the end a device such as the intragastric balloon, created
of the treatment, the patients presented BMI 31.8, for temporary treatment. In almost all morbid
EWL 34.4 %. These results can be superimposed obese patients, the weight loss is followed by
on those reported by the Italian LAP-BAND® and subsequent weight regain. Several authors have
BIB® group (GILB) relevant to 2,515 cases with reported a successful weight loss in the short
a mean weight loss of 9.0 BMI and 33.9 % time, but only few studies have investigated the
EWL21. Other important results derive from our long-term results after removal.
study which compares weight loss achieved by In our experience from March 1998 to July
BIB® versus a diet therapy at 6 months, when the 2006 (613 patients), we selected those having at
balloon was removed, and at 18 months and least a 48-month post-removal follow-up
12 months after BIB® removal. The experimental (n = 145). We excluded patients who had under-
group (BIB® + diet) consisted in 122 obese gone bariatric surgery after BIB® removal (n = 52)
patients with mean BMI 41.8 ± 6.8; the control and who had a sequential BIB® placement or
group (diet alone) comprised 128 patients with other non-surgical weight loss treatment (n = 30).
mean BMI 42.0 ± 6. Weight loss was significantly The remaining patients (n = 45) were contacted
higher in patients treated with BIB® when com- and submitted to clinical evaluation.
pared to the group of patients treated by diet alone Excess weight loss (EWL) ≥25 % when the
(weight loss 16.2 vs 6.6 kg, BMI decrease 5.7 vs BIB® was removed was considered a success 69%
2.5 kg/m2) at 6 months. The difference persisted of patients lost ≥25 % (range 25.0–69.0) of their
to a lesser degree but was still significant at fol- EW on balloon removal and were classified as
low-up (12 months); both groups showing a ten- ‘successes’, while 15 patients (31 %) lost from 0
dency to regain weight at the follow-up after the to 21.0 % of their EW and were categorized as
treatment: in the BIB® group the average weight ‘failures’. At 60 months follow-up
loss from baseline was reduced to 11.2 kg and the (60 months ± 21.47; range 48–96), 30 % (9/30) of
BMI loss to 3.5 kg/m2, while in the diet control the ‘success’ group had an EWL percentage of
150 A. Genco et al.

≥25 and were categorized as ‘long-term suc- the presence of comorbidities at baseline (80 % of
cesses’, whereas 70 % (21/30) of them had an the patients) and follow-up (30 %) (p = 0.02).
EWL percentage of <25 and were categorized as Quality of life test in the follow-up showed better
‘long-term failures’. To individualize possible pre- scores than those at baseline (p < 0.001). These
dictive factors in long-term success, we evaluated results demonstrate that, although the weight
the association between follow-up results and cycling, in patients refusing surgery, multiple
three factors: initial BMI (<35, 35–40, 40–50, intragastric balloons are the recommended treat-
>50), pre-BIB® age (>35 years, <35 years) and sex ment, allowing the patients to achieve a good
(male/female). A statistical analysis was done on weight loss, a better control of comorbidities and
the investigated predictive factors that have con- better quality of life than baseline.
firmed the associations: female gender, age
<35 years and initial BMI from 35 to 40 are long-
term success predictive factors. The results of this 14.3.5 Preoperative Strategy:
study confirm the safety and the short-term effi- Sequential Treatment
cacy of the BIB®: at 6 months about 70 % of the
treated patients lost at least 25 % of their excess In our series, the rapid weight loss induced by the
weight. At 60 months follow-up 30 % of the BIB® drastically affects the progression of
patients were able to control their weight loss and obesity-related diseases, thus determining the
had at least 25 % of their EWL percentage. These suspension or reduction of the pharmacological
results indicate a possible role for BIB® in the therapy. The dyslipidemic values improve in
long-term weight loss control. 58 %; there is significant control in hypertension
in 38 %. In 61 % joint diseases improved, includ-
ing pain regression, and in 80 % the rapid weight
14.3.4 Multiple Treatment loss led to the prompt improvement of respiratory
function and sleeping difficulties with the disap-
The multiple treatment consists of placing two pearance of apnoea (breath-holding) attacks.
intragastric balloons one after the other, respecting After BIB® treatment the apnoea index ranged
an interval of at least 30 days between the removal from 33 to 5 episodes/h. Furthermore, weight
and the second balloon placement generally in loss induced by the intragastric balloon, as dem-
patients refusing surgery. The reason underlying onstrated by various studies in the literature, led
the delay of at least 1 month is the need to allow to a significant reduction in intestinal fat and liver
the patient to ‘get the feel’ of the balloon again. volume. The role and importance of the pre-
This is probably due to the saturation of the gastric surgery use of the intragastric balloon is also
receptors which ‘adapt’ to the presence of the clearly shown in Busetto’s study [9] where the
intragastric prosthesis. We evaluated 83 patients pre-LAP-BAND® treatment together with BIB®
with BMI >40, good candidates for surgery but induces a weight loss that shortens operating
refusing it, in a clinical treatment involving mul- time and reduces the intraoperative complica-
tiple intragastric balloon placement [8]. After tions, the conversion rate for patients subse-
removing the first balloon, a second balloon was quently subjected to gastric banding and hospital
placed when the patients had regained ≥50 % of stay when compared with patients submitted
the weight loss achieved with the previous bal- directly to LAP-BAND®.
loon. Weight, comorbidities parameters and qual- In conclusion, the findings of the Italian LAP-
ity of life test were recorded until a follow-up of BAND® and BIB® (GILB group), in a study on
72 months. All the patients experienced a second 2,515 patients, indicate that the use of the intra-
balloon placement; 22.2 % were placed a third gastric balloon induced a normalization of the
device and only one patient received the fourth. At comorbidities in 44.3 % and a marked improve-
76 months follow-up mean BMI was 37.6 kg/m2 ment in 44.8 %. In only 10.9 % of the cases did
(p < 0.001) and weight cycling periods were the comorbidities show no positive effects what-
observed. Significant difference was recorded in ever from the treatment [10].
14 Endoscopic Treatment: Intragastric Balloon 151

The use of the intragastric balloon is defined as gone surgery: three at gastric level (fundoplica-
‘sequential treatment’ before any surgical treat- tion according to Nissen, a vertical gastroplasty
ment, whether bariatric or not, aimed at improv- complicated by fistula, gastric banding removed
ing comorbidities in order to reduce surgical and because of intragastric migration) and one due to
anaesthesiologic complications deriving from prior, thoracic–abdominal trauma. In three
such surgery [11, 12]. It is evident that such patients, this complication was treated and solved
changes are related to the weight loss and not to by surgical means. Two other patients died: one
the use of the BIB® per se. In any case, it has been during surgery and the other during diagnostic
demonstrated that the weight loss obtained with tests.
the balloon is greater than the reduction achieved The authors report two spontaneous desuffla-
by dieting alone. tion (1.2 %) requiring surgical removal in the
Heliosphere treatment.

14.4 Complications
14.5 Discussion and Conclusion
14.4.1 Minor Complications
Our experience, and the literature illustrated here,
In the Italian BIB® experience of 3,252 patients, indicates that the intragastric BIB® is a totally
the incidence of minor complications was 2.1 % different prosthesis from that used in the 1980s
(71 patients). The intragastric balloon was because, over a short term, it is a safe and effec-
removed due to intolerance in 13 patients (0.39 %). tive device. Even though the incidence of major
These patients decided to have it removed because complications is <1 %, its use solely for cosmetic
they found the symptoms intolerable. Breakage of purposes is not at the moment advisable, and
the device occurred in 19 patients (0.58 %) and, because four of the five perforations occurred in
except in two cases, always after the period advised patients with previous gastric surgery, the contra-
by the company (6 months). Oesophagitis diag- indication of this factor is absolute.
nosed after removal of the BIB® occurred in 39 The placement and removal procedures are
patients (1.2 %), probably due to the discontinu- easy, both for gastroenterologists and for sur-
ous use of the proton pump inhibitors. geons who perform endoscopies. Physicians
Among the Endogast complications should be must, however, take great care to follow up their
mentioned subcutaneous infections (12.2 %) and patients very closely, particularly in the first
the port erosion (5.2 %). 7 days after placement. Only an attentive and rig-
orous follow-up permits the timely diagnosis and
appropriate treatment of the dangerous complica-
14.4.2 Major Complications tions which could arise in this first phase: gastric
ischaemic ulcer, with subsequent perforation (4/5
In the same series, the overall major complica- occurred during the first 5 days after placement,
tion was seen in 32/3,252 (0.9 %) patients (10). GILB data) and dehydration.
In 19 (0.58 %) patients, the device caused a typi- In patients suffering from morbid obesity,
cal case of gastric obstruction which totally incapable of keeping to any diet and who are can-
blocked gastric emptying. This condition was didates for bariatric or other types of surgery, the
resolved with medical treatment in three cases by intragastric balloon is the only non-surgical pro-
inserting a nasogastric tube for 24–48 h, but in 16 cedure able to induce a rapid and consistent
cases this proved to be ineffective and removal of weight loss which positively affects all the
the BIB® was required. Another complication is obesity related comorbidities and reduces the
gastric ulceration, occurred in 0.15 % (five risks of surgery and anaesthesia.
patients). Gastric perforation, the most frighten- The ongoing trend relate to the use of the device
ing complication, occurred in five patients points to sequential treatment, that is, before and
(0.15 %). Four of the latter had already under- in preparation for surgery. The unexpected results
152 A. Genco et al.

deriving from the evaluation of our experience in 2. Pasulka PS, Bistrian BR, Benotti PN, et al. The risks
of surgery in obese patients. Ann Intern Med.
patients with 5-year follow-up lead us to think that
1986;104:540–6.
the BIB® will be able to play an important role in 3. Lindor KD, Hughes Jr RW, Ilstrup DM, et al.
the prevention of super-obesity, so little discussed Intragastric balloons in comparison with standard
even by the experts in this field. therapy for obesity — a randomized, double-blind
trial. Mayo Clin Proc. 1987;62(11):992–6.
Use of the intragastric balloon in adolescent
4. Lecumberri E, Krekshi W, Matía P, et al. Effectiveness
and paediatric patients is another possible and and safety of air-filled balloon Heliosphere BAG® in
important field. To be truthful, however, there is 82 consecutive obese patients. Obes Surg. 2011;21(10):
not enough scientific evidence at the moment to 1508–12.
5. Gaggiotti G, Tack J, Garrido Jr AB, et al. Adjustable
support verified affirmations.
totally implantable intragastric prosthesis (ATIIP)-
At the present time, there is no medical cure Endogast for treatment of morbid obesity: one-year
for obesity and, despite the numerous dietary follow-up of a multicenter prospective clinical survey.
treatments, the natural course of the disease is Obes Surg. 2007;17(7):949–56.
6. Mion F, Ibrahim M, Marjoux S, Ponchon T, Dugardeyn
characterized by an ongoing, sometimes unstop-
S, Roman S, Deviere J. Swallowable Obalon® gastric
pable, weight gain. There are now one billion balloons as an aid for weight loss: a pilot feasibility
overweight or obese persons worldwide. Only study. Obes Surg. 2013;23(5):730–3.
some of these patients, however, express the 7. Genco A, Balducci S, Bacci V, et al. Intragastric bal-
loon or diet alone? A retrospective evaluation. Obes
desire or are able to undergo a surgical operation.
Surg. 2008;18(8):989–92.
In this context, the intragastric balloon can play a 8. Genco A, Maselli R, Cipriano M, et al. Long-term
very clear role in interrupting the ongoing and multiple intragastric balloon treatment: a new strategy
inexorable weight gain in patients with first- to treat morbid obese patients refusing surgery.
Prospective 6-year follow-up study. Surg Obes Relat
degree obesity and in achieving positive control
Dis. 2014;10(2):307–11.
or resolution or improving of the relevant comor- 9. Busetto L, Segato G, De Luca M, et al. Preoperative
bidities. In super-obese patients, where there weight loss by intragastric balloon in super-obese
are numerous comorbidities, the weight loss patients treated with laparoscopic gastric banding:
a case–control study. Obes Surg. 2004;14(5):671–6.
obtained with the BIB® represents, on the other
10. Genco A, Bruni T, Doldi SB, et al. Bioenterics intra-
hand, a chance to reduce the surgical and anaes- gastric balloon: the Italian experience with 2,515
thesiologic complications deriving from bariatric patients. Obes Surg. 2005;15:1161–4.
surgery. 11. Weiner R, Gutberlet H, Bockhorn H. Preparation of
extremely obese patients for laparoscopic gastric
banding by gastric balloon therapy. Obes Surg.
1999;9:261–4.
References 12. Genco A, Lorenzo M, Baglio G, et al. Does the
intragrastric balloon have a predictive role in subse-
1. Ogunnaike BO, Jones SB, Jones DB, et al. Anesthetic quent LAP-BAND surgery? Italian multicenter
considerations for bariatric surgery. Anesth Analg. study results at 5-years follow-up. Surg Obes Relat
2002;95:1793–805. Dis 2014;10(3):474–8.
 Endoscopic Treatment: New
Technologies 15
Nicola Di Lorenzo and Francesco Maria Carrano

Minimally invasive surgery (MIS) is the gold 15.1 Electrical Pacing

standard in bariatric patients providing a reduced
complication rate and post-operative recovery 15.1.1 Introduction
length, compared to “open” techniques.
The trend to minimal invasiveness is continu- Electrical pacing is a modern method based on
ously evolving, including complex procedures the use of electrical stimuli to obtain weight
performed by endolumenal approaches using reduction on obese patients, while preserving
innovative technologies. normal GI anatomy. Two main approaches are
Although in experimental settings many considered for clinical application: gastric pacing
devices and techniques have been tested with the and intra-abdominal vagal blocking.
aim of reproducing the results of conventional The concept of selective autonomic activa-
surgical treatment, only a few of them have tion by electrical pacing to treat obesity was
reached the clinical field after passing both safety introduced by V. Cigaina (1996) [1] and recently
and efficacy tests. reintroduced as Implantable Gastric Stimulator®
This chapter describes currently available (IGS® –Transcend®), a gastric pacemaker which
innovative devices for obesity treatment, for stimulates the vagal innervation of the stomach
which only limited data is currently available. through a lead wire [2]. The lead is implanted
Nevertheless, the trend towards endolumenal by laparoscopy on the lesser curvature, 6 cm
approaches, for most abdominal pathologies, is from the pylorus, and distally fixed with clips to
in our opinion, unavoidable. impede dislodgement. A pace generator is con-
nected to the lead, placed on the fascia and then
fixed with sutures. During operation, the gastric
mucosa is monitored by gastroscopy to exclude
inadvertent needle perforation into the gastric
N. Di Lorenzo (*) • F.M. Carrano lumen [3].
Department of Experimental Medicine and Surgery, Preliminary studies were encouraging, with
Università di Roma Tor Vergata,
V..le Oxford 81, Rome 00133, Italy
%EWL around 10–21 at 12 months [4] however
e-mail: [email protected]; revealed poor results compared to placebo in
[email protected] more recent and wide SHAPE Trial [5].

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 153
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_15,
© Springer International Publishing Switzerland 2015
154 N. Di Lorenzo and F.M. Carrano

15.1.2 From Pacing to Modulation The mean %EWL resulting from this trial was
17.1 ± 8.9 at 3 months, 23.9 ± 11.9 at 6 months
The concept of pacing then evolved to that of and 30.0 ± 17.1 at 12 months [10].
modulation where three new devices were tested:
the Diamond System®, the Abiliti System® and 15.1.2.3 VBLOC Therapy
the VBLOC® therapy. The VBLOC® vagal blocking therapy, based on a
different principle, induces an intermittent intra-
15.1.2.1 Diamond System abdominal vagal block using high-frequency
The Diamond®(MetaCure) is a meal-activated electrical currents by two electrodes positioned
implantable system that delivers gastric contrac- laparoscopically on the anterior and posterior
tility modulation (GCM) signals that are syn- vagal trunks near the oesophagogastric junction
chronized with the intrinsic electrical activity of (EGJ). The neuroregulator with a rechargeable
the stomach and show to enhance the force of battery is placed subcutaneously.
antral contractions, increasing afferent signalling Several clinical and experimental observa-
in the vagus nerve without interfering with the tions hypothesized intermittent vagal blockade
intrinsic gastric electrical rhythm [6]. (IVB) to be an important factor for achieving and
Implant procedure is performed by laparos- maintaining clinical benefits [11–13]. According
copy and controlled by intraoperative gastros- to various clinical trials, the procedure is safe;
copy. Three bipolar leads are implanted in the results in terms of %EWL around 25 are being
stomach muscular layers, and then connected to further investigated. Post-study analysis also sug-
an implantable pulse generator located in a sub- gests that IVB has a positive effect on arterial
cutaneous pocket sited in the left anterior abdom- hypertension since the very first days of use.
inal wall [7]. Patient’s selection may play a key role, since
Although limited by the relatively small lower BMI patients seem to respond better to
numerical dimension, results from first trials VBLOC therapy. Metabolic implications also
appear encouraging and show lipidic profile emerged in a recent trial by Shikora et al., as
improvements, sustained decrease of blood pres- HbA1c was reduced at all time periods from a
sure levels from 124 ± 12 to 112 ± 10 mmHg at 6 baseline of 7.8 ± 0.2 % (mean ± SEM), mean %
months, sustained weight loss [7] and EWL of HbA1c reduction at 12 months was 1.0 ± 0.2 %.
30.5 ± 8.5 % at 1 year [8, 9] with minor adverse FPG was also reduced at all time periods from a
events. baseline of 151 ± 7 mg/dL. Mean FPG reduction
at 12 months was 28 ± 8 mg/dL [14].
15.1.2.2 Abiliti System
The Abiliti System® (IntraPace) includes a lapa-
roscopically implanted device composed of a 15.2 Endoscopic Aspiration
transgastric sensor which detects food intakes Therapy
and triggers the stimulator, placed on the lesser
curvature of the stomach, to deliver a tailored Derived from percutaneous endoscopic gastros-
gastric stimulation which should result in early tomy (PEG) tube technology, endoscopic aspira-
satiety. Differently from the previously cited tion therapy (EAT) represents a new way,
devices, the Abiliti System® constantly records although controversial, to induce weight loss by
physical activity, using a 3D accelerometer aspirating a portion of ingested meals from the
embedded in the implanted device. Patients can stomach; thanks to the AspireAssist Aspiration
download all data through a personal website and Therapy System (Aspire Bariatrics) which is
adjust diet and physical activity accordingly. composed of:
Preliminary results of 25 patients from a (a) An all-silicon A-Tube with holes in the intra-
multi-centre ongoing clinical trial conducted in gastric portion to allow aspiration of gastric
Germany suggest its safety and effectiveness. contents;
15 Endoscopic Treatment: New Technologies 155

(b) A valved Skin-Port to prevent gastric leak- cles are no longer seen in the aspirate. The
age, connected to the extra-gastric portion of whole aspiration sequence takes 5–15 min,
the A-Tube; depending on the meal size. Patients should
(c) A connector to open the Skin-Port valve with receive PPI treatment and potassium chloride
an embedded safety device (consisting of a supplements to reduce acid loss and potential
“counter” that tracks the number of times the potassium depletion [15].
connector is attached to the Skin-Port until it This technique is controversial and, until April
reaches 115 aspiration cycles when it locks 2014, independent scientific papers on the out-
the connector, so the Skin-Port cannot be comes of this technique are not yet available.
accessed for aspiration and the patient must
return to hospital to obtain a new connector
to continue aspiration therapy); 15.3 Endoluminal Treatment
(d) A “companion” device, which is a siphon
that allows two-way flow of fluids thus per- The concept of endoluminal treatment includes
mitting stomach draining while infusing many different devices and techniques.
water in the stomach. Approximately 30 %
of ingested calories are removed by aspira-
tion according to currently available data; 15.3.1 Restrictive Procedures
(e) A 600 mL soft reservoir that allows subjects
to flush tap water into the stomach to facili- The advantage of an endoluminal procedure to
tate aspiration; treat MO is the reversibility and possibility to
(f) A drain tube to dispose the aspirated content undergo surgery as RYGB, in case of unsatisfac-
into the toilet. tory weight loss [16].
The gastrostomy procedure is the standard one The new trend of minimal invasiveness MO
and the A-Tube is inserted by pulling technique treatment has lead major biomedical companies
under antibiotic. Ten to 14 days after the A-Tube to develop at least one endoscopic suturing device
placement – this is shortened within 1 cm of the to perform sutures or plication inside the stomach
abdominal wall and then attached to the Skin- cavity (see Table 15.1). Only some devices have
Port. The whole device is ready for use. been clinically introduced successfully and this
Twenty minutes after meals containing more chapter will focus on them.
than 200 kcal, patients are required to perform Some endoscopic suturing devices (ESDs)
aspiration. They flush food particles out through were primarily developed, years ago, for endolu-
the A-Tube by infusing water into the stomach minal treatment of gastroesophageal reflux dis-
from the reservoir in 150–200 mL increments ease (GERD). Being capable of applying a partial
and then reversing the flow by lowering the thickness suture on the EGJ, their previous goal
lever on the companion device to allow con- was to create a fold at the EGJ to reduce reflux.
tents to drain out of the stomach. This process Results have been controversial and largely
can be repeated several times, until food parti- debated [17].

Table 15.1 Endoscopic suturing devices

Incisionless Operating Platform® Endoscopic suturing device
TOGa system® (Satiety Inc.) (USGI Medical) (Wilson-Cook Medical)
Stomaphyx® (EndoGastric Solutions) Anubis (Storz) SafeStitch (SafeStitch Medical, Inc.)
Endo-Cinch and RESTORe Suturing Spider (Transenterix) NDO plicator® (NDO Surgical, Inc.)
System™ (C.R. Bard Inc.)
TERIS (Barosense Inc.) Endosamurai (Olympus) Overstitch (Apollo Endosurgery, Inc.)
Spiderman (Ethicon Johnson & Johnson) DDES – Direct Drive Endoscopic
system (Bard, Inc.)
156 N. Di Lorenzo and F.M. Carrano

They have been recently reintroduced in bar- rows of titanium staples are usually delivered to
iatric surgery to produce a gastric plication of create a staple line that connects the anterior and
stomach layers (mucosal and submucosal) with posterior stomach, beginning 1 cm proximal to
the aim of reducing gastric volume, and then per- the Z line and extending distally 4.5 cm, parallel
forming a trans-oral gastroplasty. to the lesser curvature [22]. According to the lat-
The first reported device used was the est method tested, a second staple line is added
EndoCinch Suturing System® (Davol Inc.). It is distally. The result of this procedure is a small,
inserted over a standard endoscope and fires a restrictive pouch along the lesser gastric curva-
straight threaded needle through a tissue fold ture [21].
obtained by suction. A series of sutures can be The first human multicentre study in 2007
placed in two rows in a full thickness manner enrolled 21 patients and reported good results
[18, 19]. in terms of safety (no serious adverse events
In 2008, Fogel et al. reported a series of 64 occurred) and EWL of 16.2 %, 22.6 % and 24.4 %,
obese patients treated by means of an endoscopic respectively, at 1, 3 and 6 months. However, this
vertical gastroplasty with a 1-year follow-up. first study showed a possible flaw of the proce-
They registered a significant reduction in BMI at dure, since gaps in the staple line were evident in
12 months (mean BMI 39.9 ± 5.1 kg/m2 vs 13 of the 21 patients. At that time, only one staple
30.6 ± 4.7 kg/m2) and %EWL of 21.1 ± 6.2, line was created [23]. Following this first trial,
39.6 ± 11.3 and 58.1 ± 19.9 at 1, 3 and 12 months, an Italian study analyzed the effects of TOGA
respectively, comparable with the control group on insulin sensitivity and secretion on a series
treated by mean of LRYGB [20]. Fogel’s excel- of nine patients. Insulinemia was significantly
lent results have not been achieved in other pub- reduced at fast and at 120′ after OGTT, as well as
lished trials. the insuline secretion rate (from 235.05 ± 27.50
to 124.77 ± 14.50 nmol/min/m2) while insulin
15.3.1.1 TOGA System sensitivity increased (from 348.45 ± 20.08 to
Promising results have been reported for a series 421.18 ± 20.84 mL/min/m2). Total insulin secre-
of patients treated by means of TOGA system tion rate was demonstrated to correlate with
(Satiety Inc.), used to create a stapled restrictive weight, fat mass and BMI [22]. A second pro-
pouch along the lesser curvature of the stomach spective, multicentre, single-arm trial with a
[16]. 1-year outcome ended in 2011 and involved 53
The TOGA system has two disposable sta- patients. A second staple line was added dis-
pling devices: the TOGA Sleeve Stapler and the tally, to prevent possible gaps. Nevertheless, 7
TOGA Restrictor. The first is used to create a ver- patients had a gap on the proximal part of the
tical sleeve along the lesser curvature of the staple line, 16 had gaps between staple lines and
stomach, approximately 8 cm in length and 2 cm 2 had a combination of gap types; this replicates
in diameter. The second is used to reduce the the same complication of Masons’s gastroplasty
sleeve outlet size by creating folds at the distal which lead to the McLean modified technique.
end of the pouch created [21]. Gap presence negatively correlates with proce-
The procedure consists in the introduction of a dure efficacy, remaining an unsolved problem
60-French bougie through the mouth and oesoph- of the TOGA procedure, since no special treat-
agus over a guide wire, to dilate and test for any ments or salvage techniques are currently avail-
resistance. The TOGA Sleeve Stapler is then able. Patients with no or small gaps (<15 mm)
introduced over the guide wire and a small endo- had a responder rate of 87.5 % whereas patients
scope is routed through a channel in the device. with large gaps (>15 mm) had a rate of 45.5 %.
Once the stomach cavity is reached, a septum There were only mild side effects related to the
with attached retraction wire spreads and orients procedures, such as nausea, vomiting, abdominal
the stomach tissue, while suction is applied from pain, throat pain and dysphagia, which resolved
the vacuum pods included in the device. Three within 1 week. After the post-procedural routine
15 Endoscopic Treatment: New Technologies 157

radiographic control, one patient was diagnosed dilation after bariatric surgery, named ROSE pro-
with asymptomatic pneumoperitoneum, which cedure. Primary Obesity Surgery Endolumenal
resolved without further complication. This sec- (POSE) is a new scar-free technique based on the
ond TOGA trial confirmed the promising results use of the Incisionless Operating Platform®
of the first, showing a %EWL of 29.3 ± 11.6 % (IOP® – USGI Medical) made of three main com-
at 3 months, 36.8 ± 15.7 % at 6 months and ponents: TransPort Multi-lumen Operating
38.7 ± 17.1 % at 12 months. Improvements in Platform®, a flexible endoscope with four work-
the metabolic profile were also reported: HbA1c ing channels functioning as flexible trocars, with
levels decreased from 7.0 % at baseline to 5.7 % insufflation capability, and allows operators to
at 12 months for nine diabetic patients. HbA1c deploy and use up to three tools simultaneously.
levels decreased from 5.9 % at baseline to 5.4 % The Platform further consists of a g-Prox® tissue
at 12 months for all others. Triglyceride lev- grasper, a flexible endoscopic tissue approxima-
els decreased from 142.9 mg/dL at baseline to tion device deployed via one of the four working
98.0 mg/dL at 12 months [21]. channels; Expandable Tissue Anchors®, suturing
technology designed to overcome the problems
15.3.1.2 RESTORe Suturing System of endolumenal suturing in the GI tract by dis-
The RESTORe Suturing System™ is a new gen- tributing forces over large tissue contact. These
eration suturing device by Bard Inc., character- anchors also have a semi-compliant nature that
ized by single-intubation, multistitch capability accommodates postoperative swelling. Their
and designed to place sutures through the muscu- plasticity allows them to withstand swelling, yet
lar wall of the stomach and approximate gastric maintain hold on tissue.
tissue. The suturing system is activated by To perform POSE, surgeons advance the
depressing a plunger on the top of the device. USGI TransPort® down the oesophagus to the
When activated, the system deploys a 3-0 poly- stomach fundus, like a traditional endoscope.
propylene suture through the tissue in the suction The tip of the device is then turned towards the
chamber and deposits the suture tag in the end of operating site and locked for stabilization. Once
the capsule [24]. the platform is in place, the flexible grasper is
The results of a very first trial have been pre- delivered to the operative site through a lumen of
sented at the XVI World congress of the IFSO the TransPort® and is then used to bite a fold of
2011 by P. Schauer after 12 months of follow-up. the stomach mucosa on which the anchors are put
Eighteen subjects with a BMI 30–45 kg/m2 (mean (Fig. 15.1). Each anchor pair is preloaded into a
38.6 kg/m2) underwent a gastric volume reduc- catheter (g-Cath®), and inserted into the grasper
tion procedure, each patient required four to eight before firing. Several folds are created in this way
plications (mean 6), and the average procedure to reduce gastric fundus and limit its ability to
time was 125 min. No serious or significant expand. Once the desired capacity is reached, the
procedure-related complications have been device is removed through the oesophagus. POSE
observed. They report a EWL >30 % for half of is reported to be performed successfully in North
the patients and an EWL 30.5 ± 16.8 % for sub- America, Europe and the Middle East. From
jects with a BMI between 30 and 35 (TRIM trial 2011 to 2012, a prospective observational study
investigators, personal communication). The was undertaken by J. C. Espinós et al. involving
RESTORe is currently being evaluated in the 45 patients: 75.6 % female; mean age 43.4 ± 9.2
TRIM (Transoral Gastric Volume Reduction as SD (range 21.0–64.0). At baseline: mean abso-
an Intervention for Weight Management) trial. lute weight, 100.8 ± 12.9 (75.5–132.5); BMI
36.7 ± 3.8 (28.1–46.6). All POSE cases were
15.3.1.3 POSE Procedure performed with no intraoperative adverse events,
A new, less invasive surgical option performing no conversions or failed procedures. No mortality
gastric plication is the POSE procedure, inspired was reported; only two minor postoperative
by the endoscopic technique used to treat pouch adverse events resulted: one case of low-grade
158 N. Di Lorenzo and F.M. Carrano

Fig. 15.2 Overstitch® Endoscopic Suturing System

(Apollo Endosurgery, Inc.)

Fig. 15.1 Creation of a gastric fold using IOP® (USGI antrum to EGJ (Fig. 15.2). Although very fashion-
Medical, Inc.) able, published data on the procedure is scarce at
the time of writing. Among the preliminary expe-
fever (resolved with oral antibiotic treatment) rience, Abu Dayyeh in Rochester (Minnesota,
and one patient returned to hospital on the second USA) performed a transoral endoscopic gastric
postoperative day with chest pain. Minor postop- volume reduction with Overstitch in four sub-
erative side effects included sore throat, stomach jects. Post-procedural abdominal pain and nau-
pain, nausea and chest pain. Three cases of vom- sea developed in three patients, while acid reflux
iting resolved within the first 12 h with no symptoms developed in one and resolved with an
requirement of additional hospital stay. To be oral proton pump inhibitor [26]. No data on EWL
noted, all patients were discharged from hospital or TBWL were reported, being only a pilot feasi-
in less than 24 h. Liquid intake began 12 h post- bility study. Long-term safety and efficacy of the
procedure with full solids by 6 weeks. Follow-up procedure are yet to be evaluated.
visits were performed in a tight schedule at 1, 2
and 3 weeks, and at 1, 2, 3, 4, 5 and 6 months. 15.3.1.5 TERIS
The mean 6-month POSE TBWL was 15.5 % The Trans-oral Endoscopic Restrictive Implant
and more than 80.0 % of POSE patients had System (TERIS® – Barosense Inc.) uses an endo-
achieved ≥25 %EWL. The overall POSE patient scopic guidance to trans-orally implant a prosthe-
mean EWL was MLT 40.0 % (calculated by met- sis placed at the cardia level to decrease food
ric) and 49.4 % (calculated with BMI 25 as ideal reservoir size at the upper part of the stomach to
end point). The authors also report that patients induce early and prolonged satiety. Five gastric
in the current POSE cohort who have reached the plications are created about 3 cm below the EGJ
9- and 12-month time points have continued their using an articulating endoscopic circular stapler.
weight-loss trend without complications [25]. The gastric restrictor is subsequently attached to
the gastric wall using silicon anchors inserted
15.3.1.4 Overstitch through the gastric plications. Primary clinical
Similar in concept, the recently redesigned results, observed in a female patient with a BMI of
Overstitch, by Apollo Endosurgery, is able to 46 kg/m2, showed no major complications during
perform transoral endoscopic gastric volume and after the procedure. The EWL was 21 and
reduction by a series of endoluminally placed, 26 % at 3 and 6 months, respectively. The observa-
full-thickness, closely spaced interrupted sutures tion of a high rate of implant obstruction led to the
through the gastric wall from the prepyloric development of a second-generation implant [27].
15 Endoscopic Treatment: New Technologies 159

Later, Fockens et al. published a study on to the device itself, including abdominal pain,
safety and efficacy using the TERIS implant. This nausea, vomiting, mainly within 2 weeks of
short-term trial included 13 patients with comor- implantation. Implant site inflammation was
bidities (BMI 40–50 kg/m2 or 35–40 kg/m2) and a found in all the patients [30].
3-month follow-up. Results reported one patient Gersin et al. carried out an open-label, sham-
with intraprocedural gastric perforation related to controlled trial on obese patients to test weight
stapler malfunctioning. Two other patients had loss before bariatric surgery due to the implanta-
a pneumoperitoneum treated conservatively in tion of DJBL. The primary end point of the trial
one case and deflated by a percutaneous hollow was the difference between the two groups, in
needle in the other. Twelve of 13 patients had a percentage of excess weight loss (EWL) at week
successful implant placement. At 3 months of 12. Thirty-seven patients were enrolled in the
follow-up, a median excess weight loss of 28 % trial, 13 received the DJBL and 24 patients in the
and a median BMI decrease of 4.2 kg/m2 (from sham group underwent EGD and mock implanta-
42.1 to 37.9 kg/m2) were reported [28]. tion. After 12 weeks, they observed a statistically
relevant difference of EWL between the two
groups: 62 % of patients in the DJBL achieved
15.3.2 Derivative Procedures 10 % or more EWL compared with 17 % of the
subjects in the sham arm. Total weight change in
A device, which applies a concept similar to the the DJBL arm was −8.2 ± 1.3 kg compared with
biliopancreatic diversion (BPD), is the duodeno- −2.1 ± 1.1 kg in the sham arm (P < 0.05) [31].
jejunal bypass liner (DJBL), a sterilized, single- In 2009, Gersin et al. published a study on the
use endoscopic device, which is minimally use of DJBL for type 2 diabetes treatment. They
invasive and used under radioscopic control. It is randomized 18 obese diabetic patients in two
composed of a nitinol anchor with tiny lateral groups: the first (12 patients) underwent DJBL
barbs for fixation, and an impermeable plastic implantation while the other (6 patients) under-
conduit made of a fluorine polymer 62 cm in went sham endoscopy. The subjects baseline
length (Fig. 15.3), which prevents contact of HbA(1c) was 9.1 ± 1.7 % and body mass index
bile–pancreatic secretions with chime prior to the 38.9 ± 6.1 kg/m2. By week 1, change in fasting
proximal segments of the jejunum [29]. glucose in the DJBL arm was −55 ± 21 mg/dL
versus +42 ± 30 mg/dL in the sham arm. At week
15.3.2.1 Results 12, HbA(1c) change was −1.3 ± 0.9 % in the
The first human experience was registered in DJBL arm and −0.7 ± 0.4 % in the sham arm, and
2007 by L. Rodriguez-Grunert et al. with a at 24 weeks, values were −2.4 ± 0.7 % in the
12-patient prospective, open-label, single-centre, DJBL arm and −0.8 ± 0.4 % in the sham arm [32].
12-week study. They reported problems with the Similar results were obtained in the
fixation of the device and adverse events related Netherlands by Greve’s group [33] that com-
pleted a randomized clinical trial including 41
patients: 30 underwent sleeve implantation and
the remaining 11 were put on diet as control
group. Only 26 devices were implanted and 4 of
them had to be explanted prior to study comple-
tion due to migration (1), anchor dislocation (1),
sleeve obstruction (1), and continuous epigastric
pain (1). No procedure related adverse events
occurred; however, each patient had at least one
adverse event during the first week after implan-
Fig. 15.3 Duodenal-jejunal bypass liner EndoBarrier® tation, mainly abdominal pain and nausea. Initial
(gi-Dynamics, Inc.) from: http://www.gidynamics.com/ mean BMI was 48.9 and 47.4 kg/m2 for the device
160 N. Di Lorenzo and F.M. Carrano

and control patients, respectively. Mean EWL (hollow viscous), thus avoiding any external inci-
after 3 months was 19.0 % for device patients sions and scars [36].
versus 6.9 % for controls. Absolute change in It requires specific endoscopic instruments
BMI at 3 months was 5.5 and 1.9 kg/m2, respec- introduced into the abdominal cavity. Several
tively. Type 2 diabetes mellitus was present at experiences of cholecystectomy and appendec-
baseline in eight patients of the device group and tomy performed by trans-vaginal or trans-gastric
improved in seven patients during the study approach in humans have been published [37,
period (lower glucose levels, HbA1c and medica- 38]. However, “pure” NOTES is still more of a
tion requirements) [33]. concept than a routine practice. It has also been
Subsequently, Escalona et al. in 2009 reported considered a very promising technique for bariat-
a 12-week pilot trial of ten patients treated with ric surgery, for the particular advantages of a
EDJBL modified with a 4-mm restrictor orifice minimally invasive approach to the abdomen of
distal to the anchor. The baseline BMI was of obese patients. Nevertheless, the complexity of
40.8 ± 4.0 kg/m2 (range 35.9–47.8 kg/m2). After bariatric procedures and the lack of appropriate
12 weeks, the EWL range was 22–64 %, corre- devices remain a main issue, which could be
sponding to a total weight loss of 16.7 ± 1.4 kg overcome by the future introduction of miniatur-
(range 12.0–26.0) [34]. ized robotic devices.
Notwithstanding the promising results, the One major point of criticism to translumenal
authors observed side effects related to the tech- surgery is the closure of access to the abdominal
nique as inflammation of the anchoring site, nau- cavity gained through the viscous, since any com-
sea and vomiting. plication rate perforating a healthy organ is con-
The group led by Sandlers in California tested sidered unacceptable, at least conceptually. Several
a similar concept, but different device, in 2011. A reports mention safe access and closure with new
unique gastroduodenojejunal bypass sleeve devices as the transmurally placed anchor systems,
secured at the EGJ with endoscopic and laparo- t-tags or bar-shaped stitches. Moreover, large-
scopic techniques was designed to create an scale clips (OTSC; Ovesco), Padlock-G® clip
endoluminal gastroduodenojejunal bypass. (Aponos Medical) and Jumbo clips® (Endoclips,
Twenty-four patients were enrolled in the trial Olympus Optical Co. Ltd.) have been developed.
and 22 underwent endoscopic implant of the Technically, the closure of the gastrotomy is
bypass sleeve, which was maintained for 12 obtained either by applying a clip after suction of
weeks and then removed endoscopically. Two the surrounding mucosal tissue, or by applying
patients required early explant due to postopera- clips first to both ends of the incision and then
tive dysphagia. Observed EWL was 39.7 %, and towards the centre of the same incision [39, 40].
all patients who presented preoperative diabetes The Queen’s NOTES group designed a novel
mellitus showed normal blood glucose levels at endoscopic method of closing gastrotomies using
12 weeks follow-up [35]. PolyLoop polyp ligature devices and endoscopic
No long-term results are available, consider- clips [41]. This method for closing the gastric
ing that DJBL is also a temporary device. defect after NOTES procedures has been tested in
animal trials on five 30-kg pigs. No complication
after surgery was reported. Endoscopic examina-
15.4 Translumenal Treatment tion carried out 1 week after surgery revealed all
the closures to be intact and identifiable only by
Natural Orifice Translumenal Endoscopic a small ulcer [42].
Surgery (NOTES) promises to open a new era for Linear staplers for flexible endoscopy have also
surgery. It can be defined as scarless abdominal been proposed to close the hole after NOTES pro-
operations performed with an endoscope passed cedure. Stapling activation is reported to be simple
through a natural orifice, then through an internal in endoscopic procedures: application in humans
incision in the stomach, vagina, bladder or colon is still under evaluation and the tightness of the
15 Endoscopic Treatment: New Technologies 161

closure has been controlled by laparoscopy in the a reliable solution and, maybe, the most suit-
reported experience. However, the visualization able in the future, fitting perfectly to the well-
and manipulation of tissue and other constrains established concept of minimal invasiveness.
limit, as of present, the use of this device [43]. The described devices will probably be
Limited literature on clinical procedure hybrid replaced by more advanced ones in the near
NOTES sleeve gastrectomy has been reported. In future, but will remain as “pioneers” of a new
2009, Fischer et al. from the UCSD published a era of bariatric treatments.
case report of a NOTES laparoscopic-assisted
transvaginal sleeve gastrectomy in a 29-year-old
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162 N. Di Lorenzo and F.M. Carrano

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multicenter study. Surg Endosc. 2008;22:589–98. 30. Rodriguez-Grunert L, Galvao Neto MP, Alamo M,
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Endosc. 2011;74(6):1248–58. doi:10.1016/j. 2009;11(11):725–32.
gie.2011.08.046. 33. Schouten R, Rijs CS, Bouvy ND, Hameeteman W,
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Castagneto M, Nanni G, Costamagna G, et al. Study randomized efficacy study of the EndoBarrier
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R, Khokhotva V, Hurlbut D, Mercer D. A reliable
 Adjustable Gastric Banding
16
Karl A. Miller

16.1 Introduction percentage excess weight loss of 50–61 % at 2–3

years. Although in the short term, weight loss
Morbid obesity (body mass index ≥40 kg/m2 or with the gastric band is exceeded by that of the
≥35 kg/m2 in the presence of comorbidities [1]) malabsorptive operations, beyond 2 years, weight
is a complex and increasingly prevalent chronic loss has been shown to be equivalent [18], with
disease that operates at the nexus of genetics, possible metabolic advantages accruing to band
hormones, environment, and behavior [2–4]. patients (e.g., decreased incidence of cholecysti-
There is no known cure for morbid obesity, and tis [21]) due to the gradual nature of weight loss
life-long treatment in association with lifestyle with banding.
change is required to minimize its progressive Since the introduction of the first gastric band
effects. No medical treatment has been success- in the early 1980s, the technique used for its
ful in maintaining weight loss and reducing the implantation has evolved in response to the clini-
comorbidities of obesity [5–7]; surgical and cal experience of surgeons, the band’s long-term
device technologies, however, have demonstrated complication profile, and advancements in band
their effectiveness [8–10] and safety [11–13] and injection-port engineering. This review pres-
over the intermediate to longer terms (i.e., 5–10 ents a summary of the development of gastric
years), providing the impetus for continued inno- banding, particularly, the primary operative tech-
vation in these areas. niques [22], and a description of a recent innova-
Laparoscopic adjustable gastric banding tion in injection-port implantation technology
(LAGB) is a proven approach to the treatment of and technique.
morbid obesity [14, 15] that comprises both an
operation and an implantable biomedical device.
The efficacy of this purely restrictive bariatric 16.2 Technical Aspects
procedure has been tested in the worldwide liter-
ature over the past decade in numerous series In 1978, Wilkinson pioneered the concept of gas-
summarized by systematic review [16–18] and tric banding in an open procedure by surround-
meta-analysis [19, 20]. These report a LAGB ing, and thus constricting, the upper stomach
with a 2-cm-wide nonadjustable mesh fabric
(Marlex®) [23], an innovation that was ineffective
K.A. Miller, MD, FACS
in achieving sufficient weight loss. In 1980,
Surgical Department, Hallein Clinic,
Buergermeister Str. 34, Hallein A-5400, Austria Dacron® graft segmentation of the upper stomach
e-mail: [email protected] by Molina resulted in unacceptably high rates of

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 165
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_16,
© Springer International Publishing Switzerland 2015
166 K.A. Miller

reoperation [24] and was abandoned. Wilkinson positioning the posterior aspect of the band at the
and Peloso, in 1981 [25], Kolle, in 1982 [26], and distal esophagus. In 2000, Weiner et al. [46] pre-
Molina and Oria, in 1983 [27], each introduced a sented an amalgam of the advantages of both
constricting-ring nonadjustable gastric band techniques in their report of a “two-step” (pars
which were, unfortunately, also associated with flaccida to perigastric) approach.
high rates of reoperation, as the stomach tissue In 2000, Catona, La Manna, and Forsell [47]
stretched postoperatively and the stoma diameter reviewed the development of gastric banding,
of the band could not be modulated. In a 1984 particularly pars flaccida technique, over the pre-
meeting presentation and 1989 report, Szinicz vious 13 years, and Fielding and Allen [48] fol-
and Muller [28] and Szinicz et al. [29] presented lowed by Ren and Fielding [49] reported the
the results of their experiments in minipigs improvements that were attainable using the pars
implanting a “reversible” gastric band, the fore- flaccida as opposed to the perigastric technique
runner of today’s adjustable gastric bands. (i.e., reduced incidence of late complications,
In 1985, the Swedish group of Hallberg and particularly gastric prolapse, to between 0.6 and
Forsell published their first report of an adjust- 3.5 %). Both bands, in wide use throughout
able gastric band [30]—the Swedish Adjustable Europe from the mid-1990s, have undergone sev-
Gastric Band (SAGB)—developed in Huddinge eral design modifications. The Lap-Band was
University Hospital, Sweden, and first implanted approved for use in the US in 2001 [39]; the
clinically in an open procedure by Klaiber in SAGB was approved in the US (as the
Switzerland [31]. The SAGB was designed to REALIZETM Band) in 2007 [50].
accomplish stoma restriction by means of a low- The most recent innovation in implantation
pressure/high-volume mechanism [32–34]. technique is mechanical injection port fixation
Kuzmak, in 1986 [35–37], described his implan- technology, as opposed to suture fixation of the
tation of a slender (1-cm wide), nonadjustable, port. In two prospective, 1-year, randomized
silicone band that created an effective 13-mm studies [51, 52], the Velocity® port (Obtech
gastric stoma; in 1986, Kuzmak modified his Medical AG, Baar, Switzerland, distributed by
nonadjustable gastric band to incorporate an Ethicon Endo-Surgery, Inc., Cincinnati, OH)
inflatable, small-diameter balloon that functioned demonstrated improved stability, speed of fixa-
in a high-pressure/low-volume manner [38] tion, and reduced complications, including
(which later became the Lap-Band®) [39]. diminished port-site pain and use of pain medica-
In the early 1990s, Catona et al. [40] and tions; Miller and Pump showed an eightfold
Broadbent et al. [41] were the first to laparoscop- improvement in speed-to-implant (i.e., from
ically perform nonadjustable gastric banding. >8 min to <1 min, P < 0.0001).
Catona et al. suggested opening the lesser omen- The perigastric approach is summarized,
tum to increase the procedure’s speed and sim- below, followed by a more detailed description of
plicity. In 1993, Belachew et al. [42] reported the pars flaccida implantation of the SAGB.
their animal studies of laparoscopic placement of
the adjustable band, and in 1994 and 1995,
Belachew et al. (Lap-Band) [43, 44], and in 1997, 16.2.1 Perigastric Approach
Forsell et al. (SAGB) [33] reported performing
the first human implantations of laparoscopic In the perigastric approach, following introduc-
adjustable gastric bands (generically, “LAGBs”). tion of the trocars and with the calibration balloon
Belachew et al. employed a perigastric technique, in place in the stomach, an incision of approxi-
Forsell et al., the pars flaccida technique, devel- mately 0.5–1 cm is made at the lesser curvature
oped specifically for use with the SAGB to reduce close to the cardia (Fig. 16.1). A passage is formed
the complications associated with nonadjustable along the posterior wall of the stomach from the
banding. Niville et al., in 1998 [45], described gastroesophageal (GE) junction above the perito-
creating an extremely small gastric pouch by neal reflection of the bursa omentalis through to
16 Adjustable Gastric Banding 167

tube into the stomach and the tube’s balloon is

slowly filled with 25 mL saline, or air. The bal-
loon is then drawn back up against the GE
junction.
The lesser omentum is grasped with forceps to
stretch the pars flaccida. An approximately 5-cm
incision is made caudal to the GE junction but
cranial to the left gastric artery (Fig. 16.1) to
avoid opening the omental bursa (lesser sac) and
prevent injury to the left gastric artery, the infe-
rior phrenic artery, the branches of the vagal
nerve, or an accessory hepatic artery. The right
crus of the diaphragm is exposed, and the tissue
medial to the right crus, 5 cm distal to the GE
Fig. 16.1 The point of dissection employed in the peri- junction, is incised approximately 0.5 cm in
gastric (A) and pars flaccida (B) techniques. (C) angle of
preparation for eventual retrocardiac tunneling.
His; (1) lesser omentum (pars flaccida); (2) caudate lobe
of the liver; (3) right crus of the diaphragm At this point, the calibration tube is advanced
into the stomach. The fundus is grasped with the
forceps and drawn caudally, with the forceps
the angle of His. Using the endodissector passed to the assistant. The avascular portion of
(Allergan, Irvine, CA), attached to the end of the the ligament at the angle of His is incised about
catheter, the gastric band is placed around the car- 1 cm in width to prepare for eventual placement
dia. The calibration balloon is used to gauge final of the gastric band. This action establishes the
positioning of the band and the creation of the so- direction of the dissection for the retrocardiac
called virtual pouch. To prevent band slippage, tunnel. Finally, the left crus of the diaphragm is
three or four sutures are placed in the greater cur- exposed approximately 1–1.5 cm.
vature. The catheter end of the band is brought
outward through the 15- or 18-mm trocar and
connected to the port, which is then fixed beneath 16.2.4 Introducing the Adjustable
the anterior rectus sheath using four nonresorb- Gastric Band (AGB)
able interrupted sutures [44, 53].
The AGB is checked to ensure that it has been
properly prepared for insertion and is free of
16.2.2 Pars Flaccida Technique leaks. The band is grasped with forceps at its
locking end flap, and positioned so that the bal-
The anatomic landmarks of the LAGB procedure loon side of the band parallels the forceps. The
are best identified by bringing the patient into a band is introduced into the abdominal cavity
30° reverse Trendelenburg position. If necessary, through the 15-mm trocar, assisting its introduc-
the subcardiac region of the stomach and GE tion, if necessary, through the trocar with the
junction should be freed from fat to ensure an forceps.
optimal view of the field.

16.2.5 Creating the Retrocardiac

16.2.3 Dissection at the Lesser Tunnel
Curvature
The Goldfinger instrument (Obtech Medical AG,
To determine the precise location of the GE junc- Baar, Switzerland, distributed by Ethicon Endo-
tion, the anesthetist passes the gastric calibration Surgery, Inc.) is introduced in front of the anterior
168 K.A. Miller

wall of the stomach corresponding to the even- 16.2.8 Placing Safety Sutures
tual course of the retrocardiac tunnel. From the
incision prepared at the right crus of the dia- The band fastening is drawn in the direction of
phragm, the Goldfinger dissector is introduced the lesser curvature in order to place the safety
retrocardially toward the incision at the angle of sutures. The anesthetist empties the calibration
His until it emerges at that incision. In order to tube completely and withdraws it into the
ensure a small pouch size (approximately 15 mL) esophagus to avoid its being inadvertently fixed
and to avoid injury to the stomach and esopha- when placing the safety sutures. To maintain the
gus, it is important not to deviate from the plane gastric band in the best position, the fundus is
of dissection during this maneuver. Any suspi- fixed to the left crus of the diaphragm with the
cion of a perforation should be investigated. first nonabsorbable suture. To surround the band
completely with a cuff of stomach wall, the fun-
dus is grasped caudal to the band and pulled in
16.2.6 Positioning the Band the direction of the crus. The suturing is contin-
ued anteriorly with two additional safety sutures
The gastric band should be positioned in the ret- between the seromuscular layer of the fundus
rocardiac tunnel so that the balloon side is ori- and the pouch, ensuring that the band fastening
ented toward the stomach wall. Using the forceps, is freely accessible. During this process, the
the suture loop of the AGB is brought to the notch assistant should insert a swab above the upper
of the Goldfinger dissector, which (with the margin of the band to ensure that the band is
attached band) is pulled, under vision, through protected.
the retrocardiac tunnel from the angle of His until
the locking end flap is visible at the lesser curva-
ture. The tab end of the AGB on the side of the 16.2.9 Testing for Leaks, Inspecting
lesser curvature is grasped with the forceps and the Operative Field
the Goldfinger dissector is carefully removed.
The anesthetist advances the calibration tube
back into the pouch and fills it with 20 mL of
16.2.7 Closing the Band, methylene blue solution. If the methylene blue
Retrocardiac Technique emerges anywhere on the stomach, the source of
injury responsible for the leak should be meticu-
The calibration balloon, if used is withdrawn to lously sought out and repaired. The poorly visi-
the point of the GE junction. The possibility of ble posterior stomach wall, especially, should be
closing the band is checked, with respect to the examined. The methylene solution should subse-
patient’s individual anatomy, by attempting to quently be suctioned away by the anesthetist and
overlap both ends of the band. If it is not readily the calibration tube removed.
possible due to a large amount of perigastric fat, The operating field is completely inspected
the “two-step” technique (pars flaccida to peri- for bleeding or injury to organs. The end of the
gastric) should be employed (see Sect. 16.2.9.1, band tubing is grasped with the forceps and
below). pulled out through the trocar in preparation for
Closing the band is accomplished by pulling the extracorporeal attachment of the port system.
the locking end flap with the forceps until it has The 15-mm trocar is carefully removed, avoid-
passed through the buckle. It is important to ing injury to the tubing system, and the fascia at
ensure that no portion of the stomach or fat has the entry site is closed with fascial suture to
been drawn into the locking mechanism of the avoid hernia formation. All trocars are removed
band, and that the band is not too tightly fitted under vision, finally, including the optical
around the stomach. trocar.
16 Adjustable Gastric Banding 169

Fig. 16.2 Adjustable

banded gastric bypass

16.2.9.1 Two-Step Technique flaccida and introduced retrocardially toward the

Another implantation option is the “two-step” incision at the angle of His on the lesser curve
maneuver, applicable when perigastric and vis- and the gastric pouch 1–2 cm above the horizon-
ceral fat are too extensive to dissect during pars tal cut edge of the pouch. Following this step, an
flaccida implantation. The fat at the lesser curva- AGB is introduced via the 15 mm port, drawn
ture containing the nerve of Latarjet at the level around the pouch and locked into place. To pre-
of the band is separated carefully from the gastric vent slippage, the band is then fixed by suturing
wall in the direction of the right crus until the cur- the gastric remnant to the gastric pouch both
vature becomes visible. A blunt articulating dis- above and below the band with nonabsorbable
sector is passed through the incision on the lesser sutures.
curvature side until it is visible at the pars flac-
cida incision site. The dissector (with attached
band) is pulled, under vision and without force, 16.2.11 Attaching the Port System
from the incised pars flaccida to the incision at
the lesser curvature close to the gastric wall until 16.2.11.1 Suture Fixation Method
the locking end flap appears at this site. The skin incision is extended to approximately
3.5 cm, and the fat is completely dissected from
the fascia of the anterior rectus sheath for safe
16.2.10 Adjustable Banded Gastric port placement. The locking connector of the port
Bypass is placed into the cut end of the tubing and fas-
tened at the port connection. The locking connec-
In case of insufficient weight loss or technical tor is pushed over the tubing toward the port until
pouch failure after RYGB, we perform an adjust- the tubing is completely fixed at the port.
able gastric band to restrict the gastric pouch as a The port should be positioned on the fascia so
salvage procedure (Fig. 16.2). After exploration as to be readily located and accessible for band
of the gastric pouch, an atraumatic grasper is adjustments, and placed in a position that will not
passed through a small opening of the pars rotate or migrate. For better visualization of the
170 K.A. Miller

fascia, the skin is held open using two Langenbeck released, and the firing lever is compressed with
hooks. Four threads are placed on the fascia; one the palm. Maintaining compression on the firing
side of each thread is guided through one of the lever, the applier is removed from the field. The
suture holes of the port and the port is placed in port is left attached to the fascia without suture
the fascia. The tubing is guided carefully into the fixation. If proper mechanical fixation is not
abdominal cavity and the threads are knotted to attainable, the port is secured with sutures using
fix the port securely. the three holes visible through the actuator ring.
In both the suture and mechanical port fixation
16.2.11.2 Mechanical Port Fixation techniques, a loop of tubing is retained inside the
Method abdomen to facilitate free movement by the
When using the SAGB-compatible Velocity® patient during exercise without dislodging
mechanical port fixation device (or “port the band or port system. The band balloon is left
applier”), the device description and operating uninflated at the conclusion of surgery.
instructions should be carefully read. A skin inci-
sion of at least 3 cm must be made to accommo-
date the mechanical fixation introducer. The fat 16.3 Clinical Management
should be dissected away from the fascia of the
anterior rectus sheath. The strain-relief end of the The first band adjustment of the LAGB should be
port locking connector is placed onto the cut end performed no sooner than 4–6 weeks postopera-
of the band tubing until the tubing passes approx- tively to avert esophageal dilation and risk of
imately 2 cm beyond the locking connector tab. band slippage. The patient should not lose more
The band tubing is pushed onto the connection than 0.5–1 kg of weight per week, there should
tube extending from the port until the tubing be no intestinal obstruction, and no abdominal
reaches the outer face of the port connection pain should be experienced with eating.
housing. It is important to ensure that locking The patient is positioned supine on the X-ray
connector tabs are aligned with the notch in the table and the area of skin above the port is disin-
connection housing before sliding the connector fected. The table is tilted to a 30–45° reverse
into the housing. The connector is turned clock- Trendelenburg position. A syringe with 3–4 mL
wise until it stops rotating. Air is aspirated from of 41 % Jopamidol® injection solution (USP), or
the port using a Huber needle. sterile 0.9 % NaCl solution is prepared. Port loca-
The port is checked to verify that the actuator tion is identified by palpation, and an atraumatic
ring is in the unlocked position, and the fastening Huber needle is inserted vertically through the
hooks of the port are retracted into the port. If skin into the chamber while holding the port
hooks are still visible, the actuator ring is rotated positioned between two fingers. If the port cannot
again. While the actuator is still in the unlocked be located in this manner, the puncture should be
position, and the tubing connected, the port is repeated under fluoroscopic control.
inserted into the applier receptacle with the red All air is removed from the band system
safety cap facing opposite the applier and the before being filled for the first time.
connection housing fitted into one of the two The water-soluble contrast agent is instilled
guide notches. Correctly inserted, the port snaps into the port. The patient swallows a barium-
into place in the applier. containing contrast agent under fluoroscopic con-
The safety cap is removed from the bottom of trol so that the correct position and filling of the
the port and the applier’s handle is grasped in the band may be gauged (Fig. 16.3). The angle of the
palm. The port is placed on the prepared fascia band with respect to the transverse plane should
and the applier is inserted at an angle, with the be 40–45°; the contrast agent should move from
tubing and connector entering the incision first. the pouch into the stomach in a continuous flow
Light downward pressure is used to situate the of 1–2 peristaltic waves. Some water-soluble
port flat on top of the fascia, the safety trigger is contrast agent may be aspirated until optimal
16 Adjustable Gastric Banding 171

placement of the band as well as employment of

tunneling sutures in fixing the band in place. The
early results of mechanical port fixation technol-
ogy and technique are promising. A potentially
more secure port position may be achieved with
the velocity port mechanical applier while reduc-
ing total operating time by 19 %.
The pars flaccida technique is associated with
a decreased rate of gastric prolapse, an asset that
may result in improved overall LAGB weight
loss and enhanced patient compliance. Gastric
band and port implantation technique will con-
tinue to evolve in response to the needs of the
Fig. 16.3 Following barium swallow under fluoroscopic
control, the angle of the band with respect to the trans- patient and the goal of increasing safety and
verse plane should be 40–45°—the shape of pouch forma- efficacy.
tion and esophageal clearance is of importance O’Brien et al. demonstrate from one center a
durable weight loss with 47 % EWL maintained
filling can be demonstrated via barium swallow. to 15 years. This weight loss occurred regardless
A maximum volume of 4 mL (depending on band of whether any revisional procedures were
systems) should not be exceeded at the first needed and showed substantial and similar long-
filling. term weight losses for LAGB and other bariatric
procedures [54]. Nevertheless, numerous reports
indicate that LAGB cannot be recommended as a
16.4 Outcomes primary procedure to the general morbidly obese
population, a careful patient selection is manda-
Regardless of the surgical technique employed, tory [55].
long-term success with LAGB is dependent on Angrisani et al. showed in a long-term follow-
recognition of the chronic, multifactorial nature up study that LAGB is a safe and effective proce-
of morbid obesity, and thus, the necessity, for the dure in patients with a BMI <35 kg/m2 [56].
patient, of enduring lifestyle change, and for the The implantation of a LAGB in failed gastric
surgeon, of long-term follow-up. Although mini- bypass procedures seems to be emerging. The
mally invasive, and performed at an ever- results of all nine studies shown by Vijgen et al.
increasing rate in most parts of the world, LAGB reported a further increase in weight loss after
is not a simple procedure, and it is associated salvage banding for failed RYGB. In case of
with distinctive long-term morbidity despite its insufficient weight loss or technical pouch failure
reputation as the least invasive bariatric operation after RYGB, all reports suggest that salvage
with the lowest perioperative morbidity and banding is a safe and feasible revisional proce-
mortality. dure [57].
Forsell et al., in their early papers on laparo- The results of the study from Silberhumer
scopic technique and adjustable banding [32–34], et al. demonstrate that LAGB is an effective and
stressed four keys to successful technique: cor- safe procedure in adolescents and children with a
rect positioning of the band to avoid gastric injury very carefully selected patient population [58]. In
or perforation, fixation of the band to avoid slip- adolescents, the attractiveness of this procedure
page down along the greater curvature, place- as first-line surgical treatment in a multidisci-
ment of the port connecting tube so as to avoid plinary setting is due to the reversibility of the
kinking, and waiting to inflate the band for 4–6 procedure without altering the physiological
weeks following surgery. Catona et al. [47] also intestinal tract in a very dynamic patient
stressed the importance of high, accurate population.
172 K.A. Miller

Even adjustable gastric banding is not very patients, health professionals, and third-party payers.
J Am Coll Surg. 2005;200(4):593–604.
popular in many centers around the world; it will
15. Weiner R, Blanco-Engert R, Weiner S, et al. Outcome
be a good alternative procedure in selected after laparoscopic adjustable gastric banding – 8 years
patients, adolescents, and low BMI patients and experience. Obes Surg. 2003;13:427–34.
nevertheless a fair salvage procedure for failed 16. Fried M, Miller K, Kormanova K. Literature review of
comparative studies of complications with Swedish
gastric bypass procedures.
band and Lap-Band. Obes Surg. 2004;14(2):256–60.
17. Chapman AE, Kiroff G, Game P, et al. Laparoscopic
adjustable gastric banding in the treatment of obesity:
a systematic literature review. Surgery. 2004;135(3):
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 Laparoscopic Sleeve Gastrectomy
17
Giovanni Casella, Emanuele Soricelli, Alfredo Genco,
Adriano Redler, and Nicola Basso

17.1 Introduction SG (LSG) first and BPD-DS after an average

11-month interval, was proposed [2, 3].
Sleeve gastrectomy (SG) is a technically simple Results obtained in terms of weight loss and
surgical procedure with low complications rate resolution of comorbidities, after SG as first stage
and negligible long-term nutritional deficiencies. of BPD-DS, encouraged and stimulated its
SG was proposed and performed in 1988 by spreading with increasing compliance of the
Hess and Hess as part of a hybrid malabsorption patients. At first, the efficacy of SG had been
procedure, the biliopancreatic diversion (BPD) attributed to the reduction of the gastric capacity
with duodenal switch (DS), because of the high and the procedure was classified as restrictive. It
incidence of marginal ulcers at the gastro-ileum became soon evident that significant modifica-
anastomosis in the original Scopinaro BPD pro- tions of the gastrointestinal hormones play a pre-
cedure [1]. In 2000, Ren et al. demonstrated the eminent role. Changes in ghrelin (GHR),
feasibility of BPD-DS with a laparoscopic glucagon-like peptide1 (GLP-1) and protein YY
approach. Because of the high rate of complica- (PYY) induced by the gastric resection are of
tions and mortality in their early experience, a paramount importance in the weight loss and glu-
two-stage laparoscopic BPD-DS, laparoscopic cose homeostasis effects of the procedure. In
addition, it has been recently shown in the experi-
mental animal that SG induces modifications of
G. Casella • E. Soricelli • A. Redler the gut microbiota instrumental in the genesis of
Department of Surgical Sciences, its metabolic effects [4].
“Sapienza” University of Rome, In 2010, the American Society for Metabolic
Vle Regina Elena, 324, Rome 00161, Italy
e-mail: [email protected];
and Bariatric Surgery (ASMBS) issued a position
[email protected]; [email protected] statement recommending LSG as an approved
A. Genco
bariatric procedure [5]. In 2011, LSG became the
Department of Surgical Sciences, second most performed bariatric operation after
Sapienza, University of Rome, gastric bypass (GBP) (27.8 % vs 46.6 %), accord-
Viale del Policlinico 155, Rome 00161, Italy ing to a survey of the International Federation for
e-mail: [email protected]
the Surgery of Obesity and Metabolic Disorders
N. Basso (*) (IFSO), with a fivefold increase when compared
Department of Surgical Sciences,
“Sapienza” University of Rome,
to data from a similar questionnaire in 2008, so
Via Napoli, 51, Rome 00184, Italy becoming the bariatric procedure with the high-
e-mail: [email protected] est growth rate [6, 7].

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 175
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_17,
© Springer International Publishing Switzerland 2015
176 G. Casella et al.

Since 2007, an International SG Summit 17.3 Surgical Technique

Conference has been held every 2 years, allowing
surgeons performing LSG to share clinical experi- The patient is positioned in 30° anti-
ences and discuss technical aspects of the proce- Trendelemburg position with legs abducted. The
dure. At the 2012 International SG Summit surgeon stands between the patient’s legs, the
Conference, 130 surgeons reported on 46,133 pro- first assistance, holding the camera, is on the left
cedures with a mean follow-up of 5 years [8–12]. side of the patient aside the scrub nurse, a second
assistant is placed on the right side (Fig. 17.1a).
Pneumoperitoneum is generally created using
17.2 Technical Aspects Veress needle placed in the left subcostal margin
(Palmer’s point). After obtaining a pneumoperi-
The laparoscopic technique has been well stan- toneum pressure of 15 mmHg, the Veress needle
dardized by Gagner in 2000 [2]. However, during is withdrawn and replaced by a 12-mm optical
the following years, several details have been trocar to allocate the camera. Four additional tro-
modified. In this chapter, we will emphasize tech- cars are placed in the upper abdominal quadrants
nical points in the light of our own experience of under direct vision (Fig. 17.1b). The procedure
about 900 cases since 2002 [13]. Although LSG is starts with the identification of the pylorus.
not a technically demanding procedure, important Using a marked grasper and stretching the gas-
key points should be respected to achieve good tric wall, a distance of 4–6 cm along the greater
long-term results on weight loss and co-morbidi- gastric curvature is measured and marked. Some
ties improvement and to minimize the incidence authors suggest 2–3 cm as distance from the
of postoperative complications. Open questions pylorus where to begin the gastric resection.
and future perspectives will be discussed. However, antrum resection may result in a defec-

Monitor Monitor

4 5
3 1
Assistant 2

Scrub table

Assistant 1
Surgeon

Fig. 17.1 (a) Operating room set up. (b) Trocar placement scheme. 1 Left subcostal, 2 Subxyphoid, 3 Optical, 4 Right
subcostal, 5 Left anterior axillary line
17 Laparoscopic Sleeve Gastrectomy 177

tive pumping mechanism causing nausea to the left hand. The dissection of the fundus is com-
patient because of delayed gastric emptying. The pleted when clear exposure of the left diaphrag-
first maneuver of the procedure is skeletoniza- matic pillar is obtained (Fig. 17.2A).
tion of the greater curvature. Radiofrequency or Anteriorly redundant Belsey’s fat pad may be
ultrasound energy instruments are used. The resected in order to better visualize the gastro-
gastro-colic ligament is dissected close to the esophageal junction and the area where the sta-
gastric wall at the median third of the greater pler will be positioned. The posterior gastric wall
curvature where the ligament is thin. In the must be freed by adhesions and occasionally it is
antrum area, adhesions between the posterior necessary to divide posterior gastric vessels,
wall of the stomach and the anterior aspect of the when present, to ensure easy maneuvering of the
pancreas are often present and may make the stomach during resection. At the end of the mobi-
access to the omental bursa more difficult. The lization the left gastric vessels and the left crus
skeletonization is completed toward the pylorus are clearly exposed and the stomach can be easily
until the 4–6 cm mark is reached and then it pro- moved on its axis like “the page of a book”
ceeds upward to the angle of His. The complete (Fig. 17.2A). Incomplete mobilization of the fun-
mobilization of the fundus is of primary impor- dus may cause incomplete fundectomy determin-
tance to achieve a correct fundectomy. In this ing an hourglass aspect of the stomach at the
phase, the surgeon uses the left subcostal port for postoperative X-ray images and influencing
the right hand and the subxiphoid trocar for the long-term results.

A B
c

a
b
c
b
a

C D
3 cm

b a

Fig. 17.2 (A) – The left gastric vessels (a) are visualized peritoneum covering the hiatus orifice (c), right pillar (a),
together with the left pillar (b). The posterior gastric wall and left pillar (b). (C) Enlarged hiatus (a). Left pillar (b).
(c) is completely free. The stomach is moved up like “the (D) Hiatoplasty. Right pillar (a). Left pillar (b)
page of a book.” B – Finger print indentation on the
178 G. Casella et al.

The ablation of the GHR producing region of (<40 Fr) correlate to a significant increase of
the stomach seems to be a crucial factor to ensure gastric leaks [17–19]. On the other hand, it is not
a proper functional result when considering EWL clear if the bougie size can significantly affect
and comorbidities resolution: in several studies, the capacity of the residual stomach and the
it has been demonstrated that GHR concentration postoperative weight loss. In our experience, the
in the gastric mucosa increases from the corpus capacity of the gastric remnant was dependent
to the fundus. For this reason, the accurate fun- not by the bougie size but by other technical
dectomy is a critical technical point [14, 15]. On points: placement of the stapler well against the
the other hand, the accurate gastroesophageal bougie, complete gastric fundus dissection, and
junction mobilization by division of the short lateral traction of the gastric walls during the
gastric vessels, of posterior gastric artery and of resection.
phrenic branches when present, in order to per- Gastric resection is performed using a linear
form an ideal fundectomy may hamper the blood stapler. The stapler is applied alongside the cali-
supply of this area and facilitate the onset of the brating bougie. Because of the decreasing thick-
gastric leak that occurs quite uniformly at the ness of the gastric wall from the antrum to the
uppermost part of the suture line. Sound judg- corpus and fundus, the cartridges must be chosen
ment must be used to balance the risks (leak) and accordingly. The staple height used by us is 4.4
the benefits (functional results). or 4.1 mm near the antrum and 3.8 or 3.5 mm on
Careful inspection of the hiatal area is per- corpus and fundus. In revisional surgery cases,
formed after complete mobilization of the gastric the presence of scar tissue indicates the use of
fundus and of the posterior gastric wall. Enlarged higher staples. The stapler is inserted through the
hiatus and hiatal hernias must be identified. right subcostal trocar for the first and second fir-
A 3 cm diameter of hiatal orifice is considered ing and then through the left subcostal trocar.
abnormal. As a practical rule in our clinical prac- Occasionally, it can be inserted through the opti-
tice, exploration of the hiatal crura is indicated by cal trocar and the camera moved to the left sub-
a macroscopically evident fingerprint indentation costal trocar. The stapler branches must be
of the diaphragm just above the esophageal emer- coplanar to the gastric walls to avoid tubule
gence from the diaphragm (Fig. 17.2B). In these twisting.
cases, the dissection of the hiatal crus is indicated Before closing and firing the staplers, the
and easily performed, because of the mobilized anterior and posterior gastric walls are fully
fundus, from the left approach (Fig. 17.2C). stretched by two graspers precisely positioned on
When present, the hernia sac and the gastro- the greater curve and moved along it (Fig. 17.3A).
esophageal fat pad are dissected and reduced At the incisura angularis, the stretching is
within the abdominal cavity. Retrogastric lipo- somewhat loosened to avoid a functional stricture
mas should be identified and removed to dimin- that may occur at this level (Fig. 17.4C). The last
ish the occurrence of the sliding of the gastric cartridge is fired 1–2 cm away from the angle of
tubule into the mediastinum. A posterior hiato- His so that the staple line does not fall in the
plasty is performed. The hiatal crus defect is “critical area” (Fig. 17.3B). The staple line is
repaired with two or three interrupted nonabsorb- reinforced by buttressing with absorbable poly-
able sutures between the right and the left dia- mer membrane (Seamguard, Gore). After mov-
phragmatic pillars (Fig. 17.2D) [16]. ing the stomach specimen away from the left
Once the stomach is completely mobilized, subcostal space, the final end of the membrane is
an oro-gastric tube is inserted by the anesthesi- fixed with two nonabsorbable sutures to the left
ologist in order to calibrate the resection. pillar to avoid sliding of the stomach tubule into
A 48-French bougie is pushed down possibly the mediastinum (Fig. 17.3C). At the end of the
through the pylorus and placed against the lesser procedure, the staple line is meticulously checked
curvature. The use of tube sizes from 30- to and bleeding spots are treated by hemostatic clips
60-French bougie is reported in the literature. or stitches (Fig. 17.3D). A nasogastric tube is
There is evidence that smaller sizes of bougie positioned in the gastric remnant and a methylene
17 Laparoscopic Sleeve Gastrectomy 179

A B

c a

1.5 cm

C D

Fig. 17.3 (A) Traction on the gastric walls by two grasp- membrane (b) is fixed to the left pillar (a) by two nylon
ers (a, b) on the greater curvature. The suture line (c) is stitches (arrows). (D) Final view. Several metal clips com-
alongside the bougie. (B) The last stapler is fired 1.5 cm plete the hemostasis on the suture line
from the angle of His. (C) The final end of the buttressing

blue dye test is routinely performed to check the and the nasogastric tube is removed at the end of
sealing of the staple line and to evaluate the resid- the procedure.
ual gastric capacity, usually 60–80 ml.
The specimen is extracted by grabbing its dis-
tal end with a grasper (Fig. 17.4A) and it is easily 17.4 Postoperative Management
brought out of the abdominal cavity through the
slightly enlarged right subcostal access without Patients are mobilized on the same day of the
the need of retrieval bags or endo loops and tak- operation and maintained with intravenous fluid
ing care not to open the specimen during these therapy, proton pump inhibitors, and analgesics.
maneuvers (Fig. 17.4B). A gauze soaked in povi- Subcutaneous low-molecular-weight-heparin is
done–iodine solution (betadine) is left for administered 6 h after surgery and is continued
1–2 min on the retrieval site to avoid infection of for 2 weeks. Short-term antibiotic therapy is
the wound [20]. added. Upper gastrointestinal contrast
When gallbladder stones are present, chole- (Gastrografin) study is performed on the second
cystectomy is routinely performed at completion or third postoperative day. Afterward patients are
of the SG procedure. The same trocars are used. started on liquid diet and discharged on the fourth
Occasionally, in complicated cases, an additional postoperative day.
5 mm trocar is added 5 cm laterally to the right Soft diets with mashed and soft foods are pre-
subcostal trocar. Drains are not routinely placed scribed for 4 weeks after surgery. One month
180 G. Casella et al.

A B

3 cm

C D E

Leak

Stenosis

Fig. 17.4 (A) Specimen extraction. Grasper (arrow) on In the background: normal post-op X-ray aspect of the
the antrum end of the gastric specimen (a). (B) Extraction gastric tubule. (E) Post SG upper GI contrast X-ray:
through a 3 cm enlarged trocar access. (C) Functional ste- organic stenosis and gastric leak. Dilation of the presteno-
nosis at the middle third (arrow) of the gastric tubule. The sis segment
prestenosis segment is not dilated. (D) Gastric specimen.

after surgery, patients resume normal diet with Oral proton pump inhibitors and urso-deoxy-
the advice of adding one type of food at a time, cholic acid for 6 months and multivitamin tablets
meat may take longer to be well tolerated. Five for 1 year are prescribed.
small meals are suggested.
Postoperative follow-up is performed at 1, 3,
6, 12, 18, and 24 months after the operation, 17.5 Complications
annually afterward. Controls involve Physical
examination, blood tests (including vitamin B12, The postoperative mortality rate varies from 0.1
folate, serum iron, calcium and vitamin D serum to 0.5 % and the postoperative morbidity rate
levels), upper gastrointestinal contrast (at 1st ranges from 0.0 to 12 % [5, 10, 12]. Early diagno-
month and 1st year), liver ultrasound (at sixth sis is the most important factor to ensure a
month). Endoscopic check is mandatory 2 years positive solution of complications. Treatment is
after the operation in all patients. often challenging and should be managed in bar-
17 Laparoscopic Sleeve Gastrectomy 181

iatric centers and by dedicated medical teams. Some technical details may lessen the inci-
Operative treatment is required only in few dence of leaks: the final portion of the line of
selected cases. resection should avoid the “critical area” remain-
Bleeding: Significant hemorrhage occurs in ing 1–2 cm laterally to the angle of His; the gas-
1.1–8.7 % of cases. Most frequently, bleeding tric resection should be more loose at the incisura
occurs within the first 24–48 h and originates angularis, the most frequent site of stenosis.
from the staple line [5, 21, 22]. Other sites of The treatment of leaks is challenging and dif-
bleeding are the gastroepiploic or short gastric ferent managements have been reported. In our
vessels divided during the mobilization of the experience, operative treatment is reserved only
stomach, the trocar accesses, hepatic or splenic in patients with hemodynamic instability and
injuries. Almost always, the bleeding is into the signs of acute peritonitis. Peritoneal toilet and
abdominal cavity, rarely determines hematemesis proper drainage are recommended. Attempts to
or melena. Once the hemodynamic parameters repair the fistula are contraindicated: recurrence
are stable, CT-scan is mandatory in order to occurs in most cases. An unsuccessful control of
define the bleeding site and to quantify the hemo- the leak, at occasion, may require total gastrec-
peritoneum. In case of hemorrhage from the sta- tomy or creation of a Roux limb. In the vast
ple line, the CT images show a hematoma close majority of patients, nonoperative management
to the gastric remnant. The treatment is interven- by percutaneous CT-guided drainage, alone or in
tional radiology or, in fewer instances, open or combination with stent placement and enteral
laparoscopic surgical exploration. Suture line nutrition, is a safe and effective treatment for
reinforcement has significantly reduced the suture line leaks [23].
occurrence of this complication. Bleeding from In an attempt to reduce the incidence of staple
the staple line increases the risk of gastric leak. line bleeding and/or leak in recent years several
The two major most debated complications different techniques have been adopted to rein-
are staple line leak and gastroesophageal reflux force the staple line during LSG. The routine use
disease (GERD). Three main factors should be of reinforcement of staple line seems to reduce
considered in their pathophysiology: intralumi- the complications rate. At present, the main
nal pressure, intra-abdominal pressure, and criti- options are: oversewing the staple line with a run-
cal vascularization of the gastroesophageal ning or inverting absorbable suture, buttressing
junction. the staple line with absorbable materials, bovine
Leak: Staple line leaks represent the most dan- pericardium strips or porcine small intestine sub-
gerous and life-threatening complication after mucosa, applying fibrin glue or hemostatic agents
LSG, with an incidence between 0 and 7 %. on the staple line [24, 25]. In all published stud-
Leaks occur mostly during the first post-op week ies, staple line buttressing was reported to reduce
(early leaks) and, in fewer instances, in the 40 significantly the incidence of bleeding; however,
days postoperative period (late leaks) [10, 11]. the preventive effect on gastric leak was less evi-
The most common location of leaks is just below dent. In a recent review of 88 papers reporting on
the esophageal gastric junction. Causative factors 8,920 patients, leak rate in LSG was significantly
to be considered in its genesis are: high intragas- reduced by buttressing the staple line with
tric pressure, thin wall of the gastric fundus, tran- absorbable polymer membrane compared to over
sitional vascularization (esophageal arteries sewing, bovine pericardium strips, or no rein-
system above, gastric arteries system below) on forcement [26].
the left side of the esophageal-gastric junction Stenosis: Stenosis is reported with an inci-
(“critical area”) causing ischemia [13]. Technical dence ranging from 0.2 to 4 % and usually occurs
factors include small bougie size and tight at the corpus-antrum transition zone (incisura
sleeves, heat from electrocautery or other energy angularis) of the gastric tubule. At this site
sources during dissection, or hemostasis which transient functional stenosis (Fig. 17.4C), due to
may determine gastric injury. dysmotility because of the muscular layers
182 G. Casella et al.

section, may occur causing high intragastric pres- ing; reduction of acid secretion; significant
sure and so favoring leak occurrence. Mechanical weight loss.
stenosis, causing significant and lasting dyspha- In a recent survey of our patients submitted to
gia and vomiting, can be determined by an incor- LSG with a 3–5 years follow-up, a 15 % inci-
rect orientation of the stapler tip during the dence of peptic esophageal lesions and of non-
resection or subsequent to an imbrication of the dysplastic Barrett’s esophagus was found with no
staple line. Twisted sleeve may cause symptom- correlation between the severity of reflux symp-
atic stenosis. An upper gastrointestinal (GI) con- toms and the degree of esophageal lesions
trast study is indicated to confirm the gastric (unpublished data). For this reason, a careful
outlet obstruction (Fig. 17.4E). Endoscopy has an follow-up schedule is recommended.
important role in terms of diagnosis and treat-
ment. Repeated endoscopic dilations are the first
therapeutic approach. Placement of endoscopic 17.6 Outcomes
stents should be considered as alternative solu-
tion. In case of persistence of symptoms with 17.6.1 Effect on Excess Weight (EW)
nutrition problems, patient’s reoperation should
be considered [27]. Conversion to Roux-en-Y EW is greatly affected by LSG: Several prospec-
gastric bypass is a valid therapy. Laparoscopic tive randomized controlled (PRC) studies show
seromyotomy of the stenotic tract (stricturo- that this procedure is more effective than inten-
plasty) has also been proposed [28]. sive medical and diet regimen or gastric banding
Hiatal hernia, GERD: In the Fourth and that it is comparable to RYGBP in inducing
International Consensus Summit on SG held in excess weight loss (EWL) [33]. Because of the
2012, there was a general agreement that when a relatively recent spreading of LSG in the clinical
hiatal hernia is present it should be repaired at the practice, the majority of studies are related to
time of the bariatric procedure. In the same short- and medium-term results, with a mean
Consensus postoperative GERD was the most EWL ranging from 49 to 81 % [21]. In 2008,
frequently reported complication with a mean Lacy’s group reported that SG at 12 months after
incidence of 7.9 % [12]. However, the clinical surgery was as effective as gastric bypass on EW
and pathophysiological relationship between SG [34]. In 2014, Schauer et al. in a PCR trial found
and GERD is still debated. In some series a post- that reductions in body weight, BMI, waist cir-
operative improvement of GERD symptoms has cumference, and waist-to-hip ratio were greater
been reported while in other series a worsening after gastric bypass and after SG than after inten-
has been registered [29–32]. Surgical technique sive medical therapy [35]. In 2014, in a PC cohort
might be of importance for the outcome of GERD study by our group BMI diminished from a 41.3
after SG, though its effective role has not been kg/m2 preoperative value to a 28.3 kg/m2 value 18
defined, yet. In order to explain these conflicting months after SG; intensive medical therapy had
data, the coexistence of different mechanisms, no significant effect [36].
which may respectively promote/worsen or Long-term results from large series are lack-
improve GERD symptoms, has been advocated. ing. In a recent review a mean EWL of 62.3 %
The former are represented by: impairment of the (nine studies enrolling 258 patients) was reported
lower esophageal sphincter’s (LES) function due at the 60 months follow-up. At the 72-month fol-
to the section of the sling fibers; sliding of the low-up the mean EWL was 53.8 % (three studies
stomach tubule into the mediastinum determin- with a total of 72 patients) [37]. In the Fourth
ing diminished intraluminal pressure in the car- International Consensus Summit on SG, in an
diac segment; increased intraluminal pressure in online questionnaire using web-based Survey
the gastric remnant and delayed emptying of the Monkey® mean EWL at 1, 2, 3, 4, 5, and 6 post-
stomach in case of mid-gastric stenosis of the operative years was, respectively, 59.3, 59.0,
lumen; the latter entail accelerated gastric empty- 54.7, 52.3, 52.4, and 50.6 % [12]. Sarela reports
17 Laparoscopic Sleeve Gastrectomy 183

an EWL of 69 % in 13 patients with 8 years fol- submitted to SG, results are superior to those
low-up [38]. after intensive medical treatment both in terms of
While the short-term WL effect induced by remission of diabetes and use of medications [35,
SG is mostly related to the reduction of the gas- 36]. The effectiveness of the SG on T2DM remis-
tric capacity, the durable WL seems to be depen- sion seems to be related to the β-cell reserve of
dent on additional factors. The mechanisms patients: diabetes duration longer than 10 years,
involve hormonal modifications, in particular low C-peptide levels, and insulin therapy are neg-
dramatic decrease of the circulating GHR (orexi- ative prognostic factors. In our series, DM remis-
genic hormone) due to the resection of the gastric sion occurred in 100 % of patients with DM
fundus, main source for this hormone, and the duration <10 years and in 31 % of patients with
increase of food mediated release of GLP-1 and DM duration >10 years [45].
PYY from the L cells of the small intestine [39]. The beneficial actions of SG on DM occur
In experimental studies, Karamanakos et al. very early after completion of the procedure. In
showed a significant increase in both fasting and the study by Peterly, GLP-1 and PYY plasma lev-
postprandial PYY levels and a marked reduction els were modified 7 days post-op [46]. In a study
in fasting GHR levels after SG [40]. by our group, insulin secretion and sensitivity,
plasma PYY, and GLP-1 levels improved just 72
h postoperatively independently by food intake.
17.6.2 Effect on Type 2 Diabetes At the same time GHR values were significantly
Mellitus (T2DM) and on Other lower than those at pre-op. These data prompted
Comorbidities us to formulate a “gastric hypothesis” [47].
The long-term antidiabetic effects of SG are
Weight-loss surgery has been shown to reduce not well documented due to the novelty of the
mortality and comorbidities and most signifi- procedure and need more extensive cases and
cantly to ameliorate or resolve T2DM in patients longer follow-up. In a small series of patients, at
with obesity [41, 42]. SG is associated with a 5 years follow-up, remission was present in
high rate of resolution of T2DM and other 87.8 % of cases [48]. In our experience in 65
obesity-associated comorbidities such as hyper- obese and diabetic patients submitted to LSG,
tension, hyperlipidemia, and sleep apnea. In the remission was present in 57 patients (87 %) and
ASMBS 2009 position statement, data from ten amelioration in 7 patients (10 %) at a mean fol-
studies (n = 754 patients) on the evolution of low-up of 63 months. Most important, once
comorbidities after SG were analyzed. T2DM remission was achieved it was maintained in all
remission ranged from 14 to 100 %, arterial cases except two, although weight regain
hypertension from 15 to 93 %, and obstructive occurred in six patients Soricelli et al. 2015.
sleep apnea (OSA) from 39 to 100 % [5]. SG exerts salutary effects on other comorbidi-
In particular the effect on T2DM resulted ties. In 2006, we reported on the ameliorating
noteworthy. In 2006, Cottam et al. reported outcome of SG on hypertension, OSA, and DM
T2DM remission in 81 % of T2DM patients sub- in super-obese patients and subsequently we doc-
mitted to LSG [43]. In the Moon Han et al. study umented cardiac remodeling with a significant
at 6 months follow–up, the EWL was 71 % and reduction of the Framingham risk score 1.5 years
the T2DM remission was 100 % [44]. In the 2007 after surgery [49].
Vidal et al. study, SG and gastric bypass (GBP) When evaluating SG outcome an additional
had a similar impact on diabetes (51.4 and 62 %, important factor to be considered is patient’s satis-
respectively, P = .332) in the short term (4 months) faction. Several papers, addressing the topic of
and an identical remission rate (84.6 %, P = .618) QoL after SG, report encouraging results. In the
at 12 months. SG was defined a “metabolic pro- D’Hondt et al. study, the Baros score was “good”
cedure” [34]. In 2012, in two PC studies it has to “excellent” in 90 % of patients [50]. In another
been reported that in diabetic obese patients retrospective study by Alley et al., QoL was
184 G. Casella et al.

superior in SG patients when compared to laparo- Gastrectomy Expert Panel Consensus Statement: best
practice guidelines based on experience of 12,000
scopic adjustable gastric banding (LAGB) patients
cases. Surg Obes Relat Dis. 2012;8(1):8–19.
[51]. 12. Gagner M, Deitel M, Erickson AL, Crosby RD.
At present SG is a very popular bariatric proce- Survey on laparoscopic sleeve gastrectomy (LSG) at
dure both among patients and surgeons. Technically, the Fourth International Consensus Summit on Sleeve
Gastrectomy. Obes Surg. 2013;23(12):2013–7.
it is not a very difficult operation although there are
13. Basso N, Casella G, Rizzello M, et al. Laparoscopic
crucial technical details that deserve much atten- sleeve gastrectomy as first stage or definitive intent in
tion: morbidity and mortality are low; there is no 300 consecutive cases. Surg Endosc. 2011;25(2):444–9.
residual “blind stomach”; there are no foreign bod- 14. Frezza EE, Chiriva-Internati M, Wachtel MS. Analysis
of the results of sleeve gastrectomy for morbid obesity
ies; malabsorption is minimal; and the treatment of
and the role of ghrelin. Surg Today. 2008;38(6):481–3.
failures is well standardized, second-stage DS, 15. Chabot F, Caron A, Laplante M, St-Pierre DH.
RYGBP, or resleeve. Although long-term results Interrelationships between ghrelin, insulin and glu-
are still lacking, SG is at present an established and cose homeostasis: Physiological relevance. World J
Diabetes. 2014;5(3):328–41.
reliable procedure that can be confidently main-
16. Soricelli E, Iossa A, Casella G, Abbatini F, Calì B,
tained in the bariatric armamentarium. Basso N. Sleeve gastrectomy and crural repair in obese
patients with gastroesophageal reflux disease and/or
hiatal hernia. Surg Obes Relat Dis. 2013;9(3):356–61.
17. Yuval JB, Mintz Y, Cohen MJ, Rivkind AI, Elazary
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 Laparoscopic Gastric Plication
18
Martin Fried

Laparoscopic greater curvature plication (LGCP), Kirk and Fusco focused on safety and efficacy
referred also as gastric plication (GP), gastric of the procedure in their studies, while compar-
curvature plication (GCP), laparoscopic total ing different types of gastric plication (the ante-
gastric vertical plication or vertical sleeve plica- rior gastric wall plication vs greater curvature
tion, has been introduced to the contemporary plication/LGCP), as well as gastric plication ver-
bariatric and metabolic field relatively recently. sus sham and simple visceral manipulation.
LGCP is not, however, a new procedure. These studies concluded that LGCP results in
significant weight loss in comparison with other
approaches and modifications. Both of the
18.1 History authors studied as well the possible influence of
different suturing materials (braided vs monofila-
In 1896, Ewart reports plication of the gastric ment) and suturing techniques (interrupted vs
greater curvature, similar to the current LGCP, as continuous sutures). Finally, Kirk reported that
treatment for a diabetic patient with dilatation of invagination of the greater curvature of the stom-
the stomach [1]. ach was a safe and effective method to achieve
LGCP as a potential bariatric operation was weight loss in rats.
proposed firstly by Kirk, who reported outcomes In 2011, Menchaca and his co-workers pub-
of his study experiments on weight loss after lished results of a canine study, comparing dura-
LGCP in rats in 1969 [2]. Kirk was followed by bility of the gastric plications infoldings achieved
Tretbar’s and Wilkinson’s reports on LGCP in with different suturing and fastening mechanisms.
human clinical studies in 1976 and in 1981 [3, 4]. Authors demonstrated that in short term, suffi-
Almost 30 years later, in 2006 and 2007, Fusco cient durability of serosa-to-serosa apposition is
and Talebour published reports on LGCP as a achieved with means of interrupted sutures,
procedure resulting in significant weight loss in sutures anchored with t-tags, or staples [8].
rats and sheep models [5–7].

18.2 The Procedure

M. Fried, PhD
1st Faculty of Medicine, Charles University Prague,
Prague, Czech Republic LGCP is mostly referred to as restrictive bariatric
procedure which reduces the stomach capacity
OB klinika -Center for Treatment of Obesity and
Metabolic Disorders , Prague, Czech Republic without a need for gastric resection or placement
e-mail: [email protected] of an implantable device. The primary goal of

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 187
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_18,
© Springer International Publishing Switzerland 2015
188 M. Fried

this procedure is to achieve long-term weight loss patients should have failed to lose weight or to
while decreasing or even avoiding complications maintain long-term weight loss, despite appropri-
seen with some of the bariatric procedures. ate surgical and/or nonsurgical comprehensive
However, the most currently published studies medical care. Consideration should be given to
reveal that alongside with the restrictive effect of reducing the BMI threshold by 2.5 for individuals
the LGCP, there seems to be a metabolic, weight of Asian genetic background and to the balance
loss independent component of the operation as between genetic and environmental/dietary fac-
well [9, 10]. tors. Patients should have shown their compliance
As with most new procedures, there have been with scheduled medical appointments.
several techniques and personal modifications
employed by different surgeons when performing
a laparoscopic greater curvature plication. 18.4 Contraindications
However, with the experience of several thou-
sand LGCP operations performed worldwide in General contraindications to bariatric surgery are
different bariatric centres, the procedure became as well applicable to LGCP patients; however,
more uniform, reproducible and standardized there are some LGCP specific contraindications.
from both the indication and contraindication General contraindications include (but are not
point of view as well as from surgical technique. limited to):
Absence of a period of identifiable medical man-
agement. Patient who is unable to participate
18.3 Indication Criteria in prolonged medical follow-up. Nonstabilized
psychotic disorders, severe depression, per-
For the LGCP apply the same indication criteria as sonality and eating disorders, unless specifi-
have been recently published in the Interdisciplinary cally advised by a psychiatrist experienced in
European Guidelines on Metabolic and Bariatric obesity. Alcohol abuse and/or drug dependen-
Surgery. These guidelines were created by and cies. Diseases threatening life in the short term.
endorsed by the European Association for the Patients who are unable to care for themselves
Study of Obesity (EASO) and the International and have no long-term family or social sup-
Federation for the Surgery of Morbid Obesity and port that will warrant such care [11, 12].
Metabolic Disorders – European chapter LGCP specific contraindications include several
(IFSO-EC) [11, 12]. According to these guide- clinical conditions. Among such contraindica-
lines, patients should be in age range from 18 to tions may be considered impaired ability to
60 years, with BMI ≥40 kg/m2 or with BMI vomit (i.e. status after Nissen fundoplication),
35–40 kg/m2 with comorbidity, in which surgi- as LGCP patients often experience a period of
cally induced weight loss is expected to improve 1–2 days of postoperative vomiting. Impaired
the disorders (such as metabolic disorders, cardio- ability to vomit may lead to substantial
respiratory disease, severe joint disease, obesity- increase of intragastric pressure during
related severe psychological problems, etc.). The attempts to vomit, resulting in tears of gastric
BMI criterion may be the current BMI or previ- wall, or even gastric perforation caused by
ously maximum attained BMI of this severity. “cheese wire” effect of plicating sutures and/
Weight loss as a result of intensified treatment or staplers. As a contraindication should be
before surgery (patients who reach a body weight considered as well previous complex and
below the required BMI for surgery) is not a con- complicated upper gastric surgery, or postsur-
traindication for the planned bariatric surgery. gical complications located in the upper third
Bariatric surgery is indicated in patients who of the stomach, especially in the fundus
exhibited a substantial weight loss in a conserva- region. Among such complications may be
tive treatment programme but started to gain considered leaks, peritonitis, reoperations
weight again, even if the required minimum with multiple fibrotic adhesions, prolonged
indication weight for surgery has not yet been gastric band migrations and others. The ratio-
attained again. To be considered for surgery, nale is that these complications usually result
18 Laparoscopic Gastric Plication 189

in compromised blood supply at the region

where they occured. Impaired blood supply at
the fundus region, coupled with devascular-
ization of the greater curvature which is a rou-
tine part of the LGCP, may result in serious
devitalization and subsequent necrosis of the
plicated stomach wall.

18.5 The LGCP Operation

5 mm
It is essential and extremely important to under-
12 mm
line that although the LGCP at the end of the
operation looks anatomically very close to sleeve 5 mm
12 mm 5 mm
gastrectomy, and several steps of the LGCP oper-
ation may seem almost identical to those applied
in sleeve gastrectomy, it is crucial to realize that
there are substantial differences in several, criti-
cal parts of the operation. If inadequate attention
is paid to these differences, there is highly
increased risk of major, serious complications
after LGCP. Most of the differences in operation
technique between LGCP and sleeve gastrectomy
will be highlighted in the following sections.

Fig. 18.1 Trocar position and size for LGCP

18.6 Critical Steps of the
Operation below the first 5 mm trocar, at the mid-clavicular
line; 10/12 mm trocar (surgeon’s right hand
18.6.1 Operation Technique working port) in the left upper quadrant, just
below the left costal margin at midclavicular line;
Patient should be placed on the operating table in and the last 5 mm trocar (for surgical assistance)
the supine position with outstretched legs, firmly at the left lower costal margin. Different varia-
strapped as steep anti-Trendelenburg position is tions in trocar positioning may be applied accord-
needed for most of the operation time. The oper- ing to surgeons’preferences, patient’s body size
ating surgeon stands in between patient’s legs, and/or institutional requirements (Fig. 18.1).
the assisting surgeon is on patient’s left side.
Pneumoperitoneum is established with a Veress
needle, Hasson’s technique or through another 18.6.2 Dissection
institutional standardized approach. The total of
five (two 10/12 mm and three 5 mm) trocars are The operation begins with dissection along the
used. Firstly, a 10/12 mm trocar (for laparoscopic greater curvature of the stomach. The easiest area
optics) is inserted left to the patient’s midline, where to start the dissection is usually at the dis-
approximately 10 cm below the left costal margin. tal body of the stomach. Dissection should be
After that, laparoscopical inspection of the entire extended proximally towards the angle of Hiss,
abdominal cavity is done. The rest of the trocars however stopping the dissection approximately
were placed in the following positions: 5 mm tro- 1–2 cm distally to the angle of Hiss (preserving
car (for liver retraction) in the uppermost subxi- the last 2–3 short gastric vessels) is recom-
phoid area; another 5 mm trocar (surgeon’s left mended. There are several reasons for leaving the
hand working port) in the right upper quadrant, top of the fundus intact, in particular in order to
 190 M. Fried

vessels are to be preserved. This is another

obvious difference from sleeve gastrectomy.
Greater curvature dissection stops distally
within 4–6 cm from the pylorus.

18.6.3 The First Plication Row (the

Inner Layer)

For sizing of the plication, an endoscope or 36 F

calibration bougie should be kept in place during
the operation. The greater curvature is imbri-
cated, starting 1–2 cm distal to the angle of Hiss
Fig. 18.2 Dissection of the greater curvature performed up to 4–6 cm of the pylorus. It is recommended to
in distance from the stomach wall use nonabsorbable running suture, 2-0 or 1-0
size. Stitches should not be more than 1.5–2 cm
apart. The stitches may be placed as full thick-
1) preserve the angle of Hiss anatomical antireflux ness, so no action or correction is to be taken in
mechanism, as well as to preserve blood supply case the stitches are visible on endoscopy. Care
2) of the most proximal fundus area, which is espe- must be taken not to cause gastric lumen obstruc-
cially susceptible to ischaemia. Stopping the dis- tion, especially from a point of view that the
section distally from the angle of Hiss helps as greater curvature is infolded inside the gastric
3) well to retain this part of the fundus in place, thus lumen, however not removed. Postoperative gas-
preventing possibility of “valve type,” intermit- tric wall oedema and venous congestion has to be
tent gastroesophageal obstruction caused by taken into account as well. Therefore, even
invagination of a floppy fundus if entirely though the narrowed stomach may look at the
dissected. end of the operation wider than after sleeve gas-
In summary, at this stage of the operation two trectomy, the actual volume of the plicated stom-
substantial differences from sleeve gastrectomy ach is close to the one after sleeve gastrectomy.
should be taken into consideration: Special attention should be paid to the two most
(a) Dissection along the greater curvature of the common areas of potential obstruction – the GE
stomach must not be carried out close to the junction and the incisura angularis. Especially,
stomach wall. Thus, approximately 1–2 cm the distal stomach parts are more susceptible to
“rim/edge” should be preserved between the obstruction. In general, the more distally the pli-
stomach (greater curvature) tissue and the cation goes, the more care (more shallow bites)
dissecting instrument. The reason is that in has to be taken to avoid an obstruction (Fig. 18.3).
LGCP the stomach (greater curvature) is
infolded, and stays in place (is not resected/
removed). Therefore, any possible traumatic 18.6.4 The Second Plication Row
or thermal injury caused by dissection close (the Outer Layer)
to stomach may result into a leak during the
early postoperative period. This is a distinct An additional second plication row (the outer
and marked difference from sleeve gastrec- layer) is applied “over” the first imbrication row
tomy, in which close to stomach wall dissec- to achieve appropriate gastric lumen, thus as
tion plays no role (Fig. 18.2). close as possible to the 36 F calibration. By add-
(b) Dissection towards the angle of Hiss should ing the second plication row, an increased (wider/
stop approximately 1–2 cm distally to the deeper) gastric fold size is created. Stitches are
angle of Hiss and the last 2–3 short gastric positioned in the same way as when suturing the
18 Laparoscopic Gastric Plication 191

author‘s personal experience with a limited num-

ber of patients who underwent stapled LGCP, it
seems that a less frequent postoperative nausea
and/or vomiting is observed, as well as less
noticeable postoperative oedema of the invagi-
nated gastric tissue in short post-period is pres-
ent. So far reported results of stapled LGCPs are
encouraging; however, longer term results are
awaited.

18.6.5 Lumen Size Control

Fig. 18.3 Correct suturing of the greater curvature As it was described, most of the surgeons use a
36 F calibration bougie for sizing of the plicated
stomach while creating the plication folds.
However, in the initial phase of starting/learning
the LGCP, endoscope kept in place during the
procedure, and subsequently used at the end of the
procedure for visualization of the lumen of the
plicated stomach is a recommended alternative.

18.6.6 Leak Test

Methylene blue, or air insufflation via endoscope,

may be used for a leak test at the end of the pro-
cedure; however, the leak test is not considered as
mandatory. Thus, there is almost negligible risk
Fig. 18.4 Laparoscopic view of plicated stomach of causing a leak intraoperatively provided the
above-mentioned intraoperative technical pre-
first row. Care must be taken, not to place the cautions are respected. In fact, apart from a mas-
stitches/bites more than 2 cm apart to minimize sive tissue destruction inflicted during the greater
the risk of underlying gastric wall/tissue hernia- curvature suturing phase, which would be,
tion through the gaps between the stitches (bites). however, obvious at the time when happened,
The procedure ends up with drying up of the there ’is no (other) risk of obscured, undetected
operation field, and a leak test, if desired (see the immediate, intraoperative perforation.
section “Leak Test“). Trocars are removed
sequentially under direct visualization at the end
of the operation, and the incision sites are closed 18.7 Intraoperavive
in institutional standard fashion (Fig. 18.4). and Immediate
There are reports on using staplers (single Postoperative Complications
stapler/clip firing), instead of the running sutures.
The staplers are used in the same way as stitches, During the LGCP similar intraoperative complica-
thus with a distance of maximum 2 cm between tions may occur as with any other gastrointestinal
the individual clips. The proximal (1–2 cm below procedure. Immediate postoperative complica-
angle of Hiss) and distal (4–6 cm to pylorus) start tions include (however are not limited to) nausea,
and end up areas remain unchanged. From vomiting and sialorrhea. Such complications can
192 M. Fried

be ameliorated with pharmacotherapy, such as complication rate was 1.2 %. The procedure was
ondancetron. In the literature, there are reports on associated with significant weight loss (p < 0.001).
complications following LGCP, including gastric At 6 months, BMI, %EBMIL and %EWL were
perforation and/or leak, peritonitis, obstruction 36.1 ± 4.7, 34.8 ± 17.3 and 31.8 ± 15.9, respec-
and infection. Perforation and/or leak may occur tively. In patients with preoperative BMI < 40,
due to stomach wall necrosis because of ischaemia 18-month %EWL approached 50 % and
induced by dissection of the greater curvature/fun- %EBMIL exceeded 50 %; 96.9 % of patients’
dus in the course of the operation, especially in the T2DM was significantly improved/resolved.
most susceptible, anterior fundus area. Ischaemia In 2013, Bradnova et al. [12] published results
may also occur due to thermic injury to the stom- of a study which explored changes in glucose
ach caused by dissection carried out too close to homoeostasis, postprandial triglyceridaemia, and
stomach wall. There are reports on gastric perfora- meal-stimulated secretion of selected gut hor-
tion caused by “cheese wire” cutting through mones (glucose-dependent insulinotropic poly-
effect of the suturing material being a result of peptide, GIP; glucagon-like peptide-1, GLP-1;
compulsive, early postoperative overeating. ghrelin and obestatin) in patients with type 2 dia-
However, most of these complications are not spe- betes mellitus (T2DM) at 1 month and 6 months
cific to LGCP, and may be considered among pos- after LGCP. Results of the study show that LGCP
sible complications associated with any upper is associated with significant weight loss both at
gastrointestinal restrictive operation. 1 month and 6 months after the LGCP (p ≤ 0.002),
mean percent excess weight loss (%EWL)
reached 29.7 ± 2.9 % at the 6-month follow-up.
18.8 Long-Term Complications Fasting hyperglycaemia and hyperinsulinaemia
(Stomach Dilatation/ improved significantly at 1 month and 6 months
Replication) after the LGCP (p < 0.05), with parallel improve-
ment in insulin sensitivity and HbA1c levels
Long-term complications include the risk of (p < 0.0001). Meal-induced glucose plasma levels
enlargement of the plicated stomach. Stomach were also lower at 1 month and 6 months after the
dilatation may result from dietary noncompliance LGCP (p < 0.0001) and postprandial triglyceri-
accompanied with repeated, massive overeating daemia was ameliorated at the 6-month follow-
or suture line disruption, or a combination of up (p < 0.001). Postprandial GIP plasma levels
both. Dilatation of plicated stomach appears to be were significantly increased both at 1 month and
very similar to those reported in a certain number 6 months after the LGCP (p < 0.0001), whereas
of sleeve gastrectomies. Rarely, psychological the overall meal-induced GLP-1 response was
intolerance of restriction is reported. not significantly changed after the procedure
(p > 0.05). Postprandial ghrelin plasma levels
decreased at 1 and 6 months after the LGCP
18.9 Clinical Outcomes (p < 0.0001) with no significant changes in circu-
lating obestatin levels. Overall conclusion is that
In 2012, Fried et al. [9] published results of LGCP induces significant weight loss and
LGCP in a series of 244 morbidly obese patients improves the metabolic profile of morbidly obese
in up to 18 months follow-up. Published data T2DM patients, while also decreases circulating
showed that in this series, the mean preoperative postprandial ghrelin levels and increases the
BMI (±SD) was 41.4 ± 5.5, mean age meal-induced GIP response.
46.1 ± 11.0 years and 27.9 % patients had Other studies published between 2007 and 2011
T2DM. Mean operative time was 70.6 min; mean have reported that LGCP offers the benefit of gas-
hospitalization, 36 h (24–72). Postoperatively, tric restriction while potentially being associated
27.9 % of the patients experienced nausea and/or with lower risks of complications in comparison
vomiting. There was no mortality reported, major with some other bariatric procedures [7, 13, 14].
18 Laparoscopic Gastric Plication 193

Brethauer et al. [15] compared LGCP out- Immediately following LGCP, 2 weeks of
comes after two different gastric plication tech- strictly liquidized diet are recommended, starting
niques: anterior gastric plication and the greater on postoperative day two. After that, patient
curvature gastric plication. In the anterior plica- should be kept on a minced/mashed diet for
tion group at 1-year follow-up the %EWL another 2 weeks.
reached 23.3 %, while the % EWL for the greater The following are examples of what is recom-
curvature gastric plication group was 53.4 %. mended in this postoperative period:
There were no complications in either procedure; Mashed potatoes, minced meat mixed into the
however, all of the patients experienced mild to mashed potatoes, broth, if vegetable, then liq-
moderate nausea early postoperatively. uidized, vegetable soup, with liquidized vegeta-
Ramos et al. [13] studied 42 morbidly obese bles (spinach, carrot, etc.), grated apple, mashed
patients who underwent laparoscopic greater cur- banana, children’s fruit snacks, steamed and
vature plication. Eighteen-month data demon- liquidized fruit. It is recommended to avoid
strated an EWL of 62 %. There were no food causing flatulence, such as broccoli and
intraoperative complications. Short-term postop- cauliflower. All accompanying drinks should be
erative complications included nausea, vomiting noncaloric, noncarconated and nonalcoholic.
and sialorrhea. A study by Sales [14] reported a The maximum amount of food and/or drinks
69.6 % EWL at 12 months in 100 patients. must not exceed 150 mL at a go. It is recom-
Twenty five percent of the patients had a preop- mended to drink either 15 min before starting a
erative BMI of <35. No major complications meal, or to wait at least 30 min after a meal. The
were reported. meal should not be mixed with drinks. It should
Talebpour and Amoli [7] reported results of be ensured that, in total, the minimum amount
LGCP performed in 100 patients. The mean of daily liquid intake is at least 2 L.
%EWL at 6, 12, 24 and 36 months was 54, 61, 60
and 57 %, respectively. Nausea and vomiting
were present in all patients. According to 18.10.2 Reversibility
Talebpour’s report, major complications linked
with the LGCP were such as leakage at the suture So far no clinical study was conducted on revers-
line, and acute gastric perforation. Reoperation ibility of the LGCP; however, it has been repeat-
was required in four cases and there were no edly clinically confirmed that in case of surgical
mortalities. emergency (e.g. leaks with peritonitis after LGCP),
it is possible to fully reverse the gastric plication
both short- and long-term postoperatively. The lon-
18.10 Clinical Management gest period after LGCP which our team has experi-
enced with dismantling the LGCP is 16 months,
18.10.1 Dietary Recommendations and the procedure was fully reversible.
After LGCP

Successful outcomes of LGCP are dependent, 18.11 LGCP Emergencies

among other factors, on patients’compliance
with dietary recommendations. Hence, failure to Most of LGCP related emergencies occur in the
follow up on dietary recommendations either early postoperative period. The overall number of
shortly postoperatively, or even in longer term serious emergencies (major complications) after
after the LGCP substantially increases the risk of LGCP is low (1.2 %) [9]. According to our expe-
treatment failure. rience, among the most frequent is gastric leak
Generally speaking, suggested dietary changes (0.6 %), followed by gastric obstruction (0.4 %)
after LGCP are rather similar to those following and ischaemia of anterior fundus wall (0.2 %).
sleeve gastrectomy. Gastric leak may occur in two variations:
194 M. Fried

(a) “classical” leak caused by clearly visible

stomach perforation, for example, due to “cheese
wire” effect of the plicating suture, (b) “obscured”
leak in which it is impossible to identify a clear
stomach perforation, however one or several sites
of plicating stitches are oozing.
Management of distinct gastric leaks should
include dismantling of both plication layers on the
entire length of the plicated stomach, and closure
of the leak area in a standard fashion as appropri-
ate in any upper GI surgical complication.
Oozing, obscured leaks at the site of the pli-
cating sutures can be managed in most of the
cases just by complete dismantling of both layers
of the plication and drainage of the perigastric
region. Usually, patients completely recover
within a few days after revisional surgery. Fig. 18.5 Dilated stomach after LGCP
Gastric obstruction may be clinically present
as total, or intermittent. Obstruction usually
occurs in the fundus area, or at the incisura angu- who failed LGCP and/or sleeve gastrectomies (in
laris, being a result of too tight suturing invagi- particular due to stomach dilatations). Re-do pli-
nating excessively voluminous part of the greater cation after failed adjustable gastric band is pos-
curvature (the invaginated stomach is too bulky sible if the patient is still willing to undergo
and after calibrating bougie is retrieved, the another gastric restriction. However, attention
invaginated stomach tissue expands and occupies must be paid not to perform the LGCP after gas-
the entire gastric lumen). Obstruction is rather tric banding which was associated with peri- or
straight forward to manage, and loosing the postoperative complications, such as bleeding in
suture line at the area of obstruction results in the region of the band, band migration or band
immediate improvement. infection. In such cases, it is highly likely that the
In case of ischaemia of the stomach wall, all the blood supply to the fundus/angle of Hiss region is
plication layers have to be taken down. After the already compromized, so further dissection of the
plication layers are taken down, it is recommended greater curvature would add to substantial risk of
to wait for several minutes and see as some parts of impaired blood supply postoperatively, which
what appears as ischaemic gastric wall, may regain may result in stomach wall necrosis. Technically,
vitality. The truly necrotic areas of the stomach it does not make sense to perform LGCP as re-do
wall have to be resected and the defect securely operation after failed gastric bypass or biliopan-
sutured and closed in two layers. After this creatic diversion; however, LGCP may be realis-
manoeuvre, the reoperation should be completed tically considered as an option in patients who
as per standard institutional/surgeons custom. failed previuos LGCP or sleeve gastrectomy.
Notably, LGCP may be beneficial in patients who
were successful in losing weight or improving
18.12 LGCP as Re-do Bariatric their comorbidities after primary sleeve gastrec-
Procedure tomy or LGCP, and who were in general satisfied
with the primary procedure. In a number of such
There are several reports on successful indication patients, the primary procedure fails mostly due
of the LGCP as a re-do procedure in patients who to stomach dilatation. Thus, re-plication of the
failed different other bariatric procedures. LGCP dilated LGCP, or re-plication of dilated sleeve
was performed as re-do surgery especially after gastrectomy is one of the preferred and rather
failed gastric bands, and as reoperation in patients straightforward alternatives (Fig. 18.5).
18 Laparoscopic Gastric Plication 195

18.13 Summary 5. Fusco PEB, et al. Comparison of anterior gastric wall

and greater gastric curvature invaginations for weight
loss in rats. Obes Surg. 2007;17:1340–5.
Even though experience with the LGCP is still 6. Fusco PEB, et al. Evaluation of gastric greater curva-
limited, and more long-term data is needed, it ture invagination for weight loss in rats. Obes Surg.
may be concluded that 3-year follow-up of sev- 2006;16:172–7.
7. Talebpour M, Amoli BS. Technical report- laparo-
eral thousands of gastric plication patients show
scopic total gastric vertical plication in morbid obesity.
that LGCP results in acceptable weight loss, sig- J Laparoendosc Adv Surg Tech. 2007;17(3):793–8.
nificant amelioration of type 2 diabetes mellitus, 8. Menchaca HJ, et al. Gastric plication: a preclinical
which appears to be weight loss independent, and study of the durability of serosa-to-serosa apposition.
Surg Obes Relat Dis. 2011;7(1):8–14.
reduction of several other, obesity-related comor-
9. Fried M, Dolezalova K, Buchwald JN, et al.
bidities. LGCP exhibits very low complication Laparoscopic greater curvature plication (LGCP) for
rates both in short- and mid-term follow-up treatment of morbid obesity in a series of 244 patients.
postoperatively. Obes Surg. 2012;22:1298–307.
10. Fried M, Yumuk V, Oppert JM, et al. Interdisciplinary
European guidelines on metabolic and bariatric sur-
gery. Obes Facts. 2013;6:449–68.
11. Fried M, Yumuk V, Oppert JM, et al. Interdisciplinary
References European guidelines on metabolic and bariatric sur-
gery. Obes Surg. 2014;24:42–55.
1. Ewart W, et al. A case of dilatation of the stomach 12. Bradnova O, Kyrou I, Hainer V, et al. Laparoscopic
treated by an operation believed to be new. Lancet. greater curvature plication in morbidly obese women
1896;148(3801):8–10. with type 2 diabetes: effects on glucose homeostasis,
2. Kirk RM. An experimental trial of gastric plication as postprandial triglyceridemia and selected gut hor-
a means of weight reduction in the rat. Br J Surg. mones. Obes Surg. 2014;24:718–26.
1969;56(12):930–2. Tretbar LL, Taylor TL, Sifers 13. Ramos A, et al. Laparoscopic greater curvature plica-
EC. Weight reduction: gastric plication for morbid tion: initial results of an alternative restrictive bariat-
obesity.J Kans Med Soc. 1976;77:488–90. ric procedure. Obes Surg. 2010;20(7):913–8.
3. Tretbar LL, Taylor TL, Sifers EC. Weight 14. Sales Puccini CE. Surset gástrico de Sales: una alter-
reduction:gastric plication for morbid obesity. J Kans native para cirugía bariátrica restrictive. Revista
Med Soc. 1976;77:488–90. Colombiana De Cirugía. 2008;23(3):131–5.
4. Wilkinson LH, Peloso OA. Gastric (reservoir) reduc- 15. Brethauer SA, et al. Laparoscopic gastric plication for
tion for morbid obesity. Arch Surg. 1981;116: the treatment of severe obesity. Surg Obes Relat Dis.
602–5. 2011;7:15–22.
 Laparoscopic Roux-en-Y Gastric
Bypass: Technical Aspects, Clinical 19
Management, and Outcomes

Kelvin D. Higa

19.1 Introduction procedure, long-term outcomes studies and qual-

ity of life factors make it the best option for most
The laparoscopic Roux-en-Y gastric bypass was patients. It is not only modifiable but also revers-
first performed by Wittgrove et al. in 1993 and ible (unlike the vertical sleeve gastrectomy).
was an act of genius [1]. This procedure helped to Fortunately, most, if not all, complications of the
bring treatment options to millions of individuals gastric bypass have minimally invasive solutions.
with the disease of morbid obesity and became Unfortunately, the most frustrating problem—
the tipping point for the discipline of minimally weight recidivism or lack of control of metabolic
invasive surgery as a whole. For the first time, disease—is a complex problem. Conversion to
a complex, reconstructive operation was more duodenal switch or biliopancreactic diversion is a
than a novelty; it became the standard of care. daunting task after gastric bypass.
Although difficult, with a long learning curve, the Little was known of physiology of the gastric
tremendous patient adoption and lower compli- bypass conceived by Mason and Ito in the 1960s
cation rates over open, traditional procedures [2]. This operation and further modifications
helped to fuel an industry and define our spe- were erroneously based on concepts of mechani-
cialty. Over 20 years later, although there have cal “restriction” or “malabsorption.” Early evolu-
been modifications by others, this original tech- tion of the procedure was focused on lowering
nique is still being practiced today—a testimony complications and side effects of the Billroth II
to the sagacity of its inventors. based procedure. Conversion of the short-loop
Despite its criticisms, the Roux-en-Y gastric gastro-enterostomy to a Roux-en-Y configura-
bypass has established itself as the standard to tion eliminated bile reflux. Transitioning from a
which all other procedures are compared. horizontal to a vertically oriented gastric pouch
Although not the most powerful metabolic improved alimentation while creating a more
stable, less distensible reservoir. With the advent
of laparoscopy and the ability to create much
smaller pouches, this did not correlate with
K.D. Higa, MD, FACS, FASMBS, UCSF improved weight loss. This clinical observation
Minimally Invasive and Bariatric Surgery, serves to underscore current concepts of the role
Fresno Heart and Surgical Hospital, of incretins, bile acids [3], and gut microbiota [4]
Advanced Laparoscopic Surgery Associates,
on satiety and food acquisition. Overall size of
205 E. River Park Circle, Suite 460,
Fresno, CA 93720, USA the gastric pouch or stability of the gastro-
e-mail: [email protected] jejunostomy is thought to be no longer relevant to

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 197
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_19,
© Springer International Publishing Switzerland 2015
198 K.D. Higa

performance, although may be critical in devastating complications of this procedure.

complications such as marginal ulceration or Surgeons are understandably concerned with
reactive hypoglycemia. patient safety, but they are also concerned with
If modification of the gastric pouch and/or the operative time and cost. The circular stapler tech-
gastro-jejunostomy has no effect on weight loss, nique as proposed by Wittgrove and Clark [14]
then the primary trigger must be in the bypass. using an endoscopically retrieved guidewire to
Whether configured as a Roux-en-Y or an omega pull the anvil of the stapler transorally into the
loop [5], there is little difference in weight loss. pouch was later modified by Jacob and Gagner
Modifications of altering limb lengths, then, [15] using only a modified anvil and NGT with-
should have pronounced effects on performance. out the need for an endoscope. Another modifica-
However, the current literature does not support tion was by Scott and de la Torre [16] who used a
this [6]. Our current studies on distalizing the transgastric placement of the anvil. All of these
bypass (shortening the alimentary tract by techniques are successful, reproducible, and safe.
increasing the biliopancreatic limb length) are The major drawbacks are the need to use an entry
encouraging, but inconclusive at this time. port larger than 12 mm to accommodate the sta-
Therefore, given the lack of standardization pler, the cost of the stapler, and an increase in
regarding gastric pouch size, anastomotic stabil- wound infections if the entry site was unprotected
ity, and limb lengths in conjunction with the con- when withdrawing the contaminated tip [17].
sistent weight loss and metabolic effects among The linear stapled anastomosis popularized by
varying researchers, one can only conclude that Williams and Champion [18], Schauer et al. [19]
the mechanism of action of the gastric bypass is and others avoided the issues with the circular-
not attributable to a single cause; it is a symphony stapled anastomosis, but required manual sutur-
of effects as a result of the anatomic construct, ing to close the enterotomy. In addition, it was
and as of yet, unknown. more difficult to calibrate the size of the anasto-
mosis. The completely hand-sewn technique
avoided many of the issues of the stapled anasto-
19.2 Surgical Construct mosis, but admittedly was the most difficult to
master [20].
The evolution of the gastric bypass has been to Clearly, no single best technique has emerged
make smaller pouches, with exclusion of the dis- as all are in use today, with excellent results [21].
tensible fundus. This has had little effect on long- However, when one considers the increasing
term weight loss when one compares open and number of revisional surgical procedures, it is in
laparoscopic series (assuming that smaller these, the most complex situations, that manual
pouches are achieved laparoscopically), but we suturing skills are necessary for superior out-
would hope this would lead to fewer complica- comes and damage control.
tions such as marginal ulceration or GERD [7–9]. Small bowel obstruction after gastric bypass is
Proponents of the banded gastric bypass argue a particularly troublesome issue because of the
that pouch stability is an important component for vulnerability of the isolated gastric remnant
both initial and sustained weight loss as indicated prone to distension and possible ischemic necro-
in Obrien’s systematic review of medium-term sis. As opposed to bowel infarction due to adhe-
weight loss [10] and Schauer’s short- term com- sions that is often limited, the entire small bowel
parative trial [11], but Herrera’s randomized con- and right colon can be at risk with an internal
trolled study of banded versus non-banded gastric hernia. This phenomenon has been described for
bypass failed to support this hypothesis [12]. the open gastric bypass, but is observed much
There are three primary methods of gastro- less often than in the laparoscopic procedures
jejunostomy: the hand-sewn, the linear stapler, due to a greater degree of post-surgical adhesions
and the circular stapler [13]. Leaks at the gastro- in the former. Delay in treatment and diagnosis
jejunostomy are feared as one of the most has led to disastrous consequences emphasizing
19 Laparoscopic Roux-en-Y Gastric Bypass: Technical Aspects, Clinical Management, and Outcomes 199

Fig. 19.1 Position and

port placement

the need for formal education of general surgeons these experts. We use five ports as per the illustra-
called upon to treat post-gastric bypass patients. tion (Fig. 19.1), but it is obvious that port place-
Our initial experience was based on our open ment is at the discretion of each individual
gastric bypass, closing potential internal hernia surgeon. Our current arrangement also allows for
spaces (except for Petersen’s) with absorbable concomitant cholecystectomy if necessary at the
sutures. We quickly found this to be inadequate time of the operation or later as indicated.
and decreased the incidence of this problem to Rather than use external landmarks such as
less than 1 % using continuous permanent sutures the umbilicus or xyphoid to determine port place-
[22]. Others eliminated the meso-colic defect of ment, we feel it better to place the trocars based
the traditional retro-colic bypass by routing the on internal anatomy and visceral relationships. In
Roux limb ante-colic, but this did not eliminate this way, triangulation and visualization will be
the need to close the jejunal and Petersen’s preserved, accommodating for variations in the
defects [23]. Most authorities agree that closure size of the liver, or length of the patient’s torso.
of mesenteric defects with nonabsorbable suture Attention must not only be given to individual
material is highly advisable, but will not conclu- trocar placement, but also the angle in which the
sively prevent internal hernias. trocar enters the skin. Some individuals’ thick,
Optimal port placement allows for dissection muscular abdominal walls do not allow for the
of the small bowel without compromising the range of motion necessary to achieve the objec-
exposure of the proximal stomach. Extremes of tive, forcing redirection of the trocar internally,
size can be challenging: adequate space to allow through the same skin incision, but different
the formation of the Roux limb in smaller patients fascial opening, or by placement of another tro-
can be as problematic as the inadequate length of car. In general, the optimal placement is to orient
instrumentation and difficulties associated with all trocars toward the midline, pointing to the
visualization of the proximal stomach in larger base of the mesocolon.
patients. It is of interest that authors maintain Extra long trocars may be necessary and
how critical proper port placement is to the suc- although some surgeons prefer to limit the num-
cess of the operation; yet there is no consistency ber of 12 mm trocars (necessary to accommodate
as to a dominant port configuration amongst stapling devices), this may limit proper stapler
200 K.D. Higa

orientation and compromise the anatomic con- Left-inferior trocar (12 mm) – This is often at the
struct. The hernia risk is minimized by either same level as the primary optical trocar and in
closing the trocar defects, or preferably, using the same line as the initial trocar. This will be
non-bladed trocars without fascial closure to the primary stapler entry site for the jejuno-
minimize postoperative pain. jejunostomy and along with the right-upper
Our port placement scheme is as follows; it quadrant trocar will triangulate very well for a
illustrates the rationale necessary for consistency comfortable manual gastro-jejunostomy.
of this technique and represents an evolutionary Liver retractor – The most optimal placement
process that has taken over 12 years to develop appears to be subxyphoid. A 5-mm port can be
(Fig. 19.1). used here, depending on the liver retractor of
Initial trocar (12 mm) – Left, upper quadrant, choice. We have found that a simple 5-mm
Palmer's point
subcostal, mid-clavicular line. This is often an instrument or similar device will provide
optical entry without prior insufflation. The excellent exposure and therefore is often
rationale is that many patients have had previ- placed without a trocar, through direct punc-
ous procedures, pelvic or otherwise—this area ture, as it will not be removed until the end of
is rarely affected with intra-abdominal adhe- the case.
sions from common open procedures. This The omentum is displaced cephalad to expose
allows dissection of midline adhesions, the ligament of Treitz. In patients whose omen-
inspection of the size of the liver, and determi- tum is adherent to pelvic structures or involved in
nation of the best level for the primary optical an incarcerated ventral hernia, we prefer to incise
port. This will also be the primary port for ver- the gastrocolic omentum and open the transverse
tical stapling of the gastric pouch. Once adhe- mesocolon from above, thus exposing the liga-
sions are mobilized, then the optical port can ment of Treitz directly. Ventral hernias are
be thoughtfully placed as to see the ligament repaired at a later date when optimal weight loss
of Treitz as well as hiatus without having to and nutrition ensure a greater degree of primary
“turn around.” Also, by keeping the initial success and the use of prosthetic mesh is not
entry away from the midline, the vena cava compromised by contamination of enteric
and aorta are not as vulnerable to injury. contents.
Primary optical trocar (12 mm) – Placement has The proximal jejunum is transected with a 1)
been described above. Optimal placement 2.5- to 3.8-mm linear stapler, depending on the
allows for forward visualization of the proxi- thickness of the bowel, and the mesentery is
mal small bowel and the hiatus. Once this tro- divided with another firing of the stapler or with
car is placed, the camera is moved to this port an ultrasonic scalpel. The Roux limb is measured
for subsequent trocar placement. I have not
found the current 5-mm scopes to provide
and a side-to-side linear anastomosis is per-
formed (Fig. 19.2). Typically, the length of the
2)
enough light delivery and therefore resolution Roux limb can be up to 150 cm without an asso-
for optimal visualization in most patients. ciated increased incidence of malabsorptive com-
Right-sided trocar (12 mm) – This trocar must be plications [24]. The enterotomy is closed with a
placed thoughtfully just as all others. Exterior single layer of absorbable suture. The mesenteric
landmarks are irrelevant. It must come in defect must be closed with a continuous, nonab-
below the liver edge, just to the right of the sorbable suture to limit the possibility of internal
midline so as to be able to triangulate on the herniation (Fig. 19.3).
hiatus as well as the ligament of Treitz; there- The Roux limb is passed through a retrocolic
fore, it should be angled toward the root of the tunnel and fixed to the transverse mesocolon with
mesocolon, rather than perpendicular to the nonabsorbable sutures, which also includes clos-
abdominal wall. It must be 12 mm to accom- ing the Petersen’s space (Figs. 19.4 and 19.5),
modate the stapler that will define the inferior again, to help prevent possible internal hernia-
gastric pouch. tion. Alternatively, some surgeons prefer an
19 Laparoscopic Roux-en-Y Gastric Bypass: Technical Aspects, Clinical Management, and Outcomes 201

antecolic route for the Roux limb, claiming a

lower incidence of postoperative bowel obstruc-
tions [25].
There are times when the mesocolon is
uncomfortably short and will not allow for the
safe passage of a retrocolic Roux limb. In these
rare instances, the decision to route the Roux
limb antecolic must be made before the transec-
tion of the jejunum. This site must be more distal
from the ligament of Treitz, typically 50–100 cm,
1)
Fig. 19.2 Jejuno-jejunostomy
to limit the tension on the gastro-jejunal anasto-
mosis. By lengthening the biliopancreatic limb,
iron and calcium absorption may be less efficient,
and the incidence of these deficiencies may be
theoretically increased or more difficult to man-
age with oral supplementation alone.
Controversy exists as to whether the large
resultant Petersen’s space associated with an
antecolic Roux limb requires closure. Clearly,
these patients are still at risk for intestinal volvu-
lous [26]. Therefore, our philosophy is to elimi-
nate the risk of postoperative bowel obstruction
Fig. 19.3 Jejunal mesenteric closure rather than simply settling for a reduction in the
incidence. However, the long-term stability of
suture closure of these defects is still to be
determined.
The liver retractor is now placed to allow dis-
section of the proximal stomach. Occasionally, a
very large liver will not allow for sufficient visu-
alization—an indication for open conversion.
However, displacement of the liver to the right,
rather than anterior, will allow sufficient expo-
sure in the largest of patients. Alternatively, the
surgeon may decide to abort the procedure, eval-
uate the cause of hepatic enlargement (usually
Fig. 19.4 Petersen’s space closure
steatosis), and institute therapy (medical weight
reduction) in anticipation of performing the pro-
cedure at a later time under more ideal circum-
stances. In this way, surgical restraint and proper
judgment may reduce the morbidity associated
with these operations.
The pouch is formed by sequential firing of a
laparoscopic linear cutter, stapling device around
a 34 Fr. orogastrically placed bougie. The first fir-
ing is horizontal, introducing the stapler from the
3)
RUQ port (Fig. 19.6), beginning no more than
5 cm distal to the esophagogastric junction, using
Fig. 19.5 Mesocolic window closure 3.8- to 4.1-mm cartridges, depending on stomach
202 K.D. Higa

Fig. 19.6 Gastric pouch formation Fig. 19.9 Posterior hiatal hernia closure

vessels, this is unwise. Optimally, it is better to

enter the lesser sack through the gastrocolic
omentum and free the posterior gastric adhesions
up to the esophageal hiatus. This protects the
pancreas and the occasional tortuous splenic
artery from inadvertent injury. After this, the
lesser curve, perigastric dissection can be per-
formed with more confidence and placement of
the stapler more precisely as not to “twist” the
stomach pouch. This occurs when posterior gas-
Fig. 19.7 Gastric pouch formation
tric adhesions prevent the initial horizontal sta-
pler from capturing equal amounts of anterior
and posterior gastric wall. The resultant twist is
not as critical as in the gastric sleeve but is not
esthetically pleasing.
Controversy exists as to whether or not to dis-
sect the hiatus and repair a hiatal hernia when pres-
ent. Autopsy studies show that a hiatal hernia is
present in up to 70 % of individuals, similar to our
observations. However, dissection of the hiatus
can add additional time and potential complica-
tions to an already complicated procedure. Our
Fig. 19.8 Gastric pouch formation studies have not shown that preoperative endos-
copy accurately predicts the absence of a hiatal
thickness. It is important to orient the stapler hernia; the only way to determine its presence is
slightly cephalad to angulate the stapler line. circumferential dissection of the esophagus. The
Subsequent firings are vertically oriented to the absence of the “anterior” dimple is not reliable as
angle of His, introducing the stapler from the the hernia space is often taken up by a large para-
LUQ port (Figs. 19.7 and 19.8). By using this esophageal lipoma that can be easily reduced into
port configuration, extra-long staplers are unnec- the abdomen once identified. Once identified, the
essary for the majority of patients. hiatal hernia is best repaired posteriorly (Fig. 19.9).
One of the critical steps in creation of the gas- The question remains: “Is it important to
tric pouch is posterior visualization at the level of repair every hiatal hernia at the time of gastric
the hiatus. Many surgeons will “bluntly” dissect bypass?” The answer is not clear. If one assumes
behind the stomach, but given the variable level that precise dissection and formation of the
of adhesions to the pancreas and the splenic gastric pouch is important to limit postoperative
19 Laparoscopic Roux-en-Y Gastric Bypass: Technical Aspects, Clinical Management, and Outcomes 203

complications, then it would be appropriate to

absolutely identify the location of the gastro-
esophageal junction, often hidden in a “sea of
fat,” to better perform more consistent recon-
struction. It has been our observation that almost
100 % of patients we have reoperated after gas-
tric bypass have a significant hiatal hernia at the
time of reoperation – something not appreciated
at the time of the first intervention.
Dissection of the hiatus and repair of the hiatal
Fig. 19.10 Gastro-jejunostomy
hernia along with removing the fat pad overlying
the angle of His may allow for more precise and
consistent pouch formation and subsequent better
long-term performance and lower complications,
but this has not been proven. Although this may
add up to 5–10 min of operative time, which is
significant, the added exposure may make for a
safer operation. Each surgeon will need to evalu-
ate this perception in the context of his or her
individual experience and skill level. Suffice it to
say, to perform a good laparoscopic gastric
bypass, the surgeon must be expert at hiatal
dissection. Fig. 19.11 Gastro-jejunostomy
Routing of the Roux limb is best determined
by the patient’s internal anatomy. As stated previ-
ously, the risk of internal herniation is the same,
whether routed antecolic or retrocolic as long as
potential internal hernia spaces are closed with
nonabsorbable sutures. It is important that there
is as little tension on the anastomosis as possible.
In most cases, an antegastric orientation makes
gastro-jejunal anastomosis more visible and eas-
ier for subsequent revision if necessary. However,
the retrogastric orientation is a more direct route
and offers unobstructed access to the anterior
Fig. 19.12 Gastro-jejunostomy
stomach.
The method of gastro-jejunal anastomosis is
not critical. Whether stapled, or hand-sewn, pri-
mary or reinforcing, sutures should be absorbable
to prevent suture migration or ulcer formation.
Choice of suture material, braided or monofila-
ment, single- or two-layer, is left to the discretion
and results of each individual surgeon (Figs. 19.10,
19.11, 19.12, 19.13, 19.14, and 19.15).
The anastomosis and proximal staple lines can
be tested with blue dye, air insufflation via the
orogastric tube, or operative endoscopy. Routine
drainage is unnecessary. The port sites are Fig. 19.13 Gastro-jejunostomy
204 K.D. Higa

surgeon’s intervening based on clinical suspi-

cion of a leak [28].
Patients are started on clear liquids the day of
surgery and are required to ambulate with assis-
tance. Preoperative oral medications can be
resumed as soon as the patient can tolerate clear
liquids. Most patients are discharged by the sec-
ond postoperative day, the majority on the first
postoperative day.
Patients are continued on a clear liquid diet for
Fig. 19.14 Gastro-jejunostomy
1 week and slowly advanced to solids over a 3- to
4-week period. Patients are instructed to take
either an H2-blocker or proton pump inhibitor for
30 days. Routine follow-up visits are at 1, 3
weeks, and quarterly for the first year, and then
on a yearly basis. Ongoing nutritional, emotional,
exercise counseling, and support groups are pro-
vided. Complete nutritional assessment occurs
on a yearly basis or when symptoms or clinical
suspicion dictates.

Fig. 19.15 Gastro-jejunostomy 19.4 Results

Long-term data regarding the laparoscopic Roux-

inspected for bleeding on withdrawal of the tro- en-Y gastric bypass have been lacking due the
cars and the skin is closed with simple absorbable difficulty with patient follow-up. Despite tremen-
monofilament sutures. dous effort, we were only able to obtain a 27 %
sample regarding our 10-year results [8].
However, we found no difference in results in
19.3 Postoperative Management comparing patients who consistently followed up
in our office and those who did not, so it is not
Perioperative antibiotic is continued for 24 h, unreasonable to extrapolate our results and they
while thromboembolism prophylaxis continues are similar to Himpens’ 9-year data [29] as well
until the patient is discharged. Analgesia is in the as from the open era.
form of patient controlled narcotic delivery sys- As important as is weight maintenance, res-
tems and intravenous ketorolac or acetamino- olution of medical comorbidities and metabolic
phen. Oral narcotics are offered when clear syndrome is well illustrated with our data and
liquids are tolerated. Metoclopramide is adminis- this emulates other reports [30] (Tables 19.1
tered routinely and a variety of antiemetic phar- and 19.2).
macologic agents are available for nurses to use
at their discretion.
Routine postoperative contrast studies add 19.5 Complications
little to the management of these patients and
serve only to delay discharge secondary to nau- Although our perioperative mortality remains
sea [27]. A normal postoperative upper gastroin- low (0.2 % overall), potential complications
testinal (UGI) study should not preclude the must be looked at in the context of the chronicity
19 Laparoscopic Roux-en-Y Gastric Bypass: Technical Aspects, Clinical Management, and Outcomes 205

Table 19.1 Reported long-term weight loss

Patients Patients at
Follow-up eligible for follow-up, n Postoperative BMI
Investigator Patients (n) (years) follow-up (n) (%) %EWL (kg/m2)
Jones [31] 352 10 71 36( 51) 62 30
Pories et al. [32] 608 10 NR 158 (NR) 55 35
Sugerman et al. [33] 1,025 10–12 361 135 (37) 52 36
Christou et al. [34] 272 12 272 161 (59) 68 38
Higa et al. [8] 242 10 242 65 (27) 57 33
Himpens et al. [29] 126 9 126 77 (61) 63 30
NR not-reported

Table 19.2 Outcomes of 242 patients: 10-year Table 19.3 Early morbidity (242 patients)
follow-up
N %
Comorbid % of Resolved or Incomplete stomach division 4 1.7
condition Patients (N) 242 improved (%) Staple-line failure 2 0.8
Osteoarthritis 110 45 84 Leak due to thermal injury 1 0.4
Diabetes 45 19 83 Marginal ulcer perforation 1 0.4
Dyslipidemia 6 2 67 Bleeding (observation only) 1 0.4
Hypertension 108 45 87 Stenosis: gastro-jejunostomy 12 5.0
Infertility 5 2 50 Stenosis: mesocolon 1 0.4
Obstructive sleep 45 19 76 Fever and readmission 6 2.5
apnea
Hypoglycemia 1 0.4
Asthma 23 10 100
Central pontine myelinolysis 1 0.4
Gastroesophageal 121 50 89
Total 31 12.8
reflux disease
Urinary stress 35 14 69
incontinence
Varicose veins 21 9 100 Table 19.4 Late morbidity (242 patients)
N %
of the disease and the permanent derangement Internal hernia 39 16.1
of the anatomic construct. A marginal ulcer- Marginal ulcer 11 4.5
Gastrogastric fistula 1 0.4
ation or internal hernia that occurs 15 years
Gallstones 17 7.0
after a laparoscopic Roux-en-y gastric bypass is
Alcohol dependency 6 2.5
still a complication of the procedure, regard-
Other substance abuse 1 0.4
less. An overall 10-year complication rate of Hernia, trocar 3 1.2
45 % seems high, but it accurately reflects our Total 78 32.2
experience and is indicative of underreporting
common to the literature. As an example, our
initial internal hernia rate was not captured in deficiencies may be entirely due to patient
our first report [22]; internal hernias are a life- choices (tobacco, NSAIDs), but it is still rele-
long risk and can present years after the proce- vant that they occurred after the procedure.
dure, so a 16 % rate without proper closure of What is also relevant is the overwhelming evi-
the defects is to be expected. (Our current inter- dence that the gastric bypass, as well as other
nal hernia rate is approximately 1 %.) Biliary operations can improve longevity as well as
tract disease and substance abuse may not be control of metabolic syndrome compared with
directly related to the gastric bypass, but there nonoperative alternatives [35–38] (Tables 19.3,
is an association. Marginal ulcers and vitamin 19.4, and 19.5).
206 K.D. Higa

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Vitamin B12 81 60 12. Zarate X, Arceo-Olaiz R, Montalvo Hernandez J,
Hemoglobin 71 52 García-García E, Pablo Pantoja J, Herrera MF. Long-
Albumin 46 34 term results of a randomized trial comparing banded
Intact parathyroid hormone 36 26 versus standard laparoscopic Roux-en-Y gastric
bypass. Surg Obes Relat Dis. 2013;9(3):395–7.
Vitamin B6 23 17
13. Madan AK, Harper JL, Tichansky DS. Techniques of
Calcium 18 13 laparoscopic gastric bypass: on-line survey of
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14. Wittgrove AC, Clark GW. Combined laparoscopic/
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gastroenterostomy. Obes Surg. 2001;11(5):565–9.
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 Laparoscopic Biliopancreatic
Diversion 20
Nicola Scopinaro

20.1 Introduction secretions, called alimentary limb (AL); (3) an

intestinal segment, between the point of meeting
This chapter is a very good occasion to clarify a and the ileocecal valve (ICV), where biliopancre-
concept which still today seems not to have been atic digestion starts and the products of it can be
understood by a large part of the bariatric surgeons: absorbed (common limb or CL).
biliopancreatic diversion (BPD) is not a particular The BPD mechanism, as described above,
operation, it is a mechanism of action, essentially should not disturb the intestinal absorption of the
consisting of delaying the meeting between food microaliments, except for the possible bypass of
and biliopancreatic juices with the aim of reducing intestinal segments with specific active absorp-
digestion, and thus intestinal absorption of the tion (e.g., duodenum for active absorption of Ca
high-caloric nutrients which need to be digested for and Fe), provided that the AL be long enough for
being absorbed. The mechanism itself does not their complete absorption, whilst it should be
necessarily provoke the obtainment of the goal, effective on reduction of fat absorption, provided
unless the time of contact between food and bilio- that the CL be short enough not to allow its com-
pancreatic secretions is insufficient to cause a com- pletion. A big question mark would obviously
plete digestion-absorption. remain for protein absorption. However, for a
The creation of a BPD necessarily requires an better comprehension of what can happen in dif-
alteration of the normal GI continuity. The basic ferently constructed BPD mechanisms, let us
components of the mechanism, no matter how it consider the behavior of the three intestinal limbs
is constructed, are as follows: (1) an intestinal in the standard BPD, which is far the most stud-
segment, immediately following the duodenum, ied model.
where the meeting between food and digestive Standard BPD [1] (Fig. 20.1) consists of a dis-
juices is prevented, called biliopancreatic limb tal gastrectomy, including the entire antrum, with
(BPL) as it only leads the biliodigestive juices to a long Roux-en-Y reconstruction where the
the point of meeting with food; (2) an intestinal enteroenterostomy (EEA) is placed 50 or 75
segment leading food from the stomach to the (exceptionally 100) cm proximal to the ileocecal
point where aliments meet the biliopancreatic valve, thus identifying the length of the CL,
while, in the current model, the GEA is 250 cm
far from the EEA (AL), and the remaining small
N. Scopinaro, FACS (Hon) bowel, from the duodenum to the EEA, belongs
Department of Surgery, University of Genoa
Medical School, Genova 16132, Italy to the BPL. As our about 3,000 measurements
e-mail: [email protected] (all done with the small bowel fully stretched)

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 209
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_20,
© Springer International Publishing Switzerland 2015
210 N. Scopinaro

300-500 ml

250 cm
Fig. 20.3 Intestinal measurement in laparoscopic
surgery

long BPL, and our studies demonstrated that little

if any of them actually reach the CL, so that no
50 cm
pancreatic digestion occurs in it. Protein and
starches are uniformly digested and absorbed in
the entire intestinal segment from the GEA to the
ICV (as well as simple sugars and short-chain
fatty acids) thanks to the action of the enterocyte
Jejunum
brush-border enzymes, while, due to the neces-
Ileum sity of bile salts, only fat absorption is limited to
the CL [2]. Therefore, the longer the AL the
Fig. 20.1 Scopinaro’s biliopancreatic diversion, 1979 greater is the protein absorption, but, due to
digestion-absorption of complex carbohydrates,
the energy absorption is also greater and thus
higher is the weight of stabilization. Moreover,
colon plays an important role in protein-energy
absorption, through the digestive enzymes of its
bacterial flora. In fact, colon has a great protein
digestive-absorptive capacity [3], which is fully
exploited in standard BPD, otherwise there would
not be protein malabsorption, which, contrary to
what happens for fat, is a percent of the intake cor-
responding to only about 30 % [4]. This is why,
despite the about fivefold increased loss of endog-
enous nitrogen (up to 5 g/day, mainly consisting of
Fig. 20.2 Intestinal measurement in open surgery
desquamated cells and dead bacterial bodies) pro-
tein-energy malnutrition (PEM), potentially the
(Figs. 20.2 and 20.3) demonstrated a mean small most severe nutritional complication of BPD, is a
bowel length of about 800 cm, and the jejunum is rare event with the intestinal lengths currently in
considered to correspond to the first 2/5 of the use. Finally, an unfavorable event is to be con-
small bowel, almost invariably the EEA is a sidered, that is, the capacity of colonic enzymes
gastro-ileal anastomosis, and the BPL is the lon- to cause fermentation of fiber to fatty acid and
gest of the three intestinal limbs. Pancreatic lactate, which are then absorbed in this caloric
enzymes are slowly digested and absorbed in the form, thus increasing calorie absorption. It was
20 Laparoscopic Biliopancreatic Diversion 211

calculated that up to 500 kcal/day can be absorbed energy absorption capacity per unit of intestinal
with this mechanism [5]. surface; (2) the entity of postoperative intestinal
In summary, except for the unavoidable reduc- adaptation phenomena; (3) the intestinal transit
tion of calcium and iron, due to the duodenal- time (which, in addition to gastric volume, can be
jejunal bypass, and of liposoluble vitamins, influenced by the intake of fluids); (4) the simple
consequent to the reduced fat absorption, assum- sugar and protein intake; (5) the number of meals
ing that simple sugars are fully absorbed by the per day and the meal duration; (6) the body
small bowel in the alimentary stream, the absorp- weight itself and the energy expenditure per unit
tion of all the other high-caloric nutrients in the of body mass. However, in each BPD individual
standard BPD essentially depends on the volume the weight of stabilization cannot be modified by
of the gastric remnant (which, if too small, can any increase or decrease of fat and starch intake,
cause a rapid gastric emptying and intestinal tran- provided that the intake is greater than the maxi-
sit, thus reducing absorption capacity) and on the mum daily absorption capacity (also defined as
length of the intestinal limbs. The BPL should be “maximum transport threshold”).
long enough to allow complete digestion- Apart from the many overt modifications of
absorption of pancreatic enzymes; the AL plus the standard BPD, like preservation of the distal
the CL should be long enough to guarantee, stomach [6] or of the entire stomach [7], or
together with the colon, a protein absorption suf- modifications of the intestinal limb lengths [8]
ficient to counteract the endogenous nitrogen (Figww. 20.4), and, more recently, the so-called
loss, as well as a sufficient water, electrolyte, and duodenal switch [9, 10] (Fig. 20.5), which will
water-soluble vitamin absorption, still not allow- be the object of another chapter of this book,
ing an excessive polysaccharide digestion- once the BPD as a mechanism of action has
absorption; CL should be short enough to reduce been clearly described it is easy to recognize it
as much as possible fat absorption, still allowing in bariatric operations which have apparently
a bile salt absorption sufficient not to cause bile nothing to do with BPD. The most obvious
acid diarrhea. Incidentally, the loss of bile salt
into the colon, together with the lack of gallblad-
der contraction, causes the constant presence of a
lithogenic bile, which in turn would cause gall-
stone formation in the almost totality of operated
patients, if a prophylactic cholecystectomy were 150-200 cc
not added to the operation in all cases.
It is very important to remember that the char-
acteristics of very long term individual and inter-
individual weight maintenance, together with
accurate studies of energy, fat, and protein intes-
tinal absorption [4], and of postoperative changes
of resting energy expenditure [2], lead to the 50 cm
hypothesis, subsequently verified by an overfeed-
ing study [2], that a maximum daily intestinal
absorption capacity exists for each standard BPD
individual for fat and starch, while simple sugars
are entirely absorbed, and protein absorption is a
percent of the intake, corresponding to about 50 cm
70 % [4]. In other words, the original intestinal
lengths and gastric volume being equal, the inter-
individual variability of the weight of stabiliza-
tion in BPD subjects is accounted for by
interindividual differences of: (1) the original Fig. 20.4 Larrad’s biliopancreatic diversion
212 N. Scopinaro

This is only partially true, as in many subjects

with standard RYGB we have found a mild to
moderate steatorrhea, in most cases confined to
the first postoperative year. Anyway, it seems
that the BPD mechanism is active, the threshold
for intestinal fat absorption being exceeded,
even if only minimally and temporarily, and
that the initial weight reduction after RYGB is
initially at least partially due to calorie malab-
sorption. The close similarity of RYGB to BPD
is witnessed by the many surgeons who, with
the very questionable aim of adding energy
malabsorption to gastric restriction, use longer
AL, or BPL, or both, thus originating opera-
tions called “distal GB” [14], or “long-limb
GB” [15, 16], or even “very very long-limb
Fig. 20.5 BPD with sleeve gastrectomy and duodenal
switch (BPD/DS) [9]
GB” [17]. These operations, prompted by poor
knowledge of the BPD mechanism, are very
dangerous, because it was repeatedly demon-
strated that to add malabsorption to gastric
restriction is either just useless or even harmful
for protein nutrition [14, 18].
Another evident case of misunderstanding
is the so-called mini-gastric bypass or MGB,
which should be more correctly and meaning-
fully named “single anastomosis GB” or “loop
GB.” Pioneered by Rutledge [19], MGB con-
sists of a GB where the pouch is created much
longer than usual (to prevent esophageal reflux),
and the Roux-Y anastomosis is replaced by a
loop one, placed in all cases 200 cm distal to
the ligament of Treitz, with the aim of spar-
ing one enteroenterostomy. The operation was
severely criticized in the USA, but it is being
increasingly performed in many non-American
countries, where the authors generally report the
same good weight loss result as in the standard
RYGB, but with less complications and shorter
hospital stay. Interestingly, with the exception
Fig. 20.6 Miller’s divided gastric bypass, 1979 of Sanchez-Pernaute [20], who replaced the
classic gastric pouch with a sleeve gastrec-
example is Roux-Y gastric bypass, where, even tomy in order to avoid also gastric bile reflux
in its classic version with short BPL and AL (Fig. 20.7), none of the surgeons who perform
[11–13] (Fig. 20.6), the meeting between food MGB (including the originator) seems to have
and biliopancreatic juices is delayed. In this realized that the operation is a BPD, already
operation it is generally assumed that the mech- published as such by Scopinaro in 1980 [21]
anism for calorie absorption reduction is inef- as one of the possible versions of the standard
fective, because the length of the CL is such BPD (Fig. 20.8), where no AL exists, as the gas-
that a complete calorie-rich aliment occurs. tric remnant directly empties into the common
20 Laparoscopic Biliopancreatic Diversion 213

limb, which, also exerting the functions of the

AL, determines the existence, the quality, and
the entity of malabsorption, and consequently is
the one that should be measured. As almost no
surgeon measures the small bowel in condition
of full reproducibility, that is fully stretched, in
case of short small bowel (e.g., around 400 cm,
which is not a very infrequent case), the 200 cm
that Rutledge and the vast majority of the other
authors measure distal to the ligament of Treitz,
thus totally ignoring what is left distal to the
GEA, could very well leave them with a com-
mon limb, whose length is not known to the sur-
geon, short enough to cause severe energy and
protein malnutrition.
An interesting example of unacknowledged
BPD is the so-called endobarrier gastrointesti-
nal liner [22], a short intraluminal sleeve
anchored to the pylorus that delays the meeting
of food with biliopancreatic juices, thus caus-
ing a certain degree of energy malabsorption
and consequent weight loss. The device,
60–100 cm long, can be left in place only tem-
Fig. 20.7 Single anastomosis duodeno-ileal bypass with porarily (generally 6 months), and it is used
sleeve gastrectomy (SADI-S, 2010) today to obtain a pre-surgical weight loss prior
to bariatric surgery.
Evidently, the number of different types of
BPD (laparoscopic or not) currently in use
today is so huge that a description of each of
them would be as impossible as useless.
Therefore, we will only describe the technical
aspects, the clinical management, and the out-
come of the laparoscopic standard BPD
(LSBPD) in our experience of little less than
300, and as reported by the few bariatric sur-
geons who used the same model of operation
(laparoscopic or not).

20.2 Technical Aspects

The surgical technique [23] entails the use of

five trocars, placed in the positions illustrated
in Fig. 20.9. The patient is placed in a mod-
80-120 cm erate anti-Trendelenburg position (20–25°).
As a rule, we prefer to do first the cholecys-
2 subjects
tectomy, which can be annoying due to the
Fig. 20.8 Scopinaro’s 1980 standard biliopancreatic
non standard trocar positions. The gastrocolic
diversion (bypass) with loop gastroenterostomy ligament is incised at about its midpoint and
214 N. Scopinaro

3 1 2 5

Fig. 20.10 Left gastric vessels

Fig. 20.9 Trocar position in laparoscopic standard BPD.

1: supraumbilical (10–12 mm), on the midline, 3–4 cm
above the superior margin of the umbilicus; 2: left hypon-
driac (10–12 mm), along the left midclavicular line, about
6 cm below the costal margin; 3: right hypondriac (10–
12 mm), along the right midclavicular line, about 6 cm
below the costal margin; 4: xiphoid (10–12 mm), on the
midline, 3 cm below the xiphoid; 5: left subcostal (5 mm),
on the left costal margin, along the left middle axillary
line

the dissection, which is carried out with a har- Fig. 20.11 Gastric measurement along the greater curve
monic scalpel, is performed until the traction
of the large curve allows for the mobilization
of the gastric fundus, which implies that the able to evaluate it by sight. Roughly, a gastric
avascular area is always sectioned. The first sectioning from the greater curve, moderately
short vessel is rarely sectioned, exceptionally stretched, at approximately 15 cm from the
the second. The dissection of the lower greater cardias (Fig. 20.11) to the lesser curve at 5 cm
curve and the sectioning of the right gastroepi- from the cardias corresponds to a gastric vol-
ploic and the right gastric vessels complete the ume of about 300 mL (Fig. 20.12). A distance
isolation of the duodenum, which is divided of 20 cm along the greater curve corresponds to
with single application of endoGIA 60. The a volume of about 400 mL. This applies both to
small curve is then isolated cranially with the the laparoscopic and the open technique, as it
ultrasound scissors, stopping 1 or 2 cm before was demonstrated by a check done in all cases
the trunk of the left gastric artery (Fig. 20.10), of conversion (which, being due to problems
and the gastric resection is carried out by with the GEA construction, was generally done
repeated firing of endoGIA 60. To measure the after division of the stomach) at the beginning
gastric stump is very easy by filling with water of our experience with the laparoscopic tech-
(35 cm H2O) a condom which has been tied at nique, when we started measuring again the
the end of a nasogastric tube. Gastric volume gastric volume in order to reacquire the ability
should be measured until the surgeon becomes the gastric stump [23].
20 Laparoscopic Biliopancreatic Diversion 215

Fig. 20.12 Gastric stump of approximately 300 mL Fig. 20.14 Gastric stump attraction through the meso-
colic rent

Fig. 20.13 Ileal division

Fig. 20.15 Gastroenteroanastomosis
The patient is then placed in a slightly
Trendelenburg position (about 10°). The small Treitz (Fig. 20.14). The distal intestinal stump
bowel is measured backward from the cecum, is identified, checked for possible torsion, and
fully stretched (Fig. 20.3), using two forceps perforated with the ultrasonic scissors at a dis-
marked at 10 cm in alternating movements. A tance from the suture line equal to the operative
mark is left at 50 cm, the ileum is divided at length of the endoGIA 45. The latter is used to
300 cm by using an endoGIA 45, and the mesen- perform a latero-lateral isoperistaltic GEA on the
tery is sectioned in depth with the ultrasonic scis- posterior wall of the stomach, as close as pos-
sors, taking care to proceed perpendicularly to its sible to the distal angle and at midway between
root (Fig. 20.13). The EEA is fashioned with a the suture line and the greater curve (Fig. 20.15),
latero-lateral technique, with an endoGIA 45 with manual closure of the conjoined defect.
through two small enterotomies made by the har- After the leak test with methylene blue intro-
monic scalpel. The conjoined defect is closed duced through the nasogastric tube, the GEA is
with a manual running seromuscular suture. anchored by two stitches to the mesocolic rent,
The left angle of the gastric stump is then in order to avoid intestinal kinkings and internal
identified, grasped, and pulled into the subme- hernias (Fig. 20.16). We always close the distal
socolic space through an incision performed in mesenteric defect and never the proximal one
the transverse mesocolon over the ligament of (Patterson).
216 N. Scopinaro

gastric volume is about 300 mL (Fig. 20.12), as a

smaller stomach has proven, in our [2, 18, 24]
and in other authors’ experience [14], to entail a
great risk of energy-protein malnutrition (PEM).
It is very important to remember that the small
bowel is to be measured fully stretched, midway
between the mesenteric and the antimesenteric
border (Figs. 20.2 and 20.3), in order to make the
measurements reproducible both in the sane and
in different hands. At the beginning of our expe-
rience with laparoscopic BPD, when the conver-
sions to open surgery were more frequent, a
check of intestinal lengths measured after con-
Fig. 20.16 Fixation of the GEA to the mesocolic rent version never showed a difference greater than
10 % between the two measurements [23], so, at
A liver wedge biopsy is always obtained. The least in our experience, we can refer to the intes-
last maneuver, as in open surgery, is the final tinal lengths independently of the conditions
intestinal check, starting from the ileocecal valve, (open or laparoscopic) in which the measure-
with the surgeon following the AL and the first ments were done. The length of 250 cm for the
aid the BPL. It takes time, but it is the only way AL is the results of decades of experience, and
to make sure that no 360° intestinal torsion exists. should not be changed, unless a longer AL is
As an alternative, the two mesenteric edges are requested to reduce to the minimum the weight
carefully inspected from the anastomoses to the loss, as in the above mentioned particular indica-
start of the mesenteric division. tions. An AL shorter than 250 cm entails a pro-
The distal stomach, as well as the gallbladder, gressively increasing risk of PEM.
is extracted through the supraumbilical opening, The CL length of 50 cm has been our gold
which sometimes needs to be widened. Two standard since the completion of the early experi-
drains are left in the Douglas pouch and under the mental phase, and it has remained the same dur-
liver. The trocars are removed under visual con- ing more than 30 years, always giving excellent
trol. The fascial defect is sutured in the supraum- and indefinitely maintained weight results.
bilical hole. The others are left as they are, with However, it demonstrated to be incompatible
simple skin suturing. with a gastric volume smaller than 300 mL, the
As to the possible modifications of gastric vol- so-called very little stomach BPD causing,
ume and intestinal lengths, being similar all the besides a 90 % loss of the excess weight, an inci-
other conditions, a larger gastric remnant gener- dence of 30 % PEM, with more than 10 % recur-
ally, but not necessarily, results in a higher weight rent form requiring surgical revision [2, 18, 24].
of stabilization, and certainly in a lower risk of This was confirmed by Sugerman et al. [14] who
protein malnutrition. It can be used precaution- had overwhelming PEM problems when, leaving
ally in patients with lower compliance, never for- the very small gastric pouch, they converted stan-
getting that low compliance should be considered dard RYGB into BPD with 200 cm AL and 50 cm
in principle a contraindication to BPD, or in case CL (so-called distal gastric bypass). In our
of low BMI type 2 diabetic or hypercholesterol- experience with BPD evolution, the progressive
emic patients, when the aim of the operation is enlargement of the gastric remnant brought the
the exploitation of the specific actions for those PEM down to around 3 % with 1 % recurrence
conditions, with little or no weight loss (see rate, and the additional lengthening of the AL
below). On the contrary, a smaller gastric volume from 200 to 250 cm made this important nutri-
results in a more rapid weight loss with lower sta- tional complication to essentially disappear, still
bilization weight. The lower acceptable limit for leaving the permanent loss of the excess weight
20 Laparoscopic Biliopancreatic Diversion 217

around 70 % [24]. With similar more than 300 mL ing in length between 400 and 500 cm, which is
gastric remnant, Clare [25] reported good results evidently our AL, is named “Roux-limb.” The
with 50 cm CL and equal AL and BPL (as our authors refer to the Sugerman “distal gastric
“half-half” BPD [26]), with little less weight loss bypass” [14], who uses the same terminology,
than the standard model and only 2 % of hypo- that is, “Roux-limb” = AL. Therefore, the Brolin
proteinemia. The same good results were and MacLean “long-limb” is apparently named
obtained by Marceau [27] with the 50 cm CL “Roux-limb” and corresponds to the biliopancre-
standard BPD. Still, the problems remained of atic limb (BPL), while the definition “Roux-
side effects, mainly represented by diarrhea, limb” in the Sugerman distal gastric bypass and
present in 13 % of operated patients. in the Rochester group “very very long limb” is
More recently, Garcia et al. [28] compared evidently referred to the alimentary limb (AL).
standard BPD (50 CL – 200 AL cm) with a modi- This gross semantic confusion, that I have repeat-
fied version (75–225 cm), showing an astonish- edly indicated as one of the greatest problems in
ing fall of malnutrition from 16 to 2 %, with bariatric surgery (I even wrote a chapter in the
slight lower weight loss. These findings go into Deitel’s book entitled “Semantics in obesity sur-
the same direction of the preliminary ones of a gery” [31]), certainly does not help the reader to
prospective randomized trial we are carrying out understand how these operations are structured,
on our patients, where a 75 cm CL results in and, even less, how they work.
modest reduction of weight loss accompanied by At the beginning of the introduction, when
a significant reduction of side effects, mainly describing the BPD as a basic mechanism of
diarrhea but also gas problems and foul smelling action, we underlined that the mechanism is
stools. effective in causing a reduction, or, to say better,
For the rest, different intestinal lengths were a limitation of calorie absorption only if the
used in modified RYGB in order to achieve a time of contact between food and biliopancre-
greater weight loss, especially in the super-obese atic secretions is reduced enough to cause
patients. To understand what the authors actually incomplete digestion and absorption of calorie
did is made difficult due to the apparently differ- rich aliment. At this point, in order to fully
ent semantics they use when defining the intesti- understand the importance of the intestinal limb
nal limbs. First, Brolin et al. in 1992 proposed the lengths, it is important to remember that not
“long-limb” RYGB [15], consisting of a “defunc- necessarily the BPD operation causes weight
tionalized jejunum” (and then a BPL) of 150 cm loss. BPD simply leads the body weight to the
compared with a BPL of 75 cm. The first opera- value corresponding to the amount of daily cal-
tion caused a greater weight loss when compared orie absorption which is allowed by its mecha-
to the second one only in the super-obese patients, nism of action. As we said, there is for each
when weight loss did not change in the morbidly BPD individual a maximum energy absorption
obese ones. These results were confirmed by capacity which, in that specific subject, if all the
MacLean et al. in 2001 [16] and subsequently by other conditions mentioned above remain con-
Brolin himself in 2005 [29]. The confusion arises stant, also remains constant and corresponds to
when the “very very long limb” RYGB is consid- a determined weight of stabilization. If the start-
ered. This operation, described first by Murr et al. ing body weight of the BPD subject corresponds
in 1999 [17] and then by Nelson et al. in 2006 to a daily energy consumption higher than the
[30], both belonging to the same group of the operation energy absorption threshold, a nega-
Mayo Clinic, Rochester, Minnesota, apparently tive calorie balance takes place causing the
consists of a gastric bypass with a short (60 cm) reduction of body weight which will stop only
“pancreatobiliary limb,” which evidently corre- when the body energy expenditure will equal
sponds to what we call BPL, a 100-cm “common the energy absorption threshold. Assuming, for
channel,” and thus our CL, while all the rest of example, that the threshold is 1,600 kcal/day,
the small bowel, from the GEA to the EEA, rang- corresponding to the body energy expenditure
218 N. Scopinaro

of 85 kg, the latter will be the weight of stabili- increase its level by elongating by 50 cm both the
zation of that subject for that operation. Any CL and the AL, which become 100 and 300 cm,
starting body weight higher than this will be respectively, thus obtaining the preservation of
forced by the negative calorie balance to reduce the above specific actions with minimal or no
to 85 kg, when the energy balance is reached weight loss at all [24, 32]. Obviously, in these
between daily intestinal energy absorption and conditions, an increase of energy intake would
daily body energy expenditure. The result will cause weight gain, but this only exceptionally
be a weight loss equal to the starting body happens, and the same applies to the hypothetical
weight minus 85 kg. However, if the starting weight gain resulting from the better glycemic
body weight is already stable at 85 kg, this homeostasis.
means that the BPD individual is eating and In conclusion, the good knowledge and the
consuming as much as the operation allows to wise use of the intestinal limbs absorption char-
absorb. Consequently, the operation causes no acteristics makes BPD an extremely ductile oper-
negative energy balance, neither weight change. ation, as it can operate in such a wide range of
The same obviously applies to the case of start- action that it can cause from the greatest weight
ing body weight lower than 85 kg. The BPD loss obtainable with any bariatric operation down
subject eats and consumes less energy than what to even no weight loss at all, still maintaining its
the BPD allows to absorb, then again nothing specific actions, like the two mentioned above.
would change in calorie balance and no weight
change would occur.
BPD possesses some metabolic specific 20.3 Clinical Management
actions which are totally independent of the
weight loss, the best known being the serum cho- 20.3.1 Postoperative Management
lesterol lowering and the beneficial effect on gly-
cemic control. Consequently, the morbidly obese One single antibiotic shot is given preoperatively,
patient, in case of hypercholesterolemia or type 2 when thromboembolic prophylaxis is started,
diabetes mellitus, besides weight loss will also that is continued for the entire first postoperative
benefit of these two weight-independent actions. month. The patient is ambulating the day of oper-
They depend on the structure of the operation, the ation. Analgesia consists of morphine and ketor-
first being due to the loss of bile salts in the colon, olac by means of a continuous delivery system
caused by the short segment of bile salt absorbing for 3 days, with paracetamol on demand.
terminal ileum in continuity, which causes Metoclopramide is administered routinely
increased bile acid neosynthesis in the liver together with intravenous fluids, that is, 3 days.
which happens at the expenses of the cholesterol NG tube is removed on the first postoperative
pool. The beneficial action on type 2 diabetes, morning. GEA transit is checked on the 2nd day
first reported by us in 1984 [26], is caused by hor- by X-ray oral contrast (leak diagnosis is based on
monal changes due to the bypass of the duode- clinical signs). Clear liquids are allowed on the
num and by the presence of aliments in the ileum. 3rd day, when i.v. fluids are discontinued. Solid
If these anatomic conditions are preserved, the food is given within the first week, according to
two beneficial specific actions remain active also the gastric emptying as shown by X-ray check.
in case of no weight loss. Therefore, the opera- Patients are discharged on 4th or 5th day (the vast
tion is precious, because it can be used for the majority of them live far from Genoa).
treatment of hypercholesterolemia and of type 2 Patients are called for routine follow-up visits
diabetes mellitus also in lean individuals, with no (with all the laboratory exams done) at 1, 4, 12,
risk of undue weight loss. In those cases, as we 24, and 36 months. Subsequently, they are not
do not know which the exact value of energy called anymore, but strongly recommended to
absorption threshold will be, in order not to take continue coming yearly, or at least sending their
the risk of undue weight loss, we deliberately complete lab exams by fax or e-mail.
20 Laparoscopic Biliopancreatic Diversion 219

PPI are prescribed for 1 year, oral Fe, Ca (2 g/ use it in case of super, and especially super-
day), and multivitamins for life. The minimum superobesity (BMI >60), in case of severe meta-
daily protein intake recommended is 90 g/day. bolic complications, especially type 2 diabetes,
Patients are encouraged to call us for any in case of single or multiple failure of previous
unpleasant clinical symptoms, even if judged not bariatric operations, and in case of very young
important. Our availability by phone is 24 h for patients. This last indication is controversial;
life. however, we have no doubts that the solution of
In the patients with type 2 diabetes as the main such a major problem for the entire life is well
or the only indication to surgery the postopera- worth all the possible risks (generally limited
tive management is essentially the same, with the to the first postoperative years) entailed by the
addition of oral glucose tolerance test (OGTT) or only operation able to yield an excellent weight
acute insulin response to intravenous glucose loss result maintained for 50 years or more. On
load (AIR), or both, plus frequent controls of the contrary, a 60-year-old patient will be very
serum glucose level. happy with an operation which can give him a
satisfactory 5–6 year long weight reduction, with
good quality of life, resolution of comorbidities,
20.4 Outcomes and no risk of late complications or rehospital-
ization, even if this will be followed by a slow
BPD has many aspects that makes it the opposite weight regain, which can be anyway reasonably
of what could be considered the ideal operation controlled.
for a bariatric surgeon. It requires a very accurate The result is that the majority of bariatric sur-
patient selection, especially as far as compliance geons have BPD in their armamentarium, but
is concerned; it is relatively difficult to perform, they do very few cases, generally obtaining good
even if the laparoscopic approach, at least up to a weight loss results, which are unavoidable if the
BMI of about 50, facilitates some of its technical right technique is used, but never reaching the
steps; it gives origin to a huge number of micronu- experience that is necessary to avoid complica-
trient and vitamin potential deficiencies, requiring tions. The series are small, the follow-up is short,
lifelong supplementation; finally, it is the possible and the overall results not such as to justify a
cause of the most dangerous nutritional complica- clinical publication. We were able to find less
tions in bariatric surgery, that is the hypoalbumin- than 30 published articles on standard BPD, most
emic form of protein-energy malnutrition (PEM), regarding initial experience [33–36], specific
a problem that can be prevented up to near disap- studies in small series, such as diabetes surgery
pearance only at the price of an accurate lifetime [37–39], hormonal research studies [40–44],
surveillance which represents a heavy engage- reports of exceptional complications [45–49], or
ment both for the patient and the person in charge comparisons between standard versus differently
for follow-up, generally the surgeon. modified intestinal limb lengths [50, 51].
On the other side, BPD is the bariatric opera- Moreover, the majority of these publications
tion which yields far the best weight loss results, refer to the operation done in open surgery, so
being able to obtain a satisfactory weight reduc- that, in order to have a minimum of published
tion in the vast majority of the super-obese material to refer to for comparison with our expe-
patients (BMI >50 kg/m) [2], as well as to guar- rience, all the material found was reported in this
antee an indefinite weight maintenance. chapter independently of the open or laparo-
Furthermore, it is the operation with the best scopic adopted technique.
metabolic effects, and the best procedure for con- Therefore, the only way to describe standard
versional surgery, especially when multiple other LBPD outcome is to report results and complica-
operations have failed. tions of our large series of patients, occasionally
Consequently, the bariatric surgeon is not reporting other authors’ data (laparoscopic or
eager to perform BPD, but he is obliged to not) when it is of some clinical interest.
220 N. Scopinaro

20.4.1 Follow-up Rate very long term are well and have satisfactory
weight loss results. The 100 % follow-up rate in
Follow-up rate reflects the outcome of your this group is simply due to the fact they are not so
patients’ population only if a direct contact is many and we are very interested in their results,
established with the near totality of your patients so we call all of them at least once a year, we find
and biochemistry values are obtained for each of them, and they are happy to come to Genoa to get
them. Therefore, even tracking all operated reassured that everything is going well with their
patients every year can result in a poor, and thus “special” operation.
meaningless follow-up rate, due to the patients’ Something similar explains the why of the
mobility, which, in countries like the USA, can excellent 67 % follow-up rate we have with our
prevent all attempts to have a reliable image of laparoscopically operated patients. Especially
your operated patients’ population. One of the those who were operated a relatively long time
many other possible biases is the geographic ago, when the laparoscopic approach was not so
distance and the diffusion of the bariatric sur- common for major surgery, feel their surgical
gery, which can push the patient to find a closer event as something “special,” so they tend to
surgeon to take care of him in case of necessity. come to us much more often than the others, with
Patient’s expectation can also affect the mean- a 67 % follow-up rate at 10 years very similar to
ing of the follow-up rate. If the patient is aware the 61 % at 20 years we had when we called all of
of the high probability of failure to lose weight our very old BPD morbidly obese type 2 diabetic
or of weight regain, in case this happens there is patients. The patients where T2DM was the main
no reason to complain with the surgeon, while if or the only indication to LBPD were all included
good weight loss results were expected the in prospective controlled or randomized con-
patient goes to the surgeon to ask the why of the trolled studies and they have a maximum 6-year
failure. In this perspective a patient with gastric follow-up with 100 % follow-up rate.
banding lost to follow-up is probably a failure,
while the opposite may be true for a BPD
patient. 20.4.2 Case Material and Weight
We call our operation patients up to the third Loss Results
year, assuming then that if they do not show up
this probably means that they are happy with the Our 290 LBPD patients (70 M, mean age
results. Therefore, our poor 20 years follow-up 39 ± 16 years), operated on from April 2000 to
includes both patients with late postoperative June 2014 for morbid obesity, had a mean preop-
problems, generally caused by long-term defi- erative weight of 125.9 ± 13.7, with a mean BMI
ciencies, and those who, as the vast majority of of 45.7 ± 4.4. Mean BMI and % loss of the IEW
them live very far from us (generally in the south- at 1, 3, and 10 years were, respectively, 30.9 ± 3.6
ern Italy), occasionally pass near to Genoa and with 66.0 ± 16,6 % (mean follow-up rate 100 %),
take the occasion to come and visit us, to say 29.8 ± 3.6 with 68.2 ± 15.1 % (93.3 %), and
hello, thank you, and to show how good are their 29.6 ± 4.0 with 68.4 ± 17.4 % (67.3 %).
results. They tell us about their operated friends, The mean reduction of the IEW is slightly
and this, compared with the small number of smaller when compared with that obtained in
patients who contact us for any complaint, can be open surgery (~70 %). This is most probably due
considered as an indirect demonstration that the to the great care taken in order not to provoke any
vast majority of our operated patients do not have intestinal damage when stretching it for measure-
significant long-term problems. ments, resulting in slightly longer alimentary and
An exception is represented by our patients common limb.
operated on because of type 2 diabetes, where we Interestingly, the initial BMI of the 655
have another substantial indirect proof that the (264 M) patients operated on in open surgery
near totality of our many operated patients at after starting the use of laparoscopic approach,
20 Laparoscopic Biliopancreatic Diversion 221

was 52.5 ± 7.3, which is much higher than the case of nonfatal pulmonary embolism. Overall
47 ± 9.2 unselected patients operated on before, operative mortality was 0.3 %.
that is in turn higher than the 45.7 ± 4.4 in the
laparoscopic series.
The improvement of our laparoscopic techni- 20.4.4 Beneficial and Unpleasant
cal skill is indicated by the fact that the mean Side Effects
BMI of our first 50 laparoscopic patients was
42.8, versus the mean BMI of 49.6 of the last 50 The other benefits of BPD in our population at 1,
operated patients. 3, and 10 years, together with the preoperative
In another 52 patients, operated on from May incidence of the condition, are listed in Table 20.1,
2007, the indication was mild obesity (BMI while unpleasant side effects are reported
30–34.9) and type 2 diabetes, with mean BMI together with late complications in Table 20.2.
33.1 ± 2.0. Finally, 47 T2DM nonobese patients Sleep apnea syndrome, Pickwickian syndrome,
(BMI 25–29.9) underwent LBPD from July and somnolence are quickly resolved after standard
2007, with a mean BMI of 27.7 ± 1.9. Those LBPD, as already observed with the open opera-
groups, in a maximum 6-year follow-up stabi- tion. Similarly, hypercholesterolemia early dis-
lized around BMI 27 and 26, respectively. appears and hypertriglyceridemia, though much
reduced, is still present only in a small minority
of cases. Differently, arterial hypertension gradu-
20.4.3 Perioperative Complications ally reduces but, though greatly reduced in all
cases, still exists in a sizeable percent of cases at
Conversion to open surgery was less than 5 %, 10 years, and, as expected due to the chronic dam-
the more frequent causes being hepatomegalia ages in many cases, leg stasis shows an immediate
and anesthetic problems. Early complications disappearance in less than half of cases, and then
were GEA edema (only exceptionally frank improves with time but is only modestly reduced
ulcer) 8 %, always resolved with intravenous PPI or even unchanged in some patients at long term.
administration, rhabdomyolysis (CPK On the contrary, as it is the rule in the morbidly
>1,000 mg/dL) 20 %, treated by massive hydrata- obese patients, type 2 diabetes quickly disappears
tion, without any renal problems, intraperitoneal at short time in the near totality of patients. The use
bleeding 1 %, two cases of GEA leak, and one of LBPD for the treatment of T2DM in nonobese

Table 20.1 Other beneficial effects of BPD

Pre-op. 1 year 3 years 10 years
Follow-up rate (%) 100 93 67
Sleep apnea syndrome (%) 25 0 0 0
Pickwickian syndromea (%) 2 0 0 0
Somnolenceb (%) 8 0 0 0
Hypertensionc (%) 62 13 9 10
Leg stasisd (%) 43 23 17 18
Hypercholesterolemiae (%) 58 1 0.5 1
Hypertiglyceridemiaf (%) 31 4 3 3
Type 2 diabetesg (%) 22 0.3 0.3 1
a
Somnolence with cyanosis, polycythemia, and hypercapnia
b
In absence of one or more features of the Pickwickian syndrome
c
Systolic pressure ≥140 mmHg, diastolic pressure ≥90 mmHg
d
Moderate or severe
e
More than 200 mg/dL
f
More than 150 mg/dL
g
ADA definition
222 N. Scopinaro

Table 20.2 Unpleasant side effects and late complica- were synthetically mentioned above. In reality, all
tions of BPD
bariatric procedures have a beneficial effect on
Pre-op. 1 year 3 years 10 years T2DM, simply because they reduce body fat,
Follow-up rate (%) 100 93 67 which is mainly responsible for insulin resistance.
Anemiaa (%) 0 7 8 14 As BPD is the procedure with the greatest weight
Stomal ulcer (%) 0 6 1 1 reduction effect, this would be already sufficient to
Intestinal 0 1 1 1 make it the most effective among the bariatric
obstruction (%)
operations on glycemic control [52]. However,
Diarrhea (%) 0 1 1 1
Meteorism (%) 0 17 4 1
insulin resistance alone would not be able to cause
Foul smelling 0 6 1 1 diabetes in presence of a healthy beta-cell, which
stools (%) can increase indefinitely its insulin production,
Hb ≤10 mg/dlc
a thus counteracting the resistance caused by any
amount of body fat and maintaining normoglyce-
mia. This is why only about 20 % of the morbidly
patients will be described below. As to the negative obese patients are diabetic. The real problem of
effects of BPD, diarrhea is almost absent already type 2 diabetes is a beta-cell more or less geneti-
by the first year, while a nice surprise is offered by cally damaged, with a limited capacity to increase
the changes in meteorism and foul smelling stools, insulin secretion. When beta-cell becomes unable
which, though being unavoidable consequences to effectively counteract the insulin resistance
of malabsorption, are strongly reduced at 3 years caused to the increasing amount of body fat, dia-
and reported as a problem only in few cases at betes occur, which can be defeated only by increas-
long term, generally due to adaptation of the eat- ing the insulin production capacity of the endocrine
ing habits. On the contrary, again as expectable, all pancreas. Unfortunately, medical therapy has in
problems of iron, calcium, and vitamin deficiencies metformin a powerful weapon against insulin
inexorably increase in incidence with time. resistance, but there are not drugs active on beta-
Preoperative comorbidity is lower, and post- cell function. On the contrary, both gastric bypass
operative comorbidity resolution is better, as it and biliopancreatic diversion have proven to pos-
happens with postoperative unpleasant side- sess a beneficial action on beta-cell, which is
effect severity and long-term reduction, when the mainly based on food stimulation of the ileum to
laparoscopic series is compared with the popula- produce GLP-1, a powerful incretin (gut hormone
tion of patients operated on in open surgery. This able to stimulate insulin secretion by the beta-cell)
is easily explained by the fact that the super- which demonstrated to possess the capacity not
obese patients are generally excluded from lapa- only to increase insulin production [53] even by
roscopic approach. The lower mean BMI in the the genetically damaged beta-cell, but even to
laparoscopic group, since the maximum absorp- increase the beta-cell mass, by stimulating regen-
tion capacity and the consequent weight of stabi- eration [54] and reducing apoptosis [55], all this
lization are more or less the same, causes a lower independently of weight loss. Therefore, while the
degree of malabsorption with all the malabsorp- antidiabetic effect of all bariatric operation gradu-
tion consequences being obviously reduced. ally reduces with reduction of body weight, RYGB
Needless to say, this especially applies to the and BPD exert their weight-independent action
cases where type 2 diabetes is the main or the also in nonobese diabetic patients. It must be said
only indication to LBPD. that, comprehensibly, the lower the initial body
weight the greater the beta-cell damage, with the
ones of the nonobese diabetic patient being so
20.4.5 Metabolic Effects weak that they cannot effectively counteract the
very small insulin resistance produced by the cor-
The two main specific actions of BPD, that on responding minimal amount of fat. Since RYGB 1)
serum cholesterol and that on type 2 diabetes, on one side possesses a smaller capacity of GLP-1
 20 Laparoscopic Biliopancreatic Diversion 223

food stimulation, thus being essentially ineffective long term, especially in the smokers. The preva-
on the very damaged beta-cell of the nonobese lence of marginal ulcer after BPD is certainly
patient, on the other side it could not be employed largely underestimated, due to the prompt use of
in these patients due to the risk of causing severe PPI by the family doctors without endoscopic
underweight. On the contrary, GLP-1 food stimu- diagnosis confirmation.
2) lation is maximal in BPD, where the stomach Supraumbilical incisional hernia is probably
directly empties in the ileum, and, as we saw, BPD also underestimated, having been observed in
can be transformed, by lengthening the CL and the 10 % of cases. Internal hernia was never observed
AL, into an operation which does not cause weight in our series, most likely due to the mesocolic
loss, still maintaining its specific effect on glyce- rent well closed by the fixation to the GEA, and
mic control. In conclusion BPD, far the most to the deep mesenteric incision which prevents
effective antidiabetes bariatric operation [56] is the occurrence of tension in the Petterson space,
today the only weapon we possess to beneficially which is never closed at operation.
act on nonobese diabetic patients. Its effect is An interesting complication were two cases of
smaller than that in the morbidly obese patients, portal vein thrombosis which caused severe small
where, in a large series of 443 preoperatively dia- bowel necrosis starting from the ligament of
betic patients, due to the very good response of an Treitz and ending before the enteroenterostomy,
only slightly damaged beta-cell, 97 % were nor- thus allowing the complete salvage of the opera-
moglycemic at 1 and 10 years, and 91 % at 20 tion by resecting the whole biliopancreatic limb
years, with a very good 61 % follow-up rate [57]; and creating a temporary short jejunostomy, with
the BPD effect is less good in the nonobese patients subsequent reconnection of the BPL to the AL. A
not because its action is reduced, but because the third similar case was immediately and success-
beta-cell response is much weaker. Nonetheless, fully treated with massive heparin therapy and
BPD proven able to obtain at 5 years diabetes did not require operation.
remission (HbA1c ≤6 %) or control (HbA1c
≤7 %) in 60 % of an unselected (mean BMI 28.0,
HbA1c 9.4 %, diabetes duration 14 years, preop- 20.4.7 Deficiencies
erative insulin therapy 60 %) population of 15 dia-
betic nonobese patients, all the other operated Laparoscopic BPD was started when the alimen-
patients having anyway considerably improved. If tary limb had already been lengthened to 250 cm,
we only consider the seven patients in this group which, together with our more than 30 year expe-
with diabetes duration lower than 10 years, the rience, caused the almost disappearance of the
percent of remission plus control goes up to 100 %. most dangerous complication. In fact only two
Interestingly, all but one of those seven patients cases of PEM (one recurrent requiring elonga-
were not on insulin before operation. Similarly, if tion) were observed in our series of LBPD.
we consider the eight patients in the same group On the contrary, as already reported above, all
on preoperative oral therapy, success was obtained problems of iron, calcium, and vitamin deficien-
in seven of them or 88 %. It is then possible to cies progressively increase with time.
obtain excellent results with BPD also in the non- For detailed information of all possible LBPD
obese patients, but only at the price of selecting the macro- and micronutrient deficiencies, compared
lower risk subjects. with other operations, as well as of protein malnu-
trition and its physiology, see Chap. 27 in this book.

20.4.6 Late Complications

20.4.8 Reoperations
Stomal ulcer was observed in up to 6 % of cases.
Its incidence is essentially concentrated in the No conversions to other type of surgery were
first postoperative years but it can occur also at done so far in our laparoscopic BPD series,
224 N. Scopinaro

nor any restoration was necessary. The only Great compliance on one side, and full
reoperation was an elongation of the common availability on the other, will make a lean,
limb which was necessary in a case of recur- healthy, happy, and safe operated subject.
rent hypoalbuminemic form of protein-energy
malnutrition.
References
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43. Garcia-Fuentes E, Garrido-Sanchez L, Garcia- 50. Gracia-Solanas JA, Elia M, Aguilella V, Ramirez JM,
Almeida JM, Garcia-Arnes J, Gallego-Perales JL, Martínez J, Bielsa MA, Martínez M. Metabolic syn-
Rivas-Marin J, Morcillo S, Cardona I, Soriguer drome after bariatric surgery. Results depending on
F. Different effect of laparoscopic Roux-en-Y gas- the technique performed. Obes Surg. 2011;21:179–85.
tric bypass and open biliopancreatic diversion of 51. Frenken M, Cho EY. Metabolic intestinal bypass sur-
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44. Hernández Hernández JR, López-Tomassetti either BPD, BPD-DS, or RYGB. Obes Facts. 2011;4
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J, Morales García D, Núñez Jorge V. Remission of 52. Buchwald H, Avidor Y, Braunwald E, Jensen MD,
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 Laparoscopic Duodenal Switch
21
Antonio Iannelli and Francesco Martini

21.1 Introduction

Duodenal switch (DS)—the modified version of

biliopancreatic diversion (BPD) originally
described by Scopinaro in 1979 [1]—was first
reported in the United States and Canada by Hess
and Hess [2] and by Marceau et al. [3], followed
by Baltasar et al. in Spain [4]. Gagner then intro-
duced the laparoscopic approach in 1999 [5].
This complex bariatric procedure consists of a
vertical gastrectomy with duodenal preservation
(sleeve gastrectomy [SG]), division of the first
portion of the duodenum, and reconnection to the
distal 250 cm of ileum. The bypassed duodenum,
jejunum, and proximal ileum (biliopancreatic
limb) are then reconnected to create a Roux-en-Y
anatomy with a common channel of 100 cm and
an alimentary channel of 150 cm (Fig. 21.1).
The DS is mainly used in super-obese patients
(BMI >50 kg/m2) as it results in an excess weight
loss (EWL) which is far better than what is reported
for other bariatric procedures such as gastric band-
ing (AGB) or gastric bypass (RYGB) [6–9].

A. Iannelli (*) • F. Martini Fig. 21.1 Illustration of the duodenal switch procedure:
Service de Chirurgie Digestive et ttransplantation the operation consists of a sleeve gastrectomy, creation of
hépatique – Hôpital Archet 2, Centre Hospitalo- an alimentary limb approximately of 150 cm and a com-
Universitaire Université de Nice Sophia Antipolis, mon channel length of 100 cm
151 route ST Antoine de Ginestière,
Nice 06202, France
e-mail: [email protected]

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 227
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_21,
© Springer International Publishing Switzerland 2015
228 A. Iannelli and F. Martini

A recent paper by Buchwald and Oien, which the surgical technique and a reduction of postop-
surveyed the International Federation for the erative morbidity [23].
Surgery of Obesity and Metabolic Disorders mem-
ber nations with an 84 % response rate, revealed
that the proportion of DS procedures in relation to 21.2 Surgical Technique
all bariatric surgeries declined from 6.1 % in 2003
to 2.1 % in 2011 [10]. A study by Lazzati et al. 21.2.1 The First Step: The Sleeve
[11], analyzing bariatric surgery trends in France Gastrectomy
from 2005 to 2011, showed a reduction in the pro-
portion of this procedure from 1 to 0.7 %. The patient is placed in the supine position with
The reasons why the procedure with the great- both arms appropriately padded and tucked to the
est weight loss, evidence of lasting effect, and sides. The SG is performed first with a six-port
reversal of obesity-related comorbidities [7, 8] is approach (Fig. 21.2). The greater curvature of the
the least performed worldwide are multiple and stomach is dissected free with the harmonic scal-
complex. Firstly, its technical complexity (espe- pel starting 6 cm proximal to the pylorus up to the
cially using laparoscopy) plays a major role: it is angle of His. Care is taken to dissect the whole
time consuming and requires a skilled surgeon. gastric fundus posteriorly, where the left pillar is
Likely, the learning curve and operative volume carefully identified and dissected free over its
may be important considerations, with a majority anterior aspect. In all cases, the vertical gastrec-
of DS being performed at tertiary specialty cen- tomy is done over a 40 Fr intraluminal boogie
ters [12, 13]. Furthermore, DS is associated with with green or gold staple cartridges. The gastric
an increased operative mortality and an increased antrum is systematically spared, and the last sta-
risk of metabolic complications (protein energy pling is fired 1 cm lateral to the esophagogastric
malnutrition and other nutrient deficiencies) com- junction. Seamguard (Gore-Tex, Flagstaff, AZ)
pared with the other bariatric procedures [14, 15]. to buttress the staple lines is selectively used.
The application of the laparoscopic tech-
nique to DS soon showed that laparoscopy is the
ideal procedure for SG, the restrictive part of the 21.2.2 The Second Step:
DS. Thus, laparoscopic SG has been used to The Duodenal Switch
obtain substantial weight loss in high-risk
patients, before proceeding with either DS or Patient’s position and port placements are the
RYGB [16]. Given the excellent results obtained same as those of the SG (Fig. 21.2). The duode-
in the short term, it was argued that the SG num is divided using a linear stapler with a blue
might work as a stand-alone procedure [17]. SG cartridge 4 cm distal to the pylorus at the level of
rapidly gained enormous consensus among bar- the gastroduodenal artery (Fig. 21.3). The small
iatric surgeons, because of its several advan- bowel is measured with a 50-cm-long tape along
tages compared with laparoscopic RYGB and the unstretched antimesenteric border. It is then
DS [18–21]. divided with the linear stapler 250 cm from the
It has been demonstrated that in the hands of ileocecal valve, and the distal end is anastomosed
experienced surgeons and in high-volume bariat- to the proximal duodenum with an intracorporeal
ric centers, DS can be performed safely as a hand-sewn continuous absorbable suture
single-step procedure [2, 8, 22]. The theoretical (Fig. 21.4). The proximal end of the divided
advantages of performing DS with the staged bowel is anastomosed to the ileum 100 cm from
approach (SG followed by DS) include the oppor- the ileocecal valve to create a 100-cm common
tunity to detect patients who might achieve good channel and a 150-cm alimentary limb. The mes-
results with SG alone, thus avoiding the morbidity enteric and Petersen spaces are closed with non-
linked to the malabsorption; the selection of absorbable running sutures. A leak test (air
patients for the second step who are compliant bubbles and blue dye) is performed at the end of
and attend the follow-up visits; simplification of the procedure.
21 Laparoscopic Duodenal Switch 229

Fig. 21.2 Positioning of the six ports

Fig. 21.3 A dissector is passed behind the duodenal bulb duodenum and guide the introduction of the linear stapler
from top (black circle) to bottom (black line) at the level which is then used to divide the duodenum. CBD common
of the gastroduodenal artery, about 4 cm distal to the bile duct, CHA common hepatic artery
pylorus. A tape is then passed at this level to lift up the

21.3 Results results of the main series of DS published to date

concerning EWL and diabetes resolution [7,
21.3.1 Weight Loss 23–28]. In all these series, except for the one of
Biertho et al. [25] the mean BMI is >50 and the
DS has proven to be successful in achieving and EWL ranges between 66 and 76 %.
maintaining significant weight loss in the super- The systematic review and meta-analysis by
obese population. Table 21.1 shows the long-term Buchwald et al. [7] included 621 studies for a
230 A. Iannelli and F. Martini

Fig. 21.4 (a) A duodenotomy is created on the posterior is created on the antimesenteric border of the jejunal loop. (b)
aspect of the duodenal bulb parallel and close to the staple The duodeno-jejunostomy is fashioned with an intracorpo-
line with monopolar electrocautery hook, then an enterotomy real hand-sewn continuous absorbable suture

Table 21.1 Main series of duodenal switch: long-term results concerning weight loss and diabetes resolution
Mortality Diabetes
No. of Leaks <30 days EWLa resolution
Author, year pts Access BMIa (%) (%) Follow-up (%) (%)
Anthone et al. 701 O 52.8 1 1.4 50 pts at 5 years 66 NR
(2003) [24]
Hess (2005) [26] 1,150 O 50.9 0.7 0.6 148 pts at 10 years 74 98
Marceau et al. 1,356 O 51.5 0.9 1.1 284 pts at 10 years 69 92
(2007) [27]
Buchwald et al. 7,761 7,147 O 50.5 NR NR 1,520 pts at 2 74 96
(2009) [7] 604 L years
Prachand et al. 198 L 58.8 NR 0.5 38 pts at 3 years 69 100
(2010) [28]
Biertho et al. 810 O 44.2 2.1 0.6 8.6 yearsa 76 93
(2010) [25]
Iannelli et al. 140 L 55.1 3.6 0 3 yearsa 73 86
(2013) [23]
pts patients, BMI body mass index, EWL excess weight loss, O laparotomy, L laparoscopy
a
Mean

total of 135,246 patients and compared bariatric percentage of excess BMI loss (EBL) was found to
surgical procedures for weight loss and type 2 be 54.4 % following RYGB compared to 74.8 %
diabetes mellitus (T2DM) resolution. This review following DS. Similarly, Prachand et al. [29] retro-
indicates that BPD/DS is the most effective spectively analyzed 350 super-obese patients who
operation with a EWL of 73 % at 2 years follow- underwent either DS or RYGB. Preoperative BMI
up, followed by RYGB (63 %), vertical banded was significantly greater in the DS group compared
gastroplasty (56 %), and AGB (49 %). to the RYGB group (58.8 kg/m2 versus 56.4 kg/m2,
The only randomized trial comparing DS and P = 0.0014). Percentage of EWL at 36 months was
RYGB, considered by most as the gold standard for significantly greater in the DS group compared to
bariatric procedure, was conducted by Sovik et al. RYGB: 68.9 % versus 54.9 %. The systematic
[14], who randomized 60 super-obese patients review and meta-analysis by Hedberg et al. [9]
(BMI 50–60 kg/m2). One year after surgery including 16 studies and 874 DS patients and 1,149
21 Laparoscopic Duodenal Switch 231

RYGB patients, showed the superiority of DS in resolution of T2DM in all BPD patients 12
terms of weight loss. months after surgery.
Biertho et al. [25] in a series of 810 morbidly In the systematic review and meta-analysis by
obese patients with mean BMI of 44.2 ± 3.6 kg/m2 Hedberg et al. [9], T2DM remission rate after DS
showed an EWL of 76 % that was maintained at was 88 %, compared with 76 % in RYGB patients
8.6 years follow-up concluded that DS was appro- (P = 0.18). The difference was not statistically sig-
priate for non–super-obese patients. Concordantly, nificant because of the low number of patients (112
Anthone et al. [24] in a series including 701 DS DS, 105 RYGB). Glycated hemoglobin levels were
patients with preoperative BMI ranging from 34 significantly lower after DS compared with RYGB.
to 95 kg/m2 found a EWL of 66 % after 5 or more Concordantly with T2DM results, hyperten-
years of follow-up. sion showed marked improvement following
BPD/DS (54–95 % resolution rate), as well as
dyslipidemia (72–100 % resolution rate) [25,
21.3.2 Evolution of Obesity-Related 31–40]. Obstructive sleep apnea was resolved in
Comorbidities 90–100 % of patients [25, 27, 33, 36, 39].

DS has a marked effect on obesity-related meta-

bolic comorbidities, specifically T2DM 21.4 Complications
(Table 21.1). In the main surgical series of DS,
the reported rates of T2DM resolution vary 21.4.1 Perioperative Morbidity
between 86 and 100 % [5, 17–22]. and Mortality
The systematic review and meta-analysis by
Buchwald et al. [7] showed that, at 2 years fol- Buchwald et al. [15], in his meta-analysis of 361
low-up, diabetes remission was by far the great- studies including 85,048 patients reported an
est for patients undergoing BPD/DS (96 %), overall mortality of 0.28 % within 30 days of
followed by RYGB (71 %), and least for pure bariatric surgery. BPD/DS had the highest early
restrictive procedures. mortality with a rate of 0.29–1.23 % for open and
Recently Mingrone et al. [30] conducted a 0–2.7 % for laparoscopic procedures.
randomized controlled trial on 60 morbidly obese The operative mortality for large DS series by
patients with a history of at least 5 years of T2D laparotomy is approximately 1 % with a range of
and a glycated hemoglobin level of 7.0 % or 0.6–1.4 % (Table 21.1) [24–27]. Laparoscopic
more. Patients were randomly assigned to receive approach seems to be associated with a lower mor-
conventional medical therapy (lifestyle modifica- tality, ranging from 0 to 0.5 %, although laparo-
tions and hypoglycemic agents) or undergo either scopic series report a smaller number of patients.
RYGB or BPD. At 2 years, T2D remission Postoperative mortality is most commonly associ-
occurred in 75 % of patients undergoing the ated with pulmonary embolus, respiratory failure,
RYGB versus 95 % of those undergoing the BPD and anastomotic leaks. In the aforementioned series
group (P < 0.001 for both comparisons). None of [23–28] the leak rate varied between 1 and 3.6 %.
the patients in the medical-therapy group showed Biertho et al. [41] analyzed a series of 1,000
remission of T2D. BPD/DS patients, comparing the laparoscopic
The same group [31] conducted a case- (228 cases) and open (772 cases) groups. In this
controlled trial with 10-year follow-up including series they reported only 1 postoperative death
50 patients (28 medical therapy, 22 BPD), which (0.1 %) due to pulmonary embolus in the laparos-
showed resolution of T2DM in all BPD patients copy group. Major complications occurred in
12 months after surgery. The remission was 7 % of the patients, with no significant differ-
definitive because none of the patients experi- ences between the two groups (7 % vs 7.4 %,
enced diabetes again in the course of the study. P = 0.1). No differences were found in the overall
Similarly, Tsoli et al.’s nonrandomized trial [32] leak or intra-abdominal abscess rate (3.5 % vs
including 24 patients (12 BPD, 12 SG) showed 4 %, P = 0.1).
232 A. Iannelli and F. Martini

An important consideration is that BPD/DS is the complete DS procedure. In this series, 72.7 %
the procedure of choice for super-obese patients of super-obese patients achieved 50.8 % EWL after
and it can be argued that surgical risk in this SG at a mean follow-up of 3 years. These results
group is higher at baseline. are in accordance with those reported by Himpens
Flum et al. [42] in the Longitudinal Assessment et al. who recorded a 27 % rate of second-stage DS
of Bariatric Surgery, a prospective multicenter in a series of 41 morbidly obese patients undergo-
observational study, including 4,776 patients, ing SG at a follow-up of >6 years.
analyzed 30-day outcomes after bariatric surgery
and showed that extreme values of BMI were sig-
nificantly associated with increased risk of major 21.4.2 Close Loop Obstruction
adverse outcomes (death; venous thromboembo-
lism; percutaneous, endoscopic, or operative rein- Diversion of the biliopancreatic secretions from
tervention; and length of stay greater than 30 the alimentary stream has a potential for closed
days). Similar conclusion were found by Kim loop obstruction, which may not be diagnosed by
et al. [43], who carried out a retrospective study of common symptoms and signs of bowel obstruc-
54 super-super-obese patients (BMI >60) oper- tion—vomiting may not occur, and air-fluid level
ated on for DS with a laparoscopic approach in 26 on a plain abdominal radiogram may not be pres-
cases and open in 28 cases. Major morbidity ent. Abdominal computed tomography (CT) scan
occurred in 23 % of patients in the laparoscopic in this situation is a study of choice and reveals a
group and in 17 % of patients in the open group dilated, fluid-filled biliopancreatic limb and the
(P = 0.63). There were two deaths in the laparo- distended distal isolated stomach, which can
scopic group (7.6 % mortality) and one death progress to gastric necrosis, perforation, or pan-
(3.5 % mortality) in the open group (P = 0.51). creatitis [44, 45]. This type of obstruction will
However, other investigators showed that the not be decompressed by insertion of the nasogas-
DS can be safely performed in patients with a tric tube and requires urgent laparotomy [45].
BMI > 50 kg/m2 as a single-stage procedure with-
out significantly increasing the mortality [8].
Topart et al. showed that BMI becomes less pre- 21.4.3 Metabolic Related
dictive of complications once the learning curve Complications
for laparoscopic DS is overcome [22].
Iannelli et al. [23] conducted a case-control DS has proven to be more malabsorptive com-
study in order to compare single-stage DS (110 pared to other bariatric surgeries and is therefore
patients) with a staged strategy (110 patients) con- associated with the highest rate of perioperative
sisting in a laparoscopic sleeve SG followed by malnutrition/metabolic related complications. Iron-
laparoscopic DS in selected patients. The authors deficiency anemia, protein calorie malnutrition,
found a trend toward fewer postoperative compli- hypocalcemia, and deficiency of fat soluble vita-
cations in the staged strategy group that did not mins, vitamin B1, vitamin B12, and folate are com-
reach statistical significance on univariate analysis. mon [46]. Aasheim et al. [47] randomized 60
However, single-stage DS was the only variable super-obese patients to receive either RYGB or DS
significantly associated with the risk of postopera- comparing 25-hydroxy vitamin D, vitamin A, and
tive complications on multivariate analysis. vitamin B1 up to 1 year postoperatively. DS patients
Furthermore, six patients (5.5 %) in the single- had lower mean 25-hydroxy vitamin D and vitamin
stage DS group required conversion to open sur- A concentrations, as well as a steeper decline in
gery and none did so in the staged group (P < .05) vitamin B1 compared to RYGB. All patients must
indicating that the staged approach simplifies the begin supplementation postoperatively and a close
surgical procedure. The main advantage of the follow-up is mandatory. However, there is no stan-
staged approach resides in the selection of patients dardized approach to replacement and data on
who do not need the malabsorptive component of patients’ compliance are lacking [48, 49].
21 Laparoscopic Duodenal Switch 233

Here, we discuss two specific complications accompanied by pitting edema at the ankles and
that are usually underemphasized and sometimes represents a serious clinical condition. It requires
life threatening: the protein deficiency syndrome immediate medical treatment with intravenous
and the intestinal bacterial overgrowth syndrome. human albumin, dietary supplements, and diuret-
ics. Severe hypoalbuminemia <25 g/L is life
21.4.3.1 Protein Deficiency Syndrome threatening and requires hospitalization [51–53].
After DS, protein metabolism is compromised When hypoalbuminemia is resistant or recur-
both by decreased absorption and by increased rent, surgical revision is the option of choice [54,
endogenous loss. The capacity to absorb protein 55]. Revision for protein deficiency was neces-
is limited by three mechanisms: the contribution sary in 6 of 1,100 patients (0.5 %) in the series of
of the stomach to protein hydrolysis is decreased, Marceau et al. [27, 50] and consisted of reintro-
the intestinal absorptive surface is reduced, and ducing a segment of the biliary channel into the
the pancreatic enzymatic activity is delayed. alimentary channel, resulting in a lengthening of
Anatomical changes can cause protein loss by both the alimentary and the common channel.
exposing intestinal mucosa to peptic action with- The length chosen varied from 50 to 225 cm
out the buffer protection of bile, by increasing based on the surgeon’s appreciation. Revision
fermentation in the colon and by disrupting intes- was successful in four, and in one other patient, a
tinal flora. second revision was necessary.
Scopinaro et al. [44] measured protein absorp- When revision is not followed by normaliza-
tion and loss after BPD, finding that protein tion of albumin levels, protein loss is most likely
absorption was decreased by 30 %, and endoge- the basic causal mechanism rather than insuffi-
nous fecal loss was increased from a normal 6 g/ cient absorption. Excessive protein loss caused
day in controls to 30 g/day. This means that daily by bacterial overgrowth is then the most probable
dietary protein requirements are doubled after a cause responsible for hypoalbuminemia.
Scopinaro-type BPD, from 40 g/day normally to
90 g/day. This protein intake can be easily met 21.4.3.2 Bacterial Overgrowth
when a patient eats normally, for example, the Syndrome
normal American style diet contains about 100 g/ Bacterial overgrowth remains the most serious
day. However, patients can be susceptible to pro- concern after any type of BPD/DS. There are sev-
tein deficiency when dietary intake is decreased eral factors that may induce changes in intestinal
(dieting), when additional protein loss occurs flora and alter microbial equilibrium in the intes-
(bacterial overgrowth), or when protein require- tinal lumen, resulting in bacterial overgrowth: the
ments increase (infection). absence of bile in a segment of intestine [56, 57],
In the experience of Marceau et al. [27, 50], the shortness of the gut [58], the decreased gas-
the prevalence of albumin deficiency, that is, tric acidity, the dysmotility [59], the protein defi-
level between 32 and 36 g/L, was about 10 % and ciency [59–61], and the presence of undigested
severe deficiency (below 32 g/L) was 2 %. They food reaching the colon. There is no study of bac-
observed a temporary decrease in serum protein 6 terial count after DS compared to normal bowel.
months after surgery when about 20 % of patients However, beneficial effects of antimicrobial
were found to have a level <36 g/L. There was agents serve as indirect evidence that bacterial
then a gradual improvement, and 2 years after the overgrowth has an impact after DS.
operation, protein levels were <36 g/L in only In about 80 % of patients, the only symptoms
6 % of patients. are increased malodorous gas and discomfort,
Mild hypoalbuminemia is usually asymptom- which are well tolerated. Fifteen percent of
atic and must be sought by routine measurements. patients can present also episodes of bloating and
It mandates dietary review and suggestions, pro- diarrhea, which are self-limited and reduced
tein supplements, and monthly follow-up. An while fasting or avoiding certain foods. A trial of
albumin level between 25 and 30 g/L is often metronidazole and/or a probiotic agent for 3–5
234 A. Iannelli and F. Martini

days alleviates these symptoms [62, 63]. If so, 7. Buchwald H, Estok R, Fahrbach K, et al. Weight and
type 2 diabetes after bariatric surgery: systematic
they can be given periodically, usually monthly.
review and meta-analysis. Am J Med. 2009;122(3):
In about 2–3 % of patients, clinical manifesta- 248–56.e5.
tions may include proctitis, nocturnal diarrhea, 8. Buchwald H, Kellogg TA, Leslie DB, et al. Duodenal
and painful abdominal distension with pseudoob- switch operative mortality and morbidity are not
impacted by body mass index. Ann Surg. 2008;248(4):
struction sometimes accompanied by mental con-
541–8.
fusion [64, 65]. This can occur many years after 9. Hedberg J, Sundstrom J, Sundbom M. Duodenal
BPD and requires oral antibiotics. Usually metro- switch versus Roux-en-Y gastric bypass for morbid
nidazole is sufficient, but nonabsorbable antibiot- obesity: systematic review and meta-analysis of
weight results, diabetes resolution and early compli-
ics like neomycin, vancomycin, or aminoglycoside
cations in single-centre comparisons. Obes Rev. 2014;
by mouth may occasionally be necessary. 15:555–63.
In rare cases Crohn’s disease-like a syndrome 10. Buchwald H, Oien DM. Metabolic/bariatric surgery
can be observed, presenting as an acute abdomen worldwide 2011. Obes Surg. 2013;23(4):427–36.
11. Lazzati A, Guy-Lachuer R, Delaunay V, et al. Bariatric
or incomplete intestinal obstruction [66].
surgery trends in France: 2005–2011. Surg Obes Relat
Symptoms include cramps and persistent abdomi- Dis. 2014;10(2):328–34.
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following 1,500 post-BPD/DS patients. In this
clinical trial of laparoscopic gastric bypass versus
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(0.8 %) at mean of 66 (range 20–126) months after Surg. 2010;97(2):160–6.
BPD/DS: 8 after Scopinaro-type BPD and 3 after 15. Buchwald H, Estok R, Fahrbach K, et al. Trends in
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 Revisional Surgery: Gastric
Banding Failure 22
Jacques M. Himpens

22.1 Introduction invariably require a reoperation. Despite the fact

that some authors recommend a rebanding proce-
Up until recently, laparoscopic adjustable gastric dure to address these severe complications [4, 5],
banding (LAGB) was the most popular bariatric there is a general consensus that band ablation
procedure in the world [1]. Hence, nowadays, and conversion to another procedure is preferable
thousands of patients carry an adjustable band. [6]. Another frequent, perhaps less obvious cause
Considering the fact that a great number of indi- of failure for the band procedure is intractable
4
viduals do not experience satisfactory outcomes gastro-esophageal reflux disease (GERD) that
after LAGB, a large pool of patients is seeking may cause respiratory symptoms [7] or may be
for a solution to address this issue. Quite often, accompanied by severe esophageal dysmotility
this solution will consist of an alternate surgical [8]. Finally, some patients experience failure of
procedure. LAGB because of extreme food intolerance [9]. 5
Band deflation is the first treatment of GERD,
esophageal dysmotility, and food intolerance, but
22.2 Common Causes of Band in a number of patients, band deflation will not
Failure and Possible Surgical suffice to cure the disease, or the condition will
Solutions return as soon as the band is reinflated. Actually,
according to most surgeons, the indications for
In a great number of individuals who underwent band salvage procedures are limited to technical
LAGB for weight loss, the band is of a high- material mishaps, such as band-tubing deconnec-
pressure type and was placed by the perigastric tion or local access port problems, including
technique. There is substantial evidence that the membrane leak or displacement hampering per-
combination of this “old type” of band and the by cutaneous adjustment. Considering the above,
now obsolete insertion technique is characterized quite logically, a high incidence of band loss was
by a high incidence of complications [2, 3]. experienced by most authors [6, 10]. Conversely,
Typical complications include pouch dilatation/ O’Brien’s team quite uniquely reported a very
1, 2, 3 band slippage and band erosion, conditions that low incidence of band loss [11]. In our experi-
ence, however, close to 50 % of patients suffered
band ablation within 10 years after LAGB [12].
J.M. Himpens, MD, PhD When removal of the band is deemed necessary
The European School of Laparoscopy,
St Pierre University Hospital, Brussels, Belgium for whatever reason, weight regain will invariably
e-mail: [email protected] occur [12, 13].

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 237
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_22,
© Springer International Publishing Switzerland 2015
 238 J.M. Himpens

In everyday practice, the most frequent indica- REDO ALGORITHM

tion for corrective surgery after LAGB remains RESTRICTIVE
6 poor weight loss or weight regain. A bariatric pro- PROCEDURE
(band, VBG, sleeve)
cedure is considered satisfactory in terms of
weight loss when excess weight loss surpasses
Result but side effects
50 % of the initial excess weight and/or when the No result
(GERD, etc)
residual body mass index (BMI) is under 35 kg/m2
[14], results that the LAGB does not achieve in the Malabsorptive
procedure (DS)
experience of most bariatric surgeons. It is likely (change completely or
Gastric Bypass
that the very weight loss mechanism of LAGB is add component)
to blame for the rather poor outcomes in terms of
weight loss. Despite rare reports questioning the Fig. 22.1 General algorithm for revisional bariatric sur-
strictly restrictive nature of LAGB [15], for most gery for other reasons than surgical complications. VBG
means vertical banded gastroplasty, SG means sleeve gas-
investigators, LAGB primarily is a caloric intake trectomy, GERD means gastro-esophageal reflux disease,
limiting procedure. As such, intestinal hormonal DS duodenal switch
implications such as Ghrelin secretion inhibition
consecutive to the surgical procedure are limited
[16, 17]. The lack of interference with orexogenic construction [21]. Recently, Greve and co-work-
peptides might be the most significant cause of the ers described a technique for performing a RYGB
inferior weight loss of LAGB compared to other while leaving the band in place [22]. We usually
bariatric procedures [18, 19]. prefer not to select this procedure, mainly because
Hence when LAGB does not result in satisfac- of its alleged restrictive character, as well as some
tory weight loss, it appears sensible to search for specific factors that are inherent to the technique,
alternate procedures that imply different weight such as anatomical situation of the stomach and
loss mechanisms. Thus, several alternate bariat- the presence of GERD.
ric procedures may be considered to replace the Anatomical situation of the stomach: We men-
LAGB. These procedures include (but are not tioned above the two typical complications after
limited to) the laproscopic sleeve gastrectomy LAGB, i.e., the band erosion and the band slip-
(LSG), the Roux-en-Y gastric bypass (RYGB), page. The anatomical changes induced by these
the omega-loop gastric bypass (OLGB, also complications may preclude safe accomplish-
called the mini-gastric bypass), and the malab- ment of some procedures. Thus, many surgeons
sorptive procedures such as biliopancreatic diver- will be reluctant to perform LSG after band ero-
sion (BPD) and duodenal switch (DS). In this sion because of the significant danger for leaks in
chapter, we will not mention more experimental an area that is already at stake because of poor
procedures such as the gastric plication, the vascular supply [23].
sleeve gastrectomy with ileal interposition, or the Presence of GERD: Patients who experienced
bipartitioning procedure advocated by Santoro. significant GERD after LAGB should probably
Logically, patients who experienced insuffi- not be converted to LSG because of documented
cient weight loss after LAGB despite an adequate concerns that LSG aggravates GERD on midterm
follow-up, likely will benefit the most from a pro- follow-up [24].
cedure with different mechanism of action
(Fig. 22.1). Hence, most surgeons will elect a
procedure that is less restrictive in nature. The 22.3 Technical Aspects
most commonly chosen procedures are the of Conversion Procedures
RYGB, the OLGB, and the typical malabsorptive After LAGB Failure
procedures DS and BPD. Some surgeons will
adjust the procedure to obtain additional malab- Band erosion (also known as intragastric migra-
sorption, by lengthening the afferent limb in tion of the band) constitutes a specific and pecu-
OLGB [20], or by distalizing the RYGB liar situation. Symptoms of this condition may
 22 Revisional Surgery: Gastric Banding Failure 239

include frank septic symptoms, but more subtle another procedure, as we usually perform it, i.e.,
signs may be present, such as vague abdominal in one stage.
discomfort and loss of restriction experienced by Unlike some, we believe that the conversion
the patient [25]. Once the condition has been procedure should imply a complete dissection of
diagnosed, band retrieval by endoscopic approach the upper pole of the stomach and of the hiatus.
is to be preferred [26]. Alternatively, laparo- Dissection of the hiatus will possibly unveil a slid-
scopic gastrotomy performed at a distance from ing or para-esophageal hernia that must be cured.
the band may be carried out, allowing for band It may also reveal a diastasis of the crurae, a condi-
NB!
removal through the opening in the stomach [27]. tion that may favor the development of an intrame-
This approach avoids the phlegmonous area sur- diastinal migration of the remnant, as experienced
rounding the erosion site and deals with the risk by two of our patients who underwent band abla-
of persisting gastric fistula. tion and conversion to RYGB (unpublished data).
Except for the specific case of band erosion One should, however, be aware of the possible
that precludes immediate conversion, once the hazards involved with the dissection around the
decision has been made to proceed with band hiatus, especially in the presence of substantial
ablation for other indications, the question deformations caused by scar tissue around the
remains if the band removal should be comple- band. One of the most dangerous steps of the dis-
mented by another bariatric procedure at the section pertains to the freeing of the right crus. The
same stage, versus after a lag time. Staged con- vena cava is located in this very area and may be
version to RYGB reportedly is characterized by a obscured by the scar tissue. The essential land-
reduced incidence of anastomotic stricture [28]. mark in the area is the caudate lobe of the liver.
Other sources, however, favor the completion of After severance of the anterior adhesions of the
the corrective procedure concomitantly with the liver to the upper part of the stomach, the bare sur-
band removal [29]. In our department, we prefer face of the stomach, obscuring the band to a cer-
to perform band ablation and conversion to a new tain degree, as well as the phreno-esophageal
bariatric construction in one stage. We believe ligament become visible. Lateral traction of the
that the band constitutes a highly visible land- band tubing allows for dissection of the lateral
mark as well as a handy retraction tool. In fact, edge of the caudate lobe (Fig. 22.2).
we usually leave the band in place until full dis- The thick peritoneal layer overlying the edge
section of the upper pole of the stomach has been of the lobe should be incised sharply, hereby
performed. Conversely, when one decides to opening the angle between the liver and the right
proceed with the delayed approach, it is impor- crus. This angle should not be dissected any fur-
tant to anticipate on possible problems during the ther to avoid lacerating the vena cava. Rather, the
revisional procedure. Hence, the gastrogastric right crus should be adequately located and, again
stitches overlying the band should be severed; to aided by forceful retraction of the band tubing in
avoid the risk of stapling across a double layer of a lateral direction, the peritoneal layer overlying
tissues should one decide to perform a gastric the crus should be incised. This latter maneuver
bypass or LSG as revisional procedure. It is prob- readily reveals the distal esophagus (Fig. 22.3),
ably preferable as well to incise or even to remove which, in turn, will allow safe dissection of the
the pseudo-capsule under the band, because this adhesions overlying the buckle of the band and
may reduce the risk of stenosis after the final pro- the right side of the band. Care must be taken not
cedure, as described some 20 years ago [30]. to damage the left gastric pedicle in this vicinity,
and in case of doubt, this step should be delayed
until later. Dissection should now be directed
22.3.1 Dissection towards the apex of the hiatus and the left crus
of the Adjustable Band should be dissected from anterior going dorsally,
but staying short of the angle of His (Fig. 22.4).
In this paragraph, we will try to highlight the Once the right side of the band has been freed, the
essential steps of band removal and conversion to lateral aspect of the band should be dissected.
240 J.M. Himpens

Fig. 22.2 The upper pole

of the stomach is usually
plastered with the liver.
After freeing the anterior
adhesions, dissection
should be oriented towards
the edge of the caudate
lobe. Opening the space at
the edge of the caudate
lobe opens the way to the
right crus

Caudate Lobe

Fig. 22.3 The peritoneum

overlying the right crus is
incised which allows for
exposing the esophagus.
The presence of the band is
advantageous for forceful
retraction of the upper pole
of the stomach

Right Crus

Starting at the previously dissected area of the one should rather err towards the distal side,
band and going to the left, the gastro-gastric because distal accidental opening of the gastric
bridge overlying the band can now be dealt with, lumen is less of an issue than a proximal perfora-
usually by following the several stitches that had tion. Severance of the gastro-gastric stitches must
been placed to fix the band (Fig. 22.5). Whenever be complete, but sometimes the most lateral por-
the plane between the proximal and the distal part tion is difficult to reach from the right side and
of the gastro-gastric bridge is not readily visible, this step should be deferred until later. Dissection
22 Revisional Surgery: Gastric Banding Failure 241

Fig. 22.4 Forceful

retraction of the band to
the right side of the patient
helps with dissecting the
left crus, while the
esophagus is well visible
and out of harm’s way

LEFT CRUS

Fig. 22.5 Before

attempting to dissect the
angle of His, the stomach
bridge overlying the band
should be incised to reveal
the ventral face of the
band, lateral to the buckle.
The stitches unting the
gastrogastric bridge
constitute an excellent
landmark

thus closes in on the angle of His, which quite root of the left crus, which obviously obscures the
often is the most difficult step. One should be field during a revision. We believe it is advanta-
aware that in an effort to provide additional stabil- geous at this stage to halt the dissection in the
ity when inserting the band, some surgeons place vicinity of the His angle and to resume dissection
a stitch from the stomach distal to the band to the at the interface between spleen and upper fundus.
242 J.M. Himpens

Fig. 22.6 A good strategy

in preparing the dissection
of the His angle is to open
the space between the
fundus of the stomach and
the spleen, which is
achieved by severance of
the uppermost short gastric
vessels. This maneuver
widely opens the lesser
sac. Subsequent ventral
retraction of the fundus
reveals the adhesions
between band and angle of
His, that can now safely be
dealt with

The first few short vessels may now be ligated, perform adequate closure of the crurae. The band
which will create a distance between the lateral should still be present at this stage because it sig-
edge of the fundus and the spleen and give access nificantly helps in a safe and correct hiatoplasty.
to the lesser sac (Fig. 22.6). By retracting the We usually perform a posterior closure and use
freed edge of the fundus anteriorly and from left one or more figure of 8 stitches of polypropylene
to right, the usually untouched posterior aspect of material, buttressed by cellulose pledgets
the stomach becomes readily visible. The thus (Surgicel, Johnson & Johnson) to avoid cutting
created space posterior to the stomach has the through the tissues when the sutures are tied
shape of a pyramid, with the edge of the fundus (Fig. 22.8). After completion of the hiatoplasty,
anteriorly as base, the pancreas posteriorly and the repair should fit snugly around a 34-French
the and spleen edge laterally, while the apex is orogastric tube. With the band completely free,
constituted by the adhesions overlying the poste- and the hiatal repair performed, transection or
rior aspect of the band, with, to the right of this opening of the band can now be carried out. The
area, the left gastric pedicle (Fig. 22.7). The pos- pseudo-capsule caused by the impression of the
terior adhesions overlying the band, including the band should be incised at this time (Fig. 22.9).
ones at the extreme left side may now be safely After removal of the band, the surgeon should
transected. The final dissection of the angle of inspect the freshly dissected upper portion of the
His, substantially facilitated by the complete free- stomach and evaluate the possibilities. Significant
ing of the tissues all around the area, concludes damage to the tissues may thus preclude safe
the preparation for the removal of the band. The stapling or suturing and may lead the surgeon to
fully dissected hiatus should be thoroughly perform a gastric bypass with eso-enteral anasto-
inspected and the surgeon should not hesitate to mosis. Conversely, if local conditions did not
22 Revisional Surgery: Gastric Banding Failure 243

Fig. 22.7 The dissection

of the upper pole of the
stomach, including the
hiatal crurae, is now
complete. Now is the right
time to perform the hiatal
closure, which is carried
out by at least one
posterior figure of 8
stitches, buttressed by
resorbable pledgets

Fig. 22.8 By lifting the

fundus from left to right,
the posterior aspect of the
band is well visible and
can be freed from its last
attachments. The main
trunk of the left gastric
artery (arrows) can be
spotted at the superior edge
of the pancreas, more often
than not in very close
vicinity of the band

allow thorough dissection of the band before (seldom) an LSG. For either technique, we are
removing it, it may be wise to abandon the efforts concerned about possible damage to the main
to obtain a small pouch and to prefer the option of trunk of the left gastric artery. This is why during
performing a BPD. Usually, however, integrity of the preparation of a gastric bypass or a LSG, we
the tissues is satisfactory and will permit the limit the dissection at the lesser curvature to a strict
planned procedure, i.e., either a gastric bypass or minimum and will focus on the greater curvature.
244 J.M. Himpens

Fig. 22.9 The band has

been removed. The
underlying pseudo-capsule
should be resected or
transected (as shown here)
to avoid subsequent
stenosis

22.3.2 Transection of the Stomach and more distally for the latter. In all cases,
however, the dissection of the lesser curvature
Over the years, we have gathered experience with is initiated posteriorly, distally to the previous
over 500 band removals and conversions to band placement, where tissues are supple and
RYGB (or, seldom, OLGB and LSG). We have tissue distortion minimal. By lifting the stom-
tried to standardize the technique and to develop ach anteriorly, the tissues at the lesser
a strategy that would be similar for whatever con- curvature are placed under traction and the
struction. The strategy implies the resection of space between the vessels and the stomach
the upper part of the fundus, even in case of itself can safely be dissected by the coagulat-
gastric bypass. This maneuver has the advantage ing hook or by the harmonic scissors, until the
of diminishing the risk of gastro-gastric fistula tip of the dissecting tool emerges on the ven-
formation in revisional procedures [31] and to tral aspect of the edge of the lesser curvature.
interfere with the production of Ghrelin, which in The thus created opening in the peritoneal
turn may improve weight loss [32]. sheet constitutes the aim for the linear stapler
We previously described that the uppermost when it transversally transects the stomach.
short gastric vessels are routinely sacrificed dur- Transection is performed from left to right,
ing the freeing of the band. With this technique, approximately at a right angle with the long
the lesser sac is widely opened, which gives free axis of the stomach (Fig. 22.10). Thanks to the
access to the posterior surface of the stomach. dissection performed at the lesser curvature,
• When the foreseen procedure is a gastric lesion to the main arterial trunk should be
bypass, the lesser curvature can now be avoided and bleeding kept minimal.
approached posteriorly. The level of dissec- After complete transverse transection of the
tion will depend on the type of bypass, i.e., stomach, the entire lateral proximal part of the
RYGB versus OLGB, and be performed rather stomach (i.e., the fundus) is forcefully pulled lat-
close to the band impression for the former erally and a 34-French orogastric tube is advanced
22 Revisional Surgery: Gastric Banding Failure 245

Fig. 22.10 The stomach

is now transected from left
to right, hereby avoiding
dissection of the lesser
curvature, that may be
distorted by adhesions. The
vessels at the lesser
curvature are dissected
from posterior, in the lesser
sac that usually has
remained untouched

by the anesthesiologist and is maneuvered close Here as well a transverse transection, perpen-
to the lesser curvature until it hits the transverse dicular on the long axis of the stomach is per-
staple line. This maneuver is essential to obtain a formed by application of a linear stapler, but
narrow gastric tube, and may prove difficult, espe- transection obviously remains incomplete to
cially in the presence of a dilated pouch. However, maintain a lumen that easily accommodates a
because of the thoroughness of dissection prior to 34-French intraluminal orogastric tube. Correct
removal of the band, it should be possible to place positioning of the large bore tube can be obtained
a grasper from the left upper quadrant trocar pos- as explained above for the bypass. Vertical sta-
terior to the stomach, and, keeping it close to the pling is performed as usual, care being taken not
lesser curvature, advance it to the root of the left to make the tube too wide and avoiding a cork-
crus, which will facilitate the correct placement of screw deformity, which can be prevented by
the large bore tube. With the 34-French tube in maintaining consistent outward traction on the
place, vertical stapling can be carried out, again greater curvature side of the stomach.
while exerting adequate outward traction on the
fundus to avoid making the gastric pouch too
wide (Fig. 22.11). After complete transection of 22.4 Outcomes of Conversion
the stomach, as described, the fundic part has Procedures After Band
been entirely isolated and should now be removed, Ablation
care being taken to sever all possible remaining
attachments. After extraction of the isolated fun- There is a general consensus that revisional sur-
dus, the proximal gastric pouch should be gery after adjustable band is sentenced by a higher
inspected. If it is deemed too long (as for RYGB) incidence of complications. It appears, however,
it can now safely be trimmed to an appropriate that revisional surgery after LAGB, is character-
size before performing a gastro-enterostomy. ized by fewer complications than after other
• When the corrective procedure is an LSG, the bariatric operations [33]. Nevertheless, in a popu-
window at the greater curvature is widened in a lation-based analysis covering 3,132 patients
caudal direction, until the antral area is reached. treated by band removal and conversion to RYGB,
246 J.M. Himpens

Fig. 22.11 After

complete transverse
transection of the stomach,
at a distance from the band
impression, a large bore
orogastric tube is advanced
by the anesthesiologist,
while the fundus is being
retracted by posterior and
outward retraction with the
assistant’s grasper. This is
an important step that may
be time consuming
especially when the fundus
is very large, as in case of
pouch dilation

Womi et al. [34] found a significantly higher inci- than after LSG. In our experience [38, 39], con-
dence of preoperative and postoperative compli- version of LAGB to LSG appeared to be safe, but
cations compared to primary gastric bypass additional weight loss was modest, which unfa-
(63,171 patients). In a retrospective study pertain- vorably compares with RYGB. Consequently, in
ing to 108 patients treated by RYGB for band fail- our department conversion of LAGB to LSG is
ure [35], our group recorded a significantly higher merely considered a first step to the completion
(22.2 %) incidence of early complications, versus of a DS [40].
10.2 % in a group of 362 patients treated by pri- Considering that LAGB is a purely restrictive
mary RYGB in the same time period. In addition, procedure, in case of poor weight loss, conversion
late complications occurred in 30.6 % of the to a malabsorptive procedure seems logical, at least
patients in the revisional gastric bypass group, theoretically. Initially it was thought that “The
which was significantly higher than in the primary BPD/DS, as opposed to the Roux-en-Y gastric
bypass group (12.7 %). Interestingly, we found no bypass (RYGB), is well suited for LASGB revi-
difference in terms of weight loss between the pri- sion, as its proximal anastomosis is at the duode-
mary and the revisional gastric bypass [35]. num, away from the gastric band scar tissue” [41].
Similarly, Hii et al. [36] found a good weight loss The technique of conversion of LAGB to LDS
after conversion of LAGB into LRYGB, but their was fine-tuned by its pioneer, Michel Gagner
study confirmed a high incidence of severe com- [42]. The initial indication for conversion to
plications linked with the procedure (13.4 % of BPD/BPDDS was recurrent band slippage [43].
major complications). Lack of success was described in over 10 % of
Concerning the conversion of LAGB to LSG, the cases [44], but some authors claim better
according to some, revisional LSG is character- results for conversion of LAGB to BPD than to
ized by a higher incidence of major complica- RYGB [45]
tions (including mortality) than revisional RYGB
[29]. In a review article, Coblijn et al. [37] found
a significantly higher leak rate for LSG compared 22.5 Patient Education
to primary LSG (5.6 % versus 0.35–2.40 %),
which was substantially higher than the leak inci- An important element for success of a corrective
dence in LRYGB (0.9 %). In addition, in this procedure after LAGB is to influence eating
study, weight-loss figures were better after RYGB behavior and overall life hygiene of the patient.
22 Revisional Surgery: Gastric Banding Failure 247

Especially in cases where the band procedure has feasible, but there is a general consensus that
failed despite adequate follow-up and despite the the conversion procedure is characterized by a
absence of surgical complications, poor weight rather high complication rate. In terms of
loss is quite often due to the development of poor weight loss, however, most corrective proce-
eating habits on the patient’s side, usually sweet dures prove more effective than the LAGB.
eating. It is obviously utopical to think that the
simple fact of changing the anatomical situation
should automatically condition the patient’s eat-
ing behavior differently. There is evidence that References
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 Revisional or Conversion
Procedures for Roux-en-Y Gastric 23
Bypass Failure

Luigi Angrisani, Antonella Santonicola,

Giampaolo Formisano, Ariola Hasani,
and Michele Lorenzo

Surgery for morbid obesity has been carried out the primary bariatric procedure without changes
since 1950s, but only after the introduction of of its anatomical scheme.
biliopancreatic diversion by Scopinaro the surgi- Inadequate weight loss, according to Reynhold
cal approach gain worldwide consensus and criteria, is considered if %EWL remains <25 %
diffusion [1, 2]. During the years, gastric restric- [12]. According to body mass index Maclean
tive, malabsorptive or combined procedures were defines failures or poor results of those patients
introduced in the bariatric surgical praxis [3, 4]. with BMI <30 kg/m [2, 13]. Success can be also
Several experiences reported risk and benefit of defined as a resolution of comorbidities and/or
each procedure, and the even increasing number improvement of quality of life.
of operated patients run parallel with a similar Roux-en-Y gastric bypass was considered by
increase of re-do operations [5, 6]. Re-do bariat- many authors not only as the primary bariatric
ric surgical procedures are mainly indicated for procedure of choice, but also as the re-do proce-
two reasons. The first reason is the presence of an dure to prefer after unsuccessful restrictive pro-
acute or chronic complication or a side effect of cedure [14–16]. Unfortunately, the bypass can
the primary bariatric procedure or metabolic and also result in an acute or chronic failure needing
nutritional sequel. The second is the absence of a re-do procedure (Table 23.1). As regarding the
postoperative weight loss or the weight regain weight loss, Fobi after 10 years of follow up
after a successful period, untreatable with conser- reported 20 % of weight loss failure [17]. Power
vative approach [7–11]. Re-do bariatric proce- reported 30 % of failure in super-obese patients
dures can be divided into conversions and [18]. These data were also confirmed by other
revisions. Conversion surgery is defined as the experiences with a weight loss failure between 10
exchange of a bariatric procedure to another one. and 20 % after 2–3 years of follow up [19, 20].
Revision surgery is defined as the modification of The Roux-en-Y gastric bypass produces its
effects with both restriction and malabsorption.
To understand the weight loss failure or
L. Angrisani, MD (*) • A. Santonicola, MD
Table 23.1 Causes of chronic failure of Roux-en-Y
G. Formisano, MD • A. Hasani, MD
gastric bypass
M. Lorenzo, MD, PhD
UOC Chirurgia Generale, Laparoscopica e Gastro-jejunal stricture
d’Urgenza, Ospedale “S.Giovanni Bosco” ASL Marginal ulcer
Napoli 1 centro, Naples, Italy Excessive weight loss (severe malnutrition)
e-mail: [email protected];
Absence of weight loss or weight regain
[email protected]

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 251
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_23,
© Springer International Publishing Switzerland 2015
 252 L. Angrisani et al.

Table 23.2 Roux-en-Y gastric bypass weight loss fail- tract increases in thickness with a corresponding
ure: therapeutic options
increase in the length of gastrointestinal villae.
Restrictive procedures Re-do surgery for Roux-en-Y gastric bypass
Endoscopy was considered a challenge in the field of bariatric
Gastro-entero anastomosis suture surgery, with high risk of complication rate and
Sealants injection patients discomfort. Recently, many authors have
Internal plication (mucosal or full thickness)
reported several endoscopic or laparoscopic bar-
Laparoscopy
iatric options, above all for the problem of weight
Nonadjustable ring positioning
regain or absence of weight loss (Table 23.2).
Adjustable band positioning
Pouch resection/Fundectomy
External plication
Malabsorptive procedures 23.1 Restrictive Procedures
BPD –DS
Length limb modification 23.1.1 Endoscopic Procedures

Endoscopic option for weight recidivism linked

recidivism, it has been postulated that the loss of to dilated gastro-jejunal anastomosis has been
the restriction is in relationship with the enlarge- suggested in several experiences to be safe with
ment of the gastric pouch, or the gastro-jejunos- minimal morbidity. Catalano et al. showed that
1, 2, 3
tomy, or both [21, 22]. Honeghan et al. in a the injection of sclerotic agents to reduce the size
multivariate analysis identified stomal dilation as of gastro-jejunal anastomosis result in weight
independently associated with weight recidivism. loss after weight regain [25]. Thompson et al.
The stoma dilation can be functionally linked to a showed that endoscopic suturing was also safe
greater quantity of food being needed to distend and feasible to reduce the gastrointestinal anasto-
the gastric pouch, causing the sensation of sati- mosis to an average of 10 mm, leading to weight
ety. It has been reported to occur as early as 6 loss in 75 % of RYGBP patients and resulting in
months from gastric bypass. Obviously, the pri- loss of 23.4 % of EBWL [23]. Recently, a viable
mary pouch dilation has the same effects on endoscopic alternative to reduce the pouch vol-
satiety. Moreover, Yimcharoen et al. demon- ume was proposed, with mucosal or total wall
strated that an enlarged gastric pouch was plication, reshaping the pouch with dedicated
observed in almost one-third of RYGB operated instruments [1, 23]. Eid et al. have reported a ran-
patients with weight regain. domized clinical trial comparing multiple full-
Another reason of weight regain in gastric thickness plications to sham endoscopy procedure
4 bypass is the presence of a gastro-gastric fistula. after weight loss failure of RYGB [26]. They sus-
This is an abnormal communication between the pended the trial prematurely because preliminary
excluded stomach and the gastric pouch. It is a results indicated the failure to achieve the pri-
rare complication (1.5–6 %) [23]. The gastro- mary efficacy end point at last in 50 % of patients
gastric fistula is responsible of weight regain for treated with plication.
the loss of both of restrictive and malabsorptive
pathway [23, 24]. In fact by the fistula the food
not passing through the stoma and bypassed 23.1.2 Laparoscopic Procedure
intestine, causing weight regain. One of most
important reasons to weight loss failure is intesti- Parikh et al. suggest resecting the pouch and ali-
nal adaptation. Scopinaro, while describing the mentary loop in a longitudinal fashion. But this
malabsorptive properties of the biliopancreatic procedure was not considered safe and effective
diversion, say that the massive intestinal adapta- enough [27]. Hamdi et al. also suggest resizing
tion phenomenon causes an increased absorptive the gastric pouch by resection and recreating the
5
surface. Between the gastro-entero anastomosis gastrojejunostomy. Perioperaitive complication
and the jejuno-jejunal anastomosis the intestinal rate was 8 % [28]. After 24 months of follow up
23 Revisional or Conversion Procedures for Roux-en-Y Gastric Bypass Failure 253

they observed 44 % of %EWL. They conclude despite these studies, long-term results on a large
that this re-do procedure can be performed with patient population who underwent pouch band-
significant weight loss, but additional studies are ing are scarce, waiting for an evidence-based
requested [28]. Gumbs et al., in case of tissue suf- confirmation.
fering from previous scars or fistulas or postop-
erative leak, suggest an external plication
mimicking the longitudinal resection suggested 23.2 Malabsorptive Procedures
by Parikh, and inspired by the gastric plication
technique [1]. This plication was performed with Parikh et al. have suggested a conversion proce-
nonabsorbable stitches across a 34 French oro- dure to duodenal switch in cases of weight loss
gastric tube. This revisional option was safe and failure after Roux-en-Y gastric bypass [33]. This
attractive in terms of safety, but long-term results procedure was initially reported on 13 patients
of these techniques are not reported. and was performed in two steps. The first step is
Another laparoscopic option to treat the pouch the conversion of gastric bypass to sleeve
enlargement is the positioning of an external ring. gastrectomy after gastro-jejunal anastomosis
Essentially two options have been described. removal and the reconnection of the gastric pouch
Fobi showed that the addition of ring proximally to the stomach remnant. The second step was to
to the gastrointestinal anastomosis is enough to complete the duodenal switch several months
reduce the food ingestion [29]. More recently after the sleeve. In this series, mortality, leaks,
were described some patients with an adjustable and malabsorptive problems were not observed.
gastric banding positioned around the upper part Four patients developed a stenosis of gastro-
of the gastric pouch. Chin et al. described their gastric stricture resolved by endoscopy in three
experience with ten patients who underwent revi- cases. Authors conclude on the bases of their
sional surgery positioning an adjustable gastric early results that the conversion of failed RYGB
banding around the RYGB pouch [30]. After 2 in DS in expert hands is a valid therapeutic option
years of follow up the %EWL was 48.7 % (range with 63 % of %EWL and BMI loss of 11 kg/m2.
21.8–98.1 %) without life threatening complica- The complication rate was acceptable, but the
tions. Bessler et al. reported their experience with number of operated patients was too small and
27 patients who underwent RYGB revision with the follow-up too short. Himpens suggested a
adjustable gastric band [31]. At 60 months of fol- slight modification of this approach to make the
low up they observed 47 % of %EWL; also, in procedure more safer, with a first stage involving
this report life threatening complications were reversal to normal anatomy, followed after 3
absent and two port-related complications and months by a sleeve gastrectomy, and then a
one band slippage were recorded. They conclude duodenal switch after 9 months from the first
that the addiction of the adjustable silicone gas- stage [34].
tric banding causes significant weight loss in An alternative considered is to switch the
patients with weight recidivism or poor weight RYGB in a distal RYGB, with a higher malab-
loss after RYGB. The absence of anastomosis or sorptive power. This option was considered
changes in limbs length makes this revisional uneventful by some authors, dangerous by other.
option safe and attractive. Recently, Vijgen
reported a review of the studies on the effects of
salvage pouch banding after failed RYGB [32]. 23.3 Causes of Gastric Bypass
In their review were included patients with both Revision or Conversion Not
adjustable and non-adjustable gastric banding Related to Weight Loss
operated via laparotomy or laparoscopy. In the
seven studies considered, all the authors support The most common indication for conversion
the opinion that the adjustable gastric banding or revision of Roux-en-Y gastric bypass is
around the pouch is a safe and feasible revisional gatrointestinal anastomosis stricture and mar-
procedure after failed RYGB [32]. Moreover, ginal ulcers [35–37]. The rate of incidence
254 L. Angrisani et al.

of gastro-jejunal stricture has been reported 3. Mognol P, Chosidow D, Marmuse JP. Laparoscopic
sleeve gastrectomy (LSG): review of a new bariat-
with a wide range: 4–36 %. In these cases the
ric procedure and initial results. Surg Technol Int.
endoscopic dilation was safe and effective in 2006;15:47–52.
80–90 % of cases with low complication rate 4. Angrisani L, Furbetta F, Doldi SB, et al. Lap Band® –
(perforation). In negative therapeutic results, a Adjustable Gastric Banding System. The Italian expe-
rience with 1863 patients operated on 6 years. Surg
more invasive approach was indicated as in mar-
Endosc. 2003;17:409–12.
ginal ulcers. The incidence of marginal ulcer 5. Lim CS, Liew V, Talbot ML, et al. Revisional bariatric
after RYGP is 1–16 %. This complication was surgery. Obes Surg. 2009;19:827–32.
linked to several factors such as eroded suture, 6. Karmali S, Brar B, Shi X, Sharma AM, de Gara C,
Birch DW. Weight recidivism post-bariatric surgery: a
drugs (NSAID), smoking, Helicobacter pylori
systematic review. Obes Surg. 2013;23:1922–33.
infection, and acid exposure (gastro-gastric 7. Elnahas A, Graybiel K, Farboukhyar F, Gmora
fistula). The treatment of these complications S, Anvari M, et al. Revisional surgery after failed
is medical by removal of all risk factors with laparoscopic adjustable gastric banding: a systematic
review. Surg Endosc. 2013;27:740–5.
administration of proton pump inhibitors and/
8. Robert M, Poncet G, Boulez J, Mion F, Espalieu P.
or other drugs. In patients refractory to medical Laparoscopic gastric bypass for failure of adjustable
therapy or preventive measures or endoscopic gastric banding: a review of 85 cases. Obes Surg.
attempts, a re-do was suggested to avoid serious 2011;21:1513–9.
9. Victorzon M. Revisional bariatric surgery by
complication such as perforation or bleeding. In
conversion to gastric bypass or sleeve. Good short term
these cases, the resection of primary gastro-jeju- outcomes at high risks. Obes Surg. 2012;22:29–33.
nal anastomosis re-doing a new communication 10. Coblijn UK, Verveld CJ, van Nagensveld BA, Lagarde
was suggested with safe results. SM. Laparoscopic Roux-en-Y Gastric Bypass or
Laparoscopic Sleeve gastrectomy as revisional pro-
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Conclusion review. Obes Surg. 2013;23:1899–914.
The Roux-en-Y gastric bypass is considered 11. Angrisani L, Borrelli V, Lorenzo M, et al. Conversion
one of the bariatric approach of choice both in of LapBand to Gastric bypass for dilated gastric
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12. Reinhold RB. Critical analysis of long term weight
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the past, the conversion or the revision of gas- 13. MacLean LD, Rhodes BM, Nohr CW. Late outcome
of isolated gastric bypass. Ann Surg. 2000;231:524–8.
tric bypass was considered a surgical chal-
14. Schouten R, Japink F, Meesters B, et al. Systematic
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15. Angrisani L, Lorenzo M, Santoro T, Nicodemi O,
acceptable rate. Both restrictive and malab-
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different success rates in terms of weight loss. 1999;9:58–62.
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 Revisional Surgery: Biliopancreatic
Diversion Failure 24
Valerio Ceriani, Ferdinando Pinna, Tiziana Lodi,
and Paolo Gaffuri

24.1 Characteristics and Results super-obese and satisfying quality of life (QoL) [2].
of Classic Biliopancreatic In a recent meta-analysis, Buchwald reported the
Diversion as Proposed by disappearance of T2 diabetes in 98.9 % of patients
Scopinaro and of hyper-lipidaemia in 99.1 % of patients, fol-
lowing BPD. However, some studies included in the
Biliopancreatic diversion (BPD), as proposed by meta-analysis used the so-called duodenal switch
Scopinaro, is a malabsorptive procedure for the variant, instead of the classic BPD [3].
treatment of morbid obesity, which has shown excel- The procedure initially described by Scopinaro
lent results in terms of percentage excess weight loss consists of two third of distal gastrectomy with a
(EWL) and improvement of co-morbidities. 200–500 ml gastric stump draining into a long-
In the Scopinaro’s series, BPD yielded the fol- limb Roux–en-Y ileal conduit, 250 cm long. The
lowing EWL: 74 %, 75 % and 78 % at 2 years, 4 biliopancreatic limb is anastomosed to the ali-
and 12 years, respectively [1]. In addition, com- mentary limb, 50 cm proximally to the ileo-cecal
plete disappearance of type 2 (T2) diabetes and valve, leaving a short common channel and
hyper-cholesterolemia was observed in 100 % of excluding both duodenum and jejunum from the
the patients [1]. alimentary transit (Fig. 24.1) [4].
Similar results have been confirmed by other After BPD, the first phase of rapid weight loss
authors. Guedea reported 70 % EWL at 5 years, occurs, lasting between several months to 1 year,
with similar results in the morbid obese and mainly due to the reduced alimentary intake
caused by the distal gastrectomy, and the post-
feeding syndrome, owing to the interaction of the
ingested material with the distal ileum. The long-
term weight loss is then maintained by the malab-
sorptive effect of the Roux-en-Y limb.
V. Ceriani • T. Lodi • P. Gaffuri
Department of General Surgery, IRCCS Multimedica,
Via Milanese 300, Sesto San Giovanni,
Milan 20099, Italy 24.2 Type and Incidence of Post-
e-mail: [email protected]; operative Complications
[email protected]
F. Pinna (*) BPD is a safe operation, with low post-operative
Second General Surgery, Ospedale San Giuseppe,
Via San Vittore 12, Milano 20123, Italy morbidity and mortality [5]. Nevertheless,
e-mail: [email protected] chronic malabsorption which is crucial for the

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 257
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_24,
© Springer International Publishing Switzerland 2015
258 V. Ceriani et al.

Guedea reported protein malnutrition in 10 %

of 74 patients, who underwent BPD and who had
a 5-year-follow-up [2]. In a recent series of 287
patients with classical BPD, severe hypoprotein-
250-500 ml emia was observed in 1.7% of patients at year 1
[7].
According to Scopinaro, protein malnutrition
can be reduced to 1 %, with a recurrence rate of
0.5 %, by correctly balancing the volume of the
gastric pouch and the length of the alimentary
limb in accordance with the patients’ alimentary
habits and the desired EWL% [8].
200 cm

24.2.2 Chronic Anaemia

Distal gastrectomy and the exclusion of the

duodenum and proximal jejunum impair
50 cm absorption of iron and folates, facilitating
chronic anaemia. Whereas macrocytic anae-
mia, due to vitamin B12 deficiency, is rarely
seen, if adequate supplementation is provided,
iron-deficiency–related microcytic anaemia
Bilio-pancreatic limb can be observed more frequently, namely in the
presence of chronic bleeding. In particular, fer-
Fig. 24.1 Biliopancreatic diversion as described by
tile women are at high risk of developing iron-
Nicola Scopinaro
deficiency anaemia after BPD. Guedea et al., in
a 5-year follow-up study, showed post-opera-
tive anaemia in 59.5 % of fertile women;
therapeutic effects can be responsible for some despite oral nutritional integrations [2]. The
negative side effects. incidence of iron-deficiency anaemia after
BPD can be reduced to 5 % using adequate
iron and folate integration [1].
24.2.1 Protein Malnutrition

This condition represents the most severe side 24.2.3 Secondary

effect of BPD. Its patophysiology is linked to sev- Hyperparathyroidism
eral aspects of the intevention: the gastric volume
affects the amount of food, and then proteins that An association between morbid obesity and sec-
can be assumed, while the length of the alimentary ondary hyperparathyroidism is well documented,
limb conditions the amount of small bowel suitable as elevated levels of parathyroid hormone (PTH)
for proteic absorbption. Moreover, after BPD, there and 1,25-OH vitamin D, together with reduced
is an increased loss of endogenous nitrogen [1, 6], levels of 25-OH Vitamin D, have been observed
requiring a higher intake of dietary proteins. Severe in up to 50 % of patients before the operation [9].
hypo-proteinemia may result, owing to an improper Hamoui observed a correlation between PTH
nutritional regime. levels and BMI in obese patients [10]. After
The incidence of protein malnutrition is higher BPD, altered absorption of calcium can be
in the first two years after the intervention, and responsible for hypo-calcemia and further eleva-
reduces thereafter. tion of PTH levels, even after appropriate
24 Revisional Surgery: Biliopancreatic Diversion Failure 259

supplementation of vitamin D [11]. As a conse- 24.3 Indications to Surgical

quence, increased bone reabsorption, bone Revision
demineralization, osteoporosis and osteomalacia
may occur [12]. Scopinaro showed histopatho- A variable rate of surgical revisions has been
logical bone demineralization in one third of required in the long term after BPD. Surgical
patients after BPD, mainly during the first 4 revision may include remodelling of the length of
years post-operatively [8]. the bowel limb, bowel continuity restoration or
High post-operative levels of markers of surgical revisions of the gastro-enteric-
bone turnover, and decreased bone-density anastomosis (GEA). In addition to GEA revision,
were observed 1 year after BPD (a peculiar due to stenosis or marginal peptic ulcers, bowel
variant), irrespective of high doses of calcium remodelling is sometimes required to treat side
integration, and in the absence of secondary effects of chronic malabsorption, insufficient
hyperparathyroidism. weight loss or weight regain, whereas restoration
Decreased bone mass was considered an of the small bowel continuity can be the final
adaptive phenomenon of the skeleton, second- option for severe relapsing protein malnutrition.
ary to decreased mechanical load after bariatric In the experience of Scopinaro, 6.3 % of patients
surgery [13]. required surgical revision after a 19-year-follow-
After BPD with duodenal switch, in a up [8], whereas in a series comparing BPD with
10-year-follow-up study, Marceau observed duodenal switch, Marceau reported that 18.5 %
bone fractures in 17 % of patients with classic of 248 BPD patients had surgical revision during
BPD [14]. However, recent studies seem to a 10-year-follow-up study [14]. However, the
exclude an increased risk of bone demineraliza- need to restore the continuity of the small bowel
tion, osteoporosis and bone fracture after bar- was comparable in the two series (2 % and 2.7 %,
iatric surgery, in comparison with a healthy respectively).
population [15, 16], thus leaving some uncer- Relapsing protein malnutrition is the most fre-
tainty concerning the clinical significance of quent reason for surgical revision. The first step
secondary hyperparathyroidism and calcium of the treatment must aim at restoring an adequate
metabolism after BPD. nutritional status before surgery, usually using
parenteral nutrition.
For a proper planning of surgery, a thorough
24.2.4 Proctologic Sequelae clinical and nutritional evaluation must be used
to detect whether chronic malabsorption is attrib-
Altered composition of faeces (lower pH in com- utable to insufficient intestinal absorption of pro-
parison to healthy people), together with teins or to insufficient nutritional intake. On a
increased frequency of bowel movements per day clinical basis, the presence of diarrhoea and the
after BPD, account for the occurrence in some overall food intake must be evaluated.
patients of proctologic disorders, such as anal fis- Diarrhoea usually means a reduced toler-
sure, prolapsing haemorrhoids, perianal abscesses ance towards the malabsorptive component of
and fistulas. the BPD.
After the implementation of adaptive mecha- In this case, in the presence of adequate daily
nisms, the incidences of these conditions tend to food intake, elongation of the common channel at
decrease over time. Nevertheless, their persis- the expense of the biliary limb could be the treat-1)
tence may severely impair the QoL and, together ment of choice.
with the “foul smell” of stools, which is charac- In the absence of diarrhoea, elongation of the
teristic of subjects with BPD, may significantly alimentary channel, moving the common channel
2)
affect the patient’s social life. proximally along the biliary limb, can provide a
 260 V. Ceriani et al.

longer ileal tract improving protein absorption, If weight regain occurs, but no wrong alimen-
without affecting the fat-related malabsorption. tary habit can be documented, and no significant
In the absence of adequate oral nutrition, the res- side effect of chronic malabsorption is clinically 5)
3) toration of the small bowel continuity should be evident, the shortening of the common channel to
considered. increase malabsorption could be the correct solu-
Among the other side effects of chronic mal- tion. Conversely, the possibility of reducing the
absorption, proctologic sequelae and chronic gastric pouch, in order to increase the restrictive
diarrhoea, in addition to “foul-smelling” stools, component, requires a word of caution, because
these can be improved by an elongation of the of the risk of insufficient protein intake.
common channel, moving proximally the biliary
4) limb along the alimentary one. In this case,
possible weight regain must be anticipated. 24.4 Physiopathological Basis
Other conditions, such as iron-deficiency of Limb Remodelling in BPD
anaemia and hyperparathyroidism, as well as
micronutrient imbalances, should be evaluated Proteins and starch can be reabsorbed along the
from a wider perspective, together with protein whole length of the alimentary limb, from the gas-
asset, desired %EWL and diarrhoea, in order to tro-enteric-anastomosis to the ileo-cecal valve.
personalize surgical re-intervention as a “tailor’s Moreover, the cecum and ascending colon, because
suite”. of intestinal adaptive phenomena, become an addi-
Insufficient weight loss: BPD is an extremely tional site of protein absorption. Simple sugars and
effective procedure, affording an excel- alcohol can be reabsorbed along the whole alimen-
lent EWL% in the vast majority of patients. tary limb as well. The short common channel
Nevertheless, suboptimal compliance to dietary remains the only site for effective reabsorption of
recommendations and lifestyle modifications fatty acids and bile salts, thus significantly reduc-
may significantly reduce the effectiveness of the ing the total amount of energy absorbed from food.
procedure, thus preventing satisfactory results. These aspects must be thoroughly considered
Moreover, in spite of an overall EWL% higher to explain the clinical results of BPD, and its
than 50 %, some patients may display a BMI adverse effects. However, they are of crucial
which is still in the obesity range (i.e. >30). These importance in cases of surgical revision.
results should be evaluated on an individual Varying the length of the common channel at
basis, considering on the one hand the overall the expense of the alimentary limb affects fat and 1)
QoL, the presence of significant side effects of energy absorption, without directly affecting
chronic malabsorption and the way the patients starch and proteins.
are able to cope with them, and, on the other, the Shortening the common channel below 50 cm
patient’s compliance to post-operative integra- or elongating it along the alimentary limb deter-
tion and nutritional advices. mines a consensual variation in the threshold of
Weight regain: Excessive adaptive phenom- fat and energy absorption. Accordingly, relative
ena after BPD may account for a significant effects on steatorrhea, diarrhoea and “foul-
long-term weight regain, but this is still open to smelling” stools can be expected.
question. Conversely, an increased dietary intake Elongating the common channel at the 2)
of alcohol and carbohydrates, such as mono and expense of the biliopancreatic limb determines
disaccharides – which can still be absorbed increased absorption of macronutrients and
along the alimentary limb – determines an energy, as a result of the elongation of the entire
increase of both energy intake and overall alimentary circuit.
weight. If this is the case, the proper manage- Elongating the alimentary limb at the expense 3)
ment should be nutritional advice, as no surgical of the biliopancreatic limb improves the absorp-
revision could conveniently cope with a wrong tion of protein and starch, without modifying the
alimentary regime. amount of fat.
24 Revisional Surgery: Biliopancreatic Diversion Failure 261

Before modifying the relative length of bowel Staplers: The presence of scars and the thick-
limbs after BPD, the surgeon must take into ness of tissues requiring transection must be
account the effectiveness of the adaptive mecha- accurately evaluated, in order to choose the most
nisms that occur after the first operation. appropriate staple cartridges. A vascular car-
Moreover, the overall capacity to eat, that is tridge is usually preferred to transect the small
greatly dependent on the total capacity of the gas- bowel far from scar tissue and for the ileo-ileal
tric pouch, must be evaluated, concomitantly and anastomosis. A blue or violet cartridge is pre-
in addition to the absorptive function of the ali- ferred for the stomach and to perform a gastro-
mentary circuit. ileal anastomosis. The same cartridge is chosen
In other words, a proper strategy before redo to transect the small bowel in the presence of sig-
surgery can be formulated only after an 18- to nificant scar and to take down a previous
24-month interval following BPD, when proper anastomosis.
adaptive mechanisms have already occurred, The staple lines must be carefully inspected
and the eating capability has been restored for bleeding and leaks, but we do not routinely
completely. perfom a methilene blue test in the operative
room when the gastric pouch is resized, or a new
gastric anastomosis is constructed.
24.5 Problems and Specific Drains: Redo surgery has an increased risk of
Aspects of Redo Bariatric anastomotic leakage and fistulas, bleeding and
Surgery infections. Therefore, surgical drains are fre-
quently used. If the gastric pouch is revised or a
Approach: Although the laparoscopic approach new gastric anastomosis is performed, a Jackson-
can be chosen for a redo procedure even in case Pratt drain is usually fitted, passing through the
of previous open bariatric surgery [17], we prefer Morrison cavity?and draining the peri-anastomotic
to perform a re-laparotomy when initial BPD had space. A drain is not routinely placed close to the
been performed using open surgery. In our opin- jejuno-ileal anastomosis.
ion, further indications to open approach include
the presence of a large incisional ventral hernia
and the requirement for additional surgery other 24.6 Technical Notes
than cholecystectomy.
When the laparoscopic approach is chosen, 24.6.1 Common Limb Elongation
we routinely induce pneumoperitoneum using
the Veress needle in the left subcostal region. Common limb elongation along the biliopancre-
Removal of previous adhesions: Extensive atic limb can be required to cure relapsing protein
post-operative adhesions are unusual after malnutrition with diarrhoea and normal food
uncomplicated laparoscopic BPD (Fig. 24.3). intake.
The most severe adhesions are usually restricted The aim is to provide a longer alimentary tract
to the region of the lesser curvature of the stom- for effective protein absorption, together with a
ach and gastro-ileal anastomosis. On the con- longer common channel for absorption of fat and
trary, there are usually no significant adhesions in energy. Scopinaro proposes elongating the com-
close proximity to both the entero-enteric anasto- mon channel from 50 to 150 cm along the bilio-
mosis and common limb. pancreatic limb, thus reaching a total length of
Adhesion removal can be safely performed 400 cm for the alimentary circuit. As a result of
either with a monopolar hook or a harmonic scal- the enhanced energy absorption, weight regain
pel. The liver border represents an excellent ana- can be expected, thus making the procedure suit-
tomical landmark. Following the liver edge, the able for patients with an excess weight loss [8].
exposure of the lesser curvature is greatly Elongation of the common channel, leav-
facilitated. ing the total length of the alimentary circuit
262 V. Ceriani et al.

unchanged, should be reserved to treat proctologic

sequelae, persistent diarrhoea and intolerance to
“foul-smelling” stools. In this case, the biliopan-
creatic limb should be moved proximally along
the alimentary limb, so creating a common chan-
40 ml
nel of 150 cm, which has been shown to be effec-
tive for this specific aim [8].

50 cm
24.6.2 Surgical Restoration

Complete (or near complete) restoration of the

small bowel length should be reserved for patients
with severe relapsing protein malnutrition and
normal food intake. In fact, this condition is char-
acterized by an insufficient absorptive capacity of
the alimentary canal. 200 cm
Various technical solutions have been pro-
posed. Perhaps the simplest solution is moving
the alimentary limb proximally, along the bilio-
pancreatic limb, just distally to the ligament of
Treitz [8]. In this way, the duodenum is still
excluded from the transit, thus preserving some Bilio-pancreatic limb
favourable effects relating to glucose metabo-
lism and T2 diabetes. If the transit through the Fig. 24.2 Structural remodelling of biliopancreatic
duodenum is maintained, in order to improve diversion
iron and calcium absorption, the alimentary limb
can be sectioned from the common channel and
anastomosed to the duodenal stump. The only gain, we reduced the gastric pouch from 500 to
residual negative effect would be a moderate 40 ml. The new procedure may resemble a long-
reduction of food intake derived from gastric limb distal gastric bypass, but, owing to its direct
resection. derivation from Scopinaro’s BPD, we refer to it
as the “structural remodelling of classic BPD”
(Fig. 24.2).
24.6.3 Structural Remodelling After increased experience with the new pro-
of BPD for Unfavourable cedure, favourable effects on calcium metabo-
Results of the Procedure lism and PTH levels were also observed,
together with a tendency for further weight loss.
While initially addressing the problem of procto- Thus we also extended the indications to the
logic sequelae in a group of patients who under- “structural remodelling after BPD” to patients
went Scopinaro’s classic BPD, we succeeded in with severe secondary hyperparathyroidism and
achieving two aims: (1) control of symptoms to those with unsatisfactory weight loss after
from chronic diarrhoea and (2) avoidance of classic BPD.
weight regain. As the technique has not been previously
To reduce the malabsorptive effects of sur- described, we will describe it in detail. We will
gery, we elongated the common limb from 50 to refer to this technique being performed using the
200 cm at the expense of the alimentary limb, and laparoscopic approach, since the open procedure
simultaneously, with the aim of avoiding weight can be performed following the same principles
24 Revisional Surgery: Biliopancreatic Diversion Failure 263

Fig. 24.3 The surgical field is free from significant adesions Fig. 24.6 The alimentary limb is transected immediately
beside the gastro-ileostomy with a 60-mm tan cartridge

Fig. 24.4 The gastric pouch is inspected and the gastro-

ileostomy identified, and dissected free from adhesions, Fig. 24.7 The lesser curvature is freed proceeding
using a monopolar hook upward to the level of the intragastric balloon

Fig. 24.5 An oro-gastric calibration balloon is inserted, Fig. 24.8 The gastric pouch is trimmed on the gastric
inflated to 40 ml and finally retracted against the cardias balloon with blue or violet cartridge
264 V. Ceriani et al.

Fig. 24.9 A new gastro-ileostomy is performed, between Fig. 24.11 A new common channel, 200 cm long is then
the alimentary limb and the posterior aspect of the new created, anastomosing the biliopancreatic limb to the ali-
gastric pouch mentary limb, at 50 cm from the gastric pouch *Alimentary
limb, **common channel, §biliopancreatic limb

the right hypochondrium, below the hepatic

edge.
When required, cholecystectomy is performed
as the first step.
The gastric pouch is inspected and the gastro-
ileostomy is identified, and dissected free from
adhesions, using a monopolar hook or a radio fre-
quency device. The alimentary limb is transected
immediately beside the gastro-ileostomy with a
60-mm white or tan cartridge.
The dissection proceeds on the lesser curvature
of the gastric pouch, freeing it from adhesions
with the liver surface up to the cardias, sparing the
Fig. 24.10 The biliopancreatic limb is identified at the gastric vessels on this side. After exposure of the
anastomotic level and taken down *Alimentary limb, cardias and of the right diaphragmatic crus, dis-
**common channel, § biliopancreatic limb section starts on the greater curvature, which is
progressively freed from the omentum up to the
and surgical steps (Figs. 24.3, 24.4, 24.5, 24.6, left crus. After dissection of the posterior surface
24.7, 24.8, 24.9, 24.10 and 24.11). of the stomach from the pancreas, an oro-gastric
The patient is placed in a moderate reverse calibration balloon is inserted, inflated to 40 ml
Trendelenburg position. Pneumoperitoneum is and finally retracted against the cardias. The lesser
induced and maintained at 14–16 mmHg using curvature is freed proceeding upward to the level
the Veress needle, which has been placed in the of the intragastric balloon. The gastric pouch is
left subcostal region. One 10–12-mm port is trimmed on the gastric balloon with a blue or vio-
placed in the midline, 20 cm caudally from the let cartridge, analogously to the similar step in the
xiphoid process. Two 12-mm ports are placed in Roux-en-Y gastric bypass. The surgical specimen
the right and left flank, at the level of the umbili- is then placed in a plastic bag, to be retrieved at
cus, forming an equilateral triangle. One addi- the end of the procedure.
tional 5-mm port is placed in the subxiphoid A new gastro-ileostomy is performed
region, on the left side of the falciform ligament (termino-lateral, isoperistaltic), between the
and another 5-mm port is placed very laterally in alimentary limb and the posterior aspect of the
24 Revisional Surgery: Biliopancreatic Diversion Failure 265

Table 24.1 Results of structural remodelling of BPD in our experience, on 27 patients with a post-operative follow-up
of 2 years
Preop Month 1 Month 3 Year 1 Year 2 p
BMI 33.6 31.3 32.5 26.9 28.7 .001
Proteinemia 6.8 6.9 7.0 6.8 6.9 ns
Sideremia 48.8 70.9 79.7 82.7 74.8 .01
PTH (ng/l) 134.1 69.8 75.3 71.7 79.3 ns
Calcemia (mmol/l) 2.14 2.21 2.22 2.3 2.31 ns
Bowel movements/day 4 (1–7) 3 (1–4) 2 (1–3) 2(1–4) 2 (1–4) .003
(median)

new gastric pouch, using a 45-mm violet linear 2. Guedea ME, Arribas del Amo D, Solanas JA, Marco
cartridge. Several interrupted full thickness CA, Bernadó AJ, Rodrigo MA, Diago VA, Díez MM.
Results of biliopancreatic diversion after five years.
stitches are used to complete the anastomosis. Obes Surg. 2004;14(6):766–72.
The alimentary limb is followed distally and 3. Buchwald H, Estok R, Fahrbach K, Banel D, Jensen
its surface is marked at 50 cm from the gastro- MD, Pories WJ, Bantle JP, Sledge I. Weight and type 2
ileostomy. Following the alimentary limb, the diabetes after bariatric surgery: systematic review and
meta-analysis. Am J Med. 2009;122(3):248–256.e5.
biliopancreatic limb is identified at the anasto- 4. Scopinaro N, Gianetta E, Adami GF, Friedman D,
motic level and taken down and anastomosed, Traverso E, Marinari GM, Cuneo S, Vitale B, Ballari F,
using a 60-mm blue or violet cartridge, on the Colombini M, Baschieri G, Bachi V. Biliopancreatic
biliopancreatic side, avoiding stricture of the diversion for obesity at eighteen years. Surgery. 1996;
119(3):261–8.
common limb. 5. Buchwald H, Avidor Y, Braunwald E, Jensen MD,
A new common channel, 200 cm long is then Pories W, Fahrbach K, Schoelles K. Bariatric surgery:
created, anastomosing the biliopancreatic limb to a systematic review and meta-analysis. JAMA. 2004;
the alimentary limb, at 50 cm from the gastric 292(14):1724–37.
6. Scopinaro N. Thirty-five years of biliopancreatic
pouch. A latero-lateral, antiperistaltic anastomo- diversion: notes on gastrointestinal physiology to
sis is performed, using a 45-mm white cartridge, complete the published information useful for a better
and several full-thickness interrupted stitches are understanding and clinical use of the operation. Obes
placed to close the remaining defect. Mesenteric Surg. 2012;22(3):427–32.
7. Crea N, Pata G, Di Betta E, Greco F, Casella C,
defects are left open. Vilardi A, Mittempergher F. Long-term results of
A Jackson-Pratt drainage is left close to the Biliopancreatic diversion with and without gastric
gastric anastomosis and the surgical specimen(s) preservation for morbid obesity. Obes Surg.
is (are) is finally retrieved in the plastic bag. 2011;21:139–145.
8. Scopinaro N, Marinari G, Camerini G, Papadia F.
Subcuticular sutures are used to close the skin. Biliopancreatic Diversion: physiological and meta-
Table 24.1 resumes our results with the proce- bolic aspects. In Bariatric Surgery. Multidisciplinary
dure on 27 consecutive patients, operated from approach and Surgical techniques. 2nd edn. Aosta:
2008 to 2012, with a post-operative follow-up of Società valdostana di chirurgia; Quart: Musumeci:
2007.
2 years. The structural remodelling of BPD 9. Lozano O, García-Díaz JD, Cancer E, Arribas I,
afforded a significant reduction of bowel move- Rubio JL, González-García I, Galván M, Alvarez J,
ments per day and of PTH levels were observed, Martín-Duce A. Phosphocalcic metabolism after
not only preventing weight regain, but definitely biliopancreatic diversion. Obes Surg. 2007;17(5):
642–8.
increasing the excess weight loss. 10. Hamoui N, Anthone G, Crookes PF. Calcium metabo-
lism in the morbidly obese. Obes Surg. 2004;14(1):
9–12.
11. Balsa JA, Botella-Carretero JI, Peromingo R, Zamarrón
References I, Arrieta F, Muñoz-Malo T, Vázquez C. Role of cal-
cium malabsorption in the development of secondary
1. Scopinaro N, Adami GF, Marinari GM, Giannetta E, hyperparathyroidism after biliopancreatic diversion.
Traverso E, Friedman D, Camerini G, Bascheri G, J Endocrinol Invest. 2008;31(10):845–50.
Simonelli A. Biliopanceratic diversion. World J Surg. 12. Balsa JA, Botella-Carretero JI, Peromingo R,
1998;22:936. Caballero C, Muñoz-Malo T, Villafruela JJ, Arrieta F,
266 V. Ceriani et al.

Zamarrón I, Vázquez C. Chronic increase of bone improves standard biliopancreatic diversion: a restro-
turnover markers after biliopanceratic diversion is spective study. Surg Obes Relat Dis. 2009;5:43–7.
related to secondary hyperparathyroidism and weight 15. Scibora LM, Ikramuddin S, Buchwald H, Petit
loss relation with bone mineral density. Obes Surg. MA. Examining the link between bariatric surgery,
2010;20:468–73. bone loss, and osteoporosis: a review of bone density
13. Tsiftsis DDA, Mylonas P, Mead N, Kalfarentzos F, studies. Obes Surg. 2012;22:654–67.
Alexandrides TK. Bone mass decreases in morbidly 16. Lalmohamed A, de Vries F, Bazelier MT, Cooper A,
obese women after long limb-biliopancreatic diver- van Staa TP, Cooper C, Harvey NC. Risk of fracture
sion and marked weight loss without secondary after bariatric surgery in the United Kingdom: popula-
hyperparathyroidism. A physiological adaptation to tion based, retrospective cohort study. BMJ.
weight loss? Obes Surg. 2009;19(11):1497–503. 2012;345:e5085.
14. Marceau P, Biron S, Hould FS, Lebel S, Marceau S, 17. Kellogg TA. Revisional bariatric surgery. Surg Clin N
Lescelleur O, Biertho L, Simard S. Duodenal Switch Am. 2011;91:1353–71.
 Internal Hernia After Bariatric
Procedures 25
Enrico Facchiano, Giovanni Quartararo,
Alessandro Sturiale, and Marcello Lucchese

25.1 Introduction defects [3]. A mean rate of 2.51 cases of IH after

Roux-en-Y gastric bypass has been reported [1].
Internal hernia (IH) represents the most common The rate of IH should raise up to 8.4 % in case of
cause of small bowel obstruction after laparo- non-closure of mesenteric defects [2].
scopic RYGBP, accounting for up to 61 % of
cases of small bowel obstruction [1, 2]. The ana-
tomic changes following bariatric surgery, the
use of laparoscopy, the postoperative weight loss
account for the high incidence of IH after bariat-
ric procedures [1].
There are three anatomical spaces resulting
from the Roux-en-Y reconstruction where IH
may occur [1]:
1. Through the transverse mesocolon defect, in
case of trans-mesocolic Roux-en-Y limb
2. The entero-enterostomy space, resulting from
the union of mesentery at the jejuno-jejunal
anastomosis
3. The Petersen’s space between the mesentery
of the Roux limb and the transverse mesoco-
lon (Fig. 25.1).
However, even if the occurrence of IH has
been described above all after RYGBP, this com-
plication can potentially occur after all the bariat-
ric procedures in which a Roux-en-Y limb is
fashioned because of the creation of mesenteric

E. Facchiano, MD (*) • G. Quartararo, MD Fig. 25.1 Potential hernia sites in laparoscopic RYGBP.
A. Sturiale, MD • M. Lucchese, MD (1) entero-enterostomy mesenteric defect; (2) space
Department of Surgery, Bariatric and Metabolic between mesentery of Roux and transverse mesocolon
Surgery Unit, Azienda Sanitaria Firenze, Santa Maria (Petersen’s space); (3) transverse mesocolon defect. All
Nuova Hospital, Piazza Santa Maria Nuova, 1, the procedures fashioning a Roux-en-Y limb result in
Florence 50122, Italy mesenteric defects that may potentially cause IH (From
e-mail: [email protected] Iannelli et al. [1])

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 267
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_25,
© Springer International Publishing Switzerland 2015
268 E. Facchiano et al.

As a matter of fact, the ever increasing use of technical details of the reconstructions of bariatric
laparoscopic approach results in an increased surgery.
incidence of IH when compared to open proce- The diagnosis of IH may be more difficult if
dures, maybe because of the reduced formation the patient presents with less evident clinical pic-
of postoperative adhesions [4]. ture. In case of chronic IH, symptoms are little
Finally, even the weight loss plays an impor- evident and not easy to recognize, laboratory and
tant role in the high incidence of IH as a conse- traditional radiological work-up are often unhelp-
quence of the reduction of intra-abdominal ful [6]. CT scan could help for the diagnosis of
adiposity that may lead to the expansion of pre- IH but a clear diagnosis remains difficult because
existent mesenterical defect [1, 5]. often only indirect signs of intestinal obstruction
IH often remains a misdiagnosed disease or an can be found [7].
incidental finding because symptoms may be CT scan should be systematically examined by
very vague and other clinical hypothesis are skilled radiologist and surgeons for these find-
advocated. On the other side, it can present with ings: direct or indirect signs of small bowel
an acute and dramatic clinical picture that can obstruction, mesenteric swirl, a thicken shape of
oblige the general surgeon to face an unusual the mesentery, mesenteric vessel engorgement,
disease. small bowel behind the superior mesenteric artery,
An appropriate knowledge of bariatric tech- displacement of the mesenteric trunk and jejuno-
niques may help the general surgeon to recognize jejunostomy standing on the right side [2, 8].
this potentially lethal complication in order to A chronic IH hernia often presents with vague,
refer suspect cases of IH to bariatric surgeons and colicky pain, which may change or disappear in
to assure the best care to patient presenting with the lateral decubitus. Nausea and postprandial
most urgent symptoms. vomiting may be present. The pain can mainly be
localized in the left upper quadrant, even if other
localizations are possible, and often resolves
25.2 Clinical Presentation spontaneously [1, 9].
and Management The presence of recurrent abdominal pain in
a patient with a past history of RYGBP, even in
The occurrence of IH after laparoscopic bariatric absence of pathological laboratory or radiological
surgery has largely been reported in the literature findings, should raise the suspicion of a misdiag-
and it is well known by bariatric surgeons. nosed IH. In these cases, a surgical exploration
However, it still represents a challenge for gen- should be advocated and should be performed by
eral surgeons who do not have a specific knowl- laparoscopy by a surgeon with a good knowledge
edge of the bariatric techniques. Moreover, a of bariatric techniques.
certain diagnosis is often difficult because of the At the surgical exploration, the bowel can
clinical presentation that can be vague and not so have an inflammatory aspect with signs of intes-
easy to recognize. tinal obstruction. In some cases, a chylous ascites
IH may present as either an acute or chronic can be found, associated or not with a white coat
clinical picture. In the first case, symptoms are on the mesentery, maybe because of a lymphatic
usually evident and the surgeon has to face a dra- stagnation secondary to the intermittent torsion
matic acute abdomen secondary to intestinal of the mesenteric vessels (Fig. 25.2).
ischemia or small bowel necrosis or perforation. At the surgical exploration, the whole small
When an acute clinical presentation is present, bowel must be examined and all the potential
the indication to emergency surgery is evident mesenteric defects must be researched. The
and a surgical operation is always required. In aspect of the herniated bowel must be observed in
these cases, an IH must always be researched by each case in order to evaluate if a resection is
examining the whole small bowel. The laparo- needed. All mesenteric defects identified, above
scopic exploration is a valid option if the surgeon all if they gave origin to a symptomatic IH,
is skilled in laparoscopy and if he knows the should be closed.
25 Internal Hernia After Bariatric Procedures 269

In case of trans-mesocolic placement of the

alimentary limb, an IH at the transverse mesoco-
lon defect must be researched. An IH hernia at
this site is often easy to recognize.
After the examination of the transverse meso-
colon defect or in case of antecolic placement,
the alimentary limb should be followed up to the
jejuno-jejunal anastomosis. This operation may
be difficult in case of IH because the herniated
bowel may be blocked in the mesenteric defect
and it can be difficult to reduce it in the physio-
logical position by simple traction. In case of IH
at the Petersen’s defect, the rotation of the mes-
entery always occurs counterclockwise. We
believe that the passage of the jejuno-jejunal
anastomosis through a mesenteric defect repre-
sents the real point of no return in the pathophysi-
ology of the IH since in all the cases it represent
the most difficult part of the herniation to reduce
at the surgical exploration. If the jejuno-jejunal
anastomosis cannot be reached by following the
alimentary limb, it can be because of an IH at the
Petersen’s defect that cannot be reduced by sim-
ple traction. In this case, we suggest moving the
Fig. 25.2 Chylous asitis (a) and white mesenteric coat limb to the left part of the abdomen in order to
(b) in a case of internal hernia. This phenomenon may be have the edge of its mesentery on the right. Once
due to lymphatic stagnation secondary to the intermittent
the right part of transverse colon and mesocolon
torsion of the mesenteric vessels
has been identified, the Petersen’s space can be
now easily recognized between the mesentery of
We herein describe the technique that we usually the Roux limb and the transverse mesocolon. If
use to perform laparoscopic exploration in patients an IH is present, some herniated intestinal loops
with clinical or radiological suspicion of IH. are evident at this level (Fig. 25.3). The IH must
The patient is placed in the supine position be obviously reduced before closing the
with both legs in the straight position and secured Petersen’s defect. The herniated bowel must be
to the operating table to allow for subsequent tilt- gently pushed clockwise through the mesenteric
ing. The surgeon stands on the patient’s right side defect till the entire herniated bowel and the
with the assistant on his right side and the moni- jejuno-jejunal anastomosis are passed through
tor is placed at the right side of the operating bed. the mesenteric defect. In case of difficulties to
The first 10-mm trocar is placed at the umbilicus, identify the sense of the rotation, the ileocecal
using an open technique and two 5-mm trocars valve can be identified and the bowel can be run
are placed in the right flank. The 10-mm port will from distal to proximal. When the entire herni-
be used to introduce a 30° camera. The operating ated bowel has been passed, the mesenteric defect
bed is tilted to the right side. can finally be closed starting caudally, at the con-
The procedure should start with the identi- vergence between the transverse mesocolon and
fication of the gastro-enterostomy. If the anasto- the mesentery of the alimentary loop using a run-
mosis is not evident because of some adhesions ning suture and proceeding cephalad. The use of
between the gastric pouch and the liver, it is prob- knotless barbed suture may be helpful.
ably better not to dissect but just to identify the Once the Petersen’s defect has been closed,
alimentary limb. the whole bowel must be explored, starting at the
270 E. Facchiano et al.

b
c

Fig. 25.3 Internal hernia at the Petersen’s defect. The Fig. 25.4 Closure of the Petersen’s defect starting at the
upper part of the image is oriented towards the head of the convergence between the transverse mesocolon and the
patients. The herniated intestinal loop (a) come from a mesentery of the alimentary loop using a running suture
counterclockwise rotation of the mesentery through the
defect delimited by the mesentery of the alimentary limb
(b) and transverse mesocolon (c). To be reduced, the her- necessary and do not recommend their system-
niated bowel must be gently pushed in the sense of the atic closure [10, 11]. The arguments reported for
arrow till all the herniated bowel and the jejuno-jejunal non-routine closure of mesenteric defects include
anastomosis is passed anatomical considerations, the intention to reduce
complications linked to mesenteric closure (i.e.,
beginning of the alimentary loop and proceeding hematomas, injury to mesenteric vessels) and the
up to the jejuno-jejunal anastomosis. At this site, idea that mesenteric closure may result in added
the other mesenteric defect must be researched. In costs in terms of operating time and suture mate-
case of evident strangulation or torsion, the diag- rials [10, 11].
nosis of IH is often easy. However, above all if the We think that no anatomical or surgical
abdominal exploration is done by laparoscopy, it details (i.e., a long jejuno-jejunostomy configu-
can be difficult to identify the sense of the torsion. ration of the Roux limb [10]), other than mes-
In these cases, the ileocecal valve can be identi- enteric closure, can prevent the formation of
fied first and the bowel can be run from distal to IH. Even if some technical features can reduce
proximal. This maneuver can be easier since the the size of mesenteric defects at the time of
distal portion of the bowel is decompressed and surgery, this does not imply that the anatomy
easier to manipulate and the hernia may reduce as may change after a significant loss of weight
the small bowel is run [2] (Fig. 25.4). [1, 9, 12]. Consideration about cost and com-
As the IH can be a potentially fatal complica- plications appear not appropriate because the
tion, in case of difficulties the conversion to open closure of mesenteric defects usually takes only
surgery is mandatory. few minutes to a skilled surgeon and mesenteric
hematomas are usually rare and easy to manage
[9, 10].
25.3 To Close or Not to Close We currently recommend to close all the
Mesenteric Defects? mesenteric defects at the time of bariatric sur-
gery using, if possible, an ante-colic Roux limb
Several studies report that the closure of mesen- positioning, thus reducing the number of poten-
teric defects when performing bariatric surgery tial mesenteric defects. Absorbable or non-
cannot eliminate the risk of internal hernia, but absorbable sutures are both useful in the lack of
can consistently reduce its incidence [1, 2, 9]. controlled studies. Barbed knotless sutures may
On the other side, some authors still report help in case of technical difficulties, above all in
that the closure of mesenteric defects are not patients with visceral fat distribution.
25 Internal Hernia After Bariatric Procedures 271

Other technical features such as the division As bariatric surgery is gaining raising pop-
of the omentum and a minimal division of the ularity with a great number of procedures per-
mesentery cannot be considered effective in the formed yearly worldwide, it is probable that
reduction of IH rate since the reduction of the general surgeons will be called to face compli-
abdominal fat secondary to weight loss can mod- cations of bariatric surgery with an increasing
ify the thickness of the omentum and the mesen- frequency. A specific knowledge of bariatric
tery producing an expansion of the defects. technique should be required to general sur-
geons to recognize and treat in emergency
Conclusion specific complications such as IH.
In conclusion, when a patient who has previ-
ously undergone a gastric bypass or other bar-
iatric procedures with a Roux limb presents
with a clinical picture of intestinal obstruction
References
should raise the suspicion of IH. In these cases, 1. Iannelli A, Facchiano E, Gugenheim J. Internal hernia
a CT scan should be performed and examined after laparoscopic Roux-en-Y gastric bypass for mor-
for specific findings of IH such as mesenteric bid obesity. Obes Surg. 2006;16(10):1265–71.
swirl, right sided jejuno-jejunostomy, and 2. Obeid A, McNeal S, Breland M, et al. Internal her-
nia after laparoscopic Roux-en-Y gastric bypass.
abnormal position or aspect of the mesenteric J Gastrointest Surg. 2014;18(2):250–5; discussion
trunk. However, as radiological findings are 255–6.
often not easy to recognize, a negative CT 3. Khwaja HA, Stewart DJ, Magee CJ, et al. Petersen
scan should not be used to exclude the diag- hernia complicating laparoscopic duodenal switch.
Surg Obes Relat Dis. 2012;8(2):236–8.
nosis of IH. 4. Garrard CL, Clements RH, Nanney L, et al. Adhesion
In case of clinical suspicion of IH, even in formation is reduced after laparoscopic surgery. Surg
case of normal laboratory and radiological Endosc. 1999;13(1):10–3.
findings, a surgical exploration is indicated 5. Quebbemann BB, Dallal RM. The orientation of the
antecolic Roux limb markedly affects the incidence of
and, when the general conditions of the internal hernias after laparoscopic gastric bypass.
patients make it feasible, it should be attempted Obes Surg. 2005;15(6):766–70; discussion 770.
laparoscopically. Conversion to open proce- 6. Champion JK, Williams M. Small bowel obstruction
dure must be considered in case of technical and internal hernias after laparoscopic Roux-en-Y
gastric bypass. Obes Surg. 2003;13(4):596–600.
difficulties in the manipulation of the bowel or 7. Onopchenko A. Radiological diagnosis of internal
in the identification of the sense of the rotation hernia after Roux-en-Y gastric bypass. Obes Surg.
of the herniated bowel. 2005;15(5):606–11.
If possible, patients with symptoms consis- 8. Comeau E, Gagner M, Inabnet WB, et al. Symptomatic
internal hernias after laparoscopic bariatric surgery.
tent with a chronic IH should be referred to a Surg Endosc. 2005;19(1):34–9.
specialized bariatric center or to a surgeon 9. Facchiano E, Iannelli A, Gugenheim J, Msika
with a specific knowledge of bariatric surgery S. Internal hernias and nonclosure of mesenteric
for a laparoscopic surgical exploration. Acute defects during laparoscopic Roux-en-Y gastric
bypass. Obes Surg. 2010;20(5):676–8.
presentation of IH remains a surgical emer- 10. Madan AK, Lo Menzo E, Dhawan N, Tichansky
gency and a surgical operation should not be DS. Internal hernias and nonclosure of mesenteric
delayed. defects during laparoscopic Roux-en-Y gastric
Even in the absence of randomized studies, bypass. Obes Surg. 2009;19(5):549–52.
11. Ortega J, Cassinello N, Sanchez-Antunez D, et al.
it is recommended to close all the mesenteric Anatomical basis for the low incidence of inter-
defects performing procedures that imply the nal hernia after a laparoscopic Roux-en-Y gastric
creation of a Roux limb. The routine closure bypass without mesenteric closure. Obes Surg.
of all the mesenteric defects do not completely 2013;23(8):1273–80.
12. Facchiano E, Lucchese M, Iannelli A. Anatomical
avoid IH formation; however, it results in basis for the low incidence of internal hernia after a
reduced incidence of this complication as laparoscopic Roux-en-Y gastric bypass without mes-
reported in several studies. enteric closure. Obes Surg. 2013;23(12):2110–1.
 Emergencies in Bariatric Surgery:
Highlights for the General 26
Surgeon

Carlo Bergamini, Giovanni Alemanno,

Enrico Facchiano, and Marcello Lucchese

26.1 Introduction At present, scientific societies are far to have

reached strict evidence-based recommendations
Bariatric surgery is safely performed in special- on these topics. However, in this chapter, we tried
ized centers: complications are <1 % in almost all to outline an up-to-date guide about specific
published experiences, with <0.35 % in some acute complications that may occur early or late
specialized centers, similar to cholecystectomy after laparoscopic bariatric surgery, which may
[1]. These complications are treated by the origi- happen to be diagnosed and managed by the gen-
nal bariatric center, where the required skills and eral surgeon, even without specific bariatric
knowledge are available. However, acute compli- experience.
cations might require emergency treatment in a
local district hospital [2–4].
The physiological effects of bariatric surgery, the 26.2 General Clinical
knowledge about its anatomic reconstruction, and Management
even the management of the health consequences of
morbid obesity are not traditionally included in gen- When an emergency occurs, the evaluation of the
eral surgery training programs. However general bariatric patient follows a typical stepwise
surgeons, regardless of their specific interest in obe- approach. Assessment and treatment of patient’s
sity surgery, should develop a basic anatomical, ABC (airway, breathing, circulation) should pre-
clinical, and surgical understanding of these proce- cede any specific consideration; no change to car-
dures because they may be called to face acute com- diac arrest resuscitation treatment algorithms for
plications of bariatric surgery during their activity. obese patients is justified [5, 6]. After resuscita-
tion, a complete evaluation should consider bar-
iatric surgery-related complications. History is
C. Bergamini (*) • G. Alemanno essential to find out details about the procedure;
General, Emergency and Mini-Invasive Surgery Unit,
Largo Brambilla, 3, Florence 50132, Italy that being said, at the beginning of the evaluation,
e-mail: [email protected]; a consultation with a bariatric surgeon (possibly
[email protected] the surgeon who performed the procedure) should
E. Facchiano • M. Lucchese be obtained.
Department of Surgery, Bariatric and Metabolic The presence of vital sign instability must take
Surgery Unit, Azienda Sanitaria Firenze, Santa Maria into account the possibility of pulmonary embo-
Nuova Hospital, Piazza Santa Maria Nuova, 1,
Florence 50122, Italy lism and sepsis. Pulmonary embolism is the lead-
e-mail: [email protected]; [email protected] ing cause of death among bariatric surgery

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 273
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_26,
© Springer International Publishing Switzerland 2015
274 C. Bergamini et al.

patients; its incidence is low with appropriate 26.3 Procedure-Specific Acute

prophylaxis, but it deserves maximal consider- Complications
ation in this group of patients. Most venous
thrombo-embolism events may occur after the 26.3.1 Adjustable Gastric Banding
initial hospital discharge [7, 8].
Sepsis and peritonitis can represent the final Laparoscopic adjustable gastric banding (LAGB)
stage of a suture or anastomotic leak; an intra- is still performed worldwide and represents the
abdominal infection from a leaking anastomo- bariatric procedure with the lower reported inci-
sis is the most common cause of mortality dence of short- and mid-term adverse events [15];
within the first 12 weeks after surgery [9]. however, long-term data show a higher incidence
Fever, hypotension, tachycardia, tachypnea, of postoperative acute complications leading to
decreased urine output, and hypoxia (with band repositioning or removal and eventually
tachycardia being the most sensitive sign [10]), conversion to other procedures. The major com-
should alert the physician for the research of a plications are pouch dilation (acute or chronic)
bariatric surgery-related causes of sepsis. The often referred to as “slippage,” erosion, and per-
knowledge of the type of surgery in the patient manent or recurrent outlet obstruction [16–18].
history will guide among the septic procedure-
specific complications. 26.3.1.1 Slippage
Evaluation of gastrointestinal (GI) bleeding, Slippage is the most common LAGB complica-
abdominal pain, nausea, and vomiting should tion and the leading cause of reoperation. It can
take into account the specific procedure compli- develop early or late during the postoperative
cations, examined in later paragraphs. Prompt course. Its reported incidence of 1–20 %, in the
fluid resuscitation should be started with non- published series, dropped (even to 0.9 %) after
glucose-containing intravenous solutions admin- the surgical technique, and the prosthesis evolved
istration. These patients require particular during the years [19, 20]. It consists in the dilata-
attention because they often show atypical fea- tion of the gastric pouch, above the band, in three
tures (physical constitution may interfere with different modalities: anterior, posterior, or sym-
the assessment of signs and symptoms). metrical. Chronic pouch dilation presents with a
Peculiarities in their management are often gradual onset of symptoms as food intolerance,
appropriate: (a) supine position should be avoided dysphagia, decrease in satiety, and sense of
due to possible respiratory problems caused by restriction. Its diagnosis and treatment is usually
excess skin and adipose tissue; (b) if endotra- managed by the bariatric surgeon. An acute
cheal intubation is necessary, anesthesiologists slippage is characterized by persistent abdominal
should be aware of the potential intubation diffi- pain, vomiting, and eventually obstructive symp-
culties [11, 12]; (c) nasogastric or orogastric intu- toms. The incidence of acute slippage dropped to
bation should consider the changed anatomy of about 2–10 % after the positioning technique of
the upper GI tract and has to be achieved very the band through the pars flaccida has been gen-
carefully, possibly avoiding blind placement; (d) erally adopted (24 % with the initial peri-gastric
drugs that can induce gastric mucosa damage technique) [21]. The radiological diagnosis is
(NSAIDs, ASA, steroids) should be avoided; and based on the modified orientation of the band on
(e) a possible thiamine deficiency, due to malnu- plain abdominal X-ray, associated with an
trition or altered food habits, must be considered. enlarged gastric pouch at the upper GI series.
If fluid replacement is indicated, start infusing Band position, connection tube location, and
non-glucose-containing solutions (normal saline continuity with the access port should be always
or Ringer’s lactate), and administer thiamine checked both on plain and contrast X-ray. Nausea,
before infusing glucose to avoid an acute onset of vomiting, and reduction of oral intake can be so
Wernicke’s syndrome [13, 14]. severe to result in severe dehydration with
26 Emergencies in Bariatric Surgery: Highlights for the General Surgeon 275

changes in the cardiovascular status and vital perforation but is part of a standard approach in a
signs. Emergency treatment consists in complete bariatric center, which includes serial upper GI
band deflation through the subcutaneous port endoscopies. Most cases do not require emer-
system, nasogastric tube positioning in the pouch gency surgery. Chronic melena, with chronic ane-
(possibly under radiographic control), and intra- mia, in the absence of abdominal symptoms and
venous administration of fluids, antiemetics, and with a stop of weight loss or even weight regain,
proton pump inhibitors [22]. This should deter- is a sign of latent band erosion and possible intra-
mine a significant improvement of the condition gastric migration.
and allow time to refer the patient to the bariatric
center. Good results can be achieved with conser-
vative treatment, especially in the symmetrical 26.3.2 Laparoscopic Sleeve
dilation, but if symptoms persist for more than Gastrectomy
3–5 days, surgical treatment is needed to prevent
gastric pouch ischemia. Gastric necrosis after late Laparoscopic sleeve gastrectomy (LSG) is today
slippage is, in fact, a rare but life-threatening recognized as a stand-alone procedure that origi-
reported complication [23, 24]; persistence or nates from the two-stage approach of the bilio-
worsening of the initial symptoms, tachycardia, pancreatic diversion with duodenal switch
raised lactate levels, and acidosis should orien- (BPD–DS). It is one of the most popular proce-
tate the diagnosis. dures and consists in a calibrated, longitudinal/
The general surgeon without prior bariatric vertical gastrectomy, performed alongside the
surgery experience, when encountering acute small curvature, using linear staplers, with com-
slippage, after a short course of conservative plete removal of the gastric fundus and body and
treatment as described earlier, must remove the part of the antrum. Early staple line complica-
band in order to treat the emergency when gastric tions are rare but most feared; bleeding and/or
outlet stenosis is evident. Laparoscopic approach leaks are usually managed by the bariatric center
in case of acute slippage is effective in over 95 % in the immediate postoperative days. Depending
of the cases and is the standard choice, provided on the local regional circumstances, more and
that no gastric necrosis is found [18]. During sur- more bariatric procedures, including sleeve gas-
gery, the band is exposed, following the connect- trectomy, are performed nowadays on a very
ing tube, and cut to remove the obstruction of the short hospitalization, with early discharge as
gastric outlet. The surgeon should be aware of the standard of care. Therefore, the general surgeon
possible fixation of the band with two to four can be confronted even with early complications
gastro-gastric sutures. In case of gastric necrosis, like bleeding or acute leaks.
appropriate resection should be performed after
the band removal. 26.3.2.1 Leaks
Suture line leakage rate after LSG ranges between
26.3.1.2 Complicated Intra-gastric 0.7 and 7 %, depending on the series and the
Band Migration patient characteristics, with a risk ranging
Intra-gastric band migration (incidence 0.8–4 %) between 1.5 and 2.4 % in recent systematic
is usually diagnosed at the radiological or endo- reviews and meta-analysis [27–29]. Revisional
scopic follow-up and usually is not a surgical surgery after initial bariatric procedure (conver-
emergency [25, 26]. Intra-operative gastric wall sion of gastric banding or vertical gastroplasty to
trauma and tight band placement may account for LSG or gastric bypass) can increase the fistula
early erosion; high band pressure, band overinfla- rate up to 20 %. The critical areas for leakage are
tion, and dietary noncompliance can cause late the top of the suture line, near the gastro-
band erosion. Band removal is mandatory because esophageal junction (89 %), and the transition
of the risk of complications as hemorrhage or point between sequential cartridges. Postoperative
276 C. Bergamini et al.

leaks may be classified into acute, late, very late, Laparoscopic approach is the best option if expe-
and chronic [28, 30, 31]. The general surgeon, in rience is available and can accomplish extensive
an emergency setting, is rarely involved in evalu- peritoneal washout, identification of the fistula
ating and taking care of either an acute or a site (check first the esophago-gastric junction),
chronic leak, generally treated by the bariatric and multiple drainage. No attempt of correction
center. They might face, however, an obese of the staple line defect is usually indicated.
patient with a “late” or “very late” leak, devel- Three main objectives are pursued: sepsis con-
oped after an initial uneventful postoperative trol, prevention of abdominal recontamination,
course, as almost 80 % of the postoperative fistu- and nutritional (parenteral and enteral) support
las appear after discharge from the bariatric [32–34].
center. All other cases of late staple line fistula, if
Symptoms and signs suggestive of a localized stable, should be referred to the bariatric center
or generalized peritonitis (pain, fever, tachycar- where the best management strategy can be
dia, tachypnea, often left pleural effusion, and adopted. Their treatment is based on percutane-
pain in the left shoulder) in a patient who recently ous drainage plus parenteral/enteral nutrition and
had bariatric surgery are likely due to a late fis- antibiotics. An endoscopic prosthesis can be
tula. Abdominal plain X-rays and contrast X-ray positioned in selected cases and/or endoscopic
studies may assist in the diagnosis, but in all sus- fibrin glue applied [35].
pected cases, a CT scan with oral Gastrografin is
essential. Misdiagnosis will worsen the patient’s
future evolution. 26.3.3 Laparoscopic Gastric Bypass
The CT scan usually shows three possible
pictures: Gastric bypass (GBP) represents the gold stan-
1. High staple line fistula (esophago-gastric dard of the surgical treatment of morbid obesity
junction) along with a left sub-diaphragmatic and includes the creation of an upper small gas-
collection tric pouch of 25–30 ml using linear staplers, with
2. “Bubbles” in the peri-gastric fat near the sta- a Roux-en-Y gastro-jejunostomy reconstruction
ple line and a peri-gastric fluid collection
without evidence of contrast medium leak 26.3.3.1 Anastomotic Leak
Anastomotic leak after GBP is a life-threatening
26.3.2.2 Multiple Leaks and Diffuse complication (incidence 0–6.1 %) [36]. It pres-
Fluid Collection ents the same problems of the superior polar
In the latter case, an emergency laparoscopy/ sleeve gastrectomy leak discussed earlier: timing
laparotomy (according to the local skill) may be (early or late), clinical presentation (from sub-
indicated to carry out a lavage of the upper clinical to sepsis), diagnosis (Gastrografin swal-
abdominal cavity and drainage as a first emer- lows, CT scan, and blood counts), and treatment
gency surgical step. Conservative treatment (conservative, including fluid resuscitation, anti-
including bowel rest, fluid resuscitation, antibi- biotics, analgesia, endoscopic stent, and transfer
otics, aspiration of esophageal and gastric secre- to the bariatric unit when possible). Surgical
tions, nutritional support, analgesia, endoscopic emergency treatment should be considered in a
stent, and transfer to the bariatric unit is appro- hemodynamically unstable patient with severe,
priate, but experienced intensive care, endos- persistent symptoms: intense washout of the
copy, and radiology units may be required. abdominal cavity and multiple drain placement
Surgical emergency treatment should be consid- should be considered. Laparoscopic approach is
ered in a hemodynamically unstable patient with the best option if the surgeon is experienced.
severe, persistent symptoms and an acute fistula Final surgical treatment should be referred to the
or a late fistula with diffuse fluid collection. bariatric center.
26 Emergencies in Bariatric Surgery: Highlights for the General Surgeon 277

26.3.4 Laparoscopic Biliopancreatic and the corresponding control can be a

Diversion and Duodenal challenge.
Switch Early bleeding from a staple or suture line can
be extra-or intra-luminal. Most early upper gas-
Biliopancreatic diversion along with its varia- trointestinal, intra-luminal hemorrhage will
tions is the bariatric/metabolic procedure with manifest with hematemesis and melena, and
the higher reported estimated weight loss. their treatment does not differ from any other
Patients require particular attention, especially in upper GI bleeding in a non-bariatric patient. In
the emergency room setting, for the changes in all cases, management includes serial blood
their gastrointestinal (GI) anatomy and physiol- counts, good intravenous access, fluids adminis-
ogy following surgery. Early or late complica- tration, stop of anticoagulants, monitoring of
tions of BPD or DS are rare and often require the vital signs, and upper GI endoscopy. If the
experience of a bariatric surgery team for their endoscopist is familiar with the anatomic
prompt resolution. Specific late complications, changes related to the bariatric procedure, endos-
even if not surgical, might be observed in an copy may reveal the bleeding point from the
emergency setting: protein malnutrition (often inner side of the staple line and control it by
not properly treated in a nonspecialized center), adrenaline injection, electro-coagulation, or
severe anemia, and Wernicke’s encephalopathy endoclips if good visualization is obtained. The
[37–39]. Stabilization of the patient is usually endoscopic examination for perforation at the
possible in order to transfer the patient to a spe- bleeding site should not be omitted. Late bleed-
cialized bariatric center. Particular attention ing in a gastric bypass can present relevant pecu-
should be addressed to appendicitis or choleli- liarities. A significant amount of later hemorrhage
thiasis after BPD or DS. Initial BPD included in a gastric bypass is related to a marginal ulcer.
cholecystectomy, appendectomy, and hepatic Severe hemorrhage or perforation can be faced
biopsy, but after the introduction of laparoscopy by a general surgeon as reported [40]. Endoscopic
and technical evolution to DS, these procedures management is essential, and only its failure can
are no longer routinely performed. indicate an angiography (selected cases) or sur-
gical exploration.
The jejuno-jejunal anastomosis of a gastric
26.4 Non-procedure-Specific bypass or the ileo-ileal anastomosis in a biliopan-
Acute Complications creatic diversion can also be responsible for
bleeding. Spiral angio-CT scan or selective
26.4.1 Bleeding angiography can assess bleeding at these sites.
Bleeding in a GBP can originate also from ero-
Bleeding can be a consequence of the staple line sion or ulcerations of the gastric remnant or even
or other sources. Trocar site bleeding, splenic from duodenal or jejunal ulceration [41].
injury, or liver lacerations from retractor injury Refractory bleeding from the gastric remnant or
are rare but possible hemorrhage sources. Usually other sites with no access for endoscopy can
these complications appear in the first 48 h after entail surgical revision.
surgery, when the patient is still under bariatric Upper gastrointestinal bleeding can occur
specialist surveillance, but routine early dis- anytime after LAGB positioning due to erosions
charge policies can bring an early postoperative or ulcers. Peptic ulcer, Mallory–Weiss tear, ero-
bleeding to the attention of a general surgeon or sive gastritis, and esophagitis can also be sources
an emergency physician. Although the clinical of bleeding in patients with LAGB. Acute upper
picture of bleeding often leaves no room for GI bleeding, occurring in late follow-up, could be
doubts (anemia, hypotension, tachycardia, the result of an active ulcer, and careful endos-
hematemesis, and melena), the site of bleeding copy should recognize and even treat it.
278 C. Bergamini et al.

The initial treatment of upper GI bleeding ineffective on a substantial portion of the gastro-
after LAGB, as of any other gastrointestinal intestinal tract (gastric remnant, biliopancreatic
bleeding, is conservative (adequate resuscitation, limb) and prolonged nonoperative management
close monitoring, assessment of the severity of may be futile and dangerous. If a Roux recon-
bleeding, blood transfusions, and emergency struction is present, a portion of the bowel is
endoscopy when necessary). When surgery excluded from the alimentary flow; the evaluat-
becomes necessary, the patient should be referred ing physician must consider that obstipation may
to the bariatric center, when the clinical situation then be absent even in a complete obstruction and
permits it. Extraluminal bleeding could be shown that the risk of a closed-loop bowel obstruction is
by the drain when present and still functional; higher than in non-bariatric patients. Finally, it
otherwise, an acute drop of hematocrit, with may be difficult to identify small incisional her-
hypotension and tachycardia, would indicate nias (trocar site hernias) in an obese patient, and
unstable hemodynamic condition that may the incidence of internal hernia is higher.
require reoperation for lavage, identification of The most common cause of SBO in the bariat-
the source, and hemostasis. At surgery, the bleed- ric population is an abdominal wall or internal
ing source (staple line, retrogastric vessels, short hernia [43]. Port site hernia could be determined
gastric vessels, omentum dissection line, splenic by the ≥10-mm trocar abdominal fascial defects
or liver injury, trocar site, etc.) will often no lon- left unclosed at the end of the laparoscopic bariat-
ger be active; intense abdominal washout, multi- ric procedures. A trocar site hernia is an uncom-
ple drainage, and supportive intensive care will mon complication of laparoscopic surgery;
suffice. Laparoscopic approach is recommended, however, it is necessary to take into consideration
but only where experience is available. this possibility in the bariatric patient: a recent
review showed that higher BMI is a significant
risk factor for its development even if its inci-
26.5 Small Bowel Obstruction dence after bariatric surgery does not seem to be
(SBO) After Bariatric higher [44]. The identification of small incisional
Procedures hernia can be exceedingly difficult in obese
patients. Emergency treatment for partial or com-
Evaluation and treatment of SBO is one of the plete bowel obstruction allows rapid reduction of
most common tasks that a general surgeon or an the herniated content. A laparoscopic approach is
emergency physician has to face. About 16 % of recommended if adequate experience is available;
surgical admissions and more than 300,000 oper- bowel resection might be necessary in case of per-
ations annually in the USA are related to SBO foration or bowel ischemia. The closure of the
[42]. The standard management algorithm, com- abdominal wall defect completes the operation.
monly practiced for SBO, includes an initial trial Internal hernia is widely recognized as the most
of nonoperative treatment using nasogastric frequent cause of SBO (>50 %) in bariatric
decompression, bowel rest, fluid resuscitation, patients [45]. SBO after GBP or BPD is deter-
and close monitoring. A substantial number of mined mainly by internal hernia. There are three
cases are treated only with such conservative classic locations where SBO can occur after GBP:
measures in the absence of signs suggesting Petersen’s space (between Roux limb’s mesentery
impending or ongoing bowel ischemia. In and transverse mesocolon), at the transverse
patients with a history of bariatric surgery, the mesocolon defect (for retrocolic bypasses), and at
outcome of commonly adopted protocols could the jejuno-jejunostomy. Obstruction can involve
be affected by several factors related to the new the alimentary limb, the biliopancreatic limb, or
anatomy and physiology of the gastrointestinal the common channel, with incidence between 0.4
tract. Physicians who are not adequately familiar and 7.5 % [46–48]. Symptoms can suggest the
with these alterations may be misled in their eval- site of obstruction: heartburn and vomiting are
uation. The nasogastric decompression may be associated with the common channel or alimentary
26 Emergencies in Bariatric Surgery: Highlights for the General Surgeon 279

limb’s obstruction; bilious vomiting originates previous GBP or BPD who presents with chronic,
from the common channel obstruction; distension intermittent abdominal pain or recurrent signs of
of the gastric remnant or biliopancreatic limb sug- a SBO should be suspected of having an internal
gests common channel and biliopancreatic limb hernia, and a referral to a bariatric center for a
obstruction. laparoscopic exploration may be warranted.
Diagnosis is based on clinical presentation, Early diagnosis and intervention are imperative
plain abdominal X-ray, and upper gastrointesti- in order to reduce morbidity and mortality asso-
nal studies. CT scan is a standard diagnostic tool ciated with intestinal necrosis.
and can demonstrate the dilatation of the Roux Acute SBO can be life-threatening in the post-
limb, of the gastric remnant, or of the biliopan- bariatric patients who have undergone a Roux-
creatic limb, depending on localization. Even en-Y reconstruction. In fact, an obstruction point
sophisticated imaging (multislice CT spiral along the biliary limb or at the small bowel anas-
scan), however, will fail to disclose internal her- tomosis will result in a closed-loop obstruction
nia in up to two of three cases. This has led to an that can be rapidly fatal if not recognized and
increasing acceptance for immediate laparo- decompressed. An invasive procedure (emergency
scopic/laparotomic exploration in bariatric surgery or percutaneous CT-guided gastrostomy)
patients with subtle symptoms of SBO. Symptom is the only option to achieve decompression
persistence, acidosis, lactate rise, or signs of an because nasogastric suctioning is precluded by
acute abdomen should prompt exploration. the anatomical changes. A closed-loop obstruc-
Laparoscopy is the best choice (if previous bar- tion can also result from an obstruction distal to
iatric surgery was also laparoscopic) where the jejuno-jejunostomy if an effective decompres-
expertise is available. Small bowel assessment sion is not obtained through the alimentary
and handling are not easy, regardless of the channel.
access. As in any laparoscopic exploration for The closed-loop obstruction of the biliopan-
SBO, a retrograde examination of the bowel creatic channel has been defined as “bypass
starting from the ileo-cecal valve is easier and obstruction” by Mason. He maintained that a uni-
less risky [49–52]. versally recognized denomination of this danger-
In case of positive identification of an internal ous nosologic entity could facilitate recognition,
hernia, a gentle reduction should be done, study, prevention, and early treatment. In gastric
followed by the closure of the mesenteric defect. bypass, the syndrome may include “gastric rem-
Patients with history of bariatric procedures, who nant dilatation,” with potential gastric necrosis,
also had other abdominal surgery (cholecystec- or gastric obstruction with perforation. When
tomy, incisional hernia repair, gynecological presenting as an acute, rapidly evolving compli-
operation, etc.), should always be checked for cation, a complete bypass obstruction has one of
potential mesenteric defects in other areas. the shortest “time to treat” (TTT) [53]. This is
Symptoms can also evolve chronically, with due to the large volume of digestive fluids accu-
intermittent and recurrent abdominal pain associ- mulated in the upper digestive tract, with possible
ated with nausea and vomiting but without a clear evolution to gastric wall necrosis and/or perfora-
obstructive picture. This can be misinterpreted as tion. Hypovolemic shock (evidenced by tachy-
food intolerance, marginal ulcer, or gastro- cardia) is thus complicated by peritonitis and
esophageal reflux disease (GERD). Quite often, sepsis due to perforation. A chronic presentation
the intermittent pinching of a loop of bowel in an is also described, with symptoms including
internal hernia defect can induce chronic, abdominal pain, nausea, hiccup, vomiting, and
intermittent abdominal pain; the mechanism tachycardia. Elevated hepatic functional markers
underlying the symptom may remain unknown, and pancreatic enzymes can be related to the
not discovered even by the most sophisticated increased duodenal pressure. CT scan may show
imaging techniques, unless a very high degree of the dilatation of the gastric remnant. The evalua-
suspicion is maintained. Any patient with tion of the stomach remnant after GBP is
280 C. Bergamini et al.

attainable also by virtual gastro-duodenoscopy impossible in a long-limb RYGBP or BPD. In a

[53]. Revision of the jejunostomy may be needed. GBP, it is possible to reach the biliary tree by advanc-
In the emergency setting, when an interventional ing the endoscope through the gastric remnant, but
radiologist is not available, it is imperative to the inability to distend it with air makes an imaging-
decompress the stomach, and subsequently, guided access challenging. The use of double-bal-
through the gastric access, it is possible to obtain loon enteroscopy to perform an endoscopic-assisted
X-ray contrast studies or endoscopy. placement of a trocar into the remnant stomach was
recently reported. An open gastrostomy is the easiest
approach to access the residual stomach. Some stud-
26.6 Biliary Tract Lithiasis After ies describe a minimally invasive technique to access
Bariatric Surgery the bypassed stomach after RYGBP: a laparoscopic
gastrostomy is obtained after induction of carbon
After bariatric surgery, the risk of gallstone forma- dioxide pneumo-peritoneum, and a 15-mm trocar is
tion increases if weight loss rate exceeds 1.5 kg/ placed into the stomach to allow the insertion of the
week or when there has been excess weight loss of endoscope. When the endoscopic procedure is com-
more than 24 % [54]. Most gallstones form in the pleted, the gastrostomy is closed with a running
first 6 months after surgery, with a symptomatic suture or a linear stapler. The procedure can be per-
onset after a mean period of 10.2 months. A recent formed at the same time of the laparoscopic chole-
meta-analysis confirmed the effectiveness of urso- cystectomy. Possibility to reach the papilla after
deoxycholic acid prophylaxis. Symptomatic gall- BPD through a surgical jejunostomy has been
stones, including acute cholecystitis in a patient reported [57–59].
with a history of bariatric surgery, should not con-
stitute a problem for the general surgeon. The
presence of choledocholithiasis can be difficult to
diagnose and treat after gastric or intestinal bypass
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 Part IV
Outcomes
 Nutritional Outcomes
27
Giovanni Camerini

27.1 Introduction gastrectomy is, on the other hand, a longitudinal

gastric resection leaving a pouch of about
The employment of surgery to treat morbid obe- 100 mL, that takes the shape of a sleeve.
sity is increasing all over the world due to the Purely restrictive procedures, by decreasing
growing prevalence of obesity, the usual failure the gastric capacity, induce an early and pro-
of conservative treatment in providing an impor- longed satiety, thereby reducing the daily volume
tant and a long-lasting weight loss, and the devel- of food intake. After these operations, which leave
opment of minimally invasive surgery. the normal absorptive physiology of the small
Current bariatric operations are classified as bowel intact, selective nutritional deficiencies are
simply gastric restrictive procedures, including unusual. However, some factors may cause nutri-
adjustable silicone gastric banding (ASGB), ver- tional deficiencies also even after restrictive sur-
tical banded gastroplasty (VBG), and sleeve gas- gery such as developed intolerance to certain
trectomy (SG), malabsorptive procedures, types of food (red meat, milk, fiber), poor eating
including biliopancreatic diversion with duode- behaviors, a too rapid and significant weight loss
nal switch (BPD-DS) or without duodenal switch or the occurrence of surgical complications.
(standard-BPD) and restrictive–malabsorptive Standard-BPD consists of a distal gastrectomy
procedures, including Roux-en-Y gastric bypass with a long Roux-en-Y reconstruction, with the
(RYGBP). The number of “malabsorptive” oper- enteroenterostomy placed 50 cm proximal to the
ations is increasing each year, because of better ileocecal valve and the gastroenteric anastomosis
and more durable results in weight loss and reso- created 250 cm proximal to the ileocecal valve
lution of comorbidities. [3]. The BPD-DS is a modification of the BPD
After ASGB, according to the laparoscopic where a sleeve gastrectomy is fashioned, the
Cadière technique [1], and after VBG, according pylorus is left intact, and the proximal duodenum
to the MacLean technique [2], the stomach is is anastomosed to the ileum 250 cm proximal to
divided into two parts, creating a proximal small the ileocecal valve [4]. After BPD, the bypass of
pouch (approximately 30 mL in size), with a the duodenum and of the entire jejunum results in
small outlet (10–12 mm in diameter). Sleeve a selective and permanent limitation of intestinal
absorption for fat and starches, and thus energy.
Both procedures, decreasing significantly the
G. Camerini
absorptive surface area, are associated with
Department of Surgery, University of Genoa,
School of Medicine, Genoa, Italy serious risks of deficiencies, unless followed with
e-mail: [email protected] appropriate supplementation.

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 285
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_27,
© Springer International Publishing Switzerland 2015
286 G. Camerini

In RYGBP, a small proximal gastric pouch studies confirm these findings [6–9]. This state of
(approximately 15–30 mL in size) with a “high calorie malnutrition” is caused by poor
75–150 cm Roux-en-Y reconstruction is anasto- food quality and eating behaviors and by the
mosed 30–50 cm distally to the ligament of chronic dieting cycles of obese people. Therefore,
Treitz, combining two mechanisms promoting independently of the bariatric procedure planned,
weight loss, restriction, and malabsorption [5]. a complete nutritional assessment including
The bypass of the distal stomach, duodenum, and serum levels of vitamins and minerals is sug-
proximal jejunum causes a greater reduction of gested, in order to correct deficiencies before sur-
absorption of nutrients, a greater weight loss and gery. Indeed such deficiencies are more difficult
a greater risk of nutrient deficiency, the longer the to correct in the postoperative period, may be
Roux limb is. theoretically worsened by malabsorptive proce-
All bariatric operations entail a profound dures and, furthermore, may interfere with the
change in digestive physiology, either restricting healing process after surgery.
ingestion or reducing absorption. After any bar-
iatric operation, a negative energy balance occurs,
the body distribution of carbohydrates, proteins, 27.3 Modifications of Eating
and lipid is altered and hormonal and enzymatic Behavior
functions are modified. Indeed, in order to reach
a reduction of energy intake and a consequent Following bariatric surgery, depending on the
weight loss, the creation of another disease is procedure involved, different modifications in
required, namely “controlled starvation.” eating behavior are required, in order to obtain
Therefore, nutritional and metabolic complica- good weight results and to minimize postopera-
tions can appear, for both supplemented and non- tive problems.
supplemented operated patients, in the short and After purely restrictive procedures, patients
in the long term, the deficits most frequently must take small meals, reducing the food volume,
observed regarding iron, vitamin B12, calcium, chew very well, separate fluids and foods, eat
vitamin D, and proteins. The importance of nutri- slowly, stop eating when they feel full. The non-
tional complications may result from several fac- adherence to these recommendations results in
tors besides the type of operation performed, regurgitation, vomiting, and food blockages.
such as subclinical deficiencies preexisting sur- After RYGBP and SG, which combine a
gery, the compliance with recommended modifi- reduction of gastric volume with hormonal
cation of the eating behaviors, and nutrient changes, the avoidance of simple sugars and
supplementation on the development of postop- drinking no beverages during meals avoid regur-
erative complications. gitation and dumping syndrome.
After malabsorptive operations, protein-rich
food should be preferred and the consumption of
27.2 Deficiencies Preexisting highly refined sugars should be avoided, in order
to Surgery to improve weight loss and to prevent dumping
syndrome. High-fat foods and skimmed milk
Obese subjects, though having an excess of stores should also be avoided to prevent excessive steat-
of energy, are paradoxically quite often not well orrhea, diarrhea, and meteorism.
nourished. If adequately screened, obese patients It is recommended that all operated patients
already reveal subclinical nutritional deficiencies receive an accurate dietary education. The non-
before surgery between 40 and 80 %. The compliance of such postoperative alimentary rules
reported prevalence for vitamin D deficiency is is the primary reason of failure of reaching a good
between 50 and 80 %, for folate 20–30 %, for weight loss and of occurrence of nutritional and
selenium 10–20 %, and for iron 25–40 %. Several metabolic problems following bariatric surgery.
27 Nutritional Outcomes 287

27.4 Supplementation After malabsorptive operations, the clinical

follow-up is lighter than after purely restrictive
It is unanimously thought that after bariatric sur- procedures, as upper gastrointestinal (GI) symp-
gery a lifelong multivitamin supplementation is toms are infrequent and weight loss is, as a rule,
required. The typical supplementation model con- good. Nevertheless, the clinical and laboratory
tains at least 1,200–2,000 mg/day of calcium citrate surveillance should be anyway frequent, in this
D, 400–800 UI/day of vitamin D, 50–100 mg/day case in order to prevent, detect, and correct nutri-
of elemental iron, 300–350 μg/day of folic acid, tional complications.
and 100–350 μg/day of vitamin B12. Such regimen This is why European guidelines recommend
supplementations are planned for lifelong daily after both categories of bariatric operations the
supplementation and not to treat deficiencies. similar following protocol: checkup after
The fact is that daily supplementation with 1 month, a minimal follow-up every 3 months for
commercially available multivitamin prepara- the first year, every 6 months for the second year
tions is often insufficient to prevent nutritional and annually thereafter [12]. Similarly, in respect
deficiencies, so that additional iron, vitamin B12, of laboratory tests, according to Pournaras, it
calcium plus vitamin D supplements are indis- should be worthwhile monitoring calcium, vita-
pensable after malabsorptive procedures. min B12, ferritin, folate, and iron indices with
Gasteyger confirmed that standard multivita- blood tests at 3, 6, 12, 24 months postoperatively,
min supplementation is not adequate after and yearly thereafter for all patients submitted to
RYGBP: almost 60 % of patients 6 months after bariatric operations [13].
surgery and 100 % after 24 months needed one or
more nutritional supplements in his study [10].
The American Society for Metabolic and 27.6 Postoperative Complications
Bariatric Surgery (ASMBS) recommends a supple-
mentation for all nutrients consisting of a dosage Vomiting and diarrhea are the most frequent gas-
double compared with the normal amount, begin- trointestinal symptoms following bariatric sur-
ning as soon as possible after the operation. However, gery. They, in turns, may generate an insufficient
controlled trials are still lacking supporting the ade- oral intake or an excess of intestinal losses, both
quacy of this model of supplementation [11]. potential causes of malnutrition, respectively,
after restrictive and malabsorptive operations.
Vomiting occurs in one third of operated
27.5 Nutritional Surveillance patients, typically during the first 6 months after
surgery and is the most common complaint after
Since evidence-based data remain scarce, the bariatric surgery [14]. During this period, the
dietary strategies, the frequency of postoperative causes of vomiting are usually related to the
visits and laboratory tests, as well as the dose of inability to modify the eating behaviors, and
mineral and vitamin supplementation of operated include insufficient chewing, drinking during
patients, are at the moment still empirical. The meals, too large meals, and food intolerance. If
only three things that are certain in the follow-up vomiting persists for more than 6 months after
of operated patients are that it must be stratified surgery, an outlet mechanical problem should be
according to the specific surgical technique, per- suspected, such as a stenosis, a displacement, or
formed by a trained multidisciplinary staff (bar- slippage in case of ASGB or a stenosis of the gas-
iatric surgeon, obesity specialist, and the troenterostomy or a marginal ulceration in case
dietician) and maintained throughout life. of BPD or RYGBP.
Frequent clinical visits are necessary after Gastroesophageal reflux disease, symptomatic
restrictive procedures, in order to achieve and gallstones and medications are additional causes
maintain a good weight loss. of late vomiting.
288 G. Camerini

Table 27.1 Micronutrients recommended dietary allowances, micronutrients supplementation for prevention, and
treatment of postsurgical nutritional deficiencies
Micronutrients R. D. A. Supplementation Treatment
Vitamin B1 1–1.3 mg 100 mg 1,500 mg
250 mg i.v.
Folic acid 400 μg 800–1,000 μg 1–5 mg
1 mg/day (pregnant women)
Vitamin B12 2.4 μg 350 μg/day p.o. 1,000–2,000 μg
1,000 μg/m i.m. 1,000 μg/w i.m.
Vitamin C 75–90 mg 75–90 mg
Vitamin A 900 μg (3,000 UI) 10,000 UI/day 25,000 UI/day
Vitamin D 5 μg (200 UI) 400–800 UI/day 50,000 UI/week
Vitamin E 15 mg 150 UI/day 800–1,200 UI/day
Vitamin K 150 μg 150 μg 5–20 mg a day
Calcium 800 mg/day 1,200–2,000 mg/day 1.2 g
Iron 8–18 mg 60–120 mg 180 mg
Selenium 55 μg 55 μg
Zinc 8–11 mg 8–11 mg 220 mg

After BPD and RYGBP, diarrhea related to three energy-rich macronutrients: proteins,
dumping syndrome, lactose intolerance, bacterial starches, and fats. This can result in a deficiency
overgrowth or any intestinal infection provokes most frequently of proteins and seldom of essen-
an excess of intestinal energy and nitrogen loses, tial fatty acids.
and can impair the nutritional status in any patient
submitted to malabsorptive operations. 27.7.1.1 Protein Depletion
We should always bear in mind that after any and Protein–Energy
bariatric surgery, the insurgence of any complica- Malnutrition
tion, as well as the occurrence of any disease, can After BPD, the reduction of protein digestion,
easily result in a catabolic state and in a meta- resulting from the reduction of the time of con-
bolic impairment in an otherwise well-nourished tact between digestive enzymes and the bolus
patient. (due to asynchronia and the delayed meeting
Regarding this aspect, Faintuch analyzed the between the alimentary bolus and the biliopan-
circumstances associated with the occurrence of creatic secretions, the reduction of enzyme secre-
severe malnutrition in 11 of 236 (4.7 %) patients tion, the faster intestinal transit time, and limited
submitted to RYGBP on average 18 months after contact with the brush border of enterocytes) and
surgery, and observed that exogenous precipitat- the reduction of intestinal absorption area, causes
ing factors were present in 64 % of them [15] a decrease in protein absorption of around 30 %.
(Tables 27.1 and 27.2). Furthermore, Scopinaro demonstrated in BPD
subjects an endogenous nitrogen loss of about
5 g/day, which greatly exceeds what is consid-
27.7 Specific Deficiencies ered to be the maximum normal in intact GI tract
individuals. Both events play a significant role in
27.7.1 Macronutrient Deficiencies the pathogenesis of protein malnutrition (PM)
after BPD [16].
The purpose of obesity surgery is the reduction of Protein malnutrition represents a dangerous
energy intake. After surgery, the modification of potential complication of malabsorptive opera-
the energy balance occurs as a consequence of a tions. Scopinaro describes two types of protein
major reduction in intake, or absorption, of the malnutrition: the sporadic and the recurrent one.
27 Nutritional Outcomes 289

Table 27.2 Clinical presentation of nutritional problems after bariatric surgery

Deficiency Causal factors Complication Diagnosis
Vitamin B1 Recurrent vomiting, glucose Beriberi, dry beriberi, Low serum thiamine level,
intravenous infusion Wernicke’s encephalopathy reduced erythrocyte
transketolase activity
Folic acid Low intake Fatigue, dyspnea, fetal Serum folate <3 ng/mL,
neural-tube defects megaloblastic anemia
Vitamin B12 Reduced intake of meat or Macrocytic anemia, B12 <200 pg/mL, elevated
milk products, decreased of neuropathy, paresthesias, methylmalonic acid
intrinsic factor, bypass of sensory abnormalities, spastic homocysteine concentrations
duodenum, rapid transit time paraparesis, visual loss
in the ileum
Vitamin A Low intake, malabsorption Night blindness, conjunctival Vitamin A <1.6 μmol/L
xerosis, keratitis, corneal
scarring, dry skin, pruritus
Vitamin D Low intake, malabsorption Osteomalacia, osteoporosis Low serum
25-hydroxyvitamin D
Vitamin E Low intake, malabsorption Hemolytic anemia, pigmented Vitamin E <7 μmol/L
retinopathy, areflexia, ataxia
Vitamin K Low intake, malabsorption Bleeding disorder Vitamin K <0.3 nmol/L
Calcium Bypass of duodenum and Osteomalacia, osteoporosis Low serum calcium
proximal jejunum, vitamin myalgias, bone pain, increased augmentation of alkaline
D deficiency, bacterial risk of fracture phosphatase and parathyroid
overgrowth hormone
Iron Low meat intake, bypass of Fatigue, dyspnea, pale Microcytic anemia, low
antrum, duodenum and conjunctiva, koilonychia serum iron, high TIBC, low
proximal jejunum, serum ferritin
gastrointestinal blood loss
Selenium Low intake Cardiomyopathy, arrhythmia, Selenium <0.7 umol/L
osteoarthritis, hair loss,
impaired immunity, low thyroid
function
Zinc Reduced intake, chronic Alopecia epithelial eruption,
diarrhea glossitis, nail dystrophy, and
immune deficiencies

The sporadic protein malnutrition can occur in alimentary limb (causing insufficient protein
the early postoperative period, because of too absorption). One or more of these factors can be
drastic protein intake reduction or the preference responsible for the complication. The concept is
for carbohydrate intake, and at any time after the that specific operation as it is, in that specific
operation, because of prolonged diarrhea or subject as he/she is, is incompatible with good
reduced food intake for any reason. Of much protein nutritional status. After two or more epi-
greater importance is the recurrent form of pro- sodes of protein malnutrition, the decision for
tein malnutrition. A number of different factors, surgical revision is made, consisting of elonga-
alone or in combination, can lead to this condi- tion of the common limb. Because, protein
tion. Patient-dependent factors are insufficient absorption depends on the length of the small
protein intake, insufficient protein absorption per bowel from the GEA to the ICV, the elongation
unit of intestinal surface, and excessive loss of must not be done along the alimentary limb, but
endogenous nitrogen. Operation-dependent fac- along the biliopancreatic one. The standard
tors are too small stomach (causing too rapid which in our hands guarantees the solution of all
emptying and too rapid intestinal transit with per- protein nutritional problems is to add 150 cm, for
manently reduced absorption) and too short a final total length of 400 cm. This obviously
290 G. Camerini

entails the restabilization of body weight at an mid-jejunum. It is therefore obvious that protein
average level which corresponds to about 25 % deficiency may occur after RYGBP as well.
regain of the original excess weight [3]. This complication, indeed quite rare after
The incidence of PM in the initial series of standard RYGBP (with 75–150 cm Roux limb
Scopinaro is included between 7 and 21 % [17]. lengths), is observed more frequently after lon-
On the contrary, another study by Trotte on ger Roux limbs, with a reported incidence of
180 patients submitted to standard-BPD demon- 7–12 % [24].
strated a protein deficiency, requiring parenteral In the randomized series of Brolin, no protein
nutrition and the elongation of the common limb, deficit was showed at a minimum of 2 years after
only in two patients [18]. standard RYGBP, while 13 % of the patients sub-
Marinari in 2004 reviewed the experience of mitted to a distal RYGBP had PM [25].
our group, in the last 858 patients with “ad hoc Kalfarentzos confirmed this difference with a
stomach ad hoc alimentary limb” BPD, 5 years 5.9 % protein deficiency rate 20 months after dis-
after the operation, and found mild hypoalbumin- tal RYGBP, but no deficiency after the standard
emia in 11 % and severe in 2.4 % of BPD patients. RYGBP [26].
Reoperations were performed in 6 % of the total After standard and distal RYGBP, 1.4 and 3 %
patient population, mainly for late recurrent pro- of patients, respectively, showed an albumin level
tein malnutrition [19]. <3 g/dL in the study of Skroubis [27].
Nanni found that the main specific complica- Clinical manifestations of PEM are hypoalbu-
tion after “ad hoc stomach ad hoc alimentary minemia, asthenia, anemia, loss of muscle mass,
limb” BPD was PM, which was observed in anomalies of the skin mucosa and nails (hair loss,
3.4 % of operated patients [20]. striated nails, dermatitis), and edema. Protein
According to Marceau, the BPD-DS proce- depletion is very easy to recognize by following
dure, due to the conservation of antrum and pylo- albumin (albumin <3.5 g/dL).
rus, would be expected to reduce diarrhea and An intake of 1.0–1.5 g/kg ideal body weight
risk of PM, when compared with standard- (60–80 g/day total protein) in the early postoper-
BPD. On the contrary, the author observed a high ative period is recommended after any bariatric
incidence of protein deficiency 79 months after operation. Due to the loss of endogenous nitro-
BPD (11 % of the patients revealed albumin lev- gen greater than normal, alimentary protein
els <3.5 g/dL, and 2.4 % <3.2 g/dL), needing requirements in BPD patients have to be increased
revisional surgery in 6 % of them [21]. by 30 %, that is approximately 90 g/day. During
Dolan also found that 18 % of patients were the postoperative visits, the assessment of protein
hypoalbuminemic at a median follow-up of intake has to be performed, and protein supple-
28 months with no significant differences mentation should be given when protein intake
between BPD and BPD-DS with a common remains inferior to 60 g/day.
channel length of 50 cm [22]. Mild-to-moderate cases of PM are usually
Rabkin, in a study on 589 consecutive corrected by more frequent dietetic counseling
patients, showed that after BPD-DS, protein and increased protein intake [27].
metabolism markers were normal within the first In case of severe PM, a prompt rehospitaliza-
3 postoperative years, but with a common chan- tion and the initiation of parenteral nutrition is
nel of 100 cm [23]. mandatory. Three weeks of total parenteral nutri-
Marceau had similar results, with the length of tion (TPN) are usually sufficient to correct the
the common channel of 100 cm instead of 50 cm, acute problem, whether PM occurs after the BPD
in a subsequent study on 465 patients who under- or RYGBP.
went BPD-DS at 4 years [4].
In condition of normal GI anatomy, half of 27.7.1.2 Essential Fatty Acids
protein absorption occurs in the duodenum, the In condition of normal GI anatomy, while bile
majority of protein uptake occurring within the salts are absorbed only in the terminal ileum, fat
27 Nutritional Outcomes 291

and fat-soluble vitamins absorption occur all limited exposure of food to acid, and the exclu-
along the small intestine, the majority of lipids sion of duodenum and proximal jejunum (where
uptake occurring in the proximal two thirds of the iron is maximally absorbed) from digestive con-
jejunum. tinuity. After gastric restrictive procedures, a
Following BPD and distal RYGBP, the meet- reduction of red meat intake, the major source of
ing between the food and biliopancreatic secre- heme, and of iron-rich foods can be an important
tions and the absorption occurs in the common factor in such deficiency.
channel, resulting in a reduction of lipid absorp- SG, entailing the removal of most of the stom-
tion of around 70 %. Based on this, Scopinaro ach, so reducing the production of hydrochloric
showed, after standard-BPD, a maximum thresh- acid, is followed by iron deficiency [28]. Indeed,
old of 40 g/day of the dietary fat absorption. hemoglobin and hematocrit were less than nor-
If it is true that the shorter the length of the mal in, respectively, 28.6 and 25 % of the 82
common channel (generally varying between 50 patients submitted to SG at 5 years, in a study by
and 100 cm), the greater the fat malabsorption, Saif et al. [29]. A Dutch study confirmed a
the consequent weight loss and maintenance are, decrease in iron levels in 43 % of patients 1 year
it is equally true that longer common channels after SG [30]. On the contrary, a report from
are better tolerated, being associated with less Saudi Arabia showed no occurrence of iron defi-
steatorrhea and diarrhea. ciency 1 year after sleeve gastrectomy [31].
Fat-soluble vitamins and essential fatty acid Although there is no solid data regarding iron
deficiencies are common following malabsorp- deficiency after purely restrictive operations, this
tive procedures. Linoleic and α-linoleic acids are complication occurs surely after RYGBP and BPD.
fundamental components for the prostaglandin The American Society of Bariatric Surgery
and leukotriene synthesis. Therefore, deficit of surgeons showed the incidence of iron defi-
essential fatty acids can induce anemia, thrombo- ciency of 14–16 % after RYBG and 21–26 %
cytopenia, alopecia, and dermatitis, even if this after BPD [32].
topic has not been studied in depth. Brolin demonstrated an iron deficiency in
Fat malabsorption, clinically expressed by ste- 49–52 %, and anemia in 35–74 % in a series of
atorrhea, never present after ASGB and SG, fre- 298 superobese patients, 3 years after RYGBP,
quently present after RYGBP, is always present depending on the Roux limb length [25].
after BPD, being the principal mechanism by Skroubis found an iron deficiency after
which BPD promotes weight loss. Therefore, spe- RYGBP increasing from 26 % preoperatively, to
cial attention to the quality of alimentary fat should 39 % at 4 years, and then decreasing to 25 % at
be given after any malabsorptive operation. 5 years [27].
BPD also reduces the iron absorption, and
many studies showed a higher prevalence of iron
27.7.2 Micronutrient Deficiencies deficiency when compared with other bariatric
operations, particularly in young women [23].
27.7.2.1 Iron In the aforementioned study by Skroubis, iron
Ingested iron is solubilized, ionized, and reduced deficiency rates increased from 32.6 % preopera-
from the alimentary ferric form to its ferrous tively to 44.4 % at 4 years and 100 % at 5 years,
form by acid gastric juices, and subsequently following BPD [27].
actively transported into the cell. Iron absorption Marceau after BPD-DS showed abnormal fer-
may occur throughout the small bowel, but it is ritin levels (<20 μg/L) in 4 % of the 92 patients
best absorbed in the duodenum and in upper preoperatively, and in 25–40 % at 5 years [21].
jejunum. Dolan reported an iron deficiency in 22.9 % of
There are several mechanisms that cause iron his patients at mean follow-up of 28 months. This
malabsorption after RYGBP and BPD, including complication was similar in patients submitted to
a relatively achlorhydric gastric pouch, with BPD with or without a duodenal switch, in spite
292 G. Camerini

of the respect of antrum, pylorus, and a cuff of Sometimes, parenteral iron infusion with iron
duodenum entailed with the latter operation [22]. dextran, ferric gluconate, or ferric sucrose is
Skroubis demonstrates no differences in the needed either in patients who have poor response
incidence of iron deficiency, in a study compar- to oral iron therapy or in case of intolerance or
ing patients submitted to RYGBP or BPD at a noncompliance. Intramuscular iron is not tolera-
5-year follow-up [27]. ble in the long run. On the contrary, intravenous
Brolin demonstrated a significant decline in iron dextran can be well tolerated by patients,
the iron status in 63 % of 140 subjects followed also as an outpatient procedure, and can be used
for 2 years after RYGBP in spite of a correct stan- regularly.
dard supplementation. This suggests that addi- After bariatric surgery, iron deficiency can
tional prophylactic iron supplements should be occur early after surgery or after some time.
provided for women to prevent iron deficiency, in Patients submitted to RYGBP and BPD require
addition to the standard supplementation [33]. postoperative screening for iron status, including
The laboratory diagnosis for iron deficiency blood count with MCV, serum iron, ferritin, and
includes anemia with a low MCV, low serum TIBC. After the first year, these values should be
iron, high TIBC, and low serum ferritin level. checked yearly or biyearly throughout life.
Subjective manifestations are fatigue, reduced
exercise tolerance and dyspnea. On examination, 27.7.2.2 Vitamin B1
the patient has pale conjunctiva, koilonychia Thiamin absorption is maximal in the small bowel,
(spoon nails), hair loss, and possibly atrophic thanks to a mechanism of active transport, medi-
glossitis. ated by a specific sodium and energy-dependent
Though malabsorption is the obvious reason carrier, and a mechanism of passive diffusion. The
to explain any iron deficiency after bariatric sur- vitamin B1 deficiency has a low prevalence: only
gery, an additional mechanism for iron deficiency 29 cases were identified in a study on 168,010 bar-
after RYGBP and BPD is the gastrointestinal iatric operations, (0–0.002 %) [34], but it is a
blood loss. Typical sites of bleeding are a mar- major complication of all bariatric operations.
ginal ulcer (on the anastomosis between the jeju- As vitamin B1 is contained in all aliments, the
num or ileum and the gastric pouch), an deficit occurs as a consequence of the association
iron-losing enteropathy of bypassed loop, an of frequent episodes of vomiting and a reduced
overgrowth of intestinal bacteria phenomenon in intake. It is not evident if the decreased absorp-
the small bowel excluded, or hemorrhoids. But tion plays a role in the development of the defi-
any pathology of the GI tract (such as a gastroin- ciency. Symptomatic thiamine deficiency has
testinal cancer) should be excluded in refractory been observed both after restrictive and malab-
cases. sorptive procedures. The small amount of liver
Oral treatment usually consists of 325 mg of thiamine stored (which last approximately
ferrous sulfate or 200 mg of ferrous fumarate 30 days) contributes to this deficiency weeks or
(providing about 65 mg of iron), one to two tab- months after surgery.
lets a day as prophylaxis, and three to four tablets Since vitamin B1 is involved in carbohydrate
a day to correct iron deficiency. The bypass of the metabolism, administration of intravenous glucose
antrum and duodenum makes the iron absorption or dextrose in patients complicated or dehydrated
very difficult in deficient patients. Preparations from vomiting, who have low vitamin B1 reserves,
containing elemental iron complexed with a has been reported to be a precipitating factor for
polysaccharide are well absorbed and can be Wernicke’s encephalopathy (bariatric beriberi).
assumed in single daily doses of 100–200 mg. A few cases of the deficiency have been
The dosage may be increased if iron parameters reported after ASGB [35].
do not improve within a few months of starting Low levels of thiamine were demonstrated in
therapy. The addition of vitamin C enhances the 0–11 % of patients 1 year after SG and in 31 % of
absorption. patients after 5 years [36].
27 Nutritional Outcomes 293

In a series of 141 patients submitted to secretion (responsible for the vitamin bioavail-
RYGBP, the prevalence of thiamine deficiency ability) and the lack of contact of food with the
was 18 % after 1 year and 11 % after 2 years [37]. duodenum and the proximal third of the jejunum,
A study on 1,663 patients submitted to BPD primary sites of its absorption.
demonstrated an incidence of 0.18 % of Gasteyger found a significant decrease in
Wernicke’s encephalopathy 3–5 months after the serum folate in 44 % of 36 women submitted to
operation [38]. ASGB 2 years after surgery [39].
The laboratory diagnosis for deficiency Folate deficiency has an incidence of 9–35 %
includes a low serum thiamine level and a reduced after bypass surgeries [40].
erythrocyte transketolase activity. Halverson demonstrated that 1 year after gas-
Wernicke’s encephalopathy classically pres- tric bypass, 63 % of patients have folate defi-
ents with a clinical triad: ocular manifestations, ciency [41].
(such as nystagmus and ocular palsies), ataxia, Another study by Brolin showed folate defi-
and mental disturbances such as confusion. More ciency in 22 % of patients 2 years after the opera-
often, an isolated peripheral neuropathy is tion [33].
described (dry beriberi) with symptoms of pain, On the contrary, the risk of folate deficiency is
burning, or tingling in the distribution of the negligible in the long term, because an important
affected sensory nerves, or peripheral extremity bacterial synthesis of the vitamin occurs in the
weakness in case of motor impairment. small intestine, progressively colonized after
In case of suspected deficiency, prompt recog- most bariatric operations.
nition and immediate treatment with 50–100 mg Clinical manifestations of folate deficiency
of parenteral thiamine every 8 h can resolve ocu- are megaloblastic anemia or a normocytic ane-
lar symptoms within a few days, but neurologic mia, characterized by increased red cell distribu-
sequelae need months to completely regress, and tion width. On the contrary, high serum folate
are often not totally reversible. levels are a specific marker for intestinal bacterial
In patients with protracted vomiting, aggres- overgrowth.
sive supplementation with thiamine for 1 month Unlike iron and vitamin B12, routine multivi-
after surgery avoids the deficiency. tamin preparation (400 μg/day) is sufficient to
Compliance to a multivitamin supplement is maintain a good folate status.
usually sufficient to prevent thiamine deficiency The correction of folate deficit consists of oral
in most of the cases. folic acid 1–5 mg daily, even if the deficiency is
The presence of a bacterial overgrowth in the as a rule corrected with multivitamin supple-
bypassed bowel must be considered when ments alone.
patients do not respond to an adequate oral ther- A folate supplement of 1 mg/day is particu-
apy, due to an increased consumption. In these larly important in pregnant women, in order to
cases, the diagnosis can be confirmed by eleva- avoid risks of fetal neural-tube defects in case of
tion of serum folate level or by the increase in deficiency.
hydrogen or methane in breath after an oral load
of glucose. 27.7.2.4 Vitamin B12
Vitamin B12 deficiency is a common conse-
27.7.2.3 Vitamin B9 (Folate) quence both of restrictive procedures and malab-
Folate deficiency, defined as serum folate levels sorptive ones, and involves multifactorial origin.
<3 ng/mL, is the most common nutrient defi- RYGBP and BPD, but also SG, excluding the
ciency after gastric restrictive procedures, usu- majority of parietal cell mass and chief cells, pri-
ally caused by a decrease in the intake of marily located in the fundus and body of the
vegetables in the immediate postoperative period. stomach, cause a significant vitamin B12 bio-
After RYGBP and BPD, the deficiency is pro- availability reduction and a decreased production
duced by a reduction of acid and pepsinogen of intrinsic factor, a glycoprotein produced by
294 G. Camerini

parietal cells, required for absorption of the vita- and development of disorders of both CNS and
min in the terminal ileum. PNS. These can include paresthesias, sensory
Further potential mechanisms for the vitamin abnormalities, spastic paraparesis, visual loss,
malabsorption after RYGBP and BPD are the cognitive, and neuropsychiatric manifestation.
bypass of duodenum and the rapid transit time in Levels of vitamin B12 <200 pg/mL can indi-
the ileum. The risk of B12 deficiency is also cate the presence of deficiency. Measurement of
increased after purely restrictive surgery, if serum methylmalonic acid and homocysteine
patients reduce their intake of meat or milk concentrations, the preferred marker of B12 sta-
products. tus, can for certain confirm the deficiency.
In a group of 100 patients planned for bariatric The optimal dosage has not yet been demon-
surgery, the incidence of vitamin B12 deficiency strated, but 350–1,000 μg a day generally cor-
has been demonstrated in 5 % of subjects [42]. rects low levels of vitamin B12 in 95 % of
SG should have a more important effect on patients. After RYGBP, oral supplementation
B12 status, compared with other restrictive pro- with crystalline vitamin B12 corrects deficiency
cedures, due to resection of the fundus and the in most cases, as ileal absorption of crystalline
body of the stomach. Indeed, deficiencies in vita- B12 remains normal. Probably in BPD patients,
min B12 have been showed at 1 and 3 years fol- nasal or sublingual preparations of vitamin B12,
lowing SG [28], but not in the study by Saif [29]. widely promoted nowadays, are better absorbed
Abnormal serum B12 levels (<180 pg/mL) than oral forms to normalize vitamin levels [46].
were observed in 154 of 429 patients (36 %) at an Parenteral treatment with cyanocobalamin
average of 22 months after gastric bypass surgery 1,000 μg every month, or 3,000 μg every
in a study [43]. 6 months, is necessary if oral supplementation is
Another study confirmed that 33 % of patients not adequate to sustain a sufficient blood level of
have vitamin B12 deficiency (<250 pg/mL) the vitamin.
1 year after gastric bypass [41]. Evaluation of vitamin B12 deficiency is
Brolin also showed vitamin B12 deficiency in indispensable in all patients submitted to RYGBP,
37 % of patients 2 years after gastric bypass [33]. BPD, and SG every year. Indeed, since symptoms
Comparing 45 and 25 patients submitted, are frequently absent, ongoing B12 deficiency in
respectively, to BPD-DS and RYGBP at 2 years, the long term causes considerable risks of irre-
Breton showed that vitamin B12 deficiency was versible neurological damage.
more common in patients with gastric bypass [44].
The prevalence of vitamin B12 deficiency 27.7.2.5 Vitamin D and Calcium
after bariatric surgery ranges from 4 to 62 % [45], It has been reported that calcium and vitamin D
whereas clinical symptoms are less common. deficiency occurs in 25–75 % of obese patients
This variability from study to study can be even prior to surgery. A negative correlation
explained both by the different length of follow- between BMI and vitamin D levels was demon-
up of studies, conditioning the time necessary to strated by Buffington [47].
deplete the considerable body storage of vitamin, Another study on 213 patients candidate for
and by the differences in regime and adherence to surgical treatment of obesity showed that hyper-
supplementation. parathyroidism was present in 25 % of subjects,
Vitamin B12 is synthesized by bacteria and it and that 21 % of patients had abnormally low lev-
is present in all forms of animal tissues, but not in els of 25-hydroxyvitamin D, PTH being posi-
fruits and vegetables. The recommended dietary tively correlated with BMI [48].
intake is about 5 μg per day. The normal human The possible explanations are a storage and
body storage of the vitamin is about 2,000 μg, so sequestration of vitamin D in adipose tissue, a
the deficiency occurs years after surgery. reduction of physical activity, an insufficient
Clinical manifestations of vitamin B12 defi- exposure to solar ultraviolet radiations with a
ciency are the pernicious (megaloblastic) anemia decreased skin production, and a lowered hepatic
27 Nutritional Outcomes 295

hydroxylation of the vitamin in obese 4 years after BPD, with a corresponding increase
population. in PTH levels in 69 % of patients at 4 years [54].
Following bariatric surgery, the rapid weight Another study on 82 subjects submitted to BPD
loss liberates vitamin D from adipose tissue, with showed that 25 % were hypocalcemic, 50 % had
a temporary increase in vitamin D hematic con- low vitamin D and 63 % had elevated PTH, at
centrations. Recent studies confirm that plasma median follow-up of 32 months [55].
concentrations of vitamin D2 increase at 1 month The duodenal switch does not improve the
after surgery and have a decreasing trend over the vitamin D status compared with standard-BPD
following months [49]. [22], while reducing the degree of fat malabsorp-
Calcium is absorbed with a specific mecha- tion by lengthening the common channel pro-
nism of active transport, mediated by a specific duces a lower incidence of vitamin D deficiency
carrier, in the duodenum and proximal jejunum, and hypocalcemia [6, 56].
and with a mechanism of passive diffusion in the Marceau showed only modest changes of the
remaining small bowel and colon. Vitamin D is bone mineral density analysis 4 and 10 years
absorbed in the jejunum and ileum. After RYGBP after BPD, provided that there is appropriate sup-
and BPD, calcium and vitamin D malabsorption plementation and close surveillance to avoid for
results from the loss of acid action, and from the specific long-term disturbances [57].
exclusion of duodenum and proximal jejunum The alterations in bone metabolism following
(the primary sites for calcium absorption), from bariatric surgery are associated in the long term
digestive continuity. Vitamin D deficiency is an with loss of bone mass and osteomalacia with
additional cause of calcium malabsorption. complaints of myalgias, difficulty walking, bone
Bacterial overgrowth in the bypassed small intes- pain, back pain, or aching of the limbs, and an
tine can further interfere with vitamin D increased risk of fracture [58]. Larger scale inves-
absorption. tigations are needed to associate with certainty
Patients submitted to restrictive bariatric sur- the deficit of vitamin D to peripheral vascular
gery can be afflicted by bone mass abnormalities disease, rheumatoid arthritis, diabetes, and can-
as well as due to a restriction of calcium intake, cer [59].
even if conclusive data are lacking in respect of As calcium decreases in the blood, parathy-
the association of ASGB or SG and of altered roid hormone levels increase, with releasing of
calcium and vitamin D homoeostasis [50]. calcium from bone and consequently osteoporo-
On the other hand, it is well known that sis. Hence serum calcium measurement is not a
patients with a rapid weight loss from any cause reliable marker in the follow-up of postoperative
are prone to bone mass loss, even in the presence calcium metabolism. Operated patients maintain
of normal vitamin D and parathyroid hormone normal serum calcium levels while bone loss and
levels. osteoporosis are in progress. Therefore, calcium,
Literature shows a prevalence of the defi- phosphorus, alkaline phosphatase, parathyroid
ciency ranging from 7 to 60 % after RYGBP [37, hormone, and 25-hydroxyvitamin D should be
49], longer bypass limb lengths being followed monitored every 6 months in patients submitted
by lower vitamin D levels [51]. Johnson con- to RYGBP or BPD.
firmed a linear reduction of vitamin D concentra- It is not known if calcium 1.2–1.5 g/day and
tion and a linear increase in PTH increasing the vitamin D 800 UI/day, contained in standard sup-
Roux limb length in RYGBP [52]. plementation, are adequate to prevent deficien-
Calcium and vitamin D deficiency appears cies in the long run. What is certainly proven is
even more severe after BPD. Metabolic bone dis- that these amounts did not always normalize
ease was present in 30 patients (73 %) in one markers of bone resorption and secondary hyper-
study by Compston et al. [53]. parathyroidism [56]. Anyway, the dosage may be
Levels of vitamin D lower than normal are increased if calcium parameters do not improve
reported in 57 and 63 %, respectively, 1 and within a few months.
296 G. Camerini

Since calcium from carbonate is not available supplementation at higher levels than the current
in the absence of gastric acidity, calcium citrate is recommended dietary allowances (RDA) (55 mcg/
more easily absorbed after bariatric surgery and it day) in patients submitted to bariatric surgery.
is the preferred preparation for replacement.
In case of important serum deficiency, the 27.7.2.7 Zinc
global dose for treatment is at least 600,000 IU of Zinc has a role in reducing the oxidative pro-
vitamin D2 (ergocalciferol), usually 50,000 IU cesses, protecting protein sulfhydryls, reducing
taken orally once per week for 6–8 weeks. the hydroxyradical formation, or inducing in the
A great prudence should be used in perform- liver, gut, and kidney the synthesis of the metallo-
ing bariatric surgery in patients previously sub- thioneins, a group of amino acids that have been
mitted to thyroid or parathyroid operations, shown to scavenge free radicals and bind some
because intractable symptomatic hypocalcemia oxidants. Therefore, zinc deprivation results in an
was described years after BPD [60, 61]. increased sensitivity to oxidative stress.
Zinc absorption occurs throughout the length
27.7.2.6 Selenium of the small intestine, the majority of zinc uptake
Selenium is a nutritional essential trace element, occurring in the jejunum and depending on lipids
a fundamental component of glutathione peroxi- absorption.
dase (GTP), an enzyme active against oxygen- Low zinc concentrations have been described
derived free radicals. Severe selenium deficiency after gastric restrictive procedures by reason of a
can induce cardiomyopathy, arrhythmia, muscle reduced intake.
wasting, osteoarthritis, hair loss, loss of skin and Since zinc absorption depends on fat absorp-
hair pigmentation, impaired immunity, low thy- tion, low zinc concentrations are observed in
roid function, and progressive encephalopathy. patients submitted to RYGBP and BPD.
The evidence linking selenium deficiency and an Vanderhoof showed no differences in either
increased incidence of cancer is conflicting. hair or serum zinc levels between 14 patients sub-
Due to the reduction in food intake, and the mitted to BPD 12–56 months earlier and 11 obese
fact that most selenium is absorbed in condition patients [63].
of normal GI anatomy in the duodenum, patients Madan found abnormal levels of zinc in 36 %
submitted to BPD and RYGBP can be prone to of 33 patients 1 year after RYGBP [42].
disturbances of selenium and GTP homeostasis. After BPD with or without the duodenal
Few clinical studies concerning selenium defi- switch, zinc deficiency was demonstrated in
ciency after bariatric surgery have been published. 10.8 % of patients, despite the fact that more than
Abnormal levels of selenium status were 80 % took correct supplementation [22]. Slater
reported preoperatively in 30 %, and 1 year after showed a zinc deficiency in half of 170 patients
RYGBP in 36 % of patients in one study [42] . 4 years after BPD-DS [54].
In another study by Freeth, a significant reduc- Despite these findings, clinical consequences
tion of serum selenium level was demonstrated of zinc deficiency, such as alopecia epithelial
3 months after GB and RYGBP, while the level eruption, glossitis, nail dystrophy, and immune
trended back toward baseline values at 12 months, deficiencies are seldom reported.
without any supplementation [62]. Indeed the transient hair loss, very often
Dolan found that 14.5 % of patients were defi- occurring a few months after bariatric surgery,
cient in selenium (<0.7 umol/L), at a median has a controversial pathogenesis (including the
follow-up of 28 months with no significant dif- “stress of weight loss,” or iron or protein spar-
ferences between BPD and BPD-DS with a com- ing), and is not always is imputable to zinc defi-
mon channel length of 50 cm and no clinical ciency [64].
consequences [22]. One study reported resolution of alopecia
There are insufficient data to justify both routine after supplementation with zinc sulfate in patients
screening for selenium deficiency and selenium submitted to VBG [65].
27 Nutritional Outcomes 297

In case of deficiency, the treatment consists of α-tocopherol. This vitamin has antioxidant prop-
oral zinc sulfate (220 mg/day). erties, preventing the propagation of free radical
damage within the cell membranes. Vitamin E
27.7.2.8 Other Fat-Soluble Vitamins deficiency should be considered, particularly fol-
Vitamin A lowing malabsorptive operations, in patients with
Vitamin A complex is a family of essential fat- hemolytic anemia, pigmented retinopathy, hypo
soluble compounds, formed by carotenoids, retinols, or areflexia, ataxia, and skeletal myopathy.
and β-carotenes, required for cell proliferation and Ledoux found a prevalence of vitamin E defi-
differentiation, growth, reproduction, and vision. ciency of 11.8 % in the ASGB group compared
The normal human liver generally stores a quantity, with 22.5 % in the RYGBP group (P < 0.05) [66].
sufficient for 1 year of vitamin A requirement. Dolan demonstrated low levels of vitamin E
Common manifestations of vitamin A defi- (<7 μmol/L), only in 5 % of patients, the majority
ciency are night blindness, conjunctival xerosis, taking supplements, at an average of 28 months
keratitis, corneal scarring, possibly leading to after BPD [22].
blindness, dry skin, dry hair, and pruritus. Other Another study showed an incidence of 4 % of
uncommon symptoms are decreased visual acu- vitamin E deficiency not increasing at 1 and
ity and reduced resistance to infections. 4 years after BPD-DS in patients taking vitamin
Ledoux showed a prevalence of vitamin A supplements [54].
deficiency of 25.5 % in the ASGB group com- Vitamin E deficiency is not common, and has
pared with 52.5 % in the RYGBP group (P < 0.01) not been shown to be clinically significant in
in one study [66]. patients following supplementation protocol [70].
Brolin reported a deficiency in 10 % of If demonstrated, the treatment of vitamin E
patients, 4 years after distal RYGBP, in spite of deficiency consists of oral vitamin E 800–
vitamin A correct supplementation [33]. 1,200 IU a day.
Several studies showed vitamin A deficiency
manifestations after BPD [67–69]. Vitamin K
Dolan demonstrated low levels of vitamin A Vitamin K includes a cluster of compounds, all
(<1.6 μmol/L) in 61 % of patients submitted to containing 2-methyl-1,4-naphthoquinone
BPD with or without duodenal switch at a mean nucleus, involved in the formation of the seven
28 months follow-up, despite an 80 % compliance vitamin K-dependent coagulation proteins (pro-
rate with multivitamin supplementation [22]. thrombin, factors VII, IX, and X, protein C, Z,
An incidence of vitamin A deficiency of 69 % and S), all fundamentals for blood clotting. The
4 years after BPD-DS, with a progressive increase vitamin has a widespread distribution, in plants
in the incidence and severity of hypovitaminemia and animal tissues, and the intestinal flora of the
was reported in another study [54]. normal gut contributes to most of the daily
Marceau showed a deficiency of vitamin A in requirements. The total body pool of vitamin K is
12 % of 233 patients 8 years after standard-BPD, surprisingly small and the turnover rapid. Its defi-
and in 5 % of 457 patients 4 years after BPD-DS ciency can entail abnormalities of coagulation
despite a prophylactic supplementation [4]. and increased bleeding tendency.
A daily supplementation of 10,000 IU of vita- Dolan compared the BPD with and without the
min A is recommended. duodenal switch and showed that half of his patients
In case of deficiency oral replacement with were deficient in vitamin K, with no significant dif-
vitamin A, 10,000 UI/day normalizes the visual ferences between the two operations [22].
acuity within few months. An incidence of vitamin K deficiency
(<0.3 nmol/L) in 68 % of patients, with a pro-
Vitamin E gressive increase in the incidence and severity
Vitamin E is a collective name for all tocol and with time after BPD, was found in another
tocotrienol molecules, which have the activity of study [54].
298 G. Camerini

Table 27.3 Recommended follow-up of the operated patient

1 month 3 months 6 months 12 months 24 months Annually
Chemistry panel All operations All operations All operations All operations All operations All operations
Blood count All operations All operations All operations All operations All operations All operations
Vitamin B1 All operations All operations RYGBP, BPD RYGBP, BPD RYGBP, BPD RYGBP, BPD
(persistent (persistent
vomiting) vomiting)
Vitamin B12 – – RYGBP, BPD All operations All operations All operations
Folic acid All operations – RYGBP, BPD RYGBP, BPD – –
Vitamin A – – RYGBP, BPD RYGBP, BPD RYGBP, BPD RYGBP, BPD
Vitamin D – RYGBP, BPD RYGBP, BPD RYGBP, BPD All operations All operations
Vitamin E – – – Optional Optional Optional
Vitamin K – – – Optional Optional Optional
Iron – RYGBP, BPD RYGBP, BPD RYGBP, BPD All operations All operations
Selenium – – – RYGBP, BPD Optional Optional
Zinc – – – RYGBP, BPD RYGBP, BPD RYGBP, BPD
Parathyroid – – – RYGBP, BPD RYGBP, BPD RYGBP, BPD
hormone
Bone density – – – RYGBP, BPD RYGBP, BPD RYGBP, BPD

reaching extreme weight loss and to patients

In spite of this, clinical manifestations of vita- with frequent vomiting or poor food intake,
min K deficiency have seldom reported after bar- even after SG or ASGB. Any deficiency can be
iatric surgery. Nevertheless, it is strongly prevented by a correct monitoring of operated
suggested to regularly monitor serum fat-soluble patients and by an adequate nutritional supple-
vitamins before and after BPD. mentation strategy. Significant nutritional com-
A daily supplementation of 300 μg of vitamin plications are uncommon and are, as a rule,
K is recommended. easily corrected, on condition that a prompt
In case of vitamin K deficiency, the therapy diagnosis and an adequate therapy are per-
consists of oral vitamin K 5–20 mg/day [13] formed by a multidisciplinary team. Even if
(Table 27.3). experts have recently developed and compiled
practical recommendations and a few clinical
Conclusion guidelines, the long-term nutritional outcome
Modern bariatric surgery has a major role in the data are presently poor, and consensus is still
control of weight and of obesity-related co- lacking on many critical issues. Further ran-
morbidities; it can be safely performed in domized prospective trials are needed to develop
selected patients, and decreases mortality rates more appropriate guidelines for follow-up and
in surgically treated obese patients. However, supplementation of operated patients.
the majority of studies suggest a long-term pat-
tern of nutritional and metabolic complications
following bariatric surgery. The type of opera-
tion suggests which metabolic problem and
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 Long-Term Follow-Up After
Bariatric Surgery 28
Konstantinos Spaniolas and Walter J. Pories

28.1 The Birth of Metabolic 28.2 Weight Loss

Surgery
The weight-loss effects of bariatric surgery have
Bariatric surgery was initially devised as the been well established. The Swedish Obese
surgical means for weight loss in patients Subjects (SOS) study prospectively followed
whose weight was deemed extremely abnor- 2,010 patients undergoing bariatric surgery, and
mal. Since that time, the obesity epidemic has compared them with 2,037 matched controls who
lead to continuously increasing the numbers of underwent medical management of obesity [3].
severely obese people, with more than a third Even though the majority of patients underwent a
of the western population being obese. Since bariatric procedure that has been subsequently
the birth of bariatric surgery in the middle of found to be suboptimal and abandoned, long-
the previous century, more bariatric procedures term follow-up results are available up to 20 years
are being performed over time. Even though after intervention. With a median follow-up of
weight loss was the primary focus of this field 15 years and a baseline BMI of 42, the mean
early on, alterations in metabolism were com- weight loss was 18 % of baseline. The weight- 36

monly seen, and attributed to malabsorption loss curves for all procedures demonstrate a com-
associated with intestinal bypasses [1, 2]. Over mon pattern: dramatic loss during the first year,
time, the metabolic and hormonal effects asso- followed by minimal gradual weight regain for
ciated with bariatric procedures have led to the the subsequent few years until plateau.
transformation of the field and the birth of met- In order to address the low percentage of Roux-
abolic surgery. en-Y gastric bypass (RYGB) in the SOS study
and complement its results, the Longitudinal
Assessment of Bariatric Surgery (LABS) study
was designed as a prospective nonrandomized
study at six clinical centers in the United States.
This is one of the few high-volume cohorts on
bariatric patients undergoing currently accepted
weight-loss procedures. Reports from the 3-year
K. Spaniolas • W.J. Pories (*) follow-up of 1,738 patients who underwent RYGB
Department of Surgery, Brody School of Medicine,
and 610 adjustable gastric banding (AGB), dem-
East Carolina University, 600 Moye Boulevard,
Greenville, NC 27858, USA onstrate median weight loss at 31.5 and 15.9 % of
e-mail: [email protected]; [email protected] baseline for the two groups, respectively [4].

M. Lucchese, N. Scopinaro (eds.), Minimally Invasive Bariatric and Metabolic Surgery: 303
Principles and Technical Aspects, DOI 10.1007/978-3-319-15356-8_28,
© Springer International Publishing Switzerland 2015
304 K. Spaniolas and W.J. Pories

Table 28.1 Long-term weight loss with bariatric surgery

Study Procedure/ Follow Weight loss
sample size Design BMI up (years)
SOS [3] AGB: 376 Prospective, matched, 42.4 14.7 18 % of baseline weight
VBG: 1,369 nonrandomized
RYGB: 265
LABS [4] RYGB: 1,738 Prospective, 46 3 RYGB: 31.5 % of baseline
AGB: 610 nonrandomized AGB: 15.9 % of baseline
Buchwald RYGB: 7,074 Meta-analysis 46.9 Variable 61.2 % EBWL
meta-analysis [5] AGB: 3,873 (AGB 47.5 %, RYGB 61.6 %,
VBG: 1,568 VBG 68.2 %, DS 70.1 %)
DS: 4,035
Utah Obesity RYGB: 418 Retrospective 45.9 6 27.7 % of baseline weight
Study [6]
East Carolina RYGB: 608 Retrospective 49.7 7.6 years: 32.5 % of baseline weight at
University [7] 317 at 5 years 5-years
158 at 10 years 32.3 % at 10-years
10 at 14 years
AGB adjustable gastric banding, VBG vertical band gastroplasty, RYGB Roux-en-Y gastric bypass, DS duodenal switch,
BMI body mass index, EBWL excess body weight loss

Table 28.1 lists long-term weight-loss diabetes control and have provided high quality
results with multiple bariatric procedures, based data in this topic. The first one evaluated 150
on multiple studies with different research obese (BMI > 27) patients with poorly controlled
methodologies. diabetes [9]. Patients were randomized to intense
medical therapy, consisting of lifestyle counsel-
ing, weight management programs, incretin ana-
28.3 Diabetes logs, and frequent visits with an endocrinologist,
vs bariatric surgery, and the purpose of the study
Diabetes remission as a concept became a focus was to achieve diabetes control. Diabetes control
of interest as a result of outcomes with bariatric (12 % vs 42 % vs 37 %) and remission (0 vs
surgery. Since this is a chronic condition, and 42 % vs 27 %) at 12-months after surgery were
long-term data are lacking, “cure” as a term is significantly more common in the bariatric sur-
seldom used. Normalization of blood glucose and gery groups than medical treatment. A similar
HgA1c in the absence of antiglycemic medica- study from Italy on 60 severely obese patients
tions defines remission. This has been histori- with poorly controlled diabetes, randomized
cally a rare occurrence with medical therapy, but patients to intense medical therapy vs RYGB vs
bariatric surgery has led to the International BPD [10]. Diabetic remission at 48 months after
Diabetes Federation suggesting surgical therapy surgery was significantly higher after RYGB
as a valid option for the treatment of diabetes. (75 %) and BPD (95 %) compared to medical
A recent meta-analysis of 19 different studies treatment (nil). The intensity of medical therapy
revealed that bariatric surgery overall is associ- is illustrated on the fact that it led to an 8 %
ated with a 0.33 risk reduction for the presence decrease in BMI and discontinuation of antihy-
of type 2 diabetes postoperatively [8]. As multi- pertensive medications in 70 % of the group.
ple single-institution studies have previously The effect of bariatric surgery on diabetes is
shown (Table 28.2), this meta-analysis again not only about remission, but also about prevent-
underlines a significant difference in risk reduc- ing its development in the severely obese. In the
tion between RYGB/biliopancreatic diversion SOS study, the adjusted odds ratio for new-onset
(BPD) and AGB (0.26 vs 0.44, p < 0.0001). diabetes was 0.25 in the surgery group compared
A few recent randomized controlled trials have to the medically treated group [18]. The preva-
assessed the effect of bariatric surgery on lence at 10 years after surgery was 5–10 %. In
28 Long-Term Follow-Up After Bariatric Surgery 305

Table 28.2 The effect of bariatric surgery on diabetes remission and improvement during follow-up
Procedure/ Follow-up
Study sample size Design BMI (years) Diabetes
LABS [4] RYGB: 1,738 Prospective, 46 3 RYGB: 67 % partial
(320 diabetics) nonrandomized remission
AGB: 610 AGB: 28.6 % partial
(98 diabetics) remission
SOS [11] AGB: 376 Prospective, 42.4 2 72 %
VBG: 1,369 matched, 10 36 %
RYGB: 265 nonrandomized
(323 diabetics)
Buchwald meta- RYGB: 7,074 Meta-analysis 46.9 Variable 76.8 % remission (AGB
analysis [5] AGB: 3,873 47.9 %, RYGB 83.7 %,
VBG: 1,568 VBG 71.6 %, DS 98.9 %)
DS: 4,035 85.4 % improvement
(2,331 diabetics)
Utah Obesity Study [6] RYGB: 418 Retrospective 45.9 6 62 % remission
(93 diabetics)
East Carolina RYGB: 608 Retrospective 49.7 Variable (−14) 82.9 % remission
University [7] (165 diabetics, 99 % normalization of IFG
165 IFG)
Virginia Commonwealth RYGB: 1,025 Retrospective 51 Variable 83 % resolution
University [12] (154 diabetics) (91 % 2)
Fresno, CA [13] RYGB: 242 Retrospective NR Variable 83 % resolution or
(45 diabetics) (51 at 10) improvement at 2 years
67 % at 10 years
University of RYGB: 191 (177 Retrospective 50.1 20 months 83 % remission
Pittsburgh [14] diabetics, 14 IFG) 17 % improvement
San Diego, CA [15] RYGB: 500 Retrospective NR Variable 97 % resolution
(85 diabetics)
University of Oslo [16] RYGB: 184 Retrospective 46 5 67 % remission
(49 diabetics) 20 % improvement
Cleveland Clinic [9] RYGB: 50 Randomized 36 1 42 % remission for RYGB
SG: 41 controlled 27 % remission for SG
(all diabetic) (no statistical difference
between the groups)
Università Cattolica del RYGB: 19 Randomized 45 2 75 % remission for RYGB
Sacro Cuore [10] BPD: 19 controlled 95 % remission for BPD
(all diabetic)
Monash University AGB: 30 Randomized 37 2 73 % remission with AGB
Medical School [17] (all diabetic) controlled vs 13 % for medical therapy
AGB adjustable gastric banding, VBG vertical band gastroplasty, RYGB Roux-en-Y gastric bypass, DS duodenal switch,
BMI body mass index, IFG impaired fasting glucose, NR nonreported

comparison, the Framingham Study addressed study randomized over 3,000 overweight and
the question of the effect of medical weight loss obese (mean BMI of 34) patients with pre-
on diabetes prevention [19]. Overweight patients diabetes to intense lifestyle changes vs metfor-
(total 618) who lost at least 1 lb/year were com- min vs placebo [20]. The incidence of diabetes
pared to patients with weight regain and ones in this high-risk group at 10 years was 40 %.
with weight stable in this time period. Adjusting Lifestyle modification (including low-caloric
for years of follow-up, diabetes at the weight- low-fat diet, moderate physical activity, and one-
stable patients occurred in 8.1 per 1,000 person- to-one educational sessions) was associated with
years; sustained weight loss led to a 37 % lower a significant decrease in the prevalence of diabe-
risk of diabetes development (relative risk 0.63). tes (OR 0.42), but less to what is achieved with
Similarly, the Diabetes Prevention Program bariatric surgery.
306 K. Spaniolas and W.J. Pories

28.4 Hypertension gery allows for improvement in the lipid profiles

in the majority of patients. In a large meta-
The effect of bariatric surgery on hypertension is analysis from 2004, improvements in hypertri-
variable, but all studies universally demonstrate glyceridemia, hypercholesterolemia, and
improvement after surgery. In a comparison anal- hyperlipidemia occurred in 92.8 % (912 of 983),
ysis of 418 patients undergoing RYGB, hyperten- 86.6 % (1,777 of 2,051), and 83 % (846 of 1,019),
sion remission was reported in 53 % of the 169 respectively [5]. These numbers for RYGB and
hypertensive patients at 2 years after bariatric DS exceeded 90 % for all measures. A more
surgery, and 42 % at 6 years [6]. Using meta- recent meta-analysis evaluating overall cardio-
analytic methods on almost 7,000 bariatric vascular risk reduction after surgery, reported a
patients, hypertension resolved postoperatively hyperlipidemia risk reduction of 0.39 for patients
in 65.6 % and improved in 81.8 % [5]. There was undergoing bariatric surgery; RYGB and BPD
a significant difference between the stapling pro- were associated with a risk reduction of 0.26 [8].
cedures (RYGB and DS) and AGB, with almost a A second recent review of 25 bariatric studies
twofold difference in the rate of hypertension reporting on lipid outcomes found resolution or
remission after intervention. A more recent anal- improvement of dyslipidemia in 76 % of patients
ysis reported similar findings with 0.52 risk participating in a bariatric surgery randomized
reduction for hypertension after bariatric surgery control trial and 68 % of patients included in
[8]. Similarly, another meta-analysis with a total observational studies [21].
of 243 randomized bariatric patients and almost Long-term assessment of lipid profiles after
17,000 observed nonrandomized patients found RYGB demonstrates sustained improvement in
hypertension improvement or resolution in 75 dyslipidemia with surgery [6]. Normalization
and 74 %, respectively [21]. for HDL, LDL, and triglycerides 6 years after
Prospective long-term data on remission of RYGB was seen in 67, 53, and 71 % of patients,
hypertension show a less pronounced impact respectively. Again, there were minimal differ-
compared to diabetes. In the 3-year follow-up of ences in these rates from year 2 to year 6 after
the LABS study, 38.2 and 17.4 % of the patients RYGB. Recent data from the LABS study shows
who underwent RYGB and AGB, respectively, that at 3 years from RYGB, the majority of patients
had remission of hypertension [4]. The SOS normalize their LDL (59.7 %), HDL (85.6 %), and
study showed that at 2 years after bariatric sur- triglycerides (85.8 %). Improvements to a lesser
gery (mostly VBG), hypertension resolution degree were also seen after AGB (22.7, 67.3, and
occurred in 34 % of the patients, while this num- 62.1 %, respectively) [4]. Long-term data are also
ber dropped to 19 % at 10 years. Given the estab- available from the SOS study [11]. Normalization
lished relationship between advancing age and of LDL, HDL, and triglycerides 10 years after
the prevalence of hypertension, this drop in bariatric surgery were found in 21, 73, and 46 %
hypertension resolution at 10 years after inter- of patients, respectively. Interestingly, there were
vention should not be viewed as failure of bariat- no significant differences in the rates of resolution
ric surgery to control this comorbidity, but rather for HDL and LDL abnormalities between year 2
as an evolution of the nature process of aging. and year 10 after surgical intervention, suggesting
that the benefit with bariatric surgery is seen early
and is long lasting.
28.5 Dyslipidemia

Abnormalities in lipids, lipoproteins, and triglyc- 28.6 Obstructive Sleep Apnea

erides are common. They are a substantial con-
tributor to the metabolic syndrome and represent There is a strong association between obesity and
a major risk factor for cardiovascular disease in the development of obstructive sleep apnea. The
diabetic and nondiabetic patients. Metabolic sur- crowded posterior oropharynx in the severely
28 Long-Term Follow-Up After Bariatric Surgery 307

obese leads to obstructive sleep apnea in up to who were evaluated for bariatric surgery but
70 % of this patient population. This leads to were denied for surgery by their insurance com-
fatigue and poor quality of life (QOL). There pany [22]. With a mean follow-up of 9 years in
seems to be a profound improvement in symp- the surgical group and 6.2 years in the controls,
tomatology with bariatric surgery, which appears all-cause mortality was 9 % vs 28 %. In a large
to be mediated directly by weight loss. A meta- comparison of almost 10,000 patients who
analysis from 2,004 included 1,921 patients with underwent bariatric surgery with a cohort of
obstructive sleep apnea who underwent bariat- nonsurgically treated severely obese patients
ric surgery [5]. Resolution and improvement of [23] with a mean follow-up of 7.1 years, there
symptoms were reported in over 80 % of this was a 40 % decrease in overall adjusted mortal-
subgroup of patients. In a similar meta-analysis ity in bariatric surgery patients. Cause-specific
with a total of 44 patients who participated in a mortality for diabetes and cardiac disease
randomized trial and 9,845 patients included in decreased by 92 and 56 %, respectively.
an observational study, sleep apnea improve- Interestingly, cancer-specific mortality decreased
ment or resolution was reported in 96 and 90 %, by 60 %. The SOS study verified the survival
respectively [21]. benefit with bariatric surgery in a large prospec-
tive cohort [24]. With a mean follow-up of
10.9 years for over 4,000 obese patients (split
28.7 Cardiovascular Risk between surgery and medical management of
obesity), the adjusted for age, gender, and
With long-lasting improvements in dyslipidemia, comorbidities hazard ratio was 0.71 for bariatric
diabetes, and hypertension, the cardiovascular surgery. The most common causes of death were
risk of severely obese individuals is also expected cardiac events and cancer. Both of these studies
to be reduced after bariatric surgery. A single- surprisingly illustrated a benefit in terms of can-
institution study of 184 patients with a 5-year cer for bariatric surgery patients.
follow-up after RYGB, reported on 112 patients In a follow-up analysis of the SOS study, a
who met criteria for the metabolic syndrome pre- significant reduction in cancer incidence was
operatively [16]. At the end of the follow-up seen with bariatric surgery [25]. The overall
period, 67 % of these patients were relieved of cancer incidence in the surgery group decreased
the metabolic syndrome. In this same cohort, the with an odds ratio of 0.67. With subgroup anal-
Framingham risk score significantly decreased ysis, this effect was significant for female
with RYGB, representing an absolute risk reduc- patients, and was independent of weight loss.
tion of 1 % and a relative risk reduction of 18.3 %. Similarly, using data from the Utah Cancer
Furthermore, the SOS study, with a median fol- Registry, cancer incidence was assessed with a
low-up of 14.7 years, has demonstrated that bar- mean follow-up of 12.5 years in a bariatric sur-
iatric surgery is associated with a significantly gery cohort [26]. Cancer incidence and cancer-
lower incidence of cardiovascular events and specific mortality were significantly decreased
cardiovascular-specific deaths [3]. in the bariatric surgery group (hazard ratio 0.75
and 0.54, respectively). Another observational
study compared 1,035 bariatric surgery patients
28.8 Cancer Risk and Overall with a control group matched for age and gen-
Survival der [27]. Cancer-related office and hospital vis-
its were significantly lower in the bariatric
Large epidemiologic studies have illustrated that surgery group (relative risk 0.22) over a 5-year
obesity is associated with higher mortality. The follow-up. Even though multiple theories exist
first study to suggest a survival benefit with bar- to explain this effect, there have been no defini-
iatric surgery retrospectively compared 154 tive studies to date to support the mechanism
patients who underwent RYGB with 78 patients behind it.
308 K. Spaniolas and W.J. Pories

28.9 Quality of Life subsequent mortality or need for transplantation

or reversal. Bariatric surgeons have since learned
Severely obese individuals have severe impair- the risk of malnutrition, the dangers of extensive
ments in QOL, and any modality to treat obesity malabsorptive procedures and the necessity for
warrants evaluation in this regard. Multiple stud- nutrition assessment and supplementation in all
ies have shown improvement in QOL after bariat- patients. The RYGB, which is the most common
ric surgery. Fifty one patients after RYGB bariatric procedure performed at present, is not
completed a bariatric-specific QOL question- without malnutrition risks.
naire, which incorporates self-esteem and activ- Most of the malnourished patients have no
ity of daily living, among objective changes in clinical symptoms but many bariatric patients
medical conditions, and only seven (14 %) were report symptomatology suggestive of nutrient
deemed as failures [13]. In a recent study from deficiencies. A study including 49 RYGB
Norway, 177 patients 5 years after RYGB com- patients, reported clinical symptoms of malnutri-
pleted QOL questionnaires [16]. Significant tion in 59 %; hair loss and/or dry skin in 39 %,
improvements were seen in all categories of a paresthesias in 12 %, and myalgias in 16 % [30].
generic questionnaire after RYGB. Using an These symptoms were seen despite the lack of
obesity-specific questionnaire, there were signifi- measured deficiencies in iron, ferritin, calcium,
cant benefits at 5 years, with marked improve- vitamin B1, vitamin B6, folate, vitamin B12,
ments in the psychosocial functioning of these vitamin C, A, or E, suggesting the involvement of
patients. Preoperatively, 74 % of patients had protein or mineral metabolism.
severe psychosocial impairment, compared to Protein deficiencies have been mostly
12 % of patients 5 years after bariatric surgery. reported with long distal bypasses. In RYGB,
Furthermore, physical capacity is improved protein deficits are infrequent and are in part
even as early as 3 months after bariatric surgery. attributed to poor intake [31]. In a study of
In a study of 67 patients with a mean preoperative 236 banded-RYGB patients, severe malnutri-
BMI of 51, significant improvements were seen tion with hypoproteinemia was identified in
in objective measurements of walking, transfer 11 (4.7 %) [32]. Most of these patients expe-
capacity, and functional independence in activi- rienced strictures requiring re-interventions or
ties of daily living [28]. persistent emesis without abnormal endoscopic
The SOS study demonstrated, using a series of findings. It is noteworthy that cause-specific
generic, obesity, and comorbidity-specific ques- mortality was 2/11 (18 %). Reporting on 174
tionnaires, that improvements in QOL were asso- patients after bariatric surgery (79 RYGB and 95
ciated with the grade of weight loss [29]. Peak BPD) patients, Skroubis et al. found only three
improvements in patients after bariatric surgery patients with hypoalbuminemia over 3 years for
were seen during the first postoperative year, fol- an incidence of 1.72 % [33]. In a large study of
lowed by small gradual decline the subsequent 824 patients who underwent BPD with 15-year
5 years, and stability thereafter for the remaining follow-up, the reoperation rate – mostly for pro-
10-year follow-up period. Compared with the tein malnutrition – was 6.3 % [34]. The authors
medically managed group, bariatric surgery at 10 found that the reoperation rate was affected by
years was associated with a significant improve- the length of the alimentary limb.
ment in QOL, health perception, social interac- Vitamin deficiencies – especially vitamin
tion, psychosocial functioning, and depression. B12 – are commonly found after RYGB. It is dif-
ficult to know if this is related to inherent proper-
ties of the operations or poor compliance with
28.10 Malnutrition and Vitamin prescribed supplementation after surgery. In a
Deficiencies retrospective study of 136 patients after laparo-
scopic RYGB who had nutrition testing done,
The detrimental nutritional effects of the jejuno- 66 % were found to have a nutritional deficiency
ileal bypass in the 1960s and 1970s led to many [13]. Vitamin B12 deficiency was identified in
patients developing liver or kidney failure, with 71 %, anemia in 39 %, abnormal vitamin B6 in
28 Long-Term Follow-Up After Bariatric Surgery 309

15 % and hypocalcemia in 14 % of the assessed Although routine vitamin supplementation is

patients. These abnormalities were evenly dis- essential in the postoperative long-term care of
tributed throughout the 10-year postoperative the bariatric patient, this practice does not elimi-
follow-up, and more frequent in the superobese nate the risk of vitamin deficiencies. In a
individuals. Another study of 170 patients with a retrospective study with a 2-year follow-up of 137
3-year follow-up after RYGB, found an increase RYGB patients undergoing routine supplementa-
in folic acid, vitamin B12, and iron at the end of tion with a standardized vitamin and mineral
follow-up, with 72.4 % of patients maintaining preparation, 59 % of patients at 6-months, 86 % at
vitamin supplementation at 3 years [35]. Anemia 12-months and 98 % at 24-months were receiving
was found in 6.5 % of patients preoperatively and at least one additional supplement [40]. Vitamin
33.5 % of patients at 3 years; low folic acid level B12 was the most frequent additional supplement
was found in 6.5 % of patients before surgery and (80 % at 2 years), followed by iron (60 %), cal-
only 0.6 % of patients at the end of follow-up. In cium/vitamin D (60 %) and folic acid (45 %).
a retrospective single-institution study of 75
RYGB patients with at-least 5 years follow-up, Conclusion
long-term vitamin deficiencies were common; Metabolic surgery has progressed beyond a
32.1 % had hypomagnesemia, 50.8 % anemia, set of operations to induce weight loss. The
30 % low iron, 40.5 % low zinc, 61.8 % vitamin four current operations also produce full and
B12 deficiency and 60.5 % abnormal vitamin D3 durable remission of the metabolic syndrome
levels [36]. It is noteworthy that only one third of (severe obesity, hypertension, type 2 diabetes,
the patients took their prescribed multivitamins and hyperlipidemia) in addition to a broad
daily. Hypoalbuminemia was only seen in 5.3 % array of related co-morbidities such as sleep
of this patient population. Interestingly, the bio- apnea, polycystic ovary disease, pseudotumor
chemical workup 2 years after bariatric surgery cerebri as well as those that are due to exces-
correlated with final excess weight loss. Fat- sive weight such as arthritis of weight-bearing
soluble vitamin (A, D, E, K) deficiencies are joints. Now that the operations can be done
uncommon after RYGB, but can be frequency with the same low mortality and morbidity
seen in BPD patients [37]. rates as routine cholecystectomy, metabolic
Mineral deficiencies are also not infrequent surgery offers an effective, indeed the most
after bariatric surgery. In a cohort of 141 bariatric effective, therapy for the most costly diseases
surgery patients (52 RYGB, 89 BPD), subclinical of the developed world. The most important
low copper levels were found in 50.6 % of the contribution of metabolic surgery, however, is
BPD patients and 3.8 % of the RYGB patients that it provides new, safe, and ethical
[38]. All but one of the BPD patients had at least approaches to study obesity, diabetes, and the
one measurement of low zinc, and at different other expressions of the metabolic syndrome,
timepoints, the prevalence of hypozincemia research that eventually and hopefully, will
ranged between 44.9 and 74.2 %. In the RYGB provide approaches including prevention and
group, for the first 3 years after surgery, the prev- medications to make surgery obsolete.
alence of hypozincemia decreased compared to
preoperative, but this increased over the follow-
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