Bariatric Surgery

Background

Bariatric surgery, or weight loss surgery, is any procedure intended to reduce weight in patients with morbid obesity. Bariatric, translated from Greek, literally means “weight medicine.” Bariatric surgery procedures are classified as restrictive (reduced stomach size; limiting the amount a patient may comfortably eat at any given time) or malabsorptive (alterations to the small intestine length to inhibit caloric absorption). Procedures may be restrictive (e.g., adjustable gastric band [or LAP-BAND®] or vertical sleeve gastrectomy [VSG]), malabsorptive (e.g., biliopancreatic diversion/duodenal switch [BPD-DS]), or both (e.g., Roux-en-Y gastric bypass [RYGB]).

Bariatric surgery centers utilize an interdisciplinary team to evaluate patients for suitability and educate them on the lifelong changes that must be implemented to be successful following surgery; patients must comply with strict dietary and exercise recommendations.

How to Use It

It is well established that surgery is often the only definitive treatment for patients with morbid obesity and is particularly effective for those patients who are 100 or more pounds overweight with comorbidities such as obstructive sleep apnea, diabetes mellitus, hypertension, and hyperlipidemia. Bariatric surgery is recommended in the American Diabetes Association guidelines for management of obesity in the treatment of type 2 diabetes mellitus (T2D).

How It Is Done

All bariatric surgeries are performed under general anesthesia using laparoscopic techniques. The VSG uses a linear stapling device along an esophageal dilator to remove and discard approximately 80% of the stomach. The remaining tubular gastric conduit is just slightly wider than the esophagus. The RYGB uses a linear stapler over a sizing balloon to create a small gastric pouch, approximately the size of an egg, that is separated from the remainder of the stomach. The remnant stomach remains in place. The duodenum is bypassed by creating an end-to-side jejunojejunostomy, and a Roux limb is anastomosed to the gastric pouch. This leaves a common channel of small bowel where food mixes with digestive juices and is absorbed into the blood circulation. Following either a VSG or RYGB, a 1- or 2-night stay is expected in the hospital. Fluoroscopic imaging using water-soluble contrast, rather than barium, may be performed during the hospitalization. Fig. 11.1 illustrates the major types of bariatric surgery.