Difficult Decisions in Bariatric Surgery

Contents
Part I: Introductory Materials
	1: “A Patient, a Surgeon, and an Insurance Agent Walk into a Bar…”
	2: Evidence-Based Medicine and Decision Making
		2.1	 Why Evidence-Based Medicine Matters
			2.1.1	 A Cautionary Tale
		2.2	 Defining the Question
		2.3	 Threats to Validity
			2.3.1	 External Validity, Generalizability
			2.3.2	 Internal Validity
			2.3.3	 Chance
			2.3.4	 Bias
			2.3.5	 Confounding
		2.4	 Levels of Evidence
		2.5	 Grading the Evidence
			2.5.1	 Risk of Bias
			2.5.2	 Inconsistency
			2.5.3	 Indirectness
			2.5.4	 Imprecision
			2.5.5	 Publication Bias
			2.5.6	 Factors That Can Increase the Quality Assessment
			2.5.7	 Confounding
		2.6	 Putting It All Together
		References
Part II: Patient Selection
	3: Bariatric Surgery for Uncontrolled Hypertension
		3.1	 Introduction
		3.2	 Search Strategy
		3.3	 The Relationship Between Hypertension and Obesity
		3.4	 Medical Management Versus Surgical Treatment
		3.5	 Treatment in the Presence of Obesity and Diabetes
		3.6	 Recommendations Based on the Data
		3.7	 A Personal View of the Data
		References
	4: Diabetes as an Indication for Bariatric Surgery
		4.1	 Introduction
		4.2	 Search Strategy
		4.3	 Results
			4.3.1	 Bariatric Surgery for Type 2 Diabetes
				4.3.1.1	 Procedure Specific Diabetes Remission Rates
				4.3.1.2	 Outcomes of Surgery Compared to Maximal Medical Treatment
				4.3.1.3	 The Role of BMI in Patient Selection
			4.3.2	 Bariatric Surgery for Type 1 Diabetes
		4.4	 Recommendations Based on the Data
		4.5	 A Personal View of the Data
		References
	5: Bariatric Procedure Selection in Diabetics
		5.1	 Introduction
		5.2	 Search Strategy
		5.3	 Results
			5.3.1	 Individualizing Procedure Choice for Diabetic Patients
			5.3.2	 Use of Decision-Aid Tools for Procedure Selection
			5.3.3	 Recidivism and Incident Diabetes
		5.4	 Recommendations Based on the Data
		5.5	 A Personal View of the Data
		References
	6: Should Patients with Obesity Hypoventilation Syndrome Undergo Bariatric Surgery
		6.1	 Introduction
		6.2	 Search Strategy
		6.3	 Results
		6.4	 Conclusions
		6.5	 A Personal View to the Data
		6.6	 Recommendations
		References
	7: Bariatric Surgery in Heart Failure
		7.1	 Introduction
		7.2	 Search Strategy
			7.2.1	 Bariatric Surgery Improves Cardiac Function
			7.2.2	 Bariatric Surgery Decreases Incidence of Heart Failure
			7.2.3	 Bariatric Surgery Reduces Morbidity and Improves Cardiac Function in Heart Failure Patients
			7.2.4	 Heart Failure Patients Are Not at Increased Risk for Major Bariatric Surgical Complications
		7.3	 Recommendations Based on Data
		7.4	 Personal View of the Data
		References
	8: Bariatric Surgery in Those with Coronary Artery Disease
		8.1	 Introduction
		8.2	 Search Strategy
		8.3	 Results
			8.3.1	 Prevalence
			8.3.2	 Benefits
			8.3.3	 Risks
			8.3.4	 Conclusion
		8.4	 Recommendations
		8.5	 Personal View of Data
		References
	9: What Are the Nutritional “Red Flags” to Look Out for Prior to Bariatric Surgery?
		9.1	 Introduction
		9.2	 Search Strategy
		9.3	 Results
			9.3.1	 Insurance Mandated Supervised Weight Loss
				9.3.1.1	 Obesity Related Micronutrient Deficiencies
				9.3.1.2	 Increasing Patients Nutrition Knowledge
		9.4	 Recommendations Based on the Data
		9.5	 A Personal View of the Data
		References
	10: Are There Psychiatric Diagnoses That Preclude Safe Bariatric Surgery?
		10.1	 Introduction
		10.2	 Search Strategy
		10.3	 Major Depressive Disorder (MDD)
		10.4	 Anxiety Disorder
		10.5	 Bipolar Disorder and Schizophrenia Spectrum Disorder
		10.6	 Alcohol Use
		10.7	 Drug Abuse and Opioid Use
		10.8	 Unspecified Psychiatric History
		10.9	 Conclusions and Recommendations
		10.10	 Personal View of the Data
		References
	11: Does Weight Loss Prior to Surgery Accurately Predict Success Following Bariatric Surgery?
		11.1	 Introduction
		11.2	 Methods/Search Strategy
		11.3	 Impact of Preoperative Weight Loss on Postoperative Metabolic Outcomes
		11.4	 Impact of Preoperative Weight Loss on Postoperative Weight Loss
		11.5	 Impact of Preoperative Weight Loss on 30-Day Morbidity
		11.6	 Recommendations
		11.7	 Personal View of the Literature
		References
	12: Optimization Prior to Knee and Hip Arthroplasty as an Indication for Bariatric Surgery
		12.1	 Introduction
		12.2	 Search Strategy
		12.3	 Results
			12.3.1	 Analyses of National and State Databases
			12.3.2	 Analyses of Individual Institution Data
			12.3.3	 Analyses of Secondary Data
		12.4	 Personal View of the Data
		12.5	 Recommendations Based on the Data
		References
Part III: Preoperative Preparation
	13: The Ideal Preoperative Bariatric Surgery Diet
		13.1	 Introduction
		13.2	 Search Strategy
		13.3	 Results
		13.4	 Recommendations Based on the Data
		13.5	 Summary of Recommendation Options
		13.6	 Personal View of the Data and Recommendations
		References
	14: Is Routine Upper Endoscopy and H. pylori Testing Indicated in Advance of Bariatric Surgery?
		14.1	 Introduction
			14.1.1	 Preoperative Screening Guidelines
		14.2	 Search Strategy
		14.3	 Results
			14.3.1	 Routine Upper Endoscopy Prior to Bariatric Surgery
			14.3.2	 Routine H. Pylori Testing Prior to Bariatric Surgery
				14.3.2.1 Perforation
				14.3.2.2 Marginal Ulcer Development
				14.3.2.3 Cancer in the Excluded Stomach
		14.4	 Recommendations Based on the Data
		14.5	 A Personal View of the Data
		14.6	 Recommendations
		References
	15: Manometry is Useful Prior to Bariatric Surgery
		15.1	 Introduction
		15.2	 Search Strategy
		15.3	 Results
			15.3.1	 Prevalence of Esophageal Disorders in Morbidly Obese Patients
			15.3.2	 Preoperative Evaluation
			15.3.3	 Bariatric Surgery and Esophageal Mechanics
				15.3.3.1	 Laparoscopic Adjustable Gastric Band
				15.3.3.2	 Sleeve Gastrectomy
				15.3.3.3	 Roux-en-Y Gastric Bypass
		15.4	 Conclusions
		15.5	 A Personal View of the Data
		15.6	 Recommendations
		References
	16: Smoking Cessation Is Essential Prior to Bariatric Surgery
		16.1	 Introduction
		16.2	 Search Strategy
		16.3	 Results
			16.3.1	 Thirty-Day Complications
			16.3.2	 Pulmonary Complications
			16.3.3	 Intensive Care Unit Admission
			16.3.4	 Venous Thromboembolism
			16.3.5	 Marginal Ulcers
			16.3.6	 Mortality
			16.3.7	 Length of Stay
			16.3.8	 Marijuana and Vaping Device Use
			16.3.9	 Other Considerations
		16.4	 Recommendation
		16.5	 Personal View of the Data
		References
	Part IV: Ethics and Bariatric Surgery
	17: Is the Insurance Requirement for Supervised Weight Loss Prior to Bariatric Surgery an Ethical Strategy to Prevent Non-compliant Patients from Undergoing Surgery?
		17.1	 Introduction
		17.2	 Search Strategy
		17.3	 Results
			17.3.1	 Respect for Patient Autonomy
			17.3.2	 Beneficence
			17.3.3	 Nonmaleficence
			17.3.4	 Distributive Justice
		17.4	 Recommendations Based on the Data
		17.5	 A Personal View of the Data
		17.6	 Recommendations
		References
	18: Ethical Concerns of Bariatric Surgery in the Pediatric Population
		18.1	 Introduction
		18.2	 Search Strategy
			18.2.1 Autonomy
		18.3	 Pediatric Patients Are Unable to Provide Their Own Consent
		18.4	 Primary Care Providers May Not Be Willing to Recommend Bariatric Surgery Despite Their Patient’s Wishes
		18.5	 The Outcomes of These Procedures Will Be Faced by Patients Well After They Have Attained the Age of Consent
		18.6	 Informed Consent for Bariatric Surgery in the Pediatric Population
			18.6.1 Beneficence
		18.7	 Medical Weight Loss Has a Very Low Success Rate as Compared to Bariatric Surgery
		18.8	 Lack of Guidelines Exist That Define a Reasonable Course of Medical Weight Loss for a Child Prior to Advancing Towards Surgical Intervention
			18.8.1 Non-maleficence
		18.9	 Data Regarding Long-Term Outcomes Is Lacking, Leading to Ethical Constraints When Performing Irreversible Operations
		18.10	 Our Preoperative Evaluations Center Around Perceived Ability to Maintain a Weight-Loss Diet, But Not on the Resilience of Children Who Face Operative Complications for an Elective Procedure
		18.11	 Mental Disorders Should Be Monitored and Addressed in the Treatment of Severe Obesity to Prevent Any Additional Harm to Adolescent Mental Health
			18.11.1 Justice
		18.12	 Ethnic and Socio-economic Disparities in Terms of Rates of Obesity and Access to Medical and Surgical Care Exist, and Certain Populations May Be Excluded from the More Efficacious Surgical Approach
		18.13	 Conclusions and Recommendations
		References
Part V: Choice of Bariatric Procedure
	19: Adjustable Gastric Banding: Why Did It Fail?
		19.1	 Introduction
		19.2	 History of the Development of Adjustable Gastric Banding
		19.3	 Mechanisms of AGB
		19.4	 From AGB to LAGB
		19.5	 Widespread Application
		19.6	 Long Term Outcomes
		19.7	 Why Did the LAGB Fail?
		19.8	 Conclusion
		References
	20: What Is the Role of Bariatric Surgery in the Treatment of Nonalcoholic Steatohepatitis?
		20.1	 Introduction
		20.2	 Search Strategy
		20.3	 Results
		20.4	 Recommendations
		20.5	 A Personal View of the Data
		References
	21: Is Roux-en-Y Gastric Bypass Less Safe Than Sleeve Gastrectomy?
		21.1	 Introduction
		21.2	 Search Strategy
		21.3	 Results
			21.3.1	 Early (<30 Days) Complications
			21.3.2	 Late (>30 Days) Complications
			21.3.3	 Internal Hernia
			21.3.4	 Gastrojejunal Stenosis/Anastomotic Stricture
			21.3.5	 Incisional Hernia
			21.3.6	 Small Bowel Obstruction
			21.3.7	 Intestinal Ulcer
			21.3.8	 GERD
			21.3.9	 Nutrient Deficiencies
		21.4	 Recommendations Based on the Data
		21.5	 A Personal View of the Data
		References
	22: The National Shift to Sleeve Gastrectomy: Long-Term Disappointment and Recidivism or Patient Preference?
		22.1	 Introduction
		22.2	 Search Strategy
		22.3	 Results
			22.3.1	 Comparative Outcomes Between Sleeve Gastrectomy and Gastric Bypass (Table 22.2)
			22.3.2	 Special Populations (Table 22.3)
			22.3.3	 Weight Loss Outcomes (Table 22.4)
			22.3.4	 Weight Regain/Lack of Treatment Effect (Table 22.5)
			22.3.5	 GERD Complications (Table 22.6)
			22.3.6	 Patient and Surgeon Preference/Resource Utilization (Table 22.7)
		22.4	 Recommendations Based on the Data
			22.4.1	 Comparative Outcomes Between Sleeve Gastrectomy and Gastric Bypass
			22.4.2	 Special Populations
			22.4.3	 Weight Loss Outcomes
			22.4.4	 Weight Regain/Lack of Treatment Effect
			22.4.5	 GERD Complications
			22.4.6	 Patient and Surgeon Preference/Resource Utilization
		22.5	 Personal View of the Data
		References
	23: Single-Stage Duodenal Switch is Better than Two-Stage
		23.1	 Introduction
		23.2	 Search Strategy
		23.3	 Results
			23.3.1	 Clinical Relevance
		23.4	 Approval of SADI
		23.5	 Recommendations
		23.6	 Personal View
		References
Part VI: Complications
	24: Stenting for Leaks After Sleeve Gastrectomy
		24.1	 Introduction
		24.2	 Search Strategy
		24.3	 Results
			24.3.1	 Patient Presentation
			24.3.2	 Leak Diagnosis/Imaging Studies
			24.3.3	 Peri-procedural Considerations
				24.3.3.1	 Patient Assessment and Stability
				24.3.3.2	 Leak Presentation and Concomitant Strictures/Stenosis
			24.3.4	 Choosing the Right Stent
				24.3.4.1	 Traditional Esophageal Stents
				24.3.4.2	 Large Bariatric Stents
			24.3.5	 Post Procedure Follow-Up and Stent Removal
				24.3.5.1	 Failure of Initial Stent Placement, Is It Worth Re-Stenting
			24.3.6	 Adjunct/Alternative Techniques
		24.4	 Recommendations Based on the Data
			24.4.1	 A Personal View of the Data
		References
	25: Reoperation for Repair of Anastomotic Leaks and Staple Line Disruptions
		25.1	 Introduction
		25.2	 Etiology
			25.2.1	 Patient Dependent Factors
			25.2.2	 Technical Factors
		25.3	 Leaks Presentation
			25.3.1	 Intraoperative Setting
			25.3.2	 Postoperative Setting
		25.4	 Diagnostic Approach
		25.5	 Management
			25.5.1	 Non-Operative Management
			25.5.2	 Reoperative Management and Drainage
		25.6	 Management of Leaks of Less Common Bariatric Surgeries
		25.7	 Conclusion
		References
	26: Gastric Sleeve Stricture, Twist or Kink, Now What?
		26.1	 Introduction
		26.2	 Search Strategy
		26.3	 Results
			26.3.1	 Diagnosis of Sleeve Stenosis
			26.3.2	 Management of Sleeve Stenosis
			26.3.3	 Single Modality Management with Balloon Dilation
			26.3.4	 Sequential Algorithms Utilizing Balloons and Stent Placement
			26.3.5	 Complications of Various Treatment Modalities
		26.4	 Recommendations Based on Results
		26.5	 Personal View of the Data
		References
	27: Hiatal Hernia Complicating Bariatric Surgery
		27.1	 Introduction
		27.2	 Search Strategy
		27.3	 Results
			27.3.1	 Clinical Relevance of Hiatal Hernias in Bariatric Surgery
			27.3.2	 A Personal View of the Data
		References
	28: Management of GERD in Duodenal Switch
		28.1	 Introduction
		28.2	 Search Strategy
		28.3	 Results
			28.3.1	 Current Evidence
			28.3.2	 Extrapolation from Vertical Sleeve Gastrectomy Literature
				28.3.2.1	 Pre-operative Screening
				28.3.2.2	 Concomitant Hiatal Hernia Repair
				28.3.2.3	 Subsequent Hiatal Hernia Repair
				28.3.2.4	 Rescue Conversion
				28.3.2.5	 Novel Approaches
		28.4	 Conclusions and Recommendations
		28.5	 Personal View of Data
		28.6	 Recommendations
		References
Part VII: Late Failure
	29: Endoscopic Management of the Dilated Gastrojejunal Anastomosis
		29.1	 Introduction
		29.2	 Search Strategy
		29.3	 Clinical Relevance of a Dilated Gastrojejunal Stoma
		29.4	 Endoscopic Plication Techniques
			29.4.1	 StomaphyX
			29.4.2	 ROSE Procedure/Incisionless Operating Platform
			29.4.3	 Endoscopic Transoral Outlet Reduction (eTOR)
			29.4.4	 Over-the-Scope Clips
		29.5	 Endoscopic Ablation and Resection Techniques
			29.5.1	 Sclerotherapy
			29.5.2	 Argon Plasma Coagulation
		29.6	 Endoscopic Mucosal Resection/Endoscopic Submucosal Resection
		29.7	 Radiofrequency Ablation
		29.8	 Cryotherapy
		29.9	 Conclusion
		29.10	 A Personal View of the Data
		References
	30: Suboptimal Weight Loss and Weight Regain: Is it Prime Time for Pharmacotherapy?
		30.1	 Introduction
		30.2	 Search Strategy
		30.3	 Suboptimal Weight Loss after Bariatric Surgery
		30.4	 Weight Regain after Bariatric Surgery
		30.5	 Evaluation of Suboptimal Weight Loss and Weight Regain after Weight Loss Surgery
		30.6	 Etiology of SWL and WR Post Bariatric Surgery
		30.7	 Re-Operative Bariatric Surgery and Procedures
		30.8	 Adjuvant Medical Therapy
		30.9	 Conclusions
		30.10	 A Personal View of the Data
		References
	31: Does Resizing the Gastric Pouch Aid in Weight Loss?
		31.1	 Introduction
		31.2	 Search Strategy
		31.3	 Results
		31.4	 Recommendations
		31.5	 Personal View on Data
		31.6	 Summarized Recommendations
		References
	32: Does Stoma Size Matter After Gastric Bypass?
		32.1	 Introduction
		32.2	 Search Strategy
		32.3	 Results
			32.3.1	 Effect of Stoma Size on Weight Loss
			32.3.2	 Effect of Stoma Size on Rates of Stenosis/Stricture
		32.4	 Conclusions
			32.4.1	 A Personal Approach to the Data
			32.4.2	 Recommendations
		References
Part VIII: The Pediatric Population
	33: Indications, Choice of Operations and Outcomes of Metabolic and Bariatric Surgery in Children
		33.1	 Introduction
		33.2	 Search Strategy
		33.3	 Results
		33.4	 Recommendations Based on the Data
		33.5	 A Personal View of the Data
		Abstracted Recommendations
		References
	34: Pediatric Bariatric Surgery and Sexual Developmental Milestones
		34.1	 Background
		34.2	 Search Strategy
			34.2.1	 Concept
		34.3	 Criteria for Considering Studies for This Review
		34.4	 Types of Participants
		34.5	 Type of Intervention
		34.6	 Type of Outcome Measures
			34.6.1	 Primary Outcome
		34.7	 Results
		34.8	 Obesity and the Reproductive Axis
		34.9	 Pediatric Bariatric Surgery and Effects on Sexual Developmental Milestones
		34.10	 A Personal View of the Data
		References
	35: Which Surgical Specialist Should Perform Metabolic Bariatric Surgery in Children and Adolescents?
		35.1	 Introduction
		35.2	 Search Strategy
		35.3	 Results
		35.4	 Recommendations Based on the Data
		35.5	 A Personal View of the Data
			35.5.1	 Recommendations in Order of Preference
		References
Part IX: The Future
	36: Deep Brain Stimulation as a Treatment for Obesity
		36.1	 Introduction
		36.2	 What Is Deep Brain Stimulation?
		36.3	 How can Deep Brain Stimulation Be Used for Obesity?
			36.3.1	 Lateral Hypothalamus: The Feeding Center of the Brain
			36.3.2	 Nucleus Accumbens: The Reward Center of the Brain
		36.4	 Ethical Considerations
		36.5	 Conclusions
		References
	37: How Manipulating the Microbiome Can Affect the Outcome Following Bariatric Surgery
		37.1	 Introduction
		37.2	 Search Strategy
		37.3	 How Bariatric Surgery Changes the Gut Microbiome
			37.3.1	 Changes in Microbial Richness
			37.3.2	 Changes in Composition
			37.3.3	 Changes in Function
		37.4	 How we Can Alter the Microbiome before and after Surgery
			37.4.1	 Diet
			37.4.2	 Probiotics
			37.4.3	 Prebiotics and Symbiotics
			37.4.4	 Other Strategies
		37.5	 Role of the Microbiome in Bariatric Surgery Complications
			37.5.1	 Short-Term Complications
			37.5.2	 Long-Term Complications/Unsatisfactory Results
		37.6	 Role of Microbial Monitoring in Post-Bariatric Surgery Follow-Up
		37.7	 Conclusions and Recommendations
		37.8	 Recommendations
		References
Index