Gastric Bypass: Bariatric and Metabolic Surgery Perspectives

Contents
Contributors
1: History of the Gastric Bypass
	References
2: Gastric Bypass: Mechanisms of Functioning
	Introduction
	The Benefits
		Weight Loss
			Food Intake
			Food Preferences
			Calorie Malabsorption
			Energy Expenditure
	Comorbidity Improvement/Resolution
		Possible Mechanisms of T2DM Resolution
		Possible Mechanisms of Dyslipidaemia Resolution
	The Complications
		Vitamin Deficiencies
			Vitamin B12 Deficiency
			Iron Deficiency
			Folic Acid Deficiency
			Hypocalcaemia and Vitamin D Deficiency
		Hair Loss
		Dental Problems
		Unexplained Abdominal Pain
		Change in Bowel Habits
		(Early) Dumping Syndrome
		Postprandial Hypoglycaemia (Late Dumping)
		Loss of Bone Density
		Kidney Stones
		Gallstones
		Gastric Remnant Distension
		Stomal Stenosis
		Marginal Ulcers
	Conclusion
	References
3: Morbid Obesity
	Morbidly Obese Patient Assessment
	Associated Complications
	Treatment of Severely Obese Patients
	References
4: Obesity and Related Diseases
	Obesity and Comorbidity
		Diabetes
		Cardiovascular Disease (CVD)
		Cancer
		Depression
		Reproduction
		Respiratory Diseases
		Cognitive Function
		Musculoskeletal Disorders
		Nonalcoholic Fatty Liver Disease
		Other Conditions
	References
5: Preparing for Gastric Bypass
	Patient Selection
	Teaching
	Biochemical Testing
	Nutritional Assessment
	Behavioral Changes
	Preoperative Weight Loss
	Psychiatric Evaluation
	Endoscopy
	Conclusion
	References
6: Preoperative Weight Loss in Gastric Bypass
	Introduction
	Impact of Preoperative Weight Loss in Surgical Outcomes
		Impact in Postoperative Weight Loss
		Impact in Complications and Other Outcomes
	Methods of Preoperative Weight Loss
	Conclusion
	References
7: Preoperative Testing and Counseling
	Introduction
	History
	Laboratory Testing
	Psychosocial and Nutritional Evaluation
	GI Evaluation
	Venous Thromboembolic Events (VTE/DVT)
	Cholelithiasis/Abdominal Ultrasound
	Medical Subspecialty Evaluation
		Pulmonary
		Cardiology
		Endocrinology
	Informed Consent
	Conclusion
	References
8: Patient Selection for Metabolic Surgery
	References
9: Psychiatric Issues During the Postoperative Period of Bariatric Surgery
	Introduction
	Psychiatric Disorders Identified During the PO
	Interference of PDs in the Outcome of BSs
	Interference of BSs on Present PDs
		Possible Psychiatric Presentations Resulting from Nutritional Deficiencies [12]
			Pellagra
			Beriberi
			Wernicke-Korsakoff Syndrome (WKS)
			Vitamin B12 Deficiency
		Psychiatric Alterations as Result of Weight Loss [12, 13]
		Psychiatric Alterations as Result of the Surgical Procedures [12]
			Immediate PO (1st Day)
			Mediate (1st Month) and Late PO (from 2nd Month)
			At Any Time in Any Surgery (Not Only BS)
		Psychopharmacological Treatment in the PO
	Conclusion
	References
10: Sleep-Disordered Breathing and Bariatric Surgery
	Introduction
	Pulmonary Complications of Obesity
	Subdivisions of Lung Volumes and Pulmonary Function Tests
	Distribution of Obesity
	Physiologic Changes and Gas Exchange in Obesity
	Effect of Obesity on Sleep
	Central Sleep Apnea and Cheyne-Stokes Respiration
	Obesity Hypoventilation Syndrome
	Obstructive Sleep Apnea
	Pathophysiology
	Diagnosis and Classification of OSA
	Treatment
	Perioperative Management of Sleep Apnea and Sleep-Disordered Breathing
	References
11: The Superobese Patient
	Introduction and Definition
	Clinical Characteristics of the Superobese Patient
	Evaluation of the Superobese Patient Before Bariatric/Metabolic Surgery
	Choice of Procedure
	Preoperative Preparation of the Patients
	Special Requirements for the Superobese Patient
	Aftercare in the Superobese Patient Population
	Conclusions
	References
12: Airway Evaluation and Management
	Introduction
		Respiratory and Airway Changes in the Obese Population
		Obesity and Perioperative Hypoxemia
		Obesity and Risk of Gastric Contents Aspiration
		Obesity and Difficult Airway (DA)
	Airway Evaluation in the Obese
		Body Mass Index (BMI)
		Mallampati Classification (MP)
		Neck Circumference (NC)
		Other Predictors of a Difficult Airway
		Difficult Supraglottic Device Ventilation Predictive Factors
	Airway Management
		Positioning
		Preoxygenation
		Anticipated Difficult Airway
		Unanticipated Difficult Airway
		Planning Extubation
	References
13: Positioning the Bariatric Surgical Patient
	Introduction
	Position and Cardiopulmonary Function
	Position and Safe Apnea Period (SAP)
	Position and Direct Laryngoscopy
	Position During Laparoscopic Bariatric Surgery
	Position and Injury
	Conclusion
	References
14: Developing the Laparoscopic Gastric Bypass
	Conclusion
	References
15: Systemic Inflammation in the Morbidly Obese Patient
	Systemic Inflammation in the Morbidly Obese Patient
		Inflammation Related to Adipose Tissue
		Cytokines and Adipocytokines
		Macrophages
		Features of the Adipose Tissue Damaged by Inflammation
			Importance of Central Obesity
			Adipose Tissue Distribution
			Metabolically Obese Normal Weight and Metabolically Healthy Obese
	References
16: Banded Gastric Bypass by Fobi Ring: Technique and Results
	Technique
	Our Centres’ Experience with Banded Gastric Bypass
		Results/Complications
	References
17: Mini-Gastric Bypass and One-Anastomosis Gastric Bypass: Rationale
	Introduction
	Method of MGB
		Creation of the Pouch
		Creation of the Malabsorptive Jejunal Bypass
		Modifying the MGB
	The One-Anastomosis Gastric Bypass (OAGB)
	Revision to MGB for Lap-Band or LSG Failure
	Advantages of MGB over the Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S)
	Rationale for Performing MGB or OAGB
		Intake Requirements
		Fear of Development of Cancer Unwarranted
		Advantages over Other Bariatric Operations
	Conclusions
	References
18: Simplified Gastric Bypass: The Brazilian Technique
	Introduction
	Laparoscopic Simplified Gastric Bypass: Step-by-Step Technique
		Position the Patient and the Surgical Team
		Pneumoperitoneum and Placement of the Trocars
		Gastric Pouch Construction
		Gastrojejunostomy
		Petersen Space Closure
		Entero-entero Anastomosis (EEA)
	References
19: Roux-en-Y Gastric Bypass in the Elderly Patient
	Introduction
	Results from the Surgical Treatment
	Conclusions
	References
20: Gastric Bypass Reoperation for Weight Regain
	Introduction
	Gastric Bypass Results
	Definition of Failure
	Causes and Diagnosis of Failure
	Medical Management
	Surgical Treatment
		Banding
		Gastric Pouch and Anastomosis Revision
		Gastrogastric Fistula Treatment
		Conversion to Distal Gastric Bypass
		Conversion to BPD-DS
	Endoscopic Revision
	Robotic Revisional Bariatric Surgery
	References
21: Conversion from Sleeve to Bypass
	Introduction
	Indications and Results
		Untreatable GERD
		Failure to Lose Weight
		Persistence of Metabolic Diseases
		Complications After Sleeve
	Surgical Technique
	Complications
	Conclusion
	References
22: Gastrojejunostomy Testing
	Intraoperative Gastrojejunostomy Testing
	Methylene Blue and Air Leak Test
	Intraoperative Endoscopy
	Pros and Cons of Intraoperative Testing
	Postoperative Testing
	References
23: Closing the Mesenteric Defects
	References
24: Preventing Complications
	Introduction
	Injuries Caused by Trocar Punctures
	Adverse Intraoperative Events
		Visceral Injuries
		Instrument Failure
		Bleeding
		Extraluminal Bleeding
			Solid Organs
			Staple Line Bleeding
			Intraluminal Bleeding
	The Gastric Pouch
		Preservation of the Neurovascular Axis
		Trapping of the Gastric Tube
		Gastrojejunal Anastomosis
		Stenosis of the Gastrojejunal Anastomosis
	The Jejunal Loop
		Error in the Measurement of the Loop
		Roux-en-O Configuration
		Position of the Alimentary Loop
		Kinking of the Loop
		Orientation of the Antecolic Roux-en-Y Loop
		Jejunojejunostomy
	References
25: Laparoscopic Gastric Bypass: Tricks and Tips
	Purpose
	Introduction
	Adequate Preoperative Preparation
	Surgical Room Checklist
		Safe Surgery
		Equipment and Instruments
		Staff Position
	Intraoperative Technical Steps
		Access and Trocars
		Making the Gastric Pouch
		Intestinal Time and Anastomosis
		Suture Test and Conclusion of the Procedure
	Postoperative
	References
26: Psychiatric Assistance in Bariatric Surgery
	Introduction
	Obesity and Prejudice
	The Relation Between PD and Obesity
	Preoperative Psychiatric Evaluation
	The Relation Between PD and BS
	Surgery on Teenagers
	Conclusion
	References
27: Perioperative Complications
	Introduction
	Patients with Obesity in the Anesthesia Setting
		Nerve Injury
		Airway Management
		Ventilation
		Cardiovascular Implications
		Pharmacotherapy Considerations
		Venous Thromboembolism (VTE)
		Esophageal Perforation
		Other Complications in the Anesthetic Setting
	Laparoscopic Access and Safety
		Vascular Injuries
			At Port Site
			Major Vascular Injury
			Minor Vascular Injury
		Bowel Injury
		Subcutaneous Emphysema
	Complications During Pouch Creation
		Transection
		Staple Misfire
		Incidental Nasogastric Tube Transection
	Troublesome Anastomosis
	Recovery Room
	Conclusion
	References
28: Abdominal Pain After Gastric Bypass
	Early Abdominal Pain
	Fistula
	Portomesenteric Thrombosis
	Early Intestinal Obstruction
	Hernia in Trocar Sites
	Late Abdominal Pain
	Remnant Gastric Distension
	Anastomotic Stenosis
	Marginal Ulcer
	Cholelithiasis
	Incisional Hernia
	Internal Hernia
	Less Frequent Conditions Post-RYGB
	References
29: Marginal Ulceration After (Laparoscopic) Roux-en-Y Gastric Bypass: Pathophysiology, Diagnostics, Treatment, and Prevention
	Introduction
		Incidence
		Pathophysiology and Risk Factors
			Anatomy
			Type of Procedure and Surgical Technique
			H. pylori
			Patient Demographics
		Symptomatology and Diagnostics
		Treatment
		Prevention
	References
30: Rhabdomyolysis
	Introduction
	Pathophysiology
	Rhabdomyolysis in Morbidly Obese
	Prevention of Rhabdomyolysis in Morbidly Obese
	Diagnosis of Rhabdomyolysis
		Clinical Findings and Physical Evaluation
			Laboratory Findings
			Image Examinations
	Rhabdomyolysis Treatment
	References
31: Depressive Disorders, Alcohol Use Disorders, and Suicidality in Bariatric Surgery
	Introduction
	Depressive Disorders
		Depressive Episode and Depressive Disorder
		Depressive Disorders Among Bariatric Surgery Patients
			Prior to Surgery
			After Surgery
	Alcohol-Related Disorders
		American Society for Metabolic and Bariatric Surgery Statement
	Suicidality During the Postoperative Period
	Final Remarks
	References
32: Nutritional Complications
	Introduction
		Anemia and Iron Deficiency
		Thiamine Deficiency
	B12
	Dumping Syndrome and Hypoglycemia
	Hair Loss
	Metabolic Bone Disease
	Loss of Fat-Free Mass (Lean Tissue Mass) and Sarcopenia
	Weight Regain
	Excessive Weight Loss
	Conclusion
	References
33: Eating Disorders
	Eating Disorders
	Binge Eating Disorder
		Binge Eating Treatment
		Bulimia Nervosa (BN)
		Night Eating Syndrome
		Grazing
		Pica and Pagophagia
		Anorexia Nervosa and PSEAD
		PSEAD Proposed Criteria
	Conclusion
	References
34: Gallbladder Stones and Choledocholitiasis
	Cholelithiasis
	Choledocholitiasis
	References
35: Hypoglycemia After Gastric Bypass
	Etiology
	Pathophysiology
	Diagnosis
	Treatment
	References
36: Dumping Syndrome
	A Brief Historical Retrospection
	Current State of Knowledge
		Early Dumping Syndrome
		Late Dumping Syndrome
	Diagnosis
		Sigstad Dumping Score [10]
		Oral Glucose Tolerance Testing (OGTT)
		HOMA-IR Valuation (According to the Local Lab) (Table 36.3)
		Continuous Glucose Monitoring (CGM)
		Mixed Meal Tolerance Test (MMTT)
		Scintigraphy
	Differential Diagnosis
	Therapy
		Nutritional Amendment
		Drug Therapy
			Acarbose
			Calcium Antagonists
			Potassium Channel Activator
			Somatostatin Analogs
			GLP-1 Analogs
		Surgical Therapy
			Endoluminal Revision of the Gastroenterostomy
			Laparoscopic Restoration of Gastric Restriction with Implants
			Laparoscopic Reversal of Roux-en-Y Gastric Bypass with Reinstallation of Pyloric Function
	References
37: Endoscopic Treatment of Roux-en-Y Gastric Bypass Complications
	Introduction
	Anastomotic Stricture
	Food Impaction
	Marginal Ulcer
	Ring Complications
		Intragastric Erosion
		Ring Slippage
	Leaks after RYGB
		Endoscopic Treatment of Weight Regain
	References
38: Endoscopic Treatment of Weight Regain After Gastric Bypass
	Introduction
	Main Findings and Justification
	Influence of the Pouch and Dilated Anastomosis on Weight Regain
	Endoscopic Treatment of Pouch and/or Anastomosis
	Diagnosis Under Endoscopy
		Measurement of the Pouch
		Measurement of the Anastomosis
	Endoscopic Technique: Treatment
	Discussion
	Conclusion
	References
39: Laparoscopic Bariatric Surgery Training and the Credentialing Process
	Introduction
	How to Train a Fellow
	Learning Curve for Lap Roux-en-Y Gastric Bypass
	Minimum Requirements for Credentialing
	References
40: Training and Credentialing the Robotic Bariatric Surgeon
	Introduction
	Intuitive Company Credentialing
	Progression Through Surgical Steps
	Vetting of Credentials
	References
41: Mechanisms of Control of Type 2 Diabetes with Gastric Bypass
	Mechanisms of Control of Type 2 Diabetes with Gastric Bypass
	Acute Effects of RYGB
		Caloric Restriction
		Gut
			Endocrine Actions of the Gut
				Gut Hormones: GLP 1, PYY, and GIP
	Fibroblast Growth Factors
		Neuro-paracrine Actions of the Gut
		Intestinal Lipid Sensing
		Intestinal Glucose Metabolism and Portal Glucose Sensor
		Bile Acid Metabolism
		Intestinal Microbiota
	Chronic Effects of RYGB
		Islet Cell Dysfunction Improvement
		Adipose Tissue Effects
	Conclusions
	References
42: The Gut and Type 2 Diabetes Mellitus
	Introduction
	Mechanism of T2DM Remission Following Gastrointestinal Surgery
		Starvation
		The Stomach
		The Upper Intestinal Hypothesis
		The Lower Intestinal Hypothesis
		Bile Acids
		Microbiota
	Conclusion
	References
43: Shifts in the Intestinal Microbiota After Gastric Bypass
	Context and Objectives
	Structure and Function of the Gut Microbiota
	Theories on the Role of the Gut Microbiota in Obesity and Diabetes
	Key Studies Examining Changes in the Gut Microbiota after Gastric Bypass
	Studies Describing Compositional Alterations
	Studies Assessing Functional Changes and Assigning Functional Annotation
	Perspectives and Future Challenges
	References
44: Infection: Diagnosis and Treatment
	Postoperative Infection in Bariatric Surgery
	Intra-abdominal Infection
		When to Indicate Reoperation
		What to Do
			Hemodynamic, Immunological, and Metabolic Support
				Hemodynamic Support
				Metabolic Support
				Immunological Support
		Antimicrobial Treatment
		Control of Focus of Infection and Underlying Disease
	Final Considerations
	References
45: Gastric Bypass in Patients with Metabolic Syndrome
	Introduction
	Mechanisms
		Eligibility Criteria for Metabolic Surgery
		Results of Metabolic Surgery and Prognostic Factors
	Surgical Technique
		RYGB Technique Description
	References
46: Gastric Bypass for Type 2 Diabetes Mellitus on BMI >35
	Introduction
	Pathophysiology of Type 2 Diabetes in Severe Obesity
	Outcomes of Gastric Bypass in Patients with Severe Obesity and Type 2 Diabetes
		Rates of Remission and Relapse of T2D After Gastric Bypass
		Predictors of Remission and Relapse of Type 2 Diabetes Following Gastric Bypass
		Scoring Systems for Predicting T2D Remission (and Relapse) After Gastric Bypass
		Effects of Gastric Bypass on T2D-Related Complications and Long-Term Premature Mortality
	Comparisons Between Outcomes of Gastric Bypass and Other Medical and Surgical Interventions in Randomized Controlled Trials
		Gastric Bypass vs Medical Management
		Gastric Bypass vs Sleeve Gastrectomy
		Gastric Bypass vs Biliopancreatic Diversion (Duodenal Switch)
		Gastric Bypass vs Laparoscopic Adjustable Gastric Banding
	Mechanisms of Glycemic Control Following Gastric Bypass
		Weight-Dependent Mechanisms of Glycemic Control After Gastric Bypass
		Weight-Independent Mechanisms of Glycemic Control After Gastric Bypass
	References
47: Gastric Bypass for Type 2 Diabetes Mellitus on BMI < 35
	Obesity and Diabetes
	Bariatric/Metabolic Surgery
	Bariatric/Metabolic Surgery Effects
	Metabolic Surgical Procedures
	Patients with BMI < 35
	STAMPEDE
	Second Diabetes Surgery Summit: DSS-II
	Conclusion
	References
48: Postoperative Care
	Postoperative Management After Metabolic Surgery
	Postoperative ICU Admission
	Complementary Examinations After Surgery
	Patient Comorbidity Management After Surgery
	Type 2 Diabetes
	Hypertension
	Dyslipidemia
	Obstructive Sleep Apnea
	Other Considerations
	Patient Discharge
	References
49: Mini Gastric Bypass: Why It Is Better than Gastric Bypass in India
	Advantages of Mini Gastric Bypass
	Cons of Mini Gastric Bypass
	Reasons for Preference of Mini Gastric Bypass in India
	Technique
	Results/Complications
	References
50: Can Bariatric Surgery Improve the Microvascular Complications of Type 2 Diabetes?
	Background
	Glucotoxicity, Inflammation and Microvascular Complications of Diabetes
	Bariatric Surgery
		Bariatric Surgery and Diabetic Kidney Disease (DKD) (Table 50.1)
		Bariatric Surgery and Diabetic Retinopathy (DR) (Table 50.2)
		Bariatric Surgery and Diabetic Neuropathy (Table 50.3)
	Conclusion
	References
Index