Obesity and Metabolic Surgery

Preface
Contents
Contributors
1: Obesity
	1.1	 Classification of Obesity
	1.2	 “Globesity”: The Current Pandemic
	1.3	 Why Are We Getting More and More Obese? Etiology and Pathophysiology
		1.3.1	 Food and Eating Habits
		1.3.2	 Lack of Physical Activity
		1.3.3	 Genetic Causes
		1.3.4	 Psychological Causes
		1.3.5	 Endocrine Causes
		1.3.6	 Drugs Promoting Weight Gain
	1.4	 Regulation of Hunger and Satiety in Obesity
		1.4.1	 Definition of Hunger and Satiety
		1.4.2	 Peripheral Mediators of Hunger and Satiety Regulation
			Ghrelin
			Nesfatin-1
			Cholecystokinin
			Pancreatic Polypeptide
			Peptide YY
			Glucagon-Like Peptide 1
			Leptin
			Insulin
			Glucagon
		1.4.3	 Signalling from the Periphery to the Brain
		1.4.4	 Central Nervous Signal Integration
		1.4.5	 Psychological Constructs
		Conclusion
	1.5	 Secondary Diseases of Obesity
		1.5.1	 Metabolic Syndrome
		1.5.2	 Diabetes Mellitus Type 2
		1.5.3	 Arterial Hypertension
		1.5.4	 Dyslipidemia
		1.5.5	 Cardiovascular Complications
		1.5.6	 Liver Disease
		1.5.7	 Obesity and Sleep-Related Breathing Disorders
		1.5.8	 Diseases of the Musculoskeletal System
		1.5.9	 Malignant Diseases
		1.5.10 Other Obesity-Related Diseases
	1.6	 Psychosocial Aspects of Obesity
		1.6.1	 Stigmatisation of Obese People
		1.6.2	 Quality of Life
		1.6.3	 Stress
		1.6.4	 Depression
		1.6.5	 Anxiety Disorders
		1.6.6	 Neglect, Abuse and Post-traumatic Stress Disorder
		1.6.7	 Eating Disorders
		1.6.8	 Personality and Personality Disorders
		1.6.9	 Substance Abuse
		1.6.10 Suicidal Tendencies
		1.6.11 Social Inequality
	References
		1.1 to 1.3
		1.5
		Further Reading
		1.4
		1.5
		1.6
2: Conservative Treatment of Obesity
	2.1	 Therapeutic Goals
	2.2	 Nutrition Therapy
	2.3	 Physical Exercise
	2.4	 Lifestyle Change: Psychotherapy and Psychoeducation
	2.5	 Drug Therapy
		2.5.1	 Orlistat
		2.5.2	 Liraglutide
		2.5.3	 Metformin
	2.6	 Multimodal Therapy Programmes
	References
		Further Readings
3: Surgical Therapy of Obesity
	3.1	 Frequency of Obesity Surgery
	3.2	 Therapeutic Goals and Evaluation Criteria
		Conclusion
	3.3	 Indications for Surgical Treatment of Obesity
	3.4	 Obesity Surgical Procedures
		3.4.1	 Laparoscopic Adjustable Gastric Banding
		3.4.2	 Laparoscopic Sleeve Gastrectomy
		3.4.3	 Laparoscopic Proximal Roux-en-Y Gastric Bypass
		3.4.4	 One-Anastomosis Laparoscopic Bypass
		3.4.5	 Biliopancreatic Diversion (According to Scopinaro)
		3.4.6	 Biliopancreatic Diversion with Duodenal Switch
	3.5	 Mechanisms of Action
		3.5.1	 Restriction and Malabsorption
			Restriction
			Malabsorption
		3.5.2	 Effects of Bariatric Surgery on the Regulation of Hunger and Satiety
			Ghrelin
			Nesfatin-1
			Cholecystokinin
			Pancreatic Polypeptide
			Peptide YY
			Glucagon-Like Peptide 1
			Leptin
			Insulin
			Glucagon
			Conclusion
		3.5.3	 Intestinal Flora (Microbiome)
			Conclusion
		3.5.4	 Bile Acids
	References
		3.1–3.3
		3.4.3
		Further Readings
		3.4.1
		3.4.2
		3.4.3
		3.4.4
4: Metabolic Surgery
	4.1	 Prospective Studies
	4.2	 Meta-Analyses
	4.3	 Postoperative Incidence of Diabetes, Micro- and Macrovascular Complications, Life Expectancy
		Conclusion
	References
		Further Readings
5: Preoperative Evaluation of the Patient
	5.1	 Surgical Evaluation
	5.2	 Internal Evaluation
	5.3	 Psychosomatic Evaluation
	5.4	 Choice of Procedure
	5.5	 Informing the Patient
	References
		5.1
		5.2
		5.3
		Further Readings
		5.2
		5.3
		5.4
		5.5
6: Operation Preparation in Bariatric Surgery
	6.1	 Operating Room
	6.2	 Instruments
	6.3	 Positioning the Patient
	6.4	 Position of the Surgical Team
	6.5	 Antibiotic Treatment
	6.6	 Anticoagulation
	6.7	 Team Time Out
	6.8	 Structure of the Pneumoperitoneum
	References
		Further Readings
7: Anaesthesiology for Bariatric Surgery
	7.1	 Pathophysiological Aspects
		7.1.1	 The Cardiovascular System
		7.1.2	 Airway
		7.1.3	 Pulmonary System
		7.1.4	 Metabolism
		7.1.5	 Pharmacokinetics
			Determination of Body Weight and Other Parameters
			Pharmacokinetic Characteristics of Important Substances
	7.2	 Organisational Aspects
		7.2.1	 Personnel
		7.2.2	 Technical Equipment
			Blood Pressure Measurement
			Storage Material
			Ultrasound
	7.3	 Pre-medication Rounds
		7.3.1	 Pre-medication Consultation
		7.3.2	 Comorbidities
			Respiratory System
			Cardiovascular System
	7.4	 Preparation of the Anaesthesia
		7.4.1	 Monitoring
		7.4.2	 Vascular Accesses
		7.4.3	 Selection of Anaesthetics
	7.5	 Induction and Maintenance of Anaesthesia
		7.5.1	 Preoxygenation
		7.5.2	 Anaesthetic Induction
		7.5.3	 Maintenance of Anaesthesia
	7.6	 Postoperative Phase
	Further Readings
8: Laparoscopic, Adjustable Gastric Banding
	8.1	 Trocar Placement
	8.2	 Dissection
	8.3	 Placement of Gastric Band
	8.4	 Fixing the Gastric Band and Port
	8.5	 Aftercare, Band Filling
	8.6	 Pitfalls
	Further Readings
9: Sleeve Gastrectomy
	9.1	 Trocar Placement
	9.2	 Exploration
	9.3	 Dissection
	9.4	 Gastric Tube Calibration
	9.5	 Resection
	9.6	 Test for Staple Line Insufficiency
	9.7	 Removal of the Resected Specimen
	9.8	 Finishing the Operation
	9.9	 Pitfalls
	References
		Further Readings
10: Laparoscopic, Proximal Roux-en-Y Gastric Bypass
	10.1 Trocar Placement
	10.2 Exploration
	10.3 Creating the Gastric Pouch
	10.4 Measurement of the Intestine
		10.4.1 Dividing the Greater Omentum
		10.4.2 Mobilizing the First Jejunum Loop
	10.5 Gastrojejunal Anastomosis
		10.5.1 Linear Stapled Anastomosis
		10.5.2 Circular Stapled Anastomosis
			Pressure Plate Inserted from the Abdomen
			Pressure Plate Inserted Orally
		10.5.3 Hand Sewn Anastomosis
	10.6 Measuring the Alimentary Loop
	10.7 Jejunojejunostomy
	10.8 Dividing of the Biliopancreatic Loop
	10.9 Testing the Gastro-entero Anastomosis for Leaks
	10.10 Closing the Mesentery
	10.11 Finishing the Operation
	10.12 Pitfalls
	Further Readings
11: Omega-Loop Bypass (One-Anastomosis Bypass, Mini-Gastric Bypass)
	11.1 Indication
	11.2 Trocar Placement
	11.3 Dissection
	11.4 Pouch
	11.5 Measuring the Bypass Length
	11.6 Anastomosis
	11.7 Omega-Loop Bypass as a Redo Procedure After Sleeve Gastrectomy
	11.8 Pitfalls
	11.9 Peri- and Postoperative Management
	11.10 Results
	11.11 Complications and Complication Management
	References
		Further Readings
12: Biliopancreatic Diversion (Operation According to Scopinaro)
	12.1 Introduction
	12.2 Indication and Preparation for Surgery
	12.3 Surgical Technique
		12.3.1 Laparoscopy, Trocar Placement and Clarification of Operability
		12.3.2 Transection of the Stomach
		12.3.3 Measurement of the Loop Lengths
		12.3.4 Small Intestine Anastomosis
		12.3.5 Gastroileostomy
		12.3.6 Simultaneous Appendectomy, Cholecystectomy and Hiatus Hernias
	12.4 Pitfalls
	12.5 Results
	12.6 Morbidity and Mortality
	References
		Further Reading
13: Biliopancreatic Diversion with Duodenal Switch
	13.1 Specific Indications for BPD-DS
	13.2 Surgical Technique
		13.2.1 Laparoscopy, Trocar Placement and Clarification of Operability
		13.2.2 Sleeve Gastrectomy
		13.2.3 Measurement of Loop Lengths
		13.2.4 Small Intestine Anastomosis (In Case of Classical Reconstruction According to Roux-en-Y)
		13.2.5 Duodenum Transection
		13.2.6 Duodenoileostomy
		13.2.7 Simultaneous Appendectomy and Cholecystectomy
	13.3 Pitfalls
	13.4 Results
	13.5 Morbidity and Mortality
	References
		Further Readings
14: Postoperative Management of Bariatric Surgery Patients
	14.1 Initial Diet Regimen After Bariatric Surgery
		14.1.1 First Stage
		14.1.2 Second Stage
		14.1.3 Third Stage
	14.2 Long-Term Nutrition After Bariatric Surgery
	14.3 Supplementation
	14.4 Surgical Aftercare
	14.5 Internal Aftercare
		14.5.1 Follow-Up in the Early Postoperative Phase
		14.5.2 Aftercare During the Weight Loss Phase (‘Honeymoon Phase’)
		14.5.3 Aftercare in the Phase of Weight Stagnation or Weight Regain
		14.5.4 Recommended Aftercare Intervals
		14.5.5 Recommended Laboratory Diagnostics
	14.6 Psychosomatic Aftercare
	14.7 Surgical Complications
		14.7.1 Early Surgical Complications
			Postoperative Leak
			Postoperative Bleeding
			Postoperative Obstruction
			Early Complications After Gastric Band Implantation
			Early Complications After a Sleeve Gastrectomy
			Early Complications After Gastric Bypass
		14.7.2 Late Surgical Complications
			Late Complications After Gastric Band Implantation
			Late Complications After Sleeve Gastrectomy
			Late Complications After Gastric Bypass Surgery
	14.8 Internal Complications
		14.8.1 Hyperinsulinemic Hypoglycemic Syndrome After Gastric Bypass Surgery
		14.8.2 Osteoporosis
		14.8.3 Further Complications
	References
		14.1–14.3
		14.7.1
		Further Readings
		14.4
		14.5
		14.6
		14.7.1
		14.7.2
		14.8
15: Revision and Redo Operations After Bariatric Procedures
	15.1 Background
	15.2 Revision/Redo Procedure After Gastric Banding
		15.2.1 Indication
		15.2.2 Procedure
	15.3 Revision/Redo Procedure After Sleeve Gastrectomy
		15.3.1 Indication
		15.3.2 Procedure
	15.4 Revision/Redo Procedure After Gastric Bypass Surgery
		15.4.1 Indication
		15.4.2 Procedure
	Further Readings
16: Special Patient Groups in Bariatric Surgery
	16.1 Surgery at Older Age
	16.2 Surgery in Childhood and Adolescence
	16.3 High Risk Patients
	References
		Further Readings
17: Obesity Centre
	17.1 Establishment and Certification of an Obesity Centre
	17.2 Interdisciplinary Treatment Team: Obesity Board
	17.3 Necessary Hospital Equipment
	17.4 Multimodal Treatment Processes
	17.5 Self-Help Groups and Internet Portals
	17.6 Patient Presentations and Information Material
	17.7 Treatment and Patient Pathways
	Further Readings
18: Alternative Techniques and Methods in Obesity Therapy
	18.1 Gastric Plication
	18.2 POSE Procedure
	18.3 Endobarrier®
	18.4 Gastric Sleeve with Ileum Interposition
	18.5 Securing Different Operation Procedures with a Band or a Ring
	18.6 Gastric Stimulator
	18.7 Gastric Balloon
	18.8 AspireAssist™
	References
		Further Readings
Index