Patient may be male or female, 45 years old with no special alimentary habits. No previous operations, no GERD, no HP
The most common bariatric procedures are the Laparoscopic adjustable gastric banding, gastric bypass and sleeve gastrectomy, all with strong pros and cons. Other operations, such as biliopancreatic diversions are more rarely performed (for various reasons). Do you think that the "ordinary" operations would be efficient for such a patient?
Hey, Dr. Dardamanis!
You must be asking about personal experience, aren't you? And we're talking about superobese patient.
If, so then if jejunum's meso is enough long I would prefer gastric by-pass... If meso is thick and short - sleeve will be the best choice in my opinion.
Best regards!
The most common and usefull bariatric operation for this case is laparoscopic gastric bypass, this procedure may correct the overweight and his diabetes.
Working with obese patients, we can see that in super obesity (BMI>50) failures are more frequent in medium and ling terms, considering the weight loss. So the question actually implies wheather a more malabsorvative operation should be performed in such patients. I found a very intersting study in the literature, you may want to have a look.
http://www.ncbi.nlm.nih.gov/pubmed/21984052
Mini gastric Bypass will give equally good results.Short mesentery may not be a problem as the pouch is long.
In my opinion there are two main factors to weigh into the equation: the effect of the operation and the side-effects. So not only looking at resolution of obesity and diabetes but also at surgical complications I would defenately prefer a gastric bypass. Restrictive procedures haven't stood the test of time and mini gastric bypass is ignoring the B1/B2 lesson. A distal bypass and DS have obvious metabolic problems.
1. First stage: A 3rd generation, small caliber (32 Fr) sleeve gastrectomy.
2. I f still needed/desired for after at least 1 year; a 2nd stage DS/BPD.
Gastric bypass with alimantary limb of 150 cms and biliopancreatic limb of 200cms ,the common limb could be variable.
Gastric bypass will correct his diabetes (success rate 79-97% ,please see our article in canadian j of surgery Can Roux-en-Y gastric bypass provide a lifelong solution for diabetes mellitus?Hussain A, Mahmood H, El-Hasani S.Can J Surg. 2009 Dec;52(6):E269-75.
Gastric bypass can also correct the weight problem ,many studies confirmed that.Also its very effective procedure for metabolic syndrome including hypertension.
However ,patient should be well informed about the complications and also about the long term follow up after gastric bypass.Other bariatric procedures are alos effective ,like biliopancreatic diversion,doudenal switch ,sleeve gastrectomy ,gastric band,gastric plication and gastric balloon.
There is great difference in opinion among surgeons.This is because of minimal access experience to perform more complex procedure than relatively easy procedure ,also because of personal experience with certain specific procedure.
There is no 100% right answer to any medical problem and the final decision has to be taken with patinet consultation,avialable resources and comorbidities.
interesting debate with very intresting and contradictive opinions! I also think that a bypass procedure is the gold standard if we also consider the risks and morbididity in long terms. But it also a fact that in long terms we may have to deal with weight regain. Please have a look in the following references about the success rates and the alimentary and biliopancreatic limbs lengths
Diniz M. d. F. H. S.et al. Different criteria for assessment of Roux-en-Y gastric bypass success: does only weight matter? Obes Surg. 2009 Oct;19(10):1384-92.
http://www.ncbi.nlm.nih.gov/pubmed/18758870
Kalfarentzos F. et al. Biliopancreatic diversion with Roux-en-Y gastric bypass and long limbs: advances in surgical treatment for super-obesity.Obes Surg. 2011 Dec;21(12):1849-58.
http://www.ncbi.nlm.nih.gov/pubmed/21984052
Dr Cutolo, Christou compared a 10/40cm short limb to 100/100 long limb bypass and found no differences but, the failure rate when all patients are
followed for at least 10 years was 20.4% for morbidly obese patients
and 34.9% for super obese patients (in both groups)
I think DS is choice in this case, but LRYGB or Laparoscopic Sleeve Gasterctomy have low complication and easier!
With super obesity, diabetes and hyoertension these patients are at relative high surgical risk. My surgical colleagues often offer such super-obese patients a two-stage surgical approach. The initial operation is typically a laparoscopic sleeve gastrectomy, which in experienced hands is relatively safe. In many patients it results in weight loss of 50-60 kg or more over 12-18 months, with improvements in both hypertension and diabetes, but then weight often plateaus. At that point a second procedure is performed, typically a BDP with DS. When performed after the initial weight loss, it is effective in producing further weight loss with an acceptably low complication rate. In a recent cohort of 35 super-obese patients, 25 were satisfided with weight loss after the first procedure, but 10 came back for the BPD-DS, and have done well.
I agree with Paul two stage proceedure is safe and is with acceptable results.First stage LSG ,if the weight reduction is not satisfactory add DJB or RNY Bypass . In countrys like India BPD-DS is not tolerated by most of the patients.
The conditions sound as if an immediate solution is needed. The gastric bypass with intense dietary counselling would be my choice; however, I am not a medical doctor.
There is great difference in opinion among surgeons, ,I think that LAGB , gastric sleeve and mini bypass are procedures with unknown long resuts to maintain weight loss, I agree with Pier Cutolothe , the gold standard for this obese patient with type 2 diabetes is a banded bypass, this technique could induce long time successfull results and may be a better choice for manteinence of weight loss and symptoms of metabolic syndrom at long term.however intense dietary counselling would be advised after operation.
Our Amiens (France) experience ans the last JACS paper clearly answer : perform a sleeve gastrectomy first to treat obesity ans T2 diabetes. Dont use 32 Ch tube because more fistula under 34 Ch tube. The result obtained 18 monthes later will make you wonder ot the interest fot by-pass second ( in exceptional inefficiency of T2 Diabetes of the LSG).
The case should be handled on a two stage process. The first stage should be a vertical sleeve gastrectomy. This would reduce the weight considerably and control the diabetes. If there is sufficient weight reduction then this procedure should suffice. If there is relapse and weight starts to rise then the second stage of biiopancreatic diversion should be done. But if the weight can be controlled to a desirable level with the vertical sleeve gastrectomy alone that would be the best option and the patient should be councelled into maintaining the weight at the desired level with sleeve gastrectomy alone as the second procedure has side effects and lifelong supplementation of micronutrients and vitamins
My first choice would be a sleeve gastrectomy as it has already showd excellent results in superobese patients (See. Vidal J, hospital clinic) in terms of resoluction of diabetes mellitus control and weight loss. SEcond stage if needed and patients wants to go for it would be DS or SADI's.
I think laparoscopic gastric bypass LGBP would be the opertaion of choice in the given clinical scenario.
It will address weight and diabetes issues.
Its very safe procedure in experienced hand.We did more than 1500 gastric bypass operations with only one mortality due to rabdomyolysis and acute renal shut down.
Morbidity of bleeding ,stricture at the gastrojejunostomy and internal herniation are also reported and its incidence is very low ( depending on the surgical experience and the used technique).
Weight gain is another problem with gastric bypass ,this is extremley rare in our series as we are very obsessive about the pouch size and make it 30-50 mls in each patient and it has worked for us very well.
In any type 2 diabetic patient ,we usually advise LGBP which works very well in type 2 diabetes especially when the diagnosis of diabetes was made in the last two years.This is because the Beta cell population has not been completley exhausted.Additional hormonal mechanism of LGBP is well known in addition to the restriction and the length of Roux limb.
More details can be found on our article in the Canadian Journal Of Surgey: Can Roux enY Gastric Bypass provide lifelong solution to diabetes mellitus (December 2009).This is a free article.
The first stage would be a laparoscopic sleeve gastrectomy that enables to reduce the factors of hypertension and diabetes. Secondarily after the good initial weight loss when the patient is in the plateau stage it is possible with less anaesthesiic risk to perform a second operation.
For sleeve we do have some incouraging results published, for mini we hardly have the technique, is it the fashion (like band) or is it a useful operation?
In my limited experience and looking at local results I would agree that lap gastric bypass may be the procedure of choice.
The technique is safe in expert hands, offers good maintained weightloss at 5 years (over70%) and reverses diabetes quicker then say sleeve gastrectomy (supposedly because the duodenum is excluded).
If lap gastric bypass is not possible for whatever reason then we would normally go for a sleeve gastrectomy. This normally achieves good weightloss but reversal of diabetes only follows the weightloss rather then being much faster like in gastric bypass. If necessary further procedures can be performed later.
I agree with Emmanuelle's answer. The less intrusive procedure is better to preform with multiple comorbidities. The issue of a poor reaction to anaethesia is valid; particularly with extreme weight. Diabetes and hypertension must be under control for any procedure, as well.
I have to go backward and ask what kind of psychological intervention has been tried? Does this person have BED (Binge Eating Disorder)? We have an influx of people who have had weight loss surgeries only to end up with alcoholism as a result of untreated BED.
In this special case with two comorbidities and a BMI of 55, it may be reasonable to initially try an Intragastric Balloon for a 6-12 months period, in order to decrease the weight and subsequent BMI, while controlling the hypertension and diabetes mellitus and decreasing the surgery complications. After the above mentioned procedure, sleeve gastrectomy or gastric bypass might be the preferred operation method due to the patient's overall condition.
a metabolic procedure like LYRGBP can be done first by an experienced bariatric surgeon.Otherwise a 2 staged procedure can be done like LSG (sleeve) first and in case of long term weight regain -then a bypass can be added.
As far as clinical conditions are well controlled, lap gastric bypass is the procedure of choice.
In experienced hands it takes no more than one hour, even in super-obese patients, so the lenght of the procedure/anesthesia should not be an issue. The technique is the best one for weight loosing, with less nutritional problems and offer the best diabetes control or cure among all surgical techniques.
It must be said that pre and post-op multidisciplinary assessment must be done in a very carefull way, or the results concerning weight re-gain and malnutrition will be far from desired.
For this patient, I would go for gastric bypass. On the other hand, if this patient is a poor candidate for general anesthesia due to compromised respiraory system, etc - Sleeve gastrectomy is a safe option as first step of a 2-staged management. After significant weight loss (ideally over 1 year), bypass can be offered. In my experience, we have followed this protocol in some cases.
If you have good follow up support you could offer (distal) VLRYG. Standard RYGB is better than nothing but will not yiel optimal result. See Thurnheer et al. Obes Surg 2012
Article A Novel Distal Very Long Roux-en Y Gastric Bypass (DVLRYGB) ...
We've been performing gastric bypass operations for 15 years, the first patient was in a very similar condition as referred above. After open gastric bypass she lost 140 lbs and re-gained 60 lbs, insulin was abandoned. similar cases are continuously been reported in our experience, which leads us to elect laparoscopic gastric bypass as our choice procedure.
In according with my experience I think the best operation for these superobese patients is a malabsorption intervention like biliointestinal by pass,
I suppose Laparoscopic Gastric Bypass will be more effective in such super obese patients. This will effectively reduce the excess body weight of about 70-80 % and help to reduce the co morbid conditions like hypertension and diabetes myelitis.
I think either Endoluminal intestinal liner or aa sleeve gastrectomy are good choices but the bariatric center could evaluate the patient and recommend the best option
One should keep in mind that with sleeve gastrectomy a significant part of ghrelin-producing tissue will be removed and food craving on a neuropeptide-level might be reduced. Grhelin ist the counteraprt of leptin and it has been shown that leptin might be ineffective in severe obesity. One should inform patients about that possible mechanism related to sleeve gastrectomy
Duodenl switch is the most effective operation for weigth loss and diabetes
Gastric bypass. Banding procedures have lost their place in bariatrics because of the very high longterm complication rate and ds has more metabolic sideeffects with very little benefit in weight loss. A lap gastric bypass would be my choice.
Making the limb longer has very little effect on weigth loss, until it's so long that the patient gets malabsorbtive problems and then it's too long for a benign procedure considering the life-long consequences.
When you have over 980 DS cases you realize that DS is the most effective and also know how to lower the side-effects. None of our DMT2 remain diabetic and as afar as WL, no opertion is as effcetive as DS
We need not give 100% result in the first go itself. If we do rygb and patient regains weight what else we can offer? My choice would be sleeve and good counselling. If pt regains weight convert to mgb with atleast 200 cm limb.
In my practice , 1st I would suggest any way to reduce the 1st 20-30 kg by other mean such as gastric balloon or silicon , then I will go for sleeve gastrectomy , since our pt is diabetic 2 and his BMI 45 I will go for biliopancreatic bypass with small gastric pouch so the benefit would be obesity & diabetes .
with DM and BMI 55 majority are in favour of LDS,if this pt is not a diabetic do we advice sleeve,RYGB or MGB!
The patient is a diabetic, supero-obese and have hypertension. LDS is the answer! You only have to trust and learn how to do the technique!
I did give you my answer to this question already several months ago
The banding operations are not performed anymore in Sweden, they are inefficient and most of them have been converted to gastric bypasses.
I strongly suspect that sleeves are going in the same direction based on results in the scandinavian obesity surgery registry (SOREG), but won't count it out before the ongoing BEST study proves this conclusively (GS vs GBP, 2000 in each arm, nation-wide RCT run from the Gothenburg group)
You should do a DS or a gastric bypass. DS is slightly more effective but with more demands on a rigorous follow-up because of potential metabolic complications. The bypass is safer in this respect.
Mainly Swedish centers participate in the Scandinavian Obesity Registry (SOReg), which to date is not a good source for analyzing the outcomes after sleeve gastrectomy (SG). The general Swedish bariatric surgeon has been late in accepting SG, and just recently started to do them (=register them in SOReg) in larger numbers. Gastric bypass (RYGB) has for years been the totally dominant procedure in my country, close to 100%. The few Scandinavians who early adopted and obtained significant experience with SG, were for many years not engaged in SOReg. In summary, a large amount of the SGs documented in SOReg so far, have been performed by surgeons in their SG learning curve.
Stating that SG outcome is comparable to gastric banding is not in accordance with (a quite vast amount of) published data.
And the Swedish BEST trial is not the only, or even the first, RCT comparing SG vs RYGB, and has very recently commenced. Although also from Sweden, I humbly acknowledge preceding RCT endeavors from more visionary pioneers in other countries, eg:
STAMPEDE (USA), started 2007
SM-BOSS (Switzerland), started 2007
SleevePass (Finland), started 2008
Strasbourg (France), started in 2009
ByBandSleeve (England)
BariSurg (Germany)
Sleeve Bypass Trial (Netherlands)
and several others,...
So, to iterate my previous answer to Dr. Dardamanis question:
SG is an excellent choice, which for many patients will be good enough. If with time not sufficient, there are several 2nd stage procedures that one may add.
M.A.Kubtan,
Head of Dept of Surgery,
Medical Faculty,
Syrian Private University.
It is almost recognized that any surgical approach would be beneficial initially in reducing weight and normalizing blood sugar , however in our experience and specifically in this case I would recommend Bilio Pancreatic Diversion since it reduces the weight and normalizing blood sugar , needless to say that the number of years of the patient with diabetes type II governed the outcome of surgery from the point of resolving Diabetes within days , weeks , or months .
Obviously the patients cooperation is of paramount importance
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