RESUMEN
BACKGROUND: Standardization of the key measurements of a procedure's finished anatomic configuration strengthens surgical practice, research, and patient outcomes. A consensus meeting was organized to define standard versions of 25 bariatric metabolic procedures. METHODS: A panel of experts in bariatric metabolic surgery from multiple continents was invited to present technique descriptions and outcomes for 4 classic, or conventional, and 21 variant and emerging procedures. Expert panel and audience discussion was followed by electronic voting on proposed standard dimensions and volumes for each procedure's key anatomic alterations. Consensus was defined as ≥ 70% agreement. RESULTS: The Bariatric Metabolic Surgery Standardization World Consensus Meeting (BMSS-WOCOM) was convened March 22-24, 2018, in New Delhi, India. Discussion confirmed heterogeneity in procedure measurements in the literature. A set of anatomic measurements to serve as the standard version of each procedure was proposed. After two voting rounds, 22/25 (88.0%) configurations posed for consideration as procedure standards achieved voting consensus by the expert panel, 1 did not attain consensus, and 2 were not voted on. All configurations were voted on by ≥ 50% of 50 expert panelists. The Consensus Statement was developed from scientific evidence collated from presenters' slides and a separate literature review, meeting video, and transcripts. Review and input was provided by consensus panel members. CONCLUSIONS: Standard versions of the finished anatomic configurations of 22 surgical procedures were established by expert consensus. The BMSS process was undertaken as a first step in developing evidence-based standard bariatric metabolic surgical procedures with the aim of improving consistency in surgery, data collection, comparison of procedures, and outcome reporting.
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Medicina Bariátrica/organización & administración , Medicina Bariátrica/normas , Cirugía Bariátrica/normas , Consenso , HumanosRESUMEN
Obesity is a chronic disease due to excess fat storage, a genetic predisposition, and strong environmental contributions. This problem is worldwide, and the incidence is increasing daily. There are medical, physical, social, economic, and psychological comorbid conditions associated with obesity. There is no cure for obesity except possibly prevention. Nonsurgical treatment has been inadequate in providing sustained weight loss. Currently, surgery offers the only viable treatment option with longterm weight loss and maintenance for the morbidly obese. Surgeries for weight loss are called bariatric surgeries. There is no one operation that is effective for all patients. Gastric bypass operations are the most common operations currently used. Because there are inherent complications from surgeries, bariatric surgeries should be performed in a multidisciplinary setting. The laparoscopic approach is being used by some surgeons in performing the various operations. The success rate--usually defined as >50% excess weight loss that is maintained for at least five years from bariatric surgery--ranges from 40% in the simple to >70% in the complex operations. The weight loss from surgical treatment results in significant improvements and, in some cases, complete resolution of comorbid conditions associated with obesity. Patients undergoing surgery for obesity need lifelong nutritional supplements and medical monitoring.
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Desviación Biliopancreática/métodos , Derivación Gástrica/métodos , Derivación Yeyunoileal/métodos , Obesidad Mórbida/cirugía , Toma de Decisiones , Humanos , LaparoscopíaRESUMEN
BACKGROUND: No bariatric operation has been documented to effect adequate weight loss in all patients. Patients with inadequate weight loss or significant weight regain with an anatomically intact short-limb gastric bypass, of which the Fobi pouch operation (FPO) for obesity is a modification, are usually revised to a distal Roux-en-Y gastric bypass (DRYGBP) to enhance weight loss. METHOD: A retrospective review of the charts of all patients who had a revision to a DRYGBP at our Center during an 8-year period was carried out and the findings analyzed. RESULTS: 65 patients who had the FPO had a revision to the DRYGBP. Most were super obese patients who, even though they had lost significant weight, were still morbidly obese. Some were patients who had not lost adequate weight or <40% excess weight, and a small number were patients who requested more weight loss even though they had a BMI of < 35. 15 patients developed protein malnutrition requiring supplemental feeding. 6 required rerevision to short-limb gastric bypass. CONCLUSION: Revision of short-limb gastric bypass to DRYGBP usually enhances weight loss but at a cost of an increased incidence of protein malnutrition.
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Derivación Gástrica/métodos , Adulto , Anastomosis en-Y de Roux , Femenino , Derivación Gástrica/efectos adversos , Humanos , Masculino , Obesidad Mórbida/cirugía , Desnutrición Proteico-Calórica/etiología , Reoperación , Estudios Retrospectivos , Insuficiencia del TratamientoRESUMEN
BACKGROUND: The effect of transecting vs. stapling the stomach in continuity in the banded gastric bypass (GBP) operation was studied. METHOD: 50 patients, 25 in each group, were enrolled into a prospective study to determine if transecting the stomach vs. stapling it in continuity in performing GBP for obesity decreases the incidence of gastro-gastric fistula formation without increased morbidity. RESULTS: The patient profiles in the 2 groups were very similar. The peri-operative complications included 1 splenic capsular injury in each group, controlled without a splenectomy. There was 1 anastomotic leak in the stapled and 1 bleeding from the cut edge of the bypassed stomach in the transected group, both requiring re-operations in the immediate postoperative period. There was no peri-operative mortality. The percent follow-up after 6 years was 80% and 88% in the stapled and transected groups respectively. The incidence of late complications of solid food intolerance, ventral incisional hernia, cholelithiasis and small bowel obstruction was similar in both groups. There were 8 gastro-gastric fistulas in the stapled group and 1 in the transected group. The reduction in body mass index and percent excess weight loss (66%) were similar in both groups. CONCLUSION: The incidence of gastro-gastric fistula may be reduced in GBP procedures by transecting the stomach as opposed to stapling it in continuity, without an increase in morbidity or mortality or any loss in the effectiveness of the operation.
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Materiales Biocompatibles Revestidos/normas , Dimetilpolisiloxanos/normas , Derivación Gástrica/instrumentación , Siliconas/normas , Engrapadoras Quirúrgicas/normas , Adulto , Índice de Masa Corporal , Colelitiasis/epidemiología , Colelitiasis/etiología , Materiales Biocompatibles Revestidos/efectos adversos , Dimetilpolisiloxanos/efectos adversos , Femenino , Derivación Gástrica/efectos adversos , Derivación Gástrica/métodos , Fístula Gástrica/etiología , Humanos , Incidencia , Obstrucción Intestinal/epidemiología , Obstrucción Intestinal/etiología , Masculino , Persona de Mediana Edad , Morbilidad , Estudios Prospectivos , Reoperación , Siliconas/efectos adversos , Engrapadoras Quirúrgicas/efectos adversos , Resultado del Tratamiento , Pérdida de PesoRESUMEN
BACKGROUND: Many patients who qualify for obesity surgery have a moderate to large panniculus (grade 1-5). They can benefit from panniculectomy done concurrently with gastric bypass (GBP) or subsequently after significant weight reduction, usually 18 months after the GBP. METHOD: Over the last 8 years, 2,231 bariatric operations were performed at the Center. 577 panniculectomies were done, with 428 (74.2%) concurrent with the GBP and 149 (25.8%) subsequent to the GBP. RESULTS: The redundant pannus weighed from 5 to 54.5 kg. Wound problems occured in 15.1% of panniculectomies. Transfusion was necessary in 1.9%. Hospital stay was 4 to 5 days, and was no greater than in patients that underwent the GBP alone. Those with grades 3-5 suffer more back-pain and problems of hygiene resulting from panniculitis. CONCLUSION: A very redundant panniculus compounds the patient's physical, social and emotional problems. Where cardiopulmonary and other medical status are satisfactory, a panniculectomy may be offered to patients with a symptomatic panniculus at the time of bariatric surgery, as a physically beneficial and cost-effective adjuvant.
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Derivación Gástrica , Lipectomía , Obesidad Mórbida/cirugía , Adulto , Femenino , Derivación Gástrica/métodos , Humanos , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios , Complicaciones PosoperatoriasRESUMEN
Gastric bypass is considered by many to be the gold standard for surgical treatment of obesity. Gastric bypass was a natural evolution from gastric operations that were used for the treatment of peptic ulcer disease. Gastric bypass, first described in 1967, has undergone many modifications. It presently exists as a hybrid operation. Gastric bypass operation has been extensively scrutinized and evaluated against other operations for the treatment of obesity. Co-morbidities due to severe obesity are usually ameliorated or arrested after the weight loss from gastric bypass. Gastric bypass operation is now being performed with a perioperative morbidity of less than 10%. The average percentage excess weight loss with gastric bypass is 70%. The success rate, defined as 50% excess weight loss after at least 2 years of follow-up, is 85%. The metabolic deficiencies of gastric bypass are controllable with supplemental intake. This report with special references to the Fobi pouch operation, a modification of gastric bypass done by the author, presents the evolution, modifications, risk, outcome, and future trends of gastric bypass for treatment of obesity.
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Derivación Gástrica , Obesidad Mórbida/cirugía , Adulto , Femenino , Derivación Gástrica/efectos adversos , Derivación Gástrica/métodos , Humanos , MasculinoRESUMEN
The Fobi-Pouch operation (FPO) for obesity is the product of clinical trials, more than 15 years of personal clinical experience and information gathered from publications, scientific meetings, and personal communications with other bariatric surgeons. The essence of the operation is the small vertical pouch (< 25 ml), an externally supported stoma, the interposed Roux-en-Y limb, the gastrostomy and the bypassed stomach marker to facilitate percutaneous transabdominal access to the bypassed segment. Patients undergoing this operation are usually given bowel prep the day before the operation, admitted the morning of the operation and started on subcutaneous heparin, prophylactic antibiotic and hydration. Antithrombotic sequential compression devices are regularly used. The hospital stay is usually 4 days. Our results and those of other surgeons who have used this modification substantiate the rationale for the modifications entailed in the FPO. Our longer-term experience and results are being compiled for publication.
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Derivación Gástrica/métodos , Anastomosis en-Y de Roux , Gastroplastia , Humanos , Complicaciones Posoperatorias/prevención & control , Elastómeros de SiliconaRESUMEN
The gastric bypass (GBP) Operation is progressively being widely used to treat severe obesity. One problem with this operation is that it leaves the bypassed segment of the gastrointestinal tract not readily available for either mechanical, radiological or endoscopic evaluation. We have addressed this problem by putting a gastrostomy tube in the bypassed stomach at the time of the GBP. A radio-opaque marker placed around the gastrostomy site enables easy radiological localization of and thus easy percutaneous access to the bypassed stomach. The surgical technique is presented.
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Derivación Gástrica , Gastrostomía/instrumentación , Derivación Gástrica/métodos , Humanos , Prótesis e Implantes , Radiografía Intervencional , EstómagoAsunto(s)
Obesidad/cirugía , Anastomosis en-Y de Roux/efectos adversos , Anastomosis en-Y de Roux/métodos , Estudios de Seguimiento , Derivación Gástrica/efectos adversos , Derivación Gástrica/métodos , Gastroplastia , Humanos , Laparoscopía , Estudios Longitudinales , Obesidad Mórbida/cirugía , Edición , Engrapadoras Quirúrgicas , Grapado Quirúrgico/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: Previous studies have documented a high incidence of gallstone formation following gastric-bypass (GBP)-induced rapid weight loss in morbidly obese patients. This study was designed to determine if a 6-month regimen of prophylactic ursodiol might prevent the development of gallstones. METHODS: A multicenter, randomized, double-blind, prospective trial evaluated 3 oral doses of ursodiol: 300, 600, and 1,200 mg versus placebo beginning within 10 days after surgery and continuing for 6 months or until gallstone development, for patients with a body mass index (BMI) > or = 40 kg/m2. All patients had normal intraoperative gallbladder sonography. Transabdominal sonography was obtained at 2, 4, and 6 months following surgery, or until gallstone formation. RESULTS: Of 233 patients with at least one postoperative sonogram, 56 were randomized to placebo, 53 to 300 mg ursodiol, 61 to 600 mg ursodiol, and 63 to 1,200 mg ursodiol. Preoperative age, sex, race, weight, BMI, and postoperative weight loss were not significantly different between groups. Gallstone formation occurred at 6 months in 32%, 13%, 2%, and 6% of the patients on the respective doses. Gallstones were significantly (P < 0.001) less frequent with ursodiol 600 and 1,200 mg than with placebo. CONCLUSION: A daily dose of 600 mg ursodiol is effective prophylaxis for gallstone formation following GBP-induced rapid weight loss.
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Colelitiasis/prevención & control , Derivación Gástrica/efectos adversos , Ácido Ursodesoxicólico/uso terapéutico , Adolescente , Adulto , Colelitiasis/etiología , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Placebos , Estudios Prospectivos , Resultado del Tratamiento , Ácido Ursodesoxicólico/administración & dosificación , Pérdida de PesoRESUMEN
The SILASTIC ring vertical gastric bypass (SRVGBP) has evolved as the rational operation to control obesity. The operation consists of a proximal vertical gastric pouch < 30 cc in size. The pouch is banded with a 5.5-cm SILASTIC ring, and this functions as the stoma which does not stretch and is large enough to allow patients to eat all varieties of food, including vegetables and meats, with minimal incidence of postprandial emesis. The continuity of the gastrointestinal tract is formed with a Roux-en-Y gastroenterostomy with each limb about 60 cm long. The bypass of the gastroduodenal axis causes decreased digestion and thus decreased absorption of fats and carbohydrates, resulting in comparably more weight loss than seen in the standard restrictive gastroplasty. The dumping experienced in this operation, which prevents patients from becoming sweet eaters and thus provides long-term weight maintenance, is not as severe as in the regular gastric bypass with a dilatable stoma. In trained hands, the morbidity and mortality from this operation is comparable to that seen in the simple restrictive gastroplasty. The complications due to this operation include staple line breakdown, marginal ulcers, stenosis, incisional hernia, dumping, and iron, vitamins A, B12, D, and E deficiencies. These deficiencies are correctable by oral or parenteral supplements as necessary. This operation yields a 90% or higher success rate (> 40% excess weight loss) in the treatment of morbid obesity [corrected].
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Derivación Gástrica/métodos , Obesidad/cirugía , Adulto , Índice de Masa Corporal , Femenino , Estudios de Seguimiento , Humanos , Masculino , Obesidad/fisiopatología , Complicaciones Posoperatorias , Factores de Tiempo , Pérdida de PesoRESUMEN
Two hundred consecutive patients undergoing surgical intervention for morbid obesity had either the gastric bypass or the vertical banded gastroplasty. Both groups were similar in patient composition. In the vertical banded gastroplasty patients, operating room time was lessened by 70 minutes, blood loss lessened by 225 mL, and hospital stay shortened by two days as compared with the gastric bypass patients. At 30 months, a 64-percent mean excess weight loss was observed in the gastric bypass vs a 56-percent mean excess weight loss in the vertical banded gastroplasty group. The vertical banded gastroplasty procedure is preferred because there is no late stomal dilation with weight gain, no vitamin B(12) deficiency, and most important, this procedure leaves the remainder of the stomach and duodenum available for endoscopic and radiologic evaluation.