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2 Bariatric Surgery

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4 Bariatric Surgery Editors Nadey S Hakim Imperial College Healthcare NHS Trust London, UK Franco Favretti Vicenza Regional Hospital, Italy Gianni Segato Vicenza Regional Hospital, Italy Bruno Dillemans St. Jan Hospital, Bruges, Belgium ICP Imperial College Press

5 Published by Imperial College Press 57 Shelton Street Covent Garden London WC2H 9HE Distributed by World Scientific Publishing Co. Pte. Ltd. 5 Toh Tuck Link, Singapore USA office: 27 Warren Street, Suite , Hackensack, NJ UK office: 57 Shelton Street, Covent Garden, London WC2H 9HE British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. BARIATRIC SURGERY Copyright 2011 by Imperial College Press All rights reserved. This book, or parts thereof, may not be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system now known or to be invented, without written permission from the Publisher. For photocopying of material in this volume, please pay a copying fee through the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. In this case permission to photocopy is not required from the publisher. ISBN ISBN Typeset by Stallion Press enquiries@stallionpress.com Printed in Singapore.

6 Contents Contributors Foreword (by Michael G. Sarr, Mayo Clinic, USA) xi xvii Chapter 1 Indications for Bariatric Surgery and Selecting 1 the Appropriate Procedure John B. Dixon Indications for Bariatric Surgery 1 References 10 Chapter 2 Anaesthesia in Bariatric Surgery 15 Ernesto Pizzirani and Giuseppe Calcarella Definitions 15 Epidemiology 16 Pathophysiologic Aspects Connected to Obesity 19 Pharmacologic Considerations 31 Evaluating the Patient Before Anaesthesia 37 General Anaesthesia 47 Loco-Regional Anaesthesia 50 Post-Operative Treatment 51 Conclusions 53 References 53 v

7 vi Contents Chapter 3 Intragastric Balloon (BIB ) in the Management 61 of Morbid Obesity Disease Alfredo Genco, Roberta Maselli and Nicola Basso Introduction 61 Results 71 Discussion and Conclusion 84 References 86 Chapter 4 Laparoscopic Adjustable Gastric Banding 91 Gianni Segato, Nadey Hakim, Maurizio De Luca and Franco Favretti Introduction 91 Indications and Contraindications 91 Preparation for Surgery 93 Surgical Instruments 93 Patient and Surgical Team Positioning 94 Procedural Steps 94 References 102 Suggested Reading 103 Chapter 5 Long-Term Results in Laparoscopic Adjustable 105 Gastric Banding (LAP-BAND ) for Obese Patients Maurizio De Luca, Luca Busetto, Gianni Segato, Nadey S. Hakim and Franco Favretti Introduction 105 Laparoscopic Technique 106 Role of the Balloon 109 Lap-Band Series at Vicenza Regional 110 Hospital, Padua Discussion 118 Life Expectancy Study 120 Conclusion 121 References 122

8 Contents vii Chapter 6 Laparoscopic Adjustable Gastric Banding 125 (LAP-BAND ): Diagnosis, Prevention and Treatment of Complications Maurizio De Luca, Luca Busetto, Gianni Segato, Nadey S. Hakim and Franco Favretti Introduction 125 Lap-Band Series at Vicenza Regional 126 Hospital, Padua Complications 127 Conclusions 151 References 152 Chapter 7 Roux-en-Y Gastric Bypass 155 Bruno Dillemans and Sebastiaan Van Cauwenberge Introduction 155 Physiology of the Roux-en-Y Gastric Bypass 156 Preoperative Evaluation 159 Medical Evaluation 160 Psychological Evaluation 160 Technical Aspects of the Laparoscopic RYGB 161 Procedure Operative Technique of the Fully Stapled 164 Laparoscopic Roux-en-Y Gastric Bypass Complications of Roux-en-Y Gastric Bypass 171 Side Effects of Roux-en-Y Gastric Bypass 179 Weight Evolution After RYGB 183 Conclusion 188 Acknowledgements 188 References 188 Chapter 8 New Technologies in Bariatric Surgery 199 Matthias Lannoo and Andre D Hoore Introduction 199

9 viii Contents Sleeve Gastrectomy 199 New Minimally Invasive Techniques in Bariatric 214 Surgery References 217 Chapter 9 Imaging of Complications After Bariatric Surgery 223 Jose C. Varghese and Shuvro H. Roy-Choudhury Introduction 223 Laparoscopic Adjustable Gastric Banding 224 Roux-en-Y Gastric Bypass (RYGB) 245 Summary 273 References 275 Chapter 10 Sequential Treatment of Obesity 285 Maurizio De Luca, Luca Busetto, Gianni Segato and Franco Favretti Introduction 285 Classification of Bariatric Operation 286 Effectiveness/Invasiveness of Various Operations 286 Undertreatment and Overtreatment 287 Surgical Treatment of Obesity 290 Conclusions 291 References 292 Chapter 11 Bariatric Surgery: When the Miracle is Not 293 Enough Melodie K. Moorehead Introduction 293 Bariatric Surgery is a Behavioural Surgery Too 296 A Holistic Approach to Bariatric Surgery: Recovery 302 Managed by Healthcare Specialists Establishing a Three-Stage Psychoeducational 305 Recovery Programme The Initial Psychoeducational Interview 311 What is the Value of Speaking the Same Language 317 in Outcomes?

10 Contents ix Discussion 320 Acknowledgements 322 References 323 Suggested Reading 324 Chapter 12 Effects of Bariatric Surgery on Co-Morbidities 327 Sebastiaan Van Cauwenberge and Bruno Dillemans Introduction 327 Hypertension 327 Obstructive Sleep Apnoea 331 Dyslipidemia 334 Type 2 Diabetes 337 Other Co-Morbidities 343 Quality of Life After Bariatric Surgery 346 References 348 Chapter 13 Impact on Life Expectancy After Bariatric 359 Surgery Luca Busetto, Elisa Calo, Marco Mazza and Giuliano Enzi Introduction 359 Impact of Morbid Obesity on Morbidity and 360 Mortality Effects of Bariatric Surgery on Metabolic 361 Co-Morbidities Effects of Bariatric Surgery on Respiratory 371 Disturbances Impact of Bariatric Surgery on Health Related 377 Quality of Life Impact of Bariatric Surgery on Life Expectancy 378 Conclusion 383 References 383 Index 389

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12 Contributors Nicola Basso Department of Surgery La Sapienza University Policlinico Umberto I Viale Regina Elena Rome, Italy Luca Busetto Department of Medical and Surgical Sciences University of Padova Via Giustiniani, Padova, Italy luca.busetto@unipd.it Giuseppe Calcarella Anaesthesiology Department Camposampiero Hospital Via P. Cosma, Camposampiero, Padova, Italy gcalcarella@ulss15.pd.it xi

13 xii Contributors Elisa Calo Department of Medical and Surgical Sciences University of Pad Via Giustiniani, Padova, Italy elisa1002@libero.it Maurizio De Luca Department of Surgery Vicenza Hospital Via F. Rodolfi, Vicenza, Italy nnwdel@tin.it Andre D Hoore Department of Abdominal Surgery Hospital UZ Leuven Gasthuisberg Campus Herestraat 49, Leuven, Belgium andre.dhoore@uzleuven.be Bruno Dillemans Department of General Surgery Hospital AZ St.-Jan AV Ruddershove, 10 B-8000 Brugge, Belgium bruno.dillemans@azbrugge.be John B. Dixon Head of Obesity Research Unit Department of Surgery Monash University Victoria 3800, Australia john.dixon@med.monash.edu.au

14 Contributors xiii Guiliano Enzi Department of Medical and Surgical Sciences University of Padova Via Giustiniani, Padova, Italy giuliano.enzi@unipd.it Franco Favretti Director Department of Surgery Vicenza Hospital Via F. Rodolfi, Vicenza, Italy ffavret@tin.it Michael G. Sarr Department of Surgery Mayo Clinically 200 First Street S.W. US-Rochester, MN 55905, USA sarr.michael@mayo.edu Alfredo Genco Department of Surgery La Sapienza University Policlinico Umberto I Viale Regina Elena Rome, Italy alfredo.genco@uniroma1.it Nadey S. Hakim Max Thorek Professor of Surgery Fellow of the American Society of Bariatric and Metabolic Surgery Lead Bariatric Surgeon Highgate Hospital London Surgical Director, West London Transplant Unit Imperial College Healthcare NHS Trust Du Cane Road London W12 0HS, UK nadey@globalnet.co.uk

15 xiv Contributors Matthias Lannoo Department of Abdominal Surgery Hospital UZ Leuven Gasthuisberg Campus Herestraat 49, Leuven, Belgium Roberta Maselli Department of Surgery La Sapienza University Policlinico Umberto I Viale Regina Elena Rome, Italy Marco Mazza Department of Medical and Surgical Sciences University of Padova Via Giustiniani, Padova, Italy marco_mazza78@yahoo.it Melodie K. Moorehead, Ph.D., ABPP Honorary Member Psychologist Board Certified by the American Board of Professional Psychology in Clinical Health Psychology 1201 Broward Blvd. Ft. Lauderdale, FL 33301, USA psydrmm@aol.com Ernesto Pizzirani Director of Anaesthesiology Anaesthesiology Department Camposampiero Hospital Via P. Cosma, Camposampiero, Padova, Italy epizzirani@ulss15.pd.it

16 Contributors xv Shuvro H. Roy-Choudhury Consultant Radiologist Heart of England NHS Trust Department of Radiology Spire Parkway Hospital 1 Damson Parkway Solihull B91 2PP, UK shuvro.roy-choudhury@heartofengland.nhs.uk Gianni Segato Department of Surgery Vicenza Hospital Via F. Rodolfi, Vicenza, Italy gsegat@tin.it Sebastiaan Van Cauwenberge Department of General Surgery Hospital AZ St.-Jan AV Ruddershove, 10 B-8000 Brugge, Belgium sebastiaan.vancauwenberge@azbrugge.be Jose C. Varghese Department of Radiology Boston University Medical Center 88 East Newton Street, 2nd Floor Boston, MA 02118, USA jose.varghese@bmc.org

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18 Foreword With the worldwide epidemic of obesity seemingly just around the corner, bariatric surgery has exploded onto the surgery scene, having now become a truly household word. This book, edited by Professor Nadey S. Hakim and colleagues, should serve as a very readable, practical text for a wide range of staff, right from the huge number of medical support staff within a bariatric centre, to the bariatric surgeon, the anaesthesiologist, the bariatrician, and, most importantly, for the general surgeon who is NOT a bariatric surgeon! This latter focus on the non-bariatric general surgeon is becoming a topic of both extreme interest and deep concern to many general surgeons, as well as Emergency Room physicians. Currently, bariatric surgery represents the most common gastric operation in the Western world, since the operative treatment for Peptic Ulcer Disease has all but disappeared. And, with our increasingly mobile population, the ever-increasing number of a spectrum of operations (which are so well reviewed in this book!), and the growth of medical tourism due to first-world costs of bariatric surgery, all physicians, as well as nonbariatric general surgeons, will be exposed on an increasing basis to patients who have undergone surgery. Thus, the education of all physicians who do not have a bariatric practice is vital. This book will do just that the readability, focus, emphasis, and clinically-oriented approach have been consciously designed to address this topic in a way appealing to both the bariatric and non-bariatric healthcare provider. This book addresses most of the practical issues in bariatric surgery. Separate chapters address patient selection, different bariatric procedures, xvii

19 xviii Foreword including intragastric balloons (this topic is being revisited currently after its dismal failure years ago), the lap band or the laparoscopic adjustable gastric banding (and its complications/success), Roux-en-Y gastric bypass, and the forms of biliopancreatic diversion. Each procedure obligates a different set of medical concerns, leads to different mechanical and/or functional complications, and requires a unique type of follow-up. The chapter on anaesthetic issues provides a fabulous focus for the book. These considerations are important, not only for the surgical staff, but also for the entire team in the operating theatre and not just for just bariatric operations but also for other operations performed on the morbidly obese patient. Finally, the book finishes with the evidence supporting the efficacy of bariatric surgery from several different aspects resolution of direct, weight-related medical co-morbidities, improvements in quality of life, and even the concept of impact on life expectancy. As a general and gastrointestinal surgeon for the last 30 years, I have witnessed (and participated in) the growth, improvements, and finally general acceptance of bariatric surgery by both the lay public but, also importantly, by the medical community. In summary, this book accomplishes its goals readability, clinical relevance, and the important topic of a global view of bariatric surgery. You will enjoy reading every chapter. Michael G. Sarr, M.D. James C. Masson Professor of Surgery Mayo Clinic, USA

20 Chapter 1 Indications for Bariatric Surgery and Selecting the Appropriate Procedure John B. Dixon Indications for Bariatric Surgery When is surgery an option for a patient? When should it be recommended as best care? In 1991, the National Institutes of Health (NIH) criteria for patient selection for gastrointestinal surgery for severe obesity were developed at a consensus conference involving expert surgeons, gastroenterologists, endocrinologists, psychiatrists, nutritionists and other health care professionals as well as the public. After weighing the evidence the panel recommended that: 1. patients seeking therapy for severe obesity for the first time should be considered for treatment in a non-surgical programme with integrated components of a dietary regimen, appropriate exercise and behavioural modification and support; 2. gastric restrictive or bypass procedures could be considered for wellinformed and motivated patients with acceptable operative risks; 3. patients who are candidates for surgical procedures should be selected carefully after evaluation by a multidisciplinary team with medical, surgical, psychiatric and nutritional expertise; 4. the operation should be performed by a surgeon substantially experienced with the appropriate procedures and working in a clinical 1