Chapter 9. Surgical Therapies for Morbid Obesity

• Body mass index (BMI) > 40.
• BMI between 35 and 40 and presence of such comorbid conditions as severe obstructive sleep apnea, pickwickian syndrome, obesity-related cardiomyopathy, degenerative joint disease, diabetes mellitus, hypertension, and hyperlipidemia.
• Failed dietary attempts at weight loss.

Absolute

• Active substance abuse.
• Severe psychiatric disorders.
• Pregnancy.
• Untreated esophagitis.

Relative

• BMI < 35.
• Age younger than 18 years.
• Age older than 60 years.
• Desire to become pregnant within 2 years.

Open Operation

• The patient should be supine with arms abducted and extended.

Laparoscopic Operation

• The patient should be supine with arms abducted and extended.
• Split-leg position is preferable.
• Contact and pressure points should be padded.
• The patient must be well secured to the operating table.

• An upper gastrointestinal study with water-soluble contrast is obtained on postoperative day 1 for the following reasons:
  • To rule out obstruction or leak from the gastrojejunostomy following Roux-en-Y gastric bypass (open and laparoscopic).
  • To rule out perforation or obstruction.
  • To document pouch size and band position following adjustable gastric band placement.
• Early ambulation is encouraged.
• Deep venous thromboembolism prophylaxis is provided with sequential compression devices and unfractionated or low-molecular-weight heparin.
• The patient is discharged home on a full liquid diet for 2 weeks. The diet is advanced to pureed and then solid food over the next 4 weeks.
• Following Roux-en-Y gastric bypass, patients must remain on lifelong supplementation with a multivitamin, calcium, and vitamin B12. They receive a proton pump inhibitor (PPI) for 3 months to prevent marginal ulceration and ursodeoxycholic acid for 6 months to reduce the risk of cholelithiasis.

Roux-en-Y Gastric Bypass: Open and Laparoscopic

• Anastomotic leak.
  • Occurs within 10 days postoperatively.
  • May be treated either conservatively or surgically.
• Stomal stenosis.
  • Occurs as a late complication, usually within 4–6 weeks of surgery.
  • Most patients respond to endoscopic dilation.
  • Refractory cases require operative revision.
• Marginal ulceration.
  • Occurs in 5–10% of patients.
  • Patients have epigastric pain or upper gastrointestinal bleeding, or both.
  • Perforation is less common but has been reported.
  • Usually responds to PPI but may require endoscopic or surgical intervention.
• Internal hernia.
  • May occur as an early or late complication in 3–5% of patients.
  • Patients typically present with acute or chronically intermittent obstructive symptoms.
  • Treatment is surgical.
• Incisional hernia (may occur in up to 15% of open operations).

Laparoscopic Adjustable Gastric Band

• Acute esophageal obstruction.
• Gastric prolapse ("slipped band") and pouch dilation.
• Band erosion.
• Esophageal dilation or dysmotility.
• Port and tubing complications (eg, breakage, migration, infection).