Principles of Metabolic Surgery

410 Pages·2012·8.84 MB·English

by  Oliver Thomusch MD (auth.), Dr. W. Konrad Karcz, Prof. Dr. Oliver Thomusch (eds.)

W. Konrad Karcz
Oliver Thomusch (Eds.)
Principles of Metabolic Surgery
W. Konrad Karcz
Oliver Thomusch (Eds.)
Principles
of Metabolic
Surgery
1 3
Dr. W. Konrad Karcz
Prof. Dr. Oliver Thomusch
Universitätsklinikum Freiburg
Abt. Allgemein- und Viszeralchirurgie
Hugstetter Str. 55
79106 Freiburg
ISBN 978-3-642-02410-8 Springer-Verlag Berlin Heidelberg New York
Bibliographic information Deutsche Bibliothek
The Deutsche Bibliothek lists this publication in Deutsche Nationalbibliographie;
detailed bibliographic data is available in the internet at <http://dnb.ddb.de>.

This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned,
specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on
microfilms or in any other way, and storage in data banks. Duplication of this publication or parts thereof is per-
mitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and
permission for use must always be obtained from Springer-Verlag. Violations are liable to prosecution under the
German Copyright Law.
Springer Medizin
Springer-Verlag GmbH
Ein Unternehmen von Springer Science+Business Media
springer.de
© Springer- Verlag Berlin Heidelberg 2012
Printed in Germany
The use of general descriptive names, registered names, trademarks, etc. in this publications does not imply,
even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
Product liability: The publishers cannot guarantee the accuracy of any information about dosage and applica-
tion contained in this book. In every individual case the user must check such information by consulting the
relevant literature.
Editor: Diana Kraplow, Heidelberg
Project Manager: Ulrike Dächert, Heidelberg
Copyediting: Mary Schäfer, Buchen-Hettingen
Drawings: Alexandra Szypowska
Typesetting: TypoStudio Tobias Schaedla, Heidelberg
Cover Design and Layout: deblik Berlin
SPIN: 12700264
Printed on acid free paper: 5 4 3 2 1 0
V
Dedication
To medical professionals dealing with obesity-related metabolic
disorders, at all levels, in the quest for knowledge
VII
Preface
Metabolic surgery is an area of increasing specialization that aims at opening new perspectives
in the treatment of morbid obesity and its associated diseases. The knowledge and expertise
accruing in this interdisciplinary field are currently driving this specialization rapidly for-
ward. However, because so many experts and disciplines are involved in promoting metabolic
surgery, it is difficult to efficiently communicate novel ideas, models, and skills. Metabolic
surgery is thriving in large centers, where the newest standards can be met and where patients
may expect the highest competence.
The objective of this book is to provide a comprehensive insight into the latest develop-
ments in metabolic surgery, thus serving the purpose of all those who are invested in treating
and managing patients suffering from morbid obesity. All medical doctors should possess the
knowledge and clinical skills to provide sufficient treatment in this multidisciplinary field.
The editors succeeded in recruiting international experts, each of whom helps individually
to shed light on the diversity of current treatment options. Each chapter provides the founda-
tion for rational decision-making at a given stage of therapy. Additionally, the book elucidates
proper perioperative management and adequate substitution strategies, as well as conservative
therapeutic approaches.
IX
Contents
4 Obesity and Modern Nutrition . . . . . . . . . . . . . . .31
I Introduction Volker Schusdziarra, MD, Johannes Erdmann, MD
4.1 Obesity – a Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
4.2 Obesity-disturbed Regulation or the
1 History of Obesity and Metabolic Nutritional Rape of Evolution? . . . . . . . . . . . . . . . . . . . 33
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 4.3 Regulation of Food Intake . . . . . . . . . . . . . . . . . . . . . . . . 34
Oliver Thomusch, MD 4.3.1 Gastrointestinal Mechanisms . . . . . . . . . . . . . . . . . . . . . 34
1.1 Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 4.3.2 Signal Transduction from GI Tract to CNS . . . . . . . . . 37
1.2 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 4.3.3 Central Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 4.4 Adipose Tissue and Tonic Control . . . . . . . . . . . . . . . . . 39
4.5 The Power of Cognitive and Sensory
2 Conservative Treatment of Overweight Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 4.6 Implication for Obesity Treatment . . . . . . . . . . . . . . . . 41
Hartmut Bertz MD, Andrea Engelhardt, MD References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.1 When to Start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.2 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 5 Physical Activity as A Significant Factor
2.3 Guidelines of the German Obesity Society . . . . . . . 15 in The Therapy of Obesity . . . . . . . . . . . . . . . . . . .47
2.4 Sports and Physiotherapy . . . . . . . . . . . . . . . . . . . . . . . . 15 Aloys Berg, MD, Daniel König, MD
2.5 Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 5.1 Conventional Therapeutic Approach . . . . . . . . . . . . . 48
2.6 Psychoactive Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 5.2 Pathophysiology and Diagnostics . . . . . . . . . . . . . . . . 48
2.7 Psychodynamic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . 17 5.3 Significance of Inactivity for the Clinical and
2.8 Pharmacological Therapy . . . . . . . . . . . . . . . . . . . . . . . . 17 Physiological Picture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
2.9 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 5.4 Practical Sport Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . 51
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 5.5 Contraindications and Complications for Sport
Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
3 Obesity in Children – a Therapeutic 5.6 Conclusions in Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Ulrike Korsten-Reck, MD
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 6 The Role of Adipokines and Gastrointestinal
3.2 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Tract Hormones in Obesity . . . . . . . . . . . . . . . . . .53
3.3 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Julian Swierczynski, MD, Tomasz Sledzinski, MD
3.4 Genetic Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
3.5 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 6.2 Free Fatty Acids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
3.6 Pediatric Obesity and Lipid Metabolic 6.3 Adipokines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 6.3.1 Obesity, Inflammation, and Cardiovascular
3.7 Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
3.7.1 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 6.3.2 Obesity and Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
3.7.2 Physical Activity during Childhood . . . . . . . . . . . . . . . 23 6.3.3 The Adipokines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
3.7.3 Physical Activity and the Onset of 6.4 Cytokines, Chemokines and Growth Factors . . . . . . 65
Overweight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 6.5 Other Adipokines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
3.8 Therapeutic Principles and Objectives . . . . . . . . . . . . 24 6.6 Miscellaneous Substances Produced by
3.9 Integration of Sports into Therapy . . . . . . . . . . . . . . . . 25 Adipose Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
3.9.1 Complications and Contraindications . . . . . . . . . . . . . 25 6.7 Steroid Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.9.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 6.8 The Gastrointestinal Tract Hormones and Obesity . . 68
3.10 Influence of Intervention on Lipid Metabolism 6.9 Circulating Adipokines and Gastrointestinal
Parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Tract Hormones in Obese Subjects Prior to and
3.11 Results of Various Intervention Approaches . . . . . . 26 Following Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . 74
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
X Contents
7 Diabetological Assessment of Metabolic 10.2.1 Public Health and Economic Crisis . . . . . . . . . . . . . .108
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 10.2.2 Success and Failure of Medical Management
Janusz Gumprecht, MD, Katarzyna Nabrdalik, MD of Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108
7.1 Role of Foregut in Diabetes . . . . . . . . . . . . . . . . . . . . . . 82 10.3 What Is the Metabolic Syndrome? . . . . . . . . . . . . . .109
7.2 Bariatric Surgery Studies . . . . . . . . . . . . . . . . . . . . . . . . . 83 10.4 History of Metabolic Surgery . . . . . . . . . . . . . . . . . . .110
7.3 Interventional Diabetology . . . . . . . . . . . . . . . . . . . . . . . 84 10.5 Pathogenesis of Metabolic Syndrome . . . . . . . . . . .110
7.4 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 10.5.1 Insulin Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 10.5.2 The Adipoinsular Axis . . . . . . . . . . . . . . . . . . . . . . . . . .111
10.5.3 The Enteroinsular Axis . . . . . . . . . . . . . . . . . . . . . . . . . .112
8 Lipids and Bariatric Surgery . . . . . . . . . . . . . . . . .89 10.6 Metabolic Effects of Gastrointestinal
Tina Schewe, MD, Karl Winkler, MD Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112
8.1 Metabolism of Lipids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 10.6.1 Intestinal Malabsorption . . . . . . . . . . . . . . . . . . . . . . .113
8.1.1 Exogenous Lipid Metabolism . . . . . . . . . . . . . . . . . . . . . 90 10.6.2 Hormonal Regulation . . . . . . . . . . . . . . . . . . . . . . . . . .114
8.1.2 Endogenous Lipid Metabolism . . . . . . . . . . . . . . . . . . . 90 10.6.3 The Gut Hypothesis . . . . . . . . . . . . . . . . . . . . . . . . . . . .114
8.1.3 Reverse Cholesterol Transport . . . . . . . . . . . . . . . . . . . . 90 10.7 Established Surgical Techniques . . . . . . . . . . . . . . . .115
8.2 Laboratory Methods of Lipid Analysis and 10.7.1 Restrictive Procedures . . . . . . . . . . . . . . . . . . . . . . . . . .115
Their Clinical Utility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 10.7.2 Malabsorptive Procedures . . . . . . . . . . . . . . . . . . . . . .116
8.3 Clinical Impact of Hyperlipidemia . . . . . . . . . . . . . . . . 91 10.7.3 Novel Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .116
8.3.1 Hypercholesterolemia . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 10.8 Ongoing Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117
8.3.2 Hypertriglyceridemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .118
8.3.3 Combined Hyperlipidemia . . . . . . . . . . . . . . . . . . . . . . . 92
8.4 Atherogenic Dyslipidemia and the Metabolic 11 Venous Thromboembolism – Prophylaxis
Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
8.5 Therapeutic Considerations . . . . . . . . . . . . . . . . . . . . . . 92 Stefan Utzolino, MD, Magnus Kaffarnik, MD
8.6 Pathophysiology of Hyperlipidemia in Obese 11.1 Risk Factors for Venous Thrombo embolism . . . . .124
Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 11.2 Clinical Signs of Thromboembolism . . . . . . . . . . . .125
8.7 Lipids after Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . 93 11.2.1 D-Dimer Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125
8.7.1 Restrictive Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 11.2.2 Imaging Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126
8.7.2 Malabsorptive Procedures . . . . . . . . . . . . . . . . . . . . . . . . 93 11.3 Pharmacokinetics in the Obese . . . . . . . . . . . . . . . . .126
8.7.3 Combined Procedures: Malabsorptive and 11.4 Thromboembolism in Medical Patients . . . . . . . . .126
Restrictive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 11.5 Thromboembolism in Bariatric Surgery . . . . . . . . .127
8.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 11.6 Dosing of Heparins in the Obese . . . . . . . . . . . . . . .127
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 11.6.1 Monitoring Low-molecular-weight Heparin . . . . .128
11.6.2 Alternatives to Heparins: Mechanical
9 The Border of Internal Medicine and Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129
Metabolic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . .99 11.6.3 Anticoagulants under Investigation . . . . . . . . . . . . .131
Iwon Karcz-Socha, MD 11.7 Bleeding Risk versus Thrombo prophylaxis . . . . . .131
9.1 Adipose Tissue as the Organ of Internal 11.8 Vena caval Filters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132
Secretion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100 11.9 Timing of Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . .132
9.2 Neurohumoral Regulation of the Body’s Energy 11.10 Duration of Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . .133
Balance and the Development of Obesity . . . . . . .100 11.11 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133
9.3 The Clinical Aspect of Obesity . . . . . . . . . . . . . . . . . . .101 11.11.1 Prophylaxis of Venous Thrombo embolism . . . . . .133
9.4 Diagnosis, and Then What? . . . . . . . . . . . . . . . . . . . . . .102 11.11.2 Therapeutic Anticoagulation . . . . . . . . . . . . . . . . . . .133
9.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
12 Principals of Nutrition after Surgical
10 Innovative Approach to Treatment Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137
of the Metabolic Syndrome . . . . . . . . . . . . . . . 107 Hartmut Bertz, MD, Andrea Engelhardt, MD
Joel Ricci, MD, Michael Timoney, MD, 12.1 Macronutrients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
George Ferzli, MD 12.1.1 Proteins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
10.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108 12.1.2 Carbohydrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
10.2 Diabetes and the Metabolic Syndrome . . . . . . . . . .108 12.1.3 Lipids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
XI
Contents
12.1.4 Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139 14.9 Airway Management . . . . . . . . . . . . . . . . . . . . . . . . . . .164
12.2 Micronutrients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139 14.10 Mechanical Ventilation during Anesthesia . . . . . .164
12.2.1 Water-soluble vitamins . . . . . . . . . . . . . . . . . . . . . . . . .139 14.11 Laparoscopic Procedures in the Obese
12.2.2 Fat-soluble vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . .140 Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .164
12.3 Trace Elements And Electrolytes . . . . . . . . . . . . . . .141 14.12 Regional Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . .165
12.4 Common Nutritional Guidelines in Bariatric 14.13 Recovery and Pain Therapy . . . . . . . . . . . . . . . . . . . . .165
or Metabolic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . .142 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .165
12.4.1 Problems in all types of bariatric surgery . . . . . . . .142
12.4.2 Nutrition after bariatric surgery . . . . . . . . . . . . . . . . .142 15 Patient Selection and Choice of the
12.5 Nutritional Problems Associated With Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Specific Bariatric Surgery Procedures And Robert E. Brolin, MD
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143 15.1 Criteria for Patient Selection . . . . . . . . . . . . . . . . . . . .170
12.5.1 Gastric Banding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143 15.2 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .170
12.5.2 Gastric Sleeve LSG . . . . . . . . . . . . . . . . . . . . . . . . . . . . .144 15.3 Algorithmic Approach to Bariatric Surgery . . . . . .171
12.5.3 Gastric Bypass (RYGB) . . . . . . . . . . . . . . . . . . . . . . . . . .144 15.4 Preoperative Manipulations . . . . . . . . . . . . . . . . . . . .172
12.5.4 Biliopancreatic Diversion (BPD) with or 15.5 Algorithms Based on Preoperative Weight . . . . . .172
without Duodenal switch (DS) . . . . . . . . . . . . . . . . .145 15.6 Algorithms Based on Preoperative
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148 Comorbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173
15.7 Algorithm Based on Preoperative Eating
Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .174
15.8 Algorithm for Revisional Surgery . . . . . . . . . . . . . . .174
II Preoperative Evaluation
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .175
and Indications for Surgery
13 Psychological and Psychiatric III Surgical Procedures
Contraindications . . . . . . . . . . . . . . . . . . . . . . . . 153
Claus Michael Gross, MD,
Ludger Tebartz van Elst, MD 16 Pathophysiology of Restrictive
13.1 General Considerations . . . . . . . . . . . . . . . . . . . . . . . .154 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
13.2 Specific Psychiatric Disorders and Bariatric Giovanni Dapri, MD, G.B.Cadière, MD,
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .154 Jaqules Himpens, MD
13.3 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .156 16.1 Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .156 16.1.1 Vertical Banded Gastroplasty . . . . . . . . . . . . . . . . . . .180
16.1.2 Adjustable Gastric Banding . . . . . . . . . . . . . . . . . . . . .181
14 Challenges of Anesthesia . . . . . . . . . . . . . . . . 159 16.1.3 Sleeve Gastrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . .182
Heike Kaltofen, MD References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .184
14.1 Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .160
14.2 Pathophysiological Changes . . . . . . . . . . . . . . . . . . . .160 17 The Gastric Banding . . . . . . . . . . . . . . . . . . . . . . 187
14.2.1 Pulmonary Function . . . . . . . . . . . . . . . . . . . . . . . . . . .160 Tomasz Szewczyk, MD, Bogdan Modzelewski, MD
14.2.2 Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . .160 17.1 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .188
14.2.3 Obesity Hypoventilation Syndrome . . . . . . . . . . . . .161 17.2 The Various Bands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189
14.2.4 Pulmonary Hypertension . . . . . . . . . . . . . . . . . . . . . . .161 17.3 The Operative Techniques . . . . . . . . . . . . . . . . . . . . . .189
14.2.5 Airway Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . .161 17.4 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .192
14.2.6 Cardiovascular System . . . . . . . . . . . . . . . . . . . . . . . . .161 17.5 Discussion: Gastric Banding – Aspects of
14.2.7 Gastrointestinal Changes . . . . . . . . . . . . . . . . . . . . . . .161 Metabolic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . .196
14.3 Preoperative Evaluation . . . . . . . . . . . . . . . . . . . . . . . .161 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .197
14.4 Premedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162
14.5 Monitoring/Vascular Access . . . . . . . . . . . . . . . . . . . .162 18 The Sleeve Gastrectomy . . . . . . . . . . . . . . . . . . 201
14.6 Anesthetic Drugs in Obese Patients . . . . . . . . . . . . .163 Daniel Krawczykowski, MD
14.7 Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . .163 18.1 Technical Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .202
14.8 Induction of Anesthesia . . . . . . . . . . . . . . . . . . . . . . . .163 18.2 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .203
XII Contents
18.3 Indications for LSG . . . . . . . . . . . . . . . . . . . . . . . . . . . . .204 21.5 The Nutritional Physiology of BPD . . . . . . . . . . . . . .245
18.4 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .204 21.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .246
18.5 Drawbacks of the Operation . . . . . . . . . . . . . . . . . . . .206
18.6 Our Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .208 22 The Biliopancreatic Diversion . . . . . . . . . . . . . 247
18.7 The Technique of SG after Gastric W. Konrad Karcz, MD, Luc Lemmens, MD,
Banding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .209 Waleed Bukhari, MD, Cheng Zhou, MD,
18.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213 Simon Küsters, MD, Marc Daoud, MD
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213 22.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248
22.2 Indications for malabsorptive surgery . . . . . . . . . .248
19 The Conventional Gastric Bypass . . . . . . . . . . 217 22.3 Operative technique – the standard BPD
Oliver Thomusch, MD, W. Konrad Karcz, MD as described by Scopinaro . . . . . . . . . . . . . . . . . . . . . .251
19.1 Mechanisms of Action . . . . . . . . . . . . . . . . . . . . . . . . . .218 22.4 Operation technique of Standard
19.1.1 Restrictive Component . . . . . . . . . . . . . . . . . . . . . . . . .218 Laparoscopic Biliopancreatic Diversion
19.1.2 Modification of Eating Behavior . . . . . . . . . . . . . . . .218 with Duodenal Switch . . . . . . . . . . . . . . . . . . . . . . . . .253
19.1.3 Endocrine Metabolic Component . . . . . . . . . . . . . . .219 22.5 Early and Late Complications . . . . . . . . . . . . . . . . . .254
19.2 Indications for the Gastric Bypass 22.6 Weight loss and Benefits . . . . . . . . . . . . . . . . . . . . . . .259
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .219 22.7 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .260
19.3 Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . .220 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .260
19.4 Perioperative Complications . . . . . . . . . . . . . . . . . . . .222
19.5 Follow-up Examinations . . . . . . . . . . . . . . . . . . . . . . . .223 23 Surgical Treatment focused of T2DM:
19.6 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .223 Looking for The Limits . . . . . . . . . . . . . . . . . . . . 265
19.7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .224 Michael Frenken, MD, Simon Kuesters, MD,
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .224 W. Konrad Karcz, MD
23.1 Indications for anti-diabetic surgery . . . . . . . . . . . .266
20 The Banded Gastric Bypass . . . . . . . . . . . . . . . 227 23.2 Remission of Insulin-dependent Type 2
Mal Fobi, MD, Malgorzata V. Stanczyk, MD, Diabetes Mellitus after BPD / DS . . . . . . . . . . . . . . . .266
Joseph Naim, MD, Kekah Che-Senge, MD 23.3 Increase in insulin sensitivity occurs in the
20.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .228 early postoperative phase . . . . . . . . . . . . . . . . . . . . . .267
20.2 Why the Band in the Gastric Bypass 23.4 Does remission of diabetes depend on
Operation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .228 duration and severity of the disease? . . . . . . . . . . .267
20.3 Surgical Technique of the Banded Gastric 23.5 Mechanisms of diabetes remission after
Bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .231 gastrointestinal surgery . . . . . . . . . . . . . . . . . . . . . . . .268
20.4 Variations in the Surgical Technique . . . . . . . . . . . .233 23.6 Morbidity and mortality of anti-diabetic
20.5 Concurrent Operations . . . . . . . . . . . . . . . . . . . . . . . . .233 surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .268
20.6 Secondary Operations . . . . . . . . . . . . . . . . . . . . . . . . .233 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .268
20.7 Perioperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . .235
20.8 Perioperative Complications . . . . . . . . . . . . . . . . . . . .236
20.9 Long-term Complications . . . . . . . . . . . . . . . . . . . . . .236
IV Accessory Medical Problems
20.10 Revision/Conversion/Reversal Operations . . . . . . .237
20.11 Weight Loss Outcome after Banded Gastric after Metabolic Surgery
Bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .237
20.12 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .237
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .237 24 Postoperative Management . . . . . . . . . . . . . . 273
Magnus Kaffarnik, MD, Carolin Kayser, MD,
21 Pathophysiology of Malabsorptive Stefan Utzolino, MD
Bariatric Procedures . . . . . . . . . . . . . . . . . . . . . . 239 24.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .274
Nicola Scopinaro, MD 24.2 Fluid Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . .274
21.1 Malabsoprtion Definision . . . . . . . . . . . . . . . . . . . . . .240 24.3 Metabolic Management and Perioperative
21.2 Basic Principles of BPD . . . . . . . . . . . . . . . . . . . . . . . . .240 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .275
21.3 Effects Other than Weight Loss . . . . . . . . . . . . . . . . .241 24.3.1 Metabolic Management . . . . . . . . . . . . . . . . . . . . . . . .275
21.4 Combination of BPD with Gastric 24.3.2 Perioperative Nutrition . . . . . . . . . . . . . . . . . . . . . . . . .275
Restriction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .243 24.4 Postoperative Analgesia . . . . . . . . . . . . . . . . . . . . . . . .277