6 WORLD GASTROENTEROLOGY NEWS MAY 2016 Editorial | Expert Point of View | Gastro 2016: EGHS-WGO | WDHD News | WGO & WGOF News | WGO Global Guidelines | Calendar of Events Bariatric Surgery and the Gastroenterologist Obesity is a global problem of epi-demic proportions. There were more than 1.9 billion overweight adults (BMI>25) in 2014 and 600 million of these were obese (BMI>30). Overall, 13% of the world’s adult population (11% males and 15% females) were obese and the prevalence of obesity has doubled between 1980-2014. In 2013, 42 million children under the age of 5 were overweight or obese 1. Obesity is a well-known risk factor for many pathological conditions, includ-ing hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, stroke, osteoarthritis, sleep apnea, and certain cancers, contribut-ing substantially to health care costs. Clinicians are limited by ineffective treatment options as dietary and behavioral modifications, exercise, and pharmacotherapy all have relatively poor long term results 2. Bariatric surgery, though drastic, seems cur-rently to be the only effective way of achieving long term persistent weight loss with improved or resolved comor-bid conditions. According to recent recommendations, patients with a BMI >35kg/m2 and depending on obesity-related co-morbidities should be offered surgery 3. Gastroenterologists are becoming increasingly involved in the care of obese patients. There is a significant association between obesity and various gastrointestinal problems, including reflux disease, vomiting, non-cardiac chest pain, diarrhea, etc. Obesity is also associated with a num-ber of gastrointestinal and hepatobili-ary conditions, like Barrett’s esopha-gus, esophageal adenocarcinoma, colonic polyps and cancer, gall stones, gall bladder cancer, pancreatic cancer, non-alcoholic fatty liver disease, hepatocellular cancer, etc., which are managed by gastroenterologists. Fur-thermore, besides the family doctor or general practitioner, increasingly in practice we may be the first medical contact for the obese or superobese and we should not be afraid to discuss (and even initiate discussion) about operative intervention or referral. However, this article is restricted to the role of gastroenterologist in bariat-ric surgery patients. The mechanism of bariatric surgery generally involves restriction, mal-absorption, or a combination of these two mechanisms. Restrictive procedures decrease the size of the stomach resulting in early satiety and reduced caloric intake. The restric-tive operations include laparoscopic adjustable gastric band (LAGB) and vertical sleeve gastrectomy (VSG). In contrast, malabsorptive procedures bypass a large part of small intestine decreasing the degree of absorption of nutrients. These procedures include Biliopancreatic diversion (BPD) with or without Duodenal switch (DS). Roux-en-Y gastric bypass (RNYGBP), the most commonly performed bariatric procedure, involves both components of restriction and malab-sorption. The procedure is technically demanding. VSG therefore is steadily gaining popularity due to technical advantages, perceived simplicity, and maintenance of anatomical continuity though the weight loss may be much less than after RNYGBP 4. The success and complication profiles of all these procedures are different. The postop-erative mortality rate of a RNYGBP at 30 days has been reported be-tween 0.2 – 0.5% depending on the technique (laparoscopic vs open) with leaks as the most common complica-tion with a reported range of 0.4-4%. The technically less demanding VSG has a reported mortality rate of ap-proximately 0.2%, again with leaks being the most common complication (1.9-2.4%) 5. A revisional procedure after bariatric surgery can be defined as a conversion, correction, or reversal. The indications for revisional surgery are treatment of severe side effects like persistent nausea, vomiting, dumping syndrome or complications of previ-ous bariatric surgery like stricture, Srikantaiah Manjunatha, MBBS, MD, MRCP(UK) Gastroenterologist Gastroenterology Unit Southern District Health Board Dunedin, New Zealand Michael Schultz, MD, PhD Associate Professor Department of Medicine University of Otago Dunedin, New Zealand
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