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The Endocrinologist’s Role in Bariatric Surgery

Bariatric surgery is indicated for certain high-risk patients who have clinically severe obesity. A key aspect of care for the post-bariatric surgery patient population is addressing non-surgical aspects of perioperative care, most notably nutritional and metabolic support. Clinical endocrinologists can and should play a central role in assisting bariatric surgery patients with this support and in making decisions on the most appropriate bariatric operation to select. A multidisciplinary team approach has been emphasized in the care of patients with metabolic diseases, including obesity, but this emphasis has not been as strong for patients undergoing or considering bariatric surgery. Clinical endocrinologists have been largely underutilized in bariatric surgery. However, these specialists can be of great assistance by: Helping manage the causes and complications of obesity. Discussing surgical risks and benefits, procedural options, and choices of surgeon and medical institution. Providing patients with education and guidance throughout the course of treatment. Nutritional Evaluation Before Bariatric Surgery According to guideline recommendations, all patients considering bariatric surgery should undergo an appropriate nutritional evaluation, including selective micronutrient measurements, before any procedure is performed. Clinical endocrinologists can help during this phase of treatment, especially for malabsorptive procedures in which more extensive perioperative nutritional evaluations are required. They can also assist patients during their protocol-derived staged meal progression based on the type of surgical procedure that is selected. Patient education on nutrition and meal-planning guidance before bariatric surgery and during the early postoperative hospital course is critical. This education can be reinforced during future outpatient visits. Additional education can be given on a balanced meal plan; appropriate intake of protein, nutritional supplements, and fluids; and parenteral...
Laparoscopic Banded Gastric Bypass

Laparoscopic Banded Gastric Bypass

In the presented video, we show a primary BRnYGB in a 38-year-old woman. The operation is performed as a two-surgeon procedure. The patient is positioned in the lithotomic position and reversed Trendelenburg tilt. The surgeon stands between the patient’s legs and one assistant stands on the left side of the patient. After insufflation of the capnoperitoneum via a 12 mm separator trocar (Applied Medical, Rancho Santa Margerita, CA), four working trocars are placed under direct view as shown (Figure 4). After lifting the left lobe of the liver aside, the subcardiac region is exposed. As shown in the film, the dissection is now started in the area of the angle of His, using the LigaSure™ instrument (Covidien, Dublin, Ireland). Then, the dissection is continued at the lesser curvature, 7-8 cm below the cardia. Here the omentum minor is dissected, and preparation is continued towards the left crus of the diaphragm. After insertion of a 32 F gastric tube the dimension of the pouch is now marked, and the gastric pouch can be separated using 3 to 4 linear staplers (blue cartridge, Covidien, Dublin, Ireland). The 32 F gastric tube should be removed prior to stapling. The pouch volume should be 15 to 25 ml [9]. The stapling line of the pouch is oversewn with a 3-0 resorbable running suture. Now the GaBP Ring is placed 2 cm from the distal end-point of the pouch. It is closed and fixed with two non-resorbable sutures. We usually use rings with a circumference of 6 to 6.5 cm. The alimentary limb is created by dividing the jejunum 50 cm below the ligament...

Bariatric Surgery for Diabetes: Significant Benefits Observed

In the United States, more than 90% of 25.8 million adults with diabetes have type 2 disease, according to the CDC. More than 1.9 million cases were diagnosed in 2010 alone among adults aged 20 and older. Approximately 90% of type 2 diabetes has been attributable to excess weight and obesity. “The results of noninvasive interventions for type 2 diabetes and obesity, such as lifestyle changes and pharmacotherapy, have been disappointing,” says Jon C. Gould, MD. “Bariatric surgery appears to be one of the most effective, long-lasting treatments for obesity. In many clinical trials, these procedures have been quite effective for individuals who are obese and have type 2 diabetes.” Riveting New Data on Bariatric Surgery Results In the June 2011 Archives of Surgery, a systematic review was published demonstrating that bariatric surgery leads to marked and long-lasting weight reduction, and may be capable of improving or even curing type 2 diabetes. The analysis reviewed findings from nine studies that followed obese patients with diabetes who underwent either gastric bypass or gastric banding for 1 year. Rick Meijer, MD, and colleagues from Amsterdam found that Roux-en-Y gastric bypass led to a reversal rate of type 2 diabetes of 83%. Adjustable gastric banding led to a reversal rate of 62%, and this effect was achieved later after surgery (Figure 1). “The presence of diabetes is a compelling argument to perform bariatric surgery in eligible patients according to nationally recognized criteria for the procedure,” says Dr. Gould. “Dr. Meijer’s study showed that glycemic control improved in the months after laparoscopic adjustable gastric banding, but it improved more rapidly and completely after...

Is Bariatric Surgery in Diabetics Cost-Effective?

Bariatric surgery has emerged as an effective approach to reducing body weight and improving obesity-related complications, especially for patients living with diabetes. The surgery has been shown to significantly reduce weight over time. Recent research also indicates that bariatric surgery may provide benefits to people with diabetes in addition to sustained weight loss. Among severely obese patients with diabetes, bariatric surgery has been associated with aiding in reductions in A1C, allowing many patients to stop taking diabetes medications. Data suggest that bariatric surgery is a successful long-term treatment of obesity for people with diabetes, but it’s important to remember that these procedures are expensive. Studies have shown that the average cost of bariatric surgery exceeds $13,000, and that doesn’t include additional costs that may ensue in the months following surgery. Consequently, evidence on the cost-effectiveness of bariatric surgery is needed. A New Cost-Effective Analysis In the September 2010 issue of Diabetes Care, my colleagues and I conducted a study to estimate the cost-effectiveness of bariatric surgery among severely obese patients with diabetes. We wanted to assess whether bariatric surgery reduces A1C and other risk factors enough to lower diabetes complications and improve quality of life. We estimated costs, quality-adjusted life-years (QALYs), and cost-effectiveness of bariatric surgeries relative to usual diabetes care for severely obese individuals who were newly diagnosed with diabetes and for those with established diabetes. “Gastric bypass and gastric banding were cost-effective methods of reducing mortality and diabetes complications in severely obese adults with diabetes.” In all of our analyses, bariatric surgery increased QALYs and increased costs. Gastric bypass surgery had cost-effectiveness ratios of $7,000 per QALY for...
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