Obesity, Bariatric and Metabolic Surgery: A Comprehensive Guide

Description

This comprehensive guide with over 100 chapters covers all the aspects of bariatric and metabolic surgery including perioperative management, surgical techniques of common as well as newer procedures, complications, controversies and outcomes. All the chapters have been revised in this second edition with addition of new chapters and sections on OAGB/MGB Surgery & Metabolic Surgery. There are dedicated sections on revisional surgery and innovative endoscopic procedures. The book is well illustrated with photos and video clips along with step-by-step guidance for a complete range of Bariatric procedures. Medical aspects of obesity and metabolic syndrome are included in the introductory sections, and the last two sections cover diverse topics in this exciting field of bariatric surgery. Written by leading experts, Obesity, Bariatric and Metabolic Surgery - A Comprehensive Guide serves as an excellent reference manual for a wide range of healthcare professionals involved within the Bariatric Multidisciplinary Team including Bariatric Surgeons, General Surgeons, Trainees, Physicians, Anaesthesiologists, Dieticians, Psychologists, Psychiatrists, Radiologists and Nursing staff. Foreword by Kelvin D. Higa Foreword by Michel Gagner Preface Acknowledgments Contents About the Editor Associate Editor Section Editors Contributors Obesity and Metabolic Syndrome 1 Introduction to Obesity 1.1 Definition of Obesity 1.2 Prevalence of Obesity 1.2.1 Worldwide 1.2.2 Obesity in the United Kingdom (UK) 1.2.3 Socioeconomics of Obesity 1.2.4 Effect of Ethnicity 1.3 Costs of Obesity 1.3.1 Individual Cost of Obesity 1.3.2 Population Cost 1.3.2.1 UK Costs 1.3.2.2 Worldwide Costs 1.4 Measurement of Obesity 1.4.1 BMI 1.4.2 Ideal Body Weight 1.4.3 Percent Excess Weight Loss and Percent Weight Loss 1.4.4 Waist Circumference and Waist-to-Hip Ratio 1.4.5 Waist and Hip Circumference Measurements 1.4.5.1 Waist Circumference 1.4.5.2 Hip Circumference 1.4.5.3 Waist-to-Hip Ratio 1.4.5.4 Skin Fold Thickness 1.4.5.5 Bioimpedance Analysis 1.5 Other Methods Used for Obesity Measurement 1.5.1 Dual Energy X-Ray Absorptiometry (DEXA) 1.5.2 Hydrometry (Dilution Method) 1.5.3 Hydrodensitometry - Underwater Weighing 1.5.4 Air Displacement Plethysmography 1.5.5 Computed Tomography or Magnetic Resonance Image 1.6 Importance of Assessing Abdominal Fat 1.7 Summary 1.8 Key Learning Points 1.9 Cross-References References 2 Etiopathogenesis of Obesity 2.1 Introduction 2.2 Regulation of Energy Balance 2.2.1 Role of the Central Nervous System 2.3 Regulation of Food Intake 2.3.1 Short-Term Mechanisms 2.3.2 Long-Term Mechanisms 2.4 Regulation of Metabolism 2.5 Etiology of Obesity 2.5.1 Inherited Causes 2.5.2 Environmental Causes 2.5.2.1 Dietary Factors 2.5.2.2 Physical Activity 2.5.2.3 Other Factors 2.5.3 Endocrine Causes 2.5.4 Hypothalamic Obesity 2.5.5 Drugs 2.5.6 Pregnancy and Menopause 2.5.7 Eating Disorders and Psychological Causes 2.6 Key Learning Points References 3 Gut-Derived Hormones and Energy Homeostasis 3.1 Hormones Secreted by the Enteroendocrine Cells 3.1.1 L-Cell Secretion 3.1.1.1 Peptide YY 3.1.1.2 Glucagon-Like-Peptide-1 3.1.1.3 Oxyntomodulin 3.1.1.4 P/D1-Type Cells and Ghrelin 3.2 Effect of Obesity on PYY, GLP-1 and OXM 3.3 The Effect of Diet Induced Weight Loss and Exercise on PYY, GLP-1 and OXM 3.4 Gut Hormone Cross-Talk and Combination Therapies 3.5 Key Learning Points References 4 Why Sustained Dietary Weight Loss Is So Difficult 4.1 Introduction 4.1.1 Importance of Human Energy Homeostasis 4.2 The Weight Set-Point Theory 4.2.1 Evidence for a Weight Set-Point in Animals 4.2.2 Evidence for a Weight Set-Point in Humans 4.2.3 How Is the Weight Set-Point Defended? 4.2.4 What Determines an Individual´s Weight Set-Point? 4.2.4.1 Genetics 4.2.4.2 Epigenetics 4.2.4.3 Environment 4.2.4.4 History of Dieting 4.2.5 Why Does the Weight Set-Point Increases with the Western Diet? 4.2.5.1 Leptin Resistance 4.2.6 How Can the Weight Set-Point Be Reduced? 4.3 Summary 4.4 Key Learning Points References 5 Obesity-Associated Comorbidities: Health Consequences 5.1 Introduction 5.2 Causes or Consequences of Obesity 5.2.1 Physiological Consequences of Excess Adipose Tissue 5.3 Characteristics of Obese Subjects 5.4 Psychological Illness and Obesity 5.4.1 Depression 5.4.2 Psychotic Illness 5.4.3 Psychological Effects of Dieting, Weight Loss, and Weight Gain 5.5 T2DM and Metabolic Syndrome 5.6 Hypertension and Obesity 5.7 Dyslipidemia 5.8 Cardiovascular Diseases 5.9 Obesity and Bladder/Urinary Tract 5.10 Obesity and the Male Reproductive System 5.11 Obesity and Female Reproductive System 5.11.1 Obesity in Pregnancy 5.12 Degenerative Arthritis 5.13 Biliary System 5.14 Esophageal Disorders 5.15 Nonalcoholic Fatty Liver Disease 5.16 Obstructive Sleep Apnea 5.17 Obesity and Cancer 5.18 Obesity and Thromboembolic Disease 5.19 Mortality 5.20 Key Learning Points References 6 Medical Management of Obesity 6.1 Introduction 6.2 Aims of Treatment 6.3 The Team 6.4 The Principles of Treatment 6.5 Overview of Assessment and Treatment 6.6 Initial Assessment 6.6.1 Genetic Causes 6.6.2 Eating Disorders 6.6.3 Medical Conditions 6.6.4 Psychiatric Disorders 6.6.5 Medication 6.7 Treatment 6.7.1 Assessing Readiness to Change 6.7.2 Barriers to Weight Loss 6.7.3 Treatment of Eating Disorders 6.7.4 Lifestyle Modification 6.7.5 Weight Loss Drugs 6.8 Who and When to Refer for Bariatric Surgery 6.9 Obesity and Coronavirus Disease (COVID-19) 6.10 Summary 6.11 Key Learning Points References Introduction to Bariatric Surgery 7 Historical Perspectives of Bariatric Surgery 7.1 Introduction 7.2 Early Approaches: JejunoIleal Bypass 7.3 Gastric Bypass 7.4 Biliopancreatic Diversion 7.5 Duodenal Switch 7.6 Gastric Restrictive Procedures: Gastroplasty and Banding 7.7 Sleeve Gastrectomy 7.8 Gastric Plication 7.9 Mini-Gastric Bypass 7.10 Laparoscopic Surgery 7.11 Endoscopic Approaches 7.11.1 Intragastric Balloons 7.11.2 Endoscopic Sleeve Liner 7.11.3 Endoscopic Gastroplasty 7.11.4 Aspiration Therapy 7.12 Other Approaches 7.13 Summary 7.14 Key Learning Points References 8 Evidence Base for Bariatric Surgery 8.1 Introduction 8.2 Outcomes of Surgery and Preoperative Expectations 8.2.1 Predictors of Outcomes 8.2.1.1 Types of Procedure 8.2.1.2 Other Predictors of Outcomes 8.2.2 Evidence Base for Bariatric Surgery in Class III Obese Patients with Type 2 Diabetes Mellitus 8.2.2.1 Randomized Controlled Trials 8.2.2.2 Long-Term Effect of Bariatric Surgery on Type 2 Diabetes Mellitus 8.2.3 Recommendations from International/National Consensus Statements on Bariatric Surgery in Patients with Type 2 Diabetes M... 8.2.4 Strategy for Managing Type 2 Diabetes Mellitus in the Severely Obese 8.3 Conclusion References 9 Patient Selection in Bariatric Surgery 9.1 Introduction 9.2 Patient Selection Criteria 9.3 Contraindications to Surgery 9.3.1 Physiological Factors 9.3.1.1 Extremes of Age Children and Adolescents Elderly 9.3.1.2 Body Mass Index 9.3.2 Medical and Surgical Factors 9.3.2.1 Pharmacotherapy 9.3.2.2 Obstructive Sleep Apnea 9.3.2.3 Diabetes, Hypertension, and Cardiovascular Problems 9.3.2.4 Malignancy 9.3.2.5 Hiatus Hernia and Ventral Hernia Hiatus Hernia Ventral Hernia 9.3.2.6 Renal Failure 9.3.2.7 Nonalcoholic Fatty Liver Disease (NAFLD) and Nonalcoholic Steatohepatitis (NASH) 9.3.2.8 Organ Transplantation 9.3.2.9 Thromboembolic Risk 9.3.2.10 Previous Abdominal Surgery 9.3.2.11 Inflammatory Bowel Disease (IBD) 9.3.2.12 Immunosuppression 9.3.2.13 Vitamin-D Deficiency 9.3.3 Smoking 9.3.4 Functional Status and Mobility 9.3.5 Psychological Factors 9.3.5.1 Active Psychiatric Disease 9.3.5.2 Psychosocial Issues 9.3.5.3 Eating Disorders 9.3.5.4 Intelligence, Understanding, and Mental Capacity 9.3.5.5 Noncompliance 9.4 Summary 9.5 Key Learning Points 9.6 Cross-References References 10 Procedure Selection in Bariatric Surgery 10.1 Introduction 10.2 Factors Affecting the Procedure Selection 10.2.1 Patient Factors 10.2.1.1 Reasons for Surgery 10.2.1.2 Comorbidities 10.2.1.3 Choice 10.2.2 Surgical Factors 10.2.3 Local/Regulatory Factors 10.3 Different Bariatric Procedures 10.3.1 Laparoscopic Adjustable Gastric Banding (LAGB) 10.3.2 Laparoscopic Sleeve Gastrectomy (LSG) 10.3.3 Laparoscopic Roux-En-Y Gastric Bypass (LRYGB) 10.3.4 Laparoscopic One-Anastomosis Gastric Bypass (OAGB) or Mini-Gastric Bypass 10.3.5 Laparoscopic Duodenal Switch (DS) 10.3.6 Laparoscopic Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy (SADI-S) 10.3.7 Endoscopic Bariatric Therapies (EBT) 10.4 Balancing Risks and Outcomes 10.5 Summary References Perioperative Assessment for Bariatric Surgery 11 Preoperative Medical Evaluation of the Bariatric Surgery Patient 11.1 Introduction 11.2 Initial Medical Assessment 11.2.1 Medical Causes of Obesity and Obesity-Associated Conditions 11.2.2 Preoperative Assessment 11.2.3 The Role of Investigations 11.2.4 The Bariatric Multidisciplinary Team (MDT) 11.2.5 Preoperative Enhanced Recovery After Bariatric Surgery (ERABS) 11.3 Management of Common Medical Conditions in the Patient Before Bariatric Surgery 11.3.1 Management of Cardiovascular Comorbidity 11.3.2 Respiratory Disease 11.3.3 Management of Thromboembolic Risk 11.3.4 Type 2 Diabetes Mellitus 11.3.5 Cholelithiasis 11.3.6 Management of Gastroesophageal Pathology 11.3.7 Medication 11.3.8 Pregnancy 11.3.9 Previous Surgery 11.4 COVID-19 and the Perioperative Management of the Bariatric Patient 11.5 Summary 11.6 Key Learning Points 11.7 Cross-References References 12 Preoperative Dietary Evaluation Prior to Bariatric Surgery 12.1 Introduction 12.2 Weight and Dieting History 12.2.1 Diet History 12.2.2 Nutritional Assessment 12.2.3 Eating Disorders 12.3 Preparation for Bariatric and Metabolic Surgery 12.3.1 Preoperative Dietetic Counseling 12.3.2 Dietetic Input into the Multidisciplinary Team 12.3.3 Preoperative Diet 12.4 Revisional Surgery 12.4.1 Inadequate Weight Loss or Weight Regain 12.4.2 Malnutrition 12.5 Summary 12.6 Key Learning Points 12.7 Cross-References References 13 Psychological Assessment of the Bariatric Surgery Patient 13.1 Rationale for Psychological Assessment in Bariatric Surgery 13.1.1 First-Generation Psychological Assessments: Identification of Contraindications 13.1.1.1 Empirical Evidence Regarding Psychological Contraindications 13.1.1.2 Consensus Evidence: Clinician´s View of Psychological Contraindications 13.1.2 Second-Generation Psychological Assessments: Psychological and Behavioral Readiness 13.1.3 Credentials of the Assessor 13.2 The Assessment Process and Content 13.2.1 Methods of Assessment 13.2.1.1 Semi-Structured Interviews 13.2.1.2 Key Areas Included in the Clinical Interview Reasons for Seeking Surgery The Patient´s Understanding and Knowledge of Their Role in Making Bariatric Surgery Effective Expectations of Outcome Weight and Dieting History Eating Patterns Current Eating Disorders Eating Disorder History Mental Health Substance Misuse Trauma and Abuse Stability and Stressors Psychological Impact of Weight, Including Stigma and Body Image Relationships and Support 13.2.2 Psychological Assessment for Revisional Bariatric Surgery 13.3 Outcome of Assessments 13.4 Summary 13.5 Key Learning Points 13.6 Cross-References References 14 Anaesthesia Considerations in the Obese Patient for Bariatric Surgery 14.1 Introduction 14.2 Bariatric Anesthesia in the UK 14.3 Preoperative Care 14.3.1 Cardiovascular Disease 14.3.1.1 Arterial Hypertension 14.3.1.2 Ischemic Heart Disease 14.3.1.3 Heart Failure 14.3.1.4 Cardiovascular Assessment 14.3.2 OSA and OHS 14.3.3 Fat Distribution 14.3.4 Airway 14.3.5 Preoperative Optimization 14.3.5.1 Smoking 14.3.5.2 T2DM 14.3.5.3 OSA 14.3.5.4 Coronavirus Disease (COVID-19) 14.3.5.5 Patients´ Expectations 14.3.5.6 Dignity 14.4 Perioperative Care 14.4.1 Induction of Anesthesia 14.4.2 Maintenance of Anesthesia 14.4.3 Analgesia and Antiemesis 14.4.4 Extubation 14.4.5 Recovery 14.5 Postoperative Care 14.5.1 Venous Thromboembolism (VTE) Prophylaxis 14.5.2 T2DM Postoperative Management 14.6 Summary 14.7 Key Learning Points References 15 Preoperative Risk Scoring Systems in Bariatric Surgery 15.1 Introduction 15.2 Obesity Surgery Mortality Risk Score 15.2.1 Limitations of OSMRS 15.3 Bariatric Mortality Risk Classification System 15.3.1 Limitations of BMR Classification System 15.4 Edmonton Obesity Staging System 15.4.1 Limitations of EOSS 15.5 Metabolic Acuity Score 15.5.1 Limitations of the MAS 15.6 Nomogram for Predicting Surgical Complications in Bariatric Surgery Patients 15.7 American Society of Anesthesiologists Physical Status Classification System 15.7.1 Limitations of the ASA Classification 15.8 Cardiac Risk Assessment for Noncardiac Surgery 15.9 Longitudinal Assessment of Bariatric Surgery (LABS), National Bariatric Surgery Registry (NBSR), and Scandinavian Obesity... 15.10 Evaluation of Comorbidity Scoring Systems in Bariatric Surgery 15.11 Summary References 16 Multidisciplinary Team in Bariatric Surgery: Structure and Role 16.1 Introduction 16.2 Obesity and the MDT 16.3 Members of the Multidisciplinary Team 16.4 Components for an Effective Bariatric MDT 16.5 Evidence Base for Multidisciplinary Team in Bariatric Surgery 16.6 Guidelines for MDT Use 16.7 Conclusion 16.8 Key Learning Points References 17 Nursing and Physiotherapy Care of the Bariatric Surgery Patient 17.1 Introduction 17.2 Preparation for Surgery 17.2.1 What Does the Preparation Include? 17.2.2 Preoperative Care of the Patients Undergoing Bariatric Surgery 17.2.3 Intraoperative Care of the Patients Undergoing Bariatric Surgery 17.2.3.1 Teamwork 17.2.3.2 Patient Positioning 17.2.3.3 Prevention of Deep Vein Thrombosis in the Operation Theatre 17.2.3.4 Stapling Devices 17.2.3.5 Recommendations for Nursing Care of the Patient Undergoing Bariatric Surgery during the Coronavirus Disease (Covid-19... 17.3 Postoperative Care of the Patient Undergoing Bariatric Surgery 17.3.1 Pain Management 17.3.2 Respiration 17.3.3 Venous Thromboembolism 17.3.4 Detecting Early Postoperative Complications 17.3.4.1 Wound Infection 17.3.4.2 Nausea and Vomiting 17.3.4.3 Postoperative Hemorrhage 17.3.4.4 Anastomotic Leak 17.3.5 Intensive Care Input 17.3.6 Discharge 17.4 The physiotherapist´s Role in the Management of Patients Undergoing Bariatric Surgery 17.4.1 Triage/First Point of Contact/Preoperative Input 17.4.2 Physiotherapy Input Postoperatively 17.4.3 Physiotherapy Led Pre- and Postoperative Exercise Groups 17.4.4 The Digital Future 17.5 Summary 17.6 Key Learning Points References 18 Peri-operative Management of the Bariatric Surgical Patient 18.1 Introduction 18.2 Physiological and Pathological Considerations in Patients with Obesity 18.2.1 Respiratory System 18.2.2 Cardiovascular System 18.2.3 Diabetes 18.2.4 Thrombosis 18.2.5 Pharmacological Considerations 18.3 Preoperative Evaluation 18.3.1 Airway Assessment 18.3.2 Respiratory Assessment 18.3.3 Cardiovascular Assessment 18.3.4 Diabetes Assessment and Management 18.3.5 Patient Optimization 18.3.6 Risk Prediction Models 18.3.7 Planning Postoperative Care 18.4 Intraoperative Care 18.4.1 Patient Preparation 18.4.2 Operating Theatre Equipment and Set-Up 18.4.3 Surgical Checklist and Staff Preparation 18.4.4 Anesthetic Induction and Patient Positioning 18.4.5 Intraoperative Phase 18.4.6 Recovery from Aesthesia 18.5 Postoperative Care 18.5.1 Immediate Post-operative Care 18.5.2 Analgesia and Antiemetics 18.5.3 Ward-Based Care 18.5.4 Thromboprophylaxis 18.5.5 Postoperative Diabetes Management 18.5.6 Identification of Complications 18.6 Summary 18.7 Key Learning Points 18.8 Cross-References References 19 Enhanced Recovery After Bariatric Surgery 19.1 Introduction 19.2 Rationale and Pathophysiology of ERABS Interventions 19.2.1 Preoperative Comorbidities and Fitness 19.2.2 Surgical Stress and the Inflammatory Response to Injury 19.2.3 Insulin Resistance and the Metabolic Response 19.2.4 Fluid Balance and Postoperative Gastrointestinal Dysfunction: Nausea, Vomiting, and Postoperative Ileus 19.2.5 Surgery and Nociception 19.2.6 Postoperative Deconditioning 19.3 Enhanced Recovery After Bariatric Surgery Guidelines and Protocols 19.4 ERABS Recommendations 19.4.1 Preadmission Information, Education, and Counseling 19.4.2 Patient Evaluation and Optimization 19.4.2.1 Glycemic Control 19.4.2.2 Smoking and Alcohol Cessation 19.4.2.3 Preoperative Weight Loss 19.4.2.4 Prehabilitation 19.4.3 Preoperative Patient Preparation 19.4.3.1 Preoperative Diet, Fasting, and Carbohydrate Loading 19.4.3.2 Preanesthetic Medication 19.4.4 Perioperative Fluid Management and PONV Prophylaxis 19.4.5 Standardized Anesthetic Protocol 19.4.6 Perioperative Interventions 19.4.7 Postoperative Opioid-Sparing Multimodal Analgesia 19.4.8 Prevention of Postoperative Ileus, Early Postoperative Nutrition, and Ambulation 19.4.9 Thromboprophylaxis 19.4.10 Standardized Discharge and Follow-Up Criteria 19.5 Evidence Base Supporting ERABS 19.6 Limitations and Challenges of ERABS Protocols 19.7 Summary and Future Research References Laparoscopic Roux-en-Y Gastric Bypass (LRYGB): Mechanism of Action, Techniques, Complications, Outcomes, and Controversies 20 Laparoscopic Roux-en-Y Gastric Bypass: Mechanism of Action 20.1 Introduction 20.2 Mechanism of Action 20.2.1 Hypoabsorption 20.2.2 Caloric Restriction 20.2.3 Energy Expenditure 20.2.4 Changes in Eating Behavior 20.2.5 Enterohormones, Incretins, and Intestinal Adaptation 20.2.5.1 Enterohormones GLP-1 GIP PYY Oxyntomodulin CCK Ghrelin 20.2.6 Adipose Tissue 20.2.6.1 Leptin 20.2.6.2 Adiponectin 20.2.7 Mechanisms of Diabetes Resolution 20.2.7.1 Foregut Hypothesis 20.2.7.2 Hindgut Hypothesis 20.2.8 Neuroendocrine Mechanism 20.2.8.1 Vagus Nerve 20.2.9 Bile Acids 20.2.10 GI Microflora 20.2.11 β(Beta)-Cell Changes 20.3 Summary 20.4 Key Learning Points 20.5 Cross-References References 21 Laparoscopic Roux-en-Y Gastric Bypass: The Linear Technique 21.1 Introduction 21.2 Preprocedural Setup 21.3 Procedural Set-up 21.4 Laparoscopic Roux-en-Y Gastric Bypass 21.5 First Variation by Sanjay Agrawal 21.6 Jejuno-Jejunal Anastomosis with Closure of the JJA Mesenteric Window 21.7 Gastric Pouch Formation 21.8 Gastrojejunal Anastomosis and Leak Test 21.9 Second Variation by Yashwant Koak 21.9.1 Advantages and Disadvantages of Both Techniques 21.9.2 Pros and Cons of Linear Stapler Technique References 22 Laparoscopic Roux-en-Y Gastric Bypass: Circular Stapler Technique with Transoral and Transabdominal Anvil Placement 22.1 Introduction 22.2 Patient Positioning and Port Placement 22.3 Jejuno-Jejunostomy 22.4 Gastric Pouch Creation 22.5 Transoral Technique 22.6 Transabdominal Placement 22.7 Advantages and Disadvantages 22.8 Postoperative Management 22.9 Conclusion 22.10 Key Learning Points References 23 Laparoscopic Roux-en-Y Gastric Bypass: The Hand-Sewn Technique 23.1 Introduction 23.2 LRYGB-HS: Technical Pearls 23.2.1 Patient Selection 23.2.2 Positioning and Placement of Ports 23.2.3 Laparoscopic Assessment 23.2.4 The Formation of Roux Limb: Technical Tips 23.2.5 The Formation of Gastric Pouch 23.2.6 The Formation of Gastro-Jejunostomy: The Hand-Sewn Technique 23.3 Postoperative Care 23.4 The Outcome of LRYGB-HS Technique 23.5 Complications and Potential Difficulties 23.6 Summary References 24 Laparoscopic Roux-en-Y Gastric Bypass: The Standardized Technique 24.1 Introduction 24.2 Preoperative Assessment 24.2.1 Nutritional Evaluation 24.2.2 Medical Evaluation 24.2.3 Psychological Evaluation 24.3 Operative Technique 24.3.1 Material List 24.3.2 Patient Positioning and Trocar Placement 24.3.3 Creation of the Gastric Pouch 24.3.4 Creation of the Gastrojejunostomy 24.3.5 Creation of the Jejuno-jejunostomy 24.3.6 Testing of the Gastrojejunostomy 24.3.7 Closure of Petersen´s Space and Mesenteric Gap During Entero-enterostomy 24.3.8 Completion 24.4 Advice for the Initial Cases 24.5 Postoperative Care 24.6 Conclusion 24.7 Key Learning Points References 25 Laparoscopic Roux-en-Y Gastric Bypass: Complications - Diagnosis and Management 25.1 Introduction 25.2 Early Complications 25.2.1 Gastrointestinal Bleeding 25.2.1.1 Types of Gastrointestinal Bleeding 25.2.1.2 Symptoms and Presentation 25.2.1.3 Management 25.2.1.4 Immediate Steps 25.2.1.5 Prevention 25.2.2 Leak 25.2.2.1 Symptoms and Presentation 25.2.2.2 Diagnosis Intraoperative Diagnosis Postoperative Diagnosis 25.2.2.3 Management 25.2.2.4 Prevention 25.2.3 Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) 25.2.3.1 Signs and Presentation 25.2.3.2 Investigations and Management 25.2.3.3 Prevention 25.3 Late Complications 25.3.1 Ulcers and Fistulas 25.3.1.1 Symptoms and Presentation 25.3.1.2 Diagnosis 25.3.1.3 Management 25.3.1.4 Prevention 25.3.2 Gastrointestinal Obstruction 25.3.2.1 Symptoms and Presentation 25.3.2.2 Investigations 25.3.3 Internal Hernia 25.3.3.1 Management 25.3.3.2 Prevention 25.3.4 Port-Site Hernia 25.3.5 Stricture 25.3.6 Acute Gastric Dilatation (of the Gastric Remnant) 25.4 Long-Term Complications 25.4.1 Intussusception 25.4.2 Bezoars 25.5 Skin Complications 25.6 Nutritional, Metabolic, and Neurological Complications 25.6.1 Postprandial Hypoglycemia and Nesidioblastosis 25.6.2 Protein Malnutrition 25.6.3 Vitamins and Trace Elements 25.7 Neurologic and Musculoskeletal Complications 25.8 Cholelithiasis 25.9 Hockey Stick/Blind Limb/Candy Cane Syndrome and Other Causes of Postprandial Pain 25.10 Conclusion References 26 Laparoscopic Roux-en-Y Gastric Bypass: Weight Loss Outcomes 26.1 Introduction 26.2 Weight Loss Outcomes 26.2.1 Comparison with Other Procedures 26.2.1.1 Comparison with Laparoscopic Adjustable Gastric Banding (LAGB) 26.2.1.2 Comparison with Laparoscopic Sleeve Gastrectomy (LSG) 26.2.1.3 Comparison with One-Anastomosis Gastric Bypass (OAGB) 26.2.1.4 Comparison with DS 26.3 Variables 26.3.1 Technical Variables 26.3.1.1 Pouch Size 26.3.1.2 Stoma Size 26.3.1.3 Anastomotic Technique 26.3.1.4 Limb Length 26.3.1.5 Banded Bypass 26.3.2 Patient Factors 26.4 Insufficient Weight Loss and Weight Regain 26.4.1 Pouch Dilatation 26.4.2 Stoma Resizing 26.4.3 Biliopancreatic Limb Prolongation 26.4.4 Conversion to Other Procedures 26.4.5 Gastro-Gastric Fistula 26.5 Summary References 27 Laparoscopic Roux-en-Y Gastric Bypass: Comorbidity Outcomes 27.1 Introduction 27.2 Comorbidity Resolution After RYGB 27.2.1 Type 2 Diabetes Mellitus 27.2.2 Hypertension 27.2.3 Dyslipidemia 27.2.4 Obstructive Sleep Apnea 27.2.5 Osteoarthritis 27.2.6 Gastroesophageal Reflux Disease 27.2.7 Nonalcoholic Fatty Liver Disease 27.2.8 Infertility 27.3 Risks Associated with Pregnancy 27.4 Cancer Risk 27.5 Overall Mortality 27.6 Quality of Life 27.7 Cost Effectiveness 27.8 Summary 27.9 Key Learning Points 27.10 Cross-References References 28 Laparoscopic Roux-en-Y Gastric Bypass: Current Controversies 28.1 Introduction 28.2 Mechanism of Action of the Gastric Bypass 28.3 Role of Open Gastric Bypass 28.4 Preferred Anastomotic Technique for the Gastrojejunostomy 28.5 Pouch Size and Surgical Outcomes 28.6 Optimal Limb Lengths 28.7 Closure of Potential Hernia Spaces: Retrocolic vs. Antecolic Roux 28.8 Gastric Bypass: The Current Scenario 28.9 Key Learning Points References 29 Laparoscopic Roux-en-Y Gastric Bypass: Current Controversies in Limb Length Measurements 29.1 Introduction 29.2 Defining Limb Lengths 29.3 Roux Limb in RYGB 29.3.1 Roux Limb and Morbid Obesity 29.3.2 Roux Limb and Super Obesity 29.3.3 Why Increasing the Roux Length May Not Increase Weight Loss 29.4 The Common Channel in RYGB 29.5 The Biliopancreatic Limb 29.5.1 BPL and RYGB 29.5.2 BPD-DS 29.5.3 OAGB 29.5.4 Why a Longer BPL Leads to Better Weight Loss 29.6 Tall 29.7 Summary 29.8 Key Learning Points References 30 Single Incision Laparoscopic Roux-en-Y Gastric Bypass 30.1 Introduction 30.2 Case Selection and Contraindication 30.3 Surgical Technique 30.3.1 Room Setup 30.3.2 Skin Incision and Port Placement 30.3.3 Gastric Pouch 30.3.4 Gastro-Jejunostomy 30.3.5 Jejuno-Jejunostomy 30.3.6 Mesenteric and Peterson Defect Closure 30.3.7 Liver Suspension Removal 30.3.8 Wound Closure 30.3.9 Surgical Results 30.4 Variations in Technique 30.4.1 Incision 30.4.2 Port Placement 30.4.3 Special Devices 30.4.4 Liver Retraction 30.4.5 Pouch Calibration 30.4.6 Pouch Creation 30.4.7 Limb Length 30.4.8 Leak Test and Drain 30.5 Complications 30.6 Technical Tips 30.7 Reoperation after SITU-LRYGB References Laparoscopic Sleeve Gastrectomy (LSG): Mechanism of Action, Technique, Complications, Outcomes, and Controversies 31 Laparoscopic Sleeve Gastrectomy: Mechanism of Action 31.1 Introduction 31.2 Debunking the ``Restrictive Theory´´ as the Main Mechanism of Action 31.3 Gastrointestinal (GI) Hormones 31.3.1 Ghrelin 31.3.2 Glucagon-Like Peptide 1 (GLP-1) 31.3.3 Peptide YY (PYY) and Oxyntomodulin 31.3.4 Glucose-Dependent Insulinotropic Polypeptide (GIP) 31.4 Other Hormones 31.4.1 Leptin 31.4.2 Adiponectin 31.5 Gut Microbiota 31.5.1 Bile Acids 31.6 Summary 31.7 Key Learning Points References 32 Laparoscopic Sleeve Gastrectomy: The Technique 32.1 Introduction 32.2 Indications and Contraindications 32.3 Diagnosis and Management 32.3.1 Workup/Preoperative Evaluation 32.3.2 Preoperative Preparation 32.3.3 Operating Room Setup 32.3.4 Positioning of Patient 32.4 Operative Steps 32.4.1 Creating Pneumoperitoneum 32.4.2 Port Placement 32.4.3 Placement of Liver Retractor 32.4.4 Mobilization of Greater Curvature 32.4.5 Dissection Near Angle of His 32.4.6 Creation of Sleeve 32.4.7 Hemostasis and Reinforcement 32.4.8 Leak Test and Organ Retrieval 32.5 Postoperative Care 32.6 Complications 32.6.1 Hemorrhage 32.6.2 Leak 32.6.3 Stricture 32.6.4 Reflux 32.6.5 Nutritional Deficiency 32.7 Special Considerations 32.7.1 Banded LSG (BLSG) 32.8 Role of Antral Resection 32.9 Hiatal Hernia (HH) Repair 32.10 Staple Line Reinforcement (SLR) in LSG 32.11 Follow-Up 32.12 Summary 32.13 Key Learning Points References 33 Laparoscopic Sleeve Gastrectomy: Early Complications 33.1 Evolution of Sleeve Gastrectomy (SG) 33.2 LSG Complications 33.3 Standard Perioperative Protocol 33.4 Intraoperative Complications 33.5 Diagnosis and Management of Post- LSG Complications 33.5.1 Diagnosis of Post-LSG Complications 33.5.1.1 Laboratory Parameters 33.5.1.2 Clinical Symptoms and Signs 33.5.1.3 Radiological Studies 33.5.1.4 Diagnostic Laparoscopy (DL) 33.5.2 Management of Post-LSG Complications 33.5.2.1 Early Post-LSG Complications Leakage Bleeding Trocar-Site Hernia Venous Thromboembolism (VTE) (Deep Venous Thrombosis and Pulmonary Embolism) Post-LSG Mortality 33.6 Summary References 34 Laparoscopic Sleeve Gastrectomy: Late (>30-Days) Complications - Diagnosis and Management 34.1 Introduction 34.2 Complications 34.2.1 Gastric Leaks 34.2.1.1 Pathogenesis 34.2.1.2 Classification of Leaks Acute Leaks Late and Chronic Leaks 34.2.1.3 Clinical Presentation and Diagnosis 34.2.1.4 Treatment Endoscopic Definitive Surgical Procedures 34.2.2 Stenosis 34.2.2.1 Clinical Features 34.2.2.2 Diagnosis 34.2.2.3 Treatment Endoscopic Balloon Dilation and Stenting Are the Two Modalities Described with Varied Success Rates 34.2.3 GERD and Hiatal Hernia 34.2.3.1 How Does Obesity Cause GERD? 34.2.3.2 LSG and GERD 34.2.3.3 Clinical Presentation and Diagnosis 34.2.3.4 Treatment 34.2.3.5 Prevention 34.2.4 LSG and Barrett´s Esophagus 34.2.4.1 Diagnosis 34.2.4.2 Surveillance 34.2.4.3 Management Nonsurgical Ablative Therapies Surgical Therapies 34.2.4.4 Screening 34.2.4.5 Prevention 34.2.5 Port Site Hernia 34.3 Summary 34.4 Key Learning Points References 35 Laparoscopic Sleeve Gastrectomy: Weight Loss Outcomes 35.1 Introduction 35.2 The Evolution of Laparoscopic Gastric Sleeve 35.3 Weight Loss Outcomes After LSG Performed During the First Decade of Its History (2000-2010) 35.4 Weight Loss Outcomes for the LSG Performed After 2010 35.5 Weight Loss Outcomes After Modified Surgical Techniques of LSG 35.5.1 LSG With or Without Antral Preservation 35.5.2 Banded Sleeve 35.6 Weight Loss Outcomes After LSG in Selected Categories of Patients 35.6.1 Low BMI Patients 35.6.2 High BMI Patients 35.6.3 Other Categories of High-Risk Patients 35.6.4 Severely Obese Adolescents and Children 35.6.5 Elderly Patients 35.6.6 Patients with Psychiatric Comorbidity 35.7 Weight Loss Outcomes After LSG as a Revisional Procedure 35.8 Summary 35.9 Key Learning Points References 36 Laparoscopic Sleeve Gastrectomy: Comorbidity Outcomes 36.1 Introduction 36.2 Comorbidities in Bariatric/Metabolic Surgery 36.3 Comorbidity Outcomes 36.3.1 T2DM 36.3.2 Arterial Hypertension 36.3.3 Hyperlipidemia 36.3.4 OSA 36.3.5 NAFLD and NASH 36.3.6 Diseases of Bones and Joints 36.4 Risk of Cancers 36.5 Gastroesophageal Reflux 36.6 Long-Term Outcomes of Comorbidities 36.7 Summary 36.8 Key Learning Points References 37 Laparoscopic Sleeve Gastrectomy: Current Controversies in Gastroesophageal Reflux 37.1 Introduction 37.2 Relationship Between Obesity and GERD 37.3 Preoperative Diagnostic Significance 37.3.1 Role of Preoperative Endoscopy 37.3.2 Difficulty of Diagnosing Hiatal Hernia 37.4 Sleeve Gastrectomy and Hiatal Hernia Repair 37.5 Sleeve Gastrectomy and Esophagitis 37.6 Sleeve Gastrectomy and Barrett´s Esophagus 37.7 Sleeve Gastrectomy and Esophageal Adenocarcinoma 37.8 Sleeve Gastrectomy and Changes in 24-Hour pH-Monitoring Results 37.9 Sleeve Gastrectomy and Changes in Combined pH-Impedance Results 37.10 Changes in Manometry Results 37.11 Prevention of GERD After Sleeve Gastrectomy: The Concept - Nissen Sleeve 37.12 Postgastrectomy Sleeve Follow-Up 37.13 Treatment of GERD After Sleeve 37.13.1 LINX Procedure 37.13.2 Lower Esophageal Sphincter Electrical Stimulation 37.13.3 Endoscopic Radiofrequency (Stretta) 37.14 Summary References 38 Single-Incision Laparoscopic Sleeve Gastrectomy 38.1 Introduction 38.2 Technique 38.2.1 Material 38.2.2 Patient and Team Positioning 38.2.3 Technique 38.3 Postoperative Management 38.4 Specific SILS Based Complications and Management 38.5 Outcomes 38.6 Conclusions 38.7 Key Learning Points References Laparoscopic One Anastomosis Gastric Bypass (OAGB)/Mini Gastric Bypass (MGB): Mechanism of Action, Techniques, Complications, ... Prelude to One Anastomosis Gastric Bypass Section 39 Laparoscopic OAGB/MGB: Mechanism of Action 39.1 Introduction 39.1.1 OAGB Is a Gastric Bypass 39.1.2 How Important Is Restriction for OAGB? 39.1.2.1 Role of Long Narrow Pouch 39.1.2.2 Banded Gastric Bypass 39.1.3 How Important Is Malabsorption for OAGB? 39.1.4 Hormonal Changes After OAGB 39.1.4.1 Incretin Effect 39.1.5 Gut Microbiota 39.1.6 Data from Animal Models 39.1.7 Future Studies 39.2 Summary 39.3 Key Learning Points 39.4 Cross-References References 40 Laparoscopic One Anastomosis Gastric Bypass/Mini Gastric Bypass: MGB Technique 40.1 Introduction 40.2 History of Mini-Gastric Bypass 40.3 Technical Details in Performing Mini-Gastric Bypass 40.3.1 Patient Positioning 40.3.2 Ports 40.3.3 Constructing the Gastric Tube 40.3.4 Running the Bowel and Construction of the Gastrojejunostomy 40.4 Critical Factors in Use of the Staple-Gun in Mini-Gastric Bypass 40.4.1 How to Prevent Staple-Line Bleeds 40.4.2 Avoiding a Twist in the Pouch 40.4.3 Postoperative Period and Follow-Up 40.5 Complications and Management 40.5.1 Immediate Postoperative Complications 40.5.2 Leak 40.5.3 Management of Late Complications 40.5.3.1 Marginal Ulcer 40.5.3.2 Malnutrition: Hypoproteinemia 40.5.3.3 Internal Hernia 40.5.3.4 Dumping Syndrome 40.5.3.5 Diarrhea 40.5.3.6 Steatorrhea and Flatulence 40.5.3.7 Bile Reflux 40.5.3.8 Cholelithiasis 40.5.3.9 Weight Regain in Mini-Gastric Bypass 40.6 Reported Results of Mini-Gastric Bypass 40.6.1 Weight Loss 40.6.2 Comorbidity Resolution 40.7 Conclusion 40.8 Key Learning Points References 41 Laparoscopic One Anastomosis Gastric Bypass (OAGB)/Mini Gastric Bypass (MGB): OAGB Technique 41.1 Introduction 41.2 Preoperative Preparation 41.3 The Standard OAGB Technique: Step-by-Step Description 41.3.1 Patient Positioning 41.3.2 First Things First: Pneumoperitoneum and Trocar Placement 41.3.3 Full SB Measurement and Designation of BPL and CCh Lengths: Degree of Hypo-absorption 41.3.4 SB Limb Lengths: Relevant Considerations 41.3.5 Omentum Transection 41.3.6 Supra-mesocolic Stage: Esophagogastric Junction (EGJ) (His Angle) Dissection 41.3.7 Gastric Reservoir Formation 41.3.8 Initial Part of the ``Anti-reflux Mechanism´´ 41.3.9 Gastroenteric Anastomosis Conformation 41.3.10 Patency and Leak Test/Termination of the Operation 41.4 Postoperative Management 41.5 Summary 41.6 Key Learning Points References 42 Laparoscopic One Anastomosis Gastric Bypass (OAGB) Mini Gastric Bypass (MGB) Early (30 Days) Complications - Diagnosis and ... 42.1 Introduction 42.2 Early Postoperative Complications with OAGB-MGB 42.2.1 Bleeding 42.2.2 Leak 42.2.3 Anastomotic Stenosis 42.2.4 Afferent Loop Syndrome 42.2.5 Remnant Stomach Obstruction 42.2.6 Respiratory Complications 42.2.7 DVT/ Pulmonary Embolism (PE) 42.3 Authors Single Center Experience 42.4 Conclusion 42.5 Key Learning Points References 43 Laparoscopic One-Anastomosis Gastric Bypass/Mini Gastric Bypass: Managing Late Complications (>30 Days) 43.1 Introduction 43.2 Reflux After OAGB/MGB: Acid or Alkaline Reflux? 43.2.1 Reflux After OAGB: Diagnosis and Medical Treatment 43.2.2 Surgical Treatment 43.2.3 Bile Reflux: Potential Risk of Cancer? 43.3 Malnutrition and Excessive Weight Loss 43.4 Marginal Ulcers 43.4.1 Signs and Symptoms 43.4.2 Diagnosis 43.4.3 Management 43.4.4 Prevention 43.4.5 Petersen´s Hernia After OAGB/MGB 43.5 Insufficient Weight Loss and Weight Regain After OAGB/MGB 43.6 Summary 43.7 Key Learning Points References 44 Laparoscopic One Anastomosis Gastric Bypass (OAGB)/ Mini Gastric Bypass (MGB): Weight Loss Outcomes 44.1 Introduction 44.2 Weight Loss Outcomes After OAGB as Primary Surgery 44.3 Weight Loss Outcomes After Revisional OAGB/MGB in Case of Failure of the First Procedure 44.3.1 AGB to OAGB/MGB 44.3.2 SG to OAGB/MGB 44.3.3 RYGB to OAGB/MGB 44.3.4 Gastric Pouch Resizing After OAGB/MGB 44.3.5 Other Revisional Procedures Following OAGB/MGB 44.4 Weight Loss Outcomes: Impact of Biliopancreatic Limb 44.5 Weight Loss Outcomes: OAGB Versus RYGB and OAGB Versus Sleeve 44.5.1 OAGB Versus RYGB 44.5.2 OAGB Versus Sleeve 44.6 Summary 44.7 Key Learning Points References 45 Laparoscopic One Anastomosis Gastric Bypass (OAGB)/Mini Gastric Bypass (MGB): Co-morbidity Outcomes 45.1 Introduction 45.2 Metabolic Syndrome 45.3 Type 2 Diabetes Mellitus (T2DM) 45.3.1 OAGB-MGB and T2DM 45.3.2 OAGB-MGB Compared to LRYGB 45.3.3 OAGB-MGB Compared to LSG 45.4 Hypertension (HT) 45.5 Nonalcoholic Steatohepatitis/Nonalcoholic Fatty Liver Disease (NASH/NAFLD) 45.6 Obstructive Sleep Apnea (OSA) 45.7 Hyperlipidemia 45.8 Osteoarthritis 45.9 Gastro-Esophageal Reflux Disease (GERD) 45.9.1 LSG Versus OAGB-MGB 45.9.2 OAGB-MGB Versus LRYGB 45.9.3 Biliary Reflux and OAGB-MGB 45.10 OAGB-MGB in Patients with BMI 50 kg/m2 45.11 OAGB-MGB in Patients with BMI 35 kg/m2 45.12 Banded OAGB-MGB 45.13 Summary 45.14 Key Learning Points References 46 Laparoscopic One Anastomosis Gastric Bypass/Mini Gastric Bypass: Bile Reflux and Carcinogenesis Risk 46.1 Introduction 46.2 Bile Reflux After OAGB and Risk of Carcinogenesis 46.3 Bile Reflux After OAGB 46.4 Summary 46.5 Key Learning Points 46.6 Cross-References References 47 Laparoscopic One Anastomosis Gastric Bypass/Mini Gastric Bypass: Limb Length and Nutritional Issues 47.1 Introduction 47.2 Small Intestine Anatomy and Physiology 47.3 Limb Lengths in Bariatric Surgery: What Have We Learnt? 47.4 Fixed Versus Tailored Limb Length Model in OAGB/MGB 47.5 Effects of Limb Length on Efficacy and Malnutrition in OAGB/MGB: Review of Literature 47.6 Summary 47.7 Key Learning Points References Laparoscopic Adjustable Gastric Banding (LAGB): Mechanism of Action, Technique, Complications, Outcomes, and Controversies 48 Laparoscopic Adjustable Gastric Banding - Mechanism of Action 48.1 Introduction 48.2 The Gastric Band as a Restrictive Procedure 48.3 Effects of the Gastric Band on Hormones 48.4 Conclusion References 49 Laparoscopic Adjustable Gastric Banding: The Technique 49.1 Introduction 49.2 Preoperative Preparation 49.3 Our Surgical Technique 49.3.1 Diaphragmatic Hiatus 49.3.2 Band Placement 49.3.3 Band Fixation 49.3.4 Port Placement 49.4 Special Circumstances 49.4.1 Portal Hypertension 49.4.2 Revision Procedures 49.5 Postoperative Care of Gastric Band Patients 49.5.1 Immediate Postoperative Care of Gastric Band Patients 49.5.2 Postoperative Follow-Up 49.5.3 Long-Term Management of Gastric Band Patients 49.6 Key Learning Points References 50 Laparoscopic Adjustable Gastric Banding: Complications - Diagnosis and Management 50.1 Introduction 50.2 Classification of Complications 50.3 General Complications 50.3.1 Infection 50.3.2 Bleeding 50.3.3 Perforation of Viscus 50.3.4 Venous Thrombo-Embolism 50.4 Specific Complications 50.4.1 Band Erosion 50.4.2 Tight/Loose Band 50.4.3 Pouch Dilatation 50.4.4 Band Slippage 50.4.4.1 Anterior Slippage 50.4.4.2 Posterior Slippage 50.4.5 Esophageal Dilatation 50.4.6 Maladaptive Eating 50.4.7 Band Intolerance 50.4.8 Port Site Infection 50.4.9 Port Site Pain 50.4.10 Port Rotation 50.4.11 Band/Tubing Leaks, Disconnection, Migration 50.4.12 Weight Loss Failure/Weight Regain 50.4.13 Gastric Band Revision Surgery 50.5 Prevention of Band Complications 50.6 Summary 50.7 Cross-References References 51 Laparoscopic Adjustable Gastric Banding: Outcomes 51.1 Introduction 51.2 Weight Loss Outcomes 51.2.1 Determinants of Effective Weight Loss Following LAGB 51.2.1.1 Meticulous Surgical Technique 51.2.1.2 Fluoroscopy-Guided Band Adjustments 51.2.1.3 Follow-up 51.3 Metabolic and Other Comorbidity Outcomes 51.3.1 Reemergence of Metabolic Complications 51.4 Patient Satisfaction and Quality of Life 51.5 Morbidity and Mortality 51.6 Future of Gastric Band 51.7 Summary References 52 Laparoscopic Adjustable Gastric Band: Current Controversies 52.1 Introduction 52.2 The Role of LAGB 52.3 Technical Issues 52.3.1 Band Placement 52.3.2 Band Slippage 52.3.3 Hiatus Hernia 52.4 Preoperative Preparation 52.5 Long-Term Complications of Surgery 52.5.1 Band-Related Complications 52.5.2 Weight Regain 52.5.3 Band Removal and Revision 52.5.4 Port Complications 52.5.5 Pregnancy and LAGB 52.6 Summary 52.7 Key Learning Points References Revisional Bariatric Surgery 53 Revisional Surgery After Vertical Banded Gastroplasty 53.1 Introduction 53.2 Preoperative Patient Evaluation 53.3 Preoperative Patient Preparation 53.4 Choice of Procedure 53.4.1 Restoration of the VBG Anatomy 53.4.2 Reversal 53.4.3 Conversion to Another Bariatric Procedure 53.4.3.1 Technical Aspects of Conversion from VBG to RYGB RYGB for Failed VBG: Results 53.5 Summary 53.6 Key Learning Points References 54 Revisional Surgery After Laparoscopic Roux-en-Y Gastric Bypass 54.1 Introduction 54.2 Preoperative Evaluation 54.3 Restorative/Corrective Surgery 54.4 Augmentation 54.5 Conversion 54.6 Reversal 54.7 Algorithm for Revision Gastric Bypass: A Personal Approach 54.8 Summary 54.9 Key Learning Points References 55 Revisional Surgery After Laparoscopic Sleeve Gastrectomy 55.1 Introduction 55.2 Patient Evaluation 55.3 Preoperative Workup 55.4 Reoperation for Weight Issues 55.5 Reoperation for Stenosis 55.6 Reoperation for Persisting Leaks 55.7 Reoperation for Hiatal Hernia with GERD 55.8 Techniques for Reoperation After Sleeve Gastrectomy 55.9 Conclusion 55.10 Key Learning Points References 56 Revisional Surgery after Laparoscopic Adjustable Gastric Banding 56.1 Introduction 56.2 Preoperative Patient Evaluation 56.3 Techniques 56.3.1 Adjustable Banded Roux-en-Y Gastric Bypass 56.3.2 Laparoscopic Roux-en-Y Gastric Bypass 56.3.3 Laparoscopic Sleeve Gastrectomy 56.3.4 One Anastomosis Gastric Bypass 56.3.5 Laparoscopic Biliopancreatic Diversion with Duodenal Switch 56.4 Other Procedures 56.5 One or Two Steps? 56.6 Summary 56.7 Key Learning Points References 57 Laparoscopic One Anastomosis Gastric Bypass/Mini Gastric Bypass: Revisional Surgery for Failure in Weight Loss and Metaboli... 57.1 Introduction 57.2 The OAGB Surgery 57.3 Weight Regain and Inadequate Weight Loss After Bariatric Surgery 57.4 Inadequate Weight Loss and Weight Regain After OAGB 57.5 Revisional Procedures Due to Inadequate Weight Loss or Weight Regain After OAGB: Technical Options 57.6 Summary 57.7 Key Learning Points References Other Operations for Obesity 58 Laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD-DS) Surgery 58.1 Introduction 58.2 Biliopancreatic Diversion (BPD) 58.3 BPD Versus BPD-DS 58.4 Patient Selection 58.5 Weight Loss 58.6 Remission of Comorbidities 58.7 Quality of Life (QoL) 58.8 BPD-DS as a Revisional Surgery 58.8.1 BPD-DS after SG 58.8.2 BPD-DS after RYGB 58.8.3 The Experts´ View of the Role of BPD-DS as a Revisional Surgery 58.9 Technical Tips and Operative Considerations 58.10 Inpatient Care and Complications 58.10.1 Operative Mortality 58.10.2 Staple Line/Anastomotic Leak 58.11 Outpatient Care and Complications 58.11.1 Vitamin and Micronutrient Deficiency 58.11.2 Protein Calorie Malnutrition 58.11.3 Small Bowel Obstruction 58.11.4 Chronic Diarrhea/Steatorrhea 58.11.5 Effect of BPD-DS on the Composition of Gut Microbiota 58.12 Single-Anastomosis Duodeno-Ileal Switch (SADI-S) 58.13 Summary 58.14 Key Learning Points 58.15 Cross-References References 59 Laparoscopic Biliopancreatic Diversion (BPD) Surgery 59.1 Introduction 59.2 The Original Scopinaro´s BPD 59.2.1 Physiology 59.2.2 Pouch Size 59.2.3 Bowel Limb Length 59.3 BPD 59.3.1 Technical Steps of Laparoscopic BPD 59.3.2 Indication for Surgery 59.4 Results 59.4.1 Side Effects 59.4.2 Postoperative Complications 59.4.3 Nutritional Complications 59.4.3.1 Vitamins 59.4.3.2 Bone Metabolism 59.4.3.3 Anemia 59.4.3.4 Protein Malnutrition 59.4.4 Weight Loss 59.4.5 Resolution of Comorbidities 59.5 Summary 59.6 Key Learning Points 59.7 Cross-References References 60 Laparoscopic Banded Bariatric Surgery 60.1 Introduction 60.2 Laparoscopic Banded Bariatric Surgeries 60.2.1 Laparoscopic BGBP 60.2.2 Laparoscopic Banded Sleeve Gastrectomy 60.2.3 Laparoscopic Banded One Anastomosis Gastric Bypass 60.3 Limitation in Reports on LBBS 60.4 Summary 60.5 Key Learning Points 60.6 Cross-References References 61 Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) Surgery 61.1 Introduction 61.2 Surgical Technique 61.3 Postoperative Management 61.4 Lessons Learnt in SADI-s 61.5 Advantages and Drawbacks 61.5.1 Advantages Over Scopinaro´s Procedure 61.5.2 Advantages Over Duodenal Switch 61.5.3 Advantages Over Gastric Bypass 61.5.4 SADIS_After Failed Sleeve 61.6 Conclusions 61.7 Key Learning Points 61.8 Cross-References References 62 Ileal Interposition with Sleeve Gastrectomy for Type 2 Diabetes Mellitus and Metabolic Syndrome 62.1 Duodenal Ileal Interposition with Sleeve Gastrectomy for Type-2 Diabetes Mellitus and Metabolic Syndrome 62.2 Introduction 62.3 Duodenal Ileal Interposition with Tailored Sleeve Gastrectomy (DII + SG) 62.3.1 Mechanisms of Action 62.3.2 Selection of Patients 62.3.3 Exclusion Criteria 62.4 Preoperative Evaluation 62.5 Procedure: Duodenal Ileal Interposition (Diverted) with Tailored Sleeve Gastrectomy 62.6 Postoperative Regimen 62.7 Results from Three Centers 62.8 Complications Encountered in These Three Centers 62.8.1 Postoperative Problems 62.8.1.1 During Hospital Stay 62.8.1.2 After Discharge 62.9 Nutritional Stability 62.10 Long-Term Results 62.11 Discussion 62.11.1 Advantages of Duodenal Ileal Interposition 62.11.2 Disadvantages 62.12 Future Trends 62.13 Summary 62.14 Jejunal Ileal Interposition with Sleeve Gastrectomy for Morbid Obesity (JII + SG) 62.14.1 Introduction 62.14.2 Mechanisms of Action 62.14.3 Selection of Patients 62.14.3.1 Inclusion Criteria and Indications 62.14.3.2 Exclusion Criteria 62.14.4 Preoperative Evaluation 62.14.5 Procedure 62.14.5.1 JII (Non-diverted) with SG 62.14.6 Postoperative Regimen 62.14.7 Efficacy of Procedure/Short and Mid-Term Outcomes 62.14.8 Complications 62.14.8.1 Postoperative Problems 62.14.8.2 Long-Term/Delayed Complications 62.14.9 Nutritional Stability 62.14.10 Long-Term Outcomes 62.14.11 Discussion 62.14.11.1 Advantages of Jejunal Ileal Interposition 62.14.11.2 Disadvantages 62.14.12 Summary and Future Trends 62.15 Key Learning Points References 63 Single Anastomosis Sleeve Ileal (SASI) Bipartition 63.1 Introduction 63.2 Why Bipartition? 63.3 Why SASI Bipartition? 63.3.1 Mechanism of Action of SASI Bipartition and SG-TB 63.3.2 Advantages of SASI Bipartition 63.3.3 Disadvantages of SASI Bipartition 63.3.4 How to Do a Perfect SASI Bipartition? 63.3.5 SASI Bipartition Postoperative Complications 63.3.6 SASI Bipartition: Bariatric Outcomes 63.3.7 SASI Bipartition: Metabolic Outcomes 63.3.7.1 Glycemic Control 63.3.7.2 Hyperlipidemia and Obesity-Related Comorbidities 63.3.7.3 Nutritional Status After SASI Bipartition 63.3.8 SASI Bipartition and Reflux Esophagitis 63.4 Future of SASI Bipartition 63.5 Summary 63.6 Key Learning Points References 64 Laparoscopic Greater Curvature Plication (LGCP) 64.1 Synonyms 64.2 Introduction 64.3 The LGCP Procedure 64.3.1 Indications 64.3.2 Contraindications 64.3.3 Patient Work-Up 64.3.4 Operating Team Position and Technical Aspects of the Operation 64.3.5 Surgical Technique 64.3.6 Leak Test 64.3.7 Postoperative Course 64.3.8 Complications 64.3.8.1 Intraoperative and Immediate Postoperative Complications 64.3.8.2 Long-Term Complications Stomach Dilatation 64.3.9 Reversibility and Reoperations 64.3.10 Tips and Tricks 64.3.10.1 Dissection of the Greater Curvature 64.3.10.2 Angle of His Region 64.3.10.3 Suture Line 64.3.11 LGCP 64.3.12 Dietary Recommendations After LGCP 64.4 Summary 64.5 Key Learning Points References 65 Laparoscopic Gastric Pacing 65.1 Introduction 65.2 Methods of Gastric Stimulation for the Treatment of Obesity 65.2.1 Gastric Pacing with Short Pulse Width and High Frequency Electric Current 65.2.2 Gastric Pacing with Long Pulse Width and Low Frequency Electric Current 65.2.3 Stimulation of Stomach Muscles during the Electrical Refractory Period 65.2.4 Closed-Loop Gastric Electrical Stimulation System 65.2.5 Surgical Technique of the Implantable Gastric Stimulator 65.2.6 Postoperative Management 65.2.7 Safety 65.3 Efficacy 65.4 Conclusions 65.5 Key Learning Points References 66 Robotic-Assisted Bariatric Surgery 66.1 Background 66.2 Setting up the Operating Room for Robotic Bariatric Surgeries 66.2.1 Operating Room Configuration for Xi Version 66.3 Adjustable Gastric Banding (AGB) 66.3.1 SG 66.3.2 RYGB 66.3.3 BPD/DS 66.4 Revisional Bariatric Surgery 66.5 Summary 66.6 Key Learning Points References Endoscopic Approaches in Obesity and Bariatric Surgery 67 Endoscopic Sleeve Gastroplasty for Obesity 67.1 Introduction 67.2 History and Technique of the Endoscopic Sleeve Gastroplasty 67.2.1 Primary Endoscopic Sleeve Gastroplasty 67.2.2 Revisional Endoscopic Sleeve Gastroplasty 67.3 Potential Complications and Contraindications 67.4 Alternative Methods for Endoscopic Sleeve Gastroplasty 67.5 Key Learning Points References 68 Intragastric Balloon Treatment for Obesity 68.1 Introduction 68.2 Indications and Contraindications to IGBs 68.3 The Management of IGB 68.4 Different Types of IGBs 68.4.1 FDA-Approved IGBs 68.4.1.1 Obalon Balloon System 68.4.1.2 Orbera Balloon 68.4.1.3 ReShape duo Integrated Dual Balloon System 68.4.2 Other Commercially Available IGBs 68.4.2.1 Spatz3 Adjustable Gastric Balloon 68.4.2.2 Elipse Intragastric Balloon 68.4.2.3 Medicone 68.4.2.4 Plenity 68.5 Summary 68.6 Key Learning Points References 69 Newer Endoluminal Interventions for Obesity 69.1 Introduction 69.2 Clinically Tested Endoluminal Interventions 69.2.1 Primary Obesity Surgery Endolumenal (POSE) Procedure Using the Incisionless Operating Platform (USGI Medical Inc., San ... 69.2.2 Apollo OverStitch (Apollo Endosurgery Inc., Austin, Texas) 69.3 Devices in the Early Phase of Development 69.3.1 Gastric Aspiration Using the AspireAssist (Aspire Bariatrics Inc., King of Prussia, Pennsylvania) 69.3.2 TransPyloric Shuttle (TPS) (BAROnova Inc., Goleta, California) 69.3.3 Elipse Balloon 69.3.4 Duodenal Mucosal Resurfacing 69.3.5 Incisionless Magnetic Anastomosis System 69.4 Summary 69.5 Key Learning Points References 70 Endoscopic Treatment of Complications After Bariatric Surgery 70.1 Introduction 70.2 Laparoscopic Adjustable Gastric Band (LAGB) Complications 70.2.1 LAGB Erosion and Slippage 70.3 Laparoscopic Roux-En-Y Gastric Bypass Complications 70.3.1 Food Impaction 70.3.2 Marginal Ulcers 70.3.3 Anastomotic Stricture 70.3.4 Choledocholithiasis 70.4 Banded Laparoscopic Roux-En-Y Gastric Bypass Complications 70.4.1 Ring Erosion 70.4.2 Ring Slippage/Intolerance/Stenosis 70.5 Gastric Fistula After RYGB and Sleeve Gastrectomy 70.6 Twisted Gastric Tube After SG 70.7 Secondary Treatment for Obesity 70.8 Summary 70.9 Key Learning Points 70.10 Cross-References References Metabolic Surgery 71 Concept of Metabolic Surgery 71.1 Introduction 71.2 Recognizing the Metabolic Benefits of Surgery 71.3 Evidence for Bariatric Surgery 71.4 Increasing Need for Metabolic Surgery 71.5 Advancing the Concept of ``Metabolic Surgery´´ 71.6 Summary 71.7 Key Learning Points 71.8 Cross-References References 72 Mechanisms of Action of Different Bariatric Surgical Procedures 72.1 Introduction 72.2 Mechanisms of Weight Loss 72.2.1 Malabsorption and Reduction of Stomach Size 72.2.2 Changes in Hunger and Satiety 72.2.3 Changes in Energy Expenditure 72.2.4 Changes in Food Preferences 72.3 Mechanisms of Improved Glucose Homeostasis After Bariatric Surgery 72.3.1 The ``Hindgut and Foregut´´ Theories 72.3.2 Bile Acids 72.3.3 Gut Microbiota 72.4 Conclusion 72.5 Key Learning Points References 73 Glycemic Control and Reduction of Cardiorenal Risk Following Bariatric Surgery 73.1 Introduction 73.2 Weight Loss Following Bariatric Surgery 73.3 Glycemic Control Following Bariatric Surgery 73.4 Other Cardiorenal Risk Factors Following Bariatric Surgery 73.4.1 Changes in Lipid Metabolism 73.4.2 Changes in Blood Pressure 73.4.3 Changes in Inflammation 73.4.4 Changes in Chronic Kidney Disease 73.4.5 Other Factors 73.5 Summary 73.6 Key Learning Points 73.7 Cross-References References 74 Resolution of Comorbidities Following Bariatric Surgery: Diabetes, Hypertension, Sleep Apnea, and Metabolic Syndrome 74.1 Introduction 74.2 T2DM 74.3 Hypertension 74.4 Sleep Apnea 74.5 Metabolic Syndrome 74.6 Mechanisms for Metabolic Improvements 74.7 Future Directions 74.8 Summary 74.9 Key Learning Points References 75 Effect of Metabolic Surgery on Non-Alcoholic Steatohepatitis 75.1 Introduction 75.2 NAFLD Spectrum 75.3 Diagnosis 75.4 Impact of Bariatric Surgery on NAFLD 75.5 Nonalcoholic Steatohepatitis (NASH) 75.6 The Role of Bariatric Surgery in the Setting of Liver Transplantation for Complicated NAFLD 75.7 Summary 75.8 Key Learning Points References 76 Multimodal Care for Diabetes Combining Pharmacotherapy and Metabolic Surgery 76.1 Introduction 76.2 Metabolic Surgery and Hard Outcomes 76.3 Relapse of Type 2 Diabetes after Metabolic Surgery 76.4 Mechanisms of Type 2 Diabetes Relapse after Metabolic Surgery 76.5 Clinical Implications of Maintaining Glycemic Control after Metabolic Surgery 76.6 Multimodal Approach 76.6.1 Adjunctive Pharmacotherapy Following Metabolic Surgery to Improve Diabetes Care 76.6.1.1 Adjunctive Antidiabetes Pharmacotherapy Liraglutide Dipeptidyl-Peptidase-4 Inhibitor Semaglutide SGLT-2 Inhibitors Empagliflozin 76.6.1.2 Adjunctive Anti-Obesity Pharmacotherapy Liraglutide Semaglutide Nonresponders to GLP-1 Agonists Canagliflozin Practical Considerations 76.7 Summary 76.8 Key Learning Points References 77 Metabolic Surgery for Type 2 Diabetes Mellitus in Patients with BMI 60 kg/m2) 88.1 Introduction 88.2 Nomenclature 88.3 Prevalence 88.4 Assessment of the Extremely Obese Patient 88.5 Assessment of the Treatment Environment 88.6 The Specialist MDT 88.6.1 Bariatric Physician 88.6.2 Dietitian 88.6.3 Psychologist 88.6.4 Anesthetist 88.6.5 Surgeon 88.7 Surgical Options 88.7.1 Preoperative Weight Loss 88.7.2 Choice of Procedure 88.7.2.1 Staged Procedures 88.7.3 Review of Publications on Extreme Obesity Bariatric Surgery 88.7.3.1 Duodenal Switch 88.7.3.2 Laparoscopic Adjustable Gastric Band (LAGB) 88.7.3.3 Sleeve Gastrectomy 88.7.3.4 Laparoscopic Roux Y Gastric Bypass 88.7.3.5 Mini-Gastric Bypass 88.7.4 Technical Aspects 88.8 Specific Post-Discharge Issues for the Extreme Obese Patient 88.8.1 Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Prophylaxis 88.8.2 Mobilization/Occupational Therapy 88.8.3 Psychological Care 88.8.4 Enforcing Dietary Change 88.8.5 Redundant Skin/Personal Hygiene 88.9 Summary 88.10 Key Learning Points 88.11 Cross-References References 89 Suboptimal Weight Loss After Bariatric Surgery: Mechanisms and Treatment Algorithms 89.1 Introduction 89.2 Definition of Weight Regain 89.3 Mechanisms of Weight Regain 89.3.1 Genetics 89.3.2 Gut Hormones 89.3.3 Physical Activity 89.3.4 Dietary Nonadherence 89.3.5 Maladaptive Eating Behaviors 89.3.6 Anatomical or Surgical Factors 89.3.7 Preoperative Risk Factors 89.4 Management Options 89.4.1 Prevention and Early Identification 89.4.2 Behavioral Therapy 89.4.3 Dietary 89.4.4 Pharmacotherapy 89.4.5 Surgical Intervention 89.4.6 Endoscopic Treatment 89.5 An Algorithm for Management of Weight Regain Following Bariatric Surgery 89.6 Summary 89.7 Key Learning Points References 90 Respiratory Considerations and Effect of Bariatric Surgery in the Obese Patient 90.1 Introduction 90.2 Impact of Obesity on Respiratory Function 90.2.1 Altered Respiratory Mechanics 90.2.2 Respiratory Muscle Dysfunction 90.2.3 Increased Work and Energy Cost of Breathing 90.2.4 Spirometry and Lung Volumes 90.2.5 Gas Exchange 90.2.6 Ventilation and Perfusion 90.2.7 Ventilatory Responses 90.2.8 Inflammatory Responses 90.3 Respiratory Diseases Associated with Obesity 90.3.1 OSA 90.3.2 OHS 90.3.3 Asthma 90.3.4 Pulmonary Embolism 90.3.5 Pulmonary Hypertension 90.4 Preoperative Respiratory Considerations 90.4.1 Assessment 90.4.2 Treatment 90.5 Impact of Bariatric Surgery on Respiratory Comorbidities 90.6 Summary 90.7 Key Learning Points References 91 Fertility, Pregnancy, and Bariatric Surgery 91.1 Introduction 91.2 Fertility 91.3 Contraception 91.4 Surgery-to-Conception Interval 91.5 Nutrition and Micronutrient Management Preconception and During Pregnancy 91.5.1 Preconception Phase 91.5.2 Pregnancy 91.5.3 Biochemical Monitoring During Pregnancy 91.6 Screening for (Gestational) Diabetes 91.7 Congenital Anomalies and Fetal Growth 91.8 Gestational Weight Gain 91.9 Surgical Complications 91.10 Is Sleeve Gastrectomy to Be Preferred in Women of Reproductive Age? 91.11 Perinatal Mental Health 91.12 Breastfeeding 91.13 Postpartum Weight Loss and Weight Retention and Regain 91.14 Long-Term Outcome in the Offspring 91.15 Summary of Clinical Care Management 91.16 Key Learning Points References 92 Cancer, Obesity and Bariatric Surgery 92.1 Introduction 92.2 Mechanisms of Carcinogenesis in Obesity 92.2.1 Chronic Inflammation 92.2.1.1 Adipokines Adiponectin Leptin 92.2.1.2 Pro-Inflammatory Proteins TNF-a and IL-6 C-Reactive Protein (CRP) Vascular Endothelial Growth Factor (VEGF) 92.2.2 Insulin Resistance 92.2.2.1 Obesity Causes Insulin Resistance 92.2.2.2 Insulin Resistance Causes Cancer 92.2.3 Sex Steroids 92.2.4 Gut Microbiome 92.3 Clinical Association Between Obesity and Cancer 92.3.1 Breast 92.3.2 Endometrial 92.3.3 Ovarian 92.3.4 Esophagus: Adenocarcinoma 92.3.5 Gastric Cardia 92.3.6 Colorectal 92.3.7 Liver 92.3.8 Pancreatobiliary 92.3.9 Renal Cell 92.3.10 Meningioma 92.3.11 Thyroid 92.3.12 Multiple Myeloma 92.3.13 Prostate 92.3.14 Lung 92.4 Non-Surgical Weight Loss and Cancer 92.4.1 Hormone-Related Cancers 92.4.1.1 Breast Cancer 92.4.1.2 Endometrial Cancer 92.4.1.3 Ovarian Cancer 92.4.2 Gastrointestinal Cancers 92.4.2.1 Gastroesophageal Cancers 92.4.2.2 Colorectal Cancer 92.4.3 Hepatopancreatobiliary Cancers 92.4.4 Kidney Cancer 92.5 Bariatric Surgery and Cancer 92.5.1 Hormone-Related Cancers 92.5.1.1 Breast Cancer 92.5.1.2 Endometrial Cancer 92.5.1.3 Ovarian Cancer 92.5.2 Gastrointestinal Cancers 92.5.2.1 Gastroesophageal Cancer 92.5.2.2 Colorectal Cancer 92.5.3 Hepatopancreatobiliary Cancers 92.5.3.1 Liver Cancer 92.5.3.2 Gallbladder Cancer 92.5.3.3 Pancreatic Cancer 92.5.4 Kidney Cancer 92.6 Summary 92.7 Key Learning Points References 93 Psychological Issues Before and After Bariatric Surgery 93.1 Introduction 93.1.1 Presurgical Issues 93.1.1.1 Influences on Eating Habits and Weight 93.1.1.2 The Impact of Dieting 93.1.1.3 The Impact of Health Conditions 93.1.1.4 The Impact of Ambivalence 93.1.1.5 The Physiological Impact of Repeated Dieting 93.1.2 Eating Disorders 93.1.3 Mental Health 93.1.4 Trauma 93.1.5 Working with Issues Before Surgery 93.2 Issues Following Weight Loss Surgery 93.2.1 Eating Behaviors 93.2.2 Emotional Eating 93.2.3 Weight Management: Loss and Regain 93.2.4 Managing Disclosure 93.2.5 Psychosocial Functioning 93.2.6 Impact on Relationships 93.2.7 Eating Disorders 93.2.7.1 Binge Eating 93.2.7.2 Postoperative Eating Avoidance 93.2.8 Perception of Self 93.2.9 Body Image and Excess Skin 93.2.10 Substance Misuse 93.2.10.1 Working with Issues after Surgery 93.3 Summary 93.4 Key Learning Points References 94 Health-Related Quality of Life Before and After Bariatric Surgery 94.1 Introduction 94.2 What Is HRQoL? 94.3 How Can HRQoL Be Measured? 94.3.1 Unidimensional Measures of Health Status 94.3.1.1 Level of Functioning 94.3.1.2 Mood 94.3.1.3 Pain 94.3.1.4 Self-Esteem 94.3.1.5 Life Satisfaction 94.3.1.6 Eating Behavior 94.3.2 Multidimensional Measures of Health Status 94.3.2.1 Single-Item Scales 94.3.2.2 Composite Scales 94.4 Measuring HRQoL in the Context of Bariatric Surgery 94.5 The Impact of Bariatric Surgery on Quality of Life 94.5.1 The Impact of Health-Related Quality of Life 94.5.2 Broader Psychosocial Outcomes 94.5.3 Summary 94.6 Some Recommendations for Practice and Research 94.7 Conclusion 94.8 Key Learning Points 94.9 Cross-References References 95 Social Aspects of Bariatric Surgery 95.1 Before Bariatric Surgery 95.1.1 Introduction: The Social Construction of Obesity 95.1.2 Consequences of the Stigma Attached to Obesity 95.1.2.1 Stigma of Obesity in Education 95.1.2.2 Stigma of Obesity in Employment 95.1.2.3 Stigma of Obesity in Personal Relationships 95.1.2.4 Stigma of Obesity in Healthcare Settings 95.2 After Bariatric Surgery 95.2.1 From Stigma to Judgment: The Social Risks of Bariatric Surgery 95.2.2 Qualitative Research as a Means of Understanding Patient Experiences 95.3 Recommendations for Practice 95.4 Summary 95.5 Key Learning Points 95.6 Cross-References References 96 Bariatric Surgery Journey: A Patient´s Perspective 96.1 Introduction 96.2 Living with Obesity 96.3 Misconception About Obesity as a Life Style Problem Only 96.4 Preoperative Issues 96.4.1 Guilt 96.4.2 Shame/Embarrassment 96.4.3 Overconfidence Regarding Outcome 96.4.4 What Do They Expect from Surgery? 96.4.5 Reluctance to Acknowledge Psychological Issues 96.4.6 Anger 96.5 Surgery 96.5.1 Often-Kept Secret 96.5.2 Struggling to Follow Clinical Advice 96.6 Postsurgery Period 96.6.1 Unrealistically High Expectations of Weight Loss 96.6.2 Gastric Band Adjustments 96.7 Main Patient Complaints About Health Providers 96.7.1 Poor Communication 96.7.2 Attitudes 96.8 A Bariatric Health Care Provider as a Patient 96.8.1 Recommendations for Clinicians Based on Feedback Received from Patients 96.9 Honesty Is Vital, and Patients Must Be Well Informed 96.9.1 Diet 96.9.2 Vitamins and Blood Tests 96.9.3 Weight Loss 96.9.4 Excess Skin 96.9.5 Support Groups 96.9.6 Weight Regains 96.9.7 Gastric Bands 96.9.8 The Future 96.10 Summary 96.11 Key Learning Points References Special Topics 97 Management of Bariatric Emergencies by the General Surgeon 97.1 Introduction 97.2 Laparoscopic Gastric Band Emergencies 97.2.1 Gastric Pouch and Esophageal Dilatation 97.2.1.1 Presentation 97.2.1.2 Diagnosis 97.2.1.3 Management 97.2.2 Band erosion 97.2.2.1 Presentation 97.2.2.2 Diagnosis 97.2.2.3 Management 97.2.3 Band Slippage 97.2.3.1 Presentation 97.2.3.2 Diagnosis 97.2.3.3 Management 97.2.4 Infected Band 97.2.4.1 Presentation and Diagnosis 97.2.4.2 Management 97.2.5 Other Early Complications 97.2.5.1 Gastric/Esophageal Perforation 97.2.5.2 Tight Band 97.3 Laparoscopic Gastric Bypass Emergencies 97.3.1 Intraluminal Bleeding 97.3.1.1 Etiology 97.3.1.2 Presentation 97.3.1.3 Management 97.3.2 Extraluminal Bleeding 97.3.2.1 Etiology 97.3.2.2 Presentation 97.3.2.3 Management 97.3.3 Leaks 97.3.3.1 Presentation 97.3.3.2 Management 97.3.4 Abdominal Pain or Colic for More Than 4 Hours 97.3.5 Internal Hernias 97.3.5.1 Presentation and Diagnosis 97.3.5.2 Management 97.3.6 Acute Gastric Dilatation 97.3.7 Nausea and Vomiting for More Than 4 Hours 97.3.7.1 Presentation 97.3.7.2 Management 97.3.8 Marginal Ulceration 97.3.9 Retrograde Intussusception 97.3.10 Laparoscopic One-Anastomosis/Mini-gastric Bypass (OAGB/MGB) 97.4 Laparoscopic Sleeve Gastrectomy Emergencies 97.4.1 Intraluminal Bleeding 97.4.1.1 Etiology 97.4.1.2 Presentation 97.4.1.3 Management 97.4.2 Leak 97.4.2.1 Etiology 97.4.2.2 Presentation and Diagnosis 97.4.2.3 Management 97.4.3 Nausea and Vomiting for More Than 4 Hours 97.4.3.1 Etiology and Presentation 97.4.3.2 Management 97.5 Intragastric Balloon Emergencies 97.5.1 Nausea and Vomiting for More Than 4 Hours 97.5.1.1 Etiology and Presentation 97.5.1.2 Management 97.5.2 Balloon Leak and Obstruction 97.5.2.1 Etiology and Presentation 97.5.2.2 Management 97.5.3 Bacterial Overgrowth in the Balloon 97.5.3.1 Etiology and Presentation 97.5.3.2 Management 97.5.3.3 Stomach Perforation due to Intragastric Balloon 97.5.3.4 Spontaneous Balloon Hyperinflation 97.6 Conclusion 97.7 Key Learning Points References 98 Gastroesophageal Reflux, Obesity, and Bariatric Surgery 98.1 Introduction 98.2 Pathophysiology of GERD Associated with Obesity 98.3 Bariatric Surgery and Gastroesophageal Reflux 98.3.1 Beneficial (Anti-Refluxogenic) Effects of Bariatric Surgery on GERD 98.3.1.1 Reduction and/or Repair of the Hiatal Hernia 98.3.1.2 Reduction in the Acid Exposure (Production) Due to Resection (All Surgeries with a Sleeve Gastrectomy Component) 98.3.1.3 Reduction in Acid Exposure Due to Exclusion (All Types of Bypasses) 98.3.1.4 Creation of a Low-Pressure System (All Types of Bypasses) 98.3.1.5 Mechanical Caudal Pull Effect (All Types of Bypasses) 98.3.2 Potential Refluxogenic Effects of Bariatric Surgery on GEJ 98.4 Evidence 98.4.1 Reflux After Laparoscopic Sleeve Gastrectomy (LSG/SG) 98.4.2 Reflux After OAGB 98.4.3 Reflux After LRYGB or RYGB 98.5 Approach to the Patient with Symptomatic Reflux After Bariatric Surgery 98.5.1 History Taking 98.5.2 Investigations 98.5.3 Management 98.5.3.1 Medical Management 98.5.3.2 Endoscopic Management 98.5.3.3 Surgical Management 98.5.4 Surveillance 98.6 Summary 98.7 Key Learning Points References 99 Bariatric Surgery After Hiatal Surgery/Antireflux Surgery 99.1 Introduction 99.1.1 Antireflux Surgery 99.1.2 Surgery for Hiatus Hernia 99.1.3 Surgery for Achalasia Cardia 99.1.4 Mesh Use 99.1.5 Mobilization of Short Gastric Vessels 99.2 Bariatric Surgery and Gastroesophageal Reflux Disease 99.2.1 Laparoscopic Sleeve Gastrectomy (LSG) and GERD 99.2.2 Laparoscopic Roux-en Y Gastric Bypass (LRYGB) and GERD 99.2.3 Laparoscopic Adjustable Gastric Banding (LAGB) and GERD 99.2.4 One Anastomosis Gastric Bypass (OAGB) and GERD 99.3 Bariatric Surgery After Antireflux/Hiatal Surgery 99.3.1 What Is the Evidence? 99.4 The Authors´ Approach 99.4.1 Does the Patient Have GERD Symptoms? 99.4.2 What Antireflux Operation Did the Patient Have? 99.5 Intra-Operative Considerations 99.6 Summary 99.7 Key Learning Points References 100 Abdominal Wall Hernia and Bariatric Surgery 100.1 Introduction 100.2 The Dilemma the Surgeon Faces with Hernia and Obesity 100.2.1 Problems with Ventral Hernia Repair in an Obese Patient 100.2.2 Open or Laparoscopic Ventral Hernia Repair? 100.2.3 Choice of Technique for Hernia Repair 100.2.3.1 Intraperitoneal on Lay Mesh Repair (IPOM) 100.2.3.2 Component Separation Techniques 100.2.3.3 Anatomical Repair 100.3 When Is the Right Time to Do a Ventral Hernia Repair? 100.3.1 Concomitant Bariatric Surgery with AWH Repair 100.3.1.1 Why Concomitant Surgery 100.3.1.2 Mesh or No Mesh? 100.3.2 Staged Procedures 100.3.2.1 Bariatric Surgery Followed by Hernia Repair 100.3.2.2 Ventral Hernia Repair Followed by Bariatric Surgery 100.4 Suggested Algorithm for Operative Repair 100.5 Summary 100.6 Key Learning Points References 101 Gallstones and Bariatric Surgery 101.1 Introduction 101.1.1 Obesity and Cholelithiasis 101.2 Cholelithiasis after Bariatric Surgery 101.3 Cholecystectomy in Patients Undergoing Bariatric Surgery 101.3.1 Prophylactic Approach 101.3.2 Selective/Elective Approach 101.3.3 Deferred/Conventional Approach 101.4 Role of Ursodeoxycholic Acid in Bariatric Surgery 101.5 Management of Common Bile Duct Stones (Choledocholithiasis) After RYGB 101.6 Percutaneous Transhepatic Instrumentation of Common Bile Duct 101.7 Laparoscopically Assisted Trans-Enteric/Trans-Gastric Endoscopic (ERCP) Access, Using Specialized Endoscopes 101.8 Open/Laparoscopic Exploration of the Common Bile Duct/Choledochoduodenostomy 101.9 Conclusion 101.10 Key Learning Points Reference 102 The Role of Primary Care in Bariatric Surgery 102.1 Introduction 102.2 Obesity Management in Primary Care 102.2.1 Diet 102.2.2 Physical Activity 102.2.3 Other Integrated Approaches 102.2.4 Drug Therapy 102.2.5 Surgery 102.3 Immediate Postoperative Care 102.4 Long-Term Care 102.4.1 Gastric Bypass and Sleeve Gastrectomy 102.4.2 Gastric Band 102.4.3 Biliopancreatic Diversion 102.5 Changes in Drug Therapy after Bariatric Surgery 102.6 Metabolic Complications after Bypass 102.7 Supplements 102.8 Diabetes Pharmacotherapy 102.9 Hypertension 102.10 Drugs Affecting Lipid Profile 102.11 Drugs for Gastric Hyperacidity 102.12 Other Effects of Weight Loss 102.13 Vitamin D Status 102.14 Re-Referral Criteria 102.15 Summary References 103 Intensive Care and Obesity 103.1 Introduction 103.2 Medical Considerations 103.2.1 Airway 103.2.2 Ventilation 103.2.3 Cardiovascular Assessment 103.2.4 Sedation and Drug Dosing 103.2.5 Renal Assessment and Renal Replacement Therapy 103.2.6 Thromboembolic Prophylaxis 103.2.7 Nutrition 103.2.8 Resuscitation 103.3 Nursing Considerations 103.3.1 Staffing 103.3.2 Hygiene Needs and Skin Care 103.3.3 Privacy and Dignity 103.4 Equipment 103.5 Conclusion 103.6 Key Learning Points References 104 Radiological Imaging in Bariatric Surgery 104.1 Introduction 104.2 Laparoscopic Adjustable Gastric Band (LAGB) 104.2.1 Early Complications in LAGB 104.2.2 Late Complications 104.2.2.1 Gastric Pouch Dilatation 104.2.2.2 Band Erosion 104.2.2.3 Other Complications 104.2.3 Gastric Band Fills 104.3 Roux-En-Y Gastric Bypass (RYGB) 104.3.1 Early Complications 104.3.1.1 Bleeding 104.3.1.2 Anastomotic Leak 104.3.1.3 Gastric Pouch Dilatation 104.3.1.4 Dilatation of the Gastric Remnant and Duodenum 104.3.1.5 Infection 104.3.1.6 Ischemia 104.3.2 Late Complications 104.3.2.1 Obstruction 104.3.2.2 Staple Line Dehiscence Leading to Gastro-Gastric Fistula 104.3.2.3 Gastrojejunal Marginal Erosion and Ulcers 104.4 One Anastomosis Gastric Bypass - Mini Gastric Bypass (OAGB-MGB) 104.5 Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) 104.6 Laparoscopic Sleeve Gastrectomy (LSG) 104.7 Duodenal Switch 104.8 Summary 104.9 Key Learning Points References 105 Adolescent Bariatric Surgery 105.1 Introduction 105.2 Definition 105.3 Prevalence 105.4 Why Is Adolescent Group So Special? 105.5 Rationale for Treatment of Obesity 105.6 Effect of Obesity on Individuals 105.7 Comorbidities 105.7.1 Cardiovascular 105.7.2 Metabolic 105.7.3 Endocrine 105.7.4 Respiratory 105.7.5 Renal 105.7.6 Hepatic 105.7.7 Orthopedic 105.7.8 Psychosocial 105.8 Treatment Options and Patient Selection 105.8.1 Lifestyle Modification 105.8.2 Patient Selection Guidelines 105.9 Preoperative Preparation 105.9.1 Role of MDT Members 105.9.1.1 Pediatrician 105.9.1.2 Dietitian 105.9.1.3 Psychologist 105.10 Surgery 105.10.1 AGB 105.10.2 VSG 105.10.3 RYGB 105.11 Psychological Impact of Surgery 105.12 Kidney Function 105.13 Role of Newer Surgical Interventions 105.13.1 Intragastric Balloons (IGBs) 105.14 Summary 105.15 Key Learning Points References 106 Body Contouring Surgery: An Overview of Principles and Techniques 106.1 Introduction 106.2 Preoperative Assessment of the MWL Patient 106.2.1 Nutritional Considerations 106.2.2 Weight Loss and Weight Stability 106.2.3 Medical and Surgical History 106.2.4 Psychological Considerations 106.2.5 Multidisciplinary Team Approach 106.3 Techniques in Body Contouring Surgery 106.3.1 Contouring of the Trunk 106.3.1.1 Upper Body Lift 106.3.1.2 Female Upper Body Lift 106.3.1.3 Upper Body Lift in Males 106.3.1.4 Lower Body Lift 106.3.2 Brachioplasty 106.3.3 Medial Thigh Lift 106.3.4 Total Body Lift 106.4 Complications of Body Contouring Surgery 106.5 Funding 106.6 Summary References 107 COVID-19, Obesity and Bariatric Surgery 107.1 Introduction 107.2 Effect of Obesity Upon COVID-19 Outcomes 107.3 Pathogenic Effects of Obesity Associated with COVID-19 107.4 Bariatric and Metabolic Surgery During COVID-19 107.5 Future Challenges 107.6 Summary 107.7 Key Learning Points References Index