Bariatric

surgery
Dr ch. Anjani
Gs Pg
 Introduction:

Obesity is defined as a disease of

accumulation of fat in the body to an extent
leading to impairment of health.
Multiple measures have been used to describe
obesity but Body mass index (BMI) is
defined as ratio of weight in kilograms and
square of height in meters is most commonly
used.
The World Health Organization defined BMI ≥ to
30 kg/m2 as being obese and gave classification
for obesity based on BMI
Obesity drastically increases the risk of developing a number of diseases including diabetes,
hypertension, obstructive sleep apnea (OSA), stroke and nonalcoholic fatty liver disease (NAFLD).

Recent meta-analysis studying all-cause mortality reported that relative to normal weight, all grades
of obesity were associated with significantly higher all-cause mortality.

Multiple modalities have been used to treat this disease. Various interventions include lifestyle
changes, specific diets, medications, devices and surgery.

Bariatric surgery is an established and integral part of the comprehensive management of morbidly
obese patients. Recent long-term studies have clearly demonstrated substantial reduction in
mortality in bariatric surgery patients as well as decreased risk of developing comorbidities
associated with obesity; thereby, leading to drop in direct health care costs.
 DEFINITION & RATIONALE
Bariatric surgery is the branch of surgery involving manipulation of the
stomach and/or small bowel to achieve weight loss and control of obesity-
related disease.
Because of the tendency for basal metabolic rate to decrease with dieting, most people will
regain all their weight, returning to the previous homeostatic set point
Bariatric surgery appears to alter this mechanism and ‘reset’ this point, with 15–25% weight
loss maintenance for up to 20 years
Bariatric surgery leads to long-term survival benefit and improves obesity-related disease and
quality of life
The phrases ‘metabolic’ or ‘diabetes’ surgery are increasingly being used in conjunction with,
or instead of, ‘bariatric surgery’ owing to the highly efective way that surgery improves the
metabolic syndrome, with weight loss being a welcome additional efect.
Type 2 diabetes is part of the ‘metabolic syndrome’, which includes high blood pressure,
dyslipidaemia and polycystic ovary syndrome.
 Bariatric surgery indications:

The 2013 European Congress on Obesity at Liverpool and American Association of Metabolic
and Bariatric Surgery (AAMBS) in 2013 has come up with the following indications for
bariatric surgery:
BMI >40
BMI >35 with co-morbidities (Hyperlipidemia, OSA, Metabolic syndrome, HTN, DM, raised
TG, reduced HDL cholesterol
Failed less invasive methods like dietary therapy and
at high risk for obesity-associated morbidity and mortality
NICE guidance on bariatric surgery, 2014
Bariatric surgery is a treatment option for anyone with BMI ≥40 kg/m2
Offer an expedited assessment for people with BMI ≥35 kg/m2 with onset of
type 2 diabetes in past 10 years
Consider an assessment for people with BMI of 30–34.9 kg/m2 with onset of type
2 diabetes within 10 years
Consider an assessment for people of Asian origin with onset of type 2 diabetes
at a lower BMI than other populations
Bariatric surgery is the option of choice for adults with BMI >50 kg/m2 when other
interventions have not been effective
People fitting the above criteria are also required to be receiving or to receive assessment in a
specialist weight management service before referral to a surgical team
 Bariatric surgery & type 2 DM:
Bariatric surgery contributes to improved beta cell function, thereby, clearly proving beneficial in type 2 diabetes mellitus.
Surgically induced improvement of type 2 may be considered effective if: Postoperative insulin dose less than or equal to
25% of the preoperative.
Postoperative oral antidiabetic treatment dose less than or equal to 50% of the preoperative one.
Postoperative reduction in glycosylated haemoglobin (HbA1c) more than 0.5% within 3 months or reaching less than 7.0%.
In 2012, Food and Drug Administration (FDA) approved the use of laparoscopic adjustable gastric banding (LAGB) for
patients with BMI 30-34.9 kg/m2 with type 2 diabetes mellitus or other obesity related comorbidities.
International Diabetes Federation also proposed the eligibility for bariatric procedures for subset of patients with type 2
diabetes mellitus and BMI of 30 kg/m2 with inadequate glyceamic control despite the optimal management.
However, bariatric surgery is not recommended as the treatment of type 2 diabetes mellitus without morbid obesity.
 Bariatric surgery & class 1 obesity:
The American Society of Metabolic and Bariatric Surgery (ASMBS) in 2012 came up with the
position statement recommending bariatric surgery for patients with BMI 30-35 kg/m2 who do
not achieve substantial and durable weight and comorbidity improvement with nonsurgical
methods.
Class I obesity was recognized as a well-defined disease that causes or exacerbates multiple
other diseases, decreases the duration of life and decreases the quality of life. There is no
current justification on grounds of evidence of clinical effectiveness, cost effectiveness ethics, or
equity that this group should be excluded from bariatric surgery.
Bariatric procedures, such as gastric banding, sleeve gastrectomy and gastric bypass, have been
shown in various randomized controlled trials to be well- tolerated and effective treatment for
patients with BMI 30-35 kg/m2 in the short and medium term.
 Bariatric surgery & age:
IN ADOLESCENTS:
Has a BMI more than 40 kg/m2 and at least one comorbidity.
Has followed at least 6 months of organized weight reducing attempts in a specialized center.
Shows skeletal and developmental maturity.
Is capable to commit to comprehensive medical and psychological evaluation before and
after surgery.
Is willing to participate in a postoperative multidisciplinary treatment program in a unit with
specialist pediatric support
IN ELDERLY:
The primary objective of bariatric surgery in elderly is to improve quality of life rather than
increasing life span.
 Contraindications:
As per European guidelines for metabolic and bariatric
surgery, following should not be considered for bariatric Other clinical contraindications include:
surgery:
Cirrhosis with portal hypertension
Absence of a period of identifiable medical management.
Active cancer
Patient who is unable to participate in prolonged
medical follow up. Prader-Willi syndrome
Non-stabilized psychotic disorders, severe depression, Pregnancy
personality and eating disorders, unless specifically
advised by a psychiatrist experienced in obesity. It has been recommended that women
Alcohol abuse and/or drug dependencies. should avoid pregnancy for at least 12-18
months after bariatric surgery.
Diseases threatening life in the short-term.
Patients who are unable to care for themselves and have
no long-term family or social support that will warrant
such care.
Specific exclusion criteria for bariatric surgery in the treatment of type 2 diabetes mellitus are as follows:
Secondary diabetes
Antibodies positive [anti-glutamic acid decarboxylase (anti-GAD) or islet cell antibody (ICA)] or C-peptide <1
ng/mL or unresponsive to mixed meal challenge.
 Types of bariatric surgery:
Malabsorptive procedures: They aim to bypass a segment
of the small bowel so that less food is absorbed. They are not only
associated with severe nutritional deficiencies but are technically
demanding as well. They do have some restrictive component, but it is
secondary to the mal- absorptive aspect of the procedure. They
include biliopancreatic diversion (BPD) biliopancreatic diversion with
duodenal switch (BPD-DS).
Restrictive procedures: They aim to restrict the amount of
food ingested by surgically reducing the size of the stomach. They do
have minimal malabsorptive component. The restrictive procedures
most commonly performed are vertical banded gastroplasty, LAGB and
sleeve gastrectomy.
Hybrid procedure: They aim to restrict food intake by creating a
small gastric pouch as well as limit the absorption by bypassing the
proximal small bowel. It leaves 95% of the small bowel intact and so
avoids many of the unwanted malabsorptive side effects such as
diarrhea and nutritional deficiencies. It is among the most common
surgical bariatric procedure performed
The Roux-en-Y gastric bypass (RYGB) and upcoming omega-loop gastric
bypass fall under this category.
Adjustable gastric banding:
Laparoscopic adjustable gastric banding is a popular
weight loss procedure in Australia and Europe,
although its use is waning after success of sleeve
gastrectomy.
It is essentially a restrictive and reversible procedure. It
involves placing an inflatable band in the upper part of
the stomach so as to create a small proximal pouch.
The band is connected to a port implanted in the
abdominal wall through a tube. The size of this pouch
can be adjusted by instilling or aspirating saline from
the gastric band through this port.
Laparoscopic adjustable gastric banding seems to be a
safer procedure as it is less invasive.
LAGB requires intensive postoperative follow-up to
achieve good results
ADVANTAGES: DISADVANTAGES:
It does not alter anatomy of It is associated with frequent, though less severe,
gastrointestinal tract and can be long-term complications including band slippage,
reversed easily. band erosion and port-site problems.
It does not lead to major
nutritional problems. Recent long-term data with mean follow-up of 14
years published by Aarts et al. (2014) reported
The adjustable restriction is an revisional surgery in 53% patients either due to
added attraction for those who insufficient weight loss or complications. Only 22%
want freedom to eat more on patients had functioning band with good result after
some occasions such as the follow-up period.
vacations. Moreover, patients who were lost to follow up did
The weight loss is gradual and almost twice as bad in terms of excess weight loss
can be tailored to one's compared to those who had regular follow-up.
requirements.
 Laparoscopic Sleeve gastrectomy:
It has become the most common bariatric surgery
worldwide.
Based on substantial comparative and long-term data
for sleeve gastrectomy, the American Society for
Metabolic and Bariatric Surgery in 2012 recognized LSG
as an acceptable option as a primary bariatric
procedure and as a first stage
procedure in high-risk patients as a
part of a planned staged approach.
The procedure of sleeve gastrectomy involves a
longitudinal resection of the stomach starting from the
antrum 5-6 cm from the pylorus and finishing at the
fundus close to the angle of His over a bougie
Most surgeons prefer to use a bougie about 36-40
French to calibrate the size of the sleeve. The average
size of the stomach that remains after the procedure is
about 150 mL. It is a relatively shorter and technically
straight forward procedure
The advantage of LSG over RYGB include absence of any anastomosis, maintenance of
normal food pathway, absence of dumping, marginal ulceration and no risk
of late internal hernias, fewer nutritional complications.
Sleeve gastrectomy has a better impact on weight loss and diabetes than gastric banding while its impact is
similar to the results achieved by RYGB.
The disadvantages include difficulty in managing suture line leaks, absence of long-
term results, propensity for de novo GERD and a possible inferior impact on
type 2 diabetes mellitus. Staple line leak , bleeding , stricture formation and
a mortality of 0.1% were among major complications.
Mean follow-up of greater than 5 years have clearly showed a weight loss of more than 50%.
The weight loss is due to multiple factors. Sleeve gastrectomy is a restrictive procedure involving
removal of over 80% of the stomach including the distensible portion. This decrease in capacity permits
intake of only a small amount of food, imparting a feeling of early satiety.
Moreover, sleeve gastrectomy has a major impact on metabolic pathways involving glucose metabolism.
Decrease in ghrelin levels, decrease in gastric emptying time and increase in incretins like glucagon like
peptide 1(GLP 1) due to early presentation of food to ileum improve glycemic control and render
positive impact on type 2 diabetes mellitus.
Owing to the above benefits or risk profile, Laparoscopic Sleeve Gastrectomy (LSG) has recently been
argued as the rightful gold standard weight loss surgery procedure.
 Roux-en-Y gastric bypass:
Introduced by Mason and Ito in mid-1960s, this procedure is most
well studied in the field of bariatric surgery. The major feature of this
surgery is creation of a proximal gastric pouch of small
size (<20 cm) that is totally separated from the remaining
stomach.
The size of the proximal gastric pouch must be small to create
adequate restriction and it should be based on
lesser curvature of the stomach to prevent dilation of over
time. The small pouch is anastomosed to a Roux loop of
jejunum creating a gastrojejunostomy of about 2 cm
in diameter. This adds to restriction component as well.
The malabsorptive component is created by anastomosing
biliopancreatic limb to the alimentary limb
carrying food, thereby, bypassing major portion of
stomach and 150-200 cm of small bowel.
No Standard length for The limbs.
The length of biliopancreatic limb from ligament of Treitz is usually
20-50 cm and length of the Roux limb is 75-150 cm depending on the
BMI and presence or absence of diabetes.
Longer length of Roux limb is associated with higher short-term
weight loss but on long-term follow-up, this difference becomes less
significant.
Another technical aspect of this surgery is the pathway of the Roux limb for gastrojejunostomy.
The pathway of Roux limb of proximal jejunum can be
anterior to the colon and stomach or
posterior to both or
posterior to colon and anterior to stomach.
The antecolic position is associated with lower incidence of internal hernia.
The RYGB is very efficacious in weight loss leading to 60-70% of excess weight loss in the first
year. Not only it has positive impact on obesity associated comorbidities, long term results are
also encouraging. Recent studies have shown 50-60% excess weight loss at 10-year follow-up.
Gastric bypass is considered as the "gold standard" of weight loss surgery.
 Bilio pancreatic diversion

The procedure includes a distal gastrectomy resulting

in 400 mL gastric pouch and division of the small bowel
250 cm proximal to ileocecal junction. The alimentary
limb is connected to gastric pouch to create Roux-en-Y
gastroenterostomy and the excluded biliopancreatic
limb is anastomosed to alimentary limb 50 cm proximal
to ileocecal junction.
Owing to high incidence of marginal ulcers, later,
modified the operation separately by performing a
vertical sleeve gastrectomy (VSG) with duodenal switch
(DS) and increasing the length of the common channel
to 100 cm.
 Bilio pancreatic diversion & duodenal
switch:

modified BPD-DS includes:

Pylorus-preserving subtotal sleeve gastrectomy
replacing the original distal gastrectomy.
Common "absorptive" channel lengthened from 75 cm
to 125 cm.
Ileoduodenal anastomosis 3-5 cm distal to the pylorus.
Incidental appendectomy and cholecystectomy.
The first laparoscopic BPD-DS was done by Michael Gagner in 1999. In fact, the laparoscopic sleeve
gastrectomy (LSG) was initially conceived as the first of a two step procedure to create DS.
The sleeve would be performed at first stage and small intestinal bypass would be performed after some
time. The goal of staging the DS was to reduce perioperative morbidity of this com- plex procedure.
Biliopancreatic diversion with duodenal switch is currently the most durable and effective bariatric surgery
for weight loss.
The efficacy on weight loss of truly malabsorptive techniques is attributable to the diversion of bile and
pancreatic juice leading to a decrease in caloric and fat absorption. In addition, hormone secretion is
altered by bypassing the proximal intestine, which has positive effects on obesity and diabetes mellitus.
However, the world- wide use of this operation is still limited with only 1-2% of all bariatric procedures
comprising of BPD-DS. Its relative technical difficulty, requirement of demanding follow-up and life time
supplementation with vitamins and micronutrients to prevent these deficiencies may explain this
limitation.
Owing to postoperative complications, BPD-DS is usually recommended only for patients who are super
obese and are highly unlikely to succeed with the diet and exercise requirements necessary for long-term
success of restrictive surgeries.
Recently, the DS was modified. The SADI (single anastomosis duodenoileostomy) is a different type of
bypass reconstruction than conventional DS.
 Upcoming bariatric
surgeries:

Omega-loop Gastric Bypass

Single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S)
Sleeve gastrectomy and ileal transposition
Endoscopic Bariatric Therapy
Omega-loop Gastric Bypass(Single Anastomosis Gastric Bypass or Mini
gastric Bypass:
First described by Robert Rutledge in 2001, this surgery has gained proponents throughout the world. It is a
modification of Mason's loop gastric bypass with a longer and narrower gastric
tube.
The stomach is divided at the junction of the body and antrum to create a longest possible gastric pouch. A
lesser curvature based tube of stomach is constructed using staplers around gastric calibration tube of size
varying from 30-36 French. A jejunal loop 200 cm distal to the ligament of Treitz is then brought up antecolic
and anastomosed to the stomach tube (antecolic loop gastrojejunostomy).

The Advantages of this Disadvantages:

procedure include Symptomatic Biliary Refux Causing
shorter operative time Gastritis Or Oesophagitis, Marginal
Ulcers
lower complication rates The Management Of Anastomotic Leaks
better weight loss. Owing To A Potentially High Volume Of
reduced hospitalization Biliary And Pancreatic Secretions
shorter learning curve.
In a recent meta-analysis showed that mini gastric bypass is at least comparable to gastric bypass in terms of weight loss with a less complex procedure. The impact
on comorbidities is also comparable.
However, they reported mortality rate was 0.14%, early complication rate was 6% and leak rate was 1%. A marginal ulceration rate of 2.8% and an anaemia rate of
4.2% were reported. Approximately 2% of patients were reported to have postoperative reflux .One of the most important concerns regarding this procedure is the
potential risk of gastric and esophageal cancers due to biliary reflux into the gastric pouch and esophagus.
Though, a long, narrow gastric pouch should make esophageal biliary reflux less likely, symptomatic biliary esophagitis requiring revisional surgery has been
reported after this procedure.
Malnutrition is another significant complication associated with this procedure and may require revisional surgery.
This procedure is believed to be more malabsorptive than RYGB accounting for the better weight loss seen with it. Long-term data, hence, is essential to determine
the risk of esophageal cancers due to biliary reflux and malnutrition.
Single-anastomosis duodenoileal bypass with sleeve
gastrectomy (SADI-S)
Novel Procedure Based On The BPD/DS
A Sleeve Gastrectomy Is Followed By An
End-to-side Duodenoileal Anastomosis.
The Length Of The Common Channel–
alimentary Limb Is 250–300 cm.
Potential Advantages Include The
Preservation Of The Pylorus, Elimination
Of One Anastomosis Compared With The
Duodenal Switch And Reducing
Operating Time And Risk Of
Perioperative Complications.
 Impact of bariatric surgery on obesity-
related comorbidities:
Diabete mellitus:
Diabetes remission is greatest for patients undergoing

BPD-DS > RYGB > LAGB.

Sleeve gastrectomy has comparable remission rate to RYGB.
Swedish Obese Study (SOS) provided the most reliable long-term data on impact of bariatric surgery
on glycemic control. Roux-en-Y gastric bypass had greater reduction in serum glucose 10 years after
surgery than rest of procedures including banding or gastroplasty.
Another recent study by Obeid et al. showed 58% remission of diabetes at 10-year follow-up.
Metabolic Syndrome:
All the parameters associated with metabolic syndrome including central obesity, dyslipidemia and hypertension
show improvement after bariatric surgery.
Obstructive Sleep Apnea:
Bariatric surgery has shown impressive remission rates for OSA. Comparing the various types of surgery, BPD and
RYGB demonstrated maximum benefit while LAGB had least impact.
Liver Disease:
Nonalcoholic fatty liver disease is present in 90-100% of the morbidly obese patients and risk of developing
cirrhosis in presence of NASH ranges between 5% and 20%. Weight loss after bariatric surgery decreases the
metabolic disease, steatosis and inflammation.
Reflux Disease:
The incidence of GERD in the bariatric population is higher than the general population, which may be, due to
excess weight, increased intra-abdominal pressure and associated hiatal hernia. Roux-en-Y gastric bypass is more
than 90% effective in resolution of GERD. Roux-en-Y gastric bypass creates such a small pouch that it has a limited
volume of acid production. Laparoscopic adjustable gastric banding also improves GERD but to a lesser extent.
However, results of sleeve gastrectomy on gastroesophageal reflux are debatable issue.
Others:
Bariatric surgery also has a beneficial impact on a number of associated diseases including polycystic ovarian
syndrome (PCOS), osteoarthritis and venous hypertension. Reduction in requirement of medication for
hypothyroidism has also been reported.
 Complications:

Bleeding is one of the life-threatening complications after bariatric surgery, particularly after gastric
bypass and sleeve gastrectomy.

Hematemesis in the first few hours after gastric bypass implies bleeding from gastrojejunostomy
unless proven otherwise.
Tachycardia, hypotension, sanguineous drain output and a drop in hematocrit are early signs.
Bleeding after sleeve gastrectomy can be extraluminal or intraluminal. Extraluminal causes
include bleeding from staple line, omental vessel, injury to spleen, liver laceration or trocar sites.
Intraluminal bleed, less common, may result from staple line bleed. An urgent re-look surgery
and control of hemorrhage is warranted.
Leak is another most feared complication, especially after gastric bypass and sleeve
gastrectomy. The most common site of leak after sleeve gastrectomy is proximal
third of stomach, near gastroesophageal junction due to high intra- gastric
pressure with impaired peristaltic activity and ischemia.
Tachycardia, tachypnea, fever and oliguria are most common alarming signs.
Leak can be early or late.
Early leak is defined as leak diagnosed within 72 hours of surgery. Pulse rate is single
most reliable parameter to diagnose it; however, tachypnea and fever may also occur.
Computed tomography (CT) scan or gastrograffin study study is imaging of choice. Re-
look surgery, repair of leak, drain placement and feeding jejunostomy are standard of
care.
Late leaks are those diagnosed after 72 hours. Repair of leak is not recommended due to
extensive inflammatory reaction. Conservative management with image guided drainage
of infected collection, parenteral antibiotics, nasojejunal feeding and insertion of stents
should be considered. Operative intervention is mandatory in case of toxemia or
peritonitis.
Stricture formation after sleeve gastrectomy and stenosis of anastomotic site after gastric bypass is
other major issue in bariatric surgery. The most common site of stricture is incisura
angularis due to luminal narrowing or kink.

In acute setting, conservative management is warranted to allow tissue edema to resolve.

Chronic stricture needs endoscopic balloon dilatations.
Anastomotic stenosis, commonly of gastrojejunostomy after RYGB, usually appears 6-12 weeks
after surgery. The use of linear stapler has decreased its incidence markedly. The diagnosis is by
endoscopy and treatment by balloon dilatation.
Marginal ulcers are a cause of concern after RYGB and mini-gastric bypass. Its incidence varies
from 3% to 15% of cases. Diagnosis is achieved by endoscopy and management is done medically
in 90% cases.
Internal hernia, due to inadequate or non-closure of mesenteric defects at the time of surgery,
leading to small bowel obstruction is most important complication of LRYGB. Emergency
exploration and closure of defect is required urgently.
Some of the complications specific to LAGB include band slippage, band
erosion, prolapse and malalignment of port and tube.

Prolapse is among the most common complication. Postoperative vomiting

predisposes this problem.
The lower stomach is pushed upward and trapped within the lumen of the band. Plain radiograph
depicting horizontal band strongly indicates prolapse.
Initial treatment is removal of all fluid from system. If failed, patient needs surgery.
The incidence of band slippage has decreased over time with pars flaccida technique of
band placement.
The incidence of band erosion varies between 1% and 39%. Laparoscopic removal of band
with repair of any gastric perforation is often required.
Perforation/leaking/kinking of tube or misalignment of port warrants revision surgery.
Nutritional deficiencies are maximum with BPD-DS followed by RYGB and LSG and least
by LAGB. Roux-en-Y gastric bypass leads to iron deficiency, vitamin B12 deficiency,
vitamin D deficiency.
Nutritional surveillance is important and supplementation should be considered. Thiamine, vitamin
B, vitamin D, zinc and folic acid are among most common deficiencies.
 Future directions:

Future research is directed in novel surgical procedures such as ileal

transposition and duodenojejunal bypass as well as in Endoscopic
Bariatric Therapy (EBT). The advent of endoscopy in the field of bariatric surgery
has provided for ambulatory and less invasive weight loss procedures with superior safety
and cost profile.
Endoscopic bariatric therapy can be used as primary therapy to induce weight loss in severe
obesity or as bridge therapy to promote weight loss specifically to reduce the risk from a
subsequent intervention including bariatric surgery.
Endoscopic bariatric therapies have varying degrees of intensity, durability and repeatability
and therefore should be considered based on intent of therapy and overall risk or benefit
profile.
Endoscopic brachy therapy:
Restrictive procedures: These
procedures decrease the food intake by inducing Malabsorptive procedures: Being analogous
early satiety. to conventional malabsorptive procedures, this
It includes primarily two types of technologies: technology is used to create a physical
1. Space occupying devices: This most
barrier between food, intestinal wall
commonly comprise of temporarily placed and bilio-pancreatic secretions. Duodenal-
prosthetic balloons placed jejunal barrier sleeve is one such device which is placed
endoscopically not only to restrict intake but endoscopically in the proximal duodenum or
also alter gastric neurohormonal physiology. gastroesophageal junction. It prevents interaction of
They are inserted and removed as outpatient chyme with proximal intestine while biliopancreatic
procedure. Polymer pills are other non- secretions pass along the outer wall of the liner and
balloon space occupying devices that expand mix with chyme in distal jejunum.
and later degrade in the stomach, thereby,
eliminating the need of endoscopic removal.
2. Devices altering the gastric
Neurohormonal modulatory
anatomy: In contrast to temporary space procedures: Although still in early stages of
occupying devices, certain endoscopic devices development, certain devices are used to manipulate
alter gastric anatomy permanently either by neurohormonal signals to induce satiety. Implantable
stapling or suturing. Transoral gastroplasty gastric devices are under trial to interfere with vagal
(TOGA) system is one such device used to create signals between brain and stomach to cause early
stapled gastric pouch endoscopically; however, satiety.
its use is technically demanding and time
consuming.
 Conclusion:

Bariatric surgery is a well-established modality in management of obesity and related

metabolic disorders. The increasing prevalence of obesity and excellent long-term results
warrants its use for management of this disease.
Of all bariatric procedure, RYGB has been the most favored owing to the high volume of
long-term data.
However, sleeve gastrectomy is becoming the most common performed bariatric procedure,
being a less complex procedure with similar results.
Obesity should be treated as a disease and awareness regarding benefits of bariatric surgery
needs to be disseminated to tackle this disease effectively.
Thank
you