Bariatric Surgery is rapidly gaining popularity. Knowing the right Indications and Contra Indications is paramount for Surgeons starting their career in Bariatric Surgery.

1. Bariatric Surgery
Indications & Contraindications
DR. SUMEET SHAH
MS, DNB, MNAMS, FIAGES
Fellowship (Minimal Access Surgery)
SENIOR CONSULTANT & COORDINATOR
MINIMAL ACCESS, METABOLIC & BARIATRIC SURGERY
MAX SUPER SPECIALTY HOSPITAL, SHALIMAR BAGH
NEW DELHI (INDIA)

2. Bariatric Surgery
Indications & Contraindications
What is obesity?
?

3. Bariatric Surgery
Indications & Contraindications
Morbid obesity is a chronic, lifelong,
multifactorial, genetically related disease
of excessive fat storage with highly
significant medical, psychological,
social, physical and economic co-
morbidities
IFSO Sept, 1996

4. Bariatric Surgery
Indications & Contraindications
 Quantification of obesity
BMI = Body Mass Index
= Body weight (Kg)
Height (in m2)

5. Bariatric Surgery
Indications & Contraindications
BARIATRIC RECOMMENDATIONS
WHO CRITERIA RECOMMENDATION
FOR ASIANS
BMI (kg per m2)
 Normal < 25.0 < 23.0
 Overweight > 25.0 > 23.0
 Obese > 30.0 > 27.5
 Severe Obesity > 35.0 > 32.5
 Morbid Obesity > 40.0 > 37.5

6. Bariatric Surgery
Indications & Contraindications
Bariatric Surgery: Multiple Health Benefits
 ~77 % Excess weight loss
 ~ 85 % resolution of OSA
 ~ 52 to 92 % resolution of HTN
 ~ 73 – 83% resolution of type 2 diabetes
 > 80 % resolution of Metabolic Syndrome
Sjostrom et al New Engl J Med 2004
Sjostrom et al, N Engl J Med 2007

7. Bariatric Surgery
Indications & Contraindications
Optimal Patient Selection
 Assess indications / contraindications
 Multi-disciplinary evaluation
 Optimize & manage comorbidities
 Educate,set realistic expectations

8. Bariatric Surgery
Indications & Contraindications
NIH Consensus Conference Criteria(1991)
 BMI > 40 or > 35 kg/m2 with co-morbidity
 Failure of non-operative Rx
 Absence of contraindications
 Well informed, compliant, motivated patient

9. Bariatric Surgery
Indications & Contraindications
Controversies
 Surgery for Adolescents & Elderly
( Age < 18 / > 65 yrs )
 Surgery for BMI < 35
 Surgery for Metabolic indications only

10. Bariatric Surgery
Indications & Contraindications
? Surgery for Adolescents
 Adolescent bariatric surgery (<18 yrs) has proven
effective but should be performed only in a
specialty centre
 Selection criteria similar
to adults
SAGES Guidelines for Clinical Application of Laparoscopic
Bariatric Surgery, 2008; Level II, Grade B,C evidence.

11. Bariatric Surgery
Indications & Contraindications
Panel of experts on Adolescent Obesity
 BMI > 40 with comorbidities
 Skeletal / physiologic maturity
 Failure of > 6 mths of structured wt loss attempts
 Commitment, ability to follow post-op instructions
 Decision making capacity
 Commitment to avoid pregnancy x 1 year
Curr Opin Paediatr 2005.

12. Bariatric Surgery
Indications & Contraindications
? Surgery for Age > 65
 Patients > 65 yrs at risk of death (early & late)
after WLS
 Should have life expectancy > 5 yrs
 Should be evaluated & treated in
an established Center of Excellence
JAMA 2005
Annals of Surgery 2004
SAGES Guidelines for Clinical Application of Laparoscopic
Bariatric Surgery, 2008; Level II, Grade B evidence.

13. Bariatric Surgery
Indications & Contraindications
? Surgery for BMI < 35
“Individuals with BMI 30-35 kg/m2 may
benefit from Lap. bariatric surgery given
the poor results of non-surgical Rx”
SAGES Guidelines for Clinical Application of Laparoscopic Bariatric Surgery,
2008; Level I, Grade B evidence.

14. Bariatric Surgery
Indications & Contraindications
Surgery for Diabetes / Metabolic Syndrome
?
 Risks vs Benefits?
 Choice of procedure?
 Economic Considerations?
 When to intervene?
? BMI < 35

15. Bariatric Surgery
Indications & Contraindications
Contraindications

16. Bariatric Surgery
Indications & Contraindications
Medical
 Severe co-morbidities / unacceptable risk
 Uncontrolled coagulopathy
 Incurable disease (cancer,AIDS, cirrhosis)
 ? Certain GI diseases (Crohns, dysmotilities)
 V.Poor QOL not expected to improve with WLS

17. Bariatric Surgery
Indications & Contraindications
Unacceptable risk of Anaesthesia
 Uncontrolled severe OSA + Pulmonary HTN
(Pulm. Syst. Pressure > 50mm Hg)
 Severe COPD (Gold Spirometric Criteria)
- FEV1 / FVC < 0.7
- FEV1 < 30% predicted, or
- FEV1 < 50% predicted + chr. resp. failure
 CHF, unstable angina
 ? Complete prolonged immobility

18. Bariatric Surgery
Indications & Contraindications
Surgical (Relative)
 Multiple previous surgeries
 Abdominal irradiation / Liver transplant
 Very large incisional hernia
 Previous int. resection for GBP / BPD-DS
 Severe GERD / Barrets for LAGB
 Need for surveillance endoscopy for GBP

19. Bariatric Surgery
Indications & Contraindications
Behavioral / Psychosocial
 Significant psychatric dis./ major depression
 Severe mental retardation
 Self destructive tendency
 Active bullimia, drug or alcohol abuse
 Inability to comprehend behavioral changes
 Inability to integrate basic lifestyle adjustments

20. Bariatric Surgery
Indications & Contraindications
Indications for Retreat / Change of surgical plan
 Extreme hepatomegaly / cirrhosis with large
varices
 Profuse visceral fat
 Poor exposure
 Extensive adhesions
 Cardiopulmonary instability

21. Bariatric Surgery
Indications & Contraindications
Indications for Retreat / Change of surgical plan

22. Bariatric Surgery
Indications & Contraindications
Revision Surgery: After Lap. Gastric Banding
Early Late
 Gastric perforation  Stomach slippage
 Stomach slippage  Malpositioned band
 Erosion
 Psychological intolerance
 AIDS
 Gastric necrosis

23. Bariatric Surgery
Indications & Contraindications
Revision Surgery: After Lap. Gastric Bypass
Mechanical problems
 Marginal ulcer
 Refractory GJ stricture
 Entero-enterostomy stenosis

24. Bariatric Surgery
Indications & Contraindications
Revision Surgery: After Lap. Gastric Bypass
Insufficient Weight loss
 Normal anatomy
 Abnormal anatomy
- Disrupted staple line
- Gastro-gastric fistula in divided GBP
- Enlarged pouch
Metabolic / Functional
 Nut. deficiency / food intolerance
 Severe dumping / unexplained chronic pain

25. Bariatric Surgery
Indications & Contraindications

26. Bariatric Surgery
Indications & Contraindications

27. Bariatric Surgery
Indications & Contraindications