18.6 Gastric Stimulator

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188

upper jejunum do not come into contact with

the food. Preliminary results on the implan-

tation of an Endobarrier™ mainly refer to

the technique, complications and short-term

results. A weight loss that is reached with

the established surgical procedures cannot

be achieved by this procedure. However, the

effects on glucose regulation in patients with

diabetes mellitus type 2 are remarkable. How-

ever, a remission without additional drug

therapy of diabetes mellitus type 2 remains

an exception.

The Endobarrier™ is an alternative for

patients who are sceptical about or reject sur-

gery. As with all procedures, an additive multi-

modal therapy should be applied especially in

this procedure. Furthermore, patients must be

informed about the necessity of replacement

or removal of the system after 12 months

at the latest. There is no acceptance of this

procedure by the health insurance so far,

therefore an individual application has to

be made. A recommendation of this system

for general use is not given by the European

Network for Health Technology in Health

Care (EUnetHTA) due to the described com-

plications.

18.4 Gastric Sleeve withIleum

Interposition

Another experimental bariatric surgical pro-

cedure, which is mainly used in obese patients

with existing diabetes mellitus type 2, is the

gastric sleeve formation with postpyloric

ileum interposition (. Fig.18.3).

In this endoscopic procedure, a gastric

sleeve resection is performed rst. Then the

post-pyloric cut of the duodenum 2–3 cm

behind the pylorus is done with a forklift

truck and the stomach is moved to the lower

abdomen. After locating the Treitz ligament,

the jejunum is marked 50cm aborally with a

suture. This is the intended site of connection

of the ileum loop to be interposed. The iden-

tication of the terminal ileum and cecum

follows. Thirty centimeter in front of the

. Fig. 18.3 a–d Gastric

sleeve formation with

postpyloric ileum

interposition. (From

Celik etal. 2015)

C. A. Jacobi

189

Bauhin’s valve a 170 cm long piece of ileum

is dissected and relocated to the middle abdo-

men. Subsequently, anastomosis of the inter-

ponate to the jejunum 50cm behind the Treitz

ligament and anastomosis to the duodenum

are performed. Additionally, the area of the

resected ileum segment is anastomosed. Thus,

three anastomoses are necessary, which can be

applied either by hand suture or mechanically

with a stapler device. The presumed mecha-

nism of this operation consists of a direct

inuence of gastrointestinal hormones in

addition to the restriction through the gastric

sleeve. The present studies mainly deal with

the perioperative complications and the post-

operative short-term results.

One of the largest series was published

by Celik’s research group (Celik et al. 2015).

360 patients at an average age of 51 years

were operated on, in whom the HbA

was

9.4% on average. The complication rate was

high (6.1%), almost 2% of the patients had

to undergo emergency revision. The average

BMI reduction was 28%. Results on HbA

reduction were not reported. Therefore, the

signicance of this operation cannot yet be

conclusively assessed.

18.5 Securing Dierent Operation

Procedures withaBand or

aRing

The use of a ring or band in the proximal por-

tion of a gastric sleeve or on the pouch of a

bypass is not new. However, in recent years

more and more different products have been

introduced to the market, which are increas-

ingly used in the clinic. The so-called Fobi-

Ring, the GaBP-Ring™ and the Minimizer™

are available. The principles of these products

are based on mechanistic thinking. The addi-

tional placement of a ring or band is intended

to prevent dilatation of the distal parts of the

stomach or intestine (. Fig.18.4). The place-

ment of a ring or band can be used for the

primary placement of a gastric bypass or a

tubular stomach. After bariatric surgery with

consecutive dilatation, the ring or band can

also be placed during a second operation.

Favourable long-term results are available

for the primary application of a band for gas-

tric bypass as well as for sleeve resection. In

a study published by Lemmens etal. (2014)

with a small number of patients with com-

plete follow-up, the average overweight loss

after a banded bypass was 85% after 4years.

Further prospective randomized studies are

still needed. The additional costs for the ring

systems are not yet covered by health insur-

ance companies.

Additional complications, such as the

migration of these systems to the gastric wall,

must be considered and communicated to the

patient during the explanation.

18.6 Gastric Stimulator

Gastric stimulation as a further experimental

procedure has been used for several years in

the treatment of obesity. There is no clearly

dened indication. With a gastric stimulator

(VBloc™, EnteroMedics) approved by the

American regulatory authority FDA for the

Gastric pouch

Ring/Band

Stomach

Duodenum

Anastomosis

. Fig. 18.4 Bypass with ring reinforcement to prevent

dilatation

Alternative Techniques andMethods inObesity Therapy

190

treatment of obesity, patients with a BMI

between 35 and 45kg/m

achieved a 24% loss

of overweight after 18months.

The system consists of a pacemaker and

electrodes, which can often be implanted on

an outpatient basis. By stimulating or block-

ing bres of the vagus nerve, hunger and the

feeling of satiety can be modied. Restriction

or malabsorption play no role in this proce-

dure.

In a review by Cha etal. (2014), the results

of 31 studies on this subject are summarised

and analysed. Although the authors conclude

that electrical stimulation of the stomach can

be a successful therapy option, there are no

data for such a conclusion. For example, the

average weight loss is only small and therefore

the indication for patients with a very high

BMI is not given. In addition, most follow-up

intervals are short and no conclusions can be

drawn about the long-term effect. Therefore,

the future and more studies on this topic will

show if this cost-intensive procedure with a

rather low overweight loss can become estab-

lished.

18.7 Gastric Balloon

Another possible intervention for short-term

weight loss before a planned bariatric proce-

dure is the implantation of a gastric balloon.

During a gastroscopy, the balloon is inserted

in an empty state and then lled with up to

700 ml of uid (. Fig. 18.5). This results

in an indirect restriction with an increased

feeling of satiation, so that a weight reduc-

tion of approximately 20% of the overweight

can be achieved. After 6 months at the lat-

est, the stomach balloon must be removed

endoscopically. Usually, the patient regains

weight rapidly after removal of the gastric

balloon, so that the gastric balloon place-

ment as an isolated method does not lead to

good long-term results with regard to weight

loss. Furthermore, the costs of the implanta-

tion are usually not covered by the insurance

companies. Within the framework of a step-

by-step concept for the treatment of obesity,

however, the implantation of a gastric balloon

might be useful to enable selected high-risk

patients to undergo established bariatric sur-

gical procedures after weight loss.

18.8 AspireAssist™

Another experimental procedure is the

AspireAssist™. This is a type of PEG probe

that is inserted into the stomach during gas-

troscopy and the end of the probe is pulled

through the abdominal wall to the outside.

The patient then has the opportunity to suck

it out or drain it with a hand pump about

20min after a meal.

This system is indicated for patients with

a BMI between 35 and 55 kg/m

. Possible

acute complications correspond to those of

PEG- attachment (bleeding, malfunction, per-

foration, infection, dislocation). Results from

clinical studies are rare. In a publication by

Sullivan etal. (2013) 11 patients were treated

with this system as well as additive nutri-

tional counselling and lifestyle intervention.

No complications were documented within

2 years. The reduction of overweight was

about 50%. The application of this system

remains controversial for a variety of reasons.

. Fig. 18.5 Gastric balloon. The lling volumes of the

mostly water-lled balloons are 400–700 ml. The S3

guideline sees its importance especially for high-risk

patients (e.g. BMI>60kg/m

) within the framework of

a step-by-step concept. (From Wirth and Hauner 2013)

C. A. Jacobi

191

References

Celik A, Ugale S, Ouoglu H, et al (2015) Technical fea-

sibility and safety prole of laparoscopic diverted

sleeve gastrectomy with ileal transposition (DSIT).

Obes Surg. 25: 1184–90

Cha R, Marescaux J, Diana M (2014) Updates on gas-

tric electrical stimulation to treat obesity: systematic

review and future perspectives. World J Gastrointest

Endosc 6:419–431

Lemmens L, Karcz WK, Bukhari W, Fink J, Kuesters

S (2014) Banded gastric bypass—four years fol-

low up in a prospective multicenter analysis. www.

biomedcentral. com/1471- 2482/14/88

Sullivan S, Stein R, Jonnalagadda S, Mullady D, Edmun-

dowicz S (2013) Aspiration therapy leads to weight

loss in obese subjects: a pilot study. Gastroenterology

145:1245–1252

Wirth A, Hauner H (eds) (2013) Adipositas. Springer,

Berlin, Heidelberg

Index

Abuse of alcohol 150

Acute abdomen 122, 159

Adherence to aftercare 150

Adhesions 118, 159

Adjustable gastric banding 39

Aftercare intervals 148

Aftercare scheme 144

Alcohol abuse 21

Alcohol sensitivity 22, 146

Alimentary limb 109, 110

Alimentary loop 111, 112, 126, 134, 155

American position 71

Anaesthesiological care 84

Anaesthetic induction 88

Anastomosis 119–120

– insufciency 128

– ulcers 159

Anastomotic insufciencies 137

Anastomotic leak 151, 154

Anastomotic stenosis 155, 158

Angle of His 93, 107, 118

Angular incisure 118

Antibiotic therapy 151

Anti-Trendelenburg position 126, 134, 135

Anxiety disorders 20, 29, 63, 149, 150

Appendectomy 127, 136

Arterial hypertension 15

Bacterial overgrowth 160

Band failure 166

Band lling 95–96

Band leakage 166

Band migration 166

Band slippage 156, 166

Band-over-bypass 169

Bariatric surgery 37

Behavioural addictions 21

Benzodiazepines 82

Bile acid malabsorption 117

Bile acids 49

Bile reux 120

Biliary reux 121, 162

Biliopancreatic diversion 52, 65

– according to Scopinaro 41

– with duodenal switch 41–42

Biliopancreatic limb 109, 110

Biliopancreatic loop 112, 155

Binge-eating disorder 20

Bleeding after LAGB 153

Bleeding after LSG 154

Blind-loop syndrome 160

Body mass index (BMI) 3, 81

Body surface area (BSA) 81

Bolus obstruction 157

BPD according to Scopinaro/BPD with DS 66

Brown adipose tissue (BAT) 6

Bulimia nervosa 20

Burden of skin sagging 146

Bursa omentalis 107

Calibration balloon 94

Calibration tube 100, 111, 119, 120

Capnoperitoneum 75

Carcinoma risk 17

Cardiac output 80

Cardiopulmonary diseases 176

Cardiovascular complications 16

Cardiovascular system 86

Catabolic state 172

Catheter breakage 157

Central venous catheter 87

Certication 180

Choice of the surgical procedure 64

Cholecystectomy 127, 136, 160

Cholecystokinin 11, 45

Cholecystolithiasis 160

Classication of obesity 3

leakage 110

Comorbidities 172

Complications 121–122

Consent 66

Contraindication for bariatric surgery 63

Contraindications 58

Conversion surgery 121

Couple's relationship 150

Covered stents 153, 154

Cushing’s syndrome 9, 60

Daily energy intake 7

Deciency of micro- and macronutrients 160

Deciency symptoms 143

Degenerative joint disease 17

Dehydration 145

Depression 19, 29, 63, 149, 150

Diabetes mellitus type 1 145

Diabetes mellitus type 2 15, 65

Diaphragmatic hernia 118

Diarrhoea 146

Dietary complications 142

Dilation of the alimentary limb 169

Dissection 93, 99–100

Drug therapy 30–31

A–D

196

Dual-X-ray absorptiometry (DXA) 161

Dumping syndrome 117, 160

Duodenoileostomy 135–136

Duodenum transection 135

Dyslipidemia 15–16

Early complications after a sleeve gastrectomy 153–154

Early complications after gastric band implanta-

tion 153

Early complications after gastric bypass 154–156

Early dumping 160

Early surgical complications 151–156

Eating behaviour 13, 149

Eating behaviour rules after bariatric interventions 141

Eating disorders 20–21, 173

Edmonton obesity staging system (EOSS) 58, 86

Endobarrier® 187–188

Endoscopic balloon dilatation 158

Endoscopic dilatation 155

Energy gap 28

Entero-entero-anastomosis 152

Epidemic of obesity 3

Esophageal dilatation 157

Excess weight loss (EWL) 37

Exercise-related activity thermogenesis (EAT) 5

Fat-free body mass 82

Fistulas 158

Fixing the gastric band 94–95

Folic acid deciency 147

Food and eating habits 6–7

Food pyramid 143

Formation of gallstones 160

French position 70

Gallstone formation 127, 128

Gastric balloon 190

Gastric band 52

– migration 157

Gastric banding 66

– explantation 167

Gastric bypass 52, 65, 66

Gastric carcinoma 122

Gastric plication 186

Gastric pouch 120, 153

Gastric sleeve 121, 189

– with ileum interposition 188

Gastric stimulator 189–190

Gastric tube 120

– calibration 100

Gastroesophageal reux disease 17, 117, 167

Gastroileostomy 126, 127

Gastrojejunal anastomosis 109–111

Gastrojejunostomy 109, 112, 119

Genetic predisposition of obesity 8

Genetic testing 173

Ghrelin 10, 45

Glucagon 12–13, 47

Glucagon-like peptide 1 12, 46

Glucose metabolism 81

Gut-brain axis 9, 43

Hair loss 146

Hernias 93

Hiatal hernia 107

Hiatus hernia 127, 134

High risk patients 176

Honeymoon phase 145

Hospital equipment 181

Hyperinsulinemia 17

Hyperinsulinemic hypoglycemia syndrome 160

– after gastric bypass surgery 161

Hypothalamus 13

Hypothyroidism 9, 60

Hypovitaminosis B

147

Hypovitaminosis B

146

Hypovitaminosis D

146, 161

Ideal body weight (IBW) 82

Ileoileostomy 134

Improvement of comorbidities 121

Indications and contraindications 124, 132

Indications for bariatric surgery 38

Inhalation anaesthetics 83

Initial diet regimen after bariatric surgery 141–142

Initial dietary regimen 121

Insulin therapy 12, 47, 145

Interdisciplinary obesity centres 58

Internal aftercare 145–148

Internal evaluation 59–62

Internal hernias 120, 122, 126, 135, 152, 159

Internal herniations 112

Internet portals 182

Intestinal ora (microbiome) 47–49

Intestinal obstruction 159

Intra-abdominal bleeding 152

Intraluminal bleeding 152

Intubation 70, 80

Iron deciency 146

Jejunal loop 109

Jejunojejunostomy 111–112

Joint decision-making process 175

Laboratory diagnostics 148

Lactose intolerance 162

Index

197

D–P

Late complications after gastric band

implantation 156–157

Late complications after sleeve gastrectomy 157–158

Late dumping 160

Late surgical complications 156–160

Leak of bile 152

Leaks 158

– of the small intestine anastomosis 154

Leptin 12, 46

Leptin-melanocortin signalling pathway 8

Linear cutter 101, 107, 108, 111

Liraglutide 30

Liver cirrhosis 118

Liver disease 172

Liver retractor 125, 134, 135

Local anaesthetics 84

Long-term nutrition after bariatric surgery 142–143

Long-term results 121

Loss of control eating 149

Macro- and micronutrient deciencies 146

Maintenance of anaesthesia 88–89

Malabsorption 42, 44, 119, 134

Malabsorptive effect 117, 121

Malabsorptive procedure 128

Measurement of loop lengths 134

Measurement of the intestine 109

Measuring the bypass length 119

Mechanisms of action 42

Mental disorders 18, 64, 149

Mesenteric occlusion 122

Metabolic surgery 119

Metabolic syndrome 14–15

Metformin 30

Methylene blue solution 112

Microbiome of the intestine 43

Monogenetic forms of obesity 8

Morbidity 128, 137, 167, 172

Mortality rate 128, 137, 167, 172

Multimodal therapy 181

Multimodal therapy programmes 31

Muscle relaxants 83

Nesfatin-1 11, 45

Non-alcoholic steatohepatits 16

Non-exercise activity thermogenesis (NEAT) 5

Nucleus arcuatus 13

Nucleus paraventricularis 13

Nutrition therapy 26–28

Nutritional deciencies 61

Obesity and sleep-related breathing disorders 16

Obesity board 65, 180–181

Obesity surgery 38

Obsessive-compulsive disorders 21

Obstruction 152

Obstructive sleep apnea syndrome (OSAS) 80, 176

Omega loop bypass 66

Omega-loop gastric bypass 40

Omentum 120

One-anastomosis laparoscopic bypass 40–41

Operating room 70

Opioids 84

Oral antidiabetics 145

Orlistat 30

Osteoporosis 161–162

Over the scope clips (OTSC) 153, 158

Pancreatic stulas 137

Pancreatic polypeptide 11, 46

Partnerships 150

Patient’s cooperation 64

Peptide YY 11, 46

Perioperative antibiotic prophylaxis 73

Peritonitis 154

Personal relationships 150

Personality disorders 21

Petersen’s cleft 120

Petersen’s space 112, 156, 159

Phase of weight stagnation 148

Physical activity 7–8

Physical exercise 28–29

Pitfalls 96, 103, 112–113, 120–121, 127, 136

Placement of a ring or band 189

Placement of gastric band 93–94

Pneumoperitoneum 75–76, 118, 125, 133, 137

Polycystic ovary syndrome 17

Port system 156

Port-site infections 166

POSE procedure 187

Position of the surgical team 72–73

Positioning the patient 70–72

Postoperative bleeding 152

Post-operative bleeding after RYGB 155

Postoperative leak 151–152

Post-operative monitoring 89

Postoperative mortality 154

Postoperative obstruction 152–153

Postoperative thromboembolism prophylaxis 80

Postpyloric ileum interposition 188

Post-traumatic stress disorder (PTSD) 20

Pouch 94, 107–111, 119, 189

– anastomosis 152

– dilatation 156, 157, 169

Pre-medication rounds 85–86

Pre-medication visit 85

Preoperative laboratory diagnostics 61

Preoxygenation 88

Preparation of the anaesthesia 86–88

Pressure plate 110–111

Propofol 82

Proximal Roux-en-Y gastric bypass 40

Psychoeducation 29–30

Index

198

Psychosocial aspects of obesity 18–22

Psychosocial development 173

Psychosomatic aftercare 148–151

Psychosomatic evaluation 62–64

Psychotherapy 29–30

Pulmonary system 80–81

Pylorus 121

Quality of life 19, 121

Ramp position 85

Re-banding 167

Recurrence of addictions 150

Reux disease 157

Reux symptomatology 162

Regain of body weight 150

Regulation of hunger and satiety 9

Regurgitation 153

Relative blood volume 80

Remission of diabetes 52

Remission rates of type 2 diabetes 127, 136

Resection 101–102

Respiratory system 86

Restriction 42, 43, 134, 186

Revision surgery 166

Revision/redo procedure

– after gastric banding 166–167

– after gastric bypass surgery 168–169

– after sleeve gastrectomy 167–168

Roux-en-Y gastric bypass 121, 124

Secondary diseases of obesity 14–18

Secondary hyperparathyroidism 146, 161

Self-help groups (SHG) 151, 182

Shift of the Roux-en-Y- anastomosis 169

Single anastomosis duodenoileal bypass with sleeve

gastrectomy 134

Sleeve dilation 168

Sleeve gastrectomy 39, 52, 65, 66, 134

Small intestine anastomosis 126, 134–135

Social inequality 22

Somatostatin analogues 161

Staple line insufciency 102

Steatosis hepatis 16

Stenoses in gastrojejunostomy 158

Stenosis of the gastric sleeve 157

Stepwise approach 176

Stigmatisation 29

– of obese people 18–19

– of obesity 9

Stomach pouch size 169

Substance abuse 21

Suicide 22, 148, 150

Supplementation 143–144, 146

Surgery at older age 172

Surgery in childhood and

adolescence 172–176

Surgical aftercare 144–145

Surgical complications 145, 151–160

Surgical evaluation 58–59

Surgical oversewing 152, 158

Suture insufciencies 151, 153, 154

Symptom burden 146

Syndromic forms of obesity 8

Team time out 75

Tension-free anastomosis 120

Therapeutic goals 26, 37–38

Thiopental 82

30-day mortality rate 121

Thromboembolic prophylaxis 74

Total body weight (TBW) 81

Total energy expenditure 5

Transection of the stomach 126

Trocar placement 92, 98–99, 106, 118, 125–126,

133–134

Trocar site hernias 159

Two-stage concept 65

Vascular accesses 85, 87–88

Ventilation 89

Verres needle 118

Very low calorie diets 27

Volatile anaesthetics 83

Vomiting 147, 149, 155

Waist-to-hip ratio 3

Weight gain promoting drugs 9

Weight regain 148, 169

Wernicke-Korsakow syndrome 147

White adipose tissue 6

Width of the gastrojejunostomy 169

Index

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18.6 Gastric Stimulator

18.7 Gastric Balloon

18.8 AspireAssist™

References

Further Readings

Index