Patient selection and choosing the optional procedure in bariatric surgery A.R khalaj M.D Minimal Invasive Surgery Research Center university of Iran

The rational for weight loss surgery 70% of diabets risk can be attributed to obesity Prevalene of hypertention in BMI>30 Men:41.9% women:37.8% prevalence of cholesterol in BMI >30 Men:22% women:27% mortality in BMI > % Medical treatment for obesity is met with discouraging results 95% regain in 2 years

Indications of bariatric surgery Be well-informed and motivated Have a BMI >40 Have acceptable risk for surgery Have failed previous non-surgical weight loss The NIH also suggested that adults with a BMI >35 who have serious comorbidities such as diabetes, sleep apnea, obesity-related cardiomyopathy, or severe joint disease may also be candidates

Contraindications to bariatric surgery untreated major depression or psychosis, binge eating disorders, current drug and alcohol abuse, severe cardiac disease with prohibitive anesthetic risks severe coagulopathy inability to comply with nutritional requirements including life-long vitamin replacement Bariatric surgery in advanced (above 65) or very young age (under 18) is controversial.

Evaluation of obese patient for bariatric Is he or she well informed and motivated? Dose this patient have any contraindications to weight loss surgery? Will this patient be able to tolerate general anesthesia? Are there any medical conditions that would make one operation better suited? Will this patient be able to tolerate the most common complications? What is dietary history of the patient? Is psychologic evaluation important?

Buchwald algorithm for patient selection There is no gold standard operation. A surgeon should be able to perform more than one operation. Patient can be matched to a specific procedure

Operation of choice for a patient : Patients dietary and psychology history Medical and surgical history Surgeon experience Patient comfort and expectation Ability of medical facility to handle most known complications

Roux-en-Y gastric bypass (RYGB)

Gastric bypass Best candidates: Diabetics BMI<50 Single Bad candidates : Noncompliance Who must take NSAID High risk for gastric pathology

Laparoscopic adjustable gastric band (LAGB)

Gastric band Best candidates: High risk patients Extremes of age Prior abdominal operations IBD Whom cannot tolerate malabsorbtion Bad candidates: Not able to participate in follow-up Hiatal hernia Super morbid obese Unwilling to make lifestyle change

Biliopancreatic diversion

Biliopancreatic diversion with duodenal switch

BPD/DS Best candidates: BMI>50 High risk for Gastric pathology Bad candidates: High operative risk Noncompliant