**7. Indications and contraindications**

The National Institute of Health (NIH) Consensus Conference in 1991 established the indications in performing bariatric surgery, at the height of the obesity epidemic. Since then, a few modifications were made differing from country to country. The National Institute of Health and Care Excellence (NICE) in UK, as well as the Asian Pacific Metabolic and Bariatric Surgery Society (APMBSS), extended the indications further in relation to presence of other co-morbidities and adjusted the BMI threshold in accordance to inherent differences in body composition [34, 35]. In 2016, the 2nd Diabetes Surgery Summit convened with leading international diabetes organizations and developed new recommendations for metabolic surgery with a lower BMI threshold for Asians due to the higher risk for diabetes despite lower BMI values [36, 37] (**Table 1**).

Contraindications to bariatric surgery include physiological, medical and surgical, and psychological factors; few are considered to be absolute contraindications (**Table 2**).

Physiological factors include age and BMI. Initial NIH guidelines have limited surgery to 18-65 years of age, but recent studies have shown that bariatric surgery is considered safe for the elderly population [38–41]. There are limited well-designed prospective studies on bariatric surgery for children and adolescents, and an important factor to take into consideration is the psychological maturity required in accepting the lifestyle changes accompanying surgical intervention.

Obstructive sleep apnea, diabetes, hypertension and cardiovascular problems are some of the health conditions that should be screened and controlled preoperatively prior to contemplating bariatric surgery. Previous abdominal surgery including abdominal wall hernias would influence practicality and applicability of any laparoscopic approach [4].


*i BMI criteria is decreased by 2.5 for Asians.*

*\*Bariatric surgery can be considered in BMI 30-34.9 with new onset diabetes.*

*\*\*Presence of diabetes or two other obesity-related co-morbidities.*

*\*\*\*Inadequately controlled hyperglycemia despite lifestyle and optimal medical therapy.*

*\*\*\*\*Inadequately controlled hyperglycemia despite optimal medical treatment.*

#### **Table 1.**

*Indications for bariatric surgery.*


#### **Table 2.**

*Contraindications for bariatric surgery.*

Active psychiatric disease and psychological instability are absolute contraindications; while poorly controlled eating disorders being a negative predictor of post-operative weight loss, is a relative contraindication [42, 43]. Smoking has been associated with development of post-operative marginal ulceration after gastric bypass, increased risk of poor wound healing and impaired health, and should be stopped at least 6 weeks before surgery [4, 44].

#### **7.1 Selection of sleeve-plus procedure**

The SGDJB and SGPJB are both relatively more recent than the RYGB and the data is still too young to provide specific indications for either procedures. Both patient and surgical factors must be considered when choosing the appropriate procedure for a safe outcome with optimal weight loss and resolution of co-morbidities. Any contraindications to SG obviously preclude both SGDJB and SGPJB such as severe gastroesophageal reflux disease and Barrett's esophagus.

All patients who are suitable candidates for SG may benefit from an additional bypass component if the BMI and diabetic history are considered. Higher BMIs such as 45 or more may benefit from a malabsorptive component but also reflect thicker visceral fat. This may pose difficulties during duodenal dissection for SGDJB. Hence, SGPJB may be a safer and easier option. Patients with long standing diabetes may also benefit from a bypass component because of the additional incretin response. Those with poorer glycemic control due to a more decompensated

#### *Sleeve-Plus Procedures in Asia: Duodenojejunal Bypass and Proximal Jejunal Bypass DOI: http://dx.doi.org/10.5772/intechopen.96042*

pancreas may consider SGDJB over SGPJB due to the combined glycemic effects from the foregut and hindgut theory. However, SGDJB is a challenging procedure and requires a more experienced surgeon's skill set.

Intraoperative findings may also influence the choice of procedure. Any evidence of vascular perfusion concerns on otherwise normal tissues may hint potential anastomotic problems. An SGPJB may be a more practical option, as the leaks from jejuno-jejunal anastomosis is easier to manage than leaks from a duodenojejunal anastomosis. The patient's current medical condition must also be considered. Severe co-morbidities such as cardiac issues may preclude contemplation for SGDJB as this requires a longer operative time compared to SGPJB.

Each surgery has its own advantages and disadvantages. However, a safe outcome is still the most important factor to consider when choosing not only between sleeve-plus procedures, but for any type of bariatric surgery.
