Professor Ralph Peterli grew up in Basel, Switzerland. During his senior year of high school, he was a foreign exchange student and sent to Phoenix, Arizona. Prof. Peterli quickly learned to appreciate the hospitality of the people and loved the beauty of the American Southwest. He went back to Phoenix every summer break during medical school, of which he graduated in Basel in 1986.
Prof. Peterli did his surgical training in Northwestern Switzerland. From the very beginning, he was interested in research and academics. He became a staff surgeon and later deputy head of a very active visceral surgery unit at St. Clara Hospital in Basel, a University affiliated private non-profit hospital. Since 1997 Professor Peterli has been head of the bariatric unit and teaching at the University of Basel. In 2008 he earned a research fellowship at the University of Lund, Sweden. In Switzerland, visceral surgeons do not subspecialize like they do in other countries. Therefore, he is as much a colorectal surgeon, general surgeon, and surgical oncologist, as he is a bariatric surgeon. From the beginning, Professor Peterli was interested in minimally invasive techniques and robotics. In 2019 the St. Clara Hospital merged with the University Hospital of Basel to become Clarunis, University Centre for Gastrointestinal and Liver Diseases: an interdisciplinary academic unit in which gastroenterologists and visceral surgeons work together on the same team. Prof. Peterli is currently the deputy head of the visceral surgical department and head of visceral surgery research and the bariatric unit.
Prof. Peterli was among the pioneers to develop the operative technique of the laparoscopic gastric banding operation including the perioperative management in Switzerland. During the last 25 years, he initiated a number of prospective and retrospective trials aimed at improving therapeutic strategies to surgically treat patients with severe obesity. It was not the number of patients operated on but the high follow-up rate reaching up to 98% at 5 years that gave his work international notoriety. This extremely high follow-up rate is partly due to the health care system in Switzerland paying for outpatient visits but also due to the disciplined nature of the Swiss resulting in high compliance and adherence. Professor Peterli’s team searched for predictors of outcome to better allocate the right patient to the different surgical options. They developed a unique staged therapeutic concept of primary gastric banding followed by biliopancreatic diversion/duodenal switch for the non-responders to banding. The concept had to be abandoned due to the better overall results seen with the laparoscopic gastric bypass and sleeve gastrectomy as primary bariatric interventions. He always wanted to work on interdisciplinary and inter-professional teams that met at eye level to develop management strategies for preoperative selection and preparation of patients as well as follow-up algorithm.
Prof. Peterli is an internationally known and respected expert in the field of bariatric and metabolic surgery as well as in metabolic research. At Clarunis in Basel, he has trained many Swiss bariatric surgeons, and for many years he has hosted national and international workshops on bariatric surgery with hands-on courses on standard procedures and revision surgery. He is also a highly regarded invited lecturer or chair of many scientific sessions.
As a researcher, Professor Peterli built a strong local, national, and international scientific network including a number of translational research projects together with his wife, Professor Bettina Wölnerhanssen. To better understand the weight loss independent mechanisms of bariatric operations, they and their collaborators looked into gut hormone profiles influencing satiety, adipokines and bile acids, food preference (functional MRI), microbiome, metabolomics, and pre- and postoperatively comparing gastric bypass with sleeve gastrectomy. They looked into regulatory factors of the gut mucosa in the development of enterohumoral cells of the upper gastro-intestinal tract comparing lean patients and patients with severe obesity before and after surgery. In addition, they established a murine model of different metabolic operations and have ongoing projects in the search of potential targets to improve the results of surgery pharmacologically. Bariatric and metabolic operations are an excellent in vivo model to study the pathophysiology of obesity and related co-morbidities, such as type 2 diabetes. He has several projects underway aimed at finding the interaction of glucose metabolism and fat tissue inflammation, searching for the role of melanocortin receptors and their precursors in adipose tissue as well as the markers of inflammation, macrophages in adipose tissue, and adipocytes. They looked into proteomics of adipocyte mitochondria in obese, diabetic patients, and lean controls. Recently they were able to challenge the paradigm that obesity leads to fat tissue inflammation and thereafter to insulin resistance: the loss of insulin/target of rapamycin (mTORC2) signaling seems to first lead to insulin resistance followed by inflammation.
Prof. Peterli is president of the Swiss Society for the Study of Morbid Obesity and Metabolic disorders (SMOB) and scientific co-chair and board member of the European Chapter of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO-EC).
Giving a Masterclass in Revisional Bariatric Surgery is not easy, mostly because there is so much to say that it would take many hours to do it. I’ve decided to simplify this theme and approach the most commonly performed procedures – Sleeve Gastrectomy (SG) and Roux-en-Y Gastric Bypass (RYGB): when to revise them and when not to. Bariatric surgery complications can be divided into early and late complications. Late complications include Weight Regain/Insufficient Weight Loss. Early Morbidity SG Early dysphagia is a rare complication of SG. It is usually caused by swallowing and usually can be treated conservatively. Leaks occur at the staple line, most commonly at the level of the angle of His. It has a prevalence of 0 to 11% and can be acute, early, late or chronic. Early management may involve drainage, endoscopic closure (stent, endo-sponge, overstitch, etc.), parenteral nutrition and dilatation of the pylorus. Eighty to ninety percent of leaks resolve in 4-6 weeks. If conservative treatment fails, surgery is the next step. Bleeding is a rare complication and, just like leaks, it occurs in the staple line. It should not happen in more than 1% of the procedures and treatment through conservative approach to re-laparoscopy. RYGB Bleeding can happen in the first days after surgery. Prevalence is supposed to be below 2.2%. Tachycardia is the main clinical sign. A CT scan provides diagnosis and helps in the evaluation of hemoperitoneum in stable patients. In cases of endoluminal bleeding, endoscopy is not only diagnostic, but also therapeutic. Stricture may happen days to weeks after surgery. It is exceedingly rare with linear anastomosis and more frequent with circular ones. Initial approach may also be conservative. Obstruction may be an acute or late complication. Clinical presentation depends on the level of obstruction. In patients with obstruction affecting the BP limb, the most pathognomonic sign is extreme nausea without vomiting. Leaks are relatively rare in RYGB. Diagnosis is confirmed by CT scan and endoscopy and is guided by clinical presentation. Treatment is not always surgical. Late Morbidity SG GERD is a very prevalent complication of SG. Endoscopy and manometry are important parts of the diagnosis and PPI is the primary treatment. Chronic stenosis may occur in 0.1 to 3.5% of patients. The cause may be a too narrow sleeve, a torsion, or a hypertrophy of the pylorus. Treatment may be endoscopic or surgical. RYGB Internal Hernia manifests as postprandial pain, avoidance of food intake, pain, and typical symptoms of small bowel obstruction. Treatment is surgical and usually entails closure of mesenteric defects. Excessive weight loss has a prevalence of 1.4% in patients submitted toRYGB. Patients should be offered the option of reversal before deficiencies and other manifestations of excessive weight loss occur. Insufficient Weight Loss/Weight Regain Obesity is a chronic disease and, as such, relapsing may occur. Insufficient weight loss may refer to a patient who does not reach the ideal weight goal, or a patient who loses weight and then regains it. The definition is not solid and is a topic for a whole debate. The key concept to keep in mind regarding the approach to these patients is that it is multidisciplinary. Every aspect of the previous procedure and patient must be analyzed and evaluated. Treatment can be conservative or surgical. Surgical treatment will depend on the index procedure and cause of failure. Many of the complications of BS can be treated conservatively. It is important to perform an accurate diagnosis, to evaluate the patient in a multidisciplinary setting, and to refrain from unnecessary interventions. Endorsed by: [Image]
With Johnson & Johnson MedTech
Published
Apr 2021
The last 30 years have brought a dramatic increase in obesity worldwide. Bariatric surgery is currently the only efficient treatment option leading to sustainable weight loss and a reduction in comorbidities in morbidly obese patients. Therefore, there has been a continuously rapid growth in the number of bariatric interventions. There are a multitude of different surgical procedures and each procedure has its own profile of advantages and disadvantages. So far there is no clear consensus on which procedure should be applied in each case. Laparoscopic gastric banding temporarily gained popularity due to its easy application and reversibility. In the meantime, an increasing number of trials have shown the considerable drawbacks of this procedure (low level of efficiency combined with poor quality of life and a high reoperation rate), and this procedure has more or less been abandoned in Europe. Until recently, the Roux-en-Y gastric bypass was regarded as the standard bariatric procedure. However, the sleeve gastrectomy is being performed with increasing frequency despite a lack of evidence regarding its long-term efficacy. The sleeve gastrectomy procedure is technically easier, faster to perform, and potentially safer compared to the Roux-en-Y gastric bypass. However, much more data on clinical and metabolic long-term outcomes is available on the Roux-en-Y gastric bypass procedure. The early and midterm results of sleeve gastrectomy showed potential benefit, but only a limited number of randomized studies have compared the outcomes of the sleeve gastrectomy and the Roux-en-Y gastric bypass head to head, most of which were underpowered because of low patient numbers, short follow-up, or both. In this lecture, Professor Ralph Peterli, explains the results of the SM-BOSS Randomized Clinical Trial that compares differences between the sleeve gastrectomy and the Roux-en-Y gastric bypass in the treatment of morbid obesity in terms of weight loss, changes in comorbidities, quality of life, and adverse events.
With International Federation for the Surgery and Other Therapies for Obesity
Published
Nov 2018
Clinical Case Early- and mid-term results of the SM-BOSS had previously been published in Annals of Surgery in 2013 and 2017 respectively, where it was concluded that sleeve was faster with equal weight loss, complications, quality of life and improvement of co-morbidities than bypass, except for gastroesophageal reflux disease GERD and dyslipidemia. At the 5-year point, 101 sleeve gastrectomy were compared to 104 gastric bypass. Sleeve patients had less weight loss when compared to the bypass. Differences in diabetes remission, complications, and quality of life were not statistically significant, although GERD and dyslipidemia leaned in favor of the bypass. In conclusion, bypass seems to better for long-term weight loss and metabolic effect and is still considered the gold standard by Dr. Peterli, and sleeve is definitely an excellent option for a 2-step treatment.
Published
Nov 2017
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