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Bariatric Surgery/ Surgery for Obesity

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  2. 2.  Obesity is defined as abnormal or excessive fat accumulation that may impair health.  Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults.  Defined as a person's weight in kilograms divided by the square of his height in meters (kg/m2).  The WHO definition is: a) a BMI greater than or equal to 25 is overweight. b) a BMI greater than or equal to 30 is obesity. What is Obesity?
  3. 3. What Is Morbid Obesity?  Clinically severe obesity at which point serious medical conditions occur as a direct result of the obesity  Defined as, >100 lb above ideal body weight, >200% of ideal weight, twice ideal body weight or a Body mass index of 40 kg/m2.
  4. 4. Prevalence of Obesity  Data from NHANES shows that the percentage of the American adult population with obesity (BMI >30) has increased from 14.5% (between 1976 and 1980) to 33.9% (between 2007 and 2008).  Extreme obesity (BMI 40) has also increased and affects 5.7% of the population.  Obesity is more common among women, poor and among blacks and Hispanics.  Obesity is estimated to cause 3,00,000 deaths annually in the U.S.  As per WHO’s The World health statistics 2012 report, one in six adults obese, one in 10 diabetic and one in three has raised blood pressure  Obesity has reached epidemic proportions in India in the 21st century, with morbid obesity affecting 5% of the country's population
  5. 5. Etiology of Obesity  Debate is ongoing regarding the relative Genetic Vs Environmental components of the disease.  Clear familial predisposition.  Specific Genes: Hundreds of genetic loci have been associated experimentally to obesity in the so-called Human Obesity Gene Map 1) FTO-Fat mass and Obesity-related gene 2) MC4R-Melanocortin 4 receptor gene Associated with obesity, increased fat mass and insulin resistance.  Thrifty Gene Hypothesis: During human development, thrifty gene allowed for more efficient absorption and use of the calories ingested. However, in modern society ,it helps increase the intake of calories in excess of metabolic needs. Role of genes versus environment
  6. 6. Central Controllers Of Appetite
  7. 7. Pathophysiology Of Obesity  Obesity can result from increased energy intake, decreased energy expenditure, or a combination of the two  The severely obese individual has, in general, persistent hunger that is not satiated by amounts of food that satisfy the non-obese.  This lack of satiety or maintenance of satiety may be the single most important factor in the process.  Nutrient ingestion into the stomach or proximal intestine elicits hormonal signals that release neuropeptides, which in turn alter body metabolism.  Hormones:  Leptin and Ghrelin are appetite stimulant, orexigenic.  Insulin and Cholecystokinin are anorexic.
  8. 8. Specific Syndromes Associated With Obesity  Cushing's syndrome  Hypothyroidism  Insulinoma  Craniopharyngioma and other disorders involving the hypothalamus
  9. 9. Classification of Obesity by BMI
  10. 10. Classification of Weight Status and Risk of Disease
  11. 11. Obesity grading and assessment in Western and Asian Population BMI Average Overweight Obese Morbidly Obese Western 20-24.9 25-29.9 30-40 >40 Asian 18-22.9 23-27.7 27.5-37.4 >37.5
  12. 12. Obesity Related Co-Morbidities Co-Morbidity ◦ Diabetes ◦ Hypertension ◦ Hyperlipidemia ◦ Cardiac disease ◦ Respiratory disease ◦ Obstructive sleep apnea ◦ Arthritis ◦ Depression ◦ Stress Incontinence ◦ Joint problems Occurrence in the Obese ◦ 14–20% ◦ 25–55% ◦ 35–53% ◦ 10–15% ◦ 10–20% ◦ 20–25% ◦ 70–90%  50%  50%
  13. 13. Medical Conditions Associated With Severe Obesity
  14. 14. Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Coronary heart disease Diabetes Dyslipidemia Hypertension Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Skin Gall bladder disease Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis Gout Medical Complications of Obesity Idiopathic intracranial hypertension Stroke Cataracts Severe pancreatitis
  16. 16. Guidelines for the Treatment of Overweight and Obese Individuals
  17. 17. Pharmacologic Therapy  Pharmacotherapy is normally used only after lifestyle changes and dietary therapies have failed.  Centrally Acting Anorexiant Medications  Sibutramine: Blocks presynaptic receptor uptake of norepinephrine and serotonin, thereby potentiating their anorexic effect in the central nervous system  Peripherally Acting Medications  Orlistat: Inhibits pancreatic lipase and thereby reduces absorption of up to 30% of ingested dietary fat.
  18. 18. Pharmacologic Therapy Antiobesity Drugs in Development: completed phase III trials  Bupropion and naltrexone (Contrave)  Bupropion with zonisamide (Empatic)  Phentermine and topiramate (Qnexa) • Drawbacks: • A maximum weight loss of up to 10% is seen. • However, weight is regained within 12-18 months.
  19. 19. • Bariatrics is the branch of medicine that deals with the causes, prevention, and treatment of obesity. • The word “bariatrics” was coined in 1965 from a German word that translates to English as “large.” • Bariatric surgery is the surgical discipline dealing with management of morbid obesity. • NIH-Bariatric Surgery is permanent treatment of choice. Surgical Treatment of Obesity
  20. 20. Metabolic Surgery  Bariatric surgery is also metabolic surgery, treating the varied metabolic consequences of the comorbid diseases arising from severe obesity.  Example: Gastric bypass for Type 2 Diabetes Mellitus.
  21. 21. History of Bariatric Surgery  Obesity surgery is not a new discipline.  The earliest Bariatric procedure performed was in 1954 at Minnesota. The procedure was Jejuno-ileal bypass.  In 1966,Gastric Bypass was introduced as a surgical procedure for weight loss at the University of Iowa.  In 1977,Griffen reported the first Roux-en-Y Gastric Bypass.  In 1980,surgeons with a more conservative approach developed the Vertical Banded Gastroplasty.  Other procedures with longer intestinal segment bypass were also introduced such as Biliopancreatic Diversions. These complex procedures are recommended in super-obese patients, i.e. BMI>60.
  23. 23. Indications For Bariatric Surgery
  24. 24. Recommended BMI values for Bariatric Surgery in Asians BMI ≥ 37.5 BMI ≥ 32.5 with two associated co- morbidities.
  25. 25. Bariatric surgery carries the potential for serious complications, morbidity and possibly mortality. 1. Severe medical disease that makes anaesthesia or prohibitively risky(ASA Class IV) 2. Surgery is contraindicated in patients who are unable to ambulate. 3. Pradder-Willi Syndrome is an absolute contraindication. 4. Cardiac complications with poor myocardial reserve. 5. Chronic obstructive airways disease or respiratory dysfunction. 6. Significant psychological disorders, or significant eating disorders. 7. Patients weighing more than 500 lb are at increased risk for mortality. 8. Age is a controversial contraindication to Bariatric surgery Contraindications to Bariatric Surgery
  26. 26. Bariatric OperationsMechanism of Action  Restrictive 1. Vertical banded gastroplasty (VBG; historic purposes only) 2. Laparoscopic adjustable gastric banding (AGB) 3. Laparoscopic sleeve gastrectomy (LSG)  Largely Restrictive, Mildly Malabsorptive Roux-en-Y gastric bypass (RYGB)  Largely Malabsorptive, Mildly Restrictive Biliopancreatic diversion (BPD) Duodenal switch (DS)
  27. 27. Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc & a degree of outlet obstruction leading to delayed gastric emptying. The goal is to reduce oral intake by limiting gastric volume, produce early satiety, and leave the alimentary canal in continuity, minimizing the risks of metabolic complications 1.VERTICAL BANDED GASTROPLASTY 2.ADJUSTABLE GASTRIC BANDING (LAGB ) 3. SLEEVE GASTRECTOMY 4.GASTRIC PLICATION 5. INTRA GASTRIC BALLOON (GASTRIC BALLOON) RESTRICTIVE PROCEDURES:
  28. 28. Malabsorption is achieved by creating a short gut syndrome and/or by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption.. Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies. 1. BILIOPANCREATIC DIVERSION 2. THE JEJUNAL-ILEAL BYPASS 3. ENDOLUMINAL SLEEVE MALABSORPTIVE PROCEDURES
  29. 29. MIXED PROCEDURES 1.GASTRIC BYPASS ROUX-EN-Y ( RYGBP) 2.SLEEVE GASTRECTOMY WITH DUODENAL SWITCH 3.IMPLANTABLE GASTRIC STIMULATION The following procedures combine restrictive and malabsorptive approaches. By adding malabsorption, food is delayed in mixing with bile and pancreatic juices that aid in the absorption of nutrients. The result is an early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat.
  30. 30. The stomach is partitioned along its axis with a non- adjustable poly-urethane band and with linear & circular staples to create a small upper stomach pouch with a restrictive orifice to the rest of the stomach. No malabsorption of micro or macro nutrients is expected. No longer done was practiced in 1980. Vertical Banded Gastroplasty (VBG)
  31. 31. ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY/ LAGB) Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993. An inflatable silicone BAND is placed around the top portion of the stomach, to form a small stomach pouch & sewed . This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL – PORT). During follow up visits, we inject or remove saline solution to make the band tighter or looser.
  32. 32. Adjustable Gastric Band • Induces weight-loss in 3 ways: 1. The small stomach pouch causes a sensation of fullness 2. Squeezing of the stomach pouch like an hour glass prolongs the sensation of fullness. 3. Suppresses appetite by central action.
  33. 33. Complications of Gastric Lap-Band • Perforation of Stomach • Slippage • Gastric Erosion(much less after Pars flaccida technique) • Dilated Esophagus • Tubing / access port problems • Mal positioning • Abdominal Pain • Heartburn • Vomiting • Inability to Adjust the Band • Failure to Lose Weight • Infection of System • Fatigue or malfunction
  34. 34. Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty Laparoscopic adjustable gastric banding  Reversible  Adjustable  Simpler to perform laparoscopically  Sustained weight loss of >50% EBW >5 years following surgery  Complications: Gastric prolapse, band erosion, rarely gastric perforation and access port complications. Vertical banded gastroplasty  Irreversible  Non adjustable  Technically difficult by laparoscopy  Weight loss of 25-50% EBW and weight gain after 2-3 years  Complications: suture line disruption, gastric leak, weight gain.
  35. 35.  Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients.  The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55% of excess body weight past 5 years in some patients.  The sleeve gastrectomy is also known as the greater curvature gastrectomy, vertical or longitudinal gastrectomy or Pylorus preserving „gastric tube creation‟.  Rapid and less traumatic operation  Good resolution of co-morbidities and good weight loss.  A further second surgical step is then easily feasible, if necessary. SLEEVE GASTRECTOMY
  36. 36. SLEEVE GASTRECTOMY  A sleeve gastrectomy involves resection of approximately 80% of the greater curvature side of the stomach.  Smaller tubular gastric “sleeve” created along the lesser curve that is based on the lesser curvature blood supply.  Ideal approximate capacity of the stomach after the procedure is about 30- 60 ml pouch
  37. 37. 
 1.MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility. Also called „Food limiting‟ operation. 2.HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue. (Ghrelin is a 28 amino-acid-peptide, secreted by the oxyntic glands of the gastric fungus. It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area.) The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum. In the SG, resection of the fundus removes the major portion of ghrelin release, therefore, appetite decreases. The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms:
  38. 38. Intragastric balloon involves placing a deflated balloon into the stomach, and then filling it to decrease the amount of gastric space. The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5– 9 BMI over half a year. Done endoscopically The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure. INTRA GASTRIC BALLOON
  39. 39.  The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery.  It‟s designed to work by inserting a flexible tube-like barrier into the duodenum & prox. Jejunum..  The barrier is placed endoscopically via the mouth and thus helps patients to loose weight by delaying digestion.  .Has to be removed after 6 months ENDO BARRIER LINER SYSTEM
  40. 40. B. MAL- ABSORPTIVE PROCEDURES Malabsorptive surgeries rearrange and/or remove part of digestive system which then limits the amount of calories and nutrients that body can absorb. Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates. 1.JEJUNAL ILEAL BYPASS – no longer performed for high complication rates. 2.ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders.
  41. 41. C. COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE 1.LAP. GASTRIC BYPASS – ROUX-EN- Y – more malabsorption than the restrictive 2.MINI- GASTRIC BYPASS- mainly restrictive 3.DUODENAL SWITCH – the sleeve stomach is the restrictive portion &the intestinal bypass (duodenal switch) is the malabsorptive component When surgery combines both restrictive and malabsorptive techniques, it is know as a “combination” procedure. Most types of bariatric surgery carry at least a small element of both components, but the following surgeries achieve a notable portion of weight loss from each…
  42. 42. 1. LAP. GASTRIC BYPASS/ LGB The Roux-en-Y gastric bypass (known simply as the LRYGBP) is the most commonly performed procedure. It primarily causes weight loss by restricting the food intake, however there is more amount of mal absorption that occurs with this operation.
  43. 43. GASTRIC BYPASS/ LRYGBP •The stomach is stapled into2 pieces, one small and one large. The small piece becomes the “new” stomach pouch. • The larger portion of the stomach stays in place, however will lie dormant for the remainder of the patient‟s life.
  44. 44. GASTRIC BYPASS/ LGB • The small intestine (the jejunum) is divided using a surgical stapler Approx. 50-70 cm from the DJ Junction.
  45. 45. GASTRIC BYPASS/ LGB Y- LIMB/ BP LIMB • The end of the Roux limb is then attached to the newly formed stomach pouch . • The Roux limb carries food to the distal intestine. • The Y limb or BPD limb carries digestive juices from the pancreas, gall bladder, liver and duodenum to the intestines • The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-170 cm from DJ Roux limb or alimentary limb 100-150 cm
  46. 46. 1. Most commonly performed. 2. Most reliable operation for long term weight loss. 3. Long term weight loss averages 60 to 75 percent of EBW. 6. Malnutrition is unusual. 7. Substantial improvement & resolution in many co-morbid obesity conditions:  Type 2 DM – 90% 
  Sleep apnea -90%
  Hypertension-70%
  Hyperlipidaemia-70%
  Heartburn from GERD- all patients.
  Urinary stress incontinence-75%  89% reduction in mortality over 5 yrs. Following surgery, compared to non-surgically treated group. ADVANTAGES OF RYGBP
  47. 47. 1. Not reversible. 2. Mortality 0.5- 1% 3. Perioperative complications 5-10% 4. Stricture of gastrojejunostomy.-10% (long term) 5. Long term risk of protein & vitamin deficiency, and marginal ulceration of GJA. 6.Long term risk of intestinal obstruction – 2%. LAPAROSCOPIC GASTRIC BYPASS COMPLICATIONS
  48. 48. Biliopancreatic Diversion (BPD)  Primarily malabsorptive but restrictive component also.  The alimentary tract beyond the proximal part of stomach is rearranged to include only distal 200 cm of ileum including common channel  Common channel-Distal 50 cm of terminal ileum for absorption of fat and protein.  The proximal end of ileum anastomosed to proximal end of stomach after performing distal hemigastrectomy.
  49. 49. Biliopancreatic Diversion with Duodenal Switch  Modification to lessen high incidence of marginal ulcer after BPD.  This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm).  The distal duodenum and jejunum, the biliopancreatic limb, are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm).  Common channel is 100cm  Entire alimentary tract is 250 cm.  This is the most aggressive bypass procedure commonly offered today.  Major difference-Sleeve gastrectomy instead of distal hemigastrectomy.
  50. 50. Post-surgical Complications  Anastomosis leaks or staple line leaks  Pulmonary Embolism or DVT  Cholelithiasis  Stomal ulceration  Dumping syndrome  Constipation
  51. 51. Nutritional Consequences  Iron deficiency anemia  B12 deficiency  Folate deficiency  Calcium and Vitamin D deficiency  Not seen with purely restrictive surgeries
  52. 52. • Bariatric surgery ameliorates metabolic abnormalities. • BMI and excess body weight decreases substantially after surgery . • Marked improvement is noted in glucose abnormalities, dyslipidemia and hypertension. • Improvement of DM II @ 2YR follow up after surgery is proportional to weight loss. • Fasting glucose and insulin resistance measured by (HOMA-IR i.e.; HOMEOSTASIS MODEL ASSESMENT INSULIN RESISTANCE) can decrease > 50% within 1 month of surgery. • Whereas INSULIN SENSITIVITY measured by the euglycemic –hyper insulinemic clamp does not change as quickly. • Hypertension – 75% saw improvement, in 50% there was complete resolution. METABOLIC IMPROVEMENTS AFTER BARIATRIC SURGERY
  53. 53. • Most women regained normal menstrual function and most had documented spontaneous ovulation. • Significant improvement in hirsutism, androgen profiles and about a 50% reduction in HOMA-IR. • Follow up for more than 2 years showed that all women resumed normal menstrual cycles, HbA1C decreased from 8.2% to 5.1% in < 3 months. • 78% saw improvement in metabolic syndrome & 48% showed improvement in PCOS . 2. ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS
  54. 54. Key features of polycystic ovarian syndrome and improvements seen after bariatric surgery. BMI: Body mass index. COMPLEX DISORDER
  55. 55. • 35% reduction in BMI and resolution of hypertension. • BMI decreases by more than 10 units • Reduction in glucose abnormalities > 80% • Excess weight loss > 80% • Reduction in Metabolic Syndrome • Improved Insulin Sensivity. 3. BARIATRIC SURGERY IN ADOLESCENTS
  56. 56. • Decrease menstrual irregularities. • PCOS women have less hyper androgenism • Sex hormone binding globulin increases • LH and FSH levels have been reported to increase • Ovulatory function measured by luteal LH and Progesterone secretion improved . • Leptin levels decrease , reflecting improved reproductive metabolic status. • Subclinical hypothyroidism significantly reduced. THE SAFE TIMING OF PREGNANCY optimal or minimal time: >12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside. 4. BARIATRIC SURGERY IN REPRODUCTIVE WOMEN:
  57. 57. Bariatric surgery represents the main option for substantial and long-term weight loss in morbidly obese subjects.. Two hypotheses have been proposed to explain the early effects of bariatric surgery on diabetes-- The Hindgut hypothesis theory- Diabetes control results from the more rapid delivery of nutrients to the distal small intestine, thereby enhancing the release of hormones such as glucagon-like peptide-1 (GLP-1). The foregut hypothesis theory – Exclusion of the proximal small intestine reduces or suppresses the secretion of anti-incretin hormones, leading to improvement of blood glucose control as a consequence increases GLP-1 plasma levels which stimulate beta cells to produce insulin secretion and suppress glucagon secretion, thereby improving glucose metabolism. Effect of Bariatric Surgery on Diabetes Mellitus
  58. 58. SUMMARY OF ALL TYPES OF SURGERY • LRYGBP – worlds best procedure, 60-70% WL, dumping syndrome, malnutrition. • LAGB- low complications, varying range of wt. loss, frequent post-op visits ( 10) • DS/BPD- more wt. loss , high complications, good for high BMI > 50, malabsorption + • VBG – longest available results, good wt. loss, improved co-morbidities, right for some pts.risks too high to justify rewards • SG- needs long term research, 1st step procedure, low risks, higher wt. loss, pouch could Stretch over time, long staple line could cause problems in future.
  60. 60. Success of Surgical Treatment ASBS 2000
  61. 61. Thank You