2. What is OBESITY
Obesity is a medical condition in which
excess body fat has accumulated to the
extent that it may have a negative effect
on health.
6. ( Klok MD, et al. The role of leptin and ghrelin in the regulation of
food intake and body weight in humans, 2007)
7. Ghrelin is a 28 a.a. peptide ligand for the growth hormone
secretagogue (GHS) receptor
Ghrelin-containing cells are of two types:
One is open to the lumen of the stomach
The second, closed type, is not open to the lumen of the gut,
but rather lies in the capillary network of the lamina propria
fasting plasma levels about 550 to 650 pg/mL
Circulating levels about 200 to 350 pg/mL
11. Weight Related Health Indicators (WRHI)
Body Mass Index (in Children/Adolescents BMI for Age/Z Score)
using measured height and weight
The measurement of height and weight is usually straightforward
Body Fat Percent
excess of total body fat: generally 20–25 % in men and 30– 35 % in
women. The classic way of measuring body fat is
1- water displacement
2- skinfold thickness
3- Impedance-type scale: NOT be used in people with pacemakers
12. Waist Circumference
Measurements take into account the location of fat
distribution in the body
Waist circumference is measured at the top of the hips
and with the tape measure going around the belly
button
High-risk central obesity is generally defined
as a waist circumference of more than 102 cm
(40 in.) for men and 88 cm (35 in.) for women.
Measuring-tape position for waist
circumference in adults (National Heart,
Lung, and Blood Institute, 2000)
18. • Sibutramine blocks presynaptic receptor uptake of
norepinephrine and serotonin
• Orlistat inhibits secretion of pancreatic lipase
• Metformin is insulin-sensitizing and antihyperglycemic
drug accompanied by decreases in LDL and insulin
without hypoglycemia
• Bupropion is antidepressant and smoking-cessation
agent inhibits norepinephrine and dopamine reuptake
• Topiramate is antiepileptic medication associated with
improvements in blood pressure and glucose tolerance
• Phentermine plus Topiramate combination
Drug
therapy
19. Intra-gastric Balloon
• Deflation of the balloon and natural expulsion.
• Nausea and persistent pain (>2 weeks after placement).
• Ulcer from decubitus.
• Peptic ulcer.
• Spontaneous deflation evolving with intestinal obstruction
• Gastric perforation
Complications
of Intragastric
balloon
procedures
Artificial bezoar produces early satiety and diminish intake, through the inflated
balloon occupies portion of gastric volume and reduce capacity of food intake.
ASMBS, 2014
21. Selection of the patient
Table-1 criteria for consideration for bariatric surgery (Richard, 2012).
• BMI>40 kg/m2 or BMI>35 kg/m2 with an correlated medical
comorbidity worsened by obesity
• Failed dietary therapy
• Psychiatrically stable without alcohol dependence or illegal drug use
• Knowledgeable about the operation and its steps
• Motivated individual
• Medical problems not preventing probable survival from surgery
22. Evaluation
General
Proper preoperative patient education
Preoperative antibiotics
Early ambulation and sequential compression
devices, without pharmacologic agents, such as
heparin, can be used successfully to prevent DVT
and PE
Prophylactic vena cava filters are inserted, if
possible on a temporary basis, in patients at
extremely high risk for DVT and PE
23. Specific Comorbid Conditions
Hypertension or Diabetes associated renal disease,
the serum creatinine level is an excellent preoperative
screening test for baseline renal function
Musculoskeletal evaluation
Especially arthritis and degenerative joint disease
Significant weight loss after bariatric surgery will make subsequent
knee and hip replacement surgery more effective and safer
24. Specific Comorbid Conditions
Metabolic problems
hyperlipidemia, hypercholesterolemia, and type 2 D.M.
Diabetes needs to be controlled preoperatively to reduce the incidence
perioperative morbidity.
Umbilical or ventral hernias
Postpone repair until after significant weight loss.
Cholelithiasis
most prevalent of the several gastrointestinal conditions
If gallstones are present, most surgeons agree that cholecystectomy needs to be
performed simultaneously with the bariatric surgery
25. Specific Comorbid Conditions
Gastroesophageal reflux disease (GERD)
common in severely obese patients due to ↑ abdominal pressure
Preoperative upper endoscopy is indicated in all patients to evaluate the
part of the stomach in patients undergoing RYGB
Nonalcoholic steatotic hepatitis (NASH)
NASH is not a contraindication to bariatric surgery if there is no cirrhosis and
portal hypertension or hepatocellular decompensation
Liver biopsy should be performed at the time of bariatric surgery
29. Vertical banded gastroplasty (VBG)
Complications of VBG
Early complication
Bleeding and fistula (gastrogastric &staple line),
subphrenic abscess and gastric perforation
outlet stenosis
DVT& pulmonary embolism (0%-2%) and wound infection.
Late complication
GERD and food intolerance
Pouch enlargement and port-site incisional hernia
Mortality
pulmonary embolism being the most common cause of
death
Vertical banded gastroplasty (Mason E, 1982)
30. 2.Laparoscopic Adjustable gastric banding
(AGB).
Early postoperative complications:
• Pouch dilatation
• Esophageal symptoms (esophageal
dysmotility with dilatation, esophageal
pulsion and divrticulae)
• Leakage of the band system
Port site infection
Incisional hernia and fascial dehiscence
Late postoperative complications
Pouch obstruction due to gradual increased
capacity of the proximal pouch with
subsequent rotation of the pouch
31. 3.Laparoscopic Sleeve Gastrectomy
(SG).
The Laparoscopic Sleeve
Gastrectomy :
A procedure that permanently
restricts the amount of food
ingested by removing two-thirds of
the stomach.
(LSG) in Bariatric Surgery (Karamanakos,
et al., 2008).
32. Disadvantages of the procedure
leakage along the long gastric staple line
Dysphagia
33. 4.Laparoscopic gastric plication
Gastric plication (ASMBS, 2011).
AIMS TO create a smaller stomach that
restricts the amount of food you can eat.
By folding the stomach wall inward and
suturing it in place over a sizing tube.
The procedure takes up to two hours to
perform and reduces stomach volume by as
much as 70 percent
35. 1.Roux En Y gastric bypass
Roux en Y gastric bypass
(Sugerman et al., 1992).
Formation of a 15–20 ml gastric pouch and the
fashioning of a Roux en Y Gastrojejunostomy
bypassing the distal stomach, duodenum and a
variable length of proximal jejunum
This reduces the size of meal ingested.
Additionally, and causes some degree of
malabsorption
36. ADVANTAGES
The national averages for excess weight loss are 33%, 66%, 75% at 3, 12, 18
The presence of dumping syndrome following gastric bypass may encourage
patients to avoid sweets
A study showed that sweet eaters were assigned to gastric bypass and non-sweet
eaters were assigned to vertical banded gastroplasty
A study showed that 96% of certain associated health conditions studied (back
pain, sleep apnea, high blood pressure, diabetes and depression) were improved
or resolved.
The improvement in type 2 D.M. often occurs almost immediately after surgery
well before weight loss is observed
38. 2.Minigastric Bypass.
Formation of a long gastric tube
approximately 1.5cm to the left of the
lesser curvature of the stomach from the
antrum to the angle of His and then a
loop gastroenterostomy is formed, about
200 cm from the ligament of Treitz
Minigastric bypass (Rutledge R, 2001)
40. 1.Biliopancreatic Diversion (BPD).
A longitudinal sleeve gastrectomy and duodenal
switch anastomosing the enteric limb to the
postpyloric duodenum after dividing the duodenum
distal to the pylorus and closing this distal duodenal
stump
Biliopancreatic Diversion
(Scopinaro et al., 1998)
41. 2.Biliopancreatic Diversion with
Duodenal Switch
Configuration of the duodenal switch (Marceau, et al., 2008)
the duodenum is divided distal to the pylorus,
followed by a pylorus-preserving sleeve
gastrectomy. Then a duodeno-enterostomy, The
common channel is now measured and the
biliopancreatic limb anastomosed to the distal ileum.
The completed procedure shows an alimentary limb
of 150cm and a common channel of 100cm
42. Adantages
Preservation of the pyloric sphincter is intended to ameliorate the
syndrome and decrease the incidence of ulcers at the duodeno-ileal
anastomosis by preserving the antropyloric pump and leaves the vagal
innervation undisturbed, and the sleeve gastrectomy itself minimizes the
ulcerogenicity by reducing the parietal cell mass
Disadvanatges
increased operative time and longer hospital stay
44. Adjustable Gastric Banding:
A trial study The LAP-BAND has been shown to resolve type 2 diabetes
A trial study Hypertension was resolved after AGP than medical treatment
A trial study weight loss after laparoscopic AGB with medically treated patients
and found that the laparoscopic AGB group had significantly better weight loss
The results of these three trials support the use of the laparoscopic AGB over
medical therapy for weight loss
45. Roux-en-Y Gastric Bypass
Resolution of comorbid conditions after open and laparoscopic
RYGB has generally been excellent. the effects of RYGB on diabetes
has shown resolution in 83.7% and improvement in 93.2% of
patients
RYGB has also been shown to resolve the symptoms of pseudo-
tumor cerebri and cure the difficult problem of venous stasis ulcers.
Immediate resolution of the symptoms of GERD occurs in more
than 90% of cases. The extremely small gastric pouch has a limited
reservoir for holding gastric juice, and the cardia is a low acid-
producing area of the stomach
Effective in improving NASH
46. Biliopancreatic Diversion and Duodenal
Switch:
The estimated weight loss after BPD-DS is the highest of the bariatric
operations , with a mean weight loss of 46.4 and 53.1 kg
BPD-DS has also been highly effective in treating comorbid conditions,
including hypertension, diabetes, lipid disorders, and obstructive sleep
apnea.
Lipid disorders and type 2 diabetes are almost uniformly resolved after
BPD-DS. Hypertension is cured in 83.4% and obstructive sleep apnea
resolves in 91.9% of patients
Supplements include multivitamins, and at least 1800 mg of oral
calcium/day. Supplemental fat-soluble vitamins, including vitamins D, K,
and A, are indicated monthly.
47. 4) Laparoscopic Sleeve Gastrectomy:
Weight loss and loss of feelings of hunger were better in the
laparoscopic sleeve gastrectomy patients compared with
laparoscopic AGB patients at 1 and 3 years after surgery.
Potential advantages of the laparoscopic sleeve gastrectomy are
the technical ease of the procedure, induction of satiety through
reduction in ghrelin levels, reduced need for postoperative
adjustments as opposed to laparoscopic AGB, preservation of the
pylorus, avoidance of dumping, reduced risk of malabsorption, and
apparent safety of the procedure in high-risk individuals.
Use of the laparoscopic sleeve gastrectomy may be advantageous
for some patient populations
48. Conclusion
Weight loss and loss of feelings of hunger were better in the laparoscopic sleeve gastrectomy
patients compared with laparoscopic AGB patients at 1 and 3 years after surgery.
Potential advantages of the laparoscopic sleeve gastrectomy are
the technical ease of the procedure,
induction of satiety through reduction in ghrelin levels,
reduced need for postoperative adjustments as opposed to laparoscopic AGB
preservation of the pylorus
avoidance of dumping,
reduced risk of malabsorption,
and apparent safety of the procedure in high-risk individuals.
Use of the laparoscopic sleeve gastrectomy may be advantageous for some patient populations.
So that it is clear that the fastest rising procedure is the laparoscopic sleeve gastrectomy; it will
probably be used by bariatric surgeons more frequently in the future
