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  • 08/07/13

Bariatric surgery 2013 may Bariatric surgery 2013 may Presentation Transcript

  • Dr Sreejoy Patnaik Member OSSI,IFSO,SAGES Minimal Access , Bariatric & Metabolic Surgery
  •  General Surgeon -1991  Laparoscopic Surgeon -1993  Endoscopic Surgeon- 1998  Single Incision Lap. Surgeon - 2010  Bariatric Surgeon -2010  NOTE Surgeon -2012  VAAFT Surgeon-2012  Metabolic Surgeon -2013  What Next ???
  • Kancherla Ravindranath August 8th 1992 did the first lapchole in Orissa With help of Dr Vinay Taunk at SCBMCH & at SHANTI
  • MANMOTH TASK
  • Obesity associated conditions Diabetes Hypertension Sleep apnea Congestive heart failure Hyperlipidemia Stroke Coronary Artery Disease Osteoarthritis Gastroesophageal Reflux Disease Non-alcoholic fatty liver Psychological disturbances
  • Cardiovascular: CAD, HTN, CHF, LVF, Venous stasi ulcers, DVT, Hyperlipidaemia Pulmonary: OSA,OHS,PAH, Asthma Endocrine: Insulin Resistance, Type 2 DM, PCOS Haemopoietic: DVT, Pulmonary Embolism G.I /Hepatobiliary: GERD, NAFLD, Hernias, Gallstones Genitourinary: Stress incontinence, UTI Obstetrics/Gynecology: Infertility, Miscarriage, Fetal abnormalities, Infant mortality, Gestational DM Musculoskeletal: Degenerative Joint diseases, Gout, Plantar fascitis, Carpel T.S Neurologic/Psychiatric: Stroke, Pseudomotor cerebri, Depression, Anxiety Cancer: Esophagus, Pancreas, Colon & Rectum, Breast, Endometrium, Kidney, Thyroid, GB
  •  BMI ≥ 35 kg/m²:  Risk of death ≈ 2.5 times greater than if BMI of 20-25 kg/m²  BMI ≥ 40 kg/m²:  Risk of death 10 times greater Obesity 2nd leading cause of preventable premature death in US (smoking)
  •  Global epidemic of obesity  Bariatric surgery is the only effective and sustained treatment for morbid obesity  Bariatric surgery resolves diabetes and other co-morbidity and saves lives  Laparoscopic surgery has significant advantages over open procedures  Surgical morbidity and mortality are very low in experienced units
  • Open Surgery (big cuts) Laparoscopic Surgery (key-hole sized cuts) Natural Orifice Surgery (no cuts)
  •  Consensus Guidelines 2003  Surgical therapy should be considered for individuals who:  Have a BMI of greater than 40 kg/m² OR  Have a BMI greater than 35 kg/m² with significant comorbidities AND  Can show that dietary attempts at weight control have been ineffective Derived from American Society of Bariatric Surgery website: www.asbs.org
  • Bariatric Surgery Diet Exercise Behavior Modification “Postoperative care, nutritional counseling, and surveillance should continue for an indefinitely long period.”
  •  Obesity related to a metabolic or endocrine disorder  H/O substance abuse or major psychiatric problem  High risk patients  Women who want to become pregnant = 18 months
  •  1. PREDOMINANTLY RESTRICTIVE1. PREDOMINANTLY RESTRICTIVE PROCEDURESPROCEDURES  2. PREDOMINANTLY MALABSORBTIVE2. PREDOMINANTLY MALABSORBTIVE PROCEDURESPROCEDURES  3. MIXED OR COMBINATION PROCEDURES3. MIXED OR COMBINATION PROCEDURES
  • By creating a small gastric pouch & a degree of outlet obstruction leading to delayed gastric emptying. The goal - 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:
  • -Malabsorption is achieved by creating a short gut syndrome -Distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption.. -No longer recommended due to their potential hazard to cause serious nutritional deficiencies. 1.BILIOPANCREATIC DIVERSION 2. THE JEJUNAL-ILEAL BYPASS 3. ENDOLUMINAL SLEEVE 4. MINI GASTRIC BYPASS MALABSORPTIVE PROCEDURES
  • MIXED OR COMBIATION 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.
  • LABORATORY EVALUATION: Basic chemistry panel, full blood count, thyroid function tests. Serum cortisol, urine cortisol, lipid profile, vitamin (A, B1, B6, B12, C).Serum Insulin, C-Peptide. UPPER ENDOSCOPY: Rule out inflammatory ulcerous gastric pathology, search and treat H pylori infection when present. ULTRASOUND OF THE ABDOMEN: To rule out cholelithiasis, which would indicate cholecystectomy along with the gastric sleeve. PREOPERATIVE EVALUATION CARDIOVASCULAR/RESPIRATORY EVALUATION: Exclude any contraindications to anesthesia by TMT, Echo, PFT, ABG , CXR etc. PSYCHIATRIC EVALUATION: To rule out any behavioral abnormalities that would contraindicate limited food intake. ENDOCRINE EVALUATION: Rule out an endocrine abnormality as the etiology of morbid obesity. DENTAL EVALUATION
  • Armamentarium in OT INSTRUMENTS TELESCOPES,TROCARS LIVER RETRACTORS ENDO-GIA STAPLERS
  • LED MARTIN LIGHTS MINDRAY BARIATRIC TABLE
  • VALLEYLAB STERRAD
  • LIGASURE HARMONIC
  • EXTRA LONG TROCARS OPTI-VIEW TROCARS GASTRIC CALIBRATION TUBE OPTICAL TROCARS & GCT
  • WARM BLANKET- BAIR HUGGER
  • SERIAL COMPRESSION DEVICE TYCO – KENDALL COMPRESSION DEVICE
  •  Dr. Cadiere 1992  Technically simple  Purely restrictive  Decrease hunger  Early satiety  Food aversion  Adjustment to stoma diameter
  • LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY/ LAGB) Restrictive Procedure 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.
  •  This Band in the stomach and 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.
  • • Perforation of Stomach • Mal positioning • Abdominal Pain • Heartburn • Vomiting • Inability to Adjust the Band • Failure to Lose Weight • Slippage • Gastric Erosion • Dilated Esophagus • Infection of System • Fatigue or malfunction Complications of Gastric Lap-Band
  • Sleeve gastrectomy is a procedure in which the stomach is reduced to about 25% of its original size, by surgical removal of a large portion of the stomach along the greater curvature. This is done by using surgical staplers to form a sleeve or a tube with a banana shape. A bougie or GCT between 36 - 40 Fr is used with the procedure . Ideal approximate capacity of the stomach after the procedure is about 30- 60 ml pouch Sleeve Gastrectomy
  • TEN STEPS OF LSGTEN STEPS OF LSG 1.1. Assembly of instruments, in order of useAssembly of instruments, in order of use 2.2. OT set up and Trocar PositionOT set up and Trocar Position 3.3. Liver Retraction –using Nathansons LiverLiver Retraction –using Nathansons Liver RetractorRetractor 4.4. Gastrolysis of greater curvature- distal to prox.Gastrolysis of greater curvature- distal to prox. Upto> of His.Upto> of His. 5.5. Resection of stomach by Stapling – starts from 4Resection of stomach by Stapling – starts from 4 cm distal to pyloruscm distal to pylorus 6.6. Suturing for staple line reinforcementSuturing for staple line reinforcement 7.7. Leak test- Methylene blue, air or UGIELeak test- Methylene blue, air or UGIE 8.8. Extraction of specimen- fish tail techniqueExtraction of specimen- fish tail technique 9.9. Closure of Ports- by needle passer.Closure of Ports- by needle passer.
  • DONE UNDER G.A 5 TO 6 PORTS The benefits are: •Less Pain •Quicker recovery and return to normal activity •Fewer complications •Less noticeable scar •Shorter hospital stay 1.1.Assembly of instruments, in order of useAssembly of instruments, in order of use 2.2. OT set up and Trocar PositionOT set up and Trocar Position
  • 1.1.Liver Retraction –using NathansonsLiver Retraction –using Nathansons Liver RetractorLiver Retractor
  • 1.1.Gastrolysis of greater curvature- distalGastrolysis of greater curvature- distal to prox. Upto> of His.to prox. Upto> of His.
  • 1.1.Resection ofResection of Stomach byStomach by Stapling – startsStapling – starts from 4 cm distal tofrom 4 cm distal to pyloruspylorus
  • Stomach stapling ends up at angle of His
  • Suturing for staple lineSuturing for staple line reinforcementreinforcement
  • Leak test- Methylene blue,Leak test- Methylene blue, air or UGIEair or UGIE
  • SLEEVE GASTRECTOMY
  • 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.
  • 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) or Incretins. 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.
  • The stomach is stapled into 2 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.
  • • The small intestine (the jejunum) is divided using a surgical stapler Approx. 70 cm from the DJ Junction.
  • 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 cmBPD LIMB OR Y
  •  “Gold Standard”  80% of bariatric proc.  Restrictive and Malabsorptive:  Reduced calorie intake  Macronutrient malabsorption
  • LAP GASTRICT BYPASS
  •  Staple line disruption (revision procedure..)  Bougie stapling  Bleeding from the staple line  Bleeding from gastric or short gastric vessels  Bleeding from the spleen  Exposure difficulty in supersuper obese patients
  • ICCSSG NEW YORK 2007  Staple line leakage  Bleeding from the staple line  Gastric stenosis Late complications  Marginal ulcer  GERD ++  Gastric dilatation and weight regain
  •  1. Pulmonary Embolism  2. Myocardial Infarction  3. Anastomotic Leak  4. Management of Leaks  5. Bleeding  6. Wound Infection  7. Small Bowel Obstruction  8. Band Obstruction  9. Dumping Syndrome  10. Stomal Stenosis  11. Esophageal Dilation  12. Band Slippage  13. Band Erosion  14. Marginal Ulcers  15. Cholelithiasis  16. Gastro-gastric Fistula  17. Malabsorption  18. Procedure Failure
  • N=104 1 year post op Number Pre-op % Worse % No change % Improved % Resolved Osteoarthritis 64 2 10 47 41 Hypercholesterolemia 62 0 4 33 63 GERD 58 0 4 24 72 Hypertension 57 0 12 18 70 Sleep Apnea 44 2 5 19 74 Hypertriglyceridemia 43 0 14 29 57 Peripheral Edema 31 0 4 55 41 Stress Incontinence 18 6 11 39 44 Asthma 18 6 12 69 13 Diabetes 18 0 0 18 82 Average 1.6% 7.8% 35.1% 55.7% 90.8% Improved or ResolvedSchauer, et al. Ann Surg 2000 Oct;232(4):515-29
  •  Rapid decrease in serum blood sugar  Decrease in medication requirements  66% to 75% complete resolution  Increased insulin sensitivity  Inhibits progression of disease  Swedish Obese Subject Trial:  Reduced relative risk by factor of 30 compared to medically treated population 1. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta- analysis. JAMA 2004;292: 1724-37. 2. Pories WJ, Swanson MS, MacDonald KG, Long SB, Morris PG, Brown BM, et al. Who would have thought it ? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;22:339-50, discussion 350-2. 3. SjostromL, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351: 2683-93.
  •  70% complete resolution  50% reduced medications  Swedish Obese Subject Trial: 2 years post op Decreased relative risk of new onset HTN = 10  Time interval for resolution not cleared 1. SjostromL, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351: 2683-93.
  •  70% prevalence in gastric bypass pts  80% improvement  No more CPAP  Decreased pCO2  Increased pO2 1. Dixon JB, et al. Predicting sleep apnea and excessive day sleepiness in the severity obese: indicators for polysomnography. Chest 2003;123:1134-41. 2. Sugerman HJ, et al. Gastric surgery for respiratory insufficiency of obestiy. Chest 1986;90:81-6.
  •  Non-alcoholic fatty liver:  Resolution of steatosis  Improved liver contour  Osteoarthritis:  50% reduced medication intake  Decreased joint stress from weight loss  Delayed operative joint intervention  Depression:  High prevalence in obese  Decreased medication use 1. Clark JM, et al. Roux-en-Y gastric bypass improves liver histology in patients with non-alcoholic fatty liver disease. Obes Res 2005;13:1180-6 2. Abu-Abeid S, et al. The influence of sugically-induced weight loss on the knee joint. Obes Surg 2005;15:1437-42. 3. Sarwer DB, et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg 2004;14:1148-56.
  •  Endoscopic plication of the pylorus with laparoscopic gastrojejeunostomy  N.O.T.E.S  SILS  ROBOTIC SURGERY 1. Kantsevoy SV, et al. Technical feasibility of endoscopic gatric reduction: a pilot study in a porcine model. Gastrointes Endosc 2007;65:510-3. 2. Deviere J, et al. Safety, feasibility and weight loss after trans-oral gastroplasty (TOGA): first human multicenter study. Surg Endosc 2007;21(suppl 1): S303.
  • Revisional Surgery Endoscopic Procedures Gastric Neuromodulation
  • Durable Excess Weight Loss > 50%
  • Technique Product Sclerotherapy Suturing EndoCinch (Bard) Spiderman (J&J) Anchors ROSE, POSE (USGI) T-Fasteners StomaphyX (Endogastric Solutions) Staplers TOGa (Satiety Inc.) Sleeves EndoBarrier (GI Dynamics) ValenTx Endoscopic Bariatric Procedures
  •  Class 3 & Super-Obesity:  Conventional Bariatric Surgery e.g. laparoscopic gastric bypass  Less Severe Obesity - Classes 1 and 2  Gastric Electrical Stimulation  Endoscopic Bariatric Procedures
  • Research Ranking scores using a combination of factors Types of Bariatric Surgery Category Average Long Term Excess Weight Loss (approx. %) Complication Rate Research Ranking* (and reason if below ‘A’ LGB Combination (primary restrictive 50 to 70% Up to 15% A Lap Gastric Banding Restrictive 25% to 80% Up to 33% A BPD/DS Mal absorptive 65% to 75% Up to 24% A Vertical Banded Gastroplasty Restrictive 50% TO 60% Up to 21% B Vertical Sleeve Gastrectomy Restrictive 65% to 75% Up to 10% B Mini Gastric Bypass Surgery Combination (primary restrictive 60% to 70% Up to 8% C TGVR Restrictive Needs more research n/a C TOGA System Restrictive n/a n/a Endobarrier Endoluminal Lining Mal absorptive n/a n/a D Implantable Maestro System Neither restrictive nor mal absorptive; electrical impulses said to affect hunger n/a n/a
  • S.L NO PATIENT NAME INTIAL BODY WEIGHT B.M.I I.B.W P.B.W WEIGHT LOSS (K.G) D.OO PROCEDURE % OF WEIGH T LOSS 1 RAGHAV GOENKA 135 KG 44.5 76 KG 72 KG 63 KG 27.02.2010 SLEEVE GASTRECTOMY 96 % 2. SANJAY SWAIN 158 KG 56 72 KG 80 KG 68 KG 23.04.2010 SLEEVE GASTRECTOMY 79 % 3. DIGBIJAY SAHOO 127 KG 45 70 100 KG 27 KG 23.04.2010 SLEEVE GASTRECTOMY 47% 4. MANOJ DAS 139 KG 56 60 KG 90 KG 49 KG 09.12.2010 SLEEVE GASTRECTOMY 58% 5. SANTOSH PRASAD 108 KG 46 57 KG 67 KG 41 KG 16.01.2011 SLEEVE GASTRECTOMY 80% 6. M.ARUNA 112 KG 44 63 KG 75 KG 32 KG 07.04.2011 SLEEVE GASTRECTOMY 65% 7. MANASMITA PRIYADARSINI 110 KG 43 60 KG 78 KG 29 KG 25.07.2011 SLEEVE GASTRECTOMY 58% 8. UMESH GOENKA 100KG 35.5 72 KG 80 KG 20 KG 04.11.11 SLEEVE GASTRECTOMY 53% 9. HEENA AGARWAL 132 KG 53 63 KG 92 KG 40 KG 17.04.2011 SLEEVE GASTRECTOMY 58% 10. KISHANLAL PANCH 109 KG 38 72 KG 83 KG 26 KG 12.05.2012 SLEEVE GASTRECTOMY 70 % TABLE SHOWING % OF WEIGHT LOSS AT SHANTI MEMORIAL HOPSPITAL
  • S.L NO PATIENT NAME INTIAL BODY WEIGHT B.M.I I.B.W P.B.W WEIGHT LOSS (K.G) D.OO PROCEDURE % OF WEIGH T LOSS 11. CHANDAN MOHANTY 149 KG 47 79 KG 95 KG 54 KG 12.05.2012 SLEEVE GASTRECTOMY 77% 2. PUSPITA DAS 100 KG 41 60 KG 75 KG 25 KG 10.06.2012 SLEEVE GASTRECTOMY 62.5% 3. GOPAL SIKARIA 107 KG 37.5 73 KG 86 KG 21 KG 10.06.2012 SLEEVE GASTRECTOMY 61% 4. SUDATTA DAS 90 KG 43 52 KG 56 KG 34 KG 07.07.2012 SLE EVE GASTRECTOMY 84.5% 5. RABINDRANAT H SENAPATI 107 KG 42 66 KG 81 KG 26 KG 15.07.2012 SLEEVE GASTRECTOMY 63% 6. SMITARANI SWAIN 100 KG 40.5 57 KG 71 KG 29 KG 19.08.2012 SLEEVE GASTRECTOMY 60% 7. VIJAY SHARMA 174 KG 56 76 KG 153 KG 21 KG 03.09.2012 SLEEVE GASTRECTOMY 21.5% 8. VINOD SHARMA 154 KG 55 71 KG 126 KG 28 KG 03.09.2012 SLEEVE GASTRECTOMY 35% 9. DINESH AGARWAL 122 KG 43 65 KG 98 KG 24 KG 01.10.2012 SLEEVE GASTRECTOMY 42% 10. APARAJITA PATNAIK 100 KG 38 65 KG 83 KG 17 KG 04.11.2012 SLEEVE GASTRECTOMY 33% TABLE SHOWING % OF WEIGHT LOSS AT SHANTI MEMORIAL HOPSPITAL
  • OUR SERIES OF PATIENTS
  • THE FUTURE –WHO KNOWS THIS DAY MIGHT COME SOON
  • THANK YOU