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PATHOPHYSIOLOGY OF BARIATRIC SURGERY

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  • Medical complication of obesity
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    • 1. Pathophysiology of BariatricPathophysiology of Bariatric SurgerySurgery DR SREEJOY PATNAIK BARIATRIC AND METABOLIC SURGEON LIFE MEMBER OSSI,IFSO,SAGES
    • 2. SHANTI MEMORIAL HOSPITAL PVT.LTD Final Phase of NABH Accredition.
    • 3. Obesity EpidemicObesity Epidemic • World epidemic encompasses 1.7 billion people • Highest in the U.S. • Approximately 2/3 of Americans are overweight, and almost half are obese • BMI subgroups of >35 and >40 are experiencing most rapid growth Buchwald et al. Jama 2004Buchwald et al. Jama 2004
    • 4. Obesity EpidemicObesity Epidemic • Rise in the prevalence of obesity is associated with rises in prevalence of obesity related comorbidities • Comorbidities responsible for 2.5 million deaths per year worldwide • Loss of life expectancy is profound • 25 year-old morbidly obese male has 22% reduction in lifespan, representing a loss of 12 years of life Buchwald et al. Jama 2004Buchwald et al. Jama 2004
    • 5. Obesity EpidemicObesity Epidemic • Diet therapy, with and without support organizations, is ineffective long term • Currently, there are no effective pharmaceutical agents to treat obesity, especially morbid obesity North American Association for theNorth American Association for the Study of Obesity. NIH 2000Study of Obesity. NIH 2000
    • 6. Definition of ObesityDefinition of Obesity according to BMIaccording to BMI UnderweightUnderweight <18.5<18.5 NormalNormal 18.5 – 24.918.5 – 24.9 OverweightOverweight 25-29.925-29.9 ObesityObesity >30>30 moderatemoderate 30.0 – 34.930.0 – 34.9 severesevere 35.0 – 39.935.0 – 39.9 morbidmorbid >40>40 BMI = W(kg)/H (m²)BMI = W(kg)/H (m²)
    • 7. BMIBMI • Calculated as follows: Weight(kg)/Height(m2 ) • Lowest mortality = BMI < 25kg/m2 • Highest mortality = BMI > 40kg/m2 • BMI > 40 = approximately 100lbs. over ideal body weight
    • 8. Why Operate?Why Operate?
    • 9. 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
    • 10. Medical Co-morbidities • 1.Metabolic • 2.Mechanical • 3.Degenerative • 4.Neoplastic • 5.Psychological
    • 11. Medical Co-morbidities Metabolic • Diabetes mellitus, type II • Hypertriglyceridemia • Hypercholesterolemia • Hypertension • Gallstones • Fatty liver disease (NASH) • Pancreatitis • Central sleep apnea • Hypercoagulable • Infertility
    • 12. Metabolic Syndrome Abdominal obesity Hyperinsulinemia High fasting plasma glucose Impaired glucose tolerance Hypertriglyceridemia Low HDL-cholesterol Hypertension
    • 13. Medical Co-morbidities Mechanical/Anatomic • Obstructive sleep apnea • GERD • GERD - associated asthma • Urinary stress incontinence • Pseudotumor cerebri • Venous stasis • DVT / PE • Fungal skin infections • Decubitus ulcers • Accidental injuries
    • 14. Medical Co-morbidities Degenerative • Cardiovascular disease • Complications of diabetes • CHF • Vertebral disc disease • NASH related cirrhosis
    • 15. Medical Co-morbidities Neoplastic • Breast Cancer • Ovarian Cancer • Endometrial Cancer • Prostate Cancer • Colorectal Cancer • Renal Cell Carcinoma • NHL • Esophageal Cancer • Gastric Cancer • Pancreatic Cancer
    • 16. Medical Co-morbidities Psychological • Anxiety disorders • Depression • Binge eating disorders • Reactive bulimia • Trauma
    • 17. Indications for SurgeryIndications for Surgery • BMI > 40 kg/m2BMI > 40 kg/m2 • BMI > 35 kg/m2 with 2 co-morbiditiesBMI > 35 kg/m2 with 2 co-morbidities • Comorbidities:Comorbidities: – HypertensionHypertension – DiabetesDiabetes – HyperlipidemiaHyperlipidemia – Sleep apneaSleep apnea – Severe arthrosisSevere arthrosis NIH ConsensusNIH Consensus ConferenceConference Ann Intern Med 1991Ann Intern Med 1991
    • 18. Indications for SurgeryIndications for Surgery • Age > 18 or < 60Age > 18 or < 60 • Failure of diet > 6 monthsFailure of diet > 6 months • Obesity history > 5Obesity history > 5 yearsyears • Low risk for surgeryLow risk for surgery • No endocrinological diseaseNo endocrinological disease • Psychologically soundPsychologically sound NIH Consensus ConferenceNIH Consensus Conference Ann Intern Med 1991Ann Intern Med 1991
    • 19. Goals of SurgeryGoals of Surgery • Effective: Loss > 50% of ExcessEffective: Loss > 50% of Excess WeightWeight • Low operative morbidityLow operative morbidity • Well toleratedWell tolerated • No long term complicationsNo long term complications
    • 20. Surgical ProceduresSurgical Procedures • Restrictive proceduresRestrictive procedures – Gastric BandingGastric Banding – Sleeve GastrectomySleeve Gastrectomy – -Gastric Plication-Gastric Plication • Malabsorptive proceduresMalabsorptive procedures – Biliopancreatic DiversionBiliopancreatic Diversion • ScopinaroScopinaro • Duodenal-Switch BPDDuodenal-Switch BPD • Hybrid proceduresHybrid procedures – Roux-en-Y Gastric Bypass / BandedRoux-en-Y Gastric Bypass / Banded – -Mini Gastric Bypass-Mini Gastric Bypass
    • 21. Bariatric Procedures Performed Today
    • 22. BBilio-pancrilio-pancreeatiatic diversionc diversion ScopinaroScopinaro SGWithSGWith duodenalduodenal switchswitch
    • 23. How does a sleeve work? One of the mechanisms involved in weight loss observed after the LSG is the dramatic reduction of the capacity of the stomach.
    • 24. Ghrelin A peptide hormone mainly produced in the fundus of the stomach, is supposed to be involved in the mechanisms regulating hunger . Secreted by the endocrine cells of the stomach (X/A-like cells), which reside in the oxyntic glands of the gastric fundus . It regulates the secretion of growth hormone release and is a potent orexigenic (appetite-stimulating) peptide & is mediated by the activation of ghrelin receptors in the hypothalamus / pituitary area . Plasma concentration rises just before the onset of meal and declines after intake of meals . Plays a key role in the complex energy balance and certain neurophysiologic mechanisms are responsible for the changes in appetite observed after bariatric surgery
    • 25. Restriction Malabsorption Gastric Bypass Loss of appetite ? Small pouch (approx 30 cc) Small anastomosis (approx. 1.5 cm) How does it work ? Alimentary Limb Between 100 to 200cm Biliopancreatic Limb Between 50 to 75 cm Ghrelin
    • 26. Pathophysiology of Bariatric Surgery of Bariatric Surgery • Role of GI Hormones in remission of Metabolic syndrome. • Recent theory- Entero-insular axis has got a role in maintaining glucose homeostasis. • Bariatric surgery results in weight loss due to surgical manipulation or bypassing of the gut & by caloric restriction - leading to remission of metabolic syndrome.
    • 27. GI HORMONES AS INCRETINS & ANTI INCRETINS
    • 28. WHAT ARE incretins ? • Incretins are a group of gastrointestinal hormones that increase the amount of insulin release from the beta cells after eating. • They also slow the rate of absorption of nutrients into the blood stream by reducing gastric emptying and reduces food intake. • Inhibits Glucagon release from the alpha cells of the Islets of Langerhans. • 1. GLP-1- Glucagon-like peptide-1 • 2 . GIP- Gastric inhibitory peptide or Glucose- dependent insulinotropic polypeptide
    • 29. Mechanism of Incretin action action
    • 30. WHAT ARE ANTI INCRETINS? • Anti incretins are a group of GI factors secreted from the duodenum & proximal jejunum, which counteract the actions of INCRETINS.
    • 31. Anti incretin action
    • 32. ANTI INCRETINS AND GLUCOSE HOMEOSTASIS
    • 33. GUT BRAIN AXIS The gut–brain axis is a major component of appetite regulation. The gut hormones have either • anorexigenic ( appetite depressant ) or • orexigenic ( appetite stimulant ) action on food intake . •These gut hormone secretions are altered following bariatric surgery
    • 34. • GHRELIN - (orexrgenic / satiety or appetite stimulant hormone) Peptide YY – an anorexegenic (or appetite depressant) hormone co-secreted with GLP-1 from the intestinal L cells in response to food intake. • PYY3-36 - ( anorxegenic hormone ) -levels are increased following LRYGB, decreases food intake & ameliorates insulin resistance and improves glycemia.
    • 35. PROPOSED THEORIES FOR IMPROVED GLYCAEMIA (A) RAPID HINDGUT DELIVERY HYPOTHESIS •Expedited or rapid delivery of ingested nutrients to lower bowel due to intestinal bypass leads to stimulation of L cells, ( distal ileum & colon ) which in turn results in increased secretion of incretin hormones & improved glucose homoeostasis. (LRYGB & BPD/DS.) •Proximal nutrient- related signals that are transmitted from the duodenum to the distal bowel by neural pathways leads to increased Incretin secretion.
    • 36. PROPOSEDT(B) FOREGUT HYPOTHESIS HEORIES FOR IMPROVED GLYCAEMIA •The proximal small intestine (foregut / BPD limb ) is excluded resulting in reduction in secretion of Anti – incretin factors ( diabetogenic hormones) in response to absence of nutrients in the fore gut. •This leads to improved glycaemia. & •Decreased Intestinal Glucagon synthesis .
    • 37. ANTI-INCRETIN / INCRETIN BALANCE • After Bariatric Surgery - a physiological balance is maintained between Anti –Incretins & Incretins, • Leads to proper beta cell function & to maintain Blood Glucose excursions within normal range. • Release of excess Anti- Incretins are prevented leading to improved glucose homeostasis.
    • 38. Diabetes, Obesity & Bariatric surgery • DM linked with obesity has – -- insulin resistance, inflammation & lipo-toxicity of beta cells, > progressive beta cell failure & hyper-glycaemia. •After Bariatric Surgery - - Glucose homeostasis improves. - Insulin sensitivity increases. - Adiponectin levels improves - Markers of insulin signals in key target tissues are enhanced.
    • 39. Hypothesis as to the mechanism responsible for the control of diabetes after gastric bypass.
    • 40. MY ExperienceS iN Bariatric Surgery
    • 41. Bariatric Procedures (n=40) 2010 • Lap adjustable gastric band 0 • Lap sleeve gastrectomy 35 • Lap gastric bypass 2 • Lap duodenal switch 0 • Lap gastric plication 0 • Ileal Transposition 0 • Revisional Bariatric procedure 1 • MGB 2
    • 42. OUR SUCCESSFUL PATIENTS KENDRAPA
    • 43. THE MOST ELIGIBLE BACHELOR CUTTACK -- FIRST CASE
    • 44. CUTTACK
    • 45. CUTTACK
    • 46. BHUBANESWA
    • 47. JABDALPUR
    • 48. BALASORE
    • 49. BHUBANESW
    • 50. HAPPY AFTER MARRIAGE
    • 51. BHAWANIPAT NA
    • 52. CUTTA
    • 53. CUTTA
    • 54. PURI
    • 55. CUTTACK
    • 56. BALASORE
    • 57. JARSUGUDA
    • 58. JAJPUR
    • 59. BHUBANESWAR
    • 60. Conclusion Big patientBig patient Big riskBig risk Big expectationsBig expectations
    • 61. FOR YOUR PATIENT HEARING
    • 62. Conclusion Multidisciplinary teamMultidisciplinary team And ProgramAnd Program