Bariatric Surgery an overview in orissa ppt.

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A brief overview of bariatric surgery , a small study of 35 cases. All had successful results.

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Bariatric Surgery an overview in orissa ppt.

  1. 1. SHANTI MEMORIAL HOSPITAL PVT. LTD
  2. 2. BARIATRIC SURGERY IN ODISHA - AN OVERVIEW DR SREEJOY PATNAIK LIFE MEMBER , SAGES, OSSI & IFSO MINIMAL ACCESS , BARIATRIC & METABOLIC SURGERY
  3. 3. OBESITY AND METABOLIC SURGERY SOCIETY OF INDIA
  4. 4. IFSO CONGRESS - 2010, 2011, 2012
  5. 5. IFSO 2013
  6. 6. Definition of Bariatric Surgery • Bariatric surgery or weight loss surgery is a variety of surgical procedures performed on obese subjects. • It is done either by • Reducing the size & capacity of the stomach. • OR by • Resecting & re-routing the small intestines to a small gastric pouch.
  7. 7. SCARY STATISTICS
  8. 8. How do we measure obesity •We classify obesity according to BMI ( Body mass index ) •BMI = body weight in kg / height in m2
  9. 9. Classification of BMI • 18-25 = Normal • 25-30 = Obese • 30-35 = Class 1 • 35-40 = Class II • 40-45 = Class III • > 45 = Morbid or super obese
  10. 10. Why we are worried about obesity? • What is its significance ? • Because of its co-morbidities
  11. 11. Comorbidities 1. Cardiovascular – CAD, HTN,CHF,LVF & Dyslipidaemia. 2. Pulmonary – OSA, OHS, PAH, Asthma 3. Haemopoetic – DVT & PE 4. GI – GERD, NAFLD, Hiatus hernia, Gallstones 5. Genito-urinary – stress incontinence, UTI
  12. 12. Comorbidities 6. Obstetrics / Gynecology – Infertility, Miscarriage, fetalabnormalities, infant mortality, gestational DM 7. Musculosketal – OA, Gout, Plantar fasciitis, carpel tunnel syndrome. 8. Neurology / Psychiatric – CVA, pseudo motor cerebri, depression and anxiety. 9. Cancer – Oesophagus, pancreas, colon & rectum, breast, endometrial, kidney, thyroid and GB.
  13. 13. Morbidity • BMI > 35 - Risk of death = 2.5 times greater • BMI > 40 - Risk of death = 10 times greater • OBESITY > 2 leading cause of preventable nd premature deaths in USA
  14. 14. Treatment of obesity
  15. 15. DRUGS • ORLISTAT • NEWER DRUGS• BELVIQ (LOCASERIN) • QSYMIA (PHENTERMINE/ TOPIRAMATE) • VICTOZA (LIRAGLUTIDE)
  16. 16. Bariatric Surgery - Goals Surgery to Create Sustainable & significant Weight Loss in Severely Obese Patients. Resolution or Cure of Co-morbidities Reduction of Obesity Related Mortality
  17. 17. GUIDELINES • SAGES – Society of American Gastro Endo surgeons. • ASMBS – American society of Metabolic & Bariatric Surgery. • NIH – National Institute of Health.
  18. 18. Whom do we advise Surgery ? BMI > 40 without comorbidities. BMI > 35 with 2 comorbidities . Age – 18 – 60 years( < 12- 65 ) Stable obesity for > 5 years Unsuccessful dietary / drug treatment Absence of Endocrine disease Pt. should be sufficiently comprehensive & compliant. No h/o excessive alcohol or drug abuse Acceptable Operative Risks
  19. 19. How do we classify the surgical procedures ? A. Restrictive B. Malabsorptive C. Combination – restrictive and malabsorptive
  20. 20. Restrictive procedures • Creation of a small gastric pouch & limiting the gastric volume & continuity is not altered. • Vertical banded Gastroplasty • Adjustable Gastric Banding • Sleeve Gastrectomy • Gastric Plication • BIB – Intra Gastric Balloon
  21. 21. RESTRICTIVE PROCEDURES LSG LGP VBG LAGB INTRA –GASTRIC BALOON
  22. 22. A Restrictive Procedure is  Safer  Easier  Faster  Easier to cheat  Less Effective for Weight Loss BUT ALSO BUT ALSO  Less beneficial for Diabetes control
  23. 23. Malabsorptive procedures • Malabsorption is achieved by creating a short gut syndrome with distal mixing of bile and pancreatic juice with ingested food. • Bilio-pancreatic diversion • Jejunal ileal bypass • Endoluminal sleeve ( Endo-barrier)
  24. 24. MAL ABSORPTIVE PROCEDURES BPD - DS ENDOLUMINAL SLEEVE OR DJ BYPASS LINER
  25. 25. A Malabsorptive Procedure is  More effective for weight loss??  More risky??  More Nutritionally demanding
  26. 26. Combination procedures • Combination of restriction alongwith malabsorption . • Small gastric pouch + a bypass. • Early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat. • RYGB • LSG with DS • MGB
  27. 27. COMBINATION PROCEDURES LSG + DS LRYGBP MGBP
  28. 28. Combining Both Restrictive & Malabsorptive methods has The Pros and Cons of Both
  29. 29. History of Bariatric Surgery • 1950s- Open Gastric Bypass, BPD • 1990- Laparoscopic Bariatrics- LRYGBP, LAGB • 2000- Laparoscopic Sleeve Gastrectomy • 2003- Gastric Plication & ileal Transposition
  30. 30. Historical Perspective Jejunoileal Bypass (JIB)   Vertical Banded Gastroplasty (VBG)
  31. 31. Gold standard procedures • Laparoscopic Sleeve Gastrectomy • Laparoscopic Roux-en-Y Gastric Bypass • Laparoscopic Mini Gastric Bypass • Laparoscopic Adjustable Gastric banding
  32. 32. Bariatric Procedures Performed Today
  33. 33. Bariatric Procedures Performed Today
  34. 34. Bariatric Procedures Performed Today
  35. 35. Selection of a procedure • There is No evidence on procedure selection -most frustrating shortfall in bariatric surgery. • Best procedure should reduce weight, induce remission of Diabetes, & improve quality of life. • • Multi disciplinary team assessment . The choice of procedure is determined by the individual’s phenotype, the aims of therapy, & peri-operative risks.
  36. 36. Selection of Procedure • Each procedure should be tailor made for each individual. • The choice of the procedure is a complex process with patient & their interests at its core. • The surgeon’s experience to deal with the inevitable complications of each procedure & to manage long term follow up care should be the goal to success.
  37. 37. Pre-op assessment • • Patient should be physically & psychologically fit. • Patients must be determined to comply with the postop. care and instructions on diet. • They should be given the correct & realistic information on what the procedure can achieve. • For each patient benefits of the procedure should outweigh the operative risks. Individualized assessment-is vital & Psychiatrist role is important.
  38. 38. • A special risk bond is signed by the patient and by 2 more family members. • Procedure may vary in peri- operative assessment ie ; diagnostic laparoscopy. • Primary aim of surgery should each procedure. be weight loss with
  39. 39. Whom we deny Bariatric Surgery ? • History of substance abuse, eating disorders, or major psychiatric problems – untreated or unresolved • Patients who are too ill or too high a risk for surgery • Women who may become pregnant soon
  40. 40. Choosing an ideal Bariatric Procedure
  41. 41. Diabetic? Sweet Eater? Cola Guzzler? Reflux? LAP GASTRIC BYPASS
  42. 42. High Risk Bariatric Subject? Super-super-obese? Not keen on severe portion control? Very young? ‘Sold’ patient? LAP SLEEVE GASTRECTOMY
  43. 43. Hostile Abdomen? Previous Intestinal Resections? ‘Sold’ Patient? ‘Sold’ Physician? LAP BAND
  44. 44. • Ideal procedure 1. Weight loss - max. with BPD-DS/ LRYGB/ MGB LSG/ LAGB. • 2. DM remission - BPD-DS/ LRYGB/ LSG/ LAGB • 3.OSA/ Asthma • 4. GERD - BPD-DS / LRYGB - LRYGB (No LSG)
  45. 45. Investigations LAB EVALUATION : CBC,FBS, 2HRPGBS, HB1AC, LFT, Urea, Creatinine, Serum Protein/albumin, Amylase, Serum fasting & post Insulin, C-peptide, lipid profile, Serum Calcium, Vit. B12, Calcitonin, TFT,Serum & urine Cortisol. HOMA-IRHomeostasis Model of Assessment-Insulin Resistance UGIE: To rule out inflammatory or ulcer pathology, & treat H.pylori infection. USG Abdomen – To rule out cholelithiases, which would indicate Lap. Cholecystectomy alongwith the primary surgery. Cardio-Respiratory evaluation – To exclude any contraindications to GA by TMT, 2D echo, PFT, ABG, CXR. Psychiatry evaluation – To rule out any behavioural abnormalities that would contraindicate limited food intake. Endocrine evaluation – To rule out an endocrine abnormality as the etiology of morbid obesity. Dental evaluation
  46. 46. HOMA-IR HOMEOSTASIS MODEL OF ASSESSMENT OF INSULIN RESISTANCE • INTERNATIONAL FORMULA • FBG(mmol/L) X Finsulin(Mu/L) / 22.5 • To assess beta cell function & insulin resistance • Estimated by euglycemic clamp method •( measuring glucose for an increased inslin level, without causing hypoglycemia)
  47. 47. Tools for Bariatric Surgery
  48. 48. Safety trocars and Gastric calibration tubes
  49. 49. STERRAD – NX STERILISER The STERRAD® NXTM Sterilizer is a self-contained stand-alone system of hardware and software designed to sterilize medical instruments and devices using a patented hydrogen
  50. 50. ENERGY SOURCES
  51. 51. ANAESTHESIA WORKSTATION , CO2 & GAS MONITORS
  52. 52. VIDEO LARYNGOSCOPES
  53. 53. FLEXIBLE LARYNGOSCOPE
  54. 54. Bair Hugger – warm blanket
  55. 55. SEQUENTIAL COMPRESSION DEVICE
  56. 56. ICU MANAGEMENT
  57. 57. Video on sleeve gastrectomy
  58. 58. Video on LRYGB
  59. 59. Video on MGB
  60. 60. Pathophysiology 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. Metabolic syndrome For Men WC > or – 40 inches TG > or – 150 mg/dl HDL < 40 mg/dl BP > or – 130/85 mmHg FBS > or – 100 mg/dl For Woman WC > 35 inches TG > 150 mg/dl HDL < 50 mg/dl BP > 130/85 mmHg FBS > 100 md/dl
  61. 61. GI HORMONES AS INCRETINS & ANTI INCRETINS
  62. 62. 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 Glucosedependent insulinotropic polypeptide
  63. 63. Mechanism of Incretin action Stimulates insulin release Lowering of blood glucose Inhibits glucagon release
  64. 64. WHAT ARE ANTI INCRETINS? • Anti incretins are a group of GI factors secreted from the duodenum & proximal jejunum, which counteract the actions of INCRETINS.
  65. 65. Anti incretin action HYPERGLYCEMIA
  66. 66. ANTI INCRETINS AND GLUCOSE HOMEOSTASIS
  67. 67. THE BADDIES
  68. 68. 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
  69. 69. • Ghrelin- (orexrgenic / satiety or appetite stimulant hormone) produced primarily by gastric fundus. -Its levels are supressed following resection of gastric rich fundus. -It stimulates insulin counter-regulatory hormones. • Peptide YY – an anorexegenic (or appetite depressant) hormone co-secreted with GLP-1 from the response to food intake. • PYY3-36 intestinal L cells in - ( anorxegenic hormone ) -levels are increased following LRYGB, decreases food intake & ameliorates insulin resistance and improves glycemia.
  70. 70. 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.
  71. 71. I & AI AFTER BYPASS
  72. 72. Hypothesis as to the mechanism responsible for the control of diabetes after gastric bypass.
  73. 73. PROPOSED THEORIES FOR IMPROVED GLYCAEMIA (B) FOREGUT HYPOTHESIS •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 .
  74. 74. ANTI-INCRETIN / INCRETIN HYPOTHESIS • 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 & there is a restoration of between Incretins & Anti-Incretins , leading to improved glucose homeostasis .
  75. 75. • 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 increased markedly - Adiponectin levels are improved - Markers of insulin signals in key target tissues are enhanced.
  76. 76. Medical Co-Morbidities Resolved with Bariatric surgery Type 2 Diabetes 95% Hypercholesterolemia 97% Hypertension 92% GERD 98% Cardiac Function 95% improvement Stress Incontinence 87% Osteoarthritis 82% Sleep Apnea 75%
  77. 77. Complications of Bariatric Surgery The other side of Mount Rushmore South Dakota USA Gutzon Borglum and his son Lincoln Borglum 1925
  78. 78. INTRA-OPERATIVE COMPLICATIONS • Trocar injuries • Splenic injury • Portal vein injury • Bowel ischemia • Misconstruction
  79. 79. EARLY COMPLICATIONS • Bleeding • Wound infection • Anastomotic leaks • Pulmonary embolism and DVT • Cardiovascular complications • Pulmonary complications
  80. 80. LATE COMPLICATIONS AFTER RYGB • • • • • • • • - Gastric remnant distension - Stomal stenosis or stricture - Marginal ulcers - Cholelithiasis - Ventral incisional hernia - Internal hernias Vomiting, diarrhea,dumping syndrome. Alopecia,cholelthiasis, hypoglycemia - Short bowel syndrome - Dumping syndrome - Metabolic and nutritional derangements - iron,vit B12, D,folic acid. - Renal failure - Postoperative hypoglycemia - Change in bowel habits - Failure to lose weight and weight regain
  81. 81. COMPLICATIONS AFTER SLEEVE • - Bleeding • - Stenosis • - Gastric leaks • - Reflux • Alopecia, cholelthiasis, hypoglycemia.
  82. 82. How Safe Is Bariatric Surgery? Mortality Rate- 0.3% Morbidity Rate- 4.1% Longitudinal Assessment of Bariatric Surgery, NEJM, 2009
  83. 83. OUR EXPERIENCE IN BARIATRIC SURGERY
  84. 84. YEAR WISE –BARIATRIC SURGERY CASES • 2010 • 2011 • 2012 • 2013 - 4 cases - 4 cases - 12 cases - 15 cases
  85. 85. PATIENT PROFILE • 2010 - 2013 • N= 35 • BMI range 35 to 60 • Comorbidities
  86. 86. Procedures (n=35) • • Lap adjustable gastric band 0 Lap sleeve gastrectomy 30 • • • • • • Lap gastric bypass 2 Lap duodenal switch 0 Lap gastric plication 0 Ileal Transposition Revisional Bariatric procedure MGB 0 1 2
  87. 87. Excess body weight loss %Follow up 3- 38 months • LSG 32- 85 • RYGB 38- 88 • MGB 33- 64 • REVISIONAL BARIATRIC (SG > MGB) 20
  88. 88. OUR PATIENT SERIES BHUBANESWAR
  89. 89. HAPPY AFTER MARRIAGE
  90. 90. JAGATSINGHPUR
  91. 91. BHAWANIPATNA
  92. 92. JAGDALPUR
  93. 93. BALASORE
  94. 94. KALAHANDI
  95. 95. KENDRAPADA
  96. 96. BRAMHAPUR
  97. 97. AFTER
  98. 98. PURI
  99. 99. CUTTACK
  100. 100. THE MOST ELIGIBLE BACHELOR CUTTACK -- FIRST CASE
  101. 101. DRAMATIC WEIGHT LOSS – 60 KGS IN 4 MONTHS
  102. 102. WITH MY DIETICIAN
  103. 103. What can be more satisfying than achieving this?
  104. 104. OUR SUCCESS
  105. 105. • Bariatric surgery dramatically improves or cures many obesity comorbidities. • But working with an inexperienced surgeon can increase your risk for complications.
  106. 106. Metabolic Surgery- A new dimension RESOLUTION OF DIABETES AFTER BARIATRIC SURGERY
  107. 107. Present status of diabetes surgery • Bariatric surgery effectively reverses type 2 diabetes in a high proportion of morbidly obese patients, within weeks or even days well before these patients have lost a significant amount of body weight • Diabetes surgery should be considered in patients with BMI > 35 and may also be appropriate for patients with BMI 30-35 Rome Diabetes Surgery Summit 2009
  108. 108. Resolution of Diabetes in the Non-Obese?
  109. 109. Resolution of diabetes in non obese Status of Ileal Transposition “Not to be done outside approved trials” Rome Diabetes Surgery Summit, 2009
  110. 110. PRACTICE POINTS • Extensive Research in the field of Bariatric surgery ( Metabolic surgery, Technology, Endoscopy ) • A career in Bariatrics is very promising……. And lucrative
  111. 111. Diabetes Surgery • Within 5 years, will gastrointestinal surgery be considered an acceptable option for the treatment of Type 2 Diabetes in the non­obese patient?
  112. 112. CONCLUSIONS- TAKE HOME MESSAGE • BS should be considered with BMI > 40 or BMI > 35 with obesity related 2 co-morbidities. • • Not all pts. are suitable for surgery. • The choice of the surgical modality should take the individual’s goals, surgeon’s experience & existing comorbidities. A multidisciplinary assessment is essential to select the appropriate candidates.
  113. 113. CONCLUSIONS- TAKE HOME MESSAGE • • Individualised care is determined by clinical evaluation. • Procedure selection - should effectively treat & prevent all co-morbidities alongwith sustained weight loss. • Experienced anaesthesist & trained OT & ICU staff is necessary for success. • Long term follow up and repeated counselling is mandatory for a safe outcome. Should be performed in experienced centres- with back up ICU and trained staff for favourable outcomes.
  114. 114. THANK YOU FOR A PATIENT HEARING & WAITING

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