morbid obesity ,definition, classification ,various treatment options ,multidisciplinary approach ,surgical options ,risks and benefits

1. MORBID
By
DR NIKHIL AMEERCHETTY ,MS

2. • Western world is more affected
• One third of the U.S. adult population is obese
• 300000 annual deaths
• second leading cause of preventable death
• morbidly obese man has a 22% reduction in life expectancy,

3. DEFINITION
• BMI equal to or greater than 40 kg/m2 without comorbidities
and >35kg/m2 with comorbidities .
National Institutes of Health. Am J Clin Nutr. 1992

4. HISTORY
• Jejunoileal bypass (JIB), was described in 1954
• Edward Mason devised the vertical banded Gastroplasty in 1960’s
• Nicola Scopinaro biliopancreatic diversion (BPD)
• Marceau duodenal switch non dividing duodenem 1993
• Hess and hess modified it to dividing the duodenum in 1998
• Gagner in 2000 laproscopic bpd-ds
• Fisher text book of surgery 6th edition .

5. CAUSES
Genetic Predisposition
Eating Disorders
Psychological Issues
Poor Diet
Lack Of Exercise
Comorbid Conditions
Metabolic Syndrome

6. CO-MORBIDITIES

7. PATHOPHYSIOLOGY
• Grehlin hormone at fundus – appetite stimulus
• GLP-1, PYY and CCk causes insulin release – reduces apetite
• Trifty genes
• Prentice AM, Natural selection of thrifty genes , Int J Obes (Lond) 2008

8. RATIONALE FOR SURGERY
• Increase life expectancy
• Decrease comorbidities
• Decrease health-care costs to society
• Swedish Obese Subjects study, which started in 1987

9. SELECTION CRITERIA
• International Federation for Surgery of Obesity and the National Institute for Clinical Excellence.
• Body mass index (BMI) >40 kg/m2 or BMI 35–39 kg/m2 with comorbid disease
• Minimum of 5 years obesity
• Failure of conservative treatment
• No alcoholism or major untreated psychiatric illness
• Avoid if likely to get pregnant within 2 years
• Age limits 18–55 (relative)
• Acceptable operative risk on preoperative assessment

10. OBESITY MULTIDISCIPLINARY TEAM (MDT)

11. PLANNING
• No bariatric operation will produce optimal long-term results without
significant changes in diet, exercise,and lifestyle.
• Low carbohydrate diet for atleast 2 weeks .
• “I will never go back to being the way I was before.”

12. PER-OPERATIVE ASSESSMENT
• Before the clinical visit
• medically supervised diet
• Initial Clinic Visit
• Group presentation on preoperative and postoperative nutritional issues by the nutritionist
• Individual assessment by the surgeon’s team
• Individual counseling session with the surgeon
• Individual counseling session with the nutritionist
• Screening blood tests

13. • Subsequent Events and Evaluations
• Screening flexible upper endoscopy
• Screening ultrasound of the gallbladder
• Subsequent Clinic Visits
• Counseling session with the surgeon (including selection of the date for surgery)
• Education session with the nurse educator
• Preoperative evaluation by the anesthesiologist
• Final paperwork by the preadmissions center

14. SPECIAL EQUIPMENT
• Hydraulically operated table accommodating up to 800 lb.
• Side attachments
• Foam cushioning
• Extra large SCD stockings
• Wide and secure padded straps for
the abdomen and legs

15. • High-flow insufflators
• Extra-long staplers
• Atraumatic graspers
• Extra-long trocars
• An ultrasonic scalpel
• A fixed retractor device for clamping and holding the liver retractor is also essential.

16. •MEDICAL TREATMENT
•SURGICAL TREATMENT

17. MEDICAL TREATMENT
• Diets
• Exercise
• Slimming clubs
• Pharmacological agents.
• 97 per cent long-term failure rate

18. SURGICAL OPTIONS
• Restrictive
• Vertical banded gastroplasty (VBG)
• Laparoscopic adjustable gastric banding (AGB)
• Laparoscopic sleeve gastrectomy (LSG)
• Largely Restrictive, Mildly Malabsorptive
• Roux-en-Y gastric bypass (RYGB)
• Largely Malabsorptive, Mildly Restrictive
• Biliopancreatic diversion (BPD)
• Duodenal switch (DS)

19. VERTICAL BAND GASTROPLASTY
• Abandoned
• Poor long-term weight loss
• High rate of late stenosis of the gastric outlet
• Regain of weight

20. LAPROSCOPIC ADJUSTIBLE GASTRIC
BANDING
• FDA approved LAP-BAND and REALIZE BAND
• Principle : Augment the early satiety, Vagal nerves feedback mechanism
• Advantage : Adjustability and Low morbidity and mortality .
• Ideal method for patients with BMI 35 - 40kg/m²
• 0.1% perioperative mortality rate

21. • 15mm pneumoperitoneum left upper quadrant, at the midclavicular line, one hand breath
below the xiphoid.
• 12-mm camera port in the midline approximately 15 cm from the xiphoid.
• 5-mm port is placed in the right upper quadrant for the surgeon’s left hand.
• 5-mm port in the left upper quadrant is placed for the assistant
• Port in the epigastrium is placed to assist in retracting the left lobe of the liver

24. SLEEVE GASTRECTOMY
• 0.2 per cent operative mortality.
• Removes most of the grehlin
• Disadvantage : leakage, sleeve expansion
• 65 per cent weight loss by 2 years
• 10-20% resleeve procedure

27. ROUX-EN-Y GASTRIC BYPASS
• 65–75 per cent excess weight loss
• Risk 0.5 per cent
• Uses : GERD or type 2 diabetes.
• Limitation : Decreases Iron absorption .
• Theories : Foregut and Hind gut theory
proposed for weight loss

29. BILIOPANCREATIC DIVERSION – WITH OR
WITHOUT
A DUODENAL SWITCH
• 75–85 per cent excess
• Mortality of 1–2 per cent
• Extreme malabsorption

30. Biliopancreatic diversion
Biliopancreatic diversion with
duodenal switch

31. RESULTS
• How to define success?
• Losing at least 50 per cent of the excess weight in the first 12–24 months.
• Decrease comorbidities
• Improved quality of life .

32. COMPARATIVE CHART

34. EMERGING TRENDS
• Neuromodulation using
• Gastric-implanted electrodes
• Vagal blocking using electrodes around the abdominal vagus,
• Endoscopically placed intraluminal sleeves
• Endoscopic gastric restriction
• Single incision and transvaginal approaches.

35. BEFORE AND AFTER VERTICAL SLEEVE GASTRECTOMY

39. • Mini gastric bypass