Dr Pravin John and Dr John Thanakumar, Anurag Hospital, Coimbatore present the differences between metabolic and obesity surgery - dept of advanced laparoscopy and obesity

1. Metabolic Surgery compared
to Bariatric Surgery
Dr PRAVIN JOHN MS
Dr John Thanakumar MS,MNAMS, FRCS
Dept of Advanced Laparoscopy & Bariatric Surgery
ANURAG HOSPITAL, Coimbatore.
·www.anuraghospital.com

2. OBESITY
Second only to smoking as a preventable cause of
death
Major morbidity and mortality

3. Global Problem - Obesity

4. Different BMI for Asians and West

5. Obesity in India
Obesity has increased in India in 21 century, with
morbid obesity affecting 5% of population
Indians are genetically susceptible to weight
accumulation especially around the waist

6. Obesity statistics Indian States
NFHS 2007

9. Impact of Obesity among the Ethnic groups

10. Metabolic Syndrome
Abdominal obesity and girth
Decreased high-density lipoprotein
Increased insulin resistance
Increased diabetic state
Increased high blood pressure

11. Diseases associated with obesity
Diabetes mellitus(Type 2)
Obstructive sleep apnea (OSA)
Coronary ischemic disease
Hypertension
Some cancers
Osteoarthritis
Also early death

12. Metabolic Syndrome
Common
More in abdominal obesity
More in advanced with age( 60 years)
Men commonly than women
South Asians appear more susceptible
Metabolic syndrome on drugs e.g. steroids, antidepressants
and antipsychotic agents.

13. Metabolic Surgery
Why the nomenclature?
· Bariatric Surgery is involved with weight loss
· Results and mechanism went beyond weight loss
· Hence the term Metabolic surgery
· 2002 Primary intent to cure Type 2 DM (T2DM)
Francesco Rubino

14. Term - Metabolic Surgery
· Acceptance after a landmark “Diabetes Surgery Summit” in
2007.
· 2 world congresses dedicated subject and statements of
relevant organizations, notably the International Diabetes
Federation in 2011.

15. Not for Low BMIs
“Metabolic” and “diabetes surgery”, however, incorrectly
referred to as a surgical approach to treat diabetes in low
BMI patients, as a set of novel and yet experimental
operations.

16. Differences between bariatric
& metabolic surgery
Metabolic surgical patients have a more balanced
male/female ratio, showed higher incidence of type 2
diabetes, hypertension, dyslipidemia, higher cardiovascular
risk & established cardiovascular disease at onset

17. Definition of Metabolic Surgery
Metabolic Surgery is defined as “a set of gastrointestinal
operations used with the intent to treat diabetes ("diabetes
surgery") and metabolic dysfunctions (which include
obesity)”
· Surgery to treat T2DM in patients with BMI above 35
should be considered “metabolic/diabetes surgery” not
“bariatric surgery”.

18. T2DM & OBESITY
· The primary risk factor for Type 2 Diabetes Mellitus is obesity
· 90% of all patients with type 2 diabetes are overweight or obese.
· Risk of diabetes increases about 42-fold in men as the BMI increases
from <23 kg/m2 to >35 kg/m2 & 93-fold in women as BMI increases
from <22 kg/m2 to >35 kg/m2 .
Diabetes Care 1994
N Engl J Med 2001

19. Benefits of Obesity Surgery
Diabetes improved in more than 85% of patients and cured in
more than 75% overall
 Cholesterol -70% improved after surgery
 Hypertension cured in 60% of patients and improved in
more than 18%.
 Sleep Apnoea cured in 85.7% of surgical patients.

20. Other Advantages of Obesity Surgery
 Improvement with fatty infiltration of liver
 Improvement in respiratory function and asthmatic
symptoms
 Reversal of mild cardiomyopathy of obesity
 Improvement in joint pain and mobility

21. Who cannot have Obesity surgery?
 Severe uncontrolled heart disease
 Uncontrolled psychiatric disorder, Low IQ
 Inability to follow instructions
 Drug abuse, and cancer

22. Laparoscopic
Adjustable Gastric Band
Laparoscopic Band
Stomach

23. Adjustable Gastric Band
Common in Europe, Australia& S.America.
Small gastric pouch(15 mL).
Weight loss is about 50-60% of excess body weight in 2 years.

24. Early Complications of Band
Injury of the stomach or esophagus
Bleeding
Food intolerance (most common)
Wound infection
Pneumonia

25. Late Complications of Gastric Band
Food intolerance or noncompliance to band (13%)
Band slippage (stomach prolapse) (2.2-8%)
Pouch dilatation
Band erosion into the stomach
Port complications
Re operation rate (2-41%)
Esophageal dilatation
Failure to lose weight
Port infection, band infection
Leakage of the balloon or tubing
Mortality rate (0.5%; 0% in some series)

26. Sleeve Gastrectomy
Shape of stomach
after surgery

27. Laparoscopic Sleeve Gastrectomy
Sleeve gastrectomy employs subtotal gastric resection to reduce
stomach to 15-20% of its original size
The mechanism related to gastric restriction or to Grehlin
changes
Initially first of 2-stage op;with simplicity & favorable outcomes
Now a primary, stand-alone procedure.
Wt loss 33-83% of excess weight. Physiologic operation

28. Laparoscopic Roux en Y Gastric
Bypass

29. Lap Roux en Y Gastric Bypass
Gastric pouch ( 20 ml) and small outlet cause sensation of satiety
& grehlin.
Malabsorption is adjusted by length of the alimentary and bilio
pancreatic limbs.
The malabsorptive element bypasses the distal stomach,
duodenum, and some of the jejunum.
The standard Roux limb is 75cm. Long gastric bypass is150cm and
the last is a very long-limb (distal gastric bypass).

30. Result of Gastric Bypass
Weight loss 65-70% of excess body weight
Long-limb bypasses give comparable weight reductions in
super obese (BMI >50 kg/m2) pts.
Weight loss generally levels off in 1-2 years.

31. Early Complications of
Roux en Y Gastric Bypass
Anastomotic leak (1-3%)
Pulmonary embolism, deep vein thrombosis (<1%)
Wound infection (more common with open approach)
Gastrointestinal hemorrhage, bleeding (0.5-2%)
Respiratory insufficiency, pneumonia
Acute distention of the distal stomach

32. Late Complications of
Gastric Bypass
Stomal stenosis, most common (20%)
Bowel obstruction, small bowel obstruction (1%)
Internal hernia
Cholelithiasis
Micronutrient deficiencies
Marginal ulcer
Staple line disruption
Ventral hernia formation
Marginal Ulcer

33. Mortality of Gastric Bypass
Operative (30-day) mortality is about 0.5%.
Less the experience, more the complications
Compared with open procedures, laparoscopy has a higher rate
of intra-abdominal complications

34. Mini Gastric Bypass
Robert Ruthledge, 2009

35. Meta analysis- DM +Obesity
135,246 pts in 621 studies
Mean age 40.2 yrs BMI 47.9
10.5% bariatric procedures
78.1% DM improved
86.6% DM resolved
Buchwald et al 2009

36. Predictors for Resolution of T2DM
in Obesity Surgery
T2DM < 5 years 95%
T2DM 6-10 yrs 74%
T2DM >10 yrs 54%
BMI > 37
Hb A1c >7.5
C peptide > 3 ng/mL
Buchwald et al 2009
Dixon et al 2008

37. Dangers of Obesity
· CAD mortality 3 times > in the obese
· Cancer higher in the obese.
· CAD and Cancer mortality is significantly reduced in the
surgical group
Swedish Obese Subjects Study, Lancet, 2009

38. RYGB and MGB compared
RYGB- Gastric Bypass
MGB - Mini Gastric Bypass
RYGB- Gastric Bypass
MGB - Mini Gastric Bypass

39. RYGB vs MGB
Selection of cases
Lap RYGB vs MGB for RYGB- Gastric Bypass morbid obesity, Ann Surg, 2005
MGB - Mini Gastric Bypass

40. RYGB and MGB
Post Surgery Results
Lap RYGB vs MGB for morbid RYGB- Gastric Bypass obesity, Ann Surg, 2005
MGB - Mini Gastric Bypass

41. LSG vs RYGB on
Co morbidities
50 Indian patients on each arm
Resolution of co morbidities equal on both lap sleeve and
RYGB - T2DM,HT, dyslipedemias, sleep apneas, jt pains
Mild increase of GERD in LSV
Asian studies better results with LSG
Lakdawala, LSG-Lap Sleeve Gastrectomy Obes Surg, 2010
RYGB- Gastric Bypass

42. DM resolution in
RYGB, SG & Band
Diabetic resolution 81.2 % for RYGB
Diabetic resolution 80.9 % for SG
Diabetic resolution 60.8 % for Banding
Greatest improvement in Blood sugars occurred in SG group
60 pts with T2DM morbidity
Abbatini, Surg Endos 2010
LSG-Lap Sleeve Gastrectomy
RYGB- Gastric Bypass

43. Potential Benefits of
Single incision laparoscopic surgery
· Superior cosmesis
· Possibly shorter operating time
· Less Pain
· ? Lower costs
· Shortened time to full recovery
Evangelos C, Surg Endos 2010
LONGER Andrew Chow, JAMA surgery, 2010
Evangelos C, Surg Endos 2010

44. Problems of Single incision
laparoscopic surgery
Loss of triangulation
Crossing of instruments
Larger access port
Not for adhesions or redo surgery
Hernia of the port site

45. Future
· Careful selection in choice and method of Metabolic
Surgery
· Multiple studies needed for comparison of SILS to standard
laparoscopic surgery

46. ANURAG HOSPITAL,
8, Krishna Nagar
Sowripalayam Main Road
Coimbatore - 641028.
www.anuraghospital.com
Tel: 0422 6587871
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