2. Fundamentals of
bariatric and metabolic
surgery
BY
D. MOHAMED MAHFOUZ
MD, MRCS
•Assisstant Prof. of G. surgery- Ain-Shams university
•Member of the Royal College of surgeons-England
•Member of the American society of metabolic and bariatric
surgery
4. Khaled Elshaari
(born in1991) is the
heaviest recorded
person alive
Ht = 1.73m
Wt = 610 kg
BMI = 204 kg/m2
He lost about 320
kg recently
5. Definition of morbid obesity
Obesity is a medical condition in which
excess body fat has accumulated to
the extent that it may have a negative
effect on health, leading to
reduced life expectancy and/or
increased health problems.
Obese patients were estimated to be
about 2.1 billion in 2013.
7. BMI classification of morbid obesity
Category
Body Mass Index
(kg/m2)
Over Ideal Body Weight
(%)
Underweight <18.5
Normal 18.5-24.9
Overweight 25.0-29.9
Obesity (class 1) 30-34.9 >20%
Severe obesity (class 2) 35-39.9 >100%
Severe obesity (class 3) 40-49.9
Superobesity >50 >250%
9. Steps of treatment of morbid
obesity
Bariatric
surgery
Pharmacotherapy
Diet, exercise and
Behavioral therapy
10. Pharmacotherapy
• Orlistat (Xenical®): Inhibits gastric and
pancreatic lipase reducing fat absorption by
30%.
• Sibutramine: a selective inhibitor of central
neuronal reuptake of serotonine and
noradrenaline, reduces food intake, it also
might augment energy expenditure in both
the basal and fed states.
• Rimonabant it blocks endocannabinoid CB1
receptors, reduce food intake, and promote
weight loss
11. • Phentermine/Topiramate ER (Qsymia®):
Phentermine is a sympathomimetic amine
which release catecholamines in the
hypothalamus, resulting in reduced
appetite and decreased food consumption,
topiramate an anti-epileptic augmenting
GABA’s effect in appetite suppression and
satiety enhancement.
• Lorcaserin (Belviq®): affects central
serotonin subtype 2A receptors, resulting
18. Indications of bariatric surgery
1. BMI ≥ 40 kg/m 2
2. BMI 35–40 kg/m2 with co-morbidities
History of failed or failure to maintain
weight loss
# #No alcohol or drug abuse nor
psychological instability.
37. Failure of weight loss or
weight regain.
It is usually due to maladaptive eating
patterns.
functional gastrogastric fistula.
Dilation of gastric pouch or the
gastrojej. Anastomosis.
41. Metabolic surgery can be considered
as part of the more generally named
“functional surgery”, which in turn may
be defined as “a surgically- induced
anatomic modification which provokes
either the reduction or the annulment of
the altered function that causes the
disease, or a functional change of
opposite direction able to counteract
partially or totally the originally altered
function” Nicola Scopinaro, 2010.
42. INCRETINS
They are hormones secreted from the
GIT, with potent insulinotrophic
activity, glucoregulatory and energy
homeostasis controlling functions
(mainly after oral glucose intake).
They include : GLP, GIP, PYY, Leptin,
Ghrelin….and a lot of other GI
hormones.
Incretin effects are diminished in type
II DM, with no markedly diminished
levels.
43. PYY (SI): a potent anorectic hormone.
GLP-1 (Ileum): responsible for the first
phase of insulin secretion, which is
defective in type 2 diabetes, also
influences glucose metabolism by
inhibiting glucagon secretion, delaying
gastric emptying, and stimulating
glycogenesis, increases B-cell mass?!!
GIP (Duodenum): Glucose dependant
insulinotropic peptide.
Leptin (adipose): Food intake and energy
regulation (↑↑in obese).
44. Patients undergoing bariatric or anti-
diabetic procedures were found to improve
within the first post-operative week.
Complete or prolonged (more than 5
years) remission is the better term used
other than the term resolution or cure.
In the meta-analysis of Rubinho at 2008
over 22.094 patients, diabetes was found
to remit in 84% after RYGB, and 95% after
BPD, The remission after RYGB and BPD
is also durable, and recurrence of
DM>10years after surgery is rare.
45. They work by
Foregut theory: Exclusion alleviates
the anti-insulin incretin effects.
Hindgut theory: Rapid delivery of
nutrients increase useful incretins
along with the “ileal brake”
mechanism.
48. Other obesity associated
diseases shown to improve or
cure with metabolic surgery
Hypertension: Cure rate may reach 88%.
Dyslipidaemias, Ischemic heart disease,
strokes and other cardio-vascular risks.
Obstructive sleep apnoea.
NASH.
