The document discusses morbid obesity and surgical management options. It defines morbid obesity as being 100 pounds or more overweight, or having a BMI over 40 kg/m2. Surgical procedures like gastric bypass, sleeve gastrectomy, and gastric banding are recommended when lifestyle changes fail to achieve weight loss. These procedures work by restricting food intake, slowing stomach emptying, or reducing nutrient absorption. Complications can include leaks, strictures, nutritional deficiencies, and infection, but bariatric surgery is generally effective for achieving long-term weight loss and resolving obesity-related health conditions.

1. MORBID OBESITY
AND SURGICAL
MANAGEMENT.
Dr Gaurav Gupta
RSO dept. of surgery
JNM medical college raipur
Dr Gaurav Gupta ,JNM Raipur

2. WHAT IS MORBID OBESITY
• Multi factorial diseaes of excess fat storage.
• Lifelong & progressive
• 100 LB ABOVE IDEAL BODY WEIGHT
• TWICE IDEAL BODY WEIGHT
• OR A BMI>40 KG/M2
• BMI > 35 WITH COMORBID CONDITIONS
Dr Gaurav Gupta ,JNM Raipur

3. HOW IS IT CALCULATED
Dr Gaurav Gupta ,JNM Raipur

4. 27.5
Dr Gaurav Gupta ,JNM Raipur

5. HOW DOES MORBID OBESITY DIFFER
FROM BEING OVERWEIGHT OR OBESE??
Overweight and obese – reversible
medical management
Morbid obesity - surgical intervention
Dr Gaurav Gupta ,JNM Raipur

6. OBESITY-PATHOPHYSIOLOGY
• Complex interaction
– genetic ,
– Behavioral
– environmental factors.
• Specific genes--FTO(fat mass and obesity related)
--MC4R(melanocortin 4 receptors)
--Thrifty genes
• Second leading cause of preventable death
,exceeded only by cigarette smoking.
Dr Gaurav Gupta ,JNM Raipur

7. .
Dr Gaurav Gupta ,JNM Raipur

8. CONDITIONS ASSOCIATED WITH MORBID
OBESITY
.
TYPE2 DIABETES
CARDIOVASCULAR
HYPERTENSION,CAD,CHF
HYPERTRIGLYCERIDEMIA
VASCULAR DS.
MENTAL HEALTH
LOW SELF ESTEEM
DEPRESSION
ORTHOPEDIC
OSTEOARTHRITIS
.
HEPATIC
CHOLELITHIASIS,CIRRHOSIS
STEATOHEPATITIS
RENAL
MICROALBUMINURIA
NEUROLOGICAL
PSEUDOTUMOR CEREBRI
SKIN
ACANTHOSIS NIGRICANS
INTERTRIGO
Dr Gaurav Gupta ,JNM Raipur

9. • REPRODUCTIVE
• FEMALE- PCOD
HYPERANDROGENISM
EARLIER MENARCHE
DYSMENORRHEA
• MALE- LATE PUBERTY
PSEUDO MICROPENIS
REDUCED ANDROGENS
• SLEEP APNEA
• BREAST,UTREINE,PROSTRATE ,COLON CANCER
• Most frequent problem– arthritis & degenerative joints
Dr Gaurav Gupta ,JNM Raipur

10. RISK ASSOCIATED WITH MORBID
OBESITY
• It is an extreme health hazard with medical
,psychological social,physical, & economic co-
morbidities.
Increased risk of developing Hypertension
DM type 2,
heart disease
stroke
gallstone disease
CA breast, prostate,colon
Dr Gaurav Gupta ,JNM Raipur

11. Dr Gaurav Gupta ,JNM Raipur

12. TREATMENT
• Diet
• Exercise
• Behavior therapy
• MEDICAL MANAGEMENT
Phentermine is an appetite suppressant
Orlistat blocks absorption of fats in the GIT
• These medications cause modest weight loss at best
and often lead to weight regain when stopped.
Dr Gaurav Gupta ,JNM Raipur

13. INDICATIONS FOR BARIATRIC SURGERY
Patients must meet the following criteria
• B MI >40 kg/m2 or BMI >35 kg/m2 with an
associated medical comorbidity.
• Failed dietary therapy
• Psychiatrically stable without alcohol dependence
or illegal drug use
Dr Gaurav Gupta ,JNM Raipur

14. .• Knowledgeable about the
operation and its sequelae
• Motivated individual
• Medical problems not precluding
probable survival from surgery
Dr Gaurav Gupta ,JNM Raipur

15. CONTRAINDICATIONS TO BARIATRIC
SURGERY
• Cardiac problem
• Respiratory dysfunction
• Significant psychological disorders
• Who are unable to ambulate
• Prader-Willi syndrome
Dr Gaurav Gupta ,JNM Raipur

16. PERIOPERATIVE EVALUATION
• LABORATORY EVALUATION:
Blood count, TFT. Serum & urine cortisol, lipid
profile, vitamin (A, B1, B6, B12, C).Serum Insulin, C-
Peptide.
• UPPER ENDOSCOPY:
Rule out gastric pathology, search and treat H
pylori infection.
• ULTRASOUND OF THE ABDOMEN:
Cholelithiasis cholecystectomy
Dr Gaurav Gupta ,JNM Raipur

17. • CARDIOVASCULAR/RESPIRATORY EVALUATION:
Exclude any contraindications to anesthesia by TMT,
Echo, PFT, ABG , CXR etc.
•
PSYCHIATRIC EVALUATION:
.
• ENDOCRINE EVALUATION:
• DENTAL EVALUATION
Dr Gaurav Gupta ,JNM Raipur

18. LAPARASCOPIC PROCEDURE
DONE UNDER G.A
5 TO 6 PORTS
THE BENEFITS ARE:
•Less Pain
•Quicker recovery
•Fewer complications(PTE)
•Less scar
•Shorter hospital stay
Dr Gaurav Gupta ,JNM Raipur

19. .
EXTRA LONG
TROCARS
OPTI-VIEW
GASTRIC
CALIBRATION TUBE
Dr Gaurav Gupta ,JNM Raipur

20. .
Dr Gaurav Gupta ,JNM Raipur

21. TYPES OF BARIATRIC SURGERY
• RESTRICTIVE
VERTICAL BANDED GASTROPLASTY (VBG)
ADJUSTABLE GASTRIC BANDING (AGB)
SLEEVE GASTRECTOMY (LSG)
GASTRIC PLICATION
GASTRIC BALOON
• Largely Restrictive, mildly malabsorbtive
Roux-en-Y gastric bypass
• PREDOMINANTLY MALABSORBTIVE
BILIOPANCREATIC DIVERSION (BPD)
DUODENAL SWITCH (DS)Dr Gaurav Gupta ,JNM Raipur

22. .
RESTRICTIVE PROCEDURES
Creats a small gastric pouch & a degree of
outlet obstruction leading to delayed gastric
emptying.
Goal is to reduce oral intake,produce early
satiety & leave alimentary canal in
continuity,minimising risks of metabolic
complications. Dr Gaurav Gupta ,JNM Raipur

23. VERTICAL BANDED GASTROPLASTY
The stomach is
partitioned along its axis
with a non- adjustable
poly-urethane band and
with linear& circular
staples to create a small
upper stomach pouch
with a restrictive orifice
to the rest of the
stomach
Dr Gaurav Gupta ,JNM Raipur

24. Dr Gaurav Gupta ,JNM Raipur

25. .ABANDONED BECAUSE OF
• POOR LONG-TERM WEIGHT LOSS,
• HIGH RATE OF LATE STENOSIS OF THE GASTRIC
OUTLET, AND
• TENDENCY FOR PATIENTS TO ADOPT A HIGH-
CALORIE LIQUID DIET, THEREBY LEADING TO
REGAIN OF WEIGHT.
Dr Gaurav Gupta ,JNM Raipur

26. LAPAROSCOPIC ADJUSTABLE
GASTRIC BANDING
TYPES OF BANDS
• LAP-BAND (INAMED Health,Santa Barbara,
Calif )
• Realize band (Ethicon Endo-Surgery,
Cincinnati, Ohio).
• The Swedish Adjustable Gastric BAND
• MIDBAND
• the Heliogast bandDr Gaurav Gupta ,JNM Raipur

27. .
AN INFLATABLE SILICONE BAND IS
PLACED AROUND THE TOP
PORTION OF THE STOMACH,
TO FORM A SMALL STOMACH
POUCH
BAND IS CONNECTED TO A TUBE
THAT LEADS TO A PORT
BELOW THE SKIN (FILL – PORT).
FOLLOW UP: INJECT OR
REMOVE SALINE TO MAKE
BAND TIGHTER OR
LOOSER
INFLATABLE
SILICONE BAND
Dr Gaurav Gupta ,JNM Raipur

28. REALIZE BAND
Dr Gaurav Gupta ,JNM Raipur

29. Dr Gaurav Gupta ,JNM Raipur

30. THIS BAND IN THE STOMACH INDUCES WEIGHT-LOSS
IN 3 WAYS:
1.SMALL STOMACH POUCH SENSATION OF
FULLNESS
2. SQUEEZING OF THE STOMACH POUCH LIKE AN
HOUR GLASS PROLONGS THE SENSATION OF
FULLNESS
3. SUPPRESSES APPETITE BY CENTRAL ACTION
Dr Gaurav Gupta ,JNM Raipur

31. COMPLICATIONS OF BANDING.
• Slippage(food
intolerance and GER)
• Perforation of Stomach
• Mal positioning
• Abdominal Pain
• Heartburn
• Vomiting
• Failure to Lose Weight
• Gastric Erosion
• Dilated Esophagus
• Infection of System
• Fatigue or malfunction
• Inability to Adjust the
Band
Dr Gaurav Gupta ,JNM Raipur

32. LAPARASCOPIC SLEEVE GASTRECTOMY
• standard procedure
• Stomach is reduced to
about 25% of its original
size
• A bougie 32 - 40 Fr is
used in the procedure
Dr Gaurav Gupta ,JNM Raipur

33. ADVANTAGES -SLEEVE GASTRECTOMY
• Simple ,rapid & less traumaticsafe in high risk
patient
• Good resolution of co-morbidities and good
weight loss
• Preservation of pylorus(no dumping)
• Reduction in internal hernias ,malabsorbtion(seen
with RYGB)
• Ability to modify the gastric sleeve later to a
lap.RYGB or lap.DS in a 2nd stage.Dr Gaurav Gupta ,JNM Raipur

34. COMPLICATION
• Leakage along the long gastric staple line.
• Long term fistula formation.
Dr Gaurav Gupta ,JNM Raipur

35. .Sleeve gastrectomy induces weight loss by:
• 1.MECHANICAL RESTRICTION by reducing the
volume of the stomach and impairing stomach
mobility. Also called ‘Food limiting’ operation.
• 2.HORMONAL MODIFICATION by removing a great
part of the Ghrelin (Hunger Hormone) production
tissue.
Dr Gaurav Gupta ,JNM Raipur

36. Postoperative period
• No nasogastric tube
• Gastrograffin study:
• UGIE – to check leakage
• From D2 to D14,liquid diet.
• next 3 weeks soft diet
• Normal diet after 1 month
Dr Gaurav Gupta ,JNM Raipur

37. INTRAGASTRIC BALOON
• Endoscopically balloon left
for max. 6 months
• Average weight loss of 5–
9 BMI IN 6months
• Stepdown procedure prior to
another bariatric surgery
Soft silicon balloon
Dr Gaurav Gupta ,JNM Raipur

38. ENDO BARRIER LINER SYSTEM
Endoscopically inserting a
flexible tube-like barrier into
the duodenum & prox.
Jejunum
Mimics the effects of gastric
bypass surgery
Loose weight by delaying
digestion
Has to be removed after 6
months
Dr Gaurav Gupta ,JNM Raipur

39. ROUX-EN-Y GASTRIC BYPASS (RYGB)
LARGELY RESTRICTIVE, MILDLY MALABSORPTIVE
Components
• Small proximal gastric pouch(10 to 15ml)
• Jejunum divided 30 to 40 cm distal to ligament of
Treitz
• Roux limb at least 75 cm in length(if BMI in
40s=80to120cm, if BMI>50=150cm)
Dr Gaurav Gupta ,JNM Raipur

40. .
ROUX LIMB
Y LIMB
Dr Gaurav Gupta ,JNM Raipur

41. Dr Gaurav Gupta ,JNM Raipur

42. ADVANTAGES OF ROUX-EN-Y BYPASS
• Most commonly performed.
• Most reliable for long term weight loss -avg 60 to 75 %.
• NO Malnutrition
• Improvement & resolution of:
Type 2 DM – 90% Sleep apnea -90%
Hypertension-70% Hyperlipidaemia -70%
Heartburn from GERD- all patients.
Dr Gaurav Gupta ,JNM Raipur

43. COMPLICATION ROUX-EN-Y BYPASS
• Irreversible.
• Stricture of gastrojejunostomy.-10% (long term)
• Dumping syndrome
• Long term risk of protein ,vitamin,iron deficiency,
& marginal ulceration of GJA.
• Long term risk of intestinal obstruction – 2%.
Dr Gaurav Gupta ,JNM Raipur

44. LARGELY MALABSORPTIVE, MILDLY
RESTRICTIVE
• BILIOPANCREATIC DIVERSION (BPD)
• DUODENAL SWITCH (DS)
• Mechanism short gut syndrome and/or by
accomplishing distal mixing of bile and pancreatic
juice with ingested nutrients thereby reducing
absorption
• Purely malabsorptive operations- not recommended
due to serious nutritional deficiencies
Dr Gaurav Gupta ,JNM Raipur

45. BILIOPANCREATIC DIVERSION (BPD)
• Wt loss- malabsorption>> restrictive
• Distal hemigastrectomy(250ml for BMI<50 & 150ml
for BMI >50)
• Effective ileum length – 250 cm
• Distal common chennal- 50 cm(for abs. fat &
protein).
Dr Gaurav Gupta ,JNM Raipur

46. BILIOPANCREATIC
DIVERSION (BPD)
250
cm
50cm
Dr Gaurav Gupta ,JNM Raipur

47. After BPD
• 2 -5 daily bowel movement.
• Excessive flatulence and foul smelling stools
• Mc long term complication protein malnutrition
the common channel may need to be lengthened
with a reoperation(4% cases).
• Ability to absorb simple sugars,alcohol,& short
chain TG is good i.e. Patient must avoid overeating
of sweets ,milk product,soft drinks,alcohol,fruits.
Dr Gaurav Gupta ,JNM Raipur

48. BILIOPANCREATIC DIVERSION
WITH DUODENAL SWITCH
• Entire length of alimentary length -250 cm
• Common channel- 100 cm
• Goal- produce a lesser curvature gastric sleeve
with a volume of 150-200 ml.
• Duodenum is divided 2cm beyond the pylorus
Dr Gaurav Gupta ,JNM Raipur

49. .
RED---FOOD
GREEN—
BILIOPANCREAT
IC SERETIONS
BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH
100 cm(distal common channel)
Entire length of
alimentary
length -250 cm
Dr Gaurav Gupta ,JNM Raipur

50. Dr Gaurav Gupta ,JNM Raipur

51. COMPLICATIONS
• Peri-operative:
Bleeding
Injury to Liver or Spleen.
• Early Post-operative Complications (30 days):
Bleeding
anastomosis leak
Infection
Strictures
Deep venous thrombosis
Pulmonary complication -Atelectatsis, pneumonia, pulmonary
embolism, respiratory arrest secondary to sleep apnea, and
acute respiratory distress syndrome (ARDS).Dr Gaurav Gupta ,JNM Raipur

52. .
Gastrointestinal (GI) complication - Ulcer, stricture,
anastomonic obstruction, and small bowel obstruction
• Late Complications (greater then 30 days):
GI ulcer (stricture, obstruction),
Nutrition deficiency (protein, vitamin or mineral)
Internal/ incisional hernia,
Failure of weight loss or regain of lost weight
Psychological Side effects –Depression, disruption of social
relationships
Dr Gaurav Gupta ,JNM Raipur

53. Dr Gaurav Gupta ,JNM Raipur

54. CONCLUSION
• Bariatric surgery is an effective
means to achieve clinically
significant, permanent weight loss
with low rates of complications.
Dr Gaurav Gupta ,JNM Raipur

55. Dr Gaurav Gupta ,JNM Raipur

56. .
Dr Gaurav Gupta ,JNM Raipur