Obesity

MORBID OBESITY&

BARIATRIC SURGERY

PRESENTATION BY DR.BARUN KUMAR

UNIT-IIA (G.S.), IPGMER

MORBID OBESITY

PROBLEM IN INDIA:

• PREVALENCE OF OBESITY HAS RISEN TO 15% (NFHS-3) FROM 2%(NFHS-1)

•AS MUCH AS 5% OF POPULATION IS MORBIDLY OBESE ( NFHS-3)

•WOMEN HAS HIGHER OBESITY RATES

•AMONG STATES, PUNJAB, KERELA AND DELHI ARE AMONG TOP 3 IN TERMS OF OBESITY

•MOST AFFECTED AGE GROUP IS 35-44 YEARS

•PREVALENCE OF OBESITY IN ADOLESCENSE BETWEEN 10-30%

OBESITY

GENETICS

DIET AND LIFESTYLE

MEDICAL

CONDITIONS

ENVIRONMENTAL FACTOR

FTO GENEMCR4 GENE

THRIFTY GENE

ENDOCRINE DISORDERSPRADER WILLI SYNDROME

DIABETES,HYPERTENSION,METABOLIC SYNDROME

WEALTH FAST FOOD CULTURE

PATHOPHYSIOLOGY:

MANAGEMENT:

MEDICAL MANAGEMENT

SURGICAL

MANAGEMENT

PSYCHOLOGICAL MOTIVATION

MANAGEMENT:

DIETARY RESTRICTIONS EXERCISE PHARMACOLO

GICAL THERAPY

•SIBUTRAMINE (BLOCK UPTAKE OF NE & SEROTONIN)•ORLISTAT ( INHIBITS PANCREATIC LIPASE)

•PRIMARY RESTRICT FAT INTAKE•PRIMARY RESTRICT CARBOHYDRATE INTAKE

MANAGEMENT:

MEDICAL MANAGEMENT:

•EVERY PATIENT SHOULD BE GIVEN A TRIAL OF MEDICALLY SUPERVISED DIET PROGRAM TO CHECK FOR ANY IMPROVEMENT

•INITIAL GOAL OF THERAPY IS TO ATTAIN A WEIGHT LOSS OF 8-10% OF BODY WEIGHT OVER A PERIOD OF 6 MONTHS OR WEIGHT LOSS OF 0.5 TO 2 lb/WEEK

• MAINTAINANCE OF WEIGHT LOSS FOR 6 MONTHS DEFINE THE INITIAL MEDICAL SUCESS WITH MEDICAL THERAPY

BARIATRIC SURGERY

INDICATIONS:BMI >40KG/M2 OR BMI >35 KG/M2 WITH AN ASSOCIATED MEDICAL COMORBODITY WORSENED BY OBESITY

FAILED DIETARY THERAPY

PSYCHIATRICALLY STABLE WITHOUT ALCOHAL DEPENDENCE OR ILLEGAL DRUG USE

MOTIVATED INDIVIDUAL

MEDICAL PROBLEMS NOT PRECLUDING PROBABLE SURVIVAL FROM SURGERY

KNOWLEDGEABLE ABOUT THE OPERATION AND ITS SEQUELAEEXCLUSION OF PRADER-WILLI SYNDROME

BARIATRIC SURGERY

PREOPERATIVE EVALUATION AND PREPARATION:

SEVERELY OBESE PATIENTS PRESENTS WITH AN ARRAY OF COMORBID CONDITIONS, REQUIRNIG PROPER SCREENING AND MANAGEMENT BOTH BEFORE AND AFTER THE OPERATION.

PROPER EDUCATION ABOUT THE PROCEDURE , EXPECTED RESULTS AND POTENTIAL COMPLICATIONS SHOULD BE GIVEN, WITH INDIVIDUAL COUNSELLING BY: SURGEON NUTRITIONISTPSYCHIATRIST/PSYCHOLOGISTANAESTHESIOLOGIST

BARIATRIC SURGERY CONDITION SCREENING/MANAGEMENT

CORONARY ARTERY DISEASE

ECG, ECHO, STRESS TEST,

OBSTRUCTIVE SLEEP APNEA

DIAGNOSTIC SLEEP STUDY, RX :POSITIVE AIRWAY PRESSURE DEVICE

HYPOVENTILLATION SYNDROME OF OBESITY

RESTING PAO2<55mm of Hg + PACO2>47mm hg WITH PUL HYPERTENSION AND POLYCYTHEMIARX:POST-OPERATIVE ICU HOSPITALIZATION

BARRETT’S ESOPHAGUS IN GERD

UPPER GI ENDOSCOPY WHILE PLANNING LRYGB

VENOUS THROMBOEMBOLISM

LMWHTEMPORARAY INF VENA CAVAL FILTERS

CHOLELITHIASIS SCREENING ULTRASOUNDOPERATION IN SAME SITTING (addn operative time of 30 mins with no inc in hospital stay morbidity)

LIVER SIZE OPERATIVE DIFFICULTYRX: LOW CALORIE DIET BEFORE OPERATION

OTHERS THYROID PROFILE, IRON, VIT-D LEVELS

BARIATRIC SURGERY

MECHANISM OF ACTION:LARGELY

MALABSORPTIVE,MILDLY RESTRICTIVE:

A)BILIO-PANCREATIC DIVISION

B)DUODENAL SWITCH

LARGELY RESTRICTIVE,MILDLY

MALABSORTIVE:ROUX EN-Y GASTRIC

BYPASS

RESTRICTIVE:A)VERTICAL BANDED

GASTROPLASTYB)LAPAROSCOPIC

ADJUSTABLE BANDING

C)LAPAROSCOPIC SLEEVE

GASTRECTOMY

BARIATRIC SURGERY HISTORY:FIRST PUBLISHED BARIATRIC PROCEDURE WAS KREMEN IN 1954 : JEJUNO-INTESTINAL BYPASS

MASON (1960) DID GASTRIC BYPASS PROCEDURE : PARTIAL GASTRECTOMY WITH LOOP GASTRO-ENETEROSTOMYMASON (1980S) DEVELOPED VERTICAL BANDED GASTROPLASTY KUZMAC (1986) ADDED AN ADJUSTABLE INFLATABLE PORTION (AGB)

SCOPINARO (1976) : BILIO-PANCREATIC DIVERSION HESS (1988) : DUODENAL SWITCH

NEW ON HORIZON ARE IMPLANTABLE GASTRIC STIMULATION INTRAGASTRIC BALLOON

BARIATRIC SURGERY

VERTICAL BAND GASTROPLASTY

PROCEDURE HAS BEEN ABONDED BECAUSE OF:

HIGH RATE OF STENOSIS OF GASTRIC OUTLLETPOOR LONG-TERM WEIGHT LOSSTENDENCY OF PATIENT TO ADOPT HIGH CALORIE LIQUID DIET

Purely restrictiveRapid sense of satietyReduced calorie intake

Pouch creationHole through anterior and posterior wallStaple line to angle of HisNondistensible band around distal

neo-pouch

BARIATRIC SURGERY LAPARASCOPIC ADJUSTABLE GASTRIC BANDING

PRINCIPLE OF ACTION:

DISTENSION OF PROXIMAL PART OF STOMACH

FEEDBACK BY VAGAL CENTER TO BRAIN

EARLY SATIETY AND DECREASE APETITE

PERFORMED FIRST BY DR.CADIERE IN 1992

OFFERS THE ADVANTAGE OF ADJUSTING STOMA DIAMETER

TECHNIQUALLY SIMPLER THAN OTHER LAPRASCOPIC PROCEDURES

BARIATRIC SURGERY

BARIATRIC SURGERY Peritoneum at the angle of his is dividedOpening created b/w angle of his and top of spleen

PARS FLACCIDA TECHNIQUE:gastro-hepatic ligament divided in its thin areaRight crus of diaphragm is identified and followed at its surface

An avascular plane is created and reached upto the opening on angle of his

Adjustable band (inserted through another 15mm port) is pulled through this tunnel and locked.Anterior gastric wall is plicated over the band.

Silastic tubing leading from the band is pulled through the 15mm portPort site is enlarged and access port is connected to the tubing and fixed with care taken to avoid kinking.

BARIATRIC SURGERY

BARIATRIC SURGERY

ROUX-EN-Y GASTRIC BYPASS•DIVISION OF JEJUNUM 30-40 CM DISTAL TO LIGAMENT OF TREITZ

A ROUX LIMB IS CREATED AND ANASTAMOSED WITH PROXIMAL SMALL POUCH OF STOMACHTHE LENGTH OF ROUX LIMB CAN BE VARIED FOR DIFFERENT PATIENTS (MIN SHOULD BE 75CM)80-120 CM FOR BMI IN THE 40S150 CM FOR BMI MORE THAN 50

THE ROUX LIMB MAY BE TAKEN THROUGH ANTECOLIC/RETROCOLIC ROUTERETROCOLIC MAY BE ANTE/RETROGASTRIC

•GASTRIC POUCH CONSTRUCTED FROM CARDIA OFSTOMACH•CLOSURE OF ALL POTENTIAL SPACES SHOULD BE DONE TO PREVENT INTERNAL HERNIA

BARIATRIC SURGERY

BARIATRIC SURGERY

BILIOPANCREATIC DIVERSION

A SHORT CHANNEL OF DISTAL 50 CM OF TERMINAL ILEUM IS RECONSTRUCTED FOR ABSORPTION OF FAT AND PROTEIN

THE ALIMENTARY TRACT BEYOND PROXIMAL PARTOF STOMACH HAVE ONLY 200 CM OF ILEUM.

THE PROXIMAL END OF THIS SEGMENT IS ANASTOMOSED WITH PROXIMAL END OF STOMACH AFTER PERFORMING HEMIGASTRECTOMY

THE VOLUME OF GASTRIC POUCH IS TAILORED ACCORDING TO PATIENTS BMI : BMI<50 = 250ML BMI>50= 150 ML

BARIATRIC SURGERY

BARIATRIC SURGERY

DUODENAL SWITCH:

THIS MODIFICATION TO BPD WAS DEVELOPED TO DECREASE THE INCIDENCE OF MARGINAL ULCERS .

A SLEEVE GASTRECTOMY IS PERFORMED(150-200ML)THE FOLLOWING PART OF OPERATION CAN BE DONEIN SAME SITTING OR POSTPONED TO ANOTHER SITTING IN CASE OF: a)INTRA-OPERATIVE INSTABILITY b)HIGH BMI (>50)SLEEVE GASTRECTOMY ALLOWS WEIGHT LOSS POST-OPERATIVELY AND MAKE FURTHER OPERATION EASY

NEXT TO SLEEVE GASTRECTOMY, DUODENUM ISDIVIDED 2CM BEYOND THE PYLORUSTHE DISTAL CONNECTIONS ARE SAME AS BPD EXCEPTFOR THE LENGTH . COMMON CHANNEL=100CM ENTERIC LIMB (WHOLE)=250CM

BARIATRIC SURGERY

BARIATRIC SURGERY SLEEVE GASTRECTOMY

WAS INITIALLY USED AS A FIRST STAGE OPERATION IN DS

LATER ON, ITS EFFECTIVENESS AS A SINGLE STAGE PROCEDURE WAS IDENTIFIED AS PATIENTS UNDERGOING TWO STAGE PROCEDURE ABONDONED THE SECOND OPERATION ALTOGETHER.

IN PRIMARY PROCEDURE, THE ENTIRE GREATER CURVATURE IS TAKEN DOWN,LEAVING TISSUE WITHIN 4-6CM OF PYLORUS, UPTO THE ANGLE OF HIS.

SEVERAL LONG TERM TRIALS ARE UNDERGOING FOR ASSESING ITS LONG-TERM EFFICACY IN CONTROLLING WEIGHT,HOWEVER, DATA UNTIL NOW SUGGESTS SUPERIOR WEIGHT LOSS THAN AGB AND EQUAL TO RYGB.

BARIATRIC SURGERY

BARIATRIC SURGERY

•ADVANTAGES OF SLEEVE GASTRECTOMY :•TECHNICAL SIMPLICITY

•PRESERVATION OF PYLORUS (AVOIDANCE OF DUMPING)

•METABOLIC REDUCTION OF GHRELIN LEVELS

•LACK OF NEED OF SERIAL ADJUSTEMENTS (AGB)

•REDUCTION IN INTERNAL HERNIAS (RYGB)

•ABILITY TO MODIFY THE SLEEVE GASTRECTOMY INTO RYGB OR DS CONFIGURATION LATER ON

BARIATRIC SURGERY IMPLANTABLE GASRIC STIMULATOR:

DEVELOPED BY CIGAINA IN 1990S

THE DEVICE CONSISTS OF A STIMULATION LEAD IMPLANTED IN LESSER CURVATURE BY LAPAROSCOPY THE DEVICE IS CONNECTED TO A SUBCUTANEOUS ELECTRIC PULSE GENERATOR

MYOELECTRIC STIMULATION GASTRIC MOTILITY STIMULATE CENTRAL HARMONES PRODUCING SATIETY INITIAL EWL DOESN’T REACH HIGH VALUES AS OTHER PROCEDURESEWL OF 70% AT 8 YEAR FOLLOW-UPLACKS SIDE EFFECTS OF RESTRICTIVE AND MALABSORTIVE PROCEDURES

BARIATRIC SURGERY

BARIATRIC SURGERY

INTRA-GASTRIC BALLOON

THE BALLOON IS PLACED ENDOSCOPICALLY IN STOMACH IN DEFLATED STATETHE BALOON IS THEN FILLED WITH SALINE,

TO CREATE A SENSE OF STOMACH FULLNES

ACTIVATES CENTRAL HARMONES SUPPRESSING FEEDING

ITS BEEN APPROVED BY FDA FOR USE IN INDIAUSED AS A PRIMARY PROCEDURE IN PATIENTS WITH VERY HIGH BMI TO REDUCE WEIGHT BEFORE THE SECONDARY DEFINITIVE PROCEDURE.

LONG TERM FOLLOW UP STUDEIS ARE NOT STILL AVAILABLE TO ASSESS ITS EFFECTIVENESS AS SINGLE PROCEDURE FOR WEIGHT REDUCTION

BARIATRIC SURGERY

BARIATRIC SURGERY

POST-OPERATIVE CARE:

A) HIGH INDEX OF SUSPICION FOR ANASTAMOTIC LEAK. SIGN:TACHYPNEA, AGITATION, FEVER SYMPTOMS: TACHYCARDIA, RIGID ABDOMEN,

DEHYDRATION INVESTIGATIONS: CONTRAST CT SCAN

RESUSCITATE OBSERVE

B) ADEQUATE PAIN CONTROL

C) DVT PROPHYLAXIS

D) PLAN FOR DISCHARGE

E)FOLLOW-UP

PREPARE TO REOPERATE

BARIATRIC SURGERY

COMPLICATIONS:

APART FROM THE USUAL COMPLICATIONS FOLLOWING INTRA-ABDOMINAL SURGERIES, EACH BARIATRIC PROCEDURE CARRIES HAS UNIQUE COMPLICATIONS

THIS DEMANDS A HIGH INDEX OF SUSPICION AND PROMPT INTERVENTIONS ON DIAGNOSIS

BARIATRIC SURGERY

Study (Year)*

PARAMETERFLUM ET AL (2009)†

O’BRIEN ET AL (2002)[10]

BUCHWALD ET AL (2004)[30]

MAGGARD ET AL (2005)29

PONCE ET AL (2005)[32]

No. of patients

1198 1120 2297 9222 1014

Mortality 0 0 0.1% 0.04 0

Postoperative complications

1.0 1.5   13.2  

Slippage   13.9    21 (PG)/1.4 (PF)

Erosions   3     0.2Port complications

  5.4     1.2

Reoperations   25.3   7.7  

DVT-PE 0.3% 0      Wound infection

  0.9  

Complications After Laparoscopic Adjustable Gastric Banding

BARIATRIC SURGERY

Study (Year)

PARAMETER SUGERMAN (2003)

MAGGARD ET AL (2005)

BUCHWALD ET AL (2004)

No. of patients 1025 11,290 5644

Mortality (%) 0.9 0.3 0.5

Gastrointestinal bleeding (%)   2.0  

Leak, major wound complications (%)

3 2.2  

Complications After Roux-en-Y Gastric Bypass

BARIATRIC SURGERY

Study (Year)

PARAMETER SCOPINARO (1998)

BUCHWALD ET AL (2004)

MAGGARD ET AL (2005) REN (2004)

Number of patients 2241 3030 2808 170

Mortality 0.5 1.1 0.9  Leak 0.1   1.8  DVT-PE 0.06      

Medical problems, malnutrition

3      

 Iron deficiency anemia 40      

 Vitamin A deficiency 2.9%     69

 Vitamin K deficiency       68

 Vitamin D deficiency       63

 Complications After Malabsorptive Operations (Biliopancreatic Diversion and Duodenal Switch)

BARIATRIC SURGERY FOLLOW-UP

A)SHORT TERM FOLLOW-UP: (UPTO 2 YEARS)

o TO MAXIMIZE CARE OF PATIENT IN POST OPERATIVE PERIOD.oASSIST PATEINT IN NEW LIFESTYLE, EATING HABBITS, EXERCISEoEARLY IDENTIFICATION OF POST-OPERATIVE COMPLICATIONS

B)MEDIUM TERM FOLLOW-UP : (2-5 YEARS)C)LONG TERM FOLLOW-UP : (>5 YEARS)

BOTH MEDIUM AND LONG TERM FOLLOW UP ARE DESIGNED FOR TASSESSMENT OF LONG TERM WEIGHT LOSS.

BARIATRIC SURGERY

RESOLUTION OF OTHER COMORBOTIES AFTER SURGERY:

DIABETES: RYGB BEING THE MOST EFFECTIVE, (85% IN 2 YEAR F.U.) RESOLUTION OF DIABETS WELL BEFORE WEIGHT LOSS ACHIEVED RUBINO AND COLLEAGUES SUGGESTED REDUCTION OF ANTI-INCRETIN EFFECT LAGB ALSO EFFECTIVE IN REDUCTION OF DIABETES 73% CASES HAD RESOLUTION IN 2 YEAR FOLLOW UP

RECOGNITION OF BARIATRIC SURGERY AS SINGLE BEST TREATMENT OF CHOICE OF DIABETES IN OBESE.

BARIATRIC SURGERY HYPERTENSION : 78.5% CASES SHOWED IMPROVEMENT AND 61.7% CASES HAD RESOLUTION IN 2 YEAR FOLLOW UP (BUCHWALD)

DYSLIPEDEMIA: 96.9% CASES SHOWED IMPROVEMENT AND 70% CASES HAD RESOLUTION IN 2 YEAR FOLLOW UP (BUCHWALD)

SLEEP APNEA: 85.7%CASES SHOWED IMPROVEMENT AND 83.6% CASES HAD RESOLUTION IN 2 YEAR FOLLOW UP (BUCHWALD)

GERD: RYGB BEING MOST EFFECTIVE (95-97% EFFICACY) LAGB EFFECTIVE TO A LESSER EXTENT

NON-ALCOHOLIC FATTY LIVER DISEASE MUSCULOSKELETAL PROBLEM

TAKE HOME MESSAGE:

OBESITY STILL REMAIN AS ONE OF THE MAJOR UNADRESSED PROBLEM IN NEW WORLD

RECOGNITION OF BARIATRIC SUREGRY AS MORE THAN “JUST COSMETIC SURGERY” IS ESSENTIAL

SURGERY REMAINS AS THE SINGLE MOST EFFECTIVE MEASURE FOR WEIGHT REDUCTION IN MORBIDLY OBESE

PATIENT SELECTION AND PROCEDURE SELECTION SHOULD BE TAILORED FOR EACH CASE

BARIATRIC SURGERY

LAPARASCOPIC BARIATRIC PROCEDURES ARE SUPERIOR OVER THEIR OPEN COUNTERPART

POST-OPERATIVE CARE AND COUNSELLING REGARDING LIFE STYLE MODIFICATION IS ESSENTIAL

NEWER UNDER-TRIAL PROCEDURES ARE THERE TO LOOK AFTER TO, IN NEAR FUTURE

REFERENCES: •SABISTON TEXTBOOK OF SURGERY 19TH EDITION

•SCHWARTZ’S PRINCIPLES OF SURGERY 9TH EDITION

•RECENT ADVANCES IN SURGICAL MANAGEMENT OF MORBID OBESITY ( LOIZIDES S, ZOGRAFAKIS J., FRANTZIDES C.)

•INTERNATIONAL ASSOCIATION FOR THE STUDY OF OBESITY- CLINICAL OBESITY

•ELSEVIER EXPERT CONSULT.COM

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