morbid obesity and surgical management

Dr Gaurav Gupta ,JNM Raipur

MORBID OBESITY AND SURGICAL MANAGEMENT

.

Dr Gaurav GuptaRSO dept. of surgeryJNM medical college raipur

Dr Gaurav Gupta ,JNM Raipur

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

Gaurav Gupta

Dr Gaurav Gupta ,JNM Raipur

HOW IS IT CALCULATED

Dr Gaurav Gupta ,JNM Raipur

27.5

Dr Gaurav Gupta ,JNM Raipur

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

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

.

Dr Gaurav Gupta ,JNM Raipur

CONDITIONS ASSOCIATED WITH MORBID OBESITY

.

TYPE2 DIABETES

CARDIOVASCULAR HYPERTENSION,CAD,CHF HYPERTRIGLYCERIDEMIA VASCULAR DS.MENTAL HEALTH LOW SELF ESTEEM DEPRESSIONORTHOPEDIC OSTEOARTHRITIS degenerative joints

.

HEPATIC CHOLELITHIASIS,CIRRHOSIS STEATOHEPATITIS RENAL MICROALBUMINURIANEUROLOGICAL PSEUDOTUMOR CEREBRISKIN ACANTHOSIS NIGRICANS

INTERTRIGO

Dr Gaurav Gupta ,JNM Raipur.

• 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

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

Dr Gaurav Gupta ,JNM Raipur

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

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

• AGE-16 TO 65 years

Dr Gaurav Gupta ,JNM Raipur

.• Knowledgeable about the operation and its sequelae

• Motivated individual

• Medical problems not precluding probable survival from surgery

Dr Gaurav Gupta ,JNM Raipur

CONTRAINDICATIONS TO BARIATRIC SURGERY

• Cardiac problem• Respiratory dysfunction• Significant psychological disorders• Who are unable to ambulate• Prader-Willi syndrome

Dr Gaurav Gupta ,JNM Raipur

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.

• 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

LAPARASCOPIC PROCEDUREDONE 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

.

EXTRA LONG TROCARS

OPTI-VIEW TROCARS

GASTRIC CALIBRATION TUBE

Dr Gaurav Gupta ,JNM Raipur

.

Dr Gaurav Gupta ,JNM Raipur

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

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

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

Dr Gaurav Gupta ,JNM Raipur

. 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

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 band

Dr Gaurav Gupta ,JNM Raipur

.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

REALIZE BAND

Dr Gaurav Gupta ,JNM Raipur

Dr Gaurav Gupta ,JNM Raipur.

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

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

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

ADVANTAGES -SLEEVE GASTRECTOMY

• Simple ,rapid & less traumaticsafe 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

COMPLICATION

• Leakage along the long gastric staple line.• Long term fistula formation.

Dr Gaurav Gupta ,JNM Raipur

.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

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

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

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

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

.

ROUX LIMB Y LIMB

Dr Gaurav Gupta ,JNM Raipur

Dr Gaurav Gupta ,JNM Raipur

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

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

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

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

BILIOPANCREATIC DIVERSION (BPD)

250 cm

50cm

Dr Gaurav Gupta ,JNM Raipur

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

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

.

RED---FOOD

GREEN—BILIOPANCREATIC SERETIONS

BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH

100 cm(distal common channel)

Entire length of alimentary length -250 cm

Dr Gaurav Gupta ,JNM Raipur

Dr Gaurav Gupta ,JNM Raipur

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

.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.

Dr Gaurav Gupta ,JNM Raipur

CONCLUSION• Bariatric surgery is an effective

means to achieve clinically significant, permanent weight loss with low rates of complications.

Dr Gaurav Gupta ,JNM Raipur

Dr Gaurav Gupta ,JNM Raipur

.