O alimentaie sntoas

Bariatric & metabolic surgeryDr. Dan TimofteUniversity of Medicine and Pharmacy Gr. T. Popa Iasi, ROMANIAThe 3rd Surgical Unit, Sf. Spiridon Hospital

What is Bariatric &metabolic surgery?

Bariatric surgery, from the Greek baros meaning weight, is synonymous with weight loss surgery. preclinical research indicates that bariatric surgery can alter the body's hormonal mechanisms and its ability to manage nutrients. This would mean that the vicious cycle is broken, hormonal triggers are reset, and patients may be able to achieve weight loss without fighting their own hormonal regulatory mechanisms Obesity is a health condition where the natural energy reserve stored in the fatty tissue is increased to a point where it is thought to be a risk factor for certain health conditions. These conditions include:HypertensionType 2 Diabetes MellitusCardiovascular Disease/MI

CancerSleep ApneaGERDPremature MortalityTaking care of patients can be extremely challengingAt their most basic, the words overweight and obesity are ways to describe having too much body fat.The most commonly used measure of weight status today is the body mass index, or BMI.

BMI uses a simple calculation based on the ratio of someones height and weight (BMI = kg/m2).

For adult men and women, a BMI between 18.5 and 24.9 is considered healthy.Overweight is defined as a BMI between 25.0 and 29.9; and a BMI of 30 or higher is considered obese.

1.6 billion people world wide are at least overweightThe highest prevalence in Canada.Almost 25% of people in the UK are overweight or obese.Even Asian countries are noticing and increaseOne can be obese yet malnourishedThe most common way to define obesity, and the definition used in most research studies, is BMI or Body Mass Index. BMI is calculated by weight, times 703, and then divided by height in inches squared. A BMI score over thirty is considered obese

(What Health, 2011)

Effect of obesity on hormones

LeptinLeptin deficient mice overfeed and rapidly become hyperinsulinemicLong arm of leptin receptor (LRb) activatesPI3 kinaseMAPKSTAT (signal transduce and activator transcription)C-fos

mecanism

AdiponectinMost abundant adipokineImportant insulin sensitizing agentInverse association of adiponecitn concentrations and cancerAntiproliferative effectsERKERK1MAPK kinasesInduces p53 and Bax

The metabolic dysregulation cycle

Eligibility CriteriaBMI 35 with risk factors ORBMI 40

BMI < 18.5: UnderweightBMI 18.5 - 24.9: NormalBMI 25.0 - 29.9: OverweightBMI 30: ObeseRecommended treatment depends on the severity of the disease

Surgery can interrupt the metabolic dysregulation cycle

The range of surgical options

Gastric SleeveGastric BandingGastric BypassGastric Plication

Gastric Sleeve

The vertical sleeve gastrectomy, also known as the sleeve gastrectomy or gastric sleeve, restricts the amount of food you eat by reducing the size of the stomach. The minimally invasive procedure removes a portion of the stomach, making the stomach roughly the size and shape of a banana.Patients who have a sleeve gastrectomy feel full after eating much less. In addition, the surgery removes the portion of the stomach that produces a hormone that can make you feel hungry, so you won't want to eat as much.This procedure can be an excellent alternative to gastric bypass or gastric banding. Sleeve gastrectomy is a simpler operation than the gastric bypass procedure because it doesnt involve rerouting or reconnecting the intestines.Sleeve Gastrectomy or Gastric Sleeve

Advantages of Sleeve Gastrectomy:

Fewer food intolerances than with gastric banding.Weight loss generally is faster with the sleeve than with gastric banding.There is no implantable band device, so slippage and erosion are not a risk.The surgical risk is lower than with gastric bypass procedures, but the weight loss is similar. No device that needs adjustment is inserted, so the follow-up regimen is not as intense as it is with gastric banding.

Disadvantages of Sleeve Gastrectomy:

Sleeve gastrectomy is not adjustable or reversible.Complication risks are slightly higher than with the band.

Risks/Complications:Standard risks associated with surgeryLeakage at the suture siteBlood clots

Sleeve Gastrectomy Animation

Gastric Banding

With gastric banding, an inflatable band is placed around the upper part of the stomach.The band creates a smaller stomach pouch, restricting the amount of food that can be consumed at one time.The band also increases the time it takes for the stomach to empty. As a result, patients achieve sustained weight loss by limiting food intake, reducing appetite and slowing digestion. Gastric Banding with the LAP-BAND or REALIZE Banding Systems

How Gastric Banding Works

The gastric banding procedure works by restricting the amount of food the stomach can hold by placing an adjustable band around the upper part of the stomach.There is no cutting or stapling needed to separate the upper stomach pouch from the lower stomach. Unlike stomach stapling, the gastric band can be adjusted to suit your needs.Minimally Invasive

During gastric banding surgery, the surgeon makes a few small incisions in the abdominal wall. Using laparoscopic techniques, a silicone adjustable band is secured around the upper part of the stomach, creating a small stomach pouch.The band is connected to tubing which attaches to an access port fixed beneath the skin of the abdomen. The port cannot be seen and can only be felt when pushing on the abdomen. The port and tubing allow for adjustments to be made. Read more about adjusting the gastric band.The stomach pouch created by the adjustable band controls the amount of food taken in. It allows a small amount of food to pass through, delaying the emptying of the stomach into the intestines. This process creates the sensation of fullness sooner and over time, hunger decreases.The procedure takes about 40 minutes and can be performed on an outpatient basis with no required hospital stay. Recovery times may vary, but patients can generally return to work and normal activities within four to seven days.Because the surgery uses laparoscopic techniques, patients experience less post-operative pain, recover quicker and are able to return to normal activities sooner, compared to other forms of bariatric surgery.Gastric Banding Animation

Gastric Bypass

Gastric bypass limits the amount of food that you can eat and digest. In a Roux-en-Y gastric bypass, the stomach is made smaller by creating a small pouch at the top of the stomach using surgical staples or a plastic band. The resulting pouch is only about the size of a walnut and can hold about one ounce of food. After the pouch has been created, most of the stomach and part of the intestines are bypassed by attaching (usually stapling) part of the intestine to the small stomach pouch. As a result, a gastric bypass patient cannot eat as much and absorbs fewer nutrients and calories.This minimally invasive, laparoscopic method allows for less time spent in the hospital and faster recovery and healing time.Minimally Invasive Gastric Bypass SurgeryAdvantages of Gastric Bypass:Rapid initial weight lossApproach is minimally invasive approachLonger clinical experience in the U.S.Slightly higher total average weight loss reported than with purely restrictive proceduresRapid improvement or resolution of type 2 diabetes and metabolic syndromeDisadvantages of Gastric Bypass:Cutting and stapling of stomach and bowel are requiredMore potential operative complicationsPortion of digestive tract is bypassed, reducing absorption of essential nutrientsPotential complications due to nutritional deficiencies"Dumping syndrome" can occurProcedure is not adjustable and difficult to reverseHigher mortality rateRisksMortality rate: 0.5 - 2 percentTotal complications: 23 percentMajor complications: 2.1 percentThe most common complications include:Standard risks associated with major surgeryNausea and vomitingSeparation of stapled areas (requires major revisional surgery)Leaks from staple lines (requires major revisional surgery)Nutritional deficienciesGastric Bypass Animation

Gastric Plication

Laparoscopic gastric plication is a newer minimally invasive weight-loss surgery technique that reduces the size of the stomach capacity to approximately three ounces.Gastric plication procedure folds the stomach in on itself to reduce its size.The procedure does not involve the use of an implanted device (such as gastric banding). Also, unlike the gastric sleeve procedure, gastric plication may be reversible because a portion of the stomach is not removed. In addition, unlike gastric bypass, gastric plication does not involve rerouting and reconnecting the intestines.It is a restrictive weight-loss surgery, meaning that it restricts the amount of food the stomach can hold. You will feel full sooner so you wont want to eat as much.Gastric plication uses laparoscopic techniques resulting in faster recovery and less scarring than open surgery. Gastric Plication - The New Weight-Loss Surgery

Advantages

No rerouting of intestines as with gastric bypassDoes not involve implanting a banding device around a portion of the stomachNo adjustments are needed as with gastric bandingProcedure may be reversible, unlike sleeve gastrectomy or gastric bypass.Disadvantages

Gastric plication is a newer procedure and hasnt been tested as long as sleeve gastrectomy, gastric banding or gastric bypass.It is not covered by insurance at this timeRisks

Standard risks associated with surgery and general anesthesiaNausea and vomitingSeparation of stitched areas (requires revisional surgery)Leaks from sutured areas (requires revisional surgery)Gastric Plication Animation

Results: Weight Loss Measures

Pathophysiology - Changes in Satiety and HungerGhrelin - stimulates hungerDecreasedLeptin - decreases hunger, sends signals to brain when full - the more fat mass the more leptin you producePeptide YY - peptide released by cells in response to eatingIncreased

Potential Complications & Side EffectsEarly ComplicationsBleedingAbdominal pain,bloatingDumping syndromeLate complicationsNausea or vomitingExcess or loose skinSmall bowel obstructionUlcersBacterial overproduction* Electrolyte and nutrient deficiencies

SurgeryTeens cannot expect a quick fix in losing weight because they need time to adjust mentally

Results: Quality of Life OutcomesAfter surgery, life expectancy increased to 80-81 years compared to no surgery at 78 years

Mortality rate of 0.3%

Meta-analysis: 136 studies and 22,094 patients Diabetes was completely resolved in 76.8% and resolved or improved in 86.0%Both hyperlipidemia and hypertension resolved or improved in 87.1%Prognosis

Figure 6. EQ-5D Results 6 Months Post-Surgery (n=31)

Obesity-related diseases improved with bariatric surgery

Results: Improvements in Comorbid ConditionsType 2 Diabetes MellitusDefining Glycemic ControlGlycemic Control at Baseline (n=66)

Risk of premature death reduced 89%

Very Low Calorie Diet (VLCD) +/- Behavior Modification

Dyslipidemia

Changes in Lipid Profile

NEJM Summary of ResultsSjstrm, et al conducted a prospective, controlled study comparing severely obese patients desiring bariatric surgery with equally obese patients not desiring surgery. The study concluded bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality.A 29% reduction in death was found after an average follow up of 10.9 years.Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects, by Sjstrm et al.The study concluded that long-term mortality for gastric-bypass patients was significantly reduced. Overall deaths were reduced by 40% Deaths from diabetes were reduced by 92% Deaths from heart disease were reduced by 56% Deaths from cancer were reduced by 60%More than 30% of what gets us old or ill it's not about our genes, it's about our life style. Dr. Dominique Lanzmann-Petithory, Hpital Emile Roux, Val de Marne, Franta.