morbid obesity and surgical management

Dr Gaurav Gupta ,JNM Raipur

MORBID OBESITY AND SURGICAL MANAGEMENT

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Dr Gaurav GuptaRSO dept. of surgeryJNM medical college 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


HOW IS IT CALCULATED


27.5


HOW DOES MORBID OBESITY DIFFER FROM BEING OVERWEIGHT OR OBESE??Overweight and obese – reversible

medical management

Morbid obesity - surgical intervention


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.


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CONDITIONS ASSOCIATED WITH MORBID OBESITY

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TYPE2 DIABETES

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

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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


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


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.


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


.• Knowledgeable about the operation and its sequelae

• Motivated individual

• Medical problems not precluding probable survival from surgery


CONTRAINDICATIONS TO BARIATRIC SURGERY

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


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


• CARDIOVASCULAR/RESPIRATORY EVALUATION:Exclude any contraindications to anesthesia by TMT, Echo, PFT, ABG , CXR etc.

•PSYCHIATRIC EVALUATION:.

• ENDOCRINE EVALUATION:

• DENTAL EVALUATION


LAPARASCOPIC PROCEDUREDONE UNDER G.A 5 TO 6 PORTS

THE BENEFITS ARE:

•Less Pain•Quicker recovery•Fewer complications(PTE)•Less scar•Shorter hospital stay


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EXTRA LONG TROCARS

OPTI-VIEW TROCARS

GASTRIC CALIBRATION TUBE


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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)


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.


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


. 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.


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


.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


REALIZE BAND


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


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


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


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.


COMPLICATION

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


.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.


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


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


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


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)


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ROUX LIMB Y LIMB


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.


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%.


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


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).


BILIOPANCREATIC DIVERSION (BPD)

250 cm

50cm


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.


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


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RED---FOOD

GREEN—BILIOPANCREATIC SERETIONS

BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH

100 cm(distal common channel)

Entire length of alimentary length -250 cm


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).

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.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


CONCLUSION• Bariatric surgery is an effective

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


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morbid obesity and surgical management

Health & Medicine