Surgical Managemen

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Obesity Refrence :

Schwartzs Principles of Surgery 10th ed Page 1099

Presented by Dr Sadatinejad, Seyyed Mohsen,student of Medicine

from Iran,Kashan 29/1/2017

DISEASE OF OBESITY - the second leading cause of preventable death in the United States

Epidemiology-2013 : obesity prevalence in the United States = 35.7% of U.S. adults (class 1 or higher)-Genetic

- parents of normal weight :10% chance of obese child (in adulthood)

- two obese parents :80-90% chance of obese child (in adulthood)

-Environment : Diet and culture- lack of satiety + excessive caloric intake-reduced metabolic activity-reduced thermogenic response to meals-intraluminal bacterial composition of the intestinal tract-.

Concurrent Medical and Social Problem

Social : NO Public facilities : size of bus or airline seats/ clothing /size of automobile cabins

thought being lazy and lacking self-discipline by others stigma of severe obesity Depression Poor self-image

Concurrent Medical and Social Problem

Medical :

DJD

low back pain

Hypertension

obstructive sleep apnea

GERD

Cholelithiasis

diabetes II

Hyperlipidemia

Asthma

cardiac arrhythmias

right-sided heart failure

migraine headaches

pseudotumor cerebri

venous stasis ulcers

DVT

fungal skin rashes

skin abscesses

stress urinary incontinence

infertility

.

dysmenorrhea

depression

abdominal wall hernias

cancers :

Uterus

Breast

Colon

Prostate

Prognosis estimate : a severely obese male at age 21 will live 12 years less and a woman 9 years less than a nonobese individual

The incidence of severe obesity ◦ for men, it is decreased above age 50◦ This is due to the fact that the severely obese man often is

dead of comorbid medical conditions, especially cardiac arrhythmias and coronary artery disease, by age 50.

Medical Management Life Style (diet + exercise + behavior modification) The success rate for the severely obese patient is only 3%.

(success = to no longer be obese and maintaining that weight loss)

Rx Orlistat, Qsymia, Lorcaserin

Surgical Management (Bariatric Surgery)

Surgical Management (Bariatric Surgery)

Surgical Management (Bariatric Surgery)

laparoscopic Adjustable gastric Banding

LAGB involves placement of an inflatable silicone band around the proximal stomach

laparoscopic Adjustable gastric Banding

outcome

5 and 7 years after LAGB, patients lost 60% and 58% of excess weight

Hypertension resolving in 55% at 1 year

Sleep apnea decreasing from 33% to 2%

GERD improving in over 50% of cases

Asthma,depression,and quality of life improving

Resolution of diabetes was 13% in the medical group versus 73% in the surgical group after a 2-year follow-up

Roux-en-Y gastric Bypassa proximal gastric pouch of small size (often <20 mL) separated from the distal stomach.

A Roux limb of proximal jejunum is anastomosed to the pouch.

Biliopancreatic limb :20-50 cm

Roux limb :75 to 150 cm

The pathway of that limb

Roux-en-Y gastric Bypass

Relative contraindications previous gastric surgery

previous antireflux surgery

severe iron deficiency anemia

distal gastric or duodenal lesions that require ongoing future endoscopy

Barrett’s esophagus with severe dysplasia.

Roux-en-Y gastric Bypass

Outcome Weight Loss : 60%-70% of excess body weight / during 1 years

GERD and venous stasis ulcers : Resolution over 90%

Diabetes II : Resolution over 80% / during 5 years

Hyperlipidemias : improve 100% and resolve totally in 70%.

Hypertension : resolves in 50-65% of cases

Roux-en-Y gastric Bypass

Complications 0.3% incidence of anastomotic leak

1-19% incidence of anastomotic stenosis

3-15% incidence of marginal ulcers

7% incidence of bowel obstruction

Postoperative nutritional complications after LRYGB

66% incidence of iron deficiency

5% incidence of iron deficiency anemia

50% incidence of vitamin B12 deficiency

15% incidence of vitamin D deficiency

Roux-en-Y gastric Bypass

Biliopancreatic Diversion with Duodenal Switch (BPD-DS)

A part of the stomach is removed

the surgeon leaves the pylorus intact

then connect it to the ileum (distal 250 cm)

Duodenal Switch

Weight loss : 70% and very durable

complication :

obstruction 1.2%

marginal ulcer 2.8%

Nutritional complication

protein malnutrition 7%

iron deficiency anemia <5%

bone demineralization (5 years) 53%

Alopecia, night blindness, gallstones

Duodenal Switch

Patient must accept frequent, voluminous bowel movements

Pateint must modify their eating pattern to restrict intake if not access to a bathroom

Contraindications :

patient must agree to close follow-up by the surgeon

Patients must have the financial affordability for the

large number of supplements

Duodenal Switch

Sleeve gastrectomyThis procedure (SG) represents the gastric portion of the DS procedure

Sleeve gastrectomyoutcome:

SG is superior to LAGB for excess weight loss at 3 years (66% vs. 48%)

SG have greater appetite suppression and a lower serum ghrelin level

Complication :

bleeding rate of the staple line

staple line leakage

Thank you for tour attention