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Gastrointestinal Gastrointestinal Surgery for Severe Surgery for Severe
ObesityObesityPrepared By:Prepared By:
Dr. Fahad Al-JindanDr. Fahad Al-Jindan
OutlineOutline
IntroductionIntroduction Who are the candidates for Who are the candidates for
SurgeriesSurgeries The Normal Digestive ProcessThe Normal Digestive Process Surgical Options Surgical Options Benefits and RisksBenefits and Risks
IntroductionIntroduction
Obesity is Obesity is chronic chronic conditioncondition
BMI>= 30 BMI>= 30 (26%)(26%)
Severe Obesity Severe Obesity BMI>=40 BMI>=40 (2.9%)(2.9%)
IntroductionIntroduction
Obesity Related Medical conditionsObesity Related Medical conditions Methods of Weight lossMethods of Weight loss• Dietary Dietary • Physical ActivityPhysical Activity• Behavior therapyBehavior therapy• SurgerySurgery
SurgerySurgery
well-established method of long-term well-established method of long-term weight control weight control
weight loss of 60% of excess weight weight loss of 60% of excess weight after five years (1)after five years (1)
Benefits outweigh the Risks (2)Benefits outweigh the Risks (2)
Candidates for SurgeryCandidates for Surgery
CandidatesCandidates
BMI >=40BMI >=40 Obesity Related Physical ProblemObesity Related Physical Problem Obesity Related Health problemsObesity Related Health problems Unlikely to lose weight with non Unlikely to lose weight with non
surgical methodssurgical methods Understand procedures, risks and Understand procedures, risks and
effectseffects Life long behavioral commitmentLife long behavioral commitment
Normal Digestive Normal Digestive ProcessProcess
How Does Surgery How Does Surgery Work??Work??
RestrictiveRestrictive Malabsorptive (Intestinal Malabsorptive (Intestinal
Bypass)Bypass) CombinedCombined
Restrictive ProceduresRestrictive Procedures
Limit food intake without effecting the Limit food intake without effecting the normal digestive processnormal digestive process
Creation of a small pouch with a narrow Creation of a small pouch with a narrow outletoutlet
Delay emptying of food and feeling of Delay emptying of food and feeling of fullnessfullness
IncludeInclude Adjustable Gastric Banding (ABG)Adjustable Gastric Banding (ABG) Vertical Banded Gastroplasty (VBG)Vertical Banded Gastroplasty (VBG)
AGBAGB Hollow band of Hollow band of
siliconesilicone
Inflatable with Salt Inflatable with Salt solutionsolution
Can be Can be Tightened/loosenedTightened/loosened
the pouch holds about the pouch holds about 1 ounce of food and 1 ounce of food and later expands to 2-3 later expands to 2-3 ounces ounces
VBGVBG Uses both a band Uses both a band
and Staplesand Staples upper stomach near upper stomach near
the esophagus is the esophagus is stapled vertically to stapled vertically to create a small pouch create a small pouch
The outlet from the The outlet from the pouch to the rest of pouch to the rest of the stomach is the stomach is restricted by a band restricted by a band
AdvantagesAdvantages
Easier to perform Easier to perform SaferSafer AGB can be done AGB can be done
LaparoscopicallyLaparoscopically Can be ReversedCan be Reversed Few nutritional Few nutritional
deficienciesdeficiencies
AdvantagesAdvantages
80% of patients lose some weight, 80% of patients lose some weight, 30% reach normal weight category 30% reach normal weight category with VBG (3)with VBG (3)
Success rate with VBG is 40 to 63% Success rate with VBG is 40 to 63% of excess body weight over a three of excess body weight over a three year period. (4)year period. (4)
50 to 60% after five years (1)50 to 60% after five years (1)
DisadvantagesDisadvantages
Less Weight loss Less Weight loss Less likely to Less likely to
maintain weight maintain weight loss over long termloss over long term
Patient FactorsPatient Factors
RisksRisks
VomitingVomiting Slippage of the Slippage of the
BandBand Tube BreaksTube Breaks Infection Infection BleedingBleeding DeathDeath
Combined Combined Restrictive/MalabsorptiveRestrictive/Malabsorptive
Most common Bariatric proceduresMost common Bariatric procedures Restrict food intake/amount of Restrict food intake/amount of
calories and nutrients the body calories and nutrients the body absorbsabsorbs
IncludeInclude Roux-en-Y gastric bypass (RGB)Roux-en-Y gastric bypass (RGB) Biliopancreatic Diversion (BPD)Biliopancreatic Diversion (BPD)
RGBRGB
creating a stomach creating a stomach pouch and attaching pouch and attaching it directly to the it directly to the small intestine small intestine
bypassing a large bypassing a large part of the stomach part of the stomach and duodenum and duodenum
Reduction of Reduction of calories and calories and nutrients absorptionnutrients absorption
BPDBPDExtensive TypeExtensive Type
Lower Portion of Lower Portion of stomach is stomach is removedremoved
Remaining pouch Remaining pouch is connected to is connected to final segment of final segment of small intestinesmall intestine
High Risk of High Risk of Nutrition Nutrition DeficiencyDeficiency
BPDBPDDuodenal SwitchDuodenal Switch
Leaves a large Leaves a large portion of stomach portion of stomach including pyloric including pyloric valvevalve
Keeps a small part Keeps a small part of the duodenumof the duodenum
AdvantagesAdvantages
Rapid Weight lossRapid Weight loss
greater weight loss greater weight loss in gastric bypass in gastric bypass (93.3 pounds) (93.3 pounds) compared to compared to gastroplasty (67 gastroplasty (67 pounds) after one pounds) after one year (2)year (2)
AdvantagesAdvantages
The success rate for weight loss for The success rate for weight loss for RGB is 68 to 72% of excess body RGB is 68 to 72% of excess body weight over a three year period, and weight over a three year period, and 75% for BPD (4)75% for BPD (4)
However, after five years the average However, after five years the average excess weight loss from gastric bypass excess weight loss from gastric bypass surgery ranges from 48 to 74% (1)surgery ranges from 48 to 74% (1)
DisadvantagesDisadvantages
More difficult More difficult
Nutritional Nutritional deficiencies (Ca, deficiencies (Ca, Fe, Vitamins)Fe, Vitamins)
Dumping Dumping SyndromeSyndrome
Dumping SyndromeDumping Syndrome
RisksRisks
Risk of Death Risk of Death
RGB <1% , BPD RGB <1% , BPD 2.5-5%2.5-5%
Abdominal Hernias Abdominal Hernias 28%28%
FinallyFinally Remember:Remember: There are no There are no
guarantees for any guarantees for any method to produce method to produce and maintain weight and maintain weight loss. loss.
Success is possible Success is possible only with maximum only with maximum cooperation and cooperation and commitment to commitment to behavioral change behavioral change and medical follow-up and medical follow-up
ReferencesReferences 1-American Society for Bariatric Surgery. Rationale for 1-American Society for Bariatric Surgery. Rationale for
the Surgical Treatment of Obesity. Updated April 6, the Surgical Treatment of Obesity. Updated April 6, 1998. 1998.
2-National Heart, Lung, and Blood Institute. Clinical 2-National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Guidelines on the Identification, Evaluation, and Treatment of Obesity in Adults: The Evidence Report. Treatment of Obesity in Adults: The Evidence Report. NHLBI Obesity Education Initiative Expert Panel on the NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Obesity in Identification, Evaluation, and Treatment of Obesity in Adults. Washington, DC: U.S. Department of Health Adults. Washington, DC: U.S. Department of Health and Human Services, 1998and Human Services, 1998
3-Gastric Surgery for Severe Obesity. National 3-Gastric Surgery for Severe Obesity. National Institute of Diabetes and Digestive and Kidney Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 96-4006, April 1996. Diseases. NIH Publication No. 96-4006, April 1996.
4-Shape Up America!, American Obesity Association. 4-Shape Up America!, American Obesity Association. Guidance for the Treatment of Adult Obesity. Bethesda, Guidance for the Treatment of Adult Obesity. Bethesda,
MD, revised 1998MD, revised 1998. . National Institute of diabetes and digestive and kidney National Institute of diabetes and digestive and kidney
diseasesdiseases The Cleveland Clinic Health Information CenterThe Cleveland Clinic Health Information Center