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Bariatric Surgery
The most effective treatment for combating obesity
Lt Col Alok Bhalla
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Weight Control:
Fashion Statement or a Medical Necessity?
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Historical PerspectivePaleolithic era -
>25,000 years ago
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Obesity is a BIG problem
now 1.7 billion worldwide
are overweight or obese
The US has the highestpercentage of obesepeople
And the numbers aregrowing
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Epidemiology of Obesity
31.3% of U.S. males
34.7% of U.S. females
30% increase in the last 10 years
Health care costs - >$100 billion/year
Results in 300,000 preventable deaths each year inthe U.S.
6-7% of total sick care costs in the Western world
due to obesity
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Indian Scenario
20-30% of adults and 10-20% of
children are obese.Its fast gaining unmanageable
proportion.
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Obesity is not a condition. It's a disease needingmedical intervention.
Surgical treatment is a medical necessity as it is theonly proven method to achieve sustained long termweight loss.
Bariatric Surgery does not involve liposuction orabdominoplasty.
Involves reducing the size of stomach with orwithout a malabsorptive procedure.
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Obesity and Life Expectancy
If current rates of obesity are left unchecked, the
current generation of American children will be thefirst in two centuries to have a shorter life expectancy
than their parents.
Olshansky SJ, et al. A Potential Decline in Life Expectancy
in the United States in the 21stCentury. NEJM, 352(11):1138-1145, 2005
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Classification of Overweight
and Obesity
A BMI of: Classifies one as:
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What Causes Obesity?
Nutrient and energy model of obesity
Metabolism
Appetite regulation Energy expenditure
Genetics
Behavior and cultural factors
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Nutrient and Energy Model
Of Obesity Obesity results from increased intake of energy
or decreased expenditure of energy, as required
by the first law of thermodynamics.
Adiposetissue
EnergyIntake
EnergyExpenditure
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Medical Complications of Obesity
Severe pancreatitisGall bladder disease
CHDDiabetesDyslipidemiaHypertension
Gynecologic abnormalities
abnormal mensesinfertilityPCOS
Nonalcoholic fattyliver diseasesteatosissteatohepatitiscirrhosis
Pulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndrome
Osteoarthritis
Skin
Cancerbreast, uterus, cervix
colon, esophagus,pancreaskidney, prostate
Phlebitisvenous stasis
Gout
Idiopathic intracranialhypertension
Stroke
Cataracts
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Consequences of Obesity Obesity is associated with a
rise in many comorbidconditions, including:
Type 2 Diabetes
Hyperlipidemia Hypertension Obstructive Sleep Apnea Heart Disease Stroke Asthma
Osteoarthritis Cancer Depression
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Obesity and Diabetes Risk
0
20
40
60
80
100
40
BMI Levels
Incidence of New Cases
per 1000 Persons/Year
-
Knowler WC et al.Am J Epidemiology1981
Overweight
19
Obese
30
Morbidly Obese
45-65
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Metabolic syndrome
MS is a clustering of risk factors :
High levels of triglycerides and serum glucose.
Low levels of high-density lipoprotein.
High blood pressure.
Abdominal obesity.
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Effects of Obesity Surgery on the Metabolic SyndromeWei-Jei Lee, MD, PhD; Ming-Te Huang, MD; Weu Wang,
ARCH SURG/VOL 139, OCT 2004
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Weight Loss Strategies
Diet therapy
Increased Physical Activity
Pharmacotherapy
Behavioral Therapy
Any combination of the above
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Dieting
Dieting is highlyineffective - 95% long
term failure rate Often results in higher
weight than before thediet
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Diet
Low calorie diets (LCD) Consist of 800-1500 kcal/day
Very low calorie diets (VLCD)
Consist of
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Exercise and Behavior Modification
Physical Exercise (3-7 sessions per week,lasting 30-60 minutes) can achieve modest
weight loss, of 2-3% of body weight. Behavior therapy in conjunction with diet
and exercise can produce weight loss of 10%over 4 months-1 year.
The fundamental problem is recidivism.
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Non Operative Treatment
Not effective in achieving medicallysignificant long term wt loss
Almost all regain wt in 5 years Combination of anorectic drugs ,diet
control, exercise and behavior modificationled to initial optimistic results but could not
be sustained with 1/3rd drop outs and only 3lbs wt loss over 4 years
Some of the drugs have dangerous sideeffects
Still all patients should give at least onetrial of non medical treatment before beingsubjected to surgery
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Pharmacotherapy
Sibutramine
Appetite suppressant
NE and Serotonin reuptake inhibitor
Side effects: Increase HR, Blood Pressure,
nervousness and insomnia
Mean weight loss 4.45 kg at 12 months
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Pharmacotherapy
Orlistat Lipase inhibitor: decreases absorption of fat.
Side effects: diarrhea, flatulence, bloating,
abdominal pain, dyspepsia
Mean weight loss: 2.89 kg at 12 months
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Pharmacotherapy
Phenteramine and DiethylproprionAppetite suppressant: sympathomimetic amine
Side effects: cardiovascular and gastrointestinal
Mean weight loss: 3.0-3.6 kg at 6 months
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Weight Loss Definitions
Excess weight=actual weight - ideal body
weight
Excess Weight Loss (EWL) is the standardin the bariatric surgery nomenclature
%EWL=(weight loss/excess weight) x 100
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Obesity warning on London buses
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Indications for Surgery
BMI 40 or More
BMI 35-39.9, if associated withco-morbidities ( Metabolic syndrome)
Motivated Patient
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Rationale for Surgery
Associated with increased Mortality
2-12 fold increase in mortality in both sexes.
Mortality rate revert back to normal followingBariatric Surgery.
Statistically significant improvement inassociated co-morbidities with 10% wt loss.
Cancer mortality rates higher in obese patients.
Increased Fertility after Bariatric Surgery.
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Goals of Surgery
* To achieve long term and medicallysignificant wt loss (Surgery a medicalnecessity as its the only treatment option to
achieve long term wt loss)* Prevention of secondary complications ofmorbid obesity
* Adhere to the time tested principle oftherapeutic intervention has to be lessharmful than the disease being treated
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Goals of Surgery
Obesity a psychological and Biologicalchallenge for the patient
Lack of respect for morbidly obese by thesociety
80% of them feel disrespect by the medicalprofessionals
Negative attitude of general public; weakwilled, ugly, awkward and self indulgent
Obesity a stigma leading to increasedpsychological distress and disorders.
At high risk of developing affective, anxietyand substance abuse disorders.
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Pre operative evaluation
Evaluation by an Endocrinologist
All patients undergoing surgery shouldhave adequate trial of medical therapy
Patients should be advised and counseledregarding life long monitoring
Surgery should be performed in a wellestablished setup
Patients should be treated with morecompassion & concerned
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Pre operative Psychological evaluation
To weed out patients with psychiatricdisorders
Select patients who will benefit fromsurgery
However it has revealed :
No single personality type
No higher incidence of psychiatric
disorders
Binge eaters
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Bariatric Surgery 1991: NIH establishes guidelines for the
surgical therapy of morbid obesity
Recommends BMI criteria
BMI > 40 BMI > 35 + significant comorbidities
This therapy now referred to as BariatricSurgery
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Stein brook, R. N., 2004
Estimated Number of Bariatric Operations
Performed in the United States, 1992-2003
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Bariatric Surgery Procedures
Its neither lipo- suction nor abdominoplastyProcedures
RestrictiveAdjustable Gastric BandingVertical Banded GastroplastySleeve Gastrectomy
MalabsorptiveBilio Pancreatic Diversion(Scopinaros Procedure)
CombinedRoux-en-Y gastric BypassSleeve Resection with DuodenalSwitch
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A Brief History of Bariatric
Surgery
Intestinal bypass ( 1950s)by Drs. Kremenand Linner
Biliopancreatic diversion (1976) by Dr.Scopinaro
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The Advent of the Roux-en-Y GBP
Based on observations of weightloss in pts receiving subtotalgastric resections for otherconditions
Today's most common form ofgastric bypass surgery is aderivative of a procedurepioneered in 1966 by Edward E.
Mason, MD, PhD, at theUniversity of Iowa
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Evolution of Gastric Banding
1980s
Alternative to Roux-en-Y in Europe &Scandinavia
1990s
Adjustable silicone band developed by DrKuzmak who devised a band with aninflatable balloon as its lining.
2000s
Laparoscopic techniques for placement
developed
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Types of Bariatric Surgery
Purely Restrictive
Gastric Balloons (not FDA approved)
Vertical-banded gastroplasty
Gastric adjustable banding
Restrictive > Malabsorptive
Short-limb/Roux-en-Y gastric bypass
Long-limb/distal Roux-en-Y gastric bypass
Malabsorptive > Restrictive
Biliopancreatic diversion (BPD)
BPD with duodenal switch
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Adjustable Gastric Band
A low pressure high volume siliconeelastomer adjustable band placedround the upper part of the
stomach, creating a small gastricpouch to hold a very small quantityof food
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Adjustable Gastric Band
Advantages
Simple and relatively safe
procedure
No anastamosis
Reversible
Disadvantages
5% Failure
Needs highly motivated patients
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Vertical Banded Gastroplasty
Commonest restrictiveprocedure in USA
Both band & staples are
used to create a smallgastric pouch
Being replaced by LAGBallover the world
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Vertical Banded Gastroplasty
Weight loss: 50-60% EWL
Plateau in weight loss reached at 2years
Operative mortality: 0.1%Operative morbidity: 5%
Long-term complications: vomiting,outlet obstruction, erosion, staple
line dehiscence
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Vertical Banded Gastroplasty
Advantages
Easier to perform
Shorter operativetime
Disadvantages
Poor operation
for sweet eaters
Restrictive only
Nonadjustable
Staple line
disruption and
leaks
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Sleeve Gastrectomy
Per se a restrictive procedurebut mostly used as an adjunctto duodenal switch for a better
outcome
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Roux-en-Y GBP Open
3 hour procedure 3-4 days in-house 4-6 weeks Return to work 60-70% EBW loss @ 2 yrs
0.5-1.0% Risk of Death
Laparoscopic 3 hour procedure 2 days in-house 2-3 weeks Return to work
60-70% EBW loss @ 2yrs 0.5-1.0% Risk of Death
* Data based on averages.
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Roux-en-Y GBP
Weight loss: 65-70% EWL
Weight loss plateaus at 1-2 years
Operative mortality: 0.5%
Operative morbidity: 5%(pulmonary emboli, anastamoticleak, bleeding, wound infection)
Buchwald J Am Coll Surg 2005
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Roux-en-Y GBP
AdvantagesCombines the advantages of both
restrictive as well as malabsorptive
procedures
DisadvantagesStaple line failure
Marginal ulcers
Narrowing of stoma
Vomiting
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Adjustable Lap Band
A silicone band is placed around theupper part of the stomach
A small pouch is created
Stomach holds less food
Induces feeling of satiety
Shorter OR time
Same day surgery
Return quickly to work
Evaluated every 6-8 weeks for gradualtightening if necessary
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Adjustable Lap Band
Adjustability is the most importantattribute.
Filled with a saline solution. By adding orremoving the saline, can be made tighter orlooser.
Adjust as necessary to support gradual,steady weight loss. Often 5-6 times in thefirst year.
- Place reservoir on anterior rectus sheath - Palpate, mark the site, no-touch
technique - Office procedure, rarely needs radiology
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Adjustable Lap Band
Weight loss: 50% EWL at 2 years
Operative mortality: 0.1%
Operative morbidity: 5%
Long-term complications: gastric prolapse,stomal obstruction, esophageal and gastricpouch dilation, gastric erosion and necrosis,access port problems.
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Adjustable Lap Band Results
OBrien: 57% EWL at 6 yrs
Dargent: 64% EWL at 3 yrs
Vertruyen: 52% EWL at 7 yrs
Belachew: 50-60% EWL at 5 yrs
Rubenstein: 54% EWL at 3 yrs
Fox: 60% EWL at 4 yrs
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LAGB Complications
Failure: 20-25%
Slip: 5.6%
Erosion: 0.6%Access Port or Tubing: 1.7%
Death: 0.05%
Pulmonary embolism: 0.1%
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Adjustable Lap Band
Advantages Simple to perform
Adjustable
Lowest mortality Minimally invasive
Shortest operative time
No need for vitamin
and mineral supplementation
Disadvantages Foreign body
Slower weight loss
Lower overall weightloss
Higher failure rate
Poor operation for sweeteaters
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Biliopancreatic Diversion
A complicated malabsorptiveprocedure
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Biliopancreatic Diversion
Advantages Highest malabsorptive component Best long term weight loss
Allows larger quantity of food intake
Disadvantages Greater chances of chronic diarrohea,,stomal
ulcers
Higher risk of nutritional deficiencies
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Duodenal Switch
A combined procedure wherea part of duodenum is kept inthe digestive pathway,
regulating release of gastriccontents in to the small bowel
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Duodenal Switch
Advantages
Better absorption of Vit B12
Better eating qualityEliminates stomal ulcers
Disadvantages
Same as biliopancreatic bypass
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BPD Duodenal Switch
3 hr procedure
2-3 day in-house
1 wk Return to work
70-75% EBW loss @ 2 yrs
2% Risk of Death
Diarrhea, Calcium and fat-soluble vitamin malabsorption
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Biliopancreatic DiversionDuodenal Switch
Weight loss: 70% EWL
Operative mortality: 1%
Operative morbidity: 5% Long-term complications: diarrhea,
malodorous stools and flatus, vitamin,
mineral and nutrient deficiencies, inparticular, protein deficiency
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Biliopancreatic DiversionDuodenal Switch
Advantages
Superior weight loss
Most durable weight
loss Most difficult to beat
Disadvantages
Protein and calcium
malnutrition
Most complicatedMalodorous stool
and flatulence
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Comparing EWL: GBP vs. Banding
Prospective matched-pair designBypass = 103 - Banding = 103
Weber M. et al 2004, Annals of Surgery
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Type 2 DM
Resolution
Buchwald, H. et al. 2004
Bariatric surgery: a systematic review and meta-analysis
989
% Resolution(95% Confidence Interval)
0 20 40 60 80 100
98.9 (96.8, 100.0)
47.9 (29.1, 66.7)
83.8 (77.3, 90.1)
Duodenal Switch
Gastric Bypass
Gastric Banding205
288
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Bariatric Surgery A SystematicReview and Metaanalysis
Buchwald, H. JAMA 2004
22,094 patients: 19% men, 72.6%
women
Mean age 39 years
Mean percentage excess weight
loss 61.2% Gastric banding: 47.5% EWL
Gastric bypass: 61.6% EWL
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Bariatric Surgery A SystematicReview and Meta-analysis
Gastroplasty: 68.2% EWL
Biliopancreatic diversion or
duodenal switch: 70.1% EWL
Operative mortality: 0.1% purely restrictive surgeries 0.5% gastric bypass
1.1% biliopancreatic diversion or
duodenal switch
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Bariatric Surgery A Systematic Review
and Meta-analysis: Overall
Diabetes completely resolved in 76.8% of
patients and resolved or improved in 86%
Hyperlipidemia improved in 70% Hypertension was resolved in 61.7% and
resolved or improved in 78.5%
Obstructive sleep apnea was resolved in
85.7% and resolved and improved in 83.6%
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Swedish Obese Subjects Study
Sjostrom, L. N Engl J Med 2004 Prospective, nonrandomized,
interventional trial involving 4047 subjects
Largest trial comparing surgical versus
medical treatment of morbid obesity
2010 patients underwent surgery (gastric
banding, gastroplasty, or gastric bypass)
2037 chose medical treatment
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Swedish Obese Subjects Study
At 2 years, weight had increased by 0.1percent in the control group and decreasedby 23.4 percent in the surgery group.
At 10 years, weight had increased by 1.6percent in the control group and decreasedby 16.1 percent in the surgery group.
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Swedish Obese Subjects Study
Energy intake was lower and the proportion ofphysically active subjects was higher in thesurgery group
Two and ten-year rates of recovery were better fordiabetes, hypertriglyceridemia, low levels ofhigh-density lipoprotein cholesterol,hypertension and hyperuricemia were morefavorable in the surgery group
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Swedish Obese Subjects Study
Surgery group had lower two and ten yearincidence rates of diabetes,
hypertriglyceridemia, and hyperuricemia
Surgically treated patients weresignificantly less likely to require
medications for cardiovascular disease ordiabetes at two and six years
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Swedish Obese Subjects Study
Costs of medications were reduced
significantly in the surgically treated group.
Surgically treated patients had dramatic
improvement in scores on validatedmeasures of quality of life
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Life Expectancy
Christou found that the 5-year death rate in
the Bariatric surgical group was 0.68% compared
with 16.2% in the medically managed patients and
89% relative risk reduction.
Flum and Dellinger found a 27% lower 15-year
death rate in those undergoing gastric bypass.
After the first postoperative year, the long-term
survival advantage increased to 33%
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Weight control is a journey,not a destination.