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Pathophysiology of Bariatric Pathophysiology of Bariatric SurgerySurgery
DR SREEJOY PATNAIKBARIATRIC AND METABOLIC SURGEON
LIFE MEMBER OSSI,IFSO,SAGES
SHANTI MEMORIAL HOSPITAL PVT.LTDFinal Phase of NABH Accredition.
Obesity EpidemicObesity Epidemic
• World epidemic encompasses 1.7 billion people
• Highest in the U.S.• Approximately 2/3 of Americans are
overweight, and almost half are obese• BMI subgroups of >35 and >40 are
experiencing most rapid growth
Buchwald et al. Jama 2004Buchwald et al. Jama 2004
Obesity EpidemicObesity Epidemic
• Rise in the prevalence of obesity is associated with rises in prevalence of obesity related comorbidities
• Comorbidities responsible for 2.5 million deaths per year worldwide
• Loss of life expectancy is profound• 25 year-old morbidly obese male has 22%
reduction in lifespan, representing a loss of 12 years of life
Buchwald et al. Jama 2004Buchwald et al. Jama 2004
Obesity EpidemicObesity Epidemic
• Diet therapy, with and without support organizations, is ineffective long term
• Currently, there are no effective pharmaceutical agents to treat obesity, especially morbid obesity
North American Association for the North American Association for the Study of Obesity. NIH 2000Study of Obesity. NIH 2000
Definition of Obesity Definition of Obesity according to BMIaccording to BMI
UnderweightUnderweight <18.5<18.5NormalNormal 18.5 – 24.918.5 – 24.9
OverweightOverweight 25-29.925-29.9
ObesityObesity >30>30moderate moderate 30.0 – 34.930.0 – 34.9severesevere 35.0 – 39.935.0 – 39.9morbidmorbid >40>40
BMI = W(kg)/H (m²)BMI = W(kg)/H (m²)
BMIBMI
• Calculated as follows: Weight(kg)/Height(m2) • Lowest mortality = BMI < 25kg/m2
• Highest mortality = BMI > 40kg/m2 • BMI > 40 = approximately 100lbs. over ideal
body weight
Pulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndrome
Nonalcoholic fatty liver diseasesteatosissteatohepatitiscirrhosis
Coronary heart disease Diabetes Dyslipidemia Hypertension
Gynecologic abnormalitiesabnormal mensesinfertilitypolycystic ovarian syndrome
Osteoarthritis
Skin
Gall bladder disease
Cancerbreast, uterus, cervixcolon, esophagus, pancreaskidney, prostate
Phlebitisvenous stasis
Gout
Medical Complications of ObesityIdiopathic intracranial hypertension
StrokeCataracts
Severe pancreatitis
Medical Co-morbidities
• Metabolic Mechanical Degenerative Neoplastic Psychological
Medical Co-morbiditiesMetabolic
Diabetes mellitus, type II Hypertriglyceridemia Hypercholesterolemia Hypertension Gallstones Fatty liver disease (NASH) Pancreatitis Central sleep apnea Hypercoagulable Infertility
Metabolic Syndrome
Abdominal obesityHyperinsulinemiaHigh fasting plasma glucoseImpaired glucose toleranceHypertriglyceridemiaLow HDL-cholesterolHypertension
Medical Co-morbiditiesMechanical/Anatomic
Obstructive sleep apnea GERD GERD - associated asthma Urinary stress incontinence Pseudotumor cerebri Venous stasis DVT / PE Fungal skin infections Decubitus ulcers Accidental injuries
Medical Co-morbiditiesDegenerative
Cardiovascular disease Complications of diabetes CHF DJD Vertebral disc disease NASH related cirrhosis
Medical Co-morbiditiesNeoplastic
Breast Cancer Ovarian Cancer Endometrial Cancer Prostate Cancer Colorectal Cancer Renal Cell Carcinoma NHL Esophageal Cancer Gastric Cancer Pancreatic Cancer
Medical Co-morbiditiesPsychological
Anxiety disorders Depression Binge eating disorders Reactive bulimia Trauma
Indications for SurgeryIndications for Surgery
• BMI > 40 kg/m2BMI > 40 kg/m2• BMI > 35 kg/m2 with co-morbiditiesBMI > 35 kg/m2 with co-morbidities
• Comorbidities:Comorbidities:– HypertensionHypertension– DiabetesDiabetes– HyperlipidemiaHyperlipidemia– Sleep apneaSleep apnea– Severe arthrosisSevere arthrosis
NIH Consensus NIH Consensus Conference Conference Ann Intern Med 1991Ann Intern Med 1991
Indications for SurgeryIndications for Surgery
• Age > 18 or < 60Age > 18 or < 60• Failure of diet > 6 monthsFailure of diet > 6 months• Obesity history > 5 Obesity history > 5 yearsyears • Low risk for surgeryLow risk for surgery• No endocrinological diseaseNo endocrinological disease• Psychologically soundPsychologically sound
NIH Consensus Conference NIH Consensus Conference Ann Intern Med 1991Ann Intern Med 1991
Goals of SurgeryGoals of Surgery
• Effective: Loss > 50% of Excess Effective: Loss > 50% of Excess WeightWeight
• Low operative morbidityLow operative morbidity• Well toleratedWell tolerated• No long term complicationsNo long term complications
Surgical ProceduresSurgical Procedures
• Restrictive proceduresRestrictive procedures– Gastric BandingGastric Banding– Sleeve GastrectomySleeve Gastrectomy
• Malabsorptive proceduresMalabsorptive procedures– Biliopancreatic DiversionBiliopancreatic Diversion
• ScopinaroScopinaro• Duodenal-Switch BPDDuodenal-Switch BPD
• Hybrid proceduresHybrid procedures– Roux-en-Y Gastric Bypass / BandedRoux-en-Y Gastric Bypass / Banded– -Mini Gastric Bypass-Mini Gastric Bypass
GastricGastric BandingBanding
Filled Band
Unfilled Band
Sleeve GastrectomySleeve Gastrectomy
BBilio-pancrilio-pancreeatiatic diversionc diversion
ScopinaroScopinaro WithWith duodenalduodenal switchswitch
SG WITH BPDSG WITH BPD
Restriction
Malabsorption
Gastric Bypass
Loss of appetite ?Small pouch (approx 30 cc)
Small anastomosis (approx. 1.5 cm)
How does it work ?
Alimentary LimbBetween 100 to 200cm
Biliopancreatic LimbBetween 50 to 75 cm
Ghrelin
Gastric Bypass: TechniqueGastric Bypass: Technique
• BPD LimbBPD Limb– 15 to 100cm
• Roux / Alimentary LimbRoux / Alimentary Limb– BMI<50: does not matter– BMI>50: 150cm
Choban Obesity Surg 2002
Brolin Ann Surg 1992Brolin Ann Surg 1992
Gastric Bypass: Follow UpGastric Bypass: Follow Up
• Clinical Pathway– 2 weeks, 1 month, 3 months, 6 months, 9
months, 1 year, 18 months and yearly – Nutritionist– Vitamins– Labs– Aggressive follow up is the key to good
outcomes
Conclusion
Big patient Big patient Big riskBig risk
Big expectationsBig expectations
Conclusion
Multidisciplinary team Multidisciplinary team And ProgramAnd Program