Bariatric Surgery Alok

8/2/2019 Bariatric Surgery Alok

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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 liposuction 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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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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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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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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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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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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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.

Bariatric Surgery Alok

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