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