Bariatric SurgeryBariatric Surgery

Mr B.M.AxisaMr B.M.Axisa

Consultant Laparoscopic and Consultant Laparoscopic and Upper GI SurgeonUpper GI Surgeon

Obesity is a DiseaseObesity is a Disease

Risk factor for:Risk factor for:

DiabetesDiabetes HypertensionHypertension HyperlipidaemiaHyperlipidaemia Coronary diseaseCoronary disease Sleep apnoeaSleep apnoea ArthropathyArthropathy CancerCancer Physcological disordersPhyscological disorders

Attitude change towards problemAttitude change towards problem

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults19851985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults19861986

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults19871987

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults19881988

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults19891989

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults19901990

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults19911991

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults19921992

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults19931993

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults19941994

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults19951995

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults19961996

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults19971997

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults19981998

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults19991999

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults 2000 2000

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults20012001

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Obesity Trends* Among U.S. Adults 2002

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults 2003 2003

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults 2004 2004

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults 2005 2005

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. Adults 2006 2006

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Management of ObesityManagement of Obesity

Conservative: Diet, Conservative: Diet, exercise, behavioural exercise, behavioural modificationmodification

Medical Medical

Surgical Surgical

Medical ManagementMedical Management

BMI of 28.0 kg/m2 or more with associated risk BMI of 28.0 kg/m2 or more with associated risk factors factors

oror

BMI of 30.0 kg/m2 or more.BMI of 30.0 kg/m2 or more.

Treatment for longer than 3 months if >5% initial Treatment for longer than 3 months if >5% initial body weight lostbody weight lost

Continue for longer than 12 months only after Continue for longer than 12 months only after discussing potential benefits and limitations.discussing potential benefits and limitations.

Rimonabant (Acomplia) withdrawnRimonabant (Acomplia) withdrawn

Orlistat (XenicalOrlistat (Xenical®®))

Inhibits absorption of fatInhibits absorption of fat

Take before mealsTake before meals

Adverse effects:Adverse effects:

FlatulenceFlatulence

Fatty oily stoolsFatty oily stools

Faecal urgencyFaecal urgency

1kg per month. 12% had 10% loss1kg per month. 12% had 10% loss

Vitamin deficienciesVitamin deficiencies

Sibutramine (ReductilSibutramine (Reductil®®))

Affects appetite centre in brainAffects appetite centre in brain

Once dailyOnce daily

Stimulant. HypertensionStimulant. Hypertension

Avoid in epilepsyAvoid in epilepsy

Need to monitor blood pressureNeed to monitor blood pressure

Similar effectiveness to XenicalSimilar effectiveness to Xenical

15% had 10% weight loss15% had 10% weight loss

Bariatric SurgeryBariatric Surgery

Patient selectionPatient selection

WeightWeightBMI > 40kg/mBMI > 40kg/m22

BMI > 35kg/mBMI > 35kg/m2 2 with medical comorbiditieswith medical comorbidities

Failure of non surgical attempts at weight Failure of non surgical attempts at weight reductionreduction

Psychological stabilityPsychological stability

Types of operationTypes of operation

RestrictiveRestrictiveRoux-en-Y gastric bypassRoux-en-Y gastric bypass

Vertical banded gastroplasty Vertical banded gastroplasty

Adjustable gastric bandingAdjustable gastric banding

MalabsorptiveMalabsorptiveBiliopancreatic diversion Biliopancreatic diversion

CombinedCombinedLong limb gastric bypassLong limb gastric bypass

Lap BandLap Band

Lesser curve dissectionLesser curve dissection

Band in placeBand in place

Suturing of BandSuturing of Band

Laparoscopic PortsLaparoscopic Ports

Gastric BypassGastric Bypass

Pouch 15-30mlsPouch 15-30mls

1.0cm opening1.0cm opening

Staple line Staple line disruption in disruption in undividedundivided

Length of Roux loopLength of Roux loop

Gastric PouchGastric Pouch

Gastrojeunal AnastomosisGastrojeunal Anastomosis

Lap BypassLap Bypass

Vertical Banded GastroplastyVertical Banded Gastroplasty

Biliopancreatic diversionBiliopancreatic diversion

Duodenal SwitchDuodenal Switch

ResultsResults

OperationOperation 5 year5 year

EWLEWL

10 year 10 year

EWLEWL

MortalityMortality

Lap bandLap band 50-70%50-70% 55%55% 0 - 0.2%0 - 0.2%

VBGVBG 60%60% -- 1-1.4%1-1.4%

Gastric Gastric bypassbypass

70%70% -- 0 – 1.2%0 – 1.2%

BPDBPD 70%70% 60-79%60-79% 1-2%1-2%

Complications: GeneralComplications: General

AtelectasisAtelectasis

DVT and Pulmonary embolismDVT and Pulmonary embolism

Wound infectionWound infection

BleedingBleeding

CholelithiasisCholelithiasis

Complications: SpecificComplications: Specific

Leaks: challenging diagnosisLeaks: challenging diagnosis

Band slippage/erosion/infectionBand slippage/erosion/infection

Acute gastric dilatationAcute gastric dilatation

Stomal ulcers 12-15% / stenosisStomal ulcers 12-15% / stenosis

Nutritional deficienciesNutritional deficienciesFe Fe Vit BVit B12 12 Folate Folate

CalciumCalcium

Malabsorptive proceduresMalabsorptive proceduresProtein calorie malnutritionProtein calorie malnutrition

Fat soluble vitamin deficiencyFat soluble vitamin deficiency

FutureFuture

Gastric pacingGastric pacing

Gene therapyGene therapy

Thank YouThank You