management of obesity an over review dr. fahad bamehriz department of surgery
TRANSCRIPT
Management of ObesityManagement of ObesityAn over reviewAn over review
Dr. fahad bamehrizDr. fahad bamehriz
Department Of SurgeryDepartment Of Surgery
Management of ObesityManagement of Obesity
Definitions &Classification.
Magnitude of obesity problem.
Clinical assessment & management.
Surgical management.
Summary.
Management of ObesityManagement of Obesity
Definitions & ClassificationDefinitions & Classification
ObesityObesity
A condition of excessive fat accumulation in the body to the extent that health and well being are adversely affected.
WHO 1997WHO 1997
Ideal Body Weight (IBW)Ideal Body Weight (IBW)
As defined by the Metropolitan Life Insurance Tables Of 1983for height, sex and body-frame, is that weight which is associated with the lowest death rate in insured populations.
Cowan et al ,Surgery for the morbidly obese Cowan et al ,Surgery for the morbidly obese patients,Chapter 9 ,2000patients,Chapter 9 ,2000
Body Mass Index
BMI = Weight ( Kg)/ Height (m2)
Classification of weightClassification of weight
WHO 1997WHO 1997
Morbidly Obese PatientsMorbidly Obese Patients
Are those individuals who weigh at least 45 kg over the ideal body weigh.
This approximates a body mass index (BMI) of at least 40 kg/m2
Cowan et al ,Surgery for the morbidly Cowan et al ,Surgery for the morbidly obese patients,Chapter 9 ,2000obese patients,Chapter 9 ,2000
Weight LossWeight Loss
EWL = Excess Weight Loss
= (preoperative weight) – (ideal weight)
% EWL = % Excess Weight Loss
= weight loss / excess weight x 100
Management of ObesityManagement of Obesity
Magnitude of obesity problemMagnitude of obesity problem
Prevalence of obesityPrevalence of obesity
WHO 1997WHO 1997
Prevalence of obesityPrevalence of obesity
Health hazards of obesityHealth hazards of obesity
Cowan et al ,Surgery for the morbidly Cowan et al ,Surgery for the morbidly obese patients,Chapter 9 ,2000obese patients,Chapter 9 ,2000
Health hazards of obesityHealth hazards of obesity
Karl et al SCNA Oct. 2001Karl et al SCNA Oct. 2001
Health hazards of obesityHealth hazards of obesity
Wadden et al SCNA OCT 2001Wadden et al SCNA OCT 2001
Health hazards of obesityHealth hazards of obesity
Bray et al CE&M 1999Bray et al CE&M 1999
Cost Related to ObesityCost Related to Obesity“The costs of obesity is substantial and accounts for 2-8 % of the total health care expenditure in countries such as The Netherlands, France, USA, Australia and Sweden.”
The Lancet August 1997The Lancet August 1997
Management of ObesityManagement of Obesity
Clinical assessment & management
Clinical assessment & managementClinical assessment & managementObesity ProgramObesity ProgramTeam ApproachTeam Approach
Bariatric surgeon.
Dietitian.
Physical therapist.
Psychiatrist.
Psychologist.
Gastro-entrologist.
Radiologist.
Nursing team.
Internist.
Endocrinologist
Cardiologist.
Pulmonologist.
Family Physician.
Anesthesiologist.
Intensivist.
Plastic Surgeons.
AssessmentAssessmentH&P.
Laboratory work up;
CBC, Renal, Hepatic, Lipid Profiles.
TFT’S, Cortisol suppression test, FBS.
Nutritional Profile.
Radiological Investigations;
U/S abdomen.
AssessmentAssessmentGastro-enterology
Gastro-scopy.
Psychiatry.
Dietitian.
Anesthesiologist.
Management OptionsManagement Options
Non-SurgicalNon-SurgicalBehavioral Therapy.
Diet.
Physical activity.
Drug therapy.
Jaw wiring.
Intra-gastric balloon.
SurgicalSurgicalRestrictive.
Mal-absorptive.
Combined.
Dietary approaches to reduce Dietary approaches to reduce body weightbody weight
Dietary ProgramsDietary ProgramsStarvation diets (fewer than 200 kcal /day).Very low energy diets (VLED)
200-800 kcal/day, commercial formula.Low energy diets (LED)
800-1500 kcal/day, natural food.Ad libitum low fat diets
15% - 25 % less fat, high CHO & protein.Atkins diet
High protein low CHO.
Dietary approaches to reduce Dietary approaches to reduce body weightbody weight
Physical ActivityPhysical Activity
Programmed physical activity.
regular scheduled activity at a relatively high intensity level.
Lifestyle physical activity.
increasing energy expenditure during the course of the day.
Physical ActivityPhysical Activity
Drug therapy of obesityDrug therapy of obesityDrugs that reduce food intakeDrugs that reduce food intake
Nor-adrenergic drugs (phentermine). Serotonin-norepinephrine re-uptake inhibitors
(Sibutramine).
Drugs that alter metabolismDrugs that alter metabolism Pre-absorptive agents (Orlistat). Post-absorptive agents (Metformin).
Drugs that increase energy expenditureDrugs that increase energy expenditure Ephedrine & Caffeine.
BioEntericsBioEnterics®® Intragastric Balloon Intragastric Balloon BIB ™ SystemBIB ™ System
B.I.B. PlacementB.I.B. Placement
Clinical resultsBMI and results
BMI <30 30-35 35-40 40-45 >45Weight 84 95 109 122 144BMI 29 33 37 42 50Weightloss kg 13 17 23 26 30BMI after 25 27 30 33 40EWL after 93 70 60 51 39% body weight 15 18 21 21 21number 19 155 179 90 46
Dr. Bolwerk
Jaw WiringJaw Wiring
Bray et al CE&M 1999Bray et al CE&M 1999
Obesity SurgeryObesity SurgeryClassificationClassification
Restrictive
Malabsorptive
Combined
%EWL after LAGB%EWL after LAGB
VBG versus ASGBVBG versus ASGB
What is LaparoscopicSleeve Gastrectomy ?(longitudinal G, Vertical G , Stomach reduction)
Resection of Greater Curve
Sleeve of stomach left in place
A Prospective Randomized Study Between LGB & LSGResults after 1&3 years
Jacques Himpens Obesity Surgery 16(1450-1456)2006
Efficacy of Obesity Surgery
operation number % EWL
Banding 4429 48.6%
VBG 3382 58.3%
Bypass 2949 68.6%
JEJUNOILEAL BYPASSJEJUNOILEAL BYPASS
%EWL in JEJUNOILEAL %EWL in JEJUNOILEAL BYPASSBYPASS
Bilio-pancreato-jejunal bypassBilio-pancreato-jejunal bypasstype threetype three
BPDDSBPDDS
Crystine Lee San Francisco California
Crystine Lee San Francisco California
King Faisal Specialist Hospital Experience in Bariatric Surgery
Dr Patrick O’ReganDr Abdelrahman SalemDr Fahad BamerhizMinimally Invasive Surgery ServiceKing Faisal Specialist Hospital & Research Center Riyadh S. A.
Obesity Surgery ProgramStarted October 2002
Offering Gastric balloon Gastric banding 333 VBG 73 Gastric bypass 85 Gastric sleeve 330 Total cases till December 2007 821
King Faisal Specialist Hospital Experience in Bariatric Surgery
020406080
100120140160180200
2002 2003 2004 2005 2006 2007
band
VBG
BYPASS
SLEEVE
How to decide which operation Age Co-morbidities Re-operative cases BMI Surgeon recommendation Patients request Word of mouth – many requests for
sleeve
KFSHRC Experiencewith sleeve gastrectomy
Started in August 2005
Why Sleeve Gastrectomy Patients not accepting Gastric Bypass Gastric Band - poor wt. loss VBG - poor QOL BPD – Patients F/U?? Encouraged by early results Pts – understanding, acceptance, word of
mouth.
Advantages of Sleeve
1. No foreign body
2. Easy to perform
3. No need for supplements
4. Low maintenance
5. Anatomical
6. Physiological ?
7. Easy to convert (second stage) – BPD or LGB
8. Ghrelin reduction
9. Good for super-obese
10.Good when PBD or LGB are contra- indicated
11. Good quality of life
Advantages cont’d
Sleeve Gastrectomydisadvantages
1. Not reversible
2. No long term follow up
3. Stomach may dilate
4. Purely restrictive ?
5. Ghrelin reduced
6. GERD (11%)
Biennial
Sleeve GastrectomyLength of Stay
94 % Same day admit
84% discharged day I or 2
3 (0.9%)conversion to open
Mean % excess wt loss
6 Months 60.5% (#170)
12 months 76% (#101)
18 months 75.4% (#39)
24 months 75.2% (#12)
Major M&M
18(5.4%) Staple line leakage
5 (1.5%) Re-op for bleeding
2 pt developed stricture
1pt developed Port site hernia
1 pt died post-op (PE)
Mean % excess wt loss at 12m
LSG 76% (#101)
LGB 72% (#62)
VBG 80% (#61)
Staple line leakage
LSG 18/330 (5.4%)
LGB 0/ 85 (0%)
VBG 4/ 73 (5.4%)
SummarySummaryObesity is a major health problem worldwide, as well as in the Kingdom.
It is secondary to imbalance between energy intake and expenditure.
Approach to management, should be team approach.
Main aim of management, is to change the behavior, which ultimately will reduce weight.
SummarySummary
Surgery is the only management option that proved to be effective in weight reduction of obese patients in long term.
We believe LSG is one of safe options of the armamentarium of beriatric surgery.
SummarySummary
Obesity surgery program at KFSH&RC offering a battery of beriatric surgery operations to match the need of different beriatric patients.
THANK YOU