surgical management of morbid obesity in adults (bariatric surgery) m k alam almaarefa college
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Surgical management of morbid obesity in adults
(Bariatric surgery)
M K ALAMALMAAREFA COLLEGE
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ILOs
At the end of this presentation students will be able to:
Define obesity and its different forms Understand epidemiology, and risk factors, Describe pathogenesis and natural history of
obesity. Clinical presentation and differential diagnosis Describe medical and surgical management
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Introduction
• Obesity- a major health problem worldwide
• Overweight individuals in the world: 1.7 billion
• Epidemic proportion in the Western society.
• Major risk factor for many diseases.
• Significant morbidity and mortality.
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Swedish study:
Bariatric surgery was associated with a
reduced number of cardiovascular
deaths and a lower incidence of
cardiovascular events in obese adults.[1]
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Bariatric Surgery
Bariatric surgery is an effective therapy for morbid obesity.
3 basic concepts for bariatric surgery:
(1) Gastric restriction- adjustable gastric banding, sleeve gastrectomy
(2) Gastric restriction with mild malabsorption- Roux-en-Y gastric bypass
(3) A combination- mild gastric restriction and malabsorption (duodenal switch).
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The 2 most common bariatric procedures:
1.Laparoscopic Adjustable gastric banding
2.Laparoscopic Roux-en-Y gastric bypass.
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Measure of obesity
• BMI (Body mass index) = Patient's mass (wt.) in kg ÷ height in meters squared.
• Normal BMI- 18.5-24.9 kg/m2.
• Overweight- BMI of 25-29.9 kg/m2
• Obese- BMI of 30 kg/m2
• Morbid obesity - BMI of 35 kg/m 2 or greater -with severe obesity-related
comorbidity, or BMI of 40 kg/m 2 or greater without comorbidity
• Waist circumference : >88 cm (35 in) in women or >102 cm (40 in) in men
strongly correlates with an increased risk of obesity-related disease.
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Aetiology
• Complex, multifactorial chronic disease
• Interaction of several factors: Genetic, endocrine,
metabolic, environmental (social and cultural),
behavioral, and psychological.
• Basic mechanism: Energy intake exceeds energy output.
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Pathophysiology
• Obesity- result of an imbalance in energy expenditure and caloric intake.
• Leptin is a hormone made primarily in adipocytes
• Leptin negative feedback signal on the hypothalamus → alter the
expression of several neuroendocrine peptides that regulate
energy intake and expenditure.
• Central resistance to leptin is a prominent feature of obesity.
• Increased leptin levels in obese strongly correlate with the BMI.
• Leptin treatment works well in patients who are leptin deficient
but in obese who have high levels has shown limited efficacy.
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Presentation
• Morbid obesity: Harbinger of many other diseases.
• Cardiovascular: Hypertension, atherosclerotic heart and
peripheral vascular disease- MI, CVA, peripheral venous
insufficiency, thrombophlebitis, pulmonary embolism.
• Respiratory: Asthma, obstructive sleep apnea.
• Metabolic: Type 2 diabetes, hyperlipidemia.
• Musculoskeletal: Back strain; disc disease; osteoarthritis
of the hips, knees, ankles, and feet
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Presentation• Gastrointestinal: Cholelithiasis, GORD, fatty liver disease, hepatic
cirrhosis, hepatic carcinoma, colorectal carcinoma.
• Urologic: Stress incontinence.
• Endocrine and reproductive: Polycystic ovary syndrome, increased
risk of fetal abnormalities, male hypogonadism.
• Carcinoma: Breast, ovary, endometrium, prostate, and pancreas.
• Dermatologic: Intertriginous dermatitis.
• Neurologic: Carpal tunnel syndrome.
• Psychologic: Depression, eating disorders, body image disturbance
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Indications for surgery
• Surgery: A treatment of last resort. Dieting, exercise, psychotherapy, and drug treatments have failed.
• National Institutes of Health (NIH): Consensus Conference Panel criteria for surgical treatment:
• BMI > 40 kg/m2
• BMI > 35 kg/m2 with high-risk comorbid diseases (Sleep apnea, Pickwickian syndrome, diabetes, or degenerative joint disease)
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Contraindications to Bariatric surgery
• Illnesses that greatly reduce life expectancy (advanced cancer and end-stage renal, hepatic, & cardiopulmonary disease.
• Illness unlikely to be improved with weight reduction,
• Patients unable to understand the nature of bariatric
surgery or the behavioral changes required afterward (untreated schizophrenia, active substance abuse).
• Noncompliance with previous medical care
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PREOPERATIVE EVALUATION
• Cardiac, pulmonary, psychiatric, & endocrine evaluations.
• Exclude patients who may not benefit from surgery.
• Optimize potential good candidates for surgery.
• Preoperative nutritional consultation: Detailed diet history
& explaining preoperative and postoperative diet protocol
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PREOPERATIVE EVALUATIONLaboratory Studies:• CBC • Biochemical profile • Liver function tests • Thyroid function tests • Lipid profile • Coagulation tests • Serum iron & total iron binding capacity (TIBC) • Vitamin B-12, folic acid, • Blood typing • Urinalysis.
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PREOPERATIVE EVALUATION
Imaging Studies:
• Chest radiography
• Ultrasonography of the gallbladder
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PREOPERATIVE EVALUATION
Diagnostic Procedures:
• Upper GI endoscopy to rule out intrinsic upper gastrointestinal disease.
After gastric bypass surgery, the ability to visualize the distal stomach and the duodenum is difficult.
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Treatment & managementMedical Therapy:
• A preoperative trial of weight loss is beneficial to
ensure patient compliance with the postoperative
diet protocol.
• A preoperative liquid diet can shrink the liver,
thus facilitating the surgical procedure.
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Surgical Therapy
Surgical Technique
• Open surgery technique
• Laparoscopic technique.
• The laparoscopic approach has currently
become the more popular approach.
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Surgical Therapy Gastric bypass
• Restrictive and a malabsorptive component.
• Restrictive element: Creation of a small gastric pouch
(approximately 20 mL in volume) and a small outlet that,
on distention by food, causes the sensation of satiety.
• Malabsorptive element: Result of bypassing the distal
stomach, the entire duodenum, and varying the length
of the jejunum.
• Separation of food from the biliopancreatic secretions.
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Surgical Therapy
Gastric bypass
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Surgical Therapy Gastric bypass
• Weight loss usually exceeds 100 lb /about 65-70% of excess
body weight/ 35% of BMI.
• Weight loss generally levels off in 1-2 years.
• Regain of 20 lb to a long-term plateau is common.
• Dumping syndrome: rapid passage of gastric pouch contents
directly into the small bowel upon ingestion of sweets. The
rapid release of insulin by the pancreas cause symptomatic
hypoglycemia.
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Surgical Therapy
Laparoscopic adjustable gastric banding
• A restrictive procedure
• Inflatable band placed around the proximal stomach. Creates a
small gastric pouch (approx. 15 mL) and a small stoma.
• Band is adjustable by adding/removing saline from the band by a
reservoir system accessible through a port. The port is placed
subcutaneously in the anterior abdominal wall.
• Adjustments, performed up to 6 times annually
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Surgical Therapy
Laparoscopic adjustable gastric banding
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Surgical Therapy
Laparoscopic adjustable gastric banding
• Chew food thoroughly to allow food to pass
• Adjusting the inflation changes the size of the opening through
which food passes but does not change the size of the gastric
pouch
• Deflation of the cuff is useful when the outlet is obstructed.
• Weight loss: 50-60% of excess body wt. in about 2 yrs.
• Can be completely reversed
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Surgical Therapy
Biliopancreatic diversion with duodenal switch
Includes the following (see the image below) :
• Lateral 75% gastrectomy, resulting in a tubular stomach
• Duodenum divided past the pyloric valve
• Ileum divided
• Distal end of ileum anastomosed to proximal duodenum
• Common channel created distally with Y-anastomosis
• Optional appendectomy and cholecystectomy
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Surgical Therapy
Biliopancreatic diversion with duodenal switch
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Surgical Therapy
Biliopancreatic diversion with duodenal switch
• Malabsorption is achieved by separating food from
biliopancreatic digestive fluids
• Fat and protein malabsorption.
• Best weight loss with the least regain
• 75-85% of excess body weight loss is at 18 months
• Pyloric preservation protects against marginal ulceration and
dumping syndrome
• The procedure is technically challenging and difficult
• Still considered investigational.
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Surgical Therapy
Laparoscopic sleeve gastrectomy
• The stomach- reduced to about 15-20% of its size.
• The mechanism of weight loss: Gastric restriction
and neurohumoral changes (due to the gastric resection).
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Surgical Therapy
Laparoscopic sleeve gastrectomy
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Surgical Therapy
Laparoscopic sleeve gastrectomy• Follow-up: 6 months to 3 years- loss of 33-
83% of their excess weight.• Results: LSG has morbidity and effectiveness
between laparoscopic adjustable gastric banding and standard Roux bypass.[25]
• Postoperative complications: Bleeding from the staple line, Intraabdominal collectionsLeak.
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Complications of Bariatric surgeryEarly:• Anastomotic leak (1-3%)
• PE, DVT (< 1%)
• Wound infection
• GI hemorrhage (0.5-2%)
• Respiratory insufficiency, pneumonia
• Acute distention of the distal stomach
Late:• Stomal stenosis(20%)
• Small bowel obstruction (1%)
• Internal hernia
• Cholelithiasis
• Micronutrient deficiencies
• Marginal ulcer
• Staple line disruption
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Complications of the adjustable gastric band
• Injury of the stomach or esophagus• Food intolerance (most common)• Band slippage (stomach prolapse) (2.2-8%)• Pouch dilatation• Band erosion into the stomach• Reoperation rate (2-41%)• Esophageal dilatation• Failure to lose weight• Port infection, band infection• Leakage of the balloon or tubing
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Postoperative care
• Patients on a high-protein, low-fat diet. • Supplement diet with multivitamins, iron, and calcium
on a twice-daily basis.• Ursodiol to minimize the risk of developing gallstones
during the period of acute weight loss. • Modify eating habits- avoid chewy meats and other
foods that may inhibit normal emptying stomach pouch.• Nutritional and metabolic blood tests on a frequent
basis- at 6 months & 12 months after surgery, and then annually thereafter.
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Nutritional deficiencies
• Malabsorption of fat soluble vitamins A, D, E, & K
• Vitamin A deficiency- night blindness
• Vitamin D deficiency- osteoporosis
• Iron deficiency
• Protein-energy malnutrition
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Post-bariatric surgery body contouring
• Consequences of massive weight loss- flabby skin, abdominal skin overhang, and pendulous breasts.
• Skin does not contract back to its pre-surgery tightness.
• Redundant rolls of tissue- associated with intertrigo and hygiene problems.
• Surgical correction of deformities significantly enhance physical and physiological changes.
• Usual time lapse between gastric bypass and plastic surgery procedures is 12-18 months.
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Post-bariatric surgery body contouring
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Body contouring procedures
• Abdominoplasty, buttock lift, lower body lift, thigh lift,
upper arm lift, facelift, breast reduction, mastopexy, and/or
augmentation.
• Multiple procedures are usually required, and a
• Staged approach improve safety and outcomes.
• Complications of procedures: hematomas, seromas, fat
necrosis, skin slough, infection, and deep vein thrombosis.
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Outcome and Prognosis
• Lifetime care: Nutritional & psychological issues
• Exercise, and lifestyle changes
• Socioeconomic advancement require patient guidance.
• Reduced cardiovascular deaths, heart attack and stroke.
• Significant decrease in low back pain
• Diabetes remission
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Thank you!