themanagementofobesity 100312193454 phpapp02

The The Management Management

of Obesityof ObesityCelso M. Fidel Celso M. Fidel

MD,FPSGS,FPCSMD,FPSGS,FPCS

Diplomate Philippine Diplomate Philippine Board of SurgeryBoard of Surgery

IntroductionIntroduction

Obesity Obesity is a very serious health problem. is a very serious health problem.

The advent of modern The advent of modern bariatric surgery bariatric surgery is is increasingly recognized as an important therapeutic increasingly recognized as an important therapeutic option for many patients with clinically significant option for many patients with clinically significant obesity.obesity.

Assessing SeverityAssessing Severity

The The body mass index body mass index (BMI) is dividing the weight (BMI) is dividing the weight in kilograms by the height in meters squaredin kilograms by the height in meters squared

In adults, a normal body mass index measures In adults, a normal body mass index measures between between 18.5 and 24.9.18.5 and 24.9.

The BMI is closely, but not necessarily precisely, The BMI is closely, but not necessarily precisely, related to body fat content.related to body fat content.

celso m. fidel


The The body mass index body mass index has proven to be a clinically has proven to be a clinically relevant measure of obesity that can be linked to relevant measure of obesity that can be linked to health outcomes. health outcomes.

The BMI associated with The BMI associated with the lowest risk of death the lowest risk of death is is within the within the normal range for normal range for most men most men and lies within and lies within the the normal to overweight range normal to overweight range for most womenfor most women..

celso m. fidel


Abdominal obesity Abdominal obesity is more predictive of the is more predictive of the presence of metabolic risk factors (e.g., insulin presence of metabolic risk factors (e.g., insulin resistance) than is an elevated BMI alone.resistance) than is an elevated BMI alone.

Waist circumference and the waist:hip ratioWaist circumference and the waist:hip ratio, , used in conjunction with the BMI, may more accurately used in conjunction with the BMI, may more accurately identify patients with central adiposity who are at risk identify patients with central adiposity who are at risk for significant medical comorbidities, including for significant medical comorbidities, including cardiovascular disease.cardiovascular disease.

celso m. fidel


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Waist circumference is more closely correlated with Waist circumference is more closely correlated with visceral obesity . Population survey data indicate that visceral obesity . Population survey data indicate that a waist circumference exceeding a waist circumference exceeding 98 cm 98 cm in men and in men and 87 cm 87 cm in women can help identify patients who have in women can help identify patients who have an increased risk for cardiovascular disease an increased risk for cardiovascular disease

celso m. fidel


Other risk factors includeOther risk factors include: :

(1) elevated fasting triglycerides (>150 mg/dL)(1) elevated fasting triglycerides (>150 mg/dL)

(2) elevated high-density lipoprotein cholesterol(2) elevated high-density lipoprotein cholesterol

(3) hypertension (blood pressure >130/85 mm Hg);(3) hypertension (blood pressure >130/85 mm Hg);

(4) hyperglycemia (fasting plasma glucose levels (4) hyperglycemia (fasting plasma glucose levels >110 mg/dL).>110 mg/dL).

The presence of any three of these risk factors The presence of any three of these risk factors identifies patients who have the metabolic identifies patients who have the metabolic syndrome. .syndrome. .


. The National Heart, Lung and Blood Institute . The National Heart, Lung and Blood Institute guidelines guidelines

define patients with body mass indices between 25 define patients with body mass indices between 25 and 29.9 kg/mand 29.9 kg/m22 body surface area as overweight body surface area as overweight

Those with BMIs exceeding 30 kg/mThose with BMIs exceeding 30 kg/m22 are classified are classified as obeseas obese


Medical obesity is further subclassified into three Medical obesity is further subclassified into three categories:categories:

class 1 obesity for patients with body mass indices class 1 obesity for patients with body mass indices between 30 and 34.9 kg/mbetween 30 and 34.9 kg/m22

class 2 obesity for BMIs between 35 and 39.9class 2 obesity for BMIs between 35 and 39.9

class 3 obesity for patients with BMIs that exceed 40 class 3 obesity for patients with BMIs that exceed 40 kg/mkg/m22


In 1991, the National Institutes of Health defined In 1991, the National Institutes of Health defined morbidly obese morbidly obese patients as those with BMIs of 35 patients as those with BMIs of 35 kg/mkg/m22 or greater who had significant obesity-related or greater who had significant obesity-related conditions, or those with BMIs 40 kg/mconditions, or those with BMIs 40 kg/m22 or greater in or greater in the absence of medical comorbidities.the absence of medical comorbidities.

SuperobesitySuperobesity is a term that is occasionally used to is a term that is occasionally used to identify patients who have BMIs equal to 50 kg/midentify patients who have BMIs equal to 50 kg/m22 or or greater. The National Institutes of Health definitions greater. The National Institutes of Health definitions are similar to those of the World Health are similar to those of the World Health Organization.Organization.


The relationship between body mass and The relationship between body mass and Weight Classification:Weight Classification:

BMI < 18.5-------------- UnderweightBMI < 18.5-------------- Underweight

BMI 18.5-24.9-------- NormalBMI 18.5-24.9-------- Normal

BMI 25---29.9--------- OverweightBMI 25---29.9--------- Overweight

BMI 30---34.9--------- Obesity class 1BMI 30---34.9--------- Obesity class 1

BMI 35---39.9--------- Obesity class 2BMI 35---39.9--------- Obesity class 2

BMI > 40------------------ Obesity class 3BMI > 40------------------ Obesity class 3

EtiologyEtiology Storage of consumed energy as triglycerides Storage of consumed energy as triglycerides

within adipose tissue is a normal physiological within adipose tissue is a normal physiological process. It is teleologically appropriate to process. It is teleologically appropriate to suppose that such a storage process would suppose that such a storage process would provide a survival advantage provide a survival advantage to the host during to the host during times of starvation or increased energy times of starvation or increased energy demands because demands because the consumption of adipose the consumption of adipose tissue via hydrolysis releases fatty acids tissue via hydrolysis releases fatty acids that that can be used as an energy source by many can be used as an energy source by many tissues. tissues.

EtiologyEtiology The changes that have been witnessed over the The changes that have been witnessed over the

past decades most likely have occurred as past decades most likely have occurred as energy expenditure has declined energy expenditure has declined due to due to less physical activity, while food intake has less physical activity, while food intake has remained the same or increased.remained the same or increased.

Energy balance Energy balance is regulated by the balance is regulated by the balance between food intake and energy expenditure. between food intake and energy expenditure.

EtiologyEtiology The The propertiesproperties of the major macronutrients of the major macronutrients

consumed by humans have substantially consumed by humans have substantially different core properties that predict their effect different core properties that predict their effect on energy intake in most instances on energy intake in most instances

Macronutrient's thermic effectMacronutrient's thermic effect, otherwise , otherwise known as known as nutrient-induced thermogenesisnutrient-induced thermogenesis, , is the energy cost to the body of absorbing, is the energy cost to the body of absorbing, processing, and storing an orally ingested food.processing, and storing an orally ingested food.

Nutritional and Metabolic Properties of the Nutritional and Metabolic Properties of the Common MacronutrientsCommon Macronutrients

Properties Fat Protein Carbohydrate Alcohol

Kcal/g 9 4 4 7

Energy density High Low Low Hjgh

Nutrient-induced thermogenesis (percent of energy content)

2-3% 25-30 % 6-8% 15-20%

Storage capacityHigh None Low None

Autoregulation Poor Good Good Poor

Ability to suppress hungerLow High High

May stimulate hunger

EtiologyEtiology As the table illustratesAs the table illustrates

1. Fat has a very high energy density and 1. Fat has a very high energy density and

storage capacitystorage capacity

2. It is subject to less autoregulation2. It is subject to less autoregulation

3. It suppresses appetite somewhat less than 3. It suppresses appetite somewhat less than

other macronutrients in generalother macronutrients in general

4. It requires the least amount of energy for it to 4. It requires the least amount of energy for it to

be metabolized. be metabolized.

Nutritional and Metabolic Properties of the Nutritional and Metabolic Properties of the Common MacronutrientsCommon Macronutrients

Properties Fat Protein Carbohydrate Alcohol

Kcal/g 9 4 4 7

Energy density High Low Low Hjgh

Nutrient-induced thermogenesis (percent of energy content)

2-3% 25-30 % 6-8% 15-20%

Storage capacityHigh None Low None

Autoregulation Poor Good Good Poor

Ability to suppress hungerLow High High

May stimulate hunger

EtiologyEtiology

For these reasons, the importance For these reasons, the importance of fat intake as a determinant of of fat intake as a determinant of weight gain should be apparent—weight gain should be apparent—especially as compared with especially as compared with protein or carbohydrate.protein or carbohydrate.

..

EtiologyEtiology Major determinants of energy expenditure areMajor determinants of energy expenditure are

The resting metabolic rate The resting metabolic rate (which is the (which is the amount of energy needed to maintain the amount of energy needed to maintain the body's core functions at rest) body's core functions at rest)

The The energy required to process the food energy required to process the food consumed consumed (which is the nutrient-induced (which is the nutrient-induced thermogenesis described abovethermogenesis described above

The The energy consumed energy consumed by physical activity. by physical activity.

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EtiologyEtiology Behavioral factors that may vary geneticallyBehavioral factors that may vary genetically

1.The 1.The preference for fat preference for fat in the dietin the diet

2. Metabolic adaptations 2. Metabolic adaptations to food restrictionto food restriction

3. Tolerance3. Tolerance for physical activity for physical activity

4. The 4. The frequencfrequency of meals.y of meals.

EtiologyEtiology Various metabolites, besides fatty acids or Various metabolites, besides fatty acids or

triglycerides, that are released by adipose triglycerides, that are released by adipose tissue during starvation include various tissue during starvation include various

CytokinesCytokines and and prostaglandinsprostaglandins that may help that may help regulate energy balance, regulate energy balance,

ResistinResistin and and FibronectinFibronectin that may influence that may influence carbohydrate metabolism carbohydrate metabolism

EtiologEtiologyy Nutrient ingestion into the stomach or proximal Nutrient ingestion into the stomach or proximal

intestine elicits hormonal signals that release intestine elicits hormonal signals that release neuropeptidesneuropeptides, which in turn alter body , which in turn alter body metabolismmetabolism

Pleptin, ghrelinPleptin, ghrelin, which is normally associated , which is normally associated with appetite stimulation (i.e., is orexigenic)with appetite stimulation (i.e., is orexigenic)

InsulinInsulin and and cholecystokinincholecystokinin are normally are normally anorexic anorexic

EtiologyEtiology Leptin is a good example of the fundamental Leptin is a good example of the fundamental

principles of neurohormonal signaling between principles of neurohormonal signaling between the periphery and the central nervous systemthe periphery and the central nervous system

Leptin is a cytokinelike polypeptide hormone Leptin is a cytokinelike polypeptide hormone that is known to influence long-term changes in that is known to influence long-term changes in satiety. It is produced predominantly by adipose satiety. It is produced predominantly by adipose tissue and its circulating levels are proportional tissue and its circulating levels are proportional to the amount of fat stored as adipose tissue.to the amount of fat stored as adipose tissue.

EtiologyEtiology Leptin’s effects on food intake are governed by Leptin’s effects on food intake are governed by

its effects on receptors within the arcuate its effects on receptors within the arcuate nucleus of the hypothalamus. There it induces nucleus of the hypothalamus. There it induces the production of -melanocyte stimulating the production of -melanocyte stimulating hormone MSH) from propiomelanocortin. hormone MSH) from propiomelanocortin.

MSH binds with melanocortin 4 receptors within MSH binds with melanocortin 4 receptors within hypothalamic nuclei and inhibits food intake.hypothalamic nuclei and inhibits food intake.

Leptin also decreases the production of appetite-Leptin also decreases the production of appetite-inducing neuropeptides such as neuropeptide inducing neuropeptides such as neuropeptide Y.Y. ..

EtiologyEtiology Humans born with homozygous loss of function Humans born with homozygous loss of function

mutations of the leptin gene (and who, therefore mutations of the leptin gene (and who, therefore cannot produce leptin) eventually develop morbid cannot produce leptin) eventually develop morbid obesity.obesity.

These unfortunate individuals continuously seek These unfortunate individuals continuously seek food and eat much more than normal Other food and eat much more than normal Other phenotypical manifestations includesphenotypical manifestations includes

Adrenal insufficiencyAdrenal insufficiency

Changes in hair colorChanges in hair color

Impaired fertility are commonly Impaired fertility are commonly

EtiologyEtiology The Prader-Willi syndrome is a well-recognized The Prader-Willi syndrome is a well-recognized

disorder characterizeddisorder characterized

by childhood-onset upper body obesityby childhood-onset upper body obesity

short statureshort stature

mental retardationmental retardation

hypogonadism. hypogonadism.

EtiologyEtiology The Prader-Willi syndrome . The Prader-Willi syndrome .

In general when such syndromes are identified, In general when such syndromes are identified, they most often include alterations in the leptin-they most often include alterations in the leptin-hypothalamic feedback loop (i.e., of important hypothalamic feedback loop (i.e., of important signal precursors such as propiomelanocortin, signal precursors such as propiomelanocortin, the leptin gene, and the leptin receptor).the leptin gene, and the leptin receptor).

Melanocortin 4 receptor mutations have also Melanocortin 4 receptor mutations have also been described but are extremely rare.been described but are extremely rare.

EtiologyEtiology Ghrelin discovered in 1999, is a growth Ghrelin discovered in 1999, is a growth

hormone secretagogue that is synthesized hormone secretagogue that is synthesized predominantly by the stomach. predominantly by the stomach.

Its levels rise just before meals and with short-Its levels rise just before meals and with short-term food restriction, or prolonged starvation in term food restriction, or prolonged starvation in general and may be an important orexigenic general and may be an important orexigenic (i.e., appetite-stimulating) signal. (i.e., appetite-stimulating) signal.

Ghrelin levels normally fall rapidly after meals. Ghrelin levels normally fall rapidly after meals. Like leptin, ghrelin metabolism may be Like leptin, ghrelin metabolism may be dysregulated in obese subjects.dysregulated in obese subjects.

EtiologyEtiology Obesity is associated with decreased circulating Obesity is associated with decreased circulating

ghrelin levels. After gastric bypass surgery, ghrelin levels. After gastric bypass surgery, ghrelin levels fall but do not increase as ghrelin levels fall but do not increase as expected before mealsexpected before meals

Low levels of ghrelin and its metabolic Low levels of ghrelin and its metabolic dysregulation may be at least partially dysregulation may be at least partially responsible for the sustained weight loss after responsible for the sustained weight loss after surgical procedures that resect and/or bypass a surgical procedures that resect and/or bypass a significant portion of the stomach.significant portion of the stomach.

Medical problems associated with ObesityMedical problems associated with Obesity

1.1. Gastroesophageal refluxGastroesophageal reflux

2. Coronary artery disease2. Coronary artery disease

3. Cerebrovascular accident3. Cerebrovascular accident

4. Congestive heart failure4. Congestive heart failure

5. Hypertension5. Hypertension

6. Dyslipidemia6. Dyslipidemia

7. Cholelithisis and gallbladder disease7. Cholelithisis and gallbladder disease

8. Osteoarthritis and degenerative joint disease8. Osteoarthritis and degenerative joint disease

9. Slap apnea9. Slap apnea


Cancer of the:Cancer of the:

1.1. EsophagusEsophagus

2. Stomach2. Stomach

3. Liver3. Liver

4. Pancreatic4. Pancreatic

5. Kidney5. Kidney

6. Non Hodgkin’s lymphoma6. Non Hodgkin’s lymphoma

7. Multiple myeloma7. Multiple myeloma

8. Prostate8. Prostate


Cancer:Cancer:

9. Ovarian9. Ovarian

10.Uterus10.Uterus

11.Gallbladder11.Gallbladder

12. Colon12. Colon

Menstrual AbnormalitiesMenstrual Abnormalities

Impaired fertility and increased risk of adverse Impaired fertility and increased risk of adverse outcome after pregnancyoutcome after pregnancy

Stress inccontinenceStress inccontinence

Medical problems associated with Medical problems associated with ObesityObesity

Morbidity from obesity is increased in the Morbidity from obesity is increased in the presence of:presence of:

1. Preexisting coronary artery or peripheral 1. Preexisting coronary artery or peripheral artery disease artery disease

2.Type II diabetes2.Type II diabetes

3. Hypertension3. Hypertension

4. Smoking4. Smoking


Morbidity from obesity is increased in the Morbidity from obesity is increased in the presence of :presence of :

5. Elevated low-density or decreased high-5. Elevated low-density or decreased high-density lipoprotein levelsdensity lipoprotein levels

6. Increased fasting blood sugar concentrations6. Increased fasting blood sugar concentrations

7. Patients with a family history of early-onset 7. Patients with a family history of early-onset heart disease heart disease

Medical problems associated with Obesity Medical problems associated with Obesity

Cardiovascular risks associated w/ significant Cardiovascular risks associated w/ significant obesity.obesity.

1. Overweight women have 50% > risk of heart 1. Overweight women have 50% > risk of heart failure compared to women with normal BMIs. failure compared to women with normal BMIs.

2.The risk is twofold higher in obese females.2.The risk is twofold higher in obese females.

3. Obese men have a 90% greater risk of heart 3. Obese men have a 90% greater risk of heart failure.failure.

4. Overall, approximately 11% of all heart failure 4. Overall, approximately 11% of all heart failure cases in men and 14% in women can be attributed cases in men and 14% in women can be attributed to obesity alone.to obesity alone.

Medical management of ObesityMedical management of Obesity

Medications are classified into: Medications are classified into:

1. Those that 1. Those that decrease food intake decrease food intake by by suppressing appetite or increasing satietysuppressing appetite or increasing satiety

2. Those that 2. Those that decrease nutrient absorptiondecrease nutrient absorption. .


Appetite suppressants are believed to work by Appetite suppressants are believed to work by increasing the availability of increasing the availability of neurotransmitters neurotransmitters which suppress appetite which suppress appetite such as: such as:

1. 1. norepinephrinenorepinephrine

2. 2. serotoninserotonin

33. dopamine. dopamine


SibutramineSibutramine works by inhibiting the uptake of works by inhibiting the uptake of these neurotransmitters. This drug may also these neurotransmitters. This drug may also stimulate thermogenesisstimulate thermogenesis, although this , although this effect is modest and constitutes only 3–5% of effect is modest and constitutes only 3–5% of the average person's resting metabolic rate.the average person's resting metabolic rate.

Randomized controlled trials indicate that the Randomized controlled trials indicate that the average patient will lose approximately 3–4 kg average patient will lose approximately 3–4 kg over 8–52 weeks of treatment. over 8–52 weeks of treatment.


OrlistatOrlistat reduces nutrient absorption reduces nutrient absorption by binding by binding to gastrointestinal lipase and prevents the to gastrointestinal lipase and prevents the hydrolysis of dietary fat into absorbable free hydrolysis of dietary fat into absorbable free fatty acids and monoacylglycerols. fatty acids and monoacylglycerols.

Patients who are treated with Patients who are treated with orlistatorlistat excrete excrete about a third of the dietary fat that they about a third of the dietary fat that they consume in their stools and can be expected to consume in their stools and can be expected to lose about 9% of their baseline weight on lose about 9% of their baseline weight on average. average.


The currently accepted approach is to The currently accepted approach is to combine caloric restriction with exercise and combine caloric restriction with exercise and behavioral modification as the initial treatment behavioral modification as the initial treatment recommendation for most overweight or obese recommendation for most overweight or obese patients.patients.

Diet modification, exercise, and behavioral Diet modification, exercise, and behavioral modifications should be the cornerstones of modifications should be the cornerstones of every treatment plan. every treatment plan.

Guidelines Treatment of Guidelines Treatment of Overweight and Obese PatientsOverweight and Obese Patients

BMI/mKg/m2

Health Risk Risk with comorbidities

Treatment

<25 Minimal Low Healthy eating,exercise & lifestyle changes

25-26.9 Low Moderate

27-29.9 Moderate High All of the above plus low caloric diet

30-34.9 High Very High All of the above plus pharmacotherapy or very low

35-39.9 Very High Extremely High Caloric diet

>40 Extremely High

Extremely High All of the above plus Bariatric Surgery

Surgical management of obesitySurgical management of obesity

Bariatric surgery should be offeredBariatric surgery should be offered

To appropriate patients with BMIs of 40 kg/mTo appropriate patients with BMIs of 40 kg/m22 or greater (or between 35 and 40 kg/mor greater (or between 35 and 40 kg/m22 if any of if any of the previously described significant medical the previously described significant medical comorbidities are present) comorbidities are present)

Who have failed medical treatment, nutritional Who have failed medical treatment, nutritional treatment, lifestyle changes, behavioral treatment, lifestyle changes, behavioral modification, or other conservative therapies. modification, or other conservative therapies.


. . CandidatesCandidates for surgical therapy must be willing for surgical therapy must be willing and able to comply with:and able to comply with:

Postoperative dietary recommendationsPostoperative dietary recommendations

ExerciseExercise

Follow-up requirements. Follow-up requirements.


. . Patients Patients who should who should not undergo bariatric not undergo bariatric surgerysurgery

1. Ongoing drug or alcohol dependency1. Ongoing drug or alcohol dependency

2. Who are unstable or otherwise unfit 2. Who are unstable or otherwise unfit

psychiatricallypsychiatrically

3. Who are unable to undergo general 3. Who are unable to undergo general

anesthesiaanesthesia


Surgical treatment is the only Surgical treatment is the only way to obtain consistent, way to obtain consistent, durable weight loss for most durable weight loss for most morbidly obese patientsmorbidly obese patients


Surgical treatment is indicated for patients with:Surgical treatment is indicated for patients with:

1. BMIs of 40 kg/m1. BMIs of 40 kg/m22 or greater or greater

2. BMIs of 35–40 kg/m2. BMIs of 35–40 kg/m22 with obesity-related with obesity-related comorbidities comorbidities

3. When medical, nutritional, and behavioral 3. When medical, nutritional, and behavioral therapies are ineffectivetherapies are ineffective


In all instances, the best care for morbidly In all instances, the best care for morbidly obese patients provides unfettered access to, obese patients provides unfettered access to, and evaluation by, a multidisciplinary team and evaluation by, a multidisciplinary team comprised of :comprised of :

1. Nutritionists1. Nutritionists

2. Physical or exercise therapists2. Physical or exercise therapists

3. Surgeons3. Surgeons

4. Medical specialists4. Medical specialists

5. Psychiatrists.5. Psychiatrists.

Criteria for Surgical Treatment of ObesityCriteria for Surgical Treatment of Obesity

1. BMI >40 or BMI between 35 and 40 in 1. BMI >40 or BMI between 35 and 40 in individuals with high-risk comorbid individuals with high-risk comorbid conditions or severe lifestyle limitations for conditions or severe lifestyle limitations for greater than 5 yearsgreater than 5 years

2. Absence of secondary cause of morbid 2. Absence of secondary cause of morbid obesityobesity

3. Ability and willingness to cooperate with 3. Ability and willingness to cooperate with long-term follow-uplong-term follow-up

4. Acceptable operative risk4. Acceptable operative risk

Criteria for Surgical Treatment of ObesityCriteria for Surgical Treatment of Obesity

Not yet uniformly recommenced Not yet uniformly recommenced for children or adolescents for children or adolescents (less than 18 years of age), or (less than 18 years of age), or patients over the age of 60patients over the age of 60

Preoperative PreparationPreoperative Preparation

Nutritional evaluation and education are Nutritional evaluation and education are critically important components of critically important components of preoperative preparation.preoperative preparation.

Psychiatric evaluation helps some Psychiatric evaluation helps some patients cope more effectively with various patients cope more effectively with various stressors that may surface in their stressors that may surface in their interpersonal relationships after surgery.interpersonal relationships after surgery.


Psychiatric evaluation helps to prepare Psychiatric evaluation helps to prepare patients for operation and their patients for operation and their postoperative recuperation, and also helps postoperative recuperation, and also helps to identify patients with to identify patients with eating disorderseating disorders, , severe depressionsevere depression, , psychosispsychosis, or , or other other mood disturbances mood disturbances that could adversely that could adversely affect outcome.affect outcome.


1. All patients should have an electrocardiogram 1. All patients should have an electrocardiogram

performed preoperatively. performed preoperatively.

2. Stress testing & even cardiac catheterization 2. Stress testing & even cardiac catheterization

may be indicated for intermediate- or high- may be indicated for intermediate- or high-

risk patients.risk patients.

3. Polysomnographic evaluation at a sleep 3. Polysomnographic evaluation at a sleep

center for all morbidly obese patients who center for all morbidly obese patients who

are being evaluated for surgical treatment.are being evaluated for surgical treatment.


4. Patients who are diagnosed with significant 4. Patients who are diagnosed with significant sleep apnea require treatment with continuous sleep apnea require treatment with continuous positive airway pressure and are at risk for positive airway pressure and are at risk for acute upper airway obstruction and significant acute upper airway obstruction and significant cardiac arrhythmias postoperatively. cardiac arrhythmias postoperatively.


5. 5. Obesity hypoventilation syndrome Obesity hypoventilation syndrome may also may also be present in many obese patients. The be present in many obese patients. The syndrome is defined by the presence of syndrome is defined by the presence of significant hypoxemia with arterial partial significant hypoxemia with arterial partial pressure of oxygen less than 55 mm Hg, and pressure of oxygen less than 55 mm Hg, and hypercarbia with a partial pressure of carbon hypercarbia with a partial pressure of carbon dioxide greater than 47 mm Hg.dioxide greater than 47 mm Hg.


6. Patients with sleep apnea, the obesity 6. Patients with sleep apnea, the obesity hypoventilation syndrome, or any other hypoventilation syndrome, or any other significant airway or parenchymal lung significant airway or parenchymal lung disease should be evaluated by a disease should be evaluated by a pulmonologist preoperativelypulmonologist preoperatively


7. Finally, many patients with severe 7. Finally, many patients with severe gastroesophageal reflux, dysphagia, nausea, gastroesophageal reflux, dysphagia, nausea, vomiting, abdominal pain, or a prior history of vomiting, abdominal pain, or a prior history of gastric or intestinal surgery may require formal gastric or intestinal surgery may require formal evaluation of the gastrointestinal tract including evaluation of the gastrointestinal tract including barium swallow, upper G I series, barium swallow, upper G I series, esophagogastroduodenoscopy, esophageal esophagogastroduodenoscopy, esophageal manometry, and pH testing and computed manometry, and pH testing and computed tomography of the abdomen with and without tomography of the abdomen with and without contrast. contrast.


8. Preoperative laboratory evaluation will typically 8. Preoperative laboratory evaluation will typically include hemoglobin, hematocrit, and platelet count include hemoglobin, hematocrit, and platelet count measurements, along with assessment of electrolyte measurements, along with assessment of electrolyte levels, BUN, creatine, blood glucose, and liver levels, BUN, creatine, blood glucose, and liver function. In women, Pap smears and pregnancy function. In women, Pap smears and pregnancy testing should be performed routinely. Hemoglobin testing should be performed routinely. Hemoglobin AA1c1c measurements are appropriate for patients with measurements are appropriate for patients with

adult-onset diabetes mellitus. Posteroanterior and adult-onset diabetes mellitus. Posteroanterior and lateral radiographs of the chest should also be lateral radiographs of the chest should also be evaluated routinely.evaluated routinely.


9. Obesity likely increases the risk of 9. Obesity likely increases the risk of postoperative wound infections. For this reason postoperative wound infections. For this reason antibiotic prophylaxis is indicated according to antibiotic prophylaxis is indicated according to the likelihood of wound contamination and the the likelihood of wound contamination and the type of procedure planned. The rate of wound type of procedure planned. The rate of wound infection after laparoscopic gastric bypass infection after laparoscopic gastric bypass appears to be reduced by at least 75% appears to be reduced by at least 75% compared with open gastric bypass surgery.compared with open gastric bypass surgery.

Historical Perspective and Historical Perspective and OverviewOverview

A useful paradigm is to categorize bariatric A useful paradigm is to categorize bariatric procedures as: procedures as:

1. Restrictive1. Restrictive

2. Malabsorptive2. Malabsorptive

3. Combination of both3. Combination of both

Historical Perspective and Historical Perspective and OverviewOverview

The rationale for the surgical treatment of The rationale for the surgical treatment of obesity has been based on three fundamental obesity has been based on three fundamental goals:goals:

1. Reducing caloric absorption by bypassing 1. Reducing caloric absorption by bypassing

portions of the stomach and small bowelportions of the stomach and small bowel

2. Reducing gastric capacity via banding, 2. Reducing gastric capacity via banding,

stapling, or transectionstapling, or transection

3. Performing operations that induce 3. Performing operations that induce

malabsorption and restrict food intake.malabsorption and restrict food intake.

. . Major Types of Bariatric Surgical Major Types of Bariatric Surgical ProceduresProcedures




3. Mostly restrictive3. Mostly restrictive

4. Mostly malabsorptive4. Mostly malabsorptive



Jejunoileal and jejunocolic bypasses (no Jejunoileal and jejunocolic bypasses (no longer recommendedlonger recommended


(1) Vertical banded gastroplasty(1) Vertical banded gastroplasty

(2) Adjustable silicone gastric banding(2) Adjustable silicone gastric banding


3. Mostly restrictive3. Mostly restrictive

(1) Short-limb (50–100 cm) Roux-en-Y (1) Short-limb (50–100 cm) Roux-en-Y

gastric bypassgastric bypass

(2) Long-limb (150 cm) Roux-en-Y gastric (2) Long-limb (150 cm) Roux-en-Y gastric

bypassbypass

4. Mostly malabsorptive4. Mostly malabsorptive

Biliopancreatic diversion with or without Biliopancreatic diversion with or without

duodenal switchduodenal switch

Vertical Banded Vertical Banded gastroplastygastroplasty

Efficacy of VBGEfficacy of VBG

VBC achieve acceptable weight loss resultsVBC achieve acceptable weight loss results

Series of 305 patients followed for 2 years- Series of 305 patients followed for 2 years- mean excess loss of 61%mean excess loss of 61%

Series of 250 patients followed for 5 years- Series of 250 patients followed for 5 years- mean excess wt. loss 60% for Morbidly excessmean excess wt. loss 60% for Morbidly excess

mean excess wt. loss 52% for super obesemean excess wt. loss 52% for super obese

A significant number of patients have required a A significant number of patients have required a reoperation following VBGreoperation following VBG


ComplicationsComplications

Over all morbidity rate of VBG- under 10%Over all morbidity rate of VBG- under 10%

mortality rate of 0- 38%mortality rate of 0- 38%

Early ComplicationsEarly Complications

Splenectomy 3%Splenectomy 3%

Peritonitis from leak 6%Peritonitis from leak 6%



Late ComplicationsLate Complications

1. Stoma stenosis1. Stoma stenosis

2. Staple line dehiscence 48%2. Staple line dehiscence 48%

3. Reflux Esophagitis3. Reflux Esophagitis

4. Intractable vomiting 30-50%4. Intractable vomiting 30-50%


AdvantagesAdvantages

1. Significant improvement in comorbidities like 1. Significant improvement in comorbidities like dyspnea, hypertension, diabetes mellitus, quality dyspnea, hypertension, diabetes mellitus, quality of lifeof life

2. Minimal long term metabolic or nutritional 2. Minimal long term metabolic or nutritional deficiencydeficiency

3. Less operating time3. Less operating time

4. No anastomosis required4. No anastomosis required


DisadvantagesDisadvantages

Long term weight loss is less successful whenLong term weight loss is less successful when

1. Patient eat sweet food1. Patient eat sweet food

2. In high liquid caloric intake2. In high liquid caloric intake

3. Less effective in terms of weight loss as 3. Less effective in terms of weight loss as

compared to gastric bypasscompared to gastric bypass

Laparoscopic Gastric bandingLaparoscopic Gastric banding

Mechanism of ActionMechanism of Action

Use of Silicone bandUse of Silicone band

Restricts amount of ingested solid foodRestricts amount of ingested solid food

Adjustable nature of the bandAdjustable nature of the band

Adjustable gastric bandAdjustable gastric band

Efficacy of lGbEfficacy of lGb

Mean Excess weight loss Mean Excess weight loss in 1 and 2 in 1 and 2 yearsyears 55 to 55 to 56%56%



Intraoperative ComplicationsIntraoperative Complications

1. Splenic injury 0 to 1 %1. Splenic injury 0 to 1 %

2. Esophageal injury 0 to 1%2. Esophageal injury 0 to 1%

3. Gastric injury 0 to 1%3. Gastric injury 0 to 1%

4. Conversion to open procedure 1 to 2 %4. Conversion to open procedure 1 to 2 %

5. Bleeding 0 to 1%5. Bleeding 0 to 1%



Early postoperative ComplicationsEarly postoperative Complications

1. Bleeding 0.5 %1. Bleeding 0.5 %

2. Wound infection 0 to 1%2. Wound infection 0 to 1%

3. Food intolerance 0 to 11%3. Food intolerance 0 to 11%



Late ComplicationsLate Complications

1. Slippage of Band 7- 21%1. Slippage of Band 7- 21%

2. Band Erosion 2 to 7.5%2. Band Erosion 2 to 7.5%

3. Leakage of reservoir3. Leakage of reservoir

4. Persistent vomiting4. Persistent vomiting



1. Simple procedure and less operative time1. Simple procedure and less operative time

2. Mortality is low 0.06%2. Mortality is low 0.06%

3. No staple liner or anastomosis3. No staple liner or anastomosis

4. Recovery is rapid and hospital stay is short4. Recovery is rapid and hospital stay is short


DisadvantagesDisadvantages

Potential for site complicaton Potential for site complicaton

Need for frequent Need for frequent

postoperative visit for postoperative visit for

gastric band adjustmentgastric band adjustment

Open roux en y gastric bypassOpen roux en y gastric bypass

Mechanism of actionMechanism of action

Both a gastric restrictiveBoth a gastric restrictive

andand

mildly malabsorptive proceduremildly malabsorptive procedure

Roux en y gastric bypassRoux en y gastric bypass

Efficacy of Open roux en y gastric bypassEfficacy of Open roux en y gastric bypass

1. Weight loss from gastric bypass is superior 1. Weight loss from gastric bypass is superior

than purely restrictive proceduresthan purely restrictive procedures. .

22. . Five year weight loss was 48 -74 % loss ofFive year weight loss was 48 -74 % loss of

excess weight.excess weight.

3. RYGB- to prevent the progression of non 3. RYGB- to prevent the progression of non

insulin dependent Diabetes Mellitus, reduceinsulin dependent Diabetes Mellitus, reduce

the mortality from Diabetes Mellitus andthe mortality from Diabetes Mellitus and

Cardiovascular disease.Cardiovascular disease.


Early ComplicationsEarly Complications

1. ANASTOMOTIC LEAK with 1. ANASTOMOTIC LEAK with

peritonitis - 1.2%peritonitis - 1.2%

2. 2. Acute distal gastric dilatationAcute distal gastric dilatation

33. . Severe wound infectionSevere wound infection


late Complicationslate Complications

1. Stomach stenosis 1. Stomach stenosis 15% 15%

2. Marginal Ulcer 13%2. Marginal Ulcer 13%

3. Intestinal Obstruction3. Intestinal Obstruction

4. Internal Hernia4. Internal Hernia

5. Staple line destruction5. Staple line destruction

6. Incisional Hernia6. Incisional Hernia


late Complicationslate Complications

7. Metabolic Complications7. Metabolic Complications

a. Deficiencies of: a. Deficiencies of:

Calcium, thiamine, Vit B12 30-70%Calcium, thiamine, Vit B12 30-70%

Folate 9- 18%Folate 9- 18%

Iron 20-49%Iron 20-49%

b. Anemia 18-35%b. Anemia 18-35%



1. RYGB is more effective than vertical bonded1. RYGB is more effective than vertical bonded

gastroplastygastroplasty

2. Presence of dumping syndrome encourages 2. Presence of dumping syndrome encourages

patient to avoid sweet foodpatient to avoid sweet food


disAdvantagesdisAdvantages

1. Dumping syndrome in a lot of patients 1. Dumping syndrome in a lot of patients

a. Due to rapid emptying hyperosmolar bolusesa. Due to rapid emptying hyperosmolar boluses

in small intestinesin small intestines

b. Bloating, nausea, vomiting, diarrhea andb. Bloating, nausea, vomiting, diarrhea and

abdominal pain after intake of milk andabdominal pain after intake of milk and

sweet productssweet products


disAdvantagesdisAdvantages

c. Vasomotor symptoms like palpitation, c. Vasomotor symptoms like palpitation,

diaphoresis and lightheadednessdiaphoresis and lightheadedness

2. Distal gastric distention – hiccups and left2. Distal gastric distention – hiccups and left

shoulder painshoulder pain

3. Internal hernia3. Internal hernia

Laparoscopic roux en y gastric bypassLaparoscopic roux en y gastric bypass

Mechanism of actionMechanism of action

1. Both gastric restrictive & mildly malabsortive1. Both gastric restrictive & mildly malabsortive

procedureprocedure

2. Small gastric pouch restricts gastric intake2. Small gastric pouch restricts gastric intake

while the Roux Y configuration provideswhile the Roux Y configuration provides

malabsorpton of calories and nutrientsmalabsorpton of calories and nutrients


EfficacyEfficacy

1. After 24 months follow up mean excess1. After 24 months follow up mean excess

weight loss ranges from 69- 82%weight loss ranges from 69- 82%

2. Most comorbidities were improved and 2. Most comorbidities were improved and

eradicatederadicated


complicationscomplications

1. Pulmonary embolism 0- 1.5%1. Pulmonary embolism 0- 1.5%

2. Anastomotic leak 1.5- 5.8%2. Anastomotic leak 1.5- 5.8%

3. Bleeding 0- 3.3%3. Bleeding 0- 3.3%

4. Stenosis of gastroepinoctomy 1.6- 6.3%4. Stenosis of gastroepinoctomy 1.6- 6.3%

5. Internal Hernia 2.5%5. Internal Hernia 2.5%

6. Marginal Ulcer 1.4%6. Marginal Ulcer 1.4%

7. Gallstone 1.4%7. Gallstone 1.4%


advantagesadvantages

1. Better cosmesis1. Better cosmesis

2. Less postoperative pain2. Less postoperative pain

3. Attenuation of postoperative stress response3. Attenuation of postoperative stress response

4. Reduce wound infection, dehiscence4. Reduce wound infection, dehiscence

5. Incisional Hernia 5. Incisional Hernia

6. Improvement of postoperative pulmonary6. Improvement of postoperative pulmonary

functionfunction


disadvantagesdisadvantages

1. Technically challenging, advance laparoscopy1. Technically challenging, advance laparoscopy

of steep learning curveof steep learning curve

2. Approach may be difficult in super obese2. Approach may be difficult in super obese

patientspatients

biliopancreatic diversion with biliopancreatic diversion with duodenal switchduodenal switch

Bilio pancreatic proceduresBilio pancreatic procedures

1. It combines gastric restriction with intestinal1. It combines gastric restriction with intestinal

malabsorption proceduremalabsorption procedure

2. Fifty (50 to 100 cms common absorptive2. Fifty (50 to 100 cms common absorptive

alimentary channel is created proximalalimentary channel is created proximal

to the ileo cecal valve and absorptionto the ileo cecal valve and absorption

is limited to that segmemtis limited to that segmemt


contraindicationscontraindications

1. Patients with anemia, hypocalcemia and1. Patients with anemia, hypocalcemia and

osteoporosisosteoporosis

2. Those who cannot comply with the strigent2. Those who cannot comply with the strigent

supplementation regimensupplementation regimen

EfficacyEfficacy

1. Excellent and durable result1. Excellent and durable result

2. Mean excess weight loss in 8 years 72-78%2. Mean excess weight loss in 8 years 72-78%


complications complications

1. Anemia 30%1. Anemia 30%

2. Protein Calorie Malnutrition 30%2. Protein Calorie Malnutrition 30%

3. Dumping syndrome3. Dumping syndrome

4. Marginal Ulcer4. Marginal Ulcer

5. Vit B 12 deficiency5. Vit B 12 deficiency

6. Hypocalcemia6. Hypocalcemia

7. Osteoporosis7. Osteoporosis

8. Night blindness8. Night blindness

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