bariatric surgery mr b.m.axisa consultant laparoscopic and upper gi surgeon
TRANSCRIPT
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