comparison of bariatric to metabolic surgery
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Dr Pravin John and Dr John Thanakumar, Anurag Hospital, Coimbatore present the differences between metabolic and obesity surgery - dept of advanced laparoscopy and obesityTRANSCRIPT
Metabolic Surgery compared to Bariatric Surgery
Dr PRAVIN JOHN MS
Dr John Thanakumar MS,MNAMS, FRCS
Dept of Advanced Laparoscopy & Bariatric SurgeryANURAG HOSPITAL, Coimbatore.
•www.anuraghospital.com
Second only to smoking as a preventable cause of death
Major morbidity and mortality
OBESITY
Global Problem - Obesity
Different BMI for Asians and West
Obesity has increased in India in 21 century, with morbid obesity affecting 5% of population
Indians are genetically susceptible to weight accumulation especially around the waist
Obesity in India
NFHS 2007
Obesity statistics Indian States
Impact of Obesity among the Ethnic groups
Abdominal obesity and girth
Decreased high-density lipoprotein
Increased insulin resistance
Increased diabetic state
Increased high blood pressure
Metabolic Syndrome
Diabetes mellitus(Type 2)
Obstructive sleep apnea (OSA)
Coronary ischemic disease
Hypertension
Some cancers
Osteoarthritis
Also early death
Diseases associated with obesity
More in abdominal obesity More in advanced with age( 60 years)
Men commonly than womenSouth Asians appear more susceptible
Metabolic syndrome on drugs e.g. steroids, antidepressants and antipsychotic agents.
Metabolic Syndrome
Common
Metabolic SurgeryWhy the nomenclature?
• Bariatric Surgery is involved with weight loss
• Results and mechanism went beyond weight loss
• Hence the term Metabolic surgery
• 2002 Primary intent to cure Type 2 DM (T2DM)
Francesco Rubino
Term - Metabolic Surgery
• Acceptance after a landmark “Diabetes Surgery Summit” in 2007.
• 2 world congresses dedicated subject and statements of relevant organizations, notably the International Diabetes
Federation in 2011.
Not for Low BMIs
“Metabolic” and “diabetes surgery”, however, incorrectly referred to as a surgical approach to treat diabetes in low
BMI patients, as a set of novel and yet experimental operations.
Differences between bariatric & metabolic surgery
Metabolic surgical patients have a more balanced male/female ratio, showed higher incidence of type 2
diabetes, hypertension, dyslipidemia, higher cardiovascular risk & established cardiovascular disease at onset
Metabolic Surgery is defined as “a set of gastrointestinal operations used with the intent to treat diabetes ("diabetes
surgery") and metabolic dysfunctions (which include obesity)”
• Surgery to treat T2DM in patients with BMI above 35 should be considered “metabolic/diabetes surgery” not
“bariatric surgery”.
Definition of Metabolic Surgery
T2DM & OBESITY
• The primary risk factor for Type 2 Diabetes Mellitus is obesity
• 90% of all patients with type 2 diabetes are overweight or obese.
• Risk of diabetes increases about 42-fold in men as the BMI increases from <23 kg/m2 to >35 kg/m2 & 93-fold in women as BMI increases
from <22 kg/m2 to >35 kg/m2 .
Diabetes Care 1994N Engl J Med 2001
Diabetes improved in more than 85% of patients and cured in more than 75% overall
Cholesterol -70% improved after surgery
Hypertension cured in 60% of patients and improved in more than 18%.
Sleep Apnoea cured in 85.7% of surgical patients.
Benefits of Obesity Surgery
Improvement with fatty infiltration of liver
Improvement in respiratory function and asthmatic symptoms
Reversal of mild cardiomyopathy of obesity
Improvement in joint pain and mobility
Other Advantages of Obesity Surgery
Severe uncontrolled heart disease
Uncontrolled psychiatric disorder, Low IQ
Inability to follow instructions
Drug abuse, and cancer
Who cannot have Obesity surgery?
LaparoscopicAdjustable Gastric Band
Stomach
Laparoscopic Band
Adjustable Gastric Band
Common in Europe, Australia& S.America.
Small gastric pouch(15 mL).
Weight loss is about 50-60% of excess body weight in 2 years.
Injury of the stomach or esophagus
Bleeding
Food intolerance (most common)
Wound infection
Pneumonia
Early Complications of Band
Food intolerance or noncompliance to band (13%)
Band slippage (stomach prolapse) (2.2-8%)
Pouch dilatation
Band erosion into the stomach
Port complications
Re operation rate (2-41%)
Esophageal dilatation
Failure to lose weight
Port infection, band infection
Leakage of the balloon or tubing
Mortality rate (0.5%; 0% in some series)
Late Complications of Gastric Band
Sleeve Gastrectomy
Shape of stomachafter surgery
Sleeve gastrectomy employs subtotal gastric resection to reduce stomach to 15-20% of its original size
The mechanism related to gastric restriction or to Grehlin changes
Initially first of 2-stage op;with simplicity & favorable outcomes
Now a primary, stand-alone procedure.
Wt loss 33-83% of excess weight. Physiologic operation
Laparoscopic Sleeve Gastrectomy
Laparoscopic Roux en Y Gastric Bypass
Gastric pouch ( 20 ml) and small outlet cause sensation of satiety & grehlin.
Malabsorption is adjusted by length of the alimentary and bilio pancreatic limbs.
The malabsorptive element bypasses the distal stomach, duodenum, and some of the jejunum.
The standard Roux limb is 75cm. Long gastric bypass is150cm and the last is a very long-limb (distal gastric bypass).
Lap Roux en Y Gastric Bypass
Weight loss 65-70% of excess body weight
Long-limb bypasses give comparable weight reductions in super obese (BMI >50 kg/m2) pts.
Weight loss generally levels off in 1-2 years.
Result of Gastric Bypass
Anastomotic leak (1-3%)
Pulmonary embolism, deep vein thrombosis (<1%)
Wound infection (more common with open approach)
Gastrointestinal hemorrhage, bleeding (0.5-2%)
Respiratory insufficiency, pneumonia
Acute distention of the distal stomach
Early Complications of Roux en Y Gastric Bypass
Stomal stenosis, most common (20%)Bowel obstruction, small bowel obstruction (1%)
Internal herniaCholelithiasis
Micronutrient deficienciesMarginal ulcer
Staple line disruptionVentral hernia formation
Late Complications of Gastric Bypass
Marginal Ulcer
Operative (30-day) mortality is about 0.5%.
Less the experience, more the complications
Compared with open procedures, laparoscopy has a higher rate of intra-abdominal complications
Mortality of Gastric Bypass
Mini Gastric Bypass
Robert Ruthledge, 2009
Meta analysis- DM +Obesity
135,246 pts in 621 studies
Mean age 40.2 yrs BMI 47.9
10.5% bariatric procedures
78.1% DM improved
86.6% DM resolved
Buchwald et al 2009
Predictors for Resolution of T2DM in Obesity Surgery
T2DM < 5 years 95%
T2DM 6-10 yrs 74%
T2DM >10 yrs 54%
BMI > 37
Hb A1c >7.5
C peptide > 3 ng/mL
Buchwald et al 2009
Dixon et al 2008
Dangers of Obesity
• CAD mortality 3 times > in the obese
• Cancer higher in the obese.
• CAD and Cancer mortality is significantly reduced in the surgical group
Swedish Obese Subjects Study, Lancet, 2009
RYGB and MGB compared
RYGB- Gastric BypassMGB - Mini Gastric Bypass
RYGB- Gastric BypassMGB - Mini Gastric Bypass
RYGB vs MGB Selection of cases
Lap RYGB vs MGB for morbid obesity, Ann Surg, 2005RYGB- Gastric BypassMGB - Mini Gastric Bypass
RYGB and MGB Post Surgery Results
Lap RYGB vs MGB for morbid obesity, Ann Surg, 2005RYGB- Gastric BypassMGB - Mini Gastric Bypass
LSG vs RYGB on Co morbidities
50 Indian patients on each arm
Resolution of co morbidities equal on both lap sleeve and RYGB - T2DM,HT, dyslipedemias, sleep apneas, jt pains
Mild increase of GERD in LSV
Asian studies better results with LSG
Lakdawala, Obes Surg, 2010LSG-Lap Sleeve GastrectomyRYGB- Gastric Bypass
DM resolution in RYGB, SG & Band
Diabetic resolution 81.2 % for RYGB
Diabetic resolution 80.9 % for SG
Diabetic resolution 60.8 % for Banding
Greatest improvement in Blood sugars occurred in SG group
60 pts with T2DM morbidityAbbatini, Surg Endos 2010
LSG-Lap Sleeve GastrectomyRYGB- Gastric Bypass
Potential Benefits of Single incision laparoscopic surgery
• Superior cosmesis
• Possibly shorter operating time
• Less Pain
• ? Lower costs
• Shortened time to full recovery
Evangelos C, Surg Endos 2010
Evangelos C, Surg Endos 2010
LONGER Andrew Chow, JAMA surgery, 2010
Problems of Single incision laparoscopic surgery
Loss of triangulation
Crossing of instruments
Larger access port
Not for adhesions or redo surgery
Hernia of the port site
Future
• Careful selection in choice and method of Metabolic Surgery
• Multiple studies needed for comparison of SILS to standard laparoscopic surgery
ANURAG HOSPITAL,
8, Krishna Nagar
Sowripalayam Main Road
Coimbatore - 641028.
www.anuraghospital.com
Tel: 0422 6587871
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