Pathophysiology of Bariatric Pathophysiology of Bariatric SurgerySurgery

DR SREEJOY PATNAIKBARIATRIC AND METABOLIC SURGEON

LIFE MEMBER OSSI,IFSO,SAGES

SHANTI MEMORIAL HOSPITAL PVT.LTDFinal Phase of NABH Accredition.

Obesity EpidemicObesity Epidemic

• World epidemic encompasses 1.7 billion people

• Highest in the U.S.• Approximately 2/3 of Americans are

overweight, and almost half are obese• BMI subgroups of >35 and >40 are

experiencing most rapid growth

Buchwald et al. Jama 2004Buchwald et al. Jama 2004

Obesity EpidemicObesity Epidemic

• Rise in the prevalence of obesity is associated with rises in prevalence of obesity related comorbidities

• Comorbidities responsible for 2.5 million deaths per year worldwide

• Loss of life expectancy is profound• 25 year-old morbidly obese male has 22%

reduction in lifespan, representing a loss of 12 years of life

Buchwald et al. Jama 2004Buchwald et al. Jama 2004

Obesity EpidemicObesity Epidemic

• Diet therapy, with and without support organizations, is ineffective long term

• Currently, there are no effective pharmaceutical agents to treat obesity, especially morbid obesity

North American Association for the North American Association for the Study of Obesity. NIH 2000Study of Obesity. NIH 2000

Definition of Obesity Definition of Obesity according to BMIaccording to BMI

UnderweightUnderweight <18.5<18.5NormalNormal 18.5 – 24.918.5 – 24.9

OverweightOverweight 25-29.925-29.9

ObesityObesity >30>30moderate moderate 30.0 – 34.930.0 – 34.9severesevere 35.0 – 39.935.0 – 39.9morbidmorbid >40>40

BMI = W(kg)/H (m²)BMI = W(kg)/H (m²)

BMIBMI

• Calculated as follows: Weight(kg)/Height(m2) • Lowest mortality = BMI < 25kg/m2

• Highest mortality = BMI > 40kg/m2 • BMI > 40 = approximately 100lbs. over ideal

body weight

Why Operate?Why Operate?

Pulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndrome

Nonalcoholic fatty liver diseasesteatosissteatohepatitiscirrhosis

Coronary heart disease Diabetes Dyslipidemia Hypertension

Gynecologic abnormalitiesabnormal mensesinfertilitypolycystic ovarian syndrome

Osteoarthritis

Skin

Gall bladder disease

Cancerbreast, uterus, cervixcolon, esophagus, pancreaskidney, prostate

Phlebitisvenous stasis

Gout

Medical Complications of ObesityIdiopathic intracranial hypertension

StrokeCataracts

Severe pancreatitis

Medical Co-morbidities

• Metabolic Mechanical Degenerative Neoplastic Psychological

Medical Co-morbiditiesMetabolic

Diabetes mellitus, type II Hypertriglyceridemia Hypercholesterolemia Hypertension Gallstones Fatty liver disease (NASH) Pancreatitis Central sleep apnea Hypercoagulable Infertility

Metabolic Syndrome

Abdominal obesityHyperinsulinemiaHigh fasting plasma glucoseImpaired glucose toleranceHypertriglyceridemiaLow HDL-cholesterolHypertension

Medical Co-morbiditiesMechanical/Anatomic

Obstructive sleep apnea GERD GERD - associated asthma Urinary stress incontinence Pseudotumor cerebri Venous stasis DVT / PE Fungal skin infections Decubitus ulcers Accidental injuries

Medical Co-morbiditiesDegenerative

Cardiovascular disease Complications of diabetes CHF DJD Vertebral disc disease NASH related cirrhosis

Medical Co-morbiditiesNeoplastic

Breast Cancer Ovarian Cancer Endometrial Cancer Prostate Cancer Colorectal Cancer Renal Cell Carcinoma NHL Esophageal Cancer Gastric Cancer Pancreatic Cancer

Medical Co-morbiditiesPsychological

Anxiety disorders Depression Binge eating disorders Reactive bulimia Trauma

Indications for SurgeryIndications for Surgery

• BMI > 40 kg/m2BMI > 40 kg/m2• BMI > 35 kg/m2 with co-morbiditiesBMI > 35 kg/m2 with co-morbidities

• Comorbidities:Comorbidities:– HypertensionHypertension– DiabetesDiabetes– HyperlipidemiaHyperlipidemia– Sleep apneaSleep apnea– Severe arthrosisSevere arthrosis

NIH Consensus NIH Consensus Conference Conference Ann Intern Med 1991Ann Intern Med 1991

Indications for SurgeryIndications for Surgery

• Age > 18 or < 60Age > 18 or < 60• Failure of diet > 6 monthsFailure of diet > 6 months• Obesity history > 5 Obesity history > 5 yearsyears • Low risk for surgeryLow risk for surgery• No endocrinological diseaseNo endocrinological disease• Psychologically soundPsychologically sound

NIH Consensus Conference NIH Consensus Conference Ann Intern Med 1991Ann Intern Med 1991

Goals of SurgeryGoals of Surgery

• Effective: Loss > 50% of Excess Effective: Loss > 50% of Excess WeightWeight

• Low operative morbidityLow operative morbidity• Well toleratedWell tolerated• No long term complicationsNo long term complications

Surgical ProceduresSurgical Procedures

• Restrictive proceduresRestrictive procedures– Gastric BandingGastric Banding– Sleeve GastrectomySleeve Gastrectomy

• Malabsorptive proceduresMalabsorptive procedures– Biliopancreatic DiversionBiliopancreatic Diversion

• ScopinaroScopinaro• Duodenal-Switch BPDDuodenal-Switch BPD

• Hybrid proceduresHybrid procedures– Roux-en-Y Gastric Bypass / BandedRoux-en-Y Gastric Bypass / Banded– -Mini Gastric Bypass-Mini Gastric Bypass

GastricGastric BandingBanding                                                                         

Filled Band

Unfilled Band

Sleeve GastrectomySleeve Gastrectomy

BBilio-pancrilio-pancreeatiatic diversionc diversion

ScopinaroScopinaro WithWith duodenalduodenal switchswitch

SG WITH BPDSG WITH BPD

Restriction

Malabsorption

Gastric Bypass

Loss of appetite ?Small pouch (approx 30 cc)

Small anastomosis (approx. 1.5 cm)

How does it work ?

Alimentary LimbBetween 100 to 200cm

Biliopancreatic LimbBetween 50 to 75 cm

Ghrelin

Gastric Bypass: TechniqueGastric Bypass: Technique

• BPD LimbBPD Limb– 15 to 100cm

• Roux / Alimentary LimbRoux / Alimentary Limb– BMI<50: does not matter– BMI>50: 150cm

Choban Obesity Surg 2002

Brolin Ann Surg 1992Brolin Ann Surg 1992

Gastric Bypass: Follow UpGastric Bypass: Follow Up

• Clinical Pathway– 2 weeks, 1 month, 3 months, 6 months, 9

months, 1 year, 18 months and yearly – Nutritionist– Vitamins– Labs– Aggressive follow up is the key to good

outcomes

Conclusion

Big patient Big patient Big riskBig risk

Big expectationsBig expectations

Conclusion

Multidisciplinary team Multidisciplinary team And ProgramAnd Program