6. Definition of Bariatric Surgery
⢠Bariatric surgery or weight loss surgery is a
variety of surgical procedures performed on
obese subjects.
⢠It is done either by ⢠Reducing the size & capacity of the stomach.
⢠OR by
⢠Resecting & re-routing the small intestines to a
small gastric pouch.
8. How do we measure obesity
â˘We classify obesity according to BMI
( Body mass index )
â˘BMI = body weight in kg / height in m2
9. Classification of BMI
⢠18-25 = Normal
⢠25-30 = Obese
⢠30-35 = Class 1
⢠35-40 = Class II
⢠40-45 = Class III
⢠> 45 = Morbid or super obese
10. Why we are worried about obesity?
⢠What is its significance ?
⢠Because of its co-morbidities
11.
12. Comorbidities
1. Cardiovascular â CAD, HTN,CHF,LVF
& Dyslipidaemia.
2. Pulmonary
â OSA, OHS, PAH, Asthma
3. Haemopoetic
â DVT & PE
4. GI
â GERD, NAFLD,
Hiatus hernia, Gallstones
5. Genito-urinary
â stress incontinence, UTI
14. Morbidity
⢠BMI > 35 - Risk of death = 2.5 times greater
⢠BMI > 40 - Risk of death = 10 times greater
⢠OBESITY > 2 leading cause of preventable
nd
premature deaths in USA
17. Bariatric Surgery - Goals
Surgery to Create Sustainable & significant
Weight Loss in Severely Obese Patients.
Resolution or Cure of Co-morbidities
Reduction of Obesity Related Mortality
18. GUIDELINES
⢠SAGES â Society of American Gastro Endo
surgeons.
⢠ASMBS â American society of Metabolic &
Bariatric Surgery.
⢠NIH â National Institute of Health.
19. Whom do we advise Surgery ?
BMI > 40 without comorbidities.
BMI > 35 with 2 comorbidities .
Age â 18 â 60 years( < 12- 65 )
Stable obesity for > 5 years
Unsuccessful dietary / drug treatment
Absence of Endocrine disease
Pt. should be sufficiently comprehensive &
compliant.
No h/o excessive alcohol or drug abuse
Acceptable Operative Risks
20. How do we classify the surgical
procedures ?
A. Restrictive
B. Malabsorptive
C. Combination â restrictive and
malabsorptive
21. Restrictive procedures
⢠Creation of a small gastric pouch & limiting
the gastric volume & continuity is not altered.
⢠Vertical banded Gastroplasty
⢠Adjustable Gastric Banding
⢠Sleeve Gastrectomy
⢠Gastric Plication
⢠BIB â Intra Gastric Balloon
23. A Restrictive Procedure is
ďś Safer
ďś Easier
ďś Faster
ďś Easier to cheat
ďś Less Effective for Weight Loss
BUT ALSO
BUT ALSO
ďś Less beneficial for Diabetes
control
24. Malabsorptive procedures
⢠Malabsorption is achieved by creating a short
gut syndrome with distal mixing of bile and
pancreatic juice with ingested food.
⢠Bilio-pancreatic diversion
⢠Jejunal ileal bypass
⢠Endoluminal sleeve ( Endo-barrier)
26. A Malabsorptive Procedure is
ďś More effective for weight loss??
ďś More risky??
ďś More Nutritionally demanding
27. Combination procedures
⢠Combination of restriction alongwith malabsorption .
⢠Small gastric pouch + a bypass.
⢠Early sense of fullness, combined with a sense of
satisfaction that reduces the desire to eat.
⢠RYGB
⢠LSG with DS
⢠MGB
36. Selection of a procedure
â˘
There is No evidence on procedure selection -most
frustrating shortfall in bariatric surgery.
â˘
Best procedure should reduce weight, induce remission
of Diabetes, & improve quality of life.
â˘
â˘
Multi disciplinary team assessment .
The choice of procedure is determined by the individualâs
phenotype, the aims of therapy, & peri-operative risks.
37. Selection of Procedure
â˘
Each procedure should be tailor made for each
individual.
â˘
The choice of the procedure is a complex process with
patient & their interests at its core.
â˘
The surgeonâs experience to deal with the inevitable
complications of each procedure & to manage long
term follow up care should be the goal to success.
38. Pre-op assessment
â˘
â˘
Patient should be physically & psychologically fit.
â˘
Patients must be determined to comply with the postop. care and instructions on diet.
â˘
They should be given the correct & realistic information
on what the procedure can achieve.
â˘
For each patient benefits of the procedure should
outweigh the operative risks.
Individualized assessment-is vital & Psychiatrist role is
important.
39. ⢠A special risk bond is signed by the patient and by
2 more family members.
⢠Procedure may vary in peri- operative assessment
ie ; diagnostic laparoscopy.
⢠Primary aim of surgery should
each procedure.
be weight loss with
40. Whom we deny Bariatric Surgery ?
⢠History of substance abuse, eating disorders, or
major psychiatric problems â untreated or
unresolved
⢠Patients who are too ill or too high a risk for
surgery
⢠Women who may become pregnant soon
46. Investigations
LAB EVALUATION : CBC,FBS, 2HRPGBS, HB1AC, LFT, Urea, Creatinine, Serum
Protein/albumin, Amylase, Serum fasting & post Insulin, C-peptide, lipid profile,
Serum Calcium, Vit. B12, Calcitonin, TFT,Serum & urine Cortisol. HOMA-IRHomeostasis Model of Assessment-Insulin Resistance
UGIE: To rule out inflammatory or ulcer pathology, & treat H.pylori infection.
USG Abdomen â To rule out cholelithiases, which would indicate Lap.
Cholecystectomy alongwith the primary surgery.
Cardio-Respiratory evaluation â To exclude any contraindications to GA by
TMT, 2D echo, PFT, ABG, CXR.
Psychiatry evaluation â To rule out any behavioural abnormalities that would
contraindicate limited food intake.
Endocrine evaluation â To rule out an endocrine abnormality as the etiology of
morbid obesity.
Dental evaluation
47. HOMA-IR
HOMEOSTASIS MODEL OF ASSESSMENT
OF INSULIN RESISTANCE
⢠INTERNATIONAL FORMULA
⢠FBG(mmol/L) X Finsulin(Mu/L) / 22.5
⢠To assess beta cell function & insulin
resistance
⢠Estimated by euglycemic clamp method
â˘(
measuring glucose for an increased inslin level, without causing
hypoglycemia)
52. STERRAD â NX
STERILISER
The STERRADÂŽ NXTM Sterilizer is a self-contained stand-alone system of hardware and
software designed to sterilize medical instruments and devices using a patented hydrogen
66. Pathophysiology of Bariatric Surgery
â˘
ROLE OF GI HORMONES IN
REMISSION OF METABOLIC
SYNDROME.
â˘
Recent theory- Entero-insular axis
has got a role in maintaining
glucose homeostasis.
â˘
Bariatric surgery results in weight
loss due to surgical manipulation or
bypassing of the gut & by caloric
restriction - leading to remission of
metabolic syndrome.
Metabolic syndrome
For Men
WC > or â 40 inches
TG > or â 150 mg/dl
HDL < 40 mg/dl
BP > or â 130/85 mmHg
FBS > or â 100 mg/dl
For Woman
WC > 35 inches
TG > 150 mg/dl
HDL < 50 mg/dl
BP > 130/85 mmHg
FBS > 100 md/dl
68. WHAT ARE INCRETINS ?
â˘
Incretins are a group of gastrointestinal hormones that
increase the amount of insulin release from the beta cells
after eating.
â˘
They also slow the rate of absorption of nutrients into the
blood stream by reducing gastric emptying and reduces food
intake.
â˘
Inhibits Glucagon release from the alpha cells of the Islets of
Langerhans.
â˘
â˘
1. GLP-1- Glucagon-like peptide-1
2 . GIP- Gastric inhibitory peptide or Glucosedependent
insulinotropic polypeptide
69. Mechanism of Incretin action
Stimulates
insulin
release
Lowering
of blood
glucose
Inhibits
glucagon
release
70.
71. WHAT ARE ANTI INCRETINS?
⢠Anti incretins are a group of GI factors
secreted from the duodenum & proximal
jejunum, which counteract the actions of
INCRETINS.
76. GUT - BRAIN AXIS
â˘The gutâbrain axis is a major component of appetite
regulation.
â˘The gut hormones have either
anorexigenic
( appetite depressant ) or orexigenic ( appetite
stimulant ) action on food intake .
â˘These gut hormone secretions are altered following
bariatric surgery
77. â˘
Ghrelin- (orexrgenic / satiety or appetite stimulant hormone)
produced primarily by gastric fundus.
-Its levels are supressed following resection of gastric rich
fundus.
-It stimulates insulin counter-regulatory hormones.
â˘
Peptide YY
â an anorexegenic (or appetite depressant)
hormone co-secreted with GLP-1 from the
response to food intake.
â˘
PYY3-36
intestinal L cells in
- ( anorxegenic hormone )
-levels are increased following LRYGB, decreases food intake &
ameliorates insulin resistance and improves glycemia.
78. PROPOSED THEORIES FOR IMPROVED GLYCAEMIA
(A) RAPID HINDGUT DELIVERY
HYPOTHESIS
â˘Expedited or rapid delivery of ingested nutrients to
lower bowel due to intestinal bypass leads to
stimulation of L cells, ( distal ileum & colon ) which in
turn results in increased secretion of INCRETIN
hormones & improved glucose homoeostasis.
(LRYGB & BPD/DS.)
â˘Proximal nutrient- related signals that are transmitted
from the duodenum to the distal bowel by neural
pathways leads to increased Incretin secretion.
80. Hypothesis as to the mechanism responsible for the
control of diabetes after gastric bypass.
81. PROPOSED THEORIES FOR IMPROVED GLYCAEMIA
(B) FOREGUT HYPOTHESIS
â˘The proximal small intestine
(foregut / BPD limb ) is
excluded resulting in reduction in secretion of Anti â
incretin factors ( diabetogenic hormones) in
response to absence of nutrients in the fore gut.
â˘This leads to improved glycaemia.
&
â˘Decreased Intestinal Glucagon synthesis
.
82. ANTI-INCRETIN / INCRETIN HYPOTHESIS
â˘
After Bariatric Surgery - a physiological balance is
maintained between Anti âIncretins & Incretins,
â˘
Leads to proper beta cell function & to maintain Blood
Glucose excursions within normal range.
â˘
Release of excess Anti- Incretins are prevented & there
is a restoration of between Incretins & Anti-Incretins ,
leading to improved glucose homeostasis .
83. â˘
Diabetes, Obesity & Bariatric
surgery
DM linked with obesity has â
-- insulin resistance, inflammation & lipo-toxicity of beta
cells,
> progressive beta cell failure & hyper-glycaemia.
â˘After Bariatric Surgery - Glucose homeostasis improves.
- Insulin sensitivity increased markedly
- Adiponectin levels are improved
- Markers of insulin signals in key target tissues are
enhanced.
84. Medical Co-Morbidities Resolved with
Bariatric surgery
Type 2 Diabetes
95%
Hypercholesterolemia
97%
Hypertension
92%
GERD
98%
Cardiac Function
95%
improvement
Stress Incontinence
87%
Osteoarthritis
82%
Sleep Apnea
75%
85.
86. Complications of Bariatric Surgery
The other side of
Mount
Rushmore
South Dakota
USA
Gutzon Borglum and his
son Lincoln Borglum
1925
115. ⢠Bariatric surgery
dramatically improves
or cures many obesity
comorbidities.
⢠But working with an
inexperienced surgeon
can increase your risk
for complications.
116. Metabolic Surgery- A new dimension
RESOLUTION OF DIABETES AFTER
BARIATRIC SURGERY
117. Present status of diabetes surgery
â˘
Bariatric surgery effectively reverses type 2 diabetes in a high
proportion of morbidly obese patients, within weeks or even days
well before these patients have lost a significant amount of body
weight
â˘
Diabetes surgery should be considered in patients with BMI > 35
and may also be appropriate for patients with BMI 30-35
Rome Diabetes Surgery Summit 2009
119. Resolution of diabetes in non obese
Status of Ileal Transposition âNot to be done outside approved trialsâ
Rome Diabetes Surgery Summit, 2009
120. PRACTICE POINTS
⢠Extensive Research in the field of Bariatric surgery
( Metabolic surgery, Technology, Endoscopy )
⢠A career in Bariatrics is very promisingâŚâŚ. And
lucrative
121. Diabetes Surgery
⢠Within 5 years, will
gastrointestinal surgery be
considered an acceptable
option for the treatment
of Type 2 Diabetes in the
nonÂobese patient?
122. CONCLUSIONS- TAKE HOME MESSAGE
â˘
BS should be considered with BMI > 40 or BMI > 35
with obesity related 2 co-morbidities.
â˘
â˘
Not all pts. are suitable for surgery.
â˘
The choice of the surgical modality should take the
individualâs goals, surgeonâs experience & existing comorbidities.
A multidisciplinary assessment is essential to select the
appropriate candidates.
123. CONCLUSIONS- TAKE HOME MESSAGE
â˘
â˘
Individualised care is determined by clinical evaluation.
â˘
Procedure selection - should effectively treat & prevent all
co-morbidities alongwith sustained weight loss.
â˘
Experienced anaesthesist & trained OT & ICU staff is
necessary for success.
â˘
Long term follow up and repeated counselling is
mandatory for a safe outcome.
Should be performed in experienced centres- with back up
ICU and trained staff for favourable outcomes.