1. Pathophysiology of BariatricPathophysiology of Bariatric
SurgerySurgery
DR SREEJOY PATNAIK
BARIATRIC AND METABOLIC SURGEON
LIFE MEMBER OSSI,IFSO,SAGES

2. SHANTI MEMORIAL HOSPITAL PVT.LTD
Final Phase of NABH Accredition.

3. 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

4. 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

5. 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 theNorth American Association for the
Study of Obesity. NIH 2000Study of Obesity. NIH 2000

6. Definition of ObesityDefinition of Obesity
according to BMIaccording to BMI
UnderweightUnderweight <18.5<18.5
NormalNormal 18.5 – 24.918.5 – 24.9
OverweightOverweight 25-29.925-29.9
ObesityObesity >30>30
moderatemoderate 30.0 – 34.930.0 – 34.9
severesevere 35.0 – 39.935.0 – 39.9
morbidmorbid >40>40
BMI = W(kg)/H (m²)BMI = W(kg)/H (m²)

7. 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

8. Why Operate?Why Operate?

9. Pulmonary disease
abnormal function
obstructive sleep apnea
hypoventilation syndrome
Nonalcoholic fatty liver
disease
steatosis
steatohepatitis
cirrhosis
Coronary heart disease
Diabetes
Dyslipidemia
Hypertension
Gynecologic abnormalities
abnormal menses
infertility
polycystic ovarian syndrome
Osteoarthritis
Skin
Gall bladder disease
Cancer
breast, uterus, cervix
colon, esophagus, pancreas
kidney, prostate
Phlebitis
venous stasis
Gout
Medical Complications of Obesity
Idiopathic intracranial
hypertension
Stroke
Cataracts
Severe pancreatitis

10. Medical Co-morbidities
• 1.Metabolic
• 2.Mechanical
• 3.Degenerative
• 4.Neoplastic
• 5.Psychological

11. Medical Co-morbidities
Metabolic
• Diabetes mellitus, type II
• Hypertriglyceridemia
• Hypercholesterolemia
• Hypertension
• Gallstones
• Fatty liver disease (NASH)
• Pancreatitis
• Central sleep apnea
• Hypercoagulable
• Infertility

12. Metabolic Syndrome
Abdominal obesity
Hyperinsulinemia
High fasting plasma
glucose
Impaired glucose
tolerance
Hypertriglyceridemia
Low HDL-cholesterol
Hypertension

13. Medical Co-morbidities
Mechanical/Anatomic
• Obstructive sleep apnea
• GERD
• GERD - associated asthma
• Urinary stress incontinence
• Pseudotumor cerebri
• Venous stasis
• DVT / PE
• Fungal skin infections
• Decubitus ulcers
• Accidental injuries

14. Medical Co-morbidities
Degenerative
• Cardiovascular disease
• Complications of diabetes
• CHF
• Vertebral disc disease
• NASH related cirrhosis

15. Medical Co-morbidities
Neoplastic
• Breast Cancer
• Ovarian Cancer
• Endometrial Cancer
• Prostate Cancer
• Colorectal Cancer
• Renal Cell Carcinoma
• NHL
• Esophageal Cancer
• Gastric Cancer
• Pancreatic Cancer

16. Medical Co-morbidities
Psychological
• Anxiety disorders
• Depression
• Binge eating disorders
• Reactive bulimia
• Trauma

17. Indications for SurgeryIndications for Surgery
• BMI > 40 kg/m2BMI > 40 kg/m2
• BMI > 35 kg/m2 with 2 co-morbiditiesBMI > 35 kg/m2 with 2 co-morbidities
• Comorbidities:Comorbidities:
– HypertensionHypertension
– DiabetesDiabetes
– HyperlipidemiaHyperlipidemia
– Sleep apneaSleep apnea
– Severe arthrosisSevere arthrosis
NIH ConsensusNIH Consensus
ConferenceConference
Ann Intern Med 1991Ann Intern Med 1991

18. Indications for SurgeryIndications for Surgery
• Age > 18 or < 60Age > 18 or < 60
• Failure of diet > 6 monthsFailure of diet > 6 months
• Obesity history > 5Obesity history > 5 yearsyears
• Low risk for surgeryLow risk for surgery
• No endocrinological diseaseNo endocrinological disease
• Psychologically soundPsychologically sound
NIH Consensus ConferenceNIH Consensus Conference
Ann Intern Med 1991Ann Intern Med 1991

19. Goals of SurgeryGoals of Surgery
• Effective: Loss > 50% of ExcessEffective: Loss > 50% of Excess
WeightWeight
• Low operative morbidityLow operative morbidity
• Well toleratedWell tolerated
• No long term complicationsNo long term complications

20. Surgical ProceduresSurgical Procedures
• Restrictive proceduresRestrictive procedures
– Gastric BandingGastric Banding
– Sleeve GastrectomySleeve Gastrectomy
– -Gastric Plication-Gastric Plication
• 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

21. Bariatric Procedures Performed Today

22. BBilio-pancrilio-pancreeatiatic diversionc diversion
ScopinaroScopinaro SGWithSGWith duodenalduodenal
switchswitch

26. How does a sleeve work?
One of the mechanisms involved in weight
loss observed after the LSG is the
dramatic reduction of the capacity of the
stomach.

27. Ghrelin
A peptide hormone mainly produced in the fundus of the stomach, is
supposed to be involved in the mechanisms regulating hunger .
Secreted by the endocrine cells of the stomach (X/A-like cells), which
reside in the oxyntic glands of the gastric fundus .
It regulates the secretion of growth hormone release and is a potent
orexigenic (appetite-stimulating) peptide & is mediated by the activation of
ghrelin receptors in the hypothalamus / pituitary area .
Plasma concentration rises just before the onset of meal and declines
after intake of meals .
Plays a key role in the complex energy balance and certain
neurophysiologic mechanisms are responsible for the changes in appetite
observed after bariatric surgery

28. Restriction
Malabsorption
Gastric Bypass
Loss of appetite
?
Small pouch (approx 30 cc)
Small anastomosis (approx. 1.5 cm)
How does it work ?
Alimentary Limb
Between 100 to 200cm
Biliopancreatic Limb
Between 50 to 75 cm
Ghrelin

29. Pathophysiology of Bariatric Surgery of
Bariatric Surgery
• Role of GI Hormones in remission of Metabolic syndrome.
• Recent theory- Entero-insular axis has got a role in maintaining
glucose homeostasis.
• Bariatric surgery results in weight loss due to surgical manipulation or
bypassing of the gut & by caloric restriction - leading to remission of
metabolic syndrome.

30. GI HORMONES AS INCRETINS &
ANTI INCRETINS

31. WHAT ARE incretins ?
• Incretins are a group of gastrointestinal hormones that increase
the amount of insulin release from the beta cells after eating.
• They also slow the rate of absorption of nutrients into the blood
stream by reducing gastric emptying and reduces food intake.
• Inhibits Glucagon release from the alpha cells of the Islets of
Langerhans.
• 1. GLP-1- Glucagon-like peptide-1
• 2 . GIP- Gastric inhibitory peptide or Glucose-
dependent insulinotropic polypeptide

32. Mechanism of Incretin action action

34. WHAT ARE ANTI INCRETINS?
• Anti incretins are a group of GI factors
secreted from the duodenum & proximal
jejunum, which counteract the actions of
INCRETINS.

35. Anti incretin action

36. ANTI INCRETINS AND GLUCOSE
HOMEOSTASIS

38. GUT BRAIN AXIS
The gut–brain axis is a major component of appetite
regulation.
The gut hormones have either
• anorexigenic ( appetite depressant ) or
• orexigenic ( appetite stimulant ) action on food intake .
•These gut hormone secretions are altered following
bariatric surgery

39. • GHRELIN - (orexrgenic / satiety or appetite stimulant
hormone)
Peptide YY – an anorexegenic (or appetite depressant)
hormone co-secreted with GLP-1 from the intestinal L cells
in response to food intake.
• PYY3-36 - ( anorxegenic hormone )
-levels are increased following LRYGB, decreases food
intake & ameliorates insulin resistance and improves
glycemia.

40. PROPOSED THEORIES FOR IMPROVED
GLYCAEMIA
(A) RAPID HINDGUT DELIVERY
HYPOTHESIS
•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.)
•Proximal nutrient- related signals that are transmitted from the duodenum
to the distal bowel by neural pathways leads to increased Incretin
secretion.

41. PROPOSEDT(B) FOREGUT HYPOTHESIS
HEORIES FOR IMPROVED
GLYCAEMIA
•The proximal small intestine (foregut / BPD limb ) is
excluded resulting in reduction in secretion of Anti –
incretin factors ( diabetogenic hormones) in
response to absence of nutrients in the fore gut.
•This leads to improved glycaemia.
&
•Decreased Intestinal Glucagon synthesis
.

42. ANTI-INCRETIN / INCRETIN BALANCE
• After Bariatric Surgery - a physiological balance is maintained
between Anti –Incretins & Incretins,
• Leads to proper beta cell function & to maintain Blood
Glucose excursions within normal range.
• Release of excess Anti- Incretins are prevented leading to
improved glucose homeostasis.

43. Diabetes, Obesity & Bariatric surgery
• DM linked with obesity has –
-- insulin resistance, inflammation & lipo-toxicity of beta
cells, > progressive beta cell failure & hyper-glycaemia.
•After Bariatric Surgery -
- Glucose homeostasis improves.
- Insulin sensitivity increases.
- Adiponectin levels improves
- Markers of insulin signals in key target tissues are enhanced.

44. Hypothesis as to the mechanism responsible for the control of
diabetes after gastric bypass.

45. MY ExperienceS iN
Bariatric Surgery

46. Bariatric Procedures (n=40) 2010
• Lap adjustable gastric band 0
• Lap sleeve gastrectomy 35
• Lap gastric bypass 2
• Lap duodenal switch 0
• Lap gastric plication 0
• Ileal Transposition 0
• Revisional Bariatric procedure 1
• MGB 2

47. OUR SUCCESSFUL PATIENTS
KENDRAPA

48. THE MOST ELIGIBLE BACHELOR
CUTTACK -- FIRST CASE

49. CUTTACK

50. CUTTACK

51. BHUBANESWA

52. JABDALPUR

53. BALASORE

54. BHUBANESW

55. HAPPY AFTER MARRIAGE

56. BHAWANIPAT
NA

57. CUTTA

58. CUTTA

59. PURI

60. CUTTACK

61. BALASORE

62. JARSUGUDA

63. JAJPUR

64. BHUBANESWAR

67. Conclusion
Big patientBig patient
Big riskBig risk
Big expectationsBig expectations

68. FOR YOUR PATIENT HEARING

69. Conclusion
Multidisciplinary teamMultidisciplinary team
And ProgramAnd Program