Dr. Kamthorn Yolsuriyanwong Department of Surgery, Faculty of...

Dr. Kamthorn Yolsuriyanwong

Department of Surgery, Faculty of Medicine, Prince of Songkla University

Bariatric = baros + iatrikos (weight) + (of healing)

• What : Classification of Obesity • Why : Obese patients be treated • When : Indication of surgery • How : Obesity surgery

Efficacy Safety Techniques

เม่ือไหร่จะเรียกว่า “อ้วน”

BMI = Weight(kg) / Height2 (m2)

ดชันีมวลกาย (Body Mass Index; BMI)

WHO. Lancet. 2004;363:157-63. IFSO. Obes Surg. 2014; 24:487-519.

WHO Asian

Classification of weight category by BMI

Body-mass index (BMI) cut-off points for public health action

Public Health Action in Asian

WHO. Lancet. 2004;363:157-63.

Classification BMI

Normal 18.5-22.9

Overweight * 23.0-24.9

Obese Class 1a 25.0-29.9

1b 30.0-34.9

2 35.0-39.9

3 ≥ 40.0

Classification of weight category by BMI in Thai (age >18 y)

ดดัแปลงจาก ศ.พญ.วรรณี นิธยิานนัท ์เกณฑก์ าหนด และกลไกการเกดิอว้นและอว้นลงพุง. อว้นและอว้นลงพุง 2554 * Aekplakorn W. Obesity 2007;15:1036-42.

South East Asia

BMI > 25 kg/m2

WHO Non-Communicable Disease Country Profiles, 2011

South East Asia

BMI > 30 kg/m2

WHO Global Report on Non-Communicable Disease, 2010

BMI ≥ 25 kg/m2 BMI ≥ 30 kg/m2

18.2

24.1

28.1

36.5

3.5

5.8

6.9

9.0

Aekplakorn W, Mo-Suwan L. Obes rev. 2009; 10: 589-92. Aekplakorn W, Hogan MC, Chongsuvivatwong V, et al. Obesity 2007;15:3113-21.

ความชุกของภาวะอ้วน (BMI ≥ 25 kg/m2)

ในประชากรจ าแนกตามภาค

Aekplakorn W, Mo-Suwan L. Obes rev. 2009; 10: 589-92. Aekplakorn W, Hogan MC, Chongsuvivatwong V, et al. Obesity 2007;15:3113-21.

ท าไม เราต้องรักษาโรคอ้วน

Source: Childers, D.K. & Allison, D.B. Int. J. obesity 34, 1231–1238 (2010).

BW ↑↑

Probability of Death↑↑

The Lancet, 2009;373:1083–1096.

BMI Lifespan

30-35 ↓2-4 ปี

> 40 ↓10 ปี

เม่ือไหร่จะต้อง...ผ่าตัด

Management of Obesity

Surgery

Indication for Bariatric Surgery

NIH

Asian BMI ≥ 32 + T2DM

or 2 obesity- related comorbidities

≥ 37

BMI ≥ 35 +

1 weight-loss- responsive

comorbidity

BMI ≥ 40

National Institutes of Health. Gastrointestinal surgery for severe obesity. Am J Clin Nutr 1992;55:615s-619s. Lee WJ, Wang W. Bariatric surgery: Asia-Pacific perspective. Obes Surg. 2005 Jun-Jul;15(6):751-7.

• Age 18-65 years old • Failure of medication treatment at least for 6 months (Diet control, Exercise & Pharmacotherapy)

• No uncontrolled psychiatric problem or drug addict • Severe/uncontrolled GERD (for sleeve & banding)

• No contraindication for surgery and anesthesia - Unstable/recent cardiac disease : CHF, IHD, angina - Severe pulmonary disease - Cirrhosis with portal hypertension - etc.

Indication for Bariatric Surgery

การผ่าตัดคือการดูดไขมัน หรือ สลายไขมัน หรือเปล่า

Is it the liposuction ?

Liposuction

Visceral fat

Subcutaneous fat

112.5 kg 54 kg

MRI

Liposuction and Lipectomy

- Not reduce visceral fat 1

- Not improve comorbidities 2,3 - Help only body contouring

1. Hernandez TL, Kittelson JM, Law CK, et al. Fat redistribution following suction lipectomy: defense of body fat and patterns of restoration. Obesity (Silver Spring). 2011 Jul;19(7):1388-95.

2. S. Klein, L. Fontana, V.L. Young et al. Absence of an effect of liposuction on insulin action and risk factors for coronary heart disease N Engl J Med, 350 (2004), p. 2549

3. Danilla S, Longton C, Valenzuela K, et al. Suction-assisted lipectomy fails to improve cardiovascular metabolic markers of disease: a meta-analysis. J Plast Reconstr Aesthet Surg. 2013 Nov;66(11):1557-63.

Gastrointestinal Surgery

Surgery

Medical Rx

Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007; 357:741-752.

2010 surgery group vs 2037 control group (matched study) Mean F/U 10.9 yr

Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007; 357:741-752.

Hazard ratio 0.76 (Odds for risk of death) P =0.04

Adams TD, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753-61.

(9949 vs 9628) (7925 each group)

Match by - age - sex - BMI - Time of Sx

1984-2002

Improvement of comorbidities

Preoperative assessment and education

• Multidisciplinary team approach

: Bariatric surgeon, Endocrinologist, Gastroenterologist,

Psychiatrist, Internist, Cardiologist, Pulmonologist, Nutritionist, Plastic surgeon, Urologist, Gynecologist, Physical therapist, Bariatric nurse, Case-manager nurse, etc.

• Screening endocrine disorder

: Cushing syndrome, Hypothyroid, etc.

• Co morbid diseases work up and control • Nutritional evaluation and education • Psychiatric evaluation • Patient education and inform consent

Preoperative preparations

• Underlying diseases : Controllable : Blood sugar (DTX) < 150 mg/dL in diabetes

BP < 140/90 mmHg Use CPAP in severe OSA

• Breathing exercise education • Venous Thromboembolism (VTE) Prophylaxis : Low molecular weight heparin (LMWH)

Un-fractionated heparin (UFH) Intermittent pneumatic compression IVC filter in known case venous thrombosis

วธีิการผ่าตัดรักษาโรคอ้วน เป็นอย่างไร How to Surgery?

การส่องกล้องผ่าตัด (Laparoscopic surgery)

Type of Bariatric Surgery

Restrictive Procedures

: Adjustable gastric banding, Sleeve gastrectomy,

Banded sleeve gastrectomy, Gastric plication, Adjustable gastric banded plication, etc.

Mal-absorptive procedures

: Duodenojejunal bypass, Jejunoileal bypass, Jejunocolonic bypass, etc.

Combined Restrictive & Mal-absorptive procedures : Roux-en-Y gastric bypass (RYGB) , Banded RYGB, Biliopancreatic

diversion with/without duodenal switch, Mini gastric bypass, Single anastomosis duodenoileal bypass with sleeve (SADIS), Loop duodenojejunal bypass with sleeve gastrectomy (LDJB-SG), etc.

ผ่าตัดรัดกระเพาะ (Adjustable gastric banding)

ผ่าตัดลดขนาดกระเพาะ (Sleeve gastrectomy)

ผ่าตัดลดขนาดกระเพาะและบายพาส/ลัดทางเดินอาหาร

(Roux-en-Y gastric Bypass)

Bariatric surgery procedures

หลังผ่าตัด น า้หนักจะลดเท่าไหร่ และเม่ือไหร่ (How much & When?)

นน. เร่ิมต้น

นน. ที่ควรเป็น

↓50% นน. ที่เกิน

120

70

95

↓ 75% นน. ที่เกิน 82

แนวโน้มน า้หนักหลังผ่าตัด

ปี

Laparoscopic Bariatric Surgery

Operative Room

Postoperative cares

• Monitor V/S : same as elective surgery • Control co morbid diseases

: Blood sugar (DTX) 100-180 mg/dL in diabetes

BP < 140/90 mmHg Use CPAP in severe OSA

• Adequate pain control • Continue mechanical VTE prophylaxis : Intermittent pneumatic compression until well ambulation

• Encourage ambulation • Nutrition education (800-1200 Kcal/day)

: Liquid diet Soft diet Regular diet

(4 weeks) (3 months)

• Upper GI contrast study (Day 1-3 after surgery)

: Look for leakage and stricture

leakage

stricture

Normal Post Sleeve Abnormal

Postoperative cares

Discharge Criteria • General condition stable • Vital sign normal • Peristalsis (+) : Flatulence • No fever • No abdominal pain • No vomiting • Good oral tolerance to water (1500-2000 ml) • Well ambulation • Wound : No sign of infection

Postoperative cares

≥ 32 + โรคร่วม

≥ 37

Postoperative Follow-up

Thank you

ตดิต่อสอบถามได้ท่ี คลินิกศัลยกรรม หรือคลินิกศัลย์-โรคอ้วน