Management of ObesityManagement of ObesityAn over reviewAn over review

Dr. fahad bamehrizDr. fahad bamehriz

Department Of SurgeryDepartment Of Surgery

Management of ObesityManagement of Obesity

Definitions &Classification.

Magnitude of obesity problem.

Clinical assessment & management.

Surgical management.

Summary.

Management of ObesityManagement of Obesity

Definitions & ClassificationDefinitions & Classification

ObesityObesity

A condition of excessive fat accumulation in the body to the extent that health and well being are adversely affected.

WHO 1997WHO 1997

Ideal Body Weight (IBW)Ideal Body Weight (IBW)

As defined by the Metropolitan Life Insurance Tables Of 1983for height, sex and body-frame, is that weight which is associated with the lowest death rate in insured populations.

Cowan et al ,Surgery for the morbidly obese Cowan et al ,Surgery for the morbidly obese patients,Chapter 9 ,2000patients,Chapter 9 ,2000

Body Mass Index

BMI = Weight ( Kg)/ Height (m2)

Classification of weightClassification of weight

WHO 1997WHO 1997

Morbidly Obese PatientsMorbidly Obese Patients

Are those individuals who weigh at least 45 kg over the ideal body weigh.

This approximates a body mass index (BMI) of at least 40 kg/m2

Cowan et al ,Surgery for the morbidly Cowan et al ,Surgery for the morbidly obese patients,Chapter 9 ,2000obese patients,Chapter 9 ,2000

Weight LossWeight Loss

EWL = Excess Weight Loss

= (preoperative weight) – (ideal weight)

% EWL = % Excess Weight Loss

= weight loss / excess weight x 100

Management of ObesityManagement of Obesity

Magnitude of obesity problemMagnitude of obesity problem

Prevalence of obesityPrevalence of obesity

WHO 1997WHO 1997

Prevalence of obesityPrevalence of obesity

Health hazards of obesityHealth hazards of obesity

Cowan et al ,Surgery for the morbidly Cowan et al ,Surgery for the morbidly obese patients,Chapter 9 ,2000obese patients,Chapter 9 ,2000

Health hazards of obesityHealth hazards of obesity

Karl et al SCNA Oct. 2001Karl et al SCNA Oct. 2001

Health hazards of obesityHealth hazards of obesity

Wadden et al SCNA OCT 2001Wadden et al SCNA OCT 2001

Health hazards of obesityHealth hazards of obesity

Bray et al CE&M 1999Bray et al CE&M 1999

Cost Related to ObesityCost Related to Obesity“The costs of obesity is substantial and accounts for 2-8 % of the total health care expenditure in countries such as The Netherlands, France, USA, Australia and Sweden.”

The Lancet August 1997The Lancet August 1997

Management of ObesityManagement of Obesity

Clinical assessment & management

Clinical assessment & managementClinical assessment & managementObesity ProgramObesity ProgramTeam ApproachTeam Approach

Bariatric surgeon.

Dietitian.

Physical therapist.

Psychiatrist.

Psychologist.

Gastro-entrologist.

Radiologist.

Nursing team.

Internist.

Endocrinologist

Cardiologist.

Pulmonologist.

Family Physician.

Anesthesiologist.

Intensivist.

Plastic Surgeons.

AssessmentAssessmentH&P.

Laboratory work up;

CBC, Renal, Hepatic, Lipid Profiles.

TFT’S, Cortisol suppression test, FBS.

Nutritional Profile.

Radiological Investigations;

U/S abdomen.

AssessmentAssessmentGastro-enterology

Gastro-scopy.

Psychiatry.

Dietitian.

Anesthesiologist.

Management OptionsManagement Options

Non-SurgicalNon-SurgicalBehavioral Therapy.

Diet.

Physical activity.

Drug therapy.

Jaw wiring.

Intra-gastric balloon.

SurgicalSurgicalRestrictive.

Mal-absorptive.

Combined.

Dietary approaches to reduce Dietary approaches to reduce body weightbody weight

Dietary ProgramsDietary ProgramsStarvation diets (fewer than 200 kcal /day).Very low energy diets (VLED)

200-800 kcal/day, commercial formula.Low energy diets (LED)

800-1500 kcal/day, natural food.Ad libitum low fat diets

15% - 25 % less fat, high CHO & protein.Atkins diet

High protein low CHO.

Dietary approaches to reduce Dietary approaches to reduce body weightbody weight

Physical ActivityPhysical Activity

Programmed physical activity.

regular scheduled activity at a relatively high intensity level.

Lifestyle physical activity.

increasing energy expenditure during the course of the day.

Physical ActivityPhysical Activity

Drug therapy of obesityDrug therapy of obesityDrugs that reduce food intakeDrugs that reduce food intake

Nor-adrenergic drugs (phentermine). Serotonin-norepinephrine re-uptake inhibitors

(Sibutramine).

Drugs that alter metabolismDrugs that alter metabolism Pre-absorptive agents (Orlistat). Post-absorptive agents (Metformin).

Drugs that increase energy expenditureDrugs that increase energy expenditure Ephedrine & Caffeine.

BioEntericsBioEnterics®® Intragastric Balloon Intragastric Balloon BIB ™ SystemBIB ™ System

B.I.B. PlacementB.I.B. Placement

Clinical resultsBMI and results

BMI <30 30-35 35-40 40-45 >45Weight 84 95 109 122 144BMI 29 33 37 42 50Weightloss kg 13 17 23 26 30BMI after 25 27 30 33 40EWL after 93 70 60 51 39% body weight 15 18 21 21 21number 19 155 179 90 46

Dr. Bolwerk

Jaw WiringJaw Wiring

Bray et al CE&M 1999Bray et al CE&M 1999

Obesity SurgeryObesity SurgeryClassificationClassification

Restrictive

Malabsorptive

Combined

%EWL after LAGB%EWL after LAGB

VBG versus ASGBVBG versus ASGB

What is LaparoscopicSleeve Gastrectomy ?(longitudinal G, Vertical G , Stomach reduction)

Resection of Greater Curve

Sleeve of stomach left in place

A Prospective Randomized Study Between LGB & LSGResults after 1&3 years

Jacques Himpens Obesity Surgery 16(1450-1456)2006

Efficacy of Obesity Surgery

operation number % EWL

Banding 4429 48.6%

VBG 3382 58.3%

Bypass 2949 68.6%

JEJUNOILEAL BYPASSJEJUNOILEAL BYPASS

%EWL in JEJUNOILEAL %EWL in JEJUNOILEAL BYPASSBYPASS

Bilio-pancreato-jejunal bypassBilio-pancreato-jejunal bypasstype threetype three

BPDDSBPDDS

Crystine Lee San Francisco California

Crystine Lee San Francisco California

King Faisal Specialist Hospital Experience in Bariatric Surgery

Dr Patrick O’ReganDr Abdelrahman SalemDr Fahad BamerhizMinimally Invasive Surgery ServiceKing Faisal Specialist Hospital & Research Center Riyadh S. A.

Obesity Surgery ProgramStarted October 2002

Offering Gastric balloon Gastric banding 333 VBG 73 Gastric bypass 85 Gastric sleeve 330 Total cases till December 2007 821

King Faisal Specialist Hospital Experience in Bariatric Surgery

020406080

100120140160180200

2002 2003 2004 2005 2006 2007

band

VBG

BYPASS

SLEEVE

How to decide which operation Age Co-morbidities Re-operative cases BMI Surgeon recommendation Patients request Word of mouth – many requests for

sleeve

KFSHRC Experiencewith sleeve gastrectomy

Started in August 2005

Why Sleeve Gastrectomy Patients not accepting Gastric Bypass Gastric Band - poor wt. loss VBG - poor QOL BPD – Patients F/U?? Encouraged by early results Pts – understanding, acceptance, word of

mouth.

Advantages of Sleeve

1. No foreign body

2. Easy to perform

3. No need for supplements

4. Low maintenance

5. Anatomical

6. Physiological ?

7. Easy to convert (second stage) – BPD or LGB

8. Ghrelin reduction

9. Good for super-obese

10.Good when PBD or LGB are contra- indicated

11. Good quality of life

Advantages cont’d

Sleeve Gastrectomydisadvantages

1. Not reversible

2. No long term follow up

3. Stomach may dilate

4. Purely restrictive ?

5. Ghrelin reduced

6. GERD (11%)

Biennial

Sleeve GastrectomyLength of Stay

94 % Same day admit

84% discharged day I or 2

3 (0.9%)conversion to open

Mean % excess wt loss

6 Months 60.5% (#170)

12 months 76% (#101)

18 months 75.4% (#39)

24 months 75.2% (#12)

Major M&M

18(5.4%) Staple line leakage

5 (1.5%) Re-op for bleeding

2 pt developed stricture

1pt developed Port site hernia

1 pt died post-op (PE)

Mean % excess wt loss at 12m

LSG 76% (#101)

LGB 72% (#62)

VBG 80% (#61)

Staple line leakage

LSG 18/330 (5.4%)

LGB 0/ 85 (0%)

VBG 4/ 73 (5.4%)

SummarySummaryObesity is a major health problem worldwide, as well as in the Kingdom.

It is secondary to imbalance between energy intake and expenditure.

Approach to management, should be team approach.

Main aim of management, is to change the behavior, which ultimately will reduce weight.

SummarySummary

Surgery is the only management option that proved to be effective in weight reduction of obese patients in long term.

We believe LSG is one of safe options of the armamentarium of beriatric surgery.

SummarySummary

Obesity surgery program at KFSH&RC offering a battery of beriatric surgery operations to match the need of different beriatric patients.

THANK YOU