dr sumer yadav

What is Obesity?

Obesity means excess accumulation of fat in the body

Once it develops it is difficult to ‘cure’ and usually persists throughout life

Obesity is usually diagnosed on the basis of calculation of Body mass indexMeasurement of waist-hip ratio

Normal Weight

(BMI 18.5 to 24.9)

Overweight(BMI 25 to 29.9)

Obese(BMI 30 to 34.9)

Severely Obese(BMI 35 to 39.9 )

Morbidly Obese(BMI > 40)

Body Mass Index (BMI)

Super Obese(BMI > 50)

BMI = weight (kg) / height (m)2

Classification of Overweight and Obese by Body Mass Index

Who guidelines Asian pacific region guidelines

underweight < 18.5 <18.5

normal 18.5-24.9 18.5-22.9

overweight 25-29.9 ≥23

At risk 23-24.9

obesity 30-34.9 (class l)35-39.9 (class ll)

25-29.9 (class l) ≥30 (class ll)

Extremely obese ≥ 40(class lll)

Morbid obesityMorbid obesity is defined as when BMI is more

than 40 kg/ m2 or more than 35 kg/ m2 in the presence of co-morbidities

Waist-to-hip ratio

Risk increase if waist circumference is more than 94 cm in men and > 80 cm in women

Waist : Hip ratiodesired

ratiomen :≤ 1

women :≤0.8

Obesity – An imbalance in energy intake and energy expenditure

The Obesity EpidemicThe weight gain cycle

Eat too muchGain weight

Can’tExercise

GetDepressed

Etiology of Obesity

FamilialGeneticGender (F>M)SocialPsychological (depression)

MULTIFACTORIAL

Role of hypothalamus in mediation ofhunger and satiety

2nd only to smoking as the leading cause of

preventable death in the United States.†

> 110,000 deaths/year in the US are associated with

obesity*

Life Expectancy

* Flegal KM et al. JAMA. 2005 Apr 20;293(15):1861-7. † † CDCCDC

Classification of obesity as per fat distribution

Android (or abdominal or central, males)-Collection of fat mostly in the abdomen (above the waist)

-apple-shaped

-Associated with insulin resistance and heart disease

Gynoid (below the waist, females)

• Collection of fat on hips and buttocks

•pear-shaped

-Associated with mechanical problems

Co-morbidities

EndocrineDiabetes

CardiovascularHypertensionHyperlipidemiaHypertriglyceridemiaCoronary and

cerebral vascular disease

Venous stasis

GynecologyInfertilityMenstrual

irregularitiesOrthopedic

DJDArthralgiaLow back pain

DermatologyFungal infection

Co-morbiditiesPulmonary

Sleep apneaAsthmaHypoventilationPulmonary

hypertension

GastrointestinalCholelithiasisGERDFatty liver /dysfunction

Socio-economicDiscrimination

PsychologicalDepressionh/o abuse

CancerEndometrialOvarianbreast

Why do we treat obesity??

• Co-morbidities

• Quality of life

• Survival – Life Expectancy

Advantages of weight loss

Weight loss of 0.5-9 kg (n=43,457) associated with 53% reduction in cancer-deaths, 44% reduction in diabetes-associated mortality and 20% reduction in total mortality

Survival increased 3-4 months for every kilogram of weight loss

Reduced hyperlipidemia, hypertension and insulin resistanceImprovement in severity of diseasesPerson feels ‘fit’ and mentally more active

Treatment goals

Prevention of further weight gainWeight loss to achieve a realistic, target BMILong-term maintenance of a lower body-weight

How much weight loss is significant?

A 5-10% reduction in weight (within 6 months) and weight maintenance should be stressed in any

weightloss program and contributes significantly to

decreased morbidity

Medical TreatmentMedications Dietary ChangesExerciseBehavioral TherapyPsychotherapyHypnosisJaw-wiring

UNSUCCESSFUL AT SIGNIFICANT OR SUSTAINED WEIGHT LOSS!

Drug therapyAppetite suppressants1. Adrenergic agents (e.g. amphetamine, methamphetamine,

phenylpropanol amine, phentermine)2. Serotonergic agents (e.g. fenfluramine, dexfenfluramine,

SSRIs like sertraline, fluoxetine)Thermogenic agents1. ephedrine, 2. caffeineNew ones1. Sibutramine2. Orlistat

Sibutramine inhibits serotonin(gray) & noradrenaline(blue) reuptake

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Why Surgery for the Treatment of the Clinically Severe Obese?“Only surgery has proven effective over the long term for most patients with clinically severe obesity.”

- NIH Consensus Conference Statement, 1991

Surgery for the treatment of clinically severe obesity is endorsed by:

The National Institutes of Health

The American Medical Association

The National Institute of Diabetes and Digestive and Kidney Diseases

American Association of Family Practitioners

Trends In Surgery 1992 - 2003

Rationale for SurgeryLong Term Outcome Data

Sustained Weight LossImprovement or Resolution of Co-morbiditiesImproved long term survival

Minimally Invasive SurgeryPublic Awareness

Obesity as a diseaseCelebrities

Indications for Surgery

BMI >40 kg/m2, or >35 kg/m2 with significant co-morbid illnesses

Multiple failed weight loss attempts

Acceptable surgical risk

Age 18-60

Demonstrates commitment and understanding of weight loss following bariatric surgery

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Ineligible PatientsExclusion Criteria:Obesity related to a metabolic or endocrine disorderHistory of substance abuse or untreated major psychiatric

diseaseSurgery contraindicated or high riskWomen who want to become pregnant within the next 18

months

Preoperative Evaluation/EducationStaff evaluation

InternistDietitianPsychologistNurseSurgeonSupport group

•Laboratory evaluation• Blood• ECG, CXR • Stress Test• Sleep study• EGD• PFTs

Consider an IVC filter for any patient with prior history of DVT/PE.

Surgical TreatmentRestrictive

Malabsorptive

•Horizontal gastroplasty•Vertical banded gastroplasty (VBG)•Adjustable gastric band•Sleeve gastrectomy•Roux-en-Y gastric bypass

•Jejunoilial bypass•Biliopancreatic diversion (Scopinaro)•Biliopancreatic diversion w/ duodenal switch

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Restrictive SurgeryRelatively easy surgical procedureLess dietary deficienciesLess weight lossMore late failures due to dilationLess effective with sweet eatersSignificant dietary compliance

Adjustable Band Gastroplasty

Gomez, Cesar. Gomez, Cesar. World Journal of SurgeryWorld Journal of Surgery, 1981, 1981

Mason E, Mason E, Archives of SurgeryArchives of Surgery, , 19821982

Polypropylene band

Transgastric window

Angle of HisGastric

Pouch

Lap Adjustable Band

• Port displacement/tube break 7%• Wound infection 4%• Stoma obstruction 2%• Slippage 2%• Elective removal 2%• Erosion <1%• Conversion to open <1%• Hemorrhage <1%• Death <0.05%

Complications: Adjustable Gastric Banding

Sleeve gastrectomy Sleeve gastrectomy

It is a surgical weight-loss procedure in which the stomach is reduced to about 15% of its original size, by surgical removal of a large portion of the stomach, following the major curve The open edges are then attached together (often with surgical staples) to form a sleeve or tube with a banana shape. The procedure permanently reduces the size of the stomach. The procedure is performed laparoscopically and is not reversible.

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Roux-en-Y Gastric-Bypass

Long-term sustained weight lossNo protein-calorie malabsorptionLittle vitamin or mineral deficienciesTechnically difficult procedure

Roux-en-Y Gastric Bypass

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The Roux-en-Y Gastric Bypass1. A small, 15 to 20cc, pouch is

created at the top of the stomach.

2. The small bowel is divided. The biliopancreatic limb is reattached to the small bowel.

3. The other end is connected to the pouch, creating the Roux limb.

The small pouch releases food slowly, causing a sensation of fullness with very little food.

The biliopancreatic limb preserves the action of the digestive tract.

Roux-en-Y Gastric Bypass

Gastric Bypass + Roux-en-Y

75 – 150 cm75 – 150 cm

~ 40cm~ 40cm

Complications:Roux-en-Y Gastric Bypass

Leak 1-2%BleedingInfectionDehydrationStricture/ Ulcer 7%Conversion to open 1%Death 0.2 - 0.5%

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Open and Laparosopic Roux-en-YBypass Complication Rates

Schauer and Ikramuddin, Surg Clin North Am, 2001 Oct;81(5):1145-79; Kral, Clin Per Gastroenterology 2001 Sep/Oct:295-305; Nguyen et al. Ann Surg 2001; 234(3)279-291

Open Lap

Mortality <1.5% <1.5%

Leak Rate <3.1% <3.0%

PE Rate <0.6% <1.5%

Hernia Rate 6.6-18% <1.8%

Wound Infection Rate

5-18% <2%

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Malabsorptive Surgery

Greater sustained weight loss with less dietary compliance

Increased risk of malnutrition and vitamin deficiency

Constant follow–up to monitor increased risk

Intermittent diarrhea

Biliopancreatic Diversion with Duodenal Switch

Jejunoileal Bypass

Payne and Dewind, Payne and Dewind, Archives of SurgeryArchives of Surgery, 1973, 1973

Biliopancratic Diversion

Marceau, et al. Marceau, et al. World Journal of SurgeryWorld Journal of Surgery, 1998, 1998

w/ duodenal switchw/o duodenal switch

75 – 100cm75 – 100cmCommon channelCommon channel

Complications:BPD with Duodenal Switch

Leak 1-2%BleedingInfectionDehydrationMalnutrition 5%Conversion to open 1%Death 0.5 – 1.1%

Mortality %EBWL

LB 0.1% 47.5

RYGB 0.5% 61.6

DS 1.1% 70.1

Buchwald et al. JAMA 2004; 292(14):1724-37

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Open and Laparoscopic Technique in Bariatric Surgery

OpenIncreased post op pain,

longer hospitalizationsIncreased incidence

of wound complications - infections, hernias, seromas

Return to work in 4-8 weeks

Laparoscopic Less post op pain,

early mobilityWound complications

are significantly reduced

2-3 day hospital stayReturn to work in

1-3 weeks

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% Excess Weight Loss as a Function of Time

Pories et al. Ann Surg 1998 May;227(5):637-43; discussion 643-4; Schauer et al Ann Surg 2000 Oct;232(4):515-29; Wittgrove et al Obes Surg 2000 Jun;10(3):233-9

0

10

20

30

40

50

60

70

80

90

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Year Post-Op

% E

WL

Open Gastric Bypass (Pories)LGB (Schauer)LGB (Wittgrove)

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76.70%

83.20%

71.80%68.80%

52.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

110%

6 n=186 12 n=101 18 n=54 24 n=19 30 n=5

6 Month Intervals

48Schauer, et al, Ann Surg 2000 Oct;232(4):515-29

N=1041 year post-op

Number Prior to Surgery % Worse % No Change % Improved % Resolved

Osteoarthritis 64 2 10 47 41

Hypercholesterimia 62 0 4 33 63

GERD 58 0 4 24 72

Hypertension 57 0 12 18 70

Sleep Apnea 44 2 5 19 74

Hypertriglyceridemia 43 0 14 29 57

Peripheral Edema 31 0 4 55 41

Stress Incontinence 18 6 11 39 44

Asthma 18 6 12 69 13

Diabetes 18 0 0 18 82

Average 1.6% 7.8% 35.1% 55.7%

90.8%Improved or Resolved

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Possible ComplicationsMay Lead to Short or Long-term Hospitalization and/or Re-operationInfection, bleeding or leaking at suture/staple linesBlockage of the intestines or pouchDehydrationBlood clots in legs or lungsVitamin and mineral deficiencyProtein malnutrition Incisional herniaDeath

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Possible Side EffectsNausea and vomitingGas and bloatingDumping syndromeLactose intoleranceTemporary hair thinningDepression and psychological distressChanges in bowel habits such as diarrhea, constipation,

gas and/or foul smelling stool

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Post-Operative Summary

On Average, Gastric-bypass Patients…Will find that they have lost 65-80% of their excess

body weight, the majority of it in the first 18 to 24 months after surgery.

May have rapid improvements in the morbid side effects of their obesity, such as type 2 diabetes, high blood pressure, sleep apnea, and high cholesterol levels.

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Bariatric Surgery as a Tool

Bariatric Surgery Will Not Work Alone. Commitment to Diet, Exercise and Support are Intricate Parts of Your Weight Loss Success.

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Pathway to Bariatric SurgeryPatient ResponsibilitiesHonesty, Responsibility, Cooperation

Bariatric Program ResponsibilitiesHonesty, Responsibility, Cooperation

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Post-Op Follow-up and Support

Surgery

Preoperative Evaluation

Pre-Op Information Exchange

Initial Contact

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Who is My Dedicated Team?SurgeonRegistered Nurse CoordinatorRegistered Dietitian Psychologist/Social WorkerExercise SpecialistInsurance CoordinatorAdministrative Assistant

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Gynecology

Internal Medicine

Anesthesiology

Gastroenterology

Reconstructive Surgery

Pulmonology

Cardiology Endocrinology

Multidisciplinary Approach

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Support Groups – The Heart of the ProgramCreate fellowship through a common bond Provide a source of up-to-date information

about surgery and latest developmentsEducate in nutrition, exercise, and post-op

needsPromote networkingIncrease bariatric surgery successSupport life-style changes

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Pre-operative Diet GoalsBegin Creating Healthy Nutritional

Patterns:Multivitamin and mineral intakeAdequate fluid intakeQuality versus quantityAvoiding the last supper syndrome

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Diet

Stage I: A low sugar, clear liquid diet,

started two to three days after surgery. It essentially provides hydration during the initial post-operative phase.

Roux-en-Y Gastric Bypass

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Diet (cont’d)

Stage II: A full liquid diet providing all the essential

requirements for the first post-operative month. Patients go home from the hospital on the stage II diet.

Stage III: A modified solid diet. The surgeon instructs the patient when to

advance to this diet. Introducing semi-solid food or solid diet too early may lead to obstruction and vomiting. It may also unduly stress the anastomosis.

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Difficult FoodsBread productsCow milk productsPasta products Fatty foods and

fried foodsCandy, chocolate,

any sugary foods and beverages

Bran cereal and other bran products

Corn, whole beans, and peas

Dried fruits and skins of fresh fruit

CoconutCarbonated beverages

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Fluids

Recommended fluid intake: min. 2 Liters/dayNon-carbonatedNon-calorieNot during mealsContinually sip water throughout the day to

ensure adequate hydrationAvoid caffeinated beveragesAvoid straws

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Vitamins, Minerals and Supplements Liquid protein supplements required to reach

75 grams of protein per dayMultivitamin with Iron morning and evening1000 mg of folate/dayB-12 supplementations500 mg of Calcium Citrate three times per dayOther supplements on an individual need basisPeriodic blood levels must be taken to ensure

adequate nutrition

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Dumping Syndrome

Dumping SyndromeEarly: immediately associated with food intake

(GI symptoms)Late: delayed onset, usually 1½ to 2 hours after

food intake (neurological symptoms)Some patients never experience Dumping Syndrome

Some surgeons consider dumping syndrome to be a beneficial effect of Gastric Bypass surgery.

It provides a quick and reliable negative feedback for intake in the “wrong” foods.

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Long-term Diet Goals

Avoid concentrated sweets due to high calorie content and the possibility of dumping

Low fat, heart healthy dietMaintain adequate water intake

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Your Role Before SurgeryCommit to improving your health

(diet, exercise, mental readiness)Discuss your health history with your surgeonAsk questions and vocalize concerns that you

may have about surgery or your careCommit to following all instructions on nutrition,

activity and other care after surgery

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Your CommitmentAdhere to dietExercise dailyCommit to lifelong follow-upAttend at least 2 support group meetings pre-op

and participate regularly post-opBuy and take in vitamin and mineral supplements

for the rest of your lifeAvoid tobacco products lifelong and alcohol for

at least 1 year post-op