BARIATRIC SURGERY

DR NANDAKISHORE DUKKIPATI

DR DEEPTI THAKKAR

• The American Medical Assn. voted in June 2013 to declare Obesity a Disease, a move that effectively defines 78 million American adults and 12 million children as having a medical condition requiring treatment.

• Experts believe if the current trends continue by 2015 approximately 2.3 billion adults will be overweight and more than 700 million will be obese. The scale of the obesity problem has a number of serious consequences for individuals and government health systems.

The Problem

• Morbid obesity affects 5% of Indian population. • India ranks 3rd in the world just after US and

China. • The phenomenon in South Asians has

characteristic features - high prevalence of abdominal obesity, with more "intra-abdominal and truncal subcutaneous adiposity," experts say which is directly related to the incidence of Cardiovascular disease.

Consequences of Obesity

• Coronary heart disease • Type 2 diabetes • Cancers (endometrial, breast, and colon) • Hypertension (high blood pressure) • Dyslipidemia (for example, high total cholesterol or high

levels of triglycerides) • Stroke • Liver and Gallbladder disease • Sleep apnoea and respiratory problems • Osteoarthritis (a degeneration of cartilage and its

underlying bone within a joint) • and Gynaecological problems (abnormal menses, infertility

Measuring Obesity

A crude population measure of obesity is the body mass index (BMI) which is a simple index of weight-for-height that is commonly used in classifying overweight and obesity in adult populations and individuals - a person's weight in kilograms is divided by the square of the height in meters (kg/m2). BMI provides the most useful population-level measure of overweight and obesity as it is the same for both sexes and for all ages of adults but it is merely a rough guide because it may not correspond to the same degree of fatness in different individuals.

Diabetes and Obesity

• . There is a strong association of type 2 diabetes with obesity. Obesity is one of the major risk factors for type 2 diabetes.

• Further obesity is a precursor of type 2 diabetes with insulin resistance. Insulin is a hormone produced by the pancreas in the body to regulate and bring down the blood sugar levels.

• In obese individuals with type 2 diabetes, the amount of insulin produced in the body may be normal but this may not meet the requirements of the body. Thus the blood sugar remains elevated. This is termed insulin resistance.

• Insulin resistance is the hallmark of type 2 diabetes seen among obese individuals. . In the obese state, adipose tissue secretes proportionally more adipokines that cause insulin resistance

Features of metabolic syndrome

• Metabolic syndrome is characterized by:-

• increased waist circumference

• high levels of triglycerides in the blood

• low levels of high-density lipoprotein (HDL)-cholesterol in blood

• high blood sugar (fasting state)

• high blood pressure

Childhood Obesity

• Over the last few decades the number of children who are overweight or obese has doubled.

• Risk factors associated with childhood obesity • Increased sedentary habits with more time spent before the television and

computer game • Lack of adequate physical activity • Excessive indulgence in fast foods and consumption of sugary and saturated fat

rich foods • Lack of time on the part of working parents who are unable to cook nutritious

meals or supervise outdoor playtime • Reduced intake of fresh fruits and vegetables • Rise of urban and suburban crimes that keep children away from out of doors • Measuring overweight and obesity in children aged 5 to 14 years is challenging -

the WHO Child Growth Standards includes BMI charts for infants and young children up to age 5 - childhood obesity is associated with a higher chance of premature death and disability in adulthood

Association between cancers and obesity

• The International Agency for Research on Cancer

has assessed the association between cancers and obesity. Their focus was on certain cancers like cancers of the colon, female breast (especially in women who have achieved menopause), endometrial or womb cancers, kidney and adenocarcinoma of the esophagus. Other cancers linked to obesity include pancreatic, ovarian, cervical and blood cancers.

• At present obesity is the 2nd leading cause of preventable cancer after cigarette smoking.

Bariatric Surgery

The evidence in support of bariatric surgery for type 2 diabetes continues to mount. Various studies have shown:

• 77% of patients with resolved diabetes. In these patients, diabetes completely disappeared or treatment (medicines, insulin) was no longer needed. In studies measuring for “resolution or improvement,” the number rose to 86% of patients.

• Rapid results. For some patients, diabetes disappeared almost immediately, within days of surgery. Others saw blood sugar levels begin to fall soon after surgery, becoming completely normal within a year.

• 92% reduction in deaths from diabetes-related causes.

Effect on Diabetes

• Reduced risk of serious complications, including: – Blindness – Limb amputation – Kidney disease – Cardiovascular conditions:

• Heart attack • Stroke • Congestive heart failure • High blood pressure

• Cut the costs (and the hassles) of diabetes medications: – Reduced or eliminated need for diabetes medicines – No more need for insulin injections

• Better and longer life

Other Benefits

• High cholesterol: lowered in 70% of patients • High blood pressure: resolved (disappeared) in 62% of

patients • Obstructive sleep apnea (breathing disturbances during

sleep): resolved in 86% of patients • • What’s more, in patients undergoing bariatric surgery,

death rates fell in these categories: • Deaths from all causes: 40% reduction • From coronary artery disease: 56% reduction • From cancer: 60% reduction • From diabetes: 92% reduction

Types of Bariatric Procedures

• Gastric banding

• Gastric Sleeve

• Gastric bypass

• Duodenal Switch