The Management of ObesityCelso M. Fidel MD,FPSGS,FPCSDiplomate Philippine Board of Surgery

Introduction Obesity is a very serious health problem. The advent of modern bariatric surgery is increasingly recognized as an important therapeutic option for many patients with clinically significant obesity.

Assessing Severity

The body mass index (BMI) is dividing the weight in kilograms by the height in meters squared In adults, a normal body mass index measures between 18.5 and 24.9. The BMI is closely, but not necessarily precisely, related to body fat content.

celso m. fidel

Assessing Severity

The body mass index has proven to be a clinically relevant measure of obesity that can be linked to health outcomes.

The BMI associated with the lowest risk of death is within the normal range for most men and lies within the normal to overweight range for most women.

celso m. fidel

Assessing Severity

Abdominal obesity is more predictive of the presence of metabolic risk factors (e.g., insulin resistance) than is an elevated BMI alone. Waist circumference and the waist:hip ratio, used in conjunction with the BMI, may more accurately identify patients with central adiposity who are at risk for significant medical comorbidities, including cardiovascular disease.

celso m. fidel

Assessing Severity

Waist circumference is more closely correlated with visceral obesity . Population survey data indicate that a waist circumference exceeding 98 cm in men and 87 cm in women can help identify patients who have an increased risk for cardiovascular disease

celso m. fidel

Assessing Severity Other risk factors include: 1. Elevated fasting triglycerides (>150 mg/dL) 2. Elevated high-density lipoprotein cholesterol 3. Hypertension (blood pressure >130/85 mm Hg) 4. Hyperglycemia (fasting plasma glucose levels >110 mg/dL) The presence of any three of these risk factors identifies patients who have the metabolic syndrome

Assessing Severity The National Heart, Lung and Blood Institute guidelines

Define patients with body mass indices between 25 and 29.9 kg/m2 body surface area as overweight

Those with BMIs exceeding 30 kg/m2 are classified as obese

Assessing Severity Medical obesity is further subclassified into three categories:

Class 1 obesity for patients with body mass indices between 30 and 34.9 kg/m2

Class 2 obesity for BMIs between 35 and 39.9

Class 3 obesity for patients with BMIs that exceed 40 kg/m2

Assessing Severity

In 1991, the National Institutes of Health defined morbidly obese individuals generally exceed ideal body weight by 100 lb or more or are 100% over ideal body weight, patients as those with BMIs of 35 kg/m2 or greater who had significant obesity-related conditions, or those with BMIs 40 kg/m2 or greater in the absence of medical comorbidities.

Assessing Severity In 1991, the National Institutes of Health defined .Superobesity is a term that is occasionally used to identify patients who have a body weight exceeding ideal body weight by 225% or more, BMIs equal to 50 kg/m2 or greater. The National Institutes of Health definitions are similar to those of the World Health Organization.

Assessing SeverityThe relationship between body mass and Weight Classification:

BMI < 18.5-------------- Underweight BMI 18.5-24.9-------- Normal BMI 25---29.9--------- Overweight BMI 30---34.9--------- Obesity class 1 BMI 35---39.9--------- Obesity class 2 BMI > 40------------------ Obesity class 3

Etiology Storage of consumed energy as triglycerides within adipose tissue is a normal physiological process. It is appropriate to suppose that such a storage process would provide a survival advantage to the host during times of starvation or increased energy demands because the consumption of adipose tissue via hydrolysis releases fatty acids that can be used as an energy source by many tissues.

Etiology The changes that have been witnessed over the past decades most likely have occurred as energy expenditure has declined due to less physical activity, while food intake has remained the same or increased.Energy balance is regulated by the balance between food intake and energy expenditure.

Etiology The properties of the major macronutrients consumed by humans have substantially different core properties that predict their effect on energy intake in most instances Macronutrient's thermic effect, otherwise known as nutrient-induced thermogenesis, is the energy cost to the body of absorbing, processing, and storing an orally ingested food.

Nutritional and Metabolic Properties of the Common Macronutrients

PropertiesFatProteinCarbohydrateAlcoholKcal/g 9447Energy densityHighLowLowHjghNutrient-induced thermogenesis (percent of energy content)2-3%25-30 %6-8%15-20%Storage capacityHighNoneLowNoneAutoregulationPoorGoodGoodPoorAbility to suppress hungerLowHighHighMay stimulate hunger

Etiology As the table illustrates 1. Fat has a very high energy density and storage capacity 2. It is subject to less autoregulation 3. It suppresses appetite somewhat less than other macronutrients in general 4. It requires the least amount of energy for it to be metabolized.

Nutritional and Metabolic Properties of the Common Macronutrients

PropertiesFatProteinCarbohydrateAlcoholKcal/g 9447Energy densityHighLowLowHjghNutrient-induced thermogenesis (percent of energy content)2-3%25-30 %6-8%15-20%Storage capacityHighNoneLowNoneAutoregulationPoorGoodGoodPoorAbility to suppress hungerLowHighHighMay stimulate hunger

Etiology For these reasons, the importance of fat intake as a determinant of weight gain should be apparentespecially as compared with protein or carbohydrate.

Etiology Major determinants of energy expenditure areThe resting metabolic rate (which is the amount of energy needed to maintain the body's core functions at rest) The energy required to process the food consumed (which is the nutrient-induced thermogenesis described aboveThe energy consumed by physical activity. .

Etiology Behavioral factors that may vary genetically

1.The preference for fat in the diet 2. Metabolic adaptations to food restriction 3. Tolerance for physical activity 4. The frequency of meals.

Etiology Various metabolites, besides fatty acids or triglycerides, that are released by adipose tissue during starvation include various Cytokines and prostaglandins that may help regulate energy balance Resistin and Fibronectin that may influence carbohydrate metabolism

Etiology Nutrient ingestion into the stomach or proximal intestine elicits hormonal signals that release neuropeptides, which in turn alter body metabolismPleptin, ghrelin, which is normally associated with appetite stimulation (i.e., is orexigenic) Insulin and cholecystokinin are normally anorexic

Etiology Leptin is a good example of the fundamental principles of neurohormonal signaling between the periphery and the central nervous system

Leptin is a cytokinelike polypeptide hormone that is known to influence long-term changes in satiety. It is produced predominantly by adipose tissue and its circulating levels are proportional to the amount of fat stored as adipose tissue.

Etiology Leptins effects on food intake are governed by its effects on receptors within the arcuate nucleus of the hypothalamus. There it induces the production of -melanocyte stimulating hormone MSH) from propiomelanocortin MSH binds with melanocortin 4 receptors within hypothalamic nuclei and inhibits food intake Leptin also decreases the production of appetite-inducing neuropeptides such as neuropeptide Y

Etiology Humans born with homozygous loss of function mutations of the leptin gene (and who, therefore cannot produce leptin) eventually develop morbid obesity. These unfortunate individuals continuously seek food and eat much more than normal Other phenotypical manifestations includes 1. Adrenal insufficiency 2. Changes in hair color 3. Impaired fertility are common

Etiology The Prader-Willi syndrome is a well-recognized disorder characterized by childhood-onset upper body obesity

short stature

mental retardation

hypogonadism.

Etiology The Prader-Willi syndrome . They often include alterations in the leptin-hypothalamic feedback loop of important signal precursors such as: 1. Propiomelanocortin 2. Leptin gene 3. Leptin receptor 4. Melanocortin 4 receptor mutations

Etiology Ghrelin discovered in 1999, is a growth hormone secretagogue that is synthesized predominantly by the stomach. Its levels rise just before meals and with short-term food restriction, or prolonged starvation in general and may be an important orexigenic (i.e., appetite-stimulating) signal. Ghrelin levels normally fall rapidly after meals. Like leptin, ghrelin metabolism may be dysregulated in obese subjects.

Etiology Obesity is associated with decreased circulating ghrelin levels. After gastric bypass surgery, ghrelin levels fall but do not increase as expected before mealsLow levels of ghrelin and its metabolic dysregulation may be at least partially responsible for the sustained weight loss after surgical procedures that resect and/or bypass a significant portion of the stomach.

Medical problems associated with Obesity Gastroesophageal reflux2. Coronary artery disease3. Cerebrovascular accident4. Congestive heart failure5. Hypertension6. Dyslipidemia7. Cholelithiasis and gallbladder disease8. Osteoarthritis and degenerative joint disease9. Slap apnea

Medical problems associated with Obesity Cancer of the: 1. Esophagus 2. Stomach 3. Liver 4. Pancreas 5. Kidney 6. Prostate 7. Ovaries 8. Uterus

Medical problems associated with Obesity Cancer: 9. Gallbladder 10. Colon Non Hodgkins lymphoma Multiple myeloma Menstrual Abnormalities Impaired fertility and increased risk of adverse outcome after pregnancy Stress inccontinence

Medical problems associated with Obesity Morbidity from obesity is increased in the presence of: 1. Preexisting coronary artery or peripheral artery disease 2.Type II diabetes 3. Hypertension 4. Smoking

Medical problems associated with Obesity Morbidity from obesity is increased in the presence of : 5. Elevated low-density or decreased high-density lipoprotein levels 6. Increased fasting blood sugar concentrations 7. Patients with a family history of early-onset heart disease

Medical problems associated with Obesity Cardiovascular risks associated w/ significant obesity. 1. Overweight women have 50% > risk of heart failure compared to women with normal BMIs. 2.The risk is twofold higher in obese females. 3. Obese men have a 90% greater risk of heart failure. 4. Overall, approximately 11% of all heart failure cases in men and 14% in women can be attributed to obesity alone.

Medical management of Obesity Medications are classified into: 1. Those that decrease food intake by suppressing appetite or increasing satiety 2. Those that decrease nutrient absorption.

Medical management of Obesity Appetite suppressants are believed to work by increasing the availability of neurotransmitters which suppress appetite such as: 1. norepinephrine 2. serotonin 3. dopamine

Medical management of Obesity

Sibutramine works by inhibiting the uptake of these neurotransmitters. This drug may also stimulate thermogenesis, although this effect is modest and constitutes only 35% of the average person's resting metabolic rate. Randomized controlled trials indicate that the average patient will lose approximately 34 kg over 852 weeks of treatment.

Medical management of Obesity Orlistat reduces nutrient absorption by binding to gastrointestinal lipase and prevents the hydrolysis of dietary fat into absorbable free fatty acids and monoacylglycerols.

Patients who are treated with orlistat excrete about a third of the dietary fat that they consume in their stools and can be expected to lose about 9% of their baseline weight on average.

Medical management of Obesity The currently accepted approach is to combine caloric restriction with exercise and behavioral modification as the initial treatment recommendation for most overweight or obese patients.

Diet modification, exercise, and behavioral modifications should be the cornerstones of every treatment plan.

Guidelines Treatment of Overweight and Obese Patients

BMI/mKg/m2 Health RiskRisk with comorbidities Treatment40Extremely HighExtremely HighAll of the above plus Bariatric Surgery

Surgical management of obesityBariatric surgery should be offeredTo appropriate patients with BMIs of 40 kg/m2 or greater (or between 35 and 40 kg/m2 if any of the previously described significant medical comorbidities are present)

Who have failed medical treatment, nutritional treatment, lifestyle changes, behavioral modification, or other conservative therapies.

Surgical management of obesity Candidates for surgical therapy must be willing and able to comply with: Postoperative dietary recommendations

Exercise

Follow-up requirements

Surgical management of obesity Patients who should not undergo bariatric surgery 1. Ongoing drug or alcohol dependency

2. Who are unstable or otherwise unfit psychiatrically 3. Who are unable to undergo general anesthesia

Surgical management of obesity

Surgical treatment is the only way to obtain consistent, durable weight loss for most morbidly obese patients

Surgical management of obesitySurgical treatment is indicated for patients with:

1. BMIs of 40 kg/m2 or greater 2. BMIs of 3540 kg/m2 with obesity-related comorbidities 3. When medical, nutritional, and behavioral therapies are ineffective

Surgical management of obesity In all instances, the best care for morbidly obese patients provides unfettered access to, and evaluation by, a multidisciplinary team comprised of : 1. Nutritionists 2. Physical or exercise therapists 3. Surgeons 4. Medical specialists 5. Psychiatrists.

Criteria for Surgical Treatment of ObesityBMI >40 or BMI between 35 and 40 in individuals with high-risk comorbid or severe lifestyle limitations for greater than 5 years 2. Absence of secondary cause of morbid obesity 3. Ability and willingness to cooperate with long-term follow-up 4. Acceptable operative risk

Criteria for Surgical Treatment of Obesity

Not yet uniformly recommenced for children or adolescents (less than 18 years of age), or patients over the age of 60

Preoperative PreparationNutritional evaluation and education are critically important components of preoperative preparation. Psychiatric evaluation helps some patients cope more effectively with various stressors that may surface in their interpersonal relationships after surgery.

Preoperative Preparation

Psychiatric evaluation helps to prepare patients for operation and their postoperative recuperation, and also helps to identify patients with eating disorders, severe depression, psychosis, or other mood disturbances that could adversely affect outcome.

Preoperative Preparation 1. All patients should have an electrocardiogram performed preoperatively. 2. Stress testing & even cardiac catheterization may be indicated for intermediate- or high- risk patients. 3. Polysomnographic evaluation at a sleep center for all morbidly obese patients who are being evaluated for surgical treatment.

Preoperative Preparation

4. Patients who are diagnosed with significant sleep apnea require treatment with continuous positive airway pressure and are at risk for acute upper airway obstruction and significant cardiac arrhythmias postoperatively.

Preoperative Preparation 5. Obesity hypoventilation syndrome may also be present in many obese patients. The syndrome is defined by the presence of significant hypoxemia with arterial partial pressure of oxygen less than 55 mm Hg, and hypercarbia with a partial pressure of carbon dioxide greater than 47 mm Hg.

Preoperative Preparation

6. Patients with sleep apnea, the obesity hypoventilation syndrome, or any other significant airway or parenchymal lung disease should be evaluated by a pulmonologist preoperatively

Preoperative Preparation 7. Finally, many patients with severe gastroesophageal reflux, dysphagia, nausea, vomiting, abdominal pain, or a prior history of gastric or intestinal surgery may require formal evaluation of the gastrointestinal tract including barium swallow, upper G I series, esophagogastroduodenoscopy, esophageal manometry, and pH testing and computed tomography of the abdomen with and without contrast.

Preoperative Preparation 8. Preoperative laboratory evaluation typically include a. Hemoglobin b. Hematocrit c.Platelet count measurements d. Assessment of electrolyte levels e. BUN f. Creatine .

Preoperative Preparation 8. Preoperative laboratory evaluation typically include g. Blood glucose h. Liver function i. Pap smears j. Pregnancy testing performed routinely. K. Hemoglobin A1c l. Posteroanterior and lateral radiographs of the chest evaluated routinely.

Preoperative Preparation 9. Obesity likely increases the risk of postoperative wound infections. Antibiotic prophylaxis is indicated according to the: a. Likelihood of wound contamination b. The type of procedure planned. Rate of wound infection after laparoscopic gastric bypass appears reduced by 75% compared with open gastric bypass surgery.

Historical Perspective and Overview A useful paradigm is to categorize bariatric procedures as: 1. Restrictive

2. Malabsorptive

3. Combination of both

Historical Perspective and Overview The rationale for the surgical treatment of obesity has been based on three fundamental goals: 1. Reducing caloric absorption by bypassing portions of the stomach and small bowel 2. Reducing gastric capacity via banding, stapling, or transection 3. Performing operations that induce malabsorption and restrict food intake.

Major Types of Bariatric Surgical Procedures 1. Malabsorptive

2. Restrictive

Major Types of Bariatric Surgical Procedures 3. Mostly restrictive

4. Mostly malabsorptive

. Major Types of Bariatric Surgical Procedures 1. Malabsorptive Jejunoileal and jejunocolic bypasses (no longer recommended

2. Restrictive (1) Vertical banded gastroplasty (2) Adjustable silicone gastric banding

. Major Types of Bariatric Surgical Procedures 3. Mostly restrictive (1) Short-limb (50100 cm) Roux-en-Y gastric bypass (2) Long-limb (150 cm) Roux-en-Y gastric bypass 4. Mostly malabsorptive Biliopancreatic diversion with or without duodenal switch

Vertical Banded gastroplasty The VBG is purely restrictive in nature, limiting the amount of solid food that can be consumed at one time, which leads to a calorie deficit. Of note, liquid intake is not limited by this procedure, and as such can be utilized to overcome the intended effect of the operation. A proximal gastric pouch empties through a calibrated stoma, which is reinforced by a strip of mesh or a Silastic ring.

Vertical Banded gastroplasty Techniques Used in VBC1. Mason first described the vertical banded Gastroplasty in 19822. Ewald tube is passed through the mouth and into the stomach to facilitate isolation of the esophagus, and later facilitates pouch volume measurement and calibration of the stoma.3.The esophagus is encircled w/ a Penrose drain. 4. The lesser omentum is opened

Vertical Banded gastroplasty Techniques Used in VBC 5. 27F thoracostomy tube is passed from this opening behind the stomach and up to the angle of His through the gastrophrenic ligament6. An anvil for a circular stapler is held in the lesser sac against the posterior stomach wall. 7. A trocar is pushed through both walls of the stomach at a point about 8 to 9 cm below the angle of His and into the anvil

Vertical Banded gastroplasty Techniques Used in VBC 8. A 2.5-cm window is created through the proximal stomach, firing a circular stapler w/ Ewald tube pressed against lesser curvature. 9. A line of four rows of 90-mm staples leads from the circular opening to the angle of His to create a pouch 50 mL in size or smaller.

Vertical Banded gastroplasty Techniques Used in VBC 10. Pouch volume is measured by instilling saline into Ewald tube. Some surgeons use a linear cutting stapler to create the pouch. 11. A strip of polypropylene mesh measuring 7 by 1.5 cm is placed around the lesser curvature channel and is sewn to itself to create a 5.0 to 5.5 cm collar circumference.

Vertical Banded gastroplasty Techniques Used in VBCThe laparoscopic technique follows the same principles.Using a five-trocar technique, the abdomen is entered and the left hepatic lobe is retracted anteriorly.2. The peritoneal reflection lateral to the angle of His is incised. 3. The gastrohepatic omentum is incised and the lesser sac is entered.

Vertical Banded gastroplasty Techniques Used in VBCThe laparoscopic technique follows the same principles. 4. A 25-mm circular stapler is used to create a window through the stomach, 4 cm below the angle of His, near the lesser curvature of the stomach.5. A 60-mm linear stapler is inserted into this opening and is fired along a 9-mm esophageal bougie to create a divided staple line leading to the angle of His.

Vertical Banded gastroplasty Techniques Used in VBCThe laparoscopic technique follows the same principles. 6. A 5-cm band of polypropylene mesh is sutured around the gastric pouch. Another technique involves linear cutting stapler to excise a wedge of fundus, creating a 20-mL pouch w/o use of circular stapler. A polypropylene mesh or polytetrafluoroethylene band is sutured around distal end of gastroplasty

Vertical Banded gastroplasty

Efficacy of VBGVBC achieve acceptable weight loss resultsSeries of 305 patients followed for 2 years- mean excess loss of 61%Series of 250 patients followed for 5 years- Mean excess wt. loss 60% for Morbidly obese Mean excess wt. loss 52% for super obese A significant number of patients have required a reoperation following VBG

Efficacy of VBG Complications Over all morbidity rate of VBG- under 10% mortality rate of 0- 38% Early Complications Splenectomy 3% Peritonitis from leak 6%

Efficacy of VBG Complications Late Complications 1. Stoma stenosis 2. Staple line dehiscence 48% 3. Reflux Esophagitis 4. Intractable vomiting 30-50%

Efficacy of VBG Advantages 1. Significant improvement in comorbidities like dyspnea, hypertension, diabetes mellitus, quality of life 2. Minimal long term metabolic or nutritional deficiency 3. Less operating time 4. No anastomosis required

Efficacy of VBG Disadvantages Long term weight loss is less successful when: 1. Patient eat sweet food 2. In high liquid caloric intake 3. Less effective in terms of weight loss as compared to gastric bypass

Laparoscopic Gastric bandingMechanism of Action Use of Silicone band Restricts amount of ingested solid food

Adjustable nature of the band

Adjustable gastric band

Efficacy of lGb

Mean Excess weight loss in 1 and 2 years 55 to 56%

Laparoscopic Gastric bandingComplications Intraoperative Complications 1. Splenic injury 0 to 1 % 2. Esophageal injury 0 to 1% 3. Gastric injury 0 to 1% 4. Conversion to open procedure 1 to 2 % 5. Bleeding 0 to 1%

Laparoscopic Gastric bandingComplications Early postoperative Complications 1. Bleeding 0.5 %

2. Wound infection 0 to 1%

3. Food intolerance 0 to 11%

Laparoscopic Gastric bandingComplications Late Complications 1. Slippage of Band 7- 21% 2. Band Erosion 2 to 7.5%

3. Leakage of reservoir 4. Persistent vomiting

Laparoscopic Gastric bandingAdvantages 1. Simple procedure and less operative time

2. Mortality is low 0.06%

3. No staple liner or anastomosis

4. Recovery is rapid and hospital stay is short

Laparoscopic Gastric bandingDisadvantages

Potential for site complicaton Need for frequent postoperative visit for gastric band adjustment

Open roux en y gastric bypassMechanism of action

Both a gastric restrictive andMildly malabsorptive procedure

Roux en y gastric bypass

Open roux en y gastric bypass 1. Weight loss from gastric bypass is superior than purely restrictive procedures. 2. Five year weight loss was 48 -74 % loss of excess weight. 3. RYGB- to prevent the progression of non insulin dependent Diabetes Mellitus, reduce the mortality from Diabetes Mellitus and Cardiovascular disease.

Open roux en y gastric bypass Early Complications 1. ANASTOMOTIC LEAK with peritonitis - 1.2%

2. Acute distal gastric dilatation

3. Severe wound infection

Open roux en y gastric bypass late Complications 1. Stomach stenosis 15% 2. Marginal Ulcer 13% 3. Intestinal Obstruction 4. Internal Hernia 5. Staple line destruction 6. Incisional Hernia

Open roux en y gastric bypass late Complications 7. Metabolic Complications a. Deficiencies of: Calcium, thiamine, Vit B12 30-70% Folate 9- 18% Iron 20-49% b. Anemia 18-35%

Open roux en y gastric bypass Advantages 1. RYGB is more effective than vertical bonded gastroplasty

2. Presence of dumping syndrome encourages patient to avoid sweet food

Open roux en y gastric bypass disAdvantages 1. Dumping syndrome in a lot of patients a. Due to rapid emptying hyperosmolar boluses in small intestines b. Bloating, nausea, vomiting, diarrhea and abdominal pain after intake of milk and sweet products

Open roux en y gastric bypass disAdvantages c. Vasomotor symptoms like palpitation, diaphoresis and lightheadedness 2. Distal gastric distention hiccups and left shoulder pain 3. Internal hernia

Laparoscopic roux en y gastric bypass Mechanism of action 1. Both gastric restrictive & mildly malabsortive procedure 2. Small gastric pouch restricts gastric intake while the Roux Y configuration provides malabsorpton of calories and nutrients

Laparoscopic roux en y gastric bypass Efficacy 1. After 24 months follow up mean excess weight loss ranges from 69- 82%

2. Most comorbidities were improved and eradicated

Laparoscopic roux en y gastric bypass complications 1. Pulmonary embolism 0- 1.5% 2. Anastomotic leak 1.5- 5.8% 3. Bleeding 0- 3.3% 4. Stenosis of gastroepinoctomy 1.6- 6.3% 5. Internal Hernia 2.5% 6. Marginal Ulcer 1.4% 7. Gallstone 1.4%

Laparoscopic roux en y gastric bypass advantages 1. Better cosmesis 2. Less postoperative pain 3. Attenuation of postoperative stress response 4. Reduce wound infection, dehiscence 5. Incisional Hernia 6. Improvement of postoperative pulmonary function

Laparoscopic roux en y gastric bypass disadvantages 1. Technically challenging, advance laparoscopy of steep learning curve

2. Approach may be difficult in super obese patients

biliopancreatic diversion with duodenal switch

Bilio pancreatic procedures Mechanism of Action 1. The BPD is a procedure developed by Nicola Scopinaro of Italy. 2. The procedure combines gastric restriction with an intestinal malabsorptive procedure. 3. A 50- to 100-cm common absorptive alimentary channel is created proximal to the ileocecal valve; digestion and absorption are limited to this segment of bowel

Bilio pancreatic procedures Indications 1.This procedure is primarily indicated for the superobese 2.Those who have failed restrictive bariatric procedures. 3. Less commonly, some surgeons perform BPD as primary operation in the non-superobese.

Bilio pancreatic procedures contraindications 1. Patients with anemia, hypocalcemia and osteoporosis

2. Those who cannot comply with the strigent supplementation regimen

Bilio pancreatic procedures Efficacy

1. Excellent and durable result

2. Mean excess weight loss in 8 years 72-78%

Bilio pancreatic procedures Technique 1.A subtotal gastrectomy is performed, leaving a proximal 200-mL gastric pouch for patient who are superobese, or 400-mL pouch for others.

2.A Roux-en-Y anastomosis is created 50 to 100 cm proximal to the ileocecal valve degree of malabsorption

Bilio pancreatic procedures Technique 3.The distal 250 cm of small intestine is anastomosed to the gastric pouch with a 2- to 3-cm stoma.

4. A concomitant cholecystectomy is performed because of the high incidence of postoperative cholelithiasis with this degree of malabsorption

Bilio pancreatic procedures Technique A modification of this technique with a duodenal switch involves 1. A greater curvature sleeve gastrectomy 2. With maintenance of the continuity of the antrum, pylorus, and first portion of the duodenum. This allows for a lower marginal ulcer rate (0 to 1%) and a lower incidence of dumping syndrome

Bilio pancreatic procedures Technique laparoscopic approach 1. Six to eight laparoscopic ports are inserted. A sleeve gastrectomy is performed to create a gastric reservoir of 150 to 200 mL.

2.To perform the biliopancreatic diversion with a duodenal switch, the continuity of the antrum, pylorus, and first portion of the duodenum is maintained.

Bilio pancreatic procedures Technique 3. This allows for a lower marginal ulcer rate (0 to 1%), and a lower incidence of dumping syndrome because the pylorus is preserved 4.The ileum is divided 250 cm proximal to the ileocecal valve and is anastomosed to the stomach. 5. A Roux-en-Y anastomosis is created, leaving a common channel 100 cm long

Bilio pancreatic procedures complications 1. Anemia 30% 2. Protein Calorie Malnutrition 30% 3. Dumping syndrome 4. Marginal Ulcer 5. Vit B 12 deficiency 6. Hypocalcemia 7. Osteoporosis 8. Night blindness

Bilio pancreatic procedures complications 9. Prolongation of prothrombin time 10. Early Surgical Complication Wound infection Wound dehiscence 1.2 %

Bilio pancreatic procedures Late complications 1. Intestinal Obstruction- 0.2% 2. Protein Malnutrition- 7% 3. Iron deficiency anemia- 1.2% 4. Stomas Ulcer- 2.8% 5. Mortality- 2.5% 6. Morbidity-15%

Bilio pancreatic procedures AdvantagesEven if patients consume a great quantity of food, the malabsorptive component of the BPD allows excellent results in terms of weight loss. This operation may be more effective than gastric bypass or restrictive surgery in patients with severe morbid obesity (e.g., BMI greater than 70 kg/m 2 ), or in those who have failed to maintain weight loss following gastric bypass or restrictive bariatric surgery.

Bilio pancreatic procedures Advantages

The laparoscopic BPD with duodenal switch is an effective minimally invasive procedure for weight loss.

Bilio pancreatic procedures Advantages

Offers better wt. loss than restrictive procedures because of the malabsorptive component of the operation. The operation may be valuable in patients w/ severe morbid obesity or in those who have failed to maintain weight loss following gastric bypass surgery or restrictive procedures

Bilio pancreatic procedures DisAdvantages1.The BPD is technically a more complex procedure than the restrictive procedures. Protein malnutrition with a. anemia b. hypoalbuminemia c. edema d. alopecia are among the serious adverse sequelae

Bilio pancreatic procedures DisAdvantages2. Severe vitamin deficiencies may occur, leading to osteoporosis and night-blindness. 3. Treatment requires prolonged hyperalimentation and supplementation.4.Patients have four to six foul-smelling stools per day, reflecting the fat malabsorption from this procedure.5. Patients may also experience bloating and heartburn following this procedure.

Bilio pancreatic procedures DisAdvantages . Replacement of fat-soluble vitamins is needed for patients following BPD or BPD-DS.The laparoscopic approach may be especially challenging in patients:With multiple previous abdominal surgeriesPrevious weight loss surgery With an enlarged fatty liverWith a large amount of intra-abdominal fat.

Bilio pancreatic procedures DisAdvantages The laparoscopic BPD is a technically demanding, lengthy laparoscopic procedure, with potential for nutritional sequelae similar to open BPD. Patients may experience 1. Abdominal bloating 2. Malodorous stools 3. Heartburn 4. Abdominal pain. .

Bilio pancreatic procedures DisAdvantages 5. Protein malnutrition with: a. Anemia b. Hypoalbuminemia c. Edema d. Alopecia are potential postoperative sequelae. Severe vitamin deficiencies may be observed.

Bilio pancreatic procedures Treatment requires 1. Prolonged hyperalimentation

2. Possibly reoperation to lengthen the common channel.

Thank You

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