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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