The Management Of Obesity

The The Management Management

of Obesityof ObesityCelso M. Fidel Celso M. Fidel

MD,FPSGS,FPCSMD,FPSGS,FPCS

Diplomate Philippine Diplomate Philippine Board of SurgeryBoard of Surgery

IntroductionIntroduction

Obesity Obesity is a very serious health problem. is a very serious health problem.

The advent of modern The advent of modern bariatric surgery bariatric surgery is is increasingly recognized as an important therapeutic increasingly recognized as an important therapeutic option for many patients with clinically significant option for many patients with clinically significant obesity.obesity.

Assessing SeverityAssessing Severity

The The body mass index body mass index (BMI) is dividing the weight (BMI) is dividing the weight in kilograms by the height in meters squaredin kilograms by the height in meters squared

In adults, a normal body mass index measures In adults, a normal body mass index measures between between 18.5 and 24.9.18.5 and 24.9.

The BMI is closely, but not necessarily precisely, The BMI is closely, but not necessarily precisely, related to body fat content.related to body fat content.

celso m. fidel


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

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

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Abdominal obesity Abdominal obesity is more predictive of the is more predictive of the presence of metabolic risk factors (e.g., insulin presence of metabolic risk factors (e.g., insulin resistance) than is an elevated BMI alone.resistance) than is an elevated BMI alone.

Waist circumference and the waist:hip ratioWaist circumference and the waist:hip ratio, , used in conjunction with the BMI, may more accurately used in conjunction with the BMI, may more accurately identify patients with central adiposity who are at risk identify patients with central adiposity who are at risk for significant medical comorbidities, including for significant medical comorbidities, including cardiovascular disease.cardiovascular disease.

celso m. fidel


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

celso m. fidel


Other risk factors includeOther risk factors include: :

1. Elevated fasting triglycerides (>150 mg/dL)1. Elevated fasting triglycerides (>150 mg/dL)

2. Elevated high-density lipoprotein cholesterol2. Elevated high-density lipoprotein cholesterol

3. Hypertension (blood pressure >130/85 mm Hg) 3. Hypertension (blood pressure >130/85 mm Hg)

4. Hyperglycemia (fasting plasma glucose levels >110 4. Hyperglycemia (fasting plasma glucose levels >110 mg/dL) mg/dL)

The presence of any three of these risk factors The presence of any three of these risk factors identifies patients who have the metabolic syndrome identifies patients who have the metabolic syndrome


The National Heart, Lung and Blood Institute The National Heart, Lung and Blood Institute guidelines guidelines

Define patients with body mass indices between 25 Define patients with body mass indices between 25 and 29.9 kg/mand 29.9 kg/m22 body surface area as body surface area as overweight overweight

Those with BMIs exceeding 30 kg/mThose with BMIs exceeding 30 kg/m22 are classified are classified as as obeseobese


Medical obesity Medical obesity is further subclassified into three is further subclassified into three categories:categories:

Class 1 obesity Class 1 obesity for patients with body mass for patients with body mass indices between 30 and 34.9 kg/mindices between 30 and 34.9 kg/m22

Class 2 obesity Class 2 obesity for BMIs between 35 and 39.9for BMIs between 35 and 39.9

Class 3 obesity Class 3 obesity for patients with BMIs that exceed for patients with BMIs that exceed 40 kg/m40 kg/m22


In 1991, the National Institutes of Health defined In 1991, the National Institutes of Health defined morbidly obesemorbidly obese individuals generally exceed ideal individuals generally exceed ideal body weight by 100 lb or more or are 100%body weight by 100 lb or more or are 100% over over ideal body weightideal body weight, , patients as those with BMIs of 35 patients as those with BMIs of 35 kg/mkg/m22 or greater who had significant obesity-related or greater who had significant obesity-related conditions, or those with BMIs 40 kg/mconditions, or those with BMIs 40 kg/m22 or greater in or greater in the absence of medical comorbidities.the absence of medical comorbidities.


In 1991, the National Institutes of Health defined In 1991, the National Institutes of Health defined ..

SuperobesitySuperobesity is a term that is occasionally used to is a term that is occasionally used to identify patients who haveidentify patients who have a body weight exceeding a body weight exceeding ideal body weight by 225% or more,ideal body weight by 225% or more, BMIs equal to BMIs equal to 50 kg/m50 kg/m22 or greater. The National Institutes of Health or greater. The National Institutes of Health definitions are similar to those of the World Health definitions are similar to those of the World Health Organization.Organization.


The relationship between body mass and The relationship between body mass and Weight Classification:Weight Classification:

BMI < 18.5-------------- BMI < 18.5-------------- UnderweightUnderweight

BMI 18.5-24.9-------- BMI 18.5-24.9-------- NormalNormal

BMI 25---29.9--------- BMI 25---29.9--------- OverweightOverweight

BMI 30---34.9--------- BMI 30---34.9--------- Obesity class 1Obesity class 1

BMI 35---39.9--------- BMI 35---39.9--------- Obesity class 2Obesity class 2

BMI > 40------------------ BMI > 40------------------ Obesity class 3Obesity class 3

EtiologyEtiology Storage of consumed energy as triglycerides Storage of consumed energy as triglycerides

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

EtiologyEtiology The changes that have been witnessed over the The changes that have been witnessed over the

past decades most likely have occurred as past decades most likely have occurred as energy expenditure has declined energy expenditure has declined due to due to less physical activity, while food intake has less physical activity, while food intake has remained the same or increased.remained the same or increased.

Energy balance Energy balance is regulated by the balance is regulated by the balance between food intake and energy expenditure. between food intake and energy expenditure.

EtiologyEtiology The The propertiesproperties of the major macronutrients of the major macronutrients

consumed by humans have substantially consumed by humans have substantially different core properties that predict their effect different core properties that predict their effect on energy intake in most instances on energy intake in most instances

Macronutrient's thermic effectMacronutrient's thermic effect, otherwise , otherwise known as known as nutrient-induced thermogenesisnutrient-induced thermogenesis, , is the energy cost to the body of absorbing, is the energy cost to the body of absorbing, processing, and storing an orally ingested food.processing, and storing an orally ingested food.

Nutritional and Metabolic Properties of the Nutritional and Metabolic Properties of the Common MacronutrientsCommon Macronutrients

Properties Fat Protein Carbohydrate Alcohol

Kcal/g 9 4 4 7

Energy density High Low Low Hjgh

Nutrient-induced thermogenesis (percent of energy content)

2-3% 25-30 % 6-8% 15-20%

Storage capacityHigh None Low None

Autoregulation Poor Good Good Poor

Ability to suppress hungerLow High High

May stimulate hunger

EtiologyEtiology As the table illustratesAs the table illustrates

1. Fat has a very high energy density and 1. Fat has a very high energy density and

storage capacitystorage capacity

2. It is subject to less autoregulation2. It is subject to less autoregulation

3. It suppresses appetite somewhat less than 3. It suppresses appetite somewhat less than

other macronutrients in generalother macronutrients in general

4. It requires the least amount of energy for it to 4. It requires the least amount of energy for it to

be metabolized. be metabolized.

Nutritional and Metabolic Properties of the Nutritional and Metabolic Properties of the Common MacronutrientsCommon Macronutrients

Properties Fat Protein Carbohydrate Alcohol

Kcal/g 9 4 4 7

Energy density High Low Low Hjgh

Nutrient-induced thermogenesis (percent of energy content)

2-3% 25-30 % 6-8% 15-20%

Storage capacityHigh None Low None

Autoregulation Poor Good Good Poor

Ability to suppress hungerLow High High

May stimulate hunger

EtiologyEtiology

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

EtiologyEtiology Major determinants of energy expenditure areMajor determinants of energy expenditure are

The resting metabolic rate The resting metabolic rate (which is the (which is the amount of energy needed to maintain the amount of energy needed to maintain the body's core functions at rest) body's core functions at rest)

The The energy required to process the food energy required to process the food consumed consumed (which is the nutrient-induced (which is the nutrient-induced thermogenesis described abovethermogenesis described above

The The energy consumed energy consumed by physical activity. by physical activity.

..

EtiologyEtiology Behavioral factors that may vary geneticallyBehavioral factors that may vary genetically

1.The 1.The preference for fat preference for fat in the dietin the diet

2. Metabolic adaptations 2. Metabolic adaptations to food restrictionto food restriction

3. Tolerance3. Tolerance for physical activity for physical activity

4. The 4. The frequencfrequency of meals.y of meals.

EtiologyEtiology Various metabolites, besides fatty acids or Various metabolites, besides fatty acids or

triglycerides, that are released by adipose triglycerides, that are released by adipose tissue during starvation include various tissue during starvation include various

CytokinesCytokines and and prostaglandinsprostaglandins that may help that may help regulate energy balance regulate energy balance

ResistinResistin and and FibronectinFibronectin that may influence that may influence carbohydrate metabolism carbohydrate metabolism

EtiologEtiologyy Nutrient ingestion into the stomach or proximal Nutrient ingestion into the stomach or proximal

intestine elicits hormonal signals that release intestine elicits hormonal signals that release neuropeptidesneuropeptides, which in turn alter body , which in turn alter body metabolismmetabolism

Pleptin, ghrelinPleptin, ghrelin, which is normally associated , which is normally associated with appetite stimulation (i.e., is orexigenic)with appetite stimulation (i.e., is orexigenic)

InsulinInsulin and and cholecystokinincholecystokinin are normally are normally anorexic anorexic

EtiologyEtiology Leptin is a good example of the fundamental Leptin is a good example of the fundamental

principles of neurohormonal signaling between principles of neurohormonal signaling between the periphery and the central nervous systemthe periphery and the central nervous system

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

EtiologyEtiology Leptin’s effects on food intake are governed by Leptin’s effects on food intake are governed by

its effects on receptors within the arcuate its effects on receptors within the arcuate nucleus of the hypothalamus. There it induces nucleus of the hypothalamus. There it induces the production of -melanocyte stimulating the production of -melanocyte stimulating hormone MSH) from propiomelanocortin hormone MSH) from propiomelanocortin

MSH binds with melanocortin 4 receptors within MSH binds with melanocortin 4 receptors within hypothalamic nuclei and inhibits food intake hypothalamic nuclei and inhibits food intake

Leptin also decreases the production of appetite-Leptin also decreases the production of appetite-inducing neuropeptides such as neuropeptide Y inducing neuropeptides such as neuropeptide Y

EtiologyEtiology Humans born with homozygous loss of function Humans born with homozygous loss of function

mutations of the leptin gene (and who, therefore mutations of the leptin gene (and who, therefore cannot produce leptin) eventually develop morbid cannot produce leptin) eventually develop morbid obesity.obesity.

These unfortunate individuals continuously seek These unfortunate individuals continuously seek food and eat much more than normal Other food and eat much more than normal Other phenotypical manifestations includesphenotypical manifestations includes

1. Adrenal insufficiency1. Adrenal insufficiency

2. Changes in hair color2. Changes in hair color

3. Impaired fertility are common 3. Impaired fertility are common

EtiologyEtiology The Prader-Willi syndrome is a well-recognized The Prader-Willi syndrome is a well-recognized

disorder characterizeddisorder characterized

by childhood-onset upper body obesityby childhood-onset upper body obesity

short statureshort stature

mental retardationmental retardation

hypogonadism. hypogonadism.

EtiologyEtiology The Prader-Willi syndrome . The Prader-Willi syndrome .

They often include alterations in the They often include alterations in the leptin-leptin-hypothalamic feedback loophypothalamic feedback loop of important of important signal precursors such as: signal precursors such as:

1. Propiomelanocortin1. Propiomelanocortin

2. Leptin gene2. Leptin gene

3. Leptin receptor 3. Leptin receptor

4. Melanocortin 4 receptor mutations 4. Melanocortin 4 receptor mutations

EtiologyEtiology Ghrelin discovered in 1999, is a growth Ghrelin discovered in 1999, is a growth

hormone secretagogue that is synthesized hormone secretagogue that is synthesized predominantly by the stomach. predominantly by the stomach.

Its levels rise just before meals and with short-Its levels rise just before meals and with short-term food restriction, or prolonged starvation in term food restriction, or prolonged starvation in general and may be an important orexigenic general and may be an important orexigenic (i.e., appetite-stimulating) signal. (i.e., appetite-stimulating) signal.

Ghrelin levels normally fall rapidly after meals. Ghrelin levels normally fall rapidly after meals. Like leptin, ghrelin metabolism may be Like leptin, ghrelin metabolism may be dysregulated in obese subjects.dysregulated in obese subjects.

EtiologyEtiology Obesity is associated with decreased circulating Obesity is associated with decreased circulating

ghrelin levels. After gastric bypass surgery, ghrelin levels. After gastric bypass surgery, ghrelin levels fall but do not increase as ghrelin levels fall but do not increase as expected before mealsexpected before meals

Low levels of ghrelin and its metabolic Low levels of ghrelin and its metabolic dysregulation may be at least partially dysregulation may be at least partially responsible for the sustained weight loss after responsible for the sustained weight loss after surgical procedures that resect and/or bypass a surgical procedures that resect and/or bypass a significant portion of the stomach.significant portion of the stomach.

Medical problems associated with ObesityMedical problems associated with Obesity

1.1. Gastroesophageal refluxGastroesophageal reflux

2. Coronary artery disease2. Coronary artery disease

3. Cerebrovascular accident3. Cerebrovascular accident

4. Congestive heart failure4. Congestive heart failure

5. Hypertension5. Hypertension

6. Dyslipidemia6. Dyslipidemia

7. Cholelithiasis and gallbladder disease7. Cholelithiasis and gallbladder disease

8. Osteoarthritis and degenerative joint disease8. Osteoarthritis and degenerative joint disease

9. Slap apnea9. Slap apnea


Cancer of the:Cancer of the:

1. Esophagus1. Esophagus

2. Stomach2. Stomach

3. Liver3. Liver

4. Pancreas4. Pancreas

5. Kidney5. Kidney

6. Prostate6. Prostate

7. Ovaries7. Ovaries

8. Uterus8. Uterus


Cancer:Cancer:

9. Gallbladder9. Gallbladder

10. Colon10. Colon

Non Hodgkin’s lymphomaNon Hodgkin’s lymphoma

Multiple myelomaMultiple myeloma

Menstrual AbnormalitiesMenstrual Abnormalities

Impaired fertility and increased risk of adverse Impaired fertility and increased risk of adverse outcome after pregnancyoutcome after pregnancy

Stress inccontinenceStress inccontinence

Medical problems associated with Medical problems associated with ObesityObesity

Morbidity from obesity is increased in the Morbidity from obesity is increased in the presence of:presence of:

1. Preexisting coronary artery or peripheral 1. Preexisting coronary artery or peripheral artery disease artery disease

2.Type II diabetes2.Type II diabetes

3. Hypertension3. Hypertension

4. Smoking4. Smoking


Morbidity from obesity is increased in the Morbidity from obesity is increased in the presence of :presence of :

5. Elevated low-density or decreased high-5. Elevated low-density or decreased high-density lipoprotein levelsdensity lipoprotein levels

6. Increased fasting blood sugar concentrations6. Increased fasting blood sugar concentrations

7. Patients with a family history of early-onset 7. Patients with a family history of early-onset heart disease heart disease

Medical problems associated with Obesity Medical problems associated with Obesity

Cardiovascular risks associated w/ significant Cardiovascular risks associated w/ significant obesity.obesity.

1. Overweight women have 50% > risk of heart 1. Overweight women have 50% > risk of heart failure compared to women with normal BMIs. failure compared to women with normal BMIs.

2.The risk is twofold higher in obese females.2.The risk is twofold higher in obese females.

3. Obese men have a 90% greater risk of heart 3. Obese men have a 90% greater risk of heart failure.failure.

4. Overall, approximately 11% of all heart failure 4. Overall, approximately 11% of all heart failure cases in men and 14% in women can be attributed cases in men and 14% in women can be attributed to obesity alone.to obesity alone.

Medical management of ObesityMedical management of Obesity

Medications are classified into: Medications are classified into:

1. Those that 1. Those that decrease food intake decrease food intake by by suppressing appetite or increasing satietysuppressing appetite or increasing satiety

2. Those that 2. Those that decrease nutrient absorptiondecrease nutrient absorption. .


Appetite suppressants are believed to work by Appetite suppressants are believed to work by increasing the availability of increasing the availability of neurotransmitters neurotransmitters which suppress appetite which suppress appetite such as: such as:

1. 1. norepinephrinenorepinephrine

2. 2. serotoninserotonin

33. dopamine. dopamine


SibutramineSibutramine works by inhibiting the uptake of works by inhibiting the uptake of these neurotransmitters. This drug may also these neurotransmitters. This drug may also stimulate thermogenesisstimulate thermogenesis, although this , although this effect is modest and constitutes only 3–5% of effect is modest and constitutes only 3–5% of the average person's resting metabolic rate.the average person's resting metabolic rate.

Randomized controlled trials indicate that the Randomized controlled trials indicate that the average patient will lose approximately 3–4 kg average patient will lose approximately 3–4 kg over 8–52 weeks of treatment. over 8–52 weeks of treatment.


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

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


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

Diet modificationDiet modification, , exerciseexercise, and , and behavioral behavioral modificationsmodifications should be the should be the cornerstonescornerstones of of every treatment plan. every treatment plan.

Guidelines Treatment of Guidelines Treatment of Overweight and Obese PatientsOverweight and Obese Patients

BMI/mKg/m2

Health Risk Risk with comorbidities

Treatment

<25 Minimal Low Healthy eating,exercise & lifestyle changes

25-26.9 Low Moderate

27-29.9 Moderate High All of the above plus low caloric diet

30-34.9 High Very High All of the above plus pharmacotherapy or very low

35-39.9 Very High Extremely High Caloric diet

>40 Extremely High

Extremely High All of the above plus Bariatric Surgery

Surgical management of obesitySurgical management of obesity

Bariatric surgery should be offeredBariatric surgery should be offered

To appropriate patients with BMIs of 40 kg/mTo appropriate patients with BMIs of 40 kg/m22 or greater (or between 35 and 40 kg/mor greater (or between 35 and 40 kg/m22 if any of if any of the previously described significant medical the previously described significant medical comorbidities are present) comorbidities are present)

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


CandidatesCandidates for surgical therapy must be willing for surgical therapy must be willing and able to comply with:and able to comply with:

Postoperative dietary recommendationsPostoperative dietary recommendations

ExerciseExercise

Follow-up requirements Follow-up requirements


PatientsPatients who should who should not undergo bariatric not undergo bariatric surgerysurgery

1. Ongoing drug or alcohol dependency1. Ongoing drug or alcohol dependency

2. Who are unstable or otherwise unfit 2. Who are unstable or otherwise unfit

psychiatricallypsychiatrically

3. Who are unable to undergo general 3. Who are unable to undergo general

anesthesiaanesthesia


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


Surgical treatment is indicated for patients with:Surgical treatment is indicated for patients with:

1. BMIs of 40 kg/m1. BMIs of 40 kg/m22 or greater or greater

2. BMIs of 35–40 kg/m2. BMIs of 35–40 kg/m22 with obesity-related with obesity-related comorbidities comorbidities

3. When medical, nutritional, and behavioral 3. When medical, nutritional, and behavioral therapies are ineffectivetherapies are ineffective


In all instances, the best care for morbidly In all instances, the best care for morbidly obese patients provides unfettered access to, obese patients provides unfettered access to, and evaluation by, a multidisciplinary team and evaluation by, a multidisciplinary team comprised of :comprised of :

1. Nutritionists1. Nutritionists

2. Physical or exercise therapists2. Physical or exercise therapists

3. Surgeons3. Surgeons

4. Medical specialists4. Medical specialists

5. Psychiatrists.5. Psychiatrists.

Criteria for Surgical Treatment of ObesityCriteria for Surgical Treatment of Obesity

1.1. BMI >40 or BMI between 35 and 40 in BMI >40 or BMI between 35 and 40 in

individuals with high-risk comorbid or individuals with high-risk comorbid or

severe lifestyle limitations for greater severe lifestyle limitations for greater

than 5 yearsthan 5 years

2. Absence of secondary cause of morbid 2. Absence of secondary cause of morbid

obesityobesity

3. Ability and willingness to cooperate with 3. Ability and willingness to cooperate with

long-term follow-uplong-term follow-up

4. Acceptable operative risk4. Acceptable operative risk

Criteria for Surgical Treatment of ObesityCriteria for Surgical Treatment of Obesity

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

Preoperative PreparationPreoperative Preparation

Nutritional evaluation and education are Nutritional evaluation and education are critically important components of critically important components of preoperative preparation.preoperative preparation.

Psychiatric evaluation helps some Psychiatric evaluation helps some patients cope more effectively with various patients cope more effectively with various stressors that may surface in their stressors that may surface in their interpersonal relationships after surgery.interpersonal relationships after surgery.


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


1. All patients should have an electrocardiogram 1. All patients should have an electrocardiogram

performed preoperatively. performed preoperatively.

2. Stress testing & even cardiac catheterization 2. Stress testing & even cardiac catheterization

may be indicated for intermediate- or high- may be indicated for intermediate- or high-

risk patients.risk patients.

3. Polysomnographic evaluation at a sleep 3. Polysomnographic evaluation at a sleep

center for all morbidly obese patients who center for all morbidly obese patients who

are being evaluated for surgical treatment.are being evaluated for surgical treatment.


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


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


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


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


8. Preoperative laboratory evaluation typically 8. Preoperative laboratory evaluation typically includeinclude

a. Hemoglobina. Hemoglobin

b. Hematocritb. Hematocrit

c.Platelet count measurements c.Platelet count measurements

d. Assessment of electrolyte levelsd. Assessment of electrolyte levels

e. BUNe. BUN

f. Creatine .f. Creatine .


8. Preoperative laboratory evaluation typically include8. Preoperative laboratory evaluation typically include

g. Blood glucoseg. Blood glucose

h. Liver functionh. Liver function

i. Pap smears i. Pap smears

j. Pregnancy testing performed routinely.j. Pregnancy testing performed routinely.

K. Hemoglobin AK. Hemoglobin A1c1c

l. Posteroanterior and lateral radiographs of the l. Posteroanterior and lateral radiographs of the chest evaluated routinely.chest evaluated routinely.


9. Obesity likely increases the risk of 9. Obesity likely increases the risk of

postoperative wound infections. Antibiotic postoperative wound infections. Antibiotic

prophylaxis is indicated according to the: prophylaxis is indicated according to the:

a. Likelihood of wound contamination a. Likelihood of wound contamination

b. The type of procedure planned. b. The type of procedure planned.

Rate of wound infection after laparoscopic Rate of wound infection after laparoscopic

gastric bypass appears reduced by 75% gastric bypass appears reduced by 75%

compared with open gastric bypass surgery.compared with open gastric bypass surgery.

Historical Perspective and Historical Perspective and OverviewOverview

A useful paradigm is to categorize bariatric A useful paradigm is to categorize bariatric procedures as: procedures as:

1. Restrictive1. Restrictive

2. Malabsorptive2. Malabsorptive

3. Combination of both3. Combination of both

Historical Perspective and Historical Perspective and OverviewOverview

The rationale for the surgical treatment of The rationale for the surgical treatment of obesity has been based on three fundamental obesity has been based on three fundamental goals:goals:

1. Reducing 1. Reducing caloric absorption caloric absorption by bypassing by bypassing

portions of the stomach and small bowelportions of the stomach and small bowel

2. Reducing 2. Reducing gastric capacitygastric capacity via banding, via banding,

stapling, or transectionstapling, or transection

3. Performing operations that 3. Performing operations that induce induce

malabsorptionmalabsorption and and restrict food intakerestrict food intake..

Major Types of Bariatric Surgical Major Types of Bariatric Surgical ProceduresProcedures



Major Types of Bariatric Surgical Major Types of Bariatric Surgical ProceduresProcedures

3. Mostly restrictive3. Mostly restrictive

4. Mostly malabsorptive4. Mostly malabsorptive

. . Major Types of Bariatric Surgical Major Types of Bariatric Surgical ProceduresProcedures


Jejunoileal and jejunocolic bypasses (no Jejunoileal and jejunocolic bypasses (no longer recommendedlonger recommended


(1) Vertical banded gastroplasty(1) Vertical banded gastroplasty

(2) Adjustable silicone gastric banding(2) Adjustable silicone gastric banding

. . Major Types of Bariatric Surgical Major Types of Bariatric Surgical ProceduresProcedures

3. Mostly restrictive3. Mostly restrictive

(1) Short-limb (50–100 cm) Roux-en-Y (1) Short-limb (50–100 cm) Roux-en-Y

gastric bypassgastric bypass

(2) Long-limb (150 cm) Roux-en-Y gastric (2) Long-limb (150 cm) Roux-en-Y gastric

bypassbypass

4. Mostly malabsorptive4. Mostly malabsorptive

Biliopancreatic diversion with or without Biliopancreatic diversion with or without

duodenal switchduodenal switch

Vertical Banded gastroplastyVertical Banded gastroplasty

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


TechniquesTechniques Used in Used in VBCVBC

1. Mason first described the vertical banded 1. Mason first described the vertical banded

Gastroplasty in 1982Gastroplasty in 1982

2. Ewald tube is passed through the mouth and 2. Ewald tube is passed through the mouth and into the stomach to facilitate isolation of the into the stomach to facilitate isolation of the esophagus, and later facilitates pouch volume esophagus, and later facilitates pouch volume measurement and calibration of the stoma.measurement and calibration of the stoma.

3.The esophagus is encircled w/ a Penrose drain. 3.The esophagus is encircled w/ a Penrose drain.

4. The lesser omentum is opened 4. The lesser omentum is opened


Techniques Techniques Used in Used in VBCVBC

5. 27F thoracostomy tube is passed from this 5. 27F thoracostomy tube is passed from this opening behind the stomach and up to the opening behind the stomach and up to the angle of His through the gastrophrenic ligamentangle of His through the gastrophrenic ligament

6. An anvil for a circular stapler is held in the 6. An anvil for a circular stapler is held in the lesser sac against the posterior stomach wall. lesser sac against the posterior stomach wall.

7. A trocar is pushed through both walls of the 7. A trocar is pushed through both walls of the stomach at a point about 8 to 9 cm below the stomach at a point about 8 to 9 cm below the angle of His and into the anvilangle of His and into the anvil



8. A 2.5-cm window is created through the8. A 2.5-cm window is created through the

proximal stomach, firing a circular stapler w/ proximal stomach, firing a circular stapler w/

Ewald tube pressed against lesser curvature.Ewald tube pressed against lesser curvature.

9. A line of four rows of 90-mm staples leads 9. A line of four rows of 90-mm staples leads from the circular opening to the angle of His to from the circular opening to the angle of His to create a pouch 50 mL in size or smaller. create a pouch 50 mL in size or smaller.



10. Pouch volume is measured by instilling 10. Pouch volume is measured by instilling

saline into Ewald tube. Some surgeons use saline into Ewald tube. Some surgeons use

a linear cutting stapler to create the pouch. a linear cutting stapler to create the pouch.

11. A strip of polypropylene mesh measuring 7 11. A strip of polypropylene mesh measuring 7

by 1.5 cm is placed around the lesser by 1.5 cm is placed around the lesser

curvature channel and is sewn to itself to curvature channel and is sewn to itself to

create a 5.0 to 5.5 cm collar circumference.create a 5.0 to 5.5 cm collar circumference.



The laparoscopic technique The laparoscopic technique follows the same follows the same principles.principles.

1.1. Using a five-trocar technique, the abdomen isUsing a five-trocar technique, the abdomen is

entered and the left hepatic lobe is retracted entered and the left hepatic lobe is retracted

anteriorly.anteriorly.

2. The peritoneal reflection lateral to the angle of 2. The peritoneal reflection lateral to the angle of His is incised. His is incised.

3. The gastrohepatic omentum is incised and the 3. The gastrohepatic omentum is incised and the lesser sac is entered. lesser sac is entered.



The laparoscopic technique The laparoscopic technique follows the same follows the same principles. principles.

4. A 25-mm circular stapler is used to create a 4. A 25-mm circular stapler is used to create a window through the stomach, 4 cm below the window through the stomach, 4 cm below the angle of His, near the lesser curvature of the angle of His, near the lesser curvature of the stomach.stomach.

5. A 60-mm linear stapler is inserted into this 5. A 60-mm linear stapler is inserted into this opening and is fired along a 9-mm esophageal opening and is fired along a 9-mm esophageal bougie to create a divided staple line leading to bougie to create a divided staple line leading to the angle of His. the angle of His.



The laparoscopic technique The laparoscopic technique follows the same follows the same principles. principles.

6. A 5-cm band of polypropylene mesh is sutured 6. A 5-cm band of polypropylene mesh is sutured around the gastric pouch. around the gastric pouch.

Another technique involves linear cutting stapler Another technique involves linear cutting stapler to excise a wedge of fundus, creating a 20-mL to excise a wedge of fundus, creating a 20-mL

pouch w/o pouch w/o use of circular stapleruse of circular stapler. A polypropylene. A polypropylene mesh or polytetrafluoroethylene band is sutured mesh or polytetrafluoroethylene band is sutured around distal end of gastroplasty around distal end of gastroplasty

Vertical Banded Vertical Banded gastroplastygastroplasty

Efficacy of VBGEfficacy of VBG

VBC achieve acceptable weight loss resultsVBC achieve acceptable weight loss results

Series of 305 patients followed for 2 years- Series of 305 patients followed for 2 years- mean excess loss of 61%mean excess loss of 61%

Series of 250 patients followed for 5 years- Series of 250 patients followed for 5 years- Mean excess wt. loss 60% for Morbidly obeseMean excess wt. loss 60% for Morbidly obese

Mean excess wt. loss 52% for super obeseMean excess wt. loss 52% for super obese

A significant number of patients have required a A significant number of patients have required a reoperation following VBGreoperation following VBG


ComplicationsComplications

Over all morbidity rate of VBG- under 10%Over all morbidity rate of VBG- under 10%

mortality rate of 0- 38%mortality rate of 0- 38%

Early ComplicationsEarly Complications

Splenectomy 3%Splenectomy 3%

Peritonitis from leak 6%Peritonitis from leak 6%



Late ComplicationsLate Complications

1. Stoma stenosis1. Stoma stenosis

2. Staple line dehiscence 48%2. Staple line dehiscence 48%

3. Reflux Esophagitis3. Reflux Esophagitis

4. Intractable vomiting 30-50%4. Intractable vomiting 30-50%


AdvantagesAdvantages

1. Significant improvement in comorbidities like 1. Significant improvement in comorbidities like

dyspnea, hypertension, diabetes mellitus, dyspnea, hypertension, diabetes mellitus,

quality of lifequality of life

2. Minimal long term metabolic or nutritional 2. Minimal long term metabolic or nutritional

deficiencydeficiency

3. Less operating time3. Less operating time

4. No anastomosis required4. No anastomosis required


DisadvantagesDisadvantages

Long term weight loss is less successful when:Long term weight loss is less successful when:

1. Patient eat sweet food1. Patient eat sweet food

2. In high liquid caloric intake2. In high liquid caloric intake

3. Less effective in terms of weight loss as 3. Less effective in terms of weight loss as

compared to gastric bypasscompared to gastric bypass

Laparoscopic Gastric bandingLaparoscopic Gastric banding

Mechanism of ActionMechanism of Action

Use of Silicone bandUse of Silicone band

Restricts amount of ingested solid foodRestricts amount of ingested solid food

Adjustable nature of the bandAdjustable nature of the band

Adjustable gastric bandAdjustable gastric band

Efficacy of lGbEfficacy of lGb

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



Intraoperative ComplicationsIntraoperative Complications

1. Splenic injury 0 to 1 %1. Splenic injury 0 to 1 %

2. Esophageal injury 0 to 1%2. Esophageal injury 0 to 1%

3. Gastric injury 0 to 1%3. Gastric injury 0 to 1%

4. Conversion to open procedure 1 to 2 %4. Conversion to open procedure 1 to 2 %

5. Bleeding 0 to 1%5. Bleeding 0 to 1%



Early postoperative ComplicationsEarly postoperative Complications

1. Bleeding 0.5 %1. Bleeding 0.5 %

2. Wound infection 0 to 1%2. Wound infection 0 to 1%

3. Food intolerance 0 to 11%3. Food intolerance 0 to 11%



Late ComplicationsLate Complications

1. Slippage of Band 7- 21%1. Slippage of Band 7- 21%

2. Band Erosion 2 to 7.5%2. Band Erosion 2 to 7.5%

3. Leakage of reservoir3. Leakage of reservoir

4. Persistent vomiting4. Persistent vomiting



1. Simple procedure and less operative time1. Simple procedure and less operative time

2. Mortality is low 0.06%2. Mortality is low 0.06%

3. No staple liner or anastomosis3. No staple liner or anastomosis

4. Recovery is rapid and hospital stay is short4. Recovery is rapid and hospital stay is short


DisadvantagesDisadvantages

Potential for site complicaton Potential for site complicaton

Need for frequent Need for frequent

postoperative visit for postoperative visit for

gastric band adjustmentgastric band adjustment

Open roux en y gastric bypassOpen roux en y gastric bypass

Mechanism of actionMechanism of action

Both a gastric restrictiveBoth a gastric restrictive

andand

Mildly malabsorptive procedureMildly malabsorptive procedure

Roux en y gastric bypassRoux en y gastric bypass


1. Weight loss from gastric bypass is superior 1. Weight loss from gastric bypass is superior

than purely restrictive proceduresthan purely restrictive procedures. .

22. . Five year weight loss was 48 -74 % loss ofFive year weight loss was 48 -74 % loss of

excess weight.excess weight.

3. RYGB- to prevent the progression of non 3. RYGB- to prevent the progression of non

insulin dependent Diabetes Mellitus, reduceinsulin dependent Diabetes Mellitus, reduce

the mortality from Diabetes Mellitus andthe mortality from Diabetes Mellitus and

Cardiovascular disease.Cardiovascular disease.


Early ComplicationsEarly Complications

1. ANASTOMOTIC LEAK with 1. ANASTOMOTIC LEAK with

peritonitis - 1.2%peritonitis - 1.2%

2. 2. Acute distal gastric dilatationAcute distal gastric dilatation

3. Severe wound infection3. Severe wound infection


late Complicationslate Complications

1. Stomach stenosis 1. Stomach stenosis 15% 15%

2. Marginal Ulcer 13%2. Marginal Ulcer 13%

3. Intestinal Obstruction3. Intestinal Obstruction

4. Internal Hernia4. Internal Hernia

5. Staple line destruction5. Staple line destruction

6. Incisional Hernia6. Incisional Hernia


late Complicationslate Complications

7. Metabolic Complications7. Metabolic Complications

a. Deficiencies of: a. Deficiencies of:

Calcium, thiamine, Vit B12 30-70%Calcium, thiamine, Vit B12 30-70%

Folate 9- 18%Folate 9- 18%

Iron 20-49%Iron 20-49%

b. Anemia 18-35%b. Anemia 18-35%



1. RYGB is more effective than vertical bonded1. RYGB is more effective than vertical bonded

gastroplastygastroplasty

2. Presence of dumping syndrome encourages 2. Presence of dumping syndrome encourages

patient to avoid sweet foodpatient to avoid sweet food


disAdvantagesdisAdvantages

1. Dumping syndrome in a lot of patients 1. Dumping syndrome in a lot of patients

a. Due to rapid emptying hyperosmolar bolusesa. Due to rapid emptying hyperosmolar boluses

in small intestinesin small intestines

b. Bloating, nausea, vomiting, diarrhea andb. Bloating, nausea, vomiting, diarrhea and

abdominal pain after intake of milk andabdominal pain after intake of milk and

sweet productssweet products


disAdvantagesdisAdvantages

c. Vasomotor symptoms like palpitation, c. Vasomotor symptoms like palpitation,

diaphoresis and lightheadednessdiaphoresis and lightheadedness

2. Distal gastric distention – hiccups and left2. Distal gastric distention – hiccups and left

shoulder painshoulder pain

3. Internal hernia3. Internal hernia

Laparoscopic roux en y gastric bypassLaparoscopic roux en y gastric bypass

Mechanism of actionMechanism of action

1. Both gastric restrictive & mildly malabsortive1. Both gastric restrictive & mildly malabsortive

procedureprocedure

2. Small gastric pouch restricts gastric intake2. Small gastric pouch restricts gastric intake

while the Roux Y configuration provideswhile the Roux Y configuration provides

malabsorpton of calories and nutrientsmalabsorpton of calories and nutrients


EfficacyEfficacy

1. After 24 months follow up mean excess1. After 24 months follow up mean excess

weight loss ranges from 69- 82%weight loss ranges from 69- 82%

2. Most comorbidities were improved and 2. Most comorbidities were improved and

eradicatederadicated


complicationscomplications

1. Pulmonary embolism 0- 1.5%1. Pulmonary embolism 0- 1.5%

2. Anastomotic leak 1.5- 5.8%2. Anastomotic leak 1.5- 5.8%

3. Bleeding 0- 3.3%3. Bleeding 0- 3.3%

4. Stenosis of gastroepinoctomy 1.6- 6.3%4. Stenosis of gastroepinoctomy 1.6- 6.3%

5. Internal Hernia 2.5%5. Internal Hernia 2.5%

6. Marginal Ulcer 1.4%6. Marginal Ulcer 1.4%

7. Gallstone 1.4%7. Gallstone 1.4%


advantagesadvantages

1. Better cosmesis1. Better cosmesis

2. Less postoperative pain2. Less postoperative pain

3. Attenuation of postoperative stress response3. Attenuation of postoperative stress response

4. Reduce wound infection, dehiscence4. Reduce wound infection, dehiscence

5. Incisional Hernia 5. Incisional Hernia

6. Improvement of postoperative pulmonary6. Improvement of postoperative pulmonary

functionfunction


disadvantagesdisadvantages

1. Technically challenging, advance laparoscopy1. Technically challenging, advance laparoscopy

of steep learning curveof steep learning curve

2. Approach may be difficult in super obese2. Approach may be difficult in super obese

patientspatients

biliopancreatic diversion with biliopancreatic diversion with duodenal switchduodenal switch

Bilio pancreatic proceduresBilio pancreatic procedures

Mechanism of ActionMechanism of Action

1. The BPD is a procedure developed by Nicola 1. The BPD is a procedure developed by Nicola

Scopinaro of Italy. Scopinaro of Italy.

2. The procedure combines gastric restriction 2. The procedure combines gastric restriction

with an intestinal malabsorptive procedure. with an intestinal malabsorptive procedure.

3. A 50- to 100-cm common absorptive 3. A 50- to 100-cm common absorptive

alimentary channel is created proximal to the alimentary channel is created proximal to the

ileocecal valve; digestion and absorption are ileocecal valve; digestion and absorption are

limited to this segment of bowellimited to this segment of bowel


IndicationsIndications

1.This procedure is primarily indicated for the 1.This procedure is primarily indicated for the

superobese superobese

2.Those who have failed restrictive bariatric 2.Those who have failed restrictive bariatric

procedures.procedures.

3. Less commonly, some surgeons perform BPD 3. Less commonly, some surgeons perform BPD

as primary operation in the non-superobese.as primary operation in the non-superobese.


contraindicationscontraindications

1. Patients with anemia, hypocalcemia and1. Patients with anemia, hypocalcemia and

osteoporosisosteoporosis

2. Those who cannot comply with the strigent2. Those who cannot comply with the strigent

supplementation regimensupplementation regimen


EfficacyEfficacy

1. Excellent and durable result1. Excellent and durable result

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

Bilio pancreatic proceduresBilio pancreatic procedures TechniqueTechnique

1.1.A subtotal gastrectomy is performed, leaving a A subtotal gastrectomy is performed, leaving a

proximal 200-mL gastric pouch for patient whoproximal 200-mL gastric pouch for patient who

are superobese, or 400-mL pouch for others. are superobese, or 400-mL pouch for others.

2.A Roux-en-Y anastomosis is created 50 to 2.A Roux-en-Y anastomosis is created 50 to 100 100

cm proximal to the ileocecal valvecm proximal to the ileocecal valve

degree of malabsorptiondegree of malabsorption


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

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


A modification of this technique with a duodenal A modification of this technique with a duodenal switch involvesswitch involves

1. A greater curvature sleeve gastrectomy1. A greater curvature sleeve gastrectomy

2. With maintenance of the continuity of the 2. With maintenance of the continuity of the antrum, pylorus, and first portion of the antrum, pylorus, and first portion of the duodenum. This allows for a lower marginal duodenum. This allows for a lower marginal ulcer rate (0 to 1%) and a lower incidence of ulcer rate (0 to 1%) and a lower incidence of dumping syndromedumping syndrome


laparoscopic approachlaparoscopic approach

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

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


3. 3. This allows for a lower marginal ulcer rate (0 This allows for a lower marginal ulcer rate (0 to 1%), and a lower incidence of dumping to 1%), and a lower incidence of dumping syndrome because the pylorus is preservedsyndrome because the pylorus is preserved

4.The ileum is divided 250 cm proximal to the 4.The ileum is divided 250 cm proximal to the ileocecal valve and is anastomosed to the ileocecal valve and is anastomosed to the stomach.stomach.

5. A Roux-en-Y anastomosis is created, leaving 5. A Roux-en-Y anastomosis is created, leaving a common channel 100 cm long a common channel 100 cm long


complications complications

1. Anemia 30%1. Anemia 30%

2. Protein Calorie Malnutrition 30%2. Protein Calorie Malnutrition 30%

3. Dumping syndrome3. Dumping syndrome

4. Marginal Ulcer4. Marginal Ulcer

5. Vit B 12 deficiency5. Vit B 12 deficiency

6. Hypocalcemia6. Hypocalcemia

7. Osteoporosis7. Osteoporosis

8. Night blindness8. Night blindness


complications complications

9. Prolongation of prothrombin time9. Prolongation of prothrombin time

10. Early Surgical Complication10. Early Surgical Complication

Wound infectionWound infection

Wound dehiscence 1.2 %Wound dehiscence 1.2 %


Late complications Late complications

1. Intestinal Obstruction- 0.2%1. Intestinal Obstruction- 0.2%

2. Protein Malnutrition- 7%2. Protein Malnutrition- 7%

3. Iron deficiency anemia- 1.2%3. Iron deficiency anemia- 1.2%

4. Stomas Ulcer- 2.8%4. Stomas Ulcer- 2.8%

5. Mortality- 2.5%5. Mortality- 2.5%

6. Morbidity-15%6. Morbidity-15%



1.1. Even if patients consume a great quantity of Even if patients consume a great quantity of food, the malabsorptive component of the BPD food, the malabsorptive component of the BPD allows excellent results in terms of weight loss. allows excellent results in terms of weight loss.

2.2. This operation may be more effective than This operation may be more effective than gastric bypass or restrictive surgery in patients gastric bypass or restrictive surgery in patients with severe morbid obesity (e.g., BMI greater with severe morbid obesity (e.g., BMI greater than 70 kg/m 2 ), or in those who have failed to than 70 kg/m 2 ), or in those who have failed to maintain weight loss following gastric bypass or maintain weight loss following gastric bypass or restrictive bariatric surgery.restrictive bariatric surgery.



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



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


DisAdvantagesDisAdvantages

1.The BPD is technically a more complex 1.The BPD is technically a more complex procedure than the restrictive procedures. procedure than the restrictive procedures. Protein malnutrition withProtein malnutrition with

a. anemiaa. anemia

b. hypoalbuminemiab. hypoalbuminemia

c. edemac. edema

d. alopecia d. alopecia

are among the serious adverse sequelae are among the serious adverse sequelae



2. Severe vitamin deficiencies may occur, leading 2. Severe vitamin deficiencies may occur, leading to osteoporosis and night-blindness. to osteoporosis and night-blindness.

3. Treatment requires prolonged 3. Treatment requires prolonged hyperalimentation and supplementation.hyperalimentation and supplementation.

4.Patients have four to six foul-smelling stools per 4.Patients have four to six foul-smelling stools per day, reflecting the fat malabsorption from this day, reflecting the fat malabsorption from this procedure.procedure.

5. Patients may also experience bloating and 5. Patients may also experience bloating and heartburn following this procedure. heartburn following this procedure.



. Replacement of fat-soluble vitamins is needed . Replacement of fat-soluble vitamins is needed for patients following BPD or BPD-DS.for patients following BPD or BPD-DS.

The The laparoscopic approach laparoscopic approach may be may be especially challenging in patients:especially challenging in patients:

1.1. With multiple previous abdominal surgeriesWith multiple previous abdominal surgeries

2.2. Previous weight loss surgery Previous weight loss surgery

3.3. With an enlarged fatty liverWith an enlarged fatty liver

4.4. With a large amount of intra-abdominal fat. With a large amount of intra-abdominal fat.



The laparoscopic BPD is a technically The laparoscopic BPD is a technically demanding, lengthy laparoscopic procedure, demanding, lengthy laparoscopic procedure, with potential for nutritional sequelae similar to with potential for nutritional sequelae similar to open BPD. Patients may experience open BPD. Patients may experience

1. Abdominal bloating1. Abdominal bloating

2. Malodorous stools2. Malodorous stools

3. Heartburn3. Heartburn

4. Abdominal pain. .4. Abdominal pain. .



5. Protein malnutrition with: 5. Protein malnutrition with:

a. Anemiaa. Anemia

b. Hypoalbuminemiab. Hypoalbuminemia

c. Edemac. Edema

d. Alopecia d. Alopecia

are potential postoperative sequelae. Severe are potential postoperative sequelae. Severe vitamin deficiencies may be observed. vitamin deficiencies may be observed.


TreatmentTreatment requires requires

1. Prolonged hyperalimentation 1. Prolonged hyperalimentation

2. Possibly reoperation to lengthen the common 2. Possibly reoperation to lengthen the common channel.channel.

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Health & Medicine

The Management Of Obesity