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Surgical Managemen
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Obesity Refrence :
Schwartzs Principles of Surgery 10th ed Page 1099
Presented by Dr Sadatinejad, Seyyed Mohsen,student of Medicine
from Iran,Kashan 29/1/2017
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DISEASE OF OBESITY - the second leading cause of preventable death in the United States
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Epidemiology-2013 : obesity prevalence in the United States = 35.7% of U.S. adults (class 1 or higher)-Genetic
- parents of normal weight :10% chance of obese child (in adulthood)
- two obese parents :80-90% chance of obese child (in adulthood)
-Environment : Diet and culture- lack of satiety + excessive caloric intake-reduced metabolic activity-reduced thermogenic response to meals-intraluminal bacterial composition of the intestinal tract-.
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Concurrent Medical and Social Problem
Social : NO Public facilities : size of bus or airline seats/ clothing /size of automobile cabins
thought being lazy and lacking self-discipline by others stigma of severe obesity Depression Poor self-image
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Concurrent Medical and Social Problem
Medical :
DJD
low back pain
Hypertension
obstructive sleep apnea
GERD
Cholelithiasis
diabetes II
Hyperlipidemia
Asthma
cardiac arrhythmias
right-sided heart failure
migraine headaches
pseudotumor cerebri
venous stasis ulcers
DVT
fungal skin rashes
skin abscesses
stress urinary incontinence
infertility
.
dysmenorrhea
depression
abdominal wall hernias
cancers :
Uterus
Breast
Colon
Prostate
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Prognosis estimate : a severely obese male at age 21 will live 12 years less and a woman 9 years less than a nonobese individual
The incidence of severe obesity ◦ for men, it is decreased above age 50◦ This is due to the fact that the severely obese man often is
dead of comorbid medical conditions, especially cardiac arrhythmias and coronary artery disease, by age 50.
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Medical Management Life Style (diet + exercise + behavior modification) The success rate for the severely obese patient is only 3%.
(success = to no longer be obese and maintaining that weight loss)
Rx Orlistat, Qsymia, Lorcaserin
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Surgical Management (Bariatric Surgery)
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Surgical Management (Bariatric Surgery)
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Surgical Management (Bariatric Surgery)
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laparoscopic Adjustable gastric Banding
LAGB involves placement of an inflatable silicone band around the proximal stomach
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laparoscopic Adjustable gastric Banding
outcome
5 and 7 years after LAGB, patients lost 60% and 58% of excess weight
Hypertension resolving in 55% at 1 year
Sleep apnea decreasing from 33% to 2%
GERD improving in over 50% of cases
Asthma,depression,and quality of life improving
Resolution of diabetes was 13% in the medical group versus 73% in the surgical group after a 2-year follow-up
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Roux-en-Y gastric Bypassa proximal gastric pouch of small size (often <20 mL) separated from the distal stomach.
A Roux limb of proximal jejunum is anastomosed to the pouch.
Biliopancreatic limb :20-50 cm
Roux limb :75 to 150 cm
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The pathway of that limb
Roux-en-Y gastric Bypass
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Relative contraindications previous gastric surgery
previous antireflux surgery
severe iron deficiency anemia
distal gastric or duodenal lesions that require ongoing future endoscopy
Barrett’s esophagus with severe dysplasia.
Roux-en-Y gastric Bypass
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Outcome Weight Loss : 60%-70% of excess body weight / during 1 years
GERD and venous stasis ulcers : Resolution over 90%
Diabetes II : Resolution over 80% / during 5 years
Hyperlipidemias : improve 100% and resolve totally in 70%.
Hypertension : resolves in 50-65% of cases
Roux-en-Y gastric Bypass
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Complications 0.3% incidence of anastomotic leak
1-19% incidence of anastomotic stenosis
3-15% incidence of marginal ulcers
7% incidence of bowel obstruction
Postoperative nutritional complications after LRYGB
66% incidence of iron deficiency
5% incidence of iron deficiency anemia
50% incidence of vitamin B12 deficiency
15% incidence of vitamin D deficiency
Roux-en-Y gastric Bypass
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Biliopancreatic Diversion with Duodenal Switch (BPD-DS)
A part of the stomach is removed
the surgeon leaves the pylorus intact
then connect it to the ileum (distal 250 cm)
Duodenal Switch
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Weight loss : 70% and very durable
complication :
obstruction 1.2%
marginal ulcer 2.8%
Nutritional complication
protein malnutrition 7%
iron deficiency anemia <5%
bone demineralization (5 years) 53%
Alopecia, night blindness, gallstones
Duodenal Switch
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Patient must accept frequent, voluminous bowel movements
Pateint must modify their eating pattern to restrict intake if not access to a bathroom
Contraindications :
patient must agree to close follow-up by the surgeon
Patients must have the financial affordability for the
large number of supplements
Duodenal Switch
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Sleeve gastrectomyThis procedure (SG) represents the gastric portion of the DS procedure
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Sleeve gastrectomyoutcome:
SG is superior to LAGB for excess weight loss at 3 years (66% vs. 48%)
SG have greater appetite suppression and a lower serum ghrelin level
Complication :
bleeding rate of the staple line
staple line leakage
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Thank you for tour attention