Obesity and

Bariatric Surgery

Dr. Sanjiv HaribhaktiMS,DNB,MCh(G.I surgery)

Chairman

Kaizen Hospital, Ahmedabad

What is Obesity?

Multifactorial disease of excess fat storage with a genetic

basis

Influenced by the environment

Lifelong and progressive

Associated with multiple serious medical problems

Why everyone talks about obesity?

Increasing incidence

Increasing awareness

Improving understanding of the disease path

physiology and course

Introduction of laparoscopic surgery

Good long term results

India 2015 !!

Patient Awareness

Health consciousness

Knowledge of complications

access to internet , reading

Availability of less painful, laparoscopic surgery , with

speedy recovery

How to Decide , Define?

BMI , universal assessment tool

Assesment of obesity

Determined by using weight and height to calculate a number called the “body mass index” (BMI)

BMI = Body weight(kg)---------------------

Height(m2)

overweight

BMI - 25 to 30

obese

BMI - 30 - 40

Morbidly Obese

BMI > 40

Assesment

Risk factors of obesity

Obesity itself is a disease

The health risks of obesity

FRIENDS TOGETHER

Metabolic Syndrome Syndrome X

Abdominal obesity

D M Type II

Dyslipidemia

Hypertension

Type 2 diabetes

Gaining as little as 4-5 kg doubles your chance of developing type 2 diabetes

More than 80% of people with diabetes are classified as overweight or obese

High blood pressure

High blood

pressure is twice

as common in

obese adults

High cholesterol

Overweight people often

have too much

cholesterol in their

blood.

High cholesterol is linked

to angina (a type of chest

pain), heart disease, heart

attack, and stroke

Arthritis

Your risk of arthritis

increases by 9 - 13% for

every 1 kg of weight that

you gain

Breathing problems

Asthma and obstructive

sleep apnea are more

common in obese people.

Mechanical and

inflammatory reasons

Cancer

Obesity may increase the risk of endometrial, breast, prostate, kidney, esophageal, and colon cancers

Women who gain more than 8 kg between the age of 18 and midlife have double the risk of developing breast cancer after menopause

Gallbladder stones

Excess Weight increase

the chances of getting

Gall bladder stones

Gastrointestinal Tract

GERD

Nonalcoholic fatty liver diseases from steatosis ,

fibrosis to cirrhosis –30 to 100% in obese patients

Pregnancy

complications

Infertility

Obesity increases the risk of diabetes during pregnancy,

delivery complications, and birth defects

Obese women have 10 times the risk of high blood

pressure during pregnancy

Prevalence of Significant Morbidities

per Weight

Mokdad AH, et al. JAMA 2003;289:76.Centers for Disease Control, National Center for Health Statistics, National Health and Nutrition Examination Survey* Increase in mortality rate from cancers of all kinds compared to lowest risk group (BMI 25-30). From: Call EE, et al.Overweight, obesity and mortality from cancer in a prospectively studies cohort of US adults. New Engl J Med 2003;348:1625.

4%

10%

18%16%

3%7%

10%

24%28%

0%

15% 14%

32%

41%

15%

26%23%

44%

51% 52%

0%

10%

20%

30%

40%

50%

60%

Diabetes Asthma Arthritis High Blood Pressure

Cancer*

BMI < 25 25 - 30 30 - 40 BMI > 40

Traditional Weight

Loss Therapies

Diet

Exercise

Lifestyle Habits

Key to success

Assesment of obesity

Target with timeline

Comittemnt

Consistency

Under proper guidence

Regular reassesment

??? Difficult

Is there a better option?

Yes ,

Better

Proven

Consistent

Minimal invasive

Surgery for

Weight Loss

Current Bariatric Surgical Procedures

Restrictive

◦ Sleeve Gastrectomy

◦ Laparoscopic Adjustable Gastric Banding

Malabsorptive

◦ Duodenal Switch / Biliopancreatic Diversion

Restrictive and Malabsorptive

◦ Roux-en-Y Gastric Bypass

Who is a candidate for

surgery?

Who Need surgery ?

Age 18 to 60 years

Patients have a Body Mass Index >40 kg/m2

Patients have a Body Mass Index between

35 and 40 kg/m2 with significant risk factors

Patients have failed other medically managed weight-loss

programs

Who don’t need surgery ?

Obesity related to a metabolic or endocrine disorder

History of substance abuse or untreated major psychiatric

disease

Women who want to become pregnant within the next 18

months

Active cancer

Advanced liver disease with PHT

Severe OSA with Pulmonary hypertension

Adjustable Gastric Banding

Laparoscopic

Mean excess weight loss at 1 year

of 42%1

Requires implanted medical device

Lowest rate of complications

1. Buchwald, H. et al., JAMA. 2004; 292:1724-37.

Vertical Sleeve Gastrectomy

Laparoscopic

Mean excess weight loss at

1 year of 60%2

No implanted medical

device

1. ASMBS, Position Statement on Sleeve Gastrectomy as a Bariatric Procedure. June 17, 2007.2. Lee CM, et al. Surg Endosc (2007) 21: 1810–1816

BMI – 61.7 kg/m2

Gastric-Bypass

Started in 1994

Long-term sustained weight loss

65 to 70 % of EWL

No protein-calorie malabsorption

Little vitamin or mineral deficiencies

Technically difficult procedure

A Combination Approach is Most Common

Laparoscopic

Most frequently performed bariatric procedure

Mean excess weight loss at 1 year of 70 %

No implanted medical device

Low rate of complications

Roux-en-Y Gastric Bypass

Resolution of Comorbidities

% Improved % Resolved

Diabetes 18 82

Hypertension 18 70

Osteoarthritis 47 41

High Cholesterol 33 63

Reflux Disease 24 72

Breathing Problems at night 19 74

Asthma 69 13

Average 35.1% 55.7%

90.8%Improved or Resolved

Deaths per 100 People with

Morbid Obesity and Heart Disease

Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality, Morbidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery 2004;240(3):416-424.

Dzavik V, Ghali WA, Norris C, et al. Long-Term Survival in 11,661 Patients with Multivessel Coronary Artery Disease in the Era of Stenting: a Report from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators. American Heart Journal 2001;142(1):119-126.

Success Rate of Weight Loss Treatments for

Morbid Obesity

Eliosoff 1997; Sjostrom NEJM 2004, Obrien J Laparoendosc Adv Surg Tech A. 2003 Aug;13(4):265-70.

TreatmentAverage Weight Loss (%

Total)% Excess Weight Loss at

Five Years

Placebo 4–6% 0%

Diet / Behavior Modification 8–12%1.6%

(10 Years)

Drug Therapy < 10% 10%

Gastric Bypass Surgery 65–85% Up to 100%

Laparoscopic Adjustable Gastric Banding

45–50% 56%

Sleeve Gastrectomy 50-60% 65%

Only surgery has proven effective over the long

term for most patients with clinically severe

obesity

Myth – surgery for weight loss is new & experimental

Open surgery ~ 50 years

Laparoscopic surgery

~ 15 years

Proven results of > 10 years of Lap. Weight

Loss Surgery

Myth - surgery for weight loss means

liposuction

Surgery Will Not Work Alone…

Commitment to Diet & Exercise

KAIZEN OBESITY CLINIC

Every Friday 4 p.m. to 6 p.m.

Multidisciplinary consultation

Obesity surgery Counseling

Support group meeting

Public awareness program

Take Home Message

• Obesity is a disease

• Needs attention before it brings all friends together

• Metabolic surgery is the ONLY safe and effective

long term solution

Thank You