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Bariatric Surgery an overview in orissa ppt.

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1. SHANTI MEMORIAL HOSPITAL PVT. LTD 2. BARIATRIC SURGERY IN ODISHA - AN OVERVIEW DR SREEJOY PATNAIK LIFE MEMBER , SAGES, OSSI & IFSO MINIMAL ACCESS , BARIATRIC &…
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  • 1. SHANTI MEMORIAL HOSPITAL PVT. LTD
  • 2. BARIATRIC SURGERY IN ODISHA - AN OVERVIEW DR SREEJOY PATNAIK LIFE MEMBER , SAGES, OSSI & IFSO MINIMAL ACCESS , BARIATRIC & METABOLIC SURGERY
  • 3. OBESITY AND METABOLIC SURGERY SOCIETY OF INDIA
  • 4. IFSO CONGRESS - 2010, 2011, 2012
  • 5. IFSO 2013
  • 6. Definition of Bariatric Surgery • Bariatric surgery or weight loss surgery is a variety of surgical procedures performed on obese subjects. • It is done either by • Reducing the size & capacity of the stomach. • OR by • Resecting & re-routing the small intestines to a small gastric pouch.
  • 7. SCARY STATISTICS
  • 8. How do we measure obesity •We classify obesity according to BMI ( Body mass index ) •BMI = body weight in kg / height in m2
  • 9. Classification of BMI • 18-25 = Normal • 25-30 = Obese • 30-35 = Class 1 • 35-40 = Class II • 40-45 = Class III • > 45 = Morbid or super obese
  • 10. Why we are worried about obesity? • What is its significance ? • Because of its co-morbidities
  • 11. Comorbidities 1. Cardiovascular – CAD, HTN,CHF,LVF & Dyslipidaemia. 2. Pulmonary – OSA, OHS, PAH, Asthma 3. Haemopoetic – DVT & PE 4. GI – GERD, NAFLD, Hiatus hernia, Gallstones 5. Genito-urinary – stress incontinence, UTI
  • 12. Comorbidities 6. Obstetrics / Gynecology – Infertility, Miscarriage, fetalabnormalities, infant mortality, gestational DM 7. Musculosketal – OA, Gout, Plantar fasciitis, carpel tunnel syndrome. 8. Neurology / Psychiatric – CVA, pseudo motor cerebri, depression and anxiety. 9. Cancer – Oesophagus, pancreas, colon & rectum, breast, endometrial, kidney, thyroid and GB.
  • 13. Morbidity • BMI > 35 - Risk of death = 2.5 times greater • BMI > 40 - Risk of death = 10 times greater • OBESITY > 2 leading cause of preventable nd premature deaths in USA
  • 14. Treatment of obesity
  • 15. DRUGS • ORLISTAT • NEWER DRUGS• BELVIQ (LOCASERIN) • QSYMIA (PHENTERMINE/ TOPIRAMATE) • VICTOZA (LIRAGLUTIDE)
  • 16. Bariatric Surgery - Goals Surgery to Create Sustainable & significant Weight Loss in Severely Obese Patients. Resolution or Cure of Co-morbidities Reduction of Obesity Related Mortality
  • 17. GUIDELINES • SAGES – Society of American Gastro Endo surgeons. • ASMBS – American society of Metabolic & Bariatric Surgery. • NIH – National Institute of Health.
  • 18. Whom do we advise Surgery ? BMI > 40 without comorbidities. BMI > 35 with 2 comorbidities . Age – 18 – 60 years( < 12- 65 ) Stable obesity for > 5 years Unsuccessful dietary / drug treatment Absence of Endocrine disease Pt. should be sufficiently comprehensive & compliant. No h/o excessive alcohol or drug abuse Acceptable Operative Risks
  • 19. How do we classify the surgical procedures ? A. Restrictive B. Malabsorptive C. Combination – restrictive and malabsorptive
  • 20. Restrictive procedures • Creation of a small gastric pouch & limiting the gastric volume & continuity is not altered. • Vertical banded Gastroplasty • Adjustable Gastric Banding • Sleeve Gastrectomy • Gastric Plication • BIB – Intra Gastric Balloon
  • 21. RESTRICTIVE PROCEDURES LSG LGP VBG LAGB INTRA –GASTRIC BALOON
  • 22. A Restrictive Procedure is  Safer  Easier  Faster  Easier to cheat  Less Effective for Weight Loss BUT ALSO BUT ALSO  Less beneficial for Diabetes control
  • 23. Malabsorptive procedures • Malabsorption is achieved by creating a short gut syndrome with distal mixing of bile and pancreatic juice with ingested food. • Bilio-pancreatic diversion • Jejunal ileal bypass • Endoluminal sleeve ( Endo-barrier)
  • 24. MAL ABSORPTIVE PROCEDURES BPD - DS ENDOLUMINAL SLEEVE OR DJ BYPASS LINER
  • 25. A Malabsorptive Procedure is  More effective for weight loss??  More risky??  More Nutritionally demanding
  • 26. Combination procedures • Combination of restriction alongwith malabsorption . • Small gastric pouch + a bypass. • Early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat. • RYGB • LSG with DS • MGB
  • 27. COMBINATION PROCEDURES LSG + DS LRYGBP MGBP
  • 28. Combining Both Restrictive & Malabsorptive methods has The Pros and Cons of Both
  • 29. History of Bariatric Surgery • 1950s- Open Gastric Bypass, BPD • 1990- Laparoscopic Bariatrics- LRYGBP, LAGB • 2000- Laparoscopic Sleeve Gastrectomy • 2003- Gastric Plication & ileal Transposition
  • 30. Historical Perspective Jejunoileal Bypass (JIB)   Vertical Banded Gastroplasty (VBG)
  • 31. Gold standard procedures • Laparoscopic Sleeve Gastrectomy • Laparoscopic Roux-en-Y Gastric Bypass • Laparoscopic Mini Gastric Bypass • Laparoscopic Adjustable Gastric banding
  • 32. Bariatric Procedures Performed Today
  • 33. Bariatric Procedures Performed Today
  • 34. Bariatric Procedures Performed Today
  • 35. Selection of a procedure • There is No evidence on procedure selection -most frustrating shortfall in bariatric surgery. • Best procedure should reduce weight, induce remission of Diabetes, & improve quality of life. • • Multi disciplinary team assessment . The choice of procedure is determined by the individual’s phenotype, the aims of therapy, & peri-operative risks.
  • 36. Selection of Procedure • Each procedure should be tailor made for each individual. • The choice of the procedure is a complex process with patient & their interests at its core. • The surgeon’s experience to deal with the inevitable complications of each procedure & to manage long term follow up care should be the goal to success.
  • 37. Pre-op assessment • • Patient should be physically & psychologically fit. • Patients must be determined to comply with the postop. care and instructions on diet. • They should be given the correct & realistic information on what the procedure can achieve. • For each patient benefits of the procedure should outweigh the operative risks. Individualized assessment-is vital & Psychiatrist role is important.
  • 38. • A special risk bond is signed by the patient and by 2 more family members. • Procedure may vary in peri- operative assessment ie ; diagnostic laparoscopy. • Primary aim of surgery should each procedure. be weight loss with
  • 39. Whom we deny Bariatric Surgery ? • History of substance abuse, eating disorders, or major psychiatric problems – untreated or unresolved • Patients who are too ill or too high a risk for surgery • Women who may become pregnant soon
  • 40. Choosing an ideal Bariatric Procedure
  • 41. Diabetic? Sweet Eater? Cola Guzzler? Reflux? LAP GASTRIC BYPASS
  • 42. High Risk Bariatric Subject? Super-super-obese? Not keen on severe portion control? Very young? ‘Sold’ patient? LAP SLEEVE GASTRECTOMY
  • 43. Hostile Abdomen? Previous Intestinal Resections? ‘Sold’ Patient? ‘Sold’ Physician? LAP BAND
  • 44. • Ideal procedure 1. Weight loss - max. with BPD-DS/ LRYGB/ MGB LSG/ LAGB. • 2. DM remission - BPD-DS/ LRYGB/ LSG/ LAGB • 3.OSA/ Asthma • 4. GERD - BPD-DS / LRYGB - LRYGB (No LSG)
  • 45. Investigations LAB EVALUATION : CBC,FBS, 2HRPGBS, HB1AC, LFT, Urea, Creatinine, Serum Protein/albumin, Amylase, Serum fasting & post Insulin, C-peptide, lipid profile, Serum Calcium, Vit. B12, Calcitonin, TFT,Serum & urine Cortisol. HOMA-IRHomeostasis Model of Assessment-Insulin Resistance UGIE: To rule out inflammatory or ulcer pathology, & treat H.pylori infection. USG Abdomen – To rule out cholelithiases, which would indicate Lap. Cholecystectomy alongwith the primary surgery. Cardio-Respiratory evaluation – To exclude any contraindications to GA by TMT, 2D echo, PFT, ABG, CXR. Psychiatry evaluation – To rule out any behavioural abnormalities that would contraindicate limited food intake. Endocrine evaluation – To rule out an endocrine abnormality as the etiology of morbid obesity. Dental evaluation
  • 46. HOMA-IR HOMEOSTASIS MODEL OF ASSESSMENT OF INSULIN RESISTANCE • INTERNATIONAL FORMULA • FBG(mmol/L) X Finsulin(Mu/L) / 22.5 • To assess beta cell function & insulin resistance • Estimated by euglycemic clamp method •( measuring glucose for an increased inslin level, without causing hypoglycemia)
  • 47. Tools for Bariatric Surgery
  • 48. Safety trocars and Gastric calibration tubes
  • 49. STERRAD – NX STERILISER The STERRAD® NXTM Sterilizer is a self-contained stand-alone system of hardware and software designed to sterilize medical instruments and devices using a patented hydrogen
  • 50. ENERGY SOURCES
  • 51. ANAESTHESIA WORKSTATION , CO2 & GAS MONITORS
  • 52. VIDEO LARYNGOSCOPES
  • 53. FLEXIBLE LARYNGOSCOPE
  • 54. Bair Hugger – warm blanket
  • 55. SEQUENTIAL COMPRESSION DEVICE
  • 56. ICU MANAGEMENT
  • 57. Video on sleeve gastrectomy
  • 58. Video on LRYGB
  • 59. Video on MGB
  • 60. Pathophysiology of Bariatric Surgery • ROLE OF GI HORMONES IN REMISSION OF METABOLIC SYNDROME. • Recent theory- Entero-insular axis has got a role in maintaining glucose homeostasis. • Bariatric surgery results in weight loss due to surgical manipulation or bypassing of the gut & by caloric restriction - leading to remission of metabolic syndrome. Metabolic syndrome For Men WC > or – 40 inches TG > or – 150 mg/dl HDL < 40 mg/dl BP > or – 130/85 mmHg FBS > or – 100 mg/dl For Woman WC > 35 inches TG > 150 mg/dl HDL < 50 mg/dl BP > 130/85 mmHg FBS > 100 md/dl
  • 61. GI HORMONES AS INCRETINS & ANTI INCRETINS
  • 62. WHAT ARE INCRETINS ? • Incretins are a group of gastrointestinal hormones that increase the amount of insulin release from the beta cells after eating. • They also slow the rate of absorption of nutrients into the blood stream by reducing gastric emptying and reduces food intake. • Inhibits Glucagon release from the alpha cells of the Islets of Langerhans. • • 1. GLP-1- Glucagon-like peptide-1 2 . GIP- Gastric inhibitory peptide or Glucosedependent insulinotropic polypeptide
  • 63. Mechanism of Incretin action Stimulates insulin release Lowering of blood glucose Inhibits glucagon release
  • 64. WHAT ARE ANTI INCRETINS? • Anti incretins are a group of GI factors secreted from the duodenum & proximal jejunum, which counteract the actions of INCRETINS.
  • 65. Anti incretin action HYPERGLYCEMIA
  • 66. ANTI INCRETINS AND GLUCOSE HOMEOSTASIS
  • 67. THE BADDIES
  • 68. GUT - BRAIN AXIS •The gut–brain axis is a major component of appetite regulation. •The gut hormones have either anorexigenic ( appetite depressant ) or orexigenic ( appetite stimulant ) action on food intake . •These gut hormone secretions are altered following bariatric surgery
  • 69. • Ghrelin- (orexrgenic / satiety or appetite stimulant hormone) produced primarily by gastric fundus. -Its levels are supressed following resection of gastric rich fundus. -It stimulates insulin counter-regulatory hormones. • Peptide YY – an anorexegenic (or appetite depressant) hormone co-secreted with GLP-1 from the response to food intake. • PYY3-36 intestinal L cells in - ( anorxegenic hormone ) -levels are increased following LRYGB, decreases food intake & ameliorates insulin resistance and improves glycemia.
  • 70. PROPOSED THEORIES FOR IMPROVED GLYCAEMIA (A) RAPID HINDGUT DELIVERY HYPOTHESIS •Expedited or rapid delivery of ingested nutrients to lower bowel due to intestinal bypass leads to stimulation of L cells, ( distal ileum & colon ) which in turn results in increased secretion of INCRETIN hormones & improved glucose homoeostasis. (LRYGB & BPD/DS.) •Proximal nutrient- related signals that are transmitted from the duodenum to the distal bowel by neural pathways leads to increased Incretin secretion.
  • 71. I & AI AFTER BYPASS
  • 72. Hypothesis as to the mechanism responsible for the control of diabetes after gastric bypass.
  • 73. PROPOSED THEORIES FOR IMPROVED GLYCAEMIA (B) FOREGUT HYPOTHESIS •The proximal small intestine (foregut / BPD limb ) is excluded resulting in reduction in secretion of Anti – incretin factors ( diabetogenic hormones) in response to absence of nutrients in the fore gut. •This leads to improved glycaemia. & •Decreased Intestinal Glucagon synthesis .
  • 74. ANTI-INCRETIN / INCRETIN HYPOTHESIS • After Bariatric Surgery - a physiological balance is maintained between Anti –Incretins & Incretins, • Leads to proper beta cell function & to maintain Blood Glucose excursions within normal range. • Release of excess Anti- Incretins are prevented & there is a restoration of between Incretins & Anti-Incretins , leading to improved glucose homeostasis .
  • 75. • Diabetes, Obesity & Bariatric surgery DM linked with obesity has – -- insulin resistance, inflammation & lipo-toxicity of beta cells, > progressive beta cell failure & hyper-glycaemia. •After Bariatric Surgery - Glucose homeostasis improves. - Insulin sensitivity increased markedly - Adiponectin levels are improved - Markers of insulin signals in key target tissues are enhanced.
  • 76. Medical Co-Morbidities Resolved with Bariatric surgery Type 2 Diabetes 95% Hypercholesterolemia 97% Hypertension 92% GERD 98% Cardiac Function 95% improvement Stress Incontinence 87% Osteoarthritis 82% Sleep Apnea 75%
  • 77. Complications of Bariatric Surgery The other side of Mount Rushmore South Dakota USA Gutzon Borglum and his son Lincoln Borglum 1925
  • 78. INTRA-OPERATIVE COMPLICATIONS • Trocar injuries • Splenic injury • Portal vein injury • Bowel ischemia • Misconstruction
  • 79. EARLY COMPLICATIONS • Bleeding • Wound infection • Anastomotic leaks • Pulmonary embolism and DVT • Cardiovascular complications • Pulmonary complications
  • 80. LATE COMPLICATIONS AFTER RYGB • • • • • • • • - Gastric remnant distension - Stomal stenosis or stricture - Marginal ulcers - Cholelithiasis - Ventral incisional hernia - Internal hernias Vomiting, diarrhea,dumping syndrome. Alopecia,cholelthiasis, hypoglycemia - Short bowel syndrome - Dumping syndrome - Metabolic and nutritional derangements - iron,vit B12, D,folic acid. - Renal failure - Postoperative hypoglycemia - Change in bowel habits - Failure to lose weight and weight regain
  • 81. COMPLICATIONS AFTER SLEEVE • - Bleeding • - Stenosis • - Gastric leaks • - Reflux • Alopecia, cholelthiasis, hypoglycemia.
  • 82. How Safe Is Bariatric Surgery? Mortality Rate- 0.3% Morbidity Rate- 4.1% Longitudinal Assessment of Bariatric Surgery, NEJM, 2009
  • 83. OUR EXPERIENCE IN BARIATRIC SURGERY
  • 84. YEAR WISE –BARIATRIC SURGERY CASES • 2010 • 2011 • 2012 • 2013 - 4 cases - 4 cases - 12 cases - 15 cases
  • 85. PATIENT PROFILE • 2010 - 2013 • N= 35 • BMI range 35 to 60 • Comorbidities
  • 86. Procedures (n=35) • • Lap adjustable gastric band 0 Lap sleeve gastrectomy 30 • • • • • • Lap gastric bypass 2 Lap duodenal switch 0 Lap gastric plication 0 Ileal Transposition Revisional Bariatric procedure MGB 0 1 2
  • 87. Excess body weight loss %Follow up 3- 38 months • LSG 32- 85 • RYGB 38- 88 • MGB 33- 64 • REVISIONAL BARIATRIC (SG > MGB) 20
  • 88. OUR PATIENT SERIES BHUBANESWAR
  • 89. HAPPY AFTER MARRIAGE
  • 90. JAGATSINGHPUR
  • 91. BHAWANIPATNA
  • 92. JAGDALPUR
  • 93. BALASORE
  • 94. KALAHANDI
  • 95. KENDRAPADA
  • 96. BRAMHAPUR
  • 97. AFTER
  • 98. PURI
  • 99. CUTTACK
  • 100. THE MOST ELIGIBLE BACHELOR CUTTACK -- FIRST CASE
  • 101. DRAMATIC WEIGHT LOSS – 60 KGS IN 4 MONTHS
  • 102. WITH MY DIETICIAN
  • 103. What can be more satisfying than achieving this?
  • 104. OUR SUCCESS
  • 105. • Bariatric surgery dramatically improves or cures many obesity comorbidities. • But working with an inexperienced surgeon can increase your risk for complications.
  • 106. Metabolic Surgery- A new dimension RESOLUTION OF DIABETES AFTER BARIATRIC SURGERY
  • 107. Present status of diabetes surgery • Bariatric surgery effectively reverses type 2 diabetes in a high proportion of morbidly obese patients, within weeks or even days well before these patients have lost a significant amount of body weight • Diabetes surgery should be considered in patients with BMI > 35 and may also be appropriate for patients with BMI 30-35 Rome Diabetes Surgery Summit 2009
  • 108. Resolution of Diabetes in the Non-Obese?
  • 109. Resolution of diabetes in non obese Status of Ileal Transposition “Not to be done outside approved trials” Rome Diabetes Surgery Summit, 2009
  • 110. PRACTICE POINTS • Extensive Research in the field of Bariatric surgery ( Metabolic surgery, Technology, Endoscopy ) • A career in Bariatrics is very promising……. And lucrative
  • 111. Diabetes Surgery • Within 5 years, will gastrointestinal surgery be considered an acceptable option for the treatment of Type 2 Diabetes in the non­obese patient?
  • 112. CONCLUSIONS- TAKE HOME MESSAGE • BS should be considered with BMI > 40 or BMI > 35 with obesity related 2 co-morbidities. • • Not all pts. are suitable for surgery. • The choice of the surgical modality should take the individual’s goals, surgeon’s experience & existing comorbidities. A multidisciplinary assessment is essential to select the appropriate candidates.
  • 113. CONCLUSIONS- TAKE HOME MESSAGE • • Individualised care is determined by clinical evaluation. • Procedure selection - should effectively treat & prevent all co-morbidities alongwith sustained weight loss. • Experienced anaesthesist & trained OT & ICU staff is necessary for success. • Long term follow up and repeated counselling is mandatory for a safe outcome. Should be performed in experienced centres- with back up ICU and trained staff for favourable outcomes.
  • 114. THANK YOU FOR A PATIENT HEARING & WAITING
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