Obesity and Bariatric Surgery Dr. Sanjiv Haribhakti MS,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? ď‚— 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)
Assesment overweight
BMI - 25 to 30 obese BMI - 30 - 40 Morbidly Obese BMI > 40
Risk factors of obesity ď‚— Obesity
itself is a disease
The health risks of obesity
FRIENDS TOGETHER Metabolic Syndrome Syndrome X Abdominal
D
obesity
M Type II Dyslipidemia Hypertension
Type 2 diabetes Gaining as little as 4-5 kg doubles your chance of developing type 2 diabetes ď‚— More than 80% of people with diabetes are classified as overweight or obese ď‚—
High blood pressure ď‚— High
blood pressure is twice as common in obese adults
High cholesterol Overweight people often have too much cholesterol in their blood. ď‚— High cholesterol is linked to angina (a type of chest pain), heart disease, heart attack, and stroke ď‚—
Arthritis ď‚—
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. ď‚— Mechanical and inflammatory reasons ď‚—
Cancer Obesity may increase the risk of endometrial, breast, prostate, kidney, esophageal, and colon cancers ď‚— Women who gain more than 8 kg between the age of 18 and midlife have double the risk of developing breast cancer after menopause ď‚—
Gallbladder stones ď‚—
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 60% 52%
51%
50% 44% 41%
40% 32%
30%
28%
26% 23%
24% 18%
20%
15%
10%
16%
14% 10%10%
15%
7% 4%
3% 0%
0% Diabetes
Asthma BMI < 25
Arthritis 25 - 30
30 - 40
High Blood Pressure BMI > 40
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.
Cancer*
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
35.1%
55.7%
Average
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 Average 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%
Treatment
Eliosoff 1997; Sjostrom NEJM 2004, Obrien J Laparoendosc Adv Surg Tech A. 2003 Aug;13(4):265-70.
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 Aloneâ&#x20AC;Ś 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