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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?


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


Obesity

itself is a disease

The health risks of obesity

FRIENDS TOGETHER
Metabolic Syndrome Syndrome X
Abdominal

obesity

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
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 dont 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: 18101816

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

46%

0%

Diet / Behavior Modification

812%

1.6%
(10 Years)

Drug Therapy

< 10%

10%

Gastric Bypass Surgery

6585%

Up to 100%

Laparoscopic Adjustable Gastric


Banding

4550%

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 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