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Obesity:

Surgical Management and


Complications
Mohsin Farooq
MS3

Prevalence
Dramatic rise in last 20
yrs
2/3 US individuals are
overweight
50% of these are obese
5% morbidly obese
Rapid growth in BMI
subgroups 35 and
40
Increase in comorbidities
2.5 million deaths per
year worldwide from
comorbidities

Percent of Obese (BMI > 30) in


U.S. Adults

Derived from Center for Disease Control and Prevention website www.cdc.gov

Percent of Obese (BMI > 30)


in U.S. Adults

Derived from Center for Disease Control and Prevention website www.cdc.gov

Morbidity
BMI 35 kg/m:
Risk of death 2.5 times greater
than if BMI of 20-25 kg/m
BMI 40 kg/m:
Risk of death 10 times greater

Obesity
2nd leading cause of preventable
premature death in US (smoking)

Where do nations rank in the


global obesity stakes?

Morbidity
Obesity associated conditions
Diabetes
Hypertension
Sleep apnea
Congestive heart failure
Hyperlipidemia
Stroke
Coronary Artery Disease
Osteoarthritis
Gastroesophageal Reflux Disease
Non-alcoholic fatty liver
Psychological disturbances

Bariatric Surgery
Only proven modality effective in inducing and
maintaining weight loss.
Indication for Bariatric Surgery for Morbid Obesity
Individuals with a BMI of 40 kg/m2 or greater
Individual with BMI 35-40 kg/m 2 + significant
comorbidity
Only after failed non-operative attempts (diet,
exercise)
1990 2000 4925 to 41,000
2005 130,000
2010 218,000

Types of weight Reduction


Surgery
Restrictive Procedures
Adjustable Gastric Banding (AGB) Lap Band
Vertical Banded Gastroplasty (VGB)
Sleeve Gastrectomy (SG)

Malabsoprtive Procedures
Biliopancreatic Diversion (BPD)
Biliopancreatic diversion with duodenal
switch (BPD/DS)

Combination of Malabsorption and Restriction


Roux-en-Y Gastric Bypass

Vertical Banded
Gastroplasty
Restrictive
Creation of proximal gastric
pouch by partitioning
(stapling) and reinforcement
with gastric band
Lose 30-50%
Disadvantages:
Weight regain due to staple
line breakdown
Reversal is complex
Non adjustable
Abandoned

Sleeve
Gastrectomy

Restrictive
85% of the stomach is
removed
sleeve from
antrum to
esophagous
Originally as part of
BPD and duodenal
switch
Better weight loss
than gastric banding

Current Procedures

BPD/DS

AGB

Gastric Bypass

Lap Band (AGB)


Restrictive
Adjustable band is
placed around upper
stomach
No physiological
changes or resections
Port of adjustment
attached to abdominal
wall
45-55% EBW loss
Least invasive
Lowest
mortality/complication

Roux-en Y gastric bypass


(RNYGB)
Malabsorptive +
Restrictive
Gold standard 80%
Pouch Formation:
Small gastric pouch (1530ml)
Transect vs stampling
Roux limb creation
Gastro-jejunostomy 75-150
cm down limb
Long limb bypass: 65% -70%
EBW loss
Decrease BMI 35%

Biliopancreatic diversion
with duodenal switch
(BPD/DD)

Malabsoptive
Subtotal gastrectomy
and duodenum is
divided,
distal small intestine
is connected to the
stomach
Most effective
against diabetes
70-90% of EBW loss
within years

Post-surgical Early
Complications
Early Complications
Anastomotic leak
DVT + PE
Bleeding
Infection

Anastomotic Leak

Gastrojejunostomy
Gastric stapled line

DVT & Pulmonary


Embolism
Sudden cause of death up to one month after
surgery
Obese patients are less mobile, especially
after surgery
20%-30% mortality rate
High risk may have vena cava filter
placement prior to surgery
Prophylaxis with compression stockings and
LMWH
Early ambulation imperative

Post-surgical Late
Complications
Nutritional Disturbance
Marginal ulcers and
strictures
Hernia
Cholelithiasis
Band slippage
Dumping Syndrome
Esophageal dilatation
Limb obstruction

Nutritional Disturbances
Most common in malabsorptive
procedures, RNYGB
Protein energy malnutrition
Iron deficiency anemia

B 12

Carbohydra
e
Lipid
B12 deficiency
Proteins
Folate deficiency Ca+
Fe +

Calcium and Vitamin D deficiency


Not seen with purely restrictive
surgeries

A, D, E, K

Improvements of
Co-morbidities
2 years after surgery diabetes mellitus was
resolved in 83% of pre-operative diabetic
patients (Sugerman et. al 2005)
2 years following surgery 69% had resolution
of hypertension
8 years post-surgery there was complete
relapse in those with gastric banding
25% decrease in total cholesterol and 40%
decrease in triglycerides 6 to 12 months after
surgery