By Dr Khaled Ahmad, MD, FACS, FASMBS Bariatric surgery By Dr Khaled Ahmad, MD, FACS, FASMBS

Disease of obesity The World Health Organization recognizes that obesity is a progressive disease resulting from multiple environmental and genetic factors. Obesity is no longer considered a cosmetic issue caused by overeating and a lack of self-control. Obesity is characterized by an excessive accumulation of body fat

Disease of obesity Obesity is characterized by an excessive accumulation of body fat. Obesity is clinically defined by measures that estimate adiposity from body weight, body build and height. One measure to define overweight and obesity is the body mass index (BMI). The BMI generally reflects the amount of excessive body fat and adult has. (exceptions : BMI of a woman who is pregnant, an athlete, a body builder and an elderly person) The BMI does not take into account a persons distribution of fat (Abdominal vs. peripheral). It is not a good measurement of the metabolic activity of a person’s fat tissue.

Body Mass Index (BMI) The BMI takes into consideration an individual’s height and weight and can be determined by using a BMI chart or by calculating according to the following formula BMI = Weight in kg divided by Height in meters squared (BMI= kg/m2)

BMI Categories Category BMI Range Normal Size 18.9 to 24.9 Overweight Class I, Obesity 30 to 34.9 Class II, Serious Obesity 35 to 39.9 Class III, Severe Obesity 40 and greater

Obesity Prevalence According to the World Health Organization, 500 million adults in the world are affected by obesity and 1 billion are affected by overweight (48 million of children)

Impact of Obesity on Health Type II Diabetes People affected by Obesity are 10X more likely to have type 2 diabetes Hypertension About 3 out of 4 hypertension cases are related to obesity Heart Disease Obesity is a major risk factor for heart disease. Obesity increases your risk of heart failure. Severe obesity is associated with arrhythmias.

Impact of Obesity on Health Respiratory Disorders Asthma is 3 to 4 X more common among people with obesity. Around 50-60% have obstructive sleep apnea (OSA). In cases of severe obesity, it is more around 90%. Cancer Obesity is believed to cause up to 90 000 cancer deaths per year. Cerebrovascular disease and stroke Gastroesophageal Reflux disease Bone/Joint damage and accidents

Bariatric surgery procedures Gastric Bypass Roux-en-Y Gastric bypass (often called gastric bypass) = ‘’GOLD STANDARD’’ of weight loss surgery Sleeve Gastrectomy Often called the sleeve. This surgery is performed by removing 80% of the stomach. The remaining portion is a tubular pouch that resembles a banana. Adjustable Gastric band Often called the band. It involves an inflatable band that is placed around the upper portion of the stomach, creating a small stomach pouch abode the band. Biliopancreatic Diversion with Duodenal Switch (BPD/DS) Gastric Bypass The BPD/DS consists of 2 components. First, a smaller tubular stomach pouch is created by removing a portion of the stomach – similar to the sleeve- next, a large portion of the small intestine is bypassed.

Gastric Bypass The procedure consists of creating a small stomach pouch (30 ml in volume) by dividing the top of the stomach from the rest of the stomach. Next, the first portion of the small intestine is divided and the bottom end of the divided small intestine is brought up and connected to the newly created small stomach pouch. Finally, we connect the top portion of the divided small intestine to the small intestine further down so that the stomach and digestive enzymes from the bypassed stomach and first portion of small intestine will mix with food.

Gastric Bypass Advantages Disadvantages Long-term weight loss (60 to 80%) Restricts the amount of food that can be consumed Produces favorable changes in gut hormones Maintenance of >50% excess weight loss Could result in greater complication rates Can lead to long-term vitamin/mineral deficiencies (b12, iron, Calcium, folate) Requires adherence to dietary recommendation, life-long vitamin supplementation

Sleeve Gastrectomy The procedure consists of removing 80% of the stomach. The new stomach pouch holds a smaller volume than the normal stomach. The surgery helps significantly reduce the amount of food that can be consumed. The surgery also has also a greater impact on gut hormones that control hunger, satiety and blood sugar control. The sleeve, similar to the gastric bypass, is known to improve type II diabetes independent of weight loss.

Gastric Bypass Advantages Disadvantages Non-reversible procedure Restricts amount of food the stomach can hold Induces rapid and significant weight loss (50% and more) Involves a short hospital stay (approx. 2 days) Favorable changes in gut hormones (suppresses hunger, reduces appetite, improve satiety) Non-reversible procedure Higher early complication rate than the AGB (band) Potential for long-term vitamin deficiency

ADJUSTABLE GASTRIC BAND The smaller stomach pouch created by inserting the inflatable band satisfies hunger and promotes fullness by eating just a small amount of food. The size of the stomach opening can be adjusted by filling the band with sterile saline which is injected through a port placed under the skin. Reducing the size of the opening is done gradually over time with repeated adjustments.

Adjustable gastric band Advantages Disadvantages Reduces the amount of food the stomach can hold Induces excess weight loss (40-50%) Requires a shorter hospital stay (24h) Procedure is reversible Procedure has lowest rate of early postoperative complications and mortality Slower and less weight loss than other surgical procedures Greater percentage of patients failing to lose at least 50% of excess body weight Can result in band slippage or band erosion into the stomach in a small percentage of patients

Biliopancreatic diversion with duodenal switch (bpd/ds) gastric bypass The duodenum is divided past the outlet of the stomach. The distal small intestine is then brought up and connected to the outlet of the newly created stomach., so that the food goes through a newly created tubular stomach pouch and empties directly into the last segment of the small intestine. The bypassed small intestine (contains bile and pancreatic enzymes) is reconnected to the last portion of the small intestine so that they can mix with the food stream. The food doesn’t mix with bile and pancreatic enzymes until very far down in the small intestine. This decreases significantly the absorption of calories and nutrients (protein and fat) and vitamins dependent on fat for absopriton (A,D,E,K)

Biliopancreatic diversion with duodenal switch (bpd/ds) gastric bypass Advantages Disadvantages Results in greater weight loss (60- 70% excess weight loss or greater) Reduces absorption of fat by 70% or more Higher complication rates and risk for mortality Longer hospital stay Greater potential to cause protein deficiencies and long-term deficiencies in a number of vitamin and minerals