what, who, How to deal with your obese friend Fahad Bamehriz, MD Centre for Minimal Access Surgery King Faisal Specialist Hospital and Research Centre Riyadh

what

Introduction Bariatric =Baros: heaviness, and pressure. It is the field of medicine encompassing the study of obesity, its causes, prevention, and treatment.

Obesity A condition of excessive fat accumulation in the body to the extent that health and well being are adversely affected. WHO 1997

Ideal Body Weight (IBW) As defined by the Metropolitan Life Insurance Tables Of 1983for height, sex and body-frame, is that weight which is associated with the lowest death rate in insured populations. Cowan et al Surgery for the morbidly obese patients Chapter 9 2000 Cowan et al ,Surgery for the morbidly obese patients,Chapter 9 ,2000

BMI = Weight ( Kg)/ Height (m2) Body Mass Index BMI = Weight ( Kg)/ Height (m2)

Introduction Obesity: - it is ≥ 20% than the ideal weight - Body Mass Index (BMI) ≥ 30 kg/m² . BMI 25- 27 = normal subject 28-30 = over-weight 30- = obese 40- 50 = morbid obesity 50-60 = super MO

Why it is important to treat ?

Medical Complications of obesity Type 2 diabetes Hypertension Hyperlipidemia CAD, CHF, CVA PVD DVT and pulmonary embolism SLEEP APNEA Pulmonary HTN Edema, skin breakdown Venous stasis, ulcers cancer Osteoarthritis Gastroesophageal reflux Gallbladder Disease Fatty Liver Menstrual irregularities Infertility Hypogonadism, ED, anorgasmia Urinary stress incontinence Pseudotumor cerebri

The Changing concept

Evidence-based guidelines for the obesity Since 1991, Obesity is a "chronic disorder that requires a continuous care model of treatment", as it recommended by National Institutes of Health (NIH) Consensus Development.

Evidence-based guidelines for the obesity All studies and committees in English literature have pointed out that in obese patients (BMI >= 30)"no current [conservative] treatments appear capable of producing permanent weight loss" accept surgery.

Do not even think about it ? Bray et al CE&M 1999

who

Bariatric Surgery: Indications 1991 NIH Consensus BMI > 40 kg/m2 BMI > 35 kg/m2 but with a serious co-morbidity: Diabetes, severe hypertension, obstructive sleep apnea, etc… Several failed attempts at dieting: “patients seeking treatment for the first time should be considered” for a non-surgical program. BMI 30- 35 kg/m2 ????? (Two studies only) ASBS, SAGES, SSAT, EAES

Clinical assessment & management Obesity Program Team Approach Bariatric surgeon. Dietitian. Physical therapist. Psychiatrist. Psychologist. Gastro-entrologist. Radiologist. Nursing team. Internist. Endocrinologist Cardiologist. Pulmonologist. Family Physician. Anesthesiologist. Intensivist. Plastic Surgeons.

how

Management Options Non-Surgical Surgical Behavioral Therapy. Diet. Physical activity. Drug therapy. Jaw wiring. Intra-gastric balloon. Surgical Restrictive. Mal-absorptive. Combined.

Type Bariatric surgery 1-Gastric Restrictive operations: -Stapled gastroplasty (VBG) - Gastric Banding (AGB) - Sleeve gastrectomy 2- Malabsorptive operations: - Gastric Bypass - Biliopancreatic Division ± Duodenal switch

Types of surgery

Important points Surgery is supportive method not for treatment Metabolic syndrome BMI ≥ 40 Surgery is supportive method not for treatment

How surgery can treat obesity The mechanism by which weight loss surgery improves weight: Reduce food intake, Modifications of the enteroinsular axis Reduce certain GI hormonal level

Choice of Procedure All types of procedures should be explained to the patient. Since obesity surgery has various competing aims, such as weight loss, adjustability, reversibility, and safety, it is difficult to draw universally valid conclusions about the optimal bar iatric procedure.

Lap. Band VS SAGB

Indications for AGB who need only 20% support Compliance ….compliance to follow dietary and sport instructions Strong and motivated patient history of significant weight loss by dieting program Better: - lower BMI - Non-sweet eater - close to follow-up

General OR information OR time is almost 1 hr Need pt is standing on table (RT position) Excess weight loss is 30-40% in 6 months Can be day- surgery case Need 1-2cc filling every 4-6 weeks

Surgical ports

AGB surgical steps

Tube position

Normal position of AGB

LAGB complications Failure rate is up to 80% ( patient- related) Mortality rate is 1 in 2000 (0.05%) Overall morbidity rate is 11.3% Major complications requiring reoperation are 1% to 4% Failure rate is up to 80% ( patient- related)

OR complications Esophageal or/and gastric perforation Pneumothorax Splenic injury Liver injury

Early complication Pain Nausea and Vomiting Bleeding System infection Dysphagia

Nurse issues Pain….. Give good pain control Nausea and Vomiting…. Give regular anti-emetic medication Bleeding…observe pulse and blood pressure System infection….observe temp Obstruction ….. Observe frequent vomiting

Sleeve Gastrectomy (longitudinal G, Vertical G , Stomach reduction) Resection of Greater Curve Sleeve of stomach left in place (Sleeve Gastrectomy) (Vertical Gastrectomy) (Stomach Reduction)

Indications for SG Who need only 50% support Super-super obese (BMI >65) Patient who refuses gastric bypass Patient who prefers one go surgery no follow-up

General OR information OR time is 1-2 hours Excess weight loss is 80% but can not be maintained for longer than 3 years Stable line leakage is 5% It may be even difficult to do or finish (duo to a lot of fat or huge Lt. liver lobe

Complication of SG As with any surgery, there can be complications. Complications can include: DVT (blood clot in leg) 0.5%Pulmonary Embolus (blood clot to lung) 0.5%Pneumonia 0.2%Splenectomy 0.5%Gastric leak and fistula1. 0%Postoperative bleeding 0.5%Small bowel obstruction .0%Death

Nurse issues 1- to avoid DVT (blood clot in leg) and Pulmonary Embolus (blood clot to lung) .. Push patient to be outside the bed in most of the time 2- to avoid Pneumonia …. Ask patient to us IS 10 times / houre 3- to discover Gastric leak and fistula… observe increase pulse rate 120/min, temp: 38c, and food coloring or saliva in JP drain 4- to discover Postoperative bleeding…observe JP drain if blood is more than 300 cc/ day

Gastric bypass First Laparoscopic gastric bypass was in 1993 by Wittgrove, Clark, and Tremblay.

Surgical indications need 60% support sweet eater Older patients, less activity and motivation Better: - bigger BMI ( BMI ≥ 50) - DM

General OR information OR time is almost 3-4 hours Need pt to be standing (RT position) Excess weight loss is 60-70% in 6 months Important points : - leakage rate is 5% - close follow-up for vitamins, Ca level

Gastric bypass complications Leakage Bowel obstruction Bleeding Dumping syendrom Diarreah Hair loss Anemia Vitamines deficiency

Nurse issues 1- to avoid DVT (blood clot in leg) and Pulmonary Embolus (blood clot to lung) .. Push patient to be outside the bed in most of the time 2- to avoid Pneumonia …. Ask patient to us IS 10 times / houre 3- to discover Gastric leak and fistula… observe increase pulse rate 120/min, temp: 38c, and food coloring or saliva in JP drain 4- to discover Postoperative bleeding…observe JP drain if blood is more than 300 cc/ day

Vertical Banded Gastroplasty

Indications for VBG Big…big size single meal eater Non-sweet eater Non-compliance patients ± motivated patients Does not loss significant by dieting history

General information VBG 60% a mean excess weight loss Less than 10% early morbidity rate Less than 1% perioperative mortality Nearly 80% failure rate (long term follow-up Poor weight loss maintenance 15% to 20% reoperation rate duo to stomal outlet stenosis or severe reflux

INTRA-GASTRIC BALLON

BIB

COMPLICATIONS OF BIB BIB (Bioenterics â Intragastric Balloon) a. Pressure necrosis of gastric wall b. Bleeding from stomach c. Migration and intestinal obstruction or impaction. d. Migration and aspiration e. Intolerance needing removal

Future of obesity treatment

What we are looking for

Major nurse issues 1- Do not accept pulse 120/min and temp 38c Should assess 1- Do not accept pulse 120/min and temp 38c 2- Food color and saliva in JP drain, do not remove the JP drain 3- Push patient to walk and use IS 10 times/h 4- Do not remove NGT nor start feeding • Success criteria : loss of at least 50%of excess weight or BMI ≤ 30

Thank You Q and A