1. 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

2. what

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

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

5. 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
Cowan et al ,Surgery for the morbidly obese patients,Chapter 9 ,2000

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

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

11. Why it is important to treat ?

12. 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

13. The Changing concept

14. 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.

15. 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.

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

17. who

18. 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 kg/m2 ????? (Two studies only)
ASBS, SAGES, SSAT, EAES

19. 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.

21. how

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

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

24. Types of surgery

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

26. 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

27. 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.

28. Lap. Band VS SAGB

30. 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

31. 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

32. Surgical ports

33. AGB surgical steps

34. Tube position

35. Normal position of AGB

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

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

38. Early complication Pain Nausea and Vomiting Bleeding System infection
Dysphagia

39. 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

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

45. 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

46. 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

47. 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

48. 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

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

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

52. 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

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

54. 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

55. Vertical Banded Gastroplasty

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

57. 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

58. INTRA-GASTRIC BALLON

59. BIB

60. 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

61. Future of obesity treatment

62. What we are looking for

63. 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

64. Thank You
Q and A