1. Gastrointestinal Surgery for Severe Obesity Prepared By: Dr. Fahad Al-Jindan Dr. Fahad Al-Jindan

2. Outline Introduction Introduction Who are the candidates for Surgeries Who are the candidates for Surgeries The Normal Digestive Process The Normal Digestive Process Surgical Options Surgical Options Benefits and Risks Benefits and Risks

3. Introduction Obesity is chronic condition Obesity is chronic condition BMI>= 30 (26%) BMI>= 30 (26%) Severe Obesity BMI>=40 (2.9%) Severe Obesity BMI>=40 (2.9%)

4. Introduction Obesity Related Medical conditions Obesity Related Medical conditions Methods of Weight loss Methods of Weight loss Dietary Dietary Physical Activity Physical Activity Behavior therapy Behavior therapy Surgery Surgery

5. Surgery well-established method of long-term weight control well-established method of long-term weight control weight loss of 60% of excess weight after five years (1) weight loss of 60% of excess weight after five years (1) Benefits outweigh the Risks (2) Benefits outweigh the Risks (2)

6. Candidates for Surgery

7. Candidates BMI >=40 BMI >=40 Obesity Related Physical Problem Obesity Related Physical Problem Obesity Related Health problems Obesity Related Health problems Unlikely to lose weight with non surgical methods Unlikely to lose weight with non surgical methods Understand procedures, risks and effects Understand procedures, risks and effects Life long behavioral commitment Life long behavioral commitment

8. Normal Digestive Process

9. How Does Surgery Work?? Restrictive Restrictive Malabsorptive (Intestinal Bypass) Malabsorptive (Intestinal Bypass) Combined Combined

10. Restrictive Procedures Limit food intake without effecting the normal digestive process Limit food intake without effecting the normal digestive process Creation of a small pouch with a narrow outlet Creation of a small pouch with a narrow outlet Delay emptying of food and feeling of fullness Delay emptying of food and feeling of fullness Include Include  Adjustable Gastric Banding (ABG)  Vertical Banded Gastroplasty (VBG)

11. AGB Hollow band of silicone Hollow band of silicone Inflatable with Salt solution Inflatable with Salt solution Can be Tightened/loosened Can be Tightened/loosened the pouch holds about 1 ounce of food and later expands to 2-3 ounces the pouch holds about 1 ounce of food and later expands to 2-3 ounces

12. VBG Uses both a band and Staples Uses both a band and Staples upper stomach near the esophagus is stapled vertically to create a small pouch upper stomach near the esophagus is stapled vertically to create a small pouch The outlet from the pouch to the rest of the stomach is restricted by a band The outlet from the pouch to the rest of the stomach is restricted by a band

13. Advantages Easier to perform Easier to perform Safer Safer AGB can be done Laparoscopically AGB can be done Laparoscopically Can be Reversed Can be Reversed Few nutritional deficiencies Few nutritional deficiencies

14. Advantages 80% of patients lose some weight, 30% reach normal weight category with VBG (3) 80% of patients lose some weight, 30% reach normal weight category with VBG (3) Success rate with VBG is 40 to 63% of excess body weight over a three year period. (4) Success rate with VBG is 40 to 63% of excess body weight over a three year period. (4) 50 to 60% after five years (1) 50 to 60% after five years (1)

15. Disadvantages Less Weight loss Less Weight loss Less likely to maintain weight loss over long term Less likely to maintain weight loss over long term Patient Factors Patient Factors

16. Risks Vomiting Vomiting Slippage of the Band Slippage of the Band Tube Breaks Tube Breaks Infection Infection Bleeding Bleeding Death Death

17. Combined Restrictive/Malabsorptive Most common Bariatric procedures Most common Bariatric procedures Restrict food intake/amount of calories and nutrients the body absorbs Restrict food intake/amount of calories and nutrients the body absorbs Include Include  Roux-en-Y gastric bypass (RGB)  Biliopancreatic Diversion (BPD)

18. RGB creating a stomach pouch and attaching it directly to the small intestine creating a stomach pouch and attaching it directly to the small intestine bypassing a large part of the stomach and duodenum bypassing a large part of the stomach and duodenum Reduction of calories and nutrients absorption Reduction of calories and nutrients absorption

19. BPD Extensive Type Lower Portion of stomach is removed Lower Portion of stomach is removed Remaining pouch is connected to final segment of small intestine Remaining pouch is connected to final segment of small intestine High Risk of Nutrition Deficiency High Risk of Nutrition Deficiency

20. BPD Duodenal Switch Leaves a large portion of stomach including pyloric valve Leaves a large portion of stomach including pyloric valve Keeps a small part of the duodenum Keeps a small part of the duodenum

21. Advantages Rapid Weight loss Rapid Weight loss greater weight loss in gastric bypass (93.3 pounds) compared to gastroplasty (67 pounds) after one year (2) greater weight loss in gastric bypass (93.3 pounds) compared to gastroplasty (67 pounds) after one year (2)

22. Advantages The success rate for weight loss for RGB is 68 to 72% of excess body weight over a three year period, and 75% for BPD (4) The success rate for weight loss for RGB is 68 to 72% of excess body weight over a three year period, and 75% for BPD (4)  However, after five years the average excess weight loss from gastric bypass surgery ranges from 48 to 74% (1)

23. Disadvantages More difficult More difficult Nutritional deficiencies (Ca, Fe, Vitamins) Nutritional deficiencies (Ca, Fe, Vitamins) Dumping Syndrome Dumping Syndrome

24. Dumping Syndrome

25. Risks Risk of Death Risk of Death RGB <1%, BPD 2.5-5% RGB <1%, BPD 2.5-5%  Abdominal Hernias 28%

26. Finally Remember: Remember:  There are no guarantees for any method to produce and maintain weight loss.  Success is possible only with maximum cooperation and commitment to behavioral change and medical follow-up

28. References 1-American Society for Bariatric Surgery. Rationale for the Surgical Treatment of Obesity. Updated April 6, 1998. 1-American Society for Bariatric Surgery. Rationale for the Surgical Treatment of Obesity. Updated April 6, 1998. 2-National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Obesity in Adults: The Evidence Report. NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Obesity in Adults. Washington, DC: U.S. Department of Health and Human Services, 1998 2-National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Obesity in Adults: The Evidence Report. NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Obesity in Adults. Washington, DC: U.S. Department of Health and Human Services, 1998 3-Gastric Surgery for Severe Obesity. National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 96-4006, April 1996. 3-Gastric Surgery for Severe Obesity. National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 96-4006, April 1996.

29. 4-Shape Up America!, American Obesity Association. Guidance for the Treatment of Adult Obesity. Bethesda, MD, revised 1998. 4-Shape Up America!, American Obesity Association. Guidance for the Treatment of Adult Obesity. Bethesda, MD, revised 1998. National Institute of diabetes and digestive and kidney diseases National Institute of diabetes and digestive and kidney diseases The Cleveland Clinic Health Information Center The Cleveland Clinic Health Information Center