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Management of Obesity An over review

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1 Management of Obesity An over review
Dr. fahad bamehriz Department Of Surgery

2 Management of Obesity Definitions &Classification.
Magnitude of obesity problem. Clinical assessment & management. Surgical management. Summary.

3 Definitions & Classification
Management of Obesity Definitions & Classification


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

6 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

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

8 Classification of weight
WHO 1997

9 Morbidly Obese Patients
Are those individuals who weigh at least 45 kg over the ideal body weigh. This approximates a body mass index (BMI) of at least 40 kg/m2 Cowan et al , Surgery for the morbidly obese patients, Chapter 9 ,2000 Cowan et al ,Surgery for the morbidly obese patients,Chapter 9 ,2000

10 Weight Loss EWL = Excess Weight Loss
= (preoperative weight) – (ideal weight) % EWL = % Excess Weight Loss = weight loss / excess weight x 100

11 Magnitude of obesity problem
Management of Obesity Magnitude of obesity problem


13 Prevalence of obesity WHO 1997

14 Prevalence of obesity

15 Health hazards of obesity
Cowan et al , Surgery for the morbidly obese patients, Chapter 9 ,2000 Cowan et al ,Surgery for the morbidly obese patients,Chapter 9 ,2000

16 Health hazards of obesity
Karl et al SCNA Oct. 2001 Karl et al SCNA Oct. 2001

17 Health hazards of obesity
Wadden et al SCNA OCT 2001

18 Health hazards of obesity
Bray et al CE&M 1999 Bray et al CE&M 1999

19 Cost Related to Obesity
“The costs of obesity is substantial and accounts for 2-8 % of the total health care expenditure in countries such as The Netherlands, France, USA, Australia and Sweden.” The Lancet August 1997 The Lancet August 1997

20 Clinical assessment & management
Management of Obesity Clinical assessment & management


22 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.

23 Assessment H&P. Laboratory work up;
CBC, Renal, Hepatic, Lipid Profiles. TFT’S, Cortisol suppression test, FBS. Nutritional Profile. Radiological Investigations; U/S abdomen.

24 Assessment Gastro-enterology Gastro-scopy. Psychiatry. Dietitian.


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

27 Dietary approaches to reduce body weight
Dietary Programs Starvation diets (fewer than 200 kcal /day). Very low energy diets (VLED) kcal/day, commercial formula. Low energy diets (LED) kcal/day, natural food. Ad libitum low fat diets 15% - 25 % less fat, high CHO & protein. Atkins diet High protein low CHO.

28 Dietary approaches to reduce body weight

29 Physical Activity Programmed physical activity.
regular scheduled activity at a relatively high intensity level. Lifestyle physical activity. increasing energy expenditure during the course of the day.

30 Physical Activity

31 Drug therapy of obesity
Drugs that reduce food intake Nor-adrenergic drugs (phentermine). Serotonin-norepinephrine re-uptake inhibitors (Sibutramine). Drugs that alter metabolism Pre-absorptive agents (Orlistat). Post-absorptive agents (Metformin). Drugs that increase energy expenditure Ephedrine & Caffeine.

32 BioEnterics® Intragastric Balloon BIB ™ System

33 B.I.B. Placement

34 Clinical results Dr. Bolwerk

35 Jaw Wiring Bray et al CE&M 1999

36 Obesity Surgery Classification
Restrictive Malabsorptive Combined


38 %EWL after LAGB


40 VBG versus ASGB

41 What is Laparoscopic Sleeve Gastrectomy
What is Laparoscopic Sleeve Gastrectomy ? (longitudinal G, Vertical G , Stomach reduction) Resection of Greater Curve Sleeve of stomach left in place (Sleeve Gastrectomy) (Vertical Gastrectomy) (Stomach Reduction)

42 A Prospective Randomized Study Between LGB & LSG Results after 1&3 years
Jacques Himpens Obesity Surgery 16( )2006


44 Efficacy of Obesity Surgery operation number % EWL
Banding 4429 48.6% VBG 3382 58.3% Bypass 2949 68.6%



47 Bilio-pancreato-jejunal bypass type three



50 Crystine Lee San Francisco California

51 King Faisal Specialist Hospital Experience in Bariatric Surgery
Dr Patrick O’Regan Dr Abdelrahman Salem Dr Fahad Bamerhiz Minimally Invasive Surgery Service King Faisal Specialist Hospital & Research Center Riyadh S. A.

52 Obesity Surgery Program
Started October 2002 Offering Gastric balloon Gastric banding VBG Gastric bypass Gastric sleeve Total cases till December

53 King Faisal Specialist Hospital Experience in Bariatric Surgery


55 How to decide which operation
Age Co-morbidities Re-operative cases BMI Surgeon recommendation Patients request Word of mouth – many requests for sleeve

56 KFSHRC Experience with sleeve gastrectomy
Started in August 2005

57 Why Sleeve Gastrectomy
Patients not accepting Gastric Bypass Gastric Band - poor wt. loss VBG - poor QOL BPD – Patients F/U?? Encouraged by early results Pts – understanding, acceptance, word of mouth.

58 Advantages of Sleeve 2. Easy to perform 3. No need for supplements
1. No foreign body 2. Easy to perform 3. No need for supplements 4. Low maintenance 5. Anatomical 6. Physiological ?

59 Advantages cont’d 7. Easy to convert (second stage) – BPD or LGB
8. Ghrelin reduction 9. Good for super-obese 10.Good when PBD or LGB are contra- indicated 11. Good quality of life

60 Sleeve Gastrectomy disadvantages
1. Not reversible 2. No long term follow up 3. Stomach may dilate 4. Purely restrictive ? 5. Ghrelin reduced 6. GERD (11%)

61 Biennial





66 Sleeve Gastrectomy Length of Stay
94 % Same day admit 84% discharged day I or 2 3 (0.9%)conversion to open

67 Mean % excess wt loss 6 Months 60.5% (#170) 12 months 76% (#101)

68 Major M&M 18(5.4%) Staple line leakage 5 (1.5%) Re-op for bleeding
2 pt developed stricture 1pt developed Port site hernia 1 pt died post-op (PE)


70 Mean % excess wt loss at 12m
LSG % (#101) LGB % (#62) VBG % (#61)

71 Staple line leakage LSG / (5.4%) LGB / (0%) VBG / (5.4%)


73 Summary Obesity is a major health problem worldwide, as well as in the Kingdom. It is secondary to imbalance between energy intake and expenditure. Approach to management, should be team approach. Main aim of management, is to change the behavior, which ultimately will reduce weight.

74 Summary Surgery is the only management option that proved to be effective in weight reduction of obese patients in long term. We believe LSG is one of safe options of the armamentarium of beriatric surgery.

75 Summary Obesity surgery program at KFSH&RC offering a battery of beriatric surgery operations to match the need of different beriatric patients.


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