Morbid obesity

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1. Morbid Obesity Facebook: Happy Friday Knight General Surgical Residency Program Thailand

2. INTRODUCTION

3. Pathogenesis Overweight develops lifestyle: sedentary sleep deprivation smoking cessation Diet: overeating fat and fast food intake night-eating syndrome and binge-eating disorder

4. pathogenesis Drug-induced: antipsychotics and antidepressants AEDs diabetic drugs Cyproheptadine , beta-blocker Neuroendocrine system Genetic and congenital disorders Prader -Will syndrome

5. https://consultqd.clevelandclinic.org/2015/07/managing-psychosocial-risk-factors-in-bariatric-surgery-patients/

6. The Chronic Disease Management Model for Primary Care of Patients with Overweight and Obesity

7. Calculate BMI BMI 18-24.99: Advise to avoid weight gain and treat other risk factors Calculate BMI annually by the clinician B MI ≥ 25 Assess and treat CVD risk factors and obesity-related comorbidities BP, FBS, lipid profile Waist circumference measurement: > 88cm in women, 102cm in men = increased CVD risk

8. Assess weight and lifestyle history Determine the potential factors history of weight gain and loss over time, details of previous weight loss attempts, dietary habits, physical activity, family history of obesity, and other medical conditions or medications that may affect weight Attempt to lose weight and success

9. Assess the need to lose weight BMI > 30 or 25-30 with risk factor Assess readiness to make lifestyle changes to achieve weight loss Determine weight loss and health goals and intervention strategies 5 – 10% weight loss within 6 months Caloric restriction: 1200-1500 kcal in women and 1500-1800 kcal in men Adjust medication

10. High intensity comprehensive lifestyle intervention Moderately-reduce caloric diet Increase physical activity > 200 min/week Behavioral changes BMI ≥ 30 or ≥ 27 with comorbidity Adding pharmacotherapy as an adjunct to lifestyle modification Orlistat: reduce intestinal fat absorption Rimonabant Sibutramine  out

11. BMI ≥ 40 or ≥ 35 with comorbidity: refer to bariatric surgeon Weight loss ≥ 5% = success: follow up and weight loss maintenance If not, refer to specialist

12. Principles of Bariatric Surgery

13. Types of commonly performed bariatric operations by mechanism of action Primarily restrictive Laparoscopic adjustable gastric banding (LAGB) Sleeve gastrectomy (SG) Primarily malabsorptive Biliopancreatic diversion (BPD) Duodenal switch (DS) Combination Roux- en -Y gastric bypass (RYGB)

14. Potential Contraindications Severe medical disease making anesthesia or surgery prohibitively risky (ASA class IV) Mentally incompetent to understand the procedure Inability or unwillingness to change lifestyle postoperatively Drug, alcohol, or other addiction Active problem of bulimia or other eating disorder Psychologically unstable Nonambulatory status Unsupportive home environment

15. Indications BMI ≥ 40 kg/m2 BMI 35 – 40 kg/m2 with comorbid medical conditions Fail attempt at medically supervised diet Psychiatrically stable

16. Preoperative Issues Patient selection Preoperative preparation Anesthesiology issues

17. Patient Selection Insurance coverage Suitable for bariatric surgery by NIH criteria Patient’s motivation to change eating habit Assessment of eating habits, knowledge, self-awareness, insight Psychological assessment

18. Preoperative Preparation Comorbidities with optimal therapy Look for hidden diseases: CAD  EKG, echo, CAG OSA  sleep study Asthma and hypoventilation syndrome of obesity  pulmonary consultation GERD  EGD to rule out Barrett’s esophagus VTE  IVC filter? Perform US to rule out GS

19. Preoperative Preparation Smoking cessation: reduce risk of marginal ulcer TFT to rule out hypothyroidism

20. Laparoscopic VS Open Minimize open technique complications: incisional hernia and wound complications Earlier hospital discharge Lower 30-days complication rates Conclusion: favor laparoscopic

21. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10 th ed. McGraw-Hill Education, 2015.

22. Postoperative Follow-Up Short term: Up to 2 years More than 5 years The goals Maximize care postoperative period Assist in adjustment to new lifestyle patterns Alert and treat post-op complications Recommend measures to limit complications Objective data Weight loss Change in BMI Improvement in medical comorbidities

23. Laparoscopic Adjustable Gastric Banding Placement of inflatable sillicone band around proximal stomach and allowing adjustment tightness of the band

24. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10 th ed. McGraw-Hill Education, 2015.

25. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10 th ed. McGraw-Hill Education, 2015.

26. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10 th ed. McGraw-Hill Education, 2015.

27. LAGB: Patient Selection Not as difficult as other operations outpatient Offer to older, more medically ill, higher risk patients efficacy of the operation in BMI >50 kg/m2 is less impressive

28. LAGB: Post-Op Care and Follow-Up Band adjustment Multivitamin supplement Postoperative support group session

29. LAGB: Complications Prolapse Slippage Erosion Port and tube complications Failure to lose weight: more common than other bariatric surgery

30. Prolapse Most common Clinical: post-op vomiting Pathogenesis: lower stomach was trapped within the lumen of the band Evaluation: band in horizontal position

31. S lippage Reduced by pars flaccida technique

32. Laparoscopic Roux- en -Y Gastric Bypass M ajor feature of the operation is a proximal gastric pouch of small size (often <20 mL) that is totally separated from the distal stomach The biliopancreatic limb is 20-50 cm long from ligament of Treitz Roux limb: 75-150 cm Longer limb, higher short-term weight loss

33. LRYGB: Patient Selection appropriate for most bariatric patients Contraindication previous gastric surgery previous antireflux surgery severe iron deficiency anemia distal gastric or duodenal lesions that require ongoing future surveillance Barrett’s esophagus with severe dysplasia

34. LRYGB: Patient Selection EGD is required Mechanical bowel preparation is advised

35. LRYGB: Post-Op Care and Follow-Up Hospitalize for 2-3 days Major concerns: adequate analgesia, adequate resuscitation, and early ambulation Employ post-op oral contrast study: to detect edema, stenosis, or other obstructive lesions at enteroenterostomy site  resulting gastric dilation and staple line rupture

36. LRYGB: Outcomes Usually lose between 60 % and 70% of excess body weight during the first year after surgery Mortality less than 0.5%

37. LRYGB: Complications Post-op nutritional complication: IDA, vitB12 def , vitD def A nastomotic leak venous thromboembolism wound infections marginal ulcers bowel obstruction postoperative transfusion Anastomotic stenosis

38. LRYGB: Complications That Need Surgical Intervention Small bowel obstruction: from internal hernia Early postoperative vomiting with obstructive picture Early postoperative hematemesis with obstructive picture: from gastrojejunostomy Intestinal leak Postoperative bleeding

39. Biliopancreatic Diversion and Duodenal Switch Resection of distal half to two-thirds of the stomach and creation of an alimentary tract of the most distal 200 cm of ileum Limited popularity

40. BPD with DS: Patient Selection Must be prepared the consequence of malabsorption Frequent, voluminous bowel movement

41. BPD with DS: Post-Op Care Monitor nutritional status closely Same potential complication seen in RYGB

42. BPD with DS: Outcomes Weight loss results: excellent and durable Gallstone formation if not removed

43. Laparoscopic Sleeve Gastrectomy Rapidly increasing in popularity Advantage: easier operation than gastric bypass, better outcome than gastric banding Indications: Super obesity (BMI> 60) Safe for both adolescent and elderly Contraindication: GERD, Barrett’s esophagus since future esophagectomy

44. SG: Post-Op Care Same as LRYGB Absence of signs of bleeding and a documented intact staple line with good gastric emptying are required prior to discharge.

45. SG: outcomes and complications Proximal staple line leakage: SG creates a high luminal pressure tube Look for distal obstruction

46. References Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American Pharmacists Association, American Society for Nutrition, American Society for Preventive Cardiology, American Society of Hypertension, Association of Black Cardiologists, National Lipid Association, Preventive Cardiovascular Nurses Association, The Endocrine Society, and WomenHeart : The National Coalition for Women with Heart Disease. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults . http:// circ.ahajournals.org/content/circulationaha/early/2013/11/11/01.cir.0000437739.71477.ee.full.pdf Brunicardi FC et al. Schwartz’s Principles of Surgery. 10 th ed. McGraw-Hill Education, 2015. ธีรพล อังกูลภักดีกุล, ปรีดา สัมฤทธิ์ประดิษฐ์, และไพศาล พงศ์ชัยฤกษ์. ศัลยศาสตร์วิวัฒน์ 44: ศัลยศาสตร์สำหรับโรคเมตาบบอลิกและโรคอ้วน.กรุงเทพมหานคร : กรุงเทพเวชสาร, 2554.