obesity-final.ppt medical and surgical aspect

obesity-final.ppt medical and surgical aspect

1. obesity

2. definition Obesity is defined as a state of excess adipose tissue mass that adversely affects health. The direct measurement of fat mass is not something that is readily undertaken in routine clinical practice, so a proxy measure, the body mass index (BMI), is generally used. This is calculated as weight/ (in kg)/height in m2

3. Epidemiology In  1997 the WHO formally recognized obesity as a global epidemic. WHO further study that by 2015, approximately 2.3 billion adults will be overweight and more than 700 million will be obese. At least 20 million children under the age of 5 years are overweight globally in 2005.

4. Etiology Multifactorial disorder Genetics: Polygenic. It has been long known that the tendency to gain weight runs in families. However, family members share not only genes but also diet and life style habits that may contribute to obesity. morbid obesity has a stronger genetic component than moderate level of excess overweight Energy imbalance. Diet ( increase Food especially Fatty diets) major cause of Obesity. Exercises (Link between physical inactivity and weight gain).

5. Etiology At an individual level, a combination of excessive  caloric  intake and a lack of  physical activity . Is the major cause of obesity.

6. Hypothyroidism. Cushing’s syndrome. Polycystic ovarian syndrome. Hypothalamic insufficiency. pancreatic insulinoma. Medical causes:

7. Medications : Cortisol and other glucocorticoids. Sulfonylurea. Antidepressants. Antipsychotics, e.g. MAOIs, Risperidone. Oral contraceptives. Insulin. Psychatric causes: Major depression. Binge eating disorders

8. Syndromes with obesity

9. Genes in obesity

10. The clinical assesment of an obese Subject History. Physical Examination. Investigation.

11. Obesity focused history Take a full Hx. Age of onset of obesity. The pattern of weight gain and loss since puberty. The level of activity and exercise. The weight of the partner and children may give an indication about shared dietary habits and lifestyle. Drug history and Past or present use of weight loss medications. The psychological aspects such as loneliness, boredom, or stress.

12. Smoking or alcohol consumption habits. Family history is important familial predisposition should be considered if at least one first degree relative is also obese. Assess any co-morbidities that are directly or indirectly related to obesity. Detailed dietary history of the patient’s current diet. Review of the systems . GERD

13. Examination: Vital signs. General examination. Thyroid. Signs of Organo Megally. e.g. liver (liver span ) Heart and lung sounds.

14. Mild hirsutism in women  Poly Cystic Ovary Syndrome ( PCOS ---- increase weight because of insulin resistance). Large neck size  Sleep apnea . Thyroid tenderness or goiter  Hypothyroidism . Dry or coarse skin and hair  Hypothyroidism . Slowed reflexes  Hypothyroidism . Proximal muscle weakness  Cushing’s syndrome, Hypothyroidism . Skin striae  Cushing’s syndrome, steroid use. Physical examination should target signs or conditions that predispose to or are complications of obesity!!

15. waist circumference It is Important to note that waist circumference is measured at the level of the iliac crest . Excess abdominal fat is clinically defined as a waist circumference of * >40 inches (>102 cm) in men *of>35 inches (>88 cm) in women. central (visceral) adiposity carry a greater health risk than peripheral adiposity. For this reason, the measurement of the waist circumference in centimeters can be a useful indicator of clinical risk, particularly for hypertension, diabetes, or dyslipidaemia.

16. waist to hip ratio (WHR) A measurement of waist to hip ratio (WHR) is an appropriate method of identifying patients with abdominal fat accumulation . The waist is measured at the narrowest point and the hips are measured at the widest point . A high WHR is defined as: *>( 0.95 )1.0 in men. *>( 0.85 )in women.

17. Secondary causes of obesity Secondary causes of obesity are medical conditions or medications that can lead to weight gain or difficulty losing weight. Evaluating for these causes involves a thorough history, physical examination, and targeted diagnostic tests.

18. Indications for Evaluating Secondary Causes of Obesity Rapid Weight Gain : Significant weight gain over a short period. Refractory Obesity : Difficulty losing weight despite adherence to diet and exercise. Associated Symptoms : Symptoms suggesting an underlying condition (e.g., fatigue, hair loss, menstrual irregularities). Family History : Family history of endocrine disorders. Physical Examination Findings : Signs such as hypertension, moon facies, abdominal striae, or goiter.

19. Common Secondary Causes and Their Tests 1.Hypothyroidism SYMPTOMS OF HYPOTHYROIDISM Weight gain Hair loss Dry skin Fatigue Constipation Menorrhagia Depression Insomnia

20. Tests : Thyroid function tests (TSH, Free T4). Interpretation : Elevated TSH low Free T4 indicate hypothyroidism.

21. 2.Cushing's Syndrome Trunchal obesity Moon like facies Buffalo hump Purplish stria Proximal myopathy Osteoporosis Hirsutism Menstrual irregularities in females

22. 24-hour urinary free cortisol, late-night salivary cortisol, low-dose dexamethasone suppression test. Interpretation : Elevated urinary or salivary cortisol levels and lack of suppression with dexamethasone suggest Cushing's syndrome . TESTS TO DIAGNOSE CUSHING SYNDROME :

23. Polycystic Ovary Syndrome (PCOS OBESITY INSULIN RESISTANCE IRREGULAR MENSTRUATION INFERTILITY HIRSUITISM ACNE DYSLIPIDEMIA METABOLIC SYNDROME AND CARDIOVASCULAR DISEASE

24. Tests : Serum testosterone, LH/FSH ratio F asting insulin G lucose levels. Interpretation : Elevated testosterone, increased LH/FSH ratio insulin resistance are indicative of PCOS.

25. Growth Hormone Deficiency Tests : Serum IGF-1 GH stimulation tests. Interpretation : Low IGF-1 and subnormal response to GH stimulation tests indicate GH deficiency .

26. Medications Assessment : Review of medication history. Common Culprits : Antipsychotics Antidepressants Corticosteroids antiepileptics insulin sulfonylureas.

27. Interpretation and Management Once a secondary cause is identified, management involves treating the underlying condition: Hypothyroidism : Thyroid hormone replacement therapy. Cushing's Syndrome : Surgical removal of the adrenal or pituitary tumor, medications to control cortisol production.

28. PCOS : Lifestyle changes, metformin, oral contraceptives, anti-androgens. Growth Hormone Deficiency : GH replacement therapy. Medication-Induced Obesity : Adjusting or switching medications under medical supervision. Early identification and treatment of secondary causes can significantly impact weight management and overall health.

29. Behavior modification: Identify the circumstances that trigger eating. Grocery shopping with a pre planned list. Do nothing else while eating (watch TV or read magazines). Eat slowly. Follow a balanced diet.

30. Surgical intervention

31. Cause of obesity is non medical . Age below 60 years. BMI above 40, or 35 with co morbedites. Conservative treatment has been tried. The patient is cooperative. Subject must be psychologically stable and wiling to follow postoperative diet instruction Criteria

32. Adjustable gastric banding

33. Reducing the stomach volume by creating a small pouch at the top of the stomach using a band. Holds approximately 110 to 220g. Pouch fills quickly and sends total stomach satiety signals to the Brain. Results In The Subject is less hungry most of the time. Early satiety for longer periods. Consumption of smaller portions.

34. 50% to 60% weight loss with exercise add 10 more %. Reduction of related co morbidities. Fully reversible. No cutting or stapling of the stomach. Quick recovery, Short hospital stay. Adjustable without further surgery. No malabsorption issues. Fewer life-threatening complications. Advantages

35. Digestive Nausea, vomiting. obstruction . Constipation. Dysphagia . Diarrhoea . Band & port specific Band slippage/ Pouch dilatation. Esophageal dilatation/ dysmotility . Erosion of the band into the gastric lume n. Port site pain & displacement . Infection of the fluid within the band . complication

36. Gastric bypass procedure

37. Its A Combination of restrictive & malabsorptive operations. The most common performed bariatric procedure in the United States. Functions by creating a small proximal gastric pouch with gastrojejunostomy.

38. Benefits : Rapid weight loss. 60% to 70% loss of excess body weight. 10% more by exercise . Complications: Anastomotic leakage &stricture. Dumping syndrome. Nutritional deficiencies. ( B12 ,EDAK ) Gallstones Complications of abdominal Surgery.

39. Sleeve Gastrectomy

40. The stomach is reduced to about 15% of its original size, by removing a large portion of the stomach, following the major curve . The open edges are then attached together (often with surgical staples ) to form a sleeve or tube with a banana shape. The procedure permanently reduces the size of the stomach. The procedure is performed laparoscopically and is not reversible .

41. Advantages: Increase in satiety. Stomach functions normally . No dumping syndrome (the pyloric portion of the stomach is left intact). No foreign body usage. Simpler and less operative time. complications: Leakages & Infection along the staple line. GERD. Gallstones. postoperative gastric fistula .

42. In summary Obesity is imbalance in energy homeostasis . We start the management by the life style modification  then medications  then surgery roux-en-Y gastric bypass is the best surgical treatment for morbidly obese patients Leak is the commonest early complication in gastric bypass In choosing the best surgical technique we have to put in mind the patients life style, so in a chocoholic we never do banding If we decide to do a surgery for morbid obese pt, pt have to loss wt first then undergo surgery, to do this, gastric balloon and after loss wt  go to surgery.

43. Thank you