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Surgical approach to obesity

Surgical approach to obesity. Human body consists of:. Water about 65% Proteins about 20% Fat: man 10-15%, woman 20-25% Mineral salts of about 5%. Obesity – definition BMI. Obesity – we can talk about when the appropriate contence of the fat is exceeded.

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Surgical approach to obesity

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  1. Surgical approach to obesity

  2. Human body consists of: • Water about 65% • Proteins about 20% • Fat: man 10-15%, woman 20-25% • Mineral salts of about 5%

  3. Obesity – definition BMI Obesity – we can talk about when the appropriate contence of the fat is exceeded. There are different ways to establish the appropriate mass of the body

  4. Morbid Obesity is a serious disease process, in which the accumulation of fatty tissue on the body becomes excessive, and interferes with, or injures the other bodily organs, causing serious and life-threatening health problems, which are called co-morbidities.

  5. Along with the percentage increase of the body fat contenence increases a non-fat body mass It hapens so till fat makes of about 45% of the body

  6. WHR - waist to hip ratio Proper values • Women 0,8 • Men 0,94

  7. Types of obesity • It is important • how much obesity is pronounced • where the fat is depoted • Visceral (apple-shaped considering mainly men) • Gluteofemoral ( pear-shaped considering mainly women)

  8. Obesity - comorbities There are strong epidemiological evidences that upperbody obesity is associated with the development of numerous obesity-associated complications as: • Diabetes • Hypertension • Cardivascular disorders • Dislpidemia

  9. Health Effects of Morbid Obesity • Shortened Life Span • Dysmetabolic Syndrome X • Heart Disease • High Blood Pressure • High Blood Cholesterol • Diabetes Mellitus • Sleep Apnea Syndrome • Respiratory Insufficiency

  10. Health Effects of Morbid Obesity • Heartburn - Reflux Disease • Asthma and Bronchitis • Gallbladder Disease • Urinary Incontinence • Degenerative Disease of Lumbo-Sacral Spine • Degenerative Arthritis • Venous Stasis Disease • Emotional/Psychological Disease

  11. Peripheral obesity is much less harmful The machanism by which visceral obesity leads to many copmlications are not known

  12. It is assumed that increased level of free fatty acids in the portal vein due to increased rate of lipolysis is a major pathophisiological factor The mechanism for increased visceral fat mobilization in upper-body obesity appear to reside at the receptors for the major lypolisis regulating hormones –catecholamins and insulin

  13. Obesity – is this a problem? • Obesity is a significant public health crisis in the developed world ( mainly US) • Prevalence is increasing rapidly

  14. Ways of treatment • Changing of lifestyle • Diet • Farmacology • Surgery

  15. There has never been a scientific study which has shown that dietary management is beneficial or effective, over the long term, in the severely obeseperson.

  16. No drug programsare sufficiently powerful, or adequately long-lasting, to produce the necessary sustained weight loss in the severely obese.

  17. Types of surgery • Gastric restrictive operations • Malabsorptive procedures

  18. Gastric restrictive operations • Laparoscopic Adjustable Gastric Banding • Vertical Banded Gastroplasty (VBG)

  19. Malabsorptive procedures • Gastric Bypass, Roux en-Y • Laparoscopic Gastric Bypass, Roux en-Y • Bilio-Pancreatic Diversion • Duodenal Switch (DSBPD)

  20. Laparoscopic Adjustable Gastric Banding

  21. It can be inserted laparoscopically, without the usual large incision. It does not require any opening in the gastrointestinal tract, so infection risk is reduced. There is no staple line to come apart. It is adjustable.

  22. Vertical Banded Gastroplasty (VBG) • Feeling of fullness is not associated with a feeling of satisfaction. • People discover that eating junk food, or eating all day longhelps them to feel more sense of satisfaction and fulfillment • weight loss is defeated.

  23. Laparoscopic Gastric Bypass, Roux en-Y • The benefits of the laparoscopic approach come from the very small incisions which are necessary, which cause much less pain, and very little scarring. • Patients are able to get up and walk within hours after surgery. • Can breath easier • Move without discomfort. • Bowel activity usually is not affected, as it is with an open incision. • Most persons find they can return to normal activities within 10 – 12 days, sometimes even sooner.

  24. Jejuno-Ileal Bypass  • This operation was one of the earliest procedures devised for serious obesity • Achieved its effects by shortening the overall length of the bowel to less than 10% of its normal length. • It caused severe, non-selective malabsorption of foods, which brought about weight loss, but also resulted in serious nutritional and metabolic side-effects, some of which were very dangerous.  • Patients could eat all they wanted, but absorbed very little of the food.  • All patients  experienced diarrhea, up to 15 - 20 bowel movements per day.  • The  procedure was responsible for strange arthritic symptoms, kidney damage, and irreversible liver damage, in many patients.

  25. The patient is placed on the table and general anesthetics are administered. Trocars are placed as shown in this picture.

  26. The stomach is sized to a small pouch by first identifying the esophago-gastric junction.

  27. A retrogastric-retrocolic tunnel is performed in the mesocolon anterior and lateral to the ligament of Treitz. This "window" will facilitate the passage of the Roux-limb.

  28. In order to create the Roux-limb, the jejunum is divided 15 cm beyond the ligament of Treitz by using an Endo GIA II stapler (US Surgical), 45 mm long with 3.5 mm staples. In addition the mesentery is also divided with a Endo GIA II stapler, but this time using the vascular load (45 mm length, 2.0 mm staples). This maneuver will facilitate mobilization of the small intestine through the mesocolon. A rubber drain is sutured to the jejunum to help with the pulling.

  29. The Roux-limb is measured according to the patient BMI (Body Mass Index) and can range from 75 to 200 cm in length. Notice that the laparoscopic grasper is used as a ruler.

  30. An end-to-side anastomosis between the proximal jejunum and the roux limb is created by firing two Endo GIA II staplers. The enterotomy is closed using another load of staples. The mesentery is also closed to prevent bowel entrapment (internal hernias).

  31. Close up view of the entero-enterostomy.

  32. The Roux-limb is now advanced through the mesocolic window (retrocolic and retrogastric) near the transected stomach.

  33. Using the rubber drain, the Roux-limb is pulled to a retrogastric position.

  34. Following an enterotomy an anastomosis between the gastric pouch and the Roux-limb is created by firing a Endo GIA II.

  35. The enterotomy is stapled shut with another load of Endo GIA II. The anastomosis is secured by placing an extra row of stitches. The gastrojejunostomy and the enterotomy site are tested for leakage by applying insufflation through an nasogastric tube (or endoscope) and submerging the area in irrigation solution.

  36. Side-Effects of the Gastric Bypass, and the Gastric Banding • Nausea • Food Intolerance • Changed Bowel Habits • Transient Hair Loss • Loss of Muscle Mass

  37. Complications of Surgery • Infection Abscess, Wound Infection, Urinary Tract Infection • Leakage of Bowel Connections • Bleeding • Obstruction of the Stomach Outlet • Lung Problems Atelectasis, Pneumonia, Pulmonary Embolism • Mortality - perioperative 1% • Chronic Nutritional Problems Protein, Vitamin, Mineral deficiency

  38. Listing of complications following vertical banded gastroplasty: LeakStenosis with persistent vomiting, if untreated, causing neurological damageUlcerIncisional herniaWound InfectionBand erosion

  39. Operate or not? • Diabetes mellitus Over 90% of Type II diabetics obtain excellent results, usually within a few days after surgery: normal blood sugar levels, normal Hemoglobin A1C values, and freedom from all their medications, including insulin injections • High blood pressure At least 70% of patients who have high blood pressure, and who are taking medications to control it, are able to stop all medications and have a normal blood pressure, usually within 2 – 3 months after surgery. When medications are still required, their dosage can be lowered, with reduction of their annoying side-effects.

  40. Listing of complications following gastric bypass: • Early: • Leak • Acute gastric dilatation • Roux-Y obstruction • Atelectasis • Wound Infection/seroma • Late: • Stomal Stenosis • Anemia • Vitamin B12 deficiency • Calcium deficiency/osteoporosis

  41. Mortality among morbidly obese person 6 years after surgery was of 9% whereas among morbidly obese without surgery was 27%

  42. Malabsorptive procedures give greater and longer lasting effect of waight loss than restrictive ones!

  43. Thank You And have a nice weekend

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