A brief overview of bariatric surgery , a small study of 35 cases. All had successful results.

1. SHANTI MEMORIAL HOSPITAL PVT. LTD

2. BARIATRIC SURGERY IN
ODISHA - AN OVERVIEW
DR SREEJOY PATNAIK
LIFE MEMBER , SAGES, OSSI & IFSO
MINIMAL ACCESS , BARIATRIC & METABOLIC
SURGERY

3. OBESITY AND METABOLIC SURGERY
SOCIETY OF INDIA

4. IFSO CONGRESS - 2010, 2011, 2012

5. IFSO
2013

6. Definition of Bariatric Surgery
• Bariatric surgery or weight loss surgery is a
variety of surgical procedures performed on
obese subjects.
• It is done either by • Reducing the size & capacity of the stomach.
• OR by
• Resecting & re-routing the small intestines to a
small gastric pouch.

7. SCARY
STATISTICS

8. How do we measure obesity
•We classify obesity according to BMI
( Body mass index )
•BMI = body weight in kg / height in m2

9. Classification of BMI
• 18-25 = Normal
• 25-30 = Obese
• 30-35 = Class 1
• 35-40 = Class II
• 40-45 = Class III
• > 45 = Morbid or super obese

10. Why we are worried about obesity?
• What is its significance ?
• Because of its co-morbidities

12. Comorbidities
1. Cardiovascular – CAD, HTN,CHF,LVF
& Dyslipidaemia.
2. Pulmonary
– OSA, OHS, PAH, Asthma
3. Haemopoetic
– DVT & PE
4. GI
– GERD, NAFLD,
Hiatus hernia, Gallstones
5. Genito-urinary
– stress incontinence, UTI

13. Comorbidities
6. Obstetrics / Gynecology
– Infertility, Miscarriage, fetalabnormalities, infant mortality,
gestational DM
7. Musculosketal
– OA, Gout, Plantar fasciitis, carpel
tunnel syndrome.
8. Neurology / Psychiatric – CVA, pseudo motor cerebri,
depression and anxiety.
9. Cancer
– Oesophagus, pancreas, colon &
rectum, breast, endometrial, kidney,
thyroid and GB.

14. Morbidity
• BMI > 35 - Risk of death = 2.5 times greater
• BMI > 40 - Risk of death = 10 times greater
• OBESITY > 2 leading cause of preventable
nd
premature deaths in USA

15. Treatment of obesity

16. DRUGS
• ORLISTAT
• NEWER DRUGS• BELVIQ (LOCASERIN)
• QSYMIA (PHENTERMINE/ TOPIRAMATE)
• VICTOZA (LIRAGLUTIDE)

17. Bariatric Surgery - Goals
Surgery to Create Sustainable & significant
Weight Loss in Severely Obese Patients.
Resolution or Cure of Co-morbidities
Reduction of Obesity Related Mortality

18. GUIDELINES
• SAGES – Society of American Gastro Endo
surgeons.
• ASMBS – American society of Metabolic &
Bariatric Surgery.
• NIH – National Institute of Health.

19. Whom do we advise Surgery ?
BMI > 40 without comorbidities.
BMI > 35 with 2 comorbidities .
Age – 18 – 60 years( < 12- 65 )
Stable obesity for > 5 years
Unsuccessful dietary / drug treatment
Absence of Endocrine disease
Pt. should be sufficiently comprehensive &
compliant.
No h/o excessive alcohol or drug abuse
Acceptable Operative Risks

20. How do we classify the surgical
procedures ?
A. Restrictive
B. Malabsorptive
C. Combination – restrictive and
malabsorptive

21. Restrictive procedures
• Creation of a small gastric pouch & limiting
the gastric volume & continuity is not altered.
• Vertical banded Gastroplasty
• Adjustable Gastric Banding
• Sleeve Gastrectomy
• Gastric Plication
• BIB – Intra Gastric Balloon

22. RESTRICTIVE PROCEDURES
LSG
LGP
VBG
LAGB
INTRA –GASTRIC BALOON

23. A Restrictive Procedure is
 Safer
 Easier
 Faster
 Easier to cheat
 Less Effective for Weight Loss
BUT ALSO
BUT ALSO
 Less beneficial for Diabetes
control

24. Malabsorptive procedures
• Malabsorption is achieved by creating a short
gut syndrome with distal mixing of bile and
pancreatic juice with ingested food.
• Bilio-pancreatic diversion
• Jejunal ileal bypass
• Endoluminal sleeve ( Endo-barrier)

25. MAL ABSORPTIVE PROCEDURES
BPD - DS
ENDOLUMINAL SLEEVE OR
DJ BYPASS LINER

26. A Malabsorptive Procedure is
 More effective for weight loss??
 More risky??
 More Nutritionally demanding

27. Combination procedures
• Combination of restriction alongwith malabsorption .
• Small gastric pouch + a bypass.
• Early sense of fullness, combined with a sense of
satisfaction that reduces the desire to eat.
• RYGB
• LSG with DS
• MGB

28. COMBINATION PROCEDURES
LSG + DS
LRYGBP
MGBP

29. Combining Both Restrictive &
Malabsorptive methods has
The Pros and Cons of Both

30. History of Bariatric Surgery
• 1950s- Open Gastric Bypass, BPD
• 1990- Laparoscopic Bariatrics- LRYGBP, LAGB
• 2000- Laparoscopic Sleeve Gastrectomy
• 2003- Gastric Plication & ileal Transposition

31. Historical Perspective
Jejunoileal Bypass (JIB)
Vertical Banded
Gastroplasty (VBG)

32. Gold standard procedures
• Laparoscopic Sleeve Gastrectomy
• Laparoscopic Roux-en-Y Gastric Bypass
• Laparoscopic Mini Gastric Bypass
• Laparoscopic Adjustable Gastric banding

33. Bariatric Procedures Performed Today

34. Bariatric Procedures Performed
Today

35. Bariatric Procedures Performed
Today

36. Selection of a procedure
•
There is No evidence on procedure selection -most
frustrating shortfall in bariatric surgery.
•
Best procedure should reduce weight, induce remission
of Diabetes, & improve quality of life.
•
•
Multi disciplinary team assessment .
The choice of procedure is determined by the individual’s
phenotype, the aims of therapy, & peri-operative risks.

37. Selection of Procedure
•
Each procedure should be tailor made for each
individual.
•
The choice of the procedure is a complex process with
patient & their interests at its core.
•
The surgeon’s experience to deal with the inevitable
complications of each procedure & to manage long
term follow up care should be the goal to success.

38. Pre-op assessment
•
•
Patient should be physically & psychologically fit.
•
Patients must be determined to comply with the postop. care and instructions on diet.
•
They should be given the correct & realistic information
on what the procedure can achieve.
•
For each patient benefits of the procedure should
outweigh the operative risks.
Individualized assessment-is vital & Psychiatrist role is
important.

39. • A special risk bond is signed by the patient and by
2 more family members.
• Procedure may vary in peri- operative assessment
ie ; diagnostic laparoscopy.
• Primary aim of surgery should
each procedure.
be weight loss with

40. Whom we deny Bariatric Surgery ?
• History of substance abuse, eating disorders, or
major psychiatric problems – untreated or
unresolved
• Patients who are too ill or too high a risk for
surgery
• Women who may become pregnant soon

41. Choosing an ideal Bariatric Procedure

42. Diabetic?
Sweet Eater?
Cola Guzzler?
Reflux?
LAP GASTRIC BYPASS

43. High Risk Bariatric Subject?
Super-super-obese?
Not keen on severe portion control?
Very young?
‘Sold’ patient?
LAP SLEEVE GASTRECTOMY

44. Hostile Abdomen?
Previous Intestinal Resections?
‘Sold’ Patient?
‘Sold’ Physician?
LAP BAND

45. •
Ideal procedure
1. Weight loss - max. with BPD-DS/ LRYGB/ MGB
LSG/ LAGB.
• 2. DM remission - BPD-DS/ LRYGB/ LSG/ LAGB
• 3.OSA/ Asthma
• 4. GERD
- BPD-DS / LRYGB
- LRYGB (No LSG)

46. Investigations
LAB EVALUATION : CBC,FBS, 2HRPGBS, HB1AC, LFT, Urea, Creatinine, Serum
Protein/albumin, Amylase, Serum fasting & post Insulin, C-peptide, lipid profile,
Serum Calcium, Vit. B12, Calcitonin, TFT,Serum & urine Cortisol. HOMA-IRHomeostasis Model of Assessment-Insulin Resistance
UGIE: To rule out inflammatory or ulcer pathology, & treat H.pylori infection.
USG Abdomen – To rule out cholelithiases, which would indicate Lap.
Cholecystectomy alongwith the primary surgery.
Cardio-Respiratory evaluation – To exclude any contraindications to GA by
TMT, 2D echo, PFT, ABG, CXR.
Psychiatry evaluation – To rule out any behavioural abnormalities that would
contraindicate limited food intake.
Endocrine evaluation – To rule out an endocrine abnormality as the etiology of
morbid obesity.
Dental evaluation

47. HOMA-IR
HOMEOSTASIS MODEL OF ASSESSMENT
OF INSULIN RESISTANCE
• INTERNATIONAL FORMULA
• FBG(mmol/L) X Finsulin(Mu/L) / 22.5
• To assess beta cell function & insulin
resistance
• Estimated by euglycemic clamp method
•(
measuring glucose for an increased inslin level, without causing
hypoglycemia)

49. Tools for Bariatric Surgery

50. Safety trocars and Gastric calibration tubes

52. STERRAD – NX
STERILISER
The STERRAD® NXTM Sterilizer is a self-contained stand-alone system of hardware and
software designed to sterilize medical instruments and devices using a patented hydrogen

53. ENERGY SOURCES

54. ANAESTHESIA WORKSTATION , CO2
& GAS MONITORS

55. VIDEO LARYNGOSCOPES

56. FLEXIBLE LARYNGOSCOPE

57. Bair Hugger –
warm blanket

58. SEQUENTIAL COMPRESSION
DEVICE

59. ICU MANAGEMENT

60. Video on sleeve gastrectomy

62. Video on LRYGB

64. Video on MGB

66. Pathophysiology of Bariatric Surgery
•
ROLE OF GI HORMONES IN
REMISSION OF METABOLIC
SYNDROME.
•
Recent theory- Entero-insular axis
has got a role in maintaining
glucose homeostasis.
•
Bariatric surgery results in weight
loss due to surgical manipulation or
bypassing of the gut & by caloric
restriction - leading to remission of
metabolic syndrome.
Metabolic syndrome
For Men
WC > or – 40 inches
TG > or – 150 mg/dl
HDL < 40 mg/dl
BP > or – 130/85 mmHg
FBS > or – 100 mg/dl
For Woman
WC > 35 inches
TG > 150 mg/dl
HDL < 50 mg/dl
BP > 130/85 mmHg
FBS > 100 md/dl

67. GI HORMONES AS INCRETINS & ANTI
INCRETINS

68. WHAT ARE INCRETINS ?
•
Incretins are a group of gastrointestinal hormones that
increase the amount of insulin release from the beta cells
after eating.
•
They also slow the rate of absorption of nutrients into the
blood stream by reducing gastric emptying and reduces food
intake.
•
Inhibits Glucagon release from the alpha cells of the Islets of
Langerhans.
•
•
1. GLP-1- Glucagon-like peptide-1
2 . GIP- Gastric inhibitory peptide or Glucosedependent
insulinotropic polypeptide

69. Mechanism of Incretin action
Stimulates
insulin
release
Lowering
of blood
glucose
Inhibits
glucagon
release

71. WHAT ARE ANTI INCRETINS?
• Anti incretins are a group of GI factors
secreted from the duodenum & proximal
jejunum, which counteract the actions of
INCRETINS.

72. Anti incretin action
HYPERGLYCEMIA

73. ANTI INCRETINS AND GLUCOSE HOMEOSTASIS

75. THE BADDIES

76. GUT - BRAIN AXIS
•The gut–brain axis is a major component of appetite
regulation.
•The gut hormones have either
anorexigenic
( appetite depressant ) or orexigenic ( appetite
stimulant ) action on food intake .
•These gut hormone secretions are altered following
bariatric surgery

77. •
Ghrelin- (orexrgenic / satiety or appetite stimulant hormone)
produced primarily by gastric fundus.
-Its levels are supressed following resection of gastric rich
fundus.
-It stimulates insulin counter-regulatory hormones.
•
Peptide YY
– an anorexegenic (or appetite depressant)
hormone co-secreted with GLP-1 from the
response to food intake.
•
PYY3-36
intestinal L cells in
- ( anorxegenic hormone )
-levels are increased following LRYGB, decreases food intake &
ameliorates insulin resistance and improves glycemia.

78. PROPOSED THEORIES FOR IMPROVED GLYCAEMIA
(A) RAPID HINDGUT DELIVERY
HYPOTHESIS
•Expedited or rapid delivery of ingested nutrients to
lower bowel due to intestinal bypass leads to
stimulation of L cells, ( distal ileum & colon ) which in
turn results in increased secretion of INCRETIN
hormones & improved glucose homoeostasis.
(LRYGB & BPD/DS.)
•Proximal nutrient- related signals that are transmitted
from the duodenum to the distal bowel by neural
pathways leads to increased Incretin secretion.

79. I & AI AFTER BYPASS

80. Hypothesis as to the mechanism responsible for the
control of diabetes after gastric bypass.

81. PROPOSED THEORIES FOR IMPROVED GLYCAEMIA
(B) FOREGUT HYPOTHESIS
•The proximal small intestine
(foregut / BPD limb ) is
excluded resulting in reduction in secretion of Anti –
incretin factors ( diabetogenic hormones) in
response to absence of nutrients in the fore gut.
•This leads to improved glycaemia.
&
•Decreased Intestinal Glucagon synthesis
.

82. ANTI-INCRETIN / INCRETIN HYPOTHESIS
•
After Bariatric Surgery - a physiological balance is
maintained between Anti –Incretins & Incretins,
•
Leads to proper beta cell function & to maintain Blood
Glucose excursions within normal range.
•
Release of excess Anti- Incretins are prevented & there
is a restoration of between Incretins & Anti-Incretins ,
leading to improved glucose homeostasis .

83. •
Diabetes, Obesity & Bariatric
surgery
DM linked with obesity has –
-- insulin resistance, inflammation & lipo-toxicity of beta
cells,
> progressive beta cell failure & hyper-glycaemia.
•After Bariatric Surgery - Glucose homeostasis improves.
- Insulin sensitivity increased markedly
- Adiponectin levels are improved
- Markers of insulin signals in key target tissues are
enhanced.

84. Medical Co-Morbidities Resolved with
Bariatric surgery
Type 2 Diabetes
95%
Hypercholesterolemia
97%
Hypertension
92%
GERD
98%
Cardiac Function
95%
improvement
Stress Incontinence
87%
Osteoarthritis
82%
Sleep Apnea
75%

86. Complications of Bariatric Surgery
The other side of
Mount
Rushmore
South Dakota
USA
Gutzon Borglum and his
son Lincoln Borglum
1925

87. INTRA-OPERATIVE COMPLICATIONS
• Trocar injuries
• Splenic injury
• Portal vein injury
• Bowel ischemia
• Misconstruction

88. EARLY COMPLICATIONS
• Bleeding
• Wound infection
• Anastomotic leaks
• Pulmonary embolism and DVT
• Cardiovascular complications
• Pulmonary complications

89. LATE COMPLICATIONS AFTER RYGB
•
•
•
•
•
•
•
•
- Gastric remnant distension
- Stomal stenosis or stricture
- Marginal ulcers
- Cholelithiasis
- Ventral incisional hernia
- Internal hernias
Vomiting, diarrhea,dumping
syndrome.
Alopecia,cholelthiasis, hypoglycemia
- Short bowel syndrome
- Dumping syndrome
- Metabolic and nutritional
derangements
- iron,vit B12, D,folic acid.
- Renal failure
- Postoperative hypoglycemia
- Change in bowel habits
- Failure to lose weight and weight
regain

90. COMPLICATIONS AFTER SLEEVE
• - Bleeding
• - Stenosis
• - Gastric leaks
• - Reflux
• Alopecia, cholelthiasis, hypoglycemia.

91. How Safe Is Bariatric Surgery?
Mortality Rate- 0.3%
Morbidity Rate- 4.1%
Longitudinal Assessment of Bariatric Surgery, NEJM, 2009

92. OUR
EXPERIENCE IN
BARIATRIC
SURGERY

93. YEAR WISE –BARIATRIC SURGERY CASES
• 2010
• 2011
• 2012
• 2013
- 4 cases
- 4 cases
- 12 cases
- 15 cases

94. PATIENT PROFILE
• 2010 - 2013
• N= 35
• BMI range 35 to 60
• Comorbidities

95. Procedures (n=35)
•
•
Lap adjustable gastric band
0
Lap sleeve gastrectomy
30
•
•
•
•
•
•
Lap gastric bypass
2
Lap duodenal switch
0
Lap gastric plication
0
Ileal Transposition
Revisional Bariatric procedure
MGB
0
1
2

96. Excess body weight loss %Follow up 3- 38 months
•
LSG
32- 85
•
RYGB
38- 88
•
MGB
33- 64
•
REVISIONAL BARIATRIC (SG > MGB)
20

97. OUR PATIENT SERIES
BHUBANESWAR

98. HAPPY AFTER MARRIAGE

99. JAGATSINGHPUR

100. BHAWANIPATNA

101. JAGDALPUR

102. BALASORE

103. KALAHANDI

104. KENDRAPADA

105. BRAMHAPUR

106. AFTER

107. PURI

108. CUTTACK

109. THE MOST ELIGIBLE BACHELOR
CUTTACK -- FIRST CASE

110. DRAMATIC WEIGHT LOSS – 60 KGS IN 4
MONTHS

112. WITH MY DIETICIAN

113. What can be more satisfying than achieving this?

114. OUR SUCCESS

115. • Bariatric surgery
dramatically improves
or cures many obesity
comorbidities.
• But working with an
inexperienced surgeon
can increase your risk
for complications.

116. Metabolic Surgery- A new dimension
RESOLUTION OF DIABETES AFTER
BARIATRIC SURGERY

117. Present status of diabetes surgery
•
Bariatric surgery effectively reverses type 2 diabetes in a high
proportion of morbidly obese patients, within weeks or even days
well before these patients have lost a significant amount of body
weight
•
Diabetes surgery should be considered in patients with BMI > 35
and may also be appropriate for patients with BMI 30-35
Rome Diabetes Surgery Summit 2009

118. Resolution of Diabetes in the Non-Obese?

119. Resolution of diabetes in non obese
Status of Ileal Transposition “Not to be done outside approved trials”
Rome Diabetes Surgery Summit, 2009

120. PRACTICE POINTS
• Extensive Research in the field of Bariatric surgery
( Metabolic surgery, Technology, Endoscopy )
• A career in Bariatrics is very promising……. And
lucrative

121. Diabetes Surgery
• Within 5 years, will
gastrointestinal surgery be
considered an acceptable
option for the treatment
of Type 2 Diabetes in the
non­obese patient?

122. CONCLUSIONS- TAKE HOME MESSAGE
•
BS should be considered with BMI > 40 or BMI > 35
with obesity related 2 co-morbidities.
•
•
Not all pts. are suitable for surgery.
•
The choice of the surgical modality should take the
individual’s goals, surgeon’s experience & existing comorbidities.
A multidisciplinary assessment is essential to select the
appropriate candidates.

123. CONCLUSIONS- TAKE HOME MESSAGE
•
•
Individualised care is determined by clinical evaluation.
•
Procedure selection - should effectively treat & prevent all
co-morbidities alongwith sustained weight loss.
•
Experienced anaesthesist & trained OT & ICU staff is
necessary for success.
•
Long term follow up and repeated counselling is
mandatory for a safe outcome.
Should be performed in experienced centres- with back up
ICU and trained staff for favourable outcomes.

124. THANK YOU
FOR A PATIENT HEARING & WAITING