Bariatric Surgery Mr B.M.Axisa Consultant Laparoscopic and Upper GI Surgeon

Obesity is a Disease Risk factor for: Diabetes Diabetes Hypertension Hypertension Hyperlipidaemia Hyperlipidaemia Coronary disease Coronary disease Sleep apnoea Sleep apnoea Arthropathy Arthropathy Cancer Cancer Physcological disorders Physcological disorders Attitude change towards problem

Obesity Trends* Among U.S. Adults 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

Obesity Trends* Among U.S. Adults 1986 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

Obesity Trends* Among U.S. Adults 1987 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

Obesity Trends* Among U.S. Adults 1988 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

Obesity Trends* Among U.S. Adults 1989 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

Obesity Trends* Among U.S. Adults 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

Obesity Trends* Among U.S. Adults 1991 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults 1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults 1993 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults 1994 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults 1996 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults 1997 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. Adults 1998 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. Adults 1999 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. Adults 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. Adults 2001 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) Obesity Trends* Among U.S. Adults 2002 No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. Adults 2003 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. Adults 2004 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. Adults 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Management of Obesity Conservative: Diet, exercise, behavioural modification MedicalSurgical

Medical Management BMI of 28.0 kg/m2 or more with associated risk factors or BMI of 30.0 kg/m2 or more. Treatment for longer than 3 months if >5% initial body weight lost Continue for longer than 12 months only after discussing potential benefits and limitations. Rimonabant (Acomplia) withdrawn

Orlistat (Xenical ® ) Inhibits absorption of fat Take before meals Adverse effects: Flatulence Fatty oily stools Faecal urgency 1kg per month. 12% had 10% loss Vitamin deficiencies

Sibutramine (Reductil ® ) Affects appetite centre in brain Once daily Stimulant. Hypertension Avoid in epilepsy Need to monitor blood pressure Similar effectiveness to Xenical 15% had 10% weight loss

Bariatric Surgery

Patient selection Weight BMI > 40kg/m 2 BMI > 35kg/m 2 with medical comorbidities Failure of non surgical attempts at weight reduction Psychological stability

Types of operation Restrictive Roux-en-Y gastric bypass Vertical banded gastroplasty Adjustable gastric banding Malabsorptive Biliopancreatic diversion Combined Long limb gastric bypass

Lap Band

Lesser curve dissection Lesser curve dissection

Band in place

Suturing of Band

Laparoscopic Ports

Gastric Bypass Pouch 15-30mls 1.0cm opening Staple line disruption in undivided Length of Roux loop

Gastric Pouch

Gastrojeunal Anastomosis

Lap Bypass

Vertical Banded Gastroplasty

Biliopancreatic diversion

Duodenal Switch

Results Operation 5 year EWL 10 year EWLMortality Lap band 50-70%55% % VBG60%-1-1.4% Gastric bypass 70%- 0 – 1.2% BPD70%60-79%1-2%

Complications: General Atelectasis DVT and Pulmonary embolism Wound infection BleedingCholelithiasis

Complications: Specific Leaks: challenging diagnosis Band slippage/erosion/infection Acute gastric dilatation Stomal ulcers 12-15% / stenosis Nutritional deficiencies Fe Vit B 12 Folate Calcium Malabsorptive procedures Protein calorie malnutrition Fat soluble vitamin deficiency

Future Gastric pacing Gene therapy

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