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SUB-SAHARAN EXPERIENCE OF SURGICAL MANAGEMENT OF OBESITY
DR. RONALD MBIINE (MMED SURGERY) PROF CHARLES IBINGIRA (MMED SURGERY) MAKERERE UNIVERSITY, UGANDA
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OUTLINE Understanding obesity in Africa
Existing treatment practices in Africa Bariatric surgery Experiences Breaking barriers to surgical care of obesity in SSA
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UNDERSTANDING OBESITY IN AFRICA
Last decade has seen a disproportionate increase in NCDs on the African continent. (New Epidemic in Africa) Obesity is a key catalyst in the evolution of NCDs including Hypertension Diabetes Mellitus Coronary Heart Disease Obstructive sleep apnea Obesity now described as a major cause for premature death in Sub-Saharan Africa.
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BACKGROUND … Over 1.3 billion people globally are overweight ( 25 < BMI <30) and 600 million people are obese ( BMI > 30) Over 340 million children and adolescents aged 5-19 were overweight or obese in 2016. In Africa, the number of overweight children under 5 has increased by nearly 50 per cent since 2000. Prevalence of obesity in Africa has increased over last 36 years by 1400% in Burkina Faso 500% in Ghana Obesity is now responsible for more deaths globally than malnutrition
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MIT Sloan 2015
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DOUBLE BURDEN OF MALNUTRITION IN AFRICA
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WHY SHOULD WE BE CONCERNED
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COST IMPLICATION OF OBESITY ON HEALTH CARE
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APPROACH TO TREATMENT OF Obesity
Conventional life style changes
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Surgical management of obesity: BARIATRIC SURGERY
Refers to variety of weight loss surgical procedures Most effective and Enduring treatment for the morbidly obese patients. In the 10-year Swedish Obesity Study: Demonstrated that gastric bypass surgery patients showed greater long-term weight loss, health-related quality-of-life improvement Reduction in various risk factors compared with controls receiving conventional treatment.
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INDICATIONS FOR BARIATRIC SURGERY
BMI of >40 or Excess of more than 45kg(100oz) of BW BMI >35 and at least one of: T2DM, HTN, Sleep apnea Sustained failure to achieve weight loss despite all non-surgical intervention.
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Brief history of bariatric surgery
First document surgical treatment for obesity: 10th century in Spain by Jewish doctor Hasdai Ibn Shaprut. on the King of Leon, D. Sancho who was morbidly obese.
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BARIATRIC SURGERY- principles
Gastric restriction: Sleeve Band Principle: Limit intake Mal-absorption Eg. Bilio-Pancreatic Diversion Principle: Limit absorption
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GASTRIC RESTRICTION Reduction in the capacity of the stomach
Simplest conducted for morbid obesity Challenge: Patients learn to adapt to frequent high carbohydrate diet. 26% patients not happy with results Include: AGB, Vertical sleeve gastrectomy(VSG)
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Laparoscopic Adjustable gastric banding(agb)
Adjustable silicone band placed around first portion of the stomach. Balloon band has an inflatable port beneath the skin allowing for adjustments of the degree of gastric restriction Weight loss is 45% of excess weight after one year Advantage: No permanent stomach resection Adjustable Disadvantage Maladaptive eating behavior Foreign body eroding into stomach Stomach prolapse
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VERTICAL SLEEVE GASTRECTOMY
Complications: GERD, Gastric tube stricture, stenosis, High risk for weight regain.
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ROUX EN Y
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Gastric bypass (ROUX & Y)
Effectiveness contributed by effects of Dumping syndrome Altered fat digestion by allowing down stream mixing of fat and bile. Ghrelin produced by the distal gastric mucosa alters eating habits hence bypassed. More effective technique with over 70% success rates in 9 to 14 months after surgery.
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BILIOPANCREATIC DIVERSION with duodenal switch (BPD-DS)
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Bpd-ds cont… Better and long lasting weight loss however
Higher risk for micronutrient and macro-nutrient deficiencies. May be restricted to patients with severe morbid obesity as well as those who are extremely compliant Less popular due to morbidity
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Types & trends of procedures for bariatric surgery
Adjustable gastric banding Roux en Y gastric bypass Sleeve gastrectomy Standard biliopancreatic diversion Duodenal switch diversion Gastric plication Mini-gastric bypass Vertical band gastroplasty
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Comparison chart
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EFFECT COMPARISON Key considerations
%Excess Body Mass Index Lost(%EBMIL)
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FOLLOW UP after bariatric surgery
Carefully monitor for nutritional deficiencies Iron, Calcium, Vitamin D, B12, Folic acid, PTH, Serum ferritin Routine mineral and Vitamin supplementation Ursodeoxycholic acid for first 6 months (Prevent gallstone formation) Continuous Therapeutic patient education Loose skin
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REVISION PROCEDURES REVISION: Defined as conversion, correction or reversal INDICATION: Severe side effects; Severe vomiting, severe dumping syndrome, intolerance to solid food. Complications of procedure: Stricture, non-healing ulcers etc… In-adequate weight loss
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LATEST ADVANCES IN BARIATRIC SURGERY
Endoscopic Sleeve Gastroplasty (ESG)- Accordion procedure Endoscopic suturing device to reduce stomach size Endoscopic gastric balloon
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EXPERIENCE AT OUR CENTER
Comprehensive Patient education Open vs Laparoscopy Bariatric surgery Cost implications for Laparoscopic Capacity building in bariatric laparoscopic surgery Commonly we do: Vertical sleeve gastrectomy Roux N Y bypass Establishing subdivision of Bariatric surgery on GI unit
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BREAKING Barriers to care
Absent organisational structures to support and advance the standard of bariatric surgery in Africa Sporadic practices across the continent. Need for Continental associations Journals Perception that Bariatric surgery is a cosmetic procedure: Inclusion on insurance programs Include Bariatric surgery on essential surgery list Constrained capacity of suitably qualified staff Linkages for advanced training in laparoscopy Creation of high volume centers Health Literacy Inform patients about surgical options for treating obesity
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TAKE HOME Obesity is the key driver of the NCD epidemic in sub-Saharan Africa Early life style adjustments are adequate in correcting disorder Bariatric surgery is an essential component in treatment of obesity as well as other NCDs and not a cosmetic option Advocacy for inclusion of surgical care in the NCD treatment package.
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ASANTE SANA
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