1. Management of Obesity An over review
Dr. fahad bamehriz
Department Of Surgery

2. Management of Obesity Definitions &Classification.
Magnitude of obesity problem.
Clinical assessment & management.
Surgical management.
Summary.

3. Definitions & Classification
Management of Obesity
Definitions & Classification

5. Obesity
A condition of excessive fat accumulation in the body to the extent that health and well being are adversely affected.
WHO 1997

6. Ideal Body Weight (IBW)
As defined by the Metropolitan Life Insurance Tables Of 1983for height, sex and body-frame, is that weight which is associated with the lowest death rate in insured populations.
Cowan et al
Surgery for the morbidly obese patients
Chapter
Cowan et al ,Surgery for the morbidly obese patients,Chapter 9 ,2000

7. Body Mass Index
BMI = Weight ( Kg)/ Height (m2)

8. Classification of weight
WHO 1997

9. Morbidly Obese Patients
Are those individuals who weigh at least 45 kg over the ideal body weigh.
This approximates a body mass index (BMI) of at least 40 kg/m2
Cowan et al ,
Surgery for the morbidly obese patients,
Chapter 9 ,2000
Cowan et al ,Surgery for the morbidly obese patients,Chapter 9 ,2000

10. Weight Loss EWL = Excess Weight Loss
= (preoperative weight) – (ideal weight)
% EWL = % Excess Weight Loss
= weight loss / excess weight x 100

11. Magnitude of obesity problem
Management of Obesity
Magnitude of obesity problem

13. Prevalence of obesity
WHO 1997

14. Prevalence of obesity

15. Health hazards of obesity
Cowan et al ,
Surgery for the morbidly obese patients,
Chapter 9 ,2000
Cowan et al ,Surgery for the morbidly obese patients,Chapter 9 ,2000

16. Health hazards of obesity
Karl et al SCNA Oct. 2001
Karl et al SCNA Oct. 2001

17. Health hazards of obesity
Wadden et al SCNA OCT 2001

18. Health hazards of obesity
Bray et al CE&M 1999
Bray et al CE&M 1999

19. Cost Related to Obesity
“The costs of obesity is substantial and accounts for 2-8 % of the total health care expenditure in countries such as The Netherlands, France, USA, Australia and Sweden.”
The Lancet August 1997
The Lancet August 1997

20. Clinical assessment & management
Management of Obesity
Clinical assessment & management

22. Clinical assessment & management Obesity Program Team Approach
Bariatric surgeon.
Dietitian.
Physical therapist.
Psychiatrist.
Psychologist.
Gastro-entrologist.
Radiologist.
Nursing team.
Internist.
Endocrinologist
Cardiologist.
Pulmonologist.
Family Physician.
Anesthesiologist.
Intensivist.
Plastic Surgeons.

23. Assessment H&P. Laboratory work up;
CBC, Renal, Hepatic, Lipid Profiles.
TFT’S, Cortisol suppression test, FBS.
Nutritional Profile.
Radiological Investigations;
U/S abdomen.

24. Assessment Gastro-enterology Gastro-scopy. Psychiatry. Dietitian.
Anesthesiologist.

26. Management Options Non-Surgical Surgical Behavioral Therapy. Diet.
Physical activity.
Drug therapy.
Jaw wiring.
Intra-gastric balloon.
Surgical
Restrictive.
Mal-absorptive.
Combined.

27. Dietary approaches to reduce body weight
Dietary Programs
Starvation diets (fewer than 200 kcal /day).
Very low energy diets (VLED)
kcal/day, commercial formula.
Low energy diets (LED)
kcal/day, natural food.
Ad libitum low fat diets
15% - 25 % less fat, high CHO & protein.
Atkins diet
High protein low CHO.

28. Dietary approaches to reduce body weight

29. Physical Activity Programmed physical activity.
regular scheduled activity at a relatively high intensity level.
Lifestyle physical activity.
increasing energy expenditure during the course of the day.

30. Physical Activity

31. Drug therapy of obesity
Drugs that reduce food intake
Nor-adrenergic drugs (phentermine).
Serotonin-norepinephrine re-uptake inhibitors (Sibutramine).
Drugs that alter metabolism
Pre-absorptive agents (Orlistat).
Post-absorptive agents (Metformin).
Drugs that increase energy expenditure
Ephedrine & Caffeine.

32. BioEnterics® Intragastric Balloon BIB ™ System

33. B.I.B. Placement

34. Clinical results
Dr. Bolwerk

35. Jaw Wiring
Bray et al CE&M 1999

36. Obesity Surgery Classification
Restrictive
Malabsorptive
Combined

38. %EWL after LAGB

40. VBG versus ASGB

41. What is Laparoscopic Sleeve Gastrectomy
What is Laparoscopic Sleeve Gastrectomy ? (longitudinal G, Vertical G , Stomach reduction)
Resection of Greater Curve
Sleeve of stomach left in place
(Sleeve Gastrectomy) (Vertical Gastrectomy) (Stomach Reduction)

42. A Prospective Randomized Study Between LGB & LSG Results after 1&3 years
Jacques Himpens Obesity Surgery 16( )2006

44. Efficacy of Obesity Surgery operation number % EWL
Banding
4429
48.6%
VBG
3382
58.3%
Bypass
2949
68.6%

45. JEJUNOILEAL BYPASS

46. %EWL in JEJUNOILEAL BYPASS

47. Bilio-pancreato-jejunal bypass type three

48. BPDDS

50. Crystine Lee San Francisco California

51. King Faisal Specialist Hospital Experience in Bariatric Surgery
Dr Patrick O’Regan
Dr Abdelrahman Salem
Dr Fahad Bamerhiz
Minimally Invasive Surgery Service
King Faisal Specialist Hospital & Research Center
Riyadh S. A.

52. Obesity Surgery Program
Started October 2002
Offering
Gastric balloon
Gastric banding
VBG
Gastric bypass
Gastric sleeve
Total cases
till December

53. King Faisal Specialist Hospital Experience in Bariatric Surgery

55. How to decide which operation
Age
Co-morbidities
Re-operative cases
BMI
Surgeon recommendation
Patients request
Word of mouth – many requests for sleeve

56. KFSHRC Experience with sleeve gastrectomy
Started in August 2005

57. Why Sleeve Gastrectomy
Patients not accepting Gastric Bypass
Gastric Band - poor wt. loss
VBG - poor QOL
BPD – Patients F/U??
Encouraged by early results
Pts – understanding, acceptance, word of mouth.

58. Advantages of Sleeve 2. Easy to perform 3. No need for supplements
1. No foreign body
2. Easy to perform
3. No need for supplements
4. Low maintenance
5. Anatomical
6. Physiological ?

59. Advantages cont’d 7. Easy to convert (second stage) – BPD or LGB
8. Ghrelin reduction
9. Good for super-obese
10.Good when PBD or LGB are contra- indicated
11. Good quality of life

60. Sleeve Gastrectomy disadvantages
1. Not reversible
2. No long term follow up
3. Stomach may dilate
4. Purely restrictive ?
5. Ghrelin reduced
6. GERD (11%)

61. Biennial

66. Sleeve Gastrectomy Length of Stay
94 % Same day admit
84% discharged day I or 2
3 (0.9%)conversion to open

67. Mean % excess wt loss 6 Months 60.5% (#170) 12 months 76% (#101)

68. Major M&M 18(5.4%) Staple line leakage 5 (1.5%) Re-op for bleeding
2 pt developed stricture
1pt developed Port site hernia
1 pt died post-op (PE)

70. Mean % excess wt loss at 12m
LSG % (#101)
LGB % (#62)
VBG % (#61)

71. Staple line leakage
LSG / (5.4%)
LGB / (0%)
VBG / (5.4%)

73. Summary
Obesity is a major health problem worldwide, as well as in the Kingdom.
It is secondary to imbalance between energy intake and expenditure.
Approach to management, should be team approach.
Main aim of management, is to change the behavior, which ultimately will reduce weight.

74. Summary
Surgery is the only management option that proved to be effective in weight reduction of obese patients in long term.
We believe LSG is one of safe options of the armamentarium of beriatric surgery.

75. Summary
Obesity surgery program at KFSH&RC offering a battery of beriatric surgery operations to match the need of different beriatric patients.

76. THANK YOU