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					              Morbid Obesity


 Done by: Laith al khateeb & Mohammad el
  sha’ar



 Supervised by : Dr.moh’d bani hani
Definitions

 Body mass index (BMI) is a term used to
  define obesity
 BMI=weight/ (height)2
 Example: ht=170 cm, wt =80kg BMI=80/1.7*1.7
  =27.68kg per m2
People are classified
                 WHO criteria


Normal           Less than 25 kg per m2


overwieght       25-30 kg per m2


obese            30-35kg per m2


Severe obesity   35-40 kg per m2


Morbid obesity   More than 40 kg per m2
 A waist to hip raitio of 1.0 or higher in men
  and 0.8 or higher in women defines upper
  body obesity and is an independent predictor
  of disease risk. This is also known as
  syndrome x and is a common problem seen in
  india
 A BMI increases above 25 kg per m2, mean
  BP and Total blood cholestrol increase and
  HDL level decrease
 The most significant observation is that
  morbidily obese patients who are between
  20 and 40 year old may experience a 12 fold
  reduction in life expectancy compared with
  age matched control subjects
 We use surgery in morbidly obese pts, on the
  other hand medical treatment is used in
  severely obese patients
Etiology

 Obesity is most commonly caused by a
  combination of excessive dietary calories,
  lack of physical activity, and genetic
  susceptibility, although a few cases are
  caused primarily
  by genes, endocrine disorders, medications o
  r psychiatric illness
 Effects of morbid obesity

 CVS:
  -htn is the most common comorbidity of
  obesity, which is corrected up to 66% of who
  lose excess weight
 -the risk of CAD is also higher in these
  population
-venous stasis disease increase also
 Endocrine:
-increase the risk of type II DM
-femenization and musculinization in men,
  infertility, amenorrhea and PCOS in women
  due to the effect of adipose tissue in
  secreting enzymes important in sex steroid
  and glucocorticoids metabolism-----results in
  increase levels of androgens and estrogen
 Pulmonary:
-obstructive sleep apnea 12-30 folds higher
Cancer:
-increase mortality rates for endometrial,
   gallbladder, uterine, cervical, ovarian and
   breast cancer in women
-increase mortality rates for colorectal and
   prostate cancer in men
 Gastrointestinal:gastroesophageal reflux
  disease[2][39]
fatty liver disease[2]
cholelithiasis (gallstones)[2]

 Psychiatry: depression in women
Non surgical treatment

 Caloric restrection, excersice, behavioral
  modification, and drug therapy
 Excerisice programs without some type of
  caloric restrection are ineffective beyond the
  loss of 6 to 10 pounds
 Drugs are popular but the are equally ineffective as a
  treatment for morbid obesity, they use appetite
  supressing medication that act by increasing the
  CNS conc. Of serotonin and mood elevating
  neurotransmitters believed to be involved in eating
  disorders.
 Amphetamines are newer pottentially addictive
  sympathommemitic medications are also used
  without significant long term success
 Orlistat: inhibits the action of lipase---no fat
  digestion
 Sibutramine: anorectic ( appetite depressant)---SE:
  tachycardia
Surgical treatment of morbid
obesity
 1.restrective ( surgical reduction of the
  stomach size to reduce amount of food
  intake)
-vertical banded gastroplasty
-laprascopic gastric bypass
-laprascopic adjustable gastric banding
   (popular)
-laprascopic sleeve resecticon---its gaining
   popularity
 2.malbsorptive ( surgical re-routing of the
  consumed food leading to reduce absorption)
 -jeujonileal bypass----not done anymore
-biliopancreatic bypass
 3.combined restrective and malabsorptive
  (size reduction with bypass)
- Laprascopic gastric bypass with long limb of
   intestine-----popular
-duodenal switch
4. Other procedures :
-gastric pacemaker----under evaluation
-gastric baloon----temporary measure
Patient selection

 Pt with BMI of 35 to 40 or above and obesity
  related comorbidities are potential
  candidates for surgical tt.
 The pt should be consulted by nutritionst,
  psychiatrist, internest and surgeon
 Pts should also be screened for comorbid
  obesity related conditions ---cxr-ecg-echo-
  abg- pft-dopplers-GTT
 The most commonly performed restrictive
  procedure is vertical banded gastroplasty and
  the most commonly performed
  malabsorptive procedure is roux-en-y gastric
  bypass
Restrictive Procedures
gastric banding

 The most popular restrective procedure currently
 A band is placed around the upper most part of
  the stomach. The band divides the stomach into
  two portion, one small and one larg. Because
  food is regulated most patients feel full faster.
 Advantages: the band is externally adjustable,
  the band can be tightened or loosened to
  regulate the amount of food passing.
 Risk: perforation or tearing which will need
  operation, N/V pouch dilation, band migration or
  slippage
Vertical banded gastroplasty

 Low complication/ moderately effective for
  weight loss
 Lost its popularity
 Studies revealed that vertical banded
  gastroplasty has inconvenient results in
  weight loss
 The cause of failure of weight loss after
  vertical banded gastroplasty is change in
  dietary habits towards high calories and
  sweet
Gastric bypass resection

 It is more effective in ‘’sweet eaters’’ than vertical
  banded gastroplasty.
 A common form of gastric bypass surgery is the
  Roux-en-Y gastric bypass. Here, a small stomach
  pouch is created with a stapler device, and
  connected to the distal small intestine. The
  upper part of the small intestine is then
  reattached in a Y-shaped configuration
 The cause of failure of weight loss after gastric
  bypass is enlarged pouch (increased capacity)
The Gastric sleeve resection

 Removes a great part of the stomach and
  leads to a considerable loss of weight. It is
  useful in those of BMI of 35-40
 Also this procedure is being done in BMI over
  60 to downgrade the obesity to a more
  managable level of about 50, after which a
  gastric bypass/ duodenal switch can be done
Malabsorptive procedures

 Here the stomach is attached to the intestine
  at a point further down to cause
  malabsorption of the consumed food
 Jejunoileal bypass and bilopancareatic bypass
  have serious nutritional complications and
  are not done anymore
 Those operations often result in a high degree of pt. Satasfaction
    because pts are able to eat large meals than with restrictive
    procedures. These procedures can produce great weight loss
    because they provide the highest levels of malabsorption
   Risks: bowel movement frequency, bloating , malodorous stool
    and gas-----it also need screening for protein malnutrition, iron
    and b-12 deficency, calcium and folate, and also fat soluble
    vitamins (A,D,E,K)
   Life long vitamin supplement is required...if not followed 25% of
    pts will develop complications
   Increase risk for gallbladder stones --- it will need removal of
    gallbladder and re-routing of bile
   Ulcer and intestinal irritation is also a common complication
   Revision of gastric bypass is required in 2-15% of cases as a result
    of staple line dehisecence, marginal ulcer, outlet obstruction, or
    inadeqauate weight loss
Combined restrectrive and
malabsorptive procedure
Roux-en-Y gastric bypass
 This variant is the most commonly employed gastric bypass
  technique, and is by far the most commonly performed
  bariatric procedure in the United States. It is the operation
  which is least likely to result in nutritional difficulties. The
  small bowel is divided about 45 cm (18 in) below the lower
  stomach outlet, and is re-arranged into a Y-configuration,
  to enable outflow of food from the small upper stomach
  pouch, via a "Roux limb". In the proximal version, the Y-
  intersection is formed near the upper (proximal) end of the
  small bowel. The Roux limb is constructed with a length of
  80 to 150 cm (31 to 59 in), preserving most of the small
  bowel for absorption of nutrients. The patient experiences
  very rapid onset of a sense of stomach-fullness, followed by
  a feeling of growing satiety, or "indifference" to food,
  shortly after the start of a meal.
 Roux-en-Y gastric bypass: the most common
  procedure used in US
 Needs to be revised in 2-15% of pts because
  of marginal ulcer, staple dehissence, outlet
  obstruction or failure of weight reduction.
 Most pts with marginal ulcer respond to
  medical treatment but if dont we use truncal
  vagetomy
   DUEODENAL SWITCH




A variation of the gastric sleeve resection
includes sleeve resection with Duodenal
switch. The part of the stomach along its
greater curve is resected. The stomach is
"tubulized" with a residual volume of about
150 ml. This volume reduction provides the
food intake restriction component of this
operation. This type of gastric resection is
anatomically and functionally irreversible.
The stomach is then disconnected from the
duodenum and connected to the distal part
of the small intestine. The duodenum and
the upper part of the small intestine are
reattached to the rest at about 75–100 cm
from the colon
Other procedure

 Intragastric ballon : soft, sillicone balloon that
  is inserted into the stomach and its filled with
  sterile saline----you will have felling of satiety
  or lack of hunger. The balloon will be
  removed after 6 months
Implantable gastric
stimulation
   Implantable Gastric Stimulation (IGS) is a pacemaker like device, where the pacemaker electrical
    leads are attached by a surgeon to the surface of the stomach. These devices are aimed at obesity
    management. This device works on either or both of the following principles. 1) Disruption of
    motility cycle 2) Stimulation of Enteric nervous system. The purpose of both techniques is to
    increase the duration of satiety and there by making the patient consume less intake.
   The first technique, although not found as effective works on keeping the food longer in the
    stomach by disrupting the natural motility cycle of stomach and there by continuing the satiety.
   The second technique is based on the fact that enteric nervous system carries signals to the brain
    that indicate the state of satiety. By stimulating this nervous system, specifically vagus nerve a
    gastric pace maker mimics the feeling of satiety to the brain.
   This device is implanted using laproscopic surgery. There are also some efforts to implant this
    device endoscopically avoiding surgery.
   It is a technology that is still in the beginning phase and being tested in Europe and Canada and
    shows great promise. However early evidence suggests that it cannot produce the same reduction
    in excess weight loss as Bariatric surgery such as Roux-en-Y or Laproscopic Adjustable Gastric
    Banding (Lap Band)
   Although less risky than surgical procedrues such as a gastric band or gastric bypass, the treatment
    can still have complications including pulmonary embolism, perforation of the stomach, and
    dislodgement of the device head.[1]
   Medtronic which makes heart pacemakers, is developing this treatment.
 THE END
 LAITH & MOHAMMAD

				
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