OBESITY AND ITS MANAGEMENT

OBESITY AND BARIATRIC SURGERY

   

You might have seen fig fat peoples around you once in a life time. Frequently we see these obese individuals in movies or documentries.  When we se them we get only one question in our mind that why therse peoples the way they are. For most of the viewers it becomes a matter of laughing after seeing these individuals. But its a matter of concern as obesity has been classified as a disease. obesity could be due to many reasons. for some it may be due to some emnzyme deficiency while for most it is familial or hereditary. some have its relation with mutation in the ob gene which gives rise to the familial type of obesity. It is necessary to take treatment, medical or surgical as soon as possible as it is related to many ill health effects.

Obesity means having too much body fat. It is different from being overweight, which means weighing too much. The weight may come from muscle, bone, fat and/or body water. Both terms mean that a person's weight is greater than what's considered healthy for his or her height.
Obesity occurs over time when you eat more calories than you use. The balance between calories-in and calories-out differs for each person. Factors that might tip the balance include your genetic makeup, overeating, eating high-fat foods and not being physically active.
Being obese increases your risk of diabetes, heart disease, stroke, arthritis and some cancers. If you are obese, losing even 5 to 10 percent of your weight can delay or prevent some of these diseases. Here we will discuss about the Surgical management for obesity which is known as bariatric surgery.

Bariatric surgery (weight-loss surgery) includes a variety of procedures performed on people who are obese. Weight loss is achieved by reducing the size of the stomach with a gastric band or through removal of a portion of the stomach  or by resecting and re-routing the small intestines to a small stomach pouch (gastric bypass surgery).The U.S. National Institutes of Health recommends bariatric surgery for obese people with a body mass index (BMI) of at least 40, and for people with BMI 35 and serious coexisting medical conditions such as diabetes.

Indications

Surgery should be considered as a treatment option for patients with a BMI of 40 kg/m² or greater who instituted but failed an adequate exercise and diet program (with or without adjunctive drug therapy) and who present with obesity-related comorbid conditions, such as hypertension, impaired glucose tolerance, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea. A doctor–patient discussion of surgical options should include the long-term side effects, such as possible need for reoperation, gallbladder disease, and malabsorption.Patients should be referred to high-volume centers with surgeons experienced in bariatric surgery.

Classification of surgical procedures

Procedures can be grouped in three main categories

Predominantly malabsorptive procedures

Predominantly malabsorptive procedures, although they also reduce stomach size, these operations are based mainly on creating malabsorption.

Biliopancreatic diversion

This complex operation is termed biliopancreatic diversion (BPD) or the Scopinaro procedure. The original form of this procedure is now rarely performed because of problems with malnourishment. It has been replaced with a modification known as duodenal switch (BPD/DS). Part of the stomach is resected, creating a smaller stomach (however the patient can eat a free diet as there is no restrictive component). The distal part of the small intestine is then connected to the pouch, bypassing the duodenum and jejunum.

In around 2% of patients there is severe malabsorption and nutritional deficiency that requires restoration of the normal absorption. The malabsorptive effect of BPD is so potent that those who undergo the procedure must take vitamin and dietary minerals above and beyond that of the normal population. Without these supplements, there is risk of serious deficiency diseases such as anemia and osteoporosis.

Jejunoileal bypass

This procedure is no longer performed.

Predominantly restrictive procedures

Procedures that are solely restrictive, act to reduce oral intake by limiting gastric volume, produces early satiety, and leave the alimentary canal in continuity, minimizing the risks of metabolic complications.

Vertical banded gastroplasty

In the vertical banded gastroplasty, also called the Mason procedure or stomach stapling, a part of the stomach is permanently stapled to create a smaller pre-stomach pouch, which serves as the new stomach.

Adjustable gastric band 

The restriction of the stomach also can be created using a silicone band, which can be adjusted by addition or removal of saline through a port placed just under the skin. This operation can be performed laparoscopically, and is commonly referred to as a "lap band". Weight loss is predominantly due to the restriction of nutrient intake that is created by the small gastric pouch and the narrow outlet.

Sleeve gastrectomy

Sleeve gastrectomy, or gastric sleeve, is a surgical weight-loss procedure in which the stomach is reduced to about 15% of its original size, by surgical removal of a large portion of the stomach, following the major curve. The open edges are then attached together (typically with surgical staples, sutures, or both) to leave the stomach shaped more like a tube, or a sleeve, with a banana shape. The procedure permanently reduces the size of the stomach. The procedure is performed laparoscopically and is not reversible.

Stomach volume is reduced, but it tends to function normally so most food items can be consumed in small amounts.

Removes the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin), although the durability of this removal has yet to be confirmed^.

Dumping syndrome is less likely due to the preservation of the pylorus (although dumping can occur anytime stomach surgery takes place).

Minimizes the chance of an ulcer occurring.

By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are significantly reduced.

Very effective as a first stage procedure for high BMI patients (BMI >55 kg/m²).

Limited results appear promising as a single stage procedure for low BMI patients (BMI 35–45 kg/m²).

Appealing option for people with existing anemia, Crohn's disease, irritable bowel syndrome, and numerous other conditions that make them too high risk for intestinal bypass procedures.

Intragastric balloon (gastric balloon)

Intragastric balloon involves placing a deflated balloon into the stomach, and then filling it to decrease the amount of gastric space. The balloon can be left in the stomach for a maximum of 6 months. The intragastric balloon may be used prior to another bariatric surgery in order to assist the patient to reach a weight which is suitable for surgery, further it can also be used on several occasions if necessary.

Gastric Plication

Basically, the procedure can best be understood as a version of the more popular gastric sleeve or gastrectomy surgery where a sleeve is created by suturing rather than removing stomach tissue thus preserving its natural nutrient absorption capabilities. Gastric Plication significantly reduces the volume of the patient's stomach, so smaller amounts of food provide a feeling of satiety. The study describes gastric sleeve plication (also referred to as gastric imbrication or laparoscopic greater curvature plication) as a restrictive technique that eliminates the complications associated with adjustable gastric banding and vertical sleeve gastrectomy—it does this by creating restriction without the use of implants and without gastric resection (cutting) and staples.

Mixed procedures

Mixed procedures apply both techniques simultaneously.

Gastric bypass surgery

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.A factor in the success of any bariatric surgery is strict post-surgical adherence to a healthier pattern of eating.

Sleeve gastrectomy with duodenal switch

A variation of the biliopancreatic diversion includes a 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.

Implantable gastric stimulation

This procedure where a device similar to a heart pacemaker is implanted by a surgeon, with the electrical leads stimulating the external surface of the stomach, is being studied in the USA. Electrical stimulation is thought to modify the activity of the enteric nervous system of the stomach, which is interpreted by the brain to give a sense of satiety, or fullness. Early evidence suggests that it is less effective than other forms of bariatric surgery.

Eating after bariatric surgery

Post-surgery, overeating is curbed because exceeding the capacity of the stomach causes nausea and vomiting. Diet restrictions after recovery from surgery depend in part on the type of surgery. Many patients will need to take a daily multivitamin pill for life to compensate for reduced absorption of essential nutrients. Because patients cannot eat a large quantity of food, physicians typically recommend a diet that is relatively high in protein and low in fats and alcohol.

Fluid recommendations

It is very common, within the first month post-surgery, for a patient to undergo volume depletion and dehydration. Patients have difficulty drinking the appropriate amount of fluids as they adapt to their new gastric volume. Limitations on oral fluid intake, reduced calorie intake, and a higher incidence of vomiting and diarrhea are all factors that have a significant contribution to dehydration.

Effectiveness of surgery

Weight loss

Biliopancreatic diversion — 117 Lbs / 53 kg

Roux-en-Y gastric bypass (RYGB) — 90 Lbs / 41 kg

Open — 95 Lbs/ 43 kg

Laparoscopic — 84 Lbs / 38 kg

Vertical banded gastroplasty — 71 Lbs / 32 kg

Laparoscopic bariatric surgery requires a hospital stay of only one or two days. Short-term complications from laparoscopic adjustable gastric banding are reported to be lower than laparoscopic Roux-en-Y surgery, and complications from laparoscopic Roux-en-Y surgery are lower than conventional (open) Roux-en-Y surgery.

Adverse effects

Complications from weight loss surgery are frequent. Common problems were gastric dumping syndrome in about 20% (bloating and diarrhea after eating, necessitating small meals or medication), leaks at the surgical site (12%), incisional hernia (7%), infections (6%) and pneumonia (4%). Mortality was 0.2%. As the rate of complications appears to be reduced when the procedure is performed by an experienced surgeon, guidelines recommend that surgery be performed in dedicated or experienced units.

Metabolic bone disease manifesting as osteopenia and secondary hyperparathyroidism have been reported after Roux-en-Y gastric bypass surgery due to reduced calcium absorption. The highest concentration of calcium transporters is in the duodenum. Since the ingested food will not pass through the duodenum after a bypass procedure, calcium levels in the blood may decrease, causing secondary hyperparathyroidism, increase in bone turnover, and a decrease in bone mass. Increased risk of fracture has also been linked to bariatric surgery.

Rapid weight loss after obesity surgery can contribute to the development of gallstones as well by increasing the lithogenicity of bile Nutritional derangements due to deficiencies of micronutrients like iron, vitamin B12, fat soluble vitamins, thiamine, and folate are especially common after malabsorptive bariatric procedures. Seizures due to hyperinsulinemic hypoglycemia have been reported. Inappropriate insulin secretion secondary to islet cell hyperplasia, called pancreatic nesidioblastosis, might explain this syndrome.