PRESENTPRESENTDESIGNATIONDESIGNATION

Senior ConsultantSenior ConsultantSurgical Gastroenterology & Minimal Access Surgical Gastroenterology & Minimal Access Surgery, Apollo hospital, Chennai.Surgery, Apollo hospital, Chennai.

PRESENT PRESENT AFFILIATIONAFFILIATION

Indian Society of GastroenterologyAssociation of Surgical GastroenterologyIndian Association of Gastro Endosurgeons International Hepato-Biliary-Pancreatic SurgeryInternational Federation Society of ObesityObesity Surgery Society of India

MAJOR MAJOR ACHIEVEMENTACHIEVEMENT

Started G.I endoscopic services in 1984 at Apollo Hospital, ChennaiEstablished GI Surgery & Minimal Access surgery departmentStarted Bariatric surgical servicesStarted FNB (MAS) & DNB (SGE)Adjunct Professor – The Tamil Nadu Dr.M.G.R. Medical UniversityAdjunct Associate Professor – University of Queens Land, Brisbane, Australia.

AWARDSAWARDS Prof. Nanjunda Rao Endowment Orations , MMC, ChennaiDr. Ranganathan Endowment lecture, RMMC, Chidembaram Prof. B. Shanmukeshwar Rao Memorial Oration, ASI-AP chapter, Hyderabad Dr. Karimulla Endowment oration, IMA, Nellore, AP

PUBLICATIONPUBLICATIONSS

26 National & International journals24 operative videos on Youtube (Prof. P K Reddy)

DR. PRASANNA KUMAR REDDYDR. PRASANNA KUMAR REDDYMB, FRCS (Eng, Edin, Glasg), FACG, D.Sc, D.lap (Fr)MB, FRCS (Eng, Edin, Glasg), FACG, D.Sc, D.lap (Fr)

SURGICAL OPTIONS FOR WEIGHT LOSS

Surgical management is the most effective method of treating morbid obesity. The weight loss is sustained for a longer period of time. Co-morbidities are resolved or improved in majority.

Like all other therapies weight loss surgeries should be combined with a change in dietary habits and life style.

INTRODUCTION

BARIATRIC SURGERY

INDICATIONS:1. BMI >40 kg/m2 or BMI 35-39.9 kg/m2 and life

threatening cardiopulmonary disease. Severe diabetes or lifestyle impairment

2. Failure to achieve adequate weight loss with nonsurgical treatment

CONTRAINDICATIONS:1. History of noncompliance with

medical care2. Certain psychiatric illness

personality disorder. Uncontrolled depression. Suicidal ideation substance abuse

3. Unlikely to survive surgery

CURRENT BARIATRIC SURGICAL PROCEDURES

Classification Procedure

Gastric Restriction Adjustable Gastric Banding

Sleeve Gastrectomy

Primarily restrictive andPartially malabsorptive

Roux-en-y-Gastric Bypass

Primarily malabsoptive and Partially restrictive

Bilio Pancreatic diversion with duodenal switch

Bilopancreatic diversion

Mini Gastric Bypass

Surgical treatment of obesity

MGB

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING

• Silicone band placed around upper stomach to create a small pouch. Outlet diameter can be changed by infusing or withdrawing saline from port.

Mean follow-up was 35 +/- 2 months. Percentage of excess weight loss was 45.8% +/- 27.4 at 6 months, 66.7% +/- 30.3 at 1 year, 72.6% +/- 28.8 at 2 years, 75.9% +/- 27.4 at 4 years, 82.8% +/- 32.6 at 6 years, 82.3% +/- 25.1 at 8 years, and 82.7% +/- 4.2 at 10 years.

Obes Surg. 2008 May;18(5):573-7.

Ten years experience with laparoscopic adjustable gastric

bandingBiagini J, Karam L et al

•Department of Surgery, Saint Joseph Hospital, Dora, Lebanon

Laparoscopic Adjustable Gastric Banding Produces Greater Weight loss than comprehensive Medical Therapy in Patients with Class I Obesity (BMI 30-35 kg/m2)

Dapri G,Himpens J,et al. Surgical Endoscopy 2006; 20(Suppl.):S46

Laparoscopic Adjustable Gastric Banding Produces Greater Weight loss than comprehensive Medical Therapy in Patients with Class I Obesity (BMI 30-35 kg/m2)

Obrien et al Ann Intern Med.2006:144-625-33

SLEEVE GASTRECTOMY

• Sleeve resection

• Mechanism

. Restrictive

. Hormonal

ACCELERATED GASTRIC EMPTYING

Melissas et al. Obesity Surgery 2007; 17.57.62

MECHANISM?

• Smaller volume capacity (less caloric

intake)

• Faster gastric emptying (earlier release

of GLP-1 and PYY? HindGut Theory?

• Decreased serum Ghrelin

• Higher and earlier Vagal stimulation

(Increased satiety)

• Other

EFFECTIVENESS ON CO-MORBIDITIES

• 42 patients had LSG 10-02 and 12-04

• 60% of major co-morbidities resolved, 24% improved

• Sleep apnea 56% resolution

• Diabetes 53% resolution

• Hypertension 67% resolution

Silecchia et at. Obesity Surgery 2005; 15(7):949

CO-MORBIDITIES AND LSGCo- Morbidity No. Of

patients6 months 12 months

Resolved (%)

Improved (%)

Resolved (%)

Improved (%)

Hypertension 12 16.6 83.3 66.6 33.3

Sleep Apnoea 10 100 -- -- --

Fatty Liver 38 -- -- -- --

Dyslipidemia 23 -- 60.86 -- 86.9

Osteoarthritis 14 -- 71.4 -- 71.4

Diabetes 30 -- 80 30 70

GERD 2 100 -- -- --

Asthma 8 -- 100 -- 100

Depression 1 100 -- -- --

GASTRIC BYPASS PROCEDURES

A small (10-30 ml) gastric pouch is anostomosed to a Roux limb of Jejunum. Increasing the length of the Roux limb increasesMalabsorption and weight loss.

LONG-TERM EFFECT OF GASTRIC BYPASS

SURGERY ON BODY WEIGHT

Pories et al.Ann Surg. 1995;222:339.

RELATIONSHIP BETWEEN SURGICAL EXPERIENCE AND PERIOPERATIVE MORTALITY IN GASTRIC BYPASS

SURGERY

BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH

• Sleeve Gastrectomy with rerouting of small intestine through nutrient limb and biliopancreatic limb.

• Digestion and absorption are limited to 100cm “common channel” of terminal ileum.

• Causes marked weight loss but can lead to significant nutritional deficicies.

Marceau P et al Wold J Sur.1998 2247;54

Effect of Different Bariatric Surgical Procedures on weight loss

Procedure

1. Laparoscopic gastric banding

2. Sleeve Gastrectomy

3. Gastric bypass procedure

4. Biliopancreatic diversion with duodenal switch

ApproximateLoss of Excess Weight

(%)

45-65

55-65

60-75

Klein et at. Gstroenterology;2002.123:882-932

ADVANTAGES

• Type 2 diabetes

• Hypertension

• Obstructive sleep apnea

• Obesity hypoventilation

• GERD

• NALD, NASH

• Pseudo tumor cerebri

• Depression

• Dysilipidemias

• Coronary artery disease

• Cardiac dysfunction

• Venous stasis disease

• Polycystic ovary syndrome

• Infertility

• Cancers

• Degenerative joint disease

• Quality of life

Major Obesity-related Co-morbidities that have

been improved by Bariatric Surgery

Long-term Survival: Canada

Christou et al. Ann Surg 2004;240:416-424

Endoscopic Bariatric procedures

CONCLUSION

Various surgical options are available to treat morbid obesity. Surgery sustains the weight loss for longer period of time. Metabolic complications related to obesity are resolved or improved. Like all other tharapies weight loss surgery should be combined with a change in dietary habits and Life style.

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