10/15/2018

The Surgical Treatment of MORBID OBESITY

By Dr.Narumalar MBBS., DGO, MS - General Surgery - Mon Apr 04, 8:55 pm

Definition:
Morbid Obesity is defined as being either 100 pounds above the ideal body weight, twice ideal body weigh or having a BMI of 40 Kgs / m².

Pathophysiology of Severe Obesity

Familial predisposition
Lack of satiety and increased caloric intake, greatly in excess of metabolic needs                                                                                                                                           increased levels of ghrelin produces increased food intake
A genetic landscape – some 20 chromosomes identified containing genes (10 autosomal dominant ) which are responsible for obesity

Co-Morbidity from Morbid Obesity
Diabetes mellitus (Type II)
High Blood Pressure
Dislipidaemia
Obstructive sleep apnoea
Venous and lymphatic stasis
Osteoarthritis
Decreased mobility
Increased cancer risk ( endometrium, prostate, breast, colorectal, cervix, ovary )
Increased risk of cardiac and cerebral vascular events Chronic respiratory hypoventilation (Pickwickian syndrome)
Hypertrophic cardiomyopathy
Pseudotumour cerebri (idiopathic intracranial hypertension)
Poor quality of life
Increased neuroses
Chronic cholecystitis
Thromboembolic disease
Urinary stress incontinence
Gastro-oesophageal reflux disease
Obesity related pulmonary hypertension
Hernia

Indications for Bariatric Surgery:
BMI > 40 Kg / m² or BMI > 35 / Kg m² with associated medical co-morbidity worsened by obesity
Failed dietary therapy
Age 18 – 55 yrs
Minimum 5 years of Morbid Obesity
No alcoholism or psychosis Knowledgeable about operation and its sequlae
Motivated & agrees for life long follow-up
Medical problems do not preclude likely survival from surgery

Pre-operative Evaluation and Preparation
Assessment of candidacy for Bariatric Surgery
Assessment of Co-Morbid conditions
Pre-operative first generation Cephalosporin
Prophylaxis against deep vein thrombosis:
(i) Ambulation within 4 to 6 hours of surgery
(ii) Sequential compression device stockings
(iii) Low molecular weight heparin

Alogrithm for managing morbidly obese patients suitable for surgery:

Bariatric Operations – Mechanism of action:
Restrictive :
Vertical Banded Gastroplasty (VBG) – historic purposes only
Adjustable Gastric Banding (AGB)
Largely Restrictive / Mildly Malabsorptive :
Roux-en- y Gastric Bye-pass (RYGB)
Largely malabsorptive / Mildly Restrictive :
Bilio Pancreatic Diversion (BPD)
Duodenal Switch (DS)

Vertical Banded Gastroplasty:

A gastric pouch created using circular and linear staplers
Capacity of pouch should be < 50 ml
Exit of the pouch is banded with 1.5 cm of PTFE or similar material of 5 cm in circumference

Complications of VBG:
Vomiting is universal
Wound herniation
Stomal stenosis
Staple line disruption

Adjustable Gastric Banding:

Initial dissection:

Dissection of the lesser curvature:

Dissection of the phrenogastric ligament:

Retrogastric tunnel:

Introduction and placement of the LASGB:

Tightening:

Suture stabilisation of the LASGB:

Placement of the injection reservoir:

LASGB Adjustment:

Radiologic follow-up:

(a) Picture of the ALGB device. Note the subcutaneous injection port (1), the connecting silicone catheter (2), and the band (3).
(b) Fluoroscopic anteroposterior (AP) view and
(c) Diagrammatic view following the placement of an ALGB system.
Note the band (3) around the upper portion of the stomach.

Fluoroscopic AP view of an ALGB procedure

demonstrates the size of a normal pouch (arrowheads), which should not be larger than 20 ml, and stoma, which should be adjusted to 3-4 mm (arrow) by injection of 3.0- 3.5 ml of saline into the system.

(a) Fluoroscopic AP view and
(b). Diagrammatic view

show acute concentric pouch dilatation arrowheads) secondary to a too narrow stoma (arrow) after overinflation of the band by the radiologist. Notice the normal position of the band.

Roux-en-y Gastric Bye-pass:

Roux-en-y Gastric Bye-pass Essential Components:
Small proximal gastric pouch
Gastric pouch constructed of cardia of stomach to prevent dilation and minimise acid production
Gastric pouch divided from distal stomach
Roux limb atleast 75 cm in length
Entero enterostomy constructed to avoid stenosis or obstruction
Closure of all potential spaces for internal hernias

Bilio pancreatic diversion:

Bilio pancreatic diversion promotes malabsorption particularly fat and protein
Intestinal tract is reconstructed to allow a short common channel of distal 50 cms terminal ileum
Alimentary tract beyond the proximal stomach is re-arranged to include only distal 200 cm of ileum
Proximal end of ileum anastomosed to proximal stomach after a distal hemigastrectomy
The distal end is anastomosed to the terminal ileum within 50-100 cm distance from the ileo-ceacal valve

Duodenal Switch:

Lessens the high incidence of marginal ulcers after BPD
Mechanism of weight loss similar to BPD
Appendectomy done. Common channel is 100 cms. Entire alimentary tract is 250 cms
Sleeve Gastrectomy of the greater curvature of stomach is performed
Duodenum divided 2 cm beyond the pylorus
Distal anastomosis is created at 100 cms proximal to ileo caecal valve
The duodeno ileostomy is an anti colic end to side duodeno enterostomy
Cholecystectomy is a routine part of DS

Post operative Care:
Meticulous attention to vital signs
Dreaded complication – gastro intestinal leak manifest as tachycardia, tachypnoea or agitation
Appropriate fluid resuscitation – 400 ml / hr of balanced salt solution
Adequate pain control
DVT prophylaxis
Radiographic study of the gastro intestinal tract on the first post operative day:
(i) to document the pouch size
(ii) to identify partial obstruction of distal anastomosis

Follow-up:
Adjustable Gastric Banding:
First month – evaluate oral intake, food tolerence and wound
healing
Goal : 1 –2 Kg / week of weight loss
Roux-en-y Gastric Byepass:
3rd week – assess wound healing ; advance from liquid to solid
food
1st year – monitor weight loss
Blood sampling for potential anaemias
Risk of iron and Vit. B12 deficiency exists for life
Bilio pancreatic diversion / Duodenal Switch:
1st 2 weeks watch for diarrhoea. Dehydration to be avoided
Fat soluble vitamins to be replaced.

247 Comments

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