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What is the history of the Prevalence of Obesity in US Adults... Chronologically?

1991 - Highest percentage was 15-20%
2007 - 25-29% primarily in the midwest states
- > 30 in southern states
2010 - 12 US states at >30%
- 11 US states at 20-24%
- 22 US states at 25-29%
Obese children are 30% heavier than in 1990


1

What is Morbid (Severe) Obesity?

- Patients who weigh 100% over ideal weight.
- Patients with a BMI > 35
- Patients who develop disease states as a result of obesity

2

What is are the causes of Obesity?

- Energy Imbalance
- Overeating
- Genetic Factors
- Inability to feel full
- Cultural factors
- Environmental factors
- Calories intake increased
- Increased Sugar consumption - Cane and Beet sugar, Corn sweeteners
-Increased expenditures for food, due to increased consumption


3

Why treat Morbid Obesity?

- There is proven weight-associated mortality

4

What are the areas in the body affected by morbid obesity?

- Starts at the head
- Stroke, Pseudotumor, Diabetic Retinopathy
- Goes to the toes
- Diabetic Neuropathy, Infection; Venous Stasis
- Gets to every organ in-between
- Lungs, heart liver, spleen, esophagus, gall bladder, colon, kidneys, uterus, breasts, bladder, prostate, pancreas

5

What are the medical complications of Obesity?

- Pulmonary Diseases
- Abnormal function
- OSA
- Hypoventilation Syndrome
- Idiopathic intracranial hypertension
-Stroke
-Cataracts
- Nonalcoholic Fatty liver disease
-Steatosis
-Steatohepatitis
-Cirrhosis
- Gallbladder disease
- Gynecologic abnormalities
- Abnormal Menses
- Infertility
- polycystic ovarian syndrome
- Coronary heart disease
- Diabetes
- Dyslipidemia
- Hypertension
- Severe pancreatitis
- Cancer
- Breast, uterus, cervix, colon, esophagus, pancreas, kidney, prostate
- Osteoarthritis
- Skin
- Gout
- Phlebitis
- Venous Stasis


6

BPD - 1993

- Pylorus is preserved
- The first part of the duodenum is included in the enteric limb
- Decreased size of the stomach by 60% (sleeve)
- Increases the length of the common channel
- Decreases dumping syndrome, B12 deficiencies and stomal ulcers

7

Sleeve Gastrectomy

- Tubular stomach
- 2/3 of stomach is removed
- Stomach capacity ~ 100ml
- Based upon Magnestrasse and ill Procedure
- Initially used in 2 stage procedure for super morbidly obese
- Weight loss proved promising with some patients electing not to proceed with the second portion of the procedure

8

Advantages of Gastric Sleeve

- Preserves the Pylorus
- prevents dumping syndrome
- No malabsorption
- No foreign object - no adjustments
- Weight loss is comparable to Gastric Bypass
- Feasibility of a 2nd procedure if needed

9

Disadvantages of Gastric Sleeve

- Lack of long-term data for durability of procedure compared to GBP and LAGB

10

Vertical Gastric Sleeve Anatomy and Physiology

- Removal of the greater curvature of the stomach
- approximately 75-80% removed
-Hormonal effect
- Reduction in ghrelin by resection of the fundus
- Positive impact on sensation of satiety
- Creates a long gastric tube or sleeve
- sized by a bougie (32-40 French may be used)
- Pouch is between 50ml and 180 ml
- Restrictive component
- Less distensibility than normal stomach

11

Efficacy of Vertical Gastric Sleeve

- 33 - 85% (average 60%) EWL at 5 years
- Resolution of co morbidities comparable to those seen with other restrictive procedures:
- T2DM - 66%
- HTN - 54%
- OSA - 62%
- GERD - 69%
- Postoperative 30-day mortality rate - 0.1%

12

Complications of Gastric Sleeve

- Similar to gastric bypass
- Gastric leak
- Bleeding
- Stricture and Obstruction
- Pulmonary embolism/DVT
- Pneumonia
- Infection
- Dehydration
- Nausea and Vomiting

13

Gastric Leak

- Incidence: 0-2.2%
- Proximal staple line leaks - 1.3%
- Distal staple line leaks - 0.5%
- Causes
- Staple line dehiscence
- related to higher intraluminal pressures Postop
- at criss-cross of stapling (staples over staples)
- patient induced
- Ischemic - due to electrocautery or vessel sealing systems



14

Gastric Leak Complications

- Abdominal pain (epigastric or left flank)
- Tachycardia (sustained 120 BPM for 4 hours)
- Tachypnea
- Fever
- Hypotension
- Low urine output
- Leukocytosis

15

Gastric Leak Diagnosis

- UGI
- Abdominal CT Scan
- surgical exploration

16

Gastric Leak Treatment

- Medical management
- Percutaneous drainage, parenteral/enteral nutrition, antibiotics
- Stents, endoscopic injection of fibrin glue
- Surgical management

17

Gastric Sleeve - Bleeding

Incidence - 2 %
Endoluminnal and or extraluninal
- Causes
- Increased risk due to long suture line
- Stomach has thick wall with 3 layers of very well vascularized muscle

18

Gastric Sleeve - Bleed - Diagnosis

- Melena
- Hematemesis
- Hypotension
- Tachycardia
- Decreased Hgb/Hct
- Drain output

19

Gastric Sleeve - Bleed - Treatment

- Blood transfusion
- Reoperation

20

Gastric Sleeve - Gastric Stricture and Obstruction

Incidence - 0-0.63%
Causes:
- latrogenic - size of bougie
- "Floppy" sleeve

21

Gastric Sleeve - Stricture/Obstruction symptoms

- nausea and vomiting

22

Gastric sleeve - Stricture and obstruction

Treatment -
- Endoscopic dilatation
- Hydration

23

Pulmonary Embolism - DVT

Incidence - ~1% without high risk attributes
- Responsible for nearly 1/3 of deaths in bariatric surgery patients

24

PE/DVT Risk Factors

- Male gender
- Age
- High BMI
- Smoking
- Estrogen/HRT
- Decreased mobility status
- Surgery



25

PE/DVT Prevention

- VTE Prophylaxis preop and postop
- Low dose unfractionated Heparin (LDUH)
- Low molecular weight heparin (LMWH)
- Early ambulation
- Graded compression stockings
- Intermittent pneumatic compression devices
-Prophylactic IVC filter
- Combination of above

26

Gastric Sleeve - Nausea and vomiting

- Usually occurs during the first 24-36 hours postop
- Causes:
- Diameter of the sleeve
- Manipulation/inflammation of stomach tissue
- Gastric stricture
- Gastric ulcers
- Patient issues
- Measuremet of food, speed of drinking and eating

27

Gastric Sleeve - Treatment of N/V

- Nutrition assessment and or counseling
- Hydration
- Antiemetic
- Thiamine replacement
- Endoscopic Evaluation