This document discusses bariatric surgery as a treatment for obesity, diabetes, and hypertension - known as the "dangerous triad". It outlines the obesity epidemic globally and in India. Bariatric surgery is presented as the most effective long-term treatment, as other options like diet, exercise, and medication often only achieve temporary weight loss. The document describes various bariatric surgical procedures and their mechanisms for weight loss and resolving comorbidities. Case studies are presented demonstrating successful weight loss and comorbidity resolution through bariatric surgery. Risks are low but include leaks, strictures, and potential for weight regain. A multidisciplinary team approach is emphasized for best outcomes.

1. “DANGEROUS TRIAD OF
OBESITY, DIABETES &
HYPERTENSION”
- IS SURGERY
THE SINGLE
ANSWER?
DR SREEJOY PATNAIK

2. Bariatric & Metabolic Surgery Dept.Bariatric & Metabolic Surgery Dept.
Shanti Memorial Hospital Pvt Ltd.Shanti Memorial Hospital Pvt Ltd.
DR SREEJOY PATNAIK
LIFE MEMBER OSSI,IFSO,SAGES
www.obesityinindia.com, www.shantimemorialhospital.com

3. Obesity EpidemicObesity Epidemic
• World epidemic - 1.7 billion people
• BMI >35 & >40 showing rapid growth
• Rise in obesity > rise in comorbidities
• Comorbidities > 2.5 million deaths per year
• Morbid obesity - reduction in lifespan
Buchwald et al. Jama 2004Buchwald et al. Jama 2004

4. Obesity EpidemicObesity Epidemic
• T/t :
• Diet therapy alone is ineffective in long term .
• Currently, there are no effective pharmaceutical agents to treat
obesity, especially morbid obesity
North American Association for theNorth American Association for the
Study of Obesity. NIH 2000Study of Obesity. NIH 2000

5. Obesity in India
• Morbid obesity - 10% of the country's population.
• Unhealthy, processed food has become much more
accessible in global food markets.
• Indians are genetically susceptible to weight accumulation
especially around the waist.
• A SNP (single nucleotide polymorphism) GENE named
rs12970134 to be mostly associated with waist
circumference

6. AETIOLOGY :
MULTIFACTORIAL COMPLEX DISEASE
GENETIC
LACK OF PHYSICAL ACTIVITY
& MEDICAL REASONS
LIFESTYLE CAUSES

7. • Calculated as follows: Weight(kg)/Height(m2
)
• Mortality lowest = BMI < 25kg/m2
• Mortality highest = BMI > 40kg/m2
Definition of ObesityDefinition of Obesity
according to BMIaccording to BMI
BMIBMI

8. CLASSIFICATION OF OBESITY

10. Waist to Hip Ratio

14. HEALTH RISKSHEALTH RISKS

15. Negative Effects of Obesity

16. Pulmonary disease
abnormal function
obstructive sleep apnea
hypoventilation syndrome
Nonalcoholic fatty liver
disease
steatosis
steatohepatitis
cirrhosis
Coronary heart disease
Diabetes
Dyslipidemia
Hypertension
Gynecologic abnormalities
abnormal menses
infertility
polycystic ovarian syndrome
Osteoarthritis
Skin
Gall bladder disease
Cancer
breast, uterus, cervix
colon, esophagus, pancreas
kidney, prostate
Phlebitis
venous stasis
Gout
Medical Complications of Obesity
Idiopathic intracranial
hypertension
Stroke
Cataracts
Severe pancreatitis

17. Metabolic Syndrome or Syndrome X
THE DANGEROUS TRIAD
Abdominal obesity
Hyperinsulinemia
High fasting plasma glucose
Impaired glucose tolerance
Hypertriglyceridemia
Low HDL-cholesterol
Hypertension

18. TREATMENT OF OBESITY
1.DIET
2.EXERCISE
3.BEHAVIOURAL/LIFESTYLE
MODIFICATION
4.MEDICAL / DRUGS
5. SURGERY

19. Medical Treatment of Obesity
Diet – low in calories, fat and carbohydrates (1200 cal/ day)
Exercise– 40 minutes 5 times per week
Behavior Modification – eat 3 sensible meals per day, avoid
snacking
Drugs/Prescription medications-Stimulants/appetite suppressants
– Antidepressants (Meridia®)
– Reduce fat absorption (Orlistat)

20. Disadvantages of medical treatment:
Most patients (95-97%) regain weight that was lost
within 2-5 years following diet or drug treatment
The average amount of weight loss is relatively
small – 10-20 Kgs
Drug therapy may be associated with severe
complications

21. Disadvantages of medical treatment:
Most insurance companies do not cover costs
• Very difficult to maintain these programs in
the long term
• “Yo-Yo” effect leads to significant weight
fluctuations

22. Surgical Treatment of Obesity
• Surgeons who specialize in treating obesity
or the Dangerous Triad are known as
Bariatric or a Metabolic surgeon.
• Bariatric surgery leads to significant and
long lasting irreversible weight-loss
alongwith resolution of comorbidities in
severely obese patients

23. Bariatric and Metabolic Surgery
• Bariatric Surgery - from the Greek “baros”
meaning “weight”, is synonymous with weight
loss surgery.
• Metabolic surgery - be defined as “a set of GI
operations used with the intent to treat
diabetes ("diabetes surgery") and metabolic
syndrome. (X- syndrome )”.

24. Indications for SurgeryIndications for Surgery
NIH Guidelines
BMI > 35 WITH 1 OR MORE COMORBID CONDITIONS (DM /
HTN )
BMI > 40 WITHOUT ANY COMORBID CONDITIONS
PREVIOUSLY FAILED WEIGHT LOSS ATTEMPTS ( e.g, non-
surgical interventions, diet control, behavioral modifications,
exercise )

25. Indications for SurgeryIndications for Surgery
• Age > 18 or < 65
• Failure of diet > 6 months
• Obesity history > 5 years
• Low risk for surgery
• No endocrinological disease
• Psychologically sound
NIH Consensus ConferenceNIH Consensus Conference
Ann Intern Med 1991Ann Intern Med 1991

26. Goals of Surgery
• Effective: Loss > 50% of Excess Weight
• Low operative morbidity & mortality
• Well tolerated
• No long term complications

27. 5 TO 6 PORTS
The benefits are:
•Less Pain
•Quicker recovery and
return to normal activity
•Fewer complications
•Less noticeable scar
•Shorter hospital stay
Laparoscopic Procedure

28. Surgical ProceduresSurgical Procedures
• 1.RESTRICTIVE PROCEDURESES
• Restrictive surgeries shrink the size of the stomach which
reduces the amount of food it can hold. This makes you feel
full when eating much sooner than you did before surgery
–Gastric Banding
–Sleeve Gastrectomy
–-Gastric Plication

29. 2. MALABSORPTIVE PROCEDURES
Malabsorptive surgeries rearrange and/or remove part
your digestive system which then limits the amount of
calories and nutrients that your body can absorb.
–Biliopancreatic Diversion
• Scopinaro
• Duodenal-Switch BPD

30. 3. HYBRID PROCEDURES
– When surgery combines both restrictive and
malabsorptive component, it is known as a
“combination” procedure.
– Roux-en-Y Gastric Bypass / Banded
– -Mini Gastric Bypass

31. Bariatric Procedures Performed Today
Restrictive procedure
We reduce the
size of stomach
75%

32. How does a sleeve work?
One of the mechanisms
involved in weight loss
observed after the LSG is the
dramatic reduction of the
capacity of the stomach.
Ghrelin
An orexigenic (appetite-stimulating)
peptide hormone mainly produced in the
fundus of the stomach, is supposed to be
involved in the mechanisms regulating
hunger .

33. MALABSORPTIVE PROCEEDURE
Bilio-pancreatic diversion
Scopinaro SG with DS

34. HYBRID PROCEDURE / COMBINATION
We do restriction by
making a small stomach
pouch, alongwith create a
malabsorption by
bypassing the BPD limb.

35. RestrictionRestriction
Malabsorption
Gastric Bypass
Loss of appetite
?
Small pouch (approx 30 cc)
Small anastomosis (approx. 1.5 cm)
How does it work ?
Alimentary Limb
Between 100 to 200cm
Biliopancreatic Limb
Between 50 to 75 cm
Ghrelin

36. MINI GASRIC BYPASS

37. OPERATION THEATRE LAY OUT

38. POST OP ICU LAY
OUT

39. GI HORMONES AS INCRETINS &
ANTI INCRETINS

40. Mechanism of Incretin action action

41. PROPOSED THEORIES FOR IMPROVED GLYCAEMIA
(A) RAPID HINDGUT DELIVERY HYPOTHESIS
• Rapid delivery of ingested nutrients to lower bowel due
to intestinal bypass leads to stimulation of L cells, ( distal
ileum & colon ) which in turn results in increased secretion
of incretin hormones & improved glucose homoeostasis.
•Proximal nutrient related signals that are transmitted from the
duodenum to the distal bowel by neural pathways leads to increased
Incretin secretion.

42. PROPOSEDT(B) FOREGUT HYPOTHESIS
HEORIES FOR IMPROVED
GLYCAEMIA
•The proximal small intestine (foregut / BPD limb ) is excluded
resulting in reduction in secretion of Anti – incretin factors
( diabetogenic hormones) in response to absence of nutrients in
the fore gut.
•This leads to improved glycaemia.
&
•Decreased Intestinal Glucagon synthesis
.

43. Benefits of Weight Loss Surgery
Significant weight loss
• Lower cholesterol – D-30
• Lower blood pressure
• Improvement of Type II diabetes –D-1
• Improvement of cardiovascular health
• Relief of sleep apnea
• Relief of digestive problems –GERD
• Decreased joint pain
• Improved mobility
• Improved self image

44. Resolution of Comorbidities following
Bariatric / Metabolic Surgery

45. MY ExperienceS iN
Bariatric Surgery

46. Bariatric Procedures (n=50) 2010
• Lap adjustable gastric band 0
• Lap sleeve gastrectomy 37
• Lap gastric bypass 2
• Lap duodenal switch 0
• Lap gastric plication 0
• Ileal Transposition 0
• Revisional Bariatric procedure 1
• MGB 10

47. OUR SUCCESSFUL PATIENTS
SANJAY
Age: 34
BW: 158 kg
BMI: 56
HTN: (+)
DM: (+)
ASTHMA: (+)
OA: (+)
Hypothyroidism: (+)

48. SANJAY
Age: 36
BW: 80 kg
BMI: 30
LOST 78 KGS

49. RAGHAV
Age: 22
BW: 135 kg
BMI: 44.5
HTN: (+)
DM: (+)

50. Age: 25
BW: 72 kg
BMI: 23.5
LOST 63 KGS

51. SANTOSH
Age: 57
BW: 105 kg
BMI: 46
HTN: (+)
DM: (+)
OA: (+)
Hypothyroidism: (+)

52. SANTOSH
Age: 60
Body Weight: 60 kg
BMI: 25
LOST 35 KGS

53. SUDATTA
Age: 31
BW: 100 kg
BMI: 37
HTN +
PCOD +

54. SUDATTA
Age: 32
BW: 50kg
BMI: 23
LOST 50 KGS

55. APARAJITA
Age: 29
BW: 96 kg
BMI: 36
OA: (+)
PCOD +

56. APARAJITA
Age: 29
BW: 60 kg
BMI: 26
LOST 36 KGS

57. HAPPY AFTER MARRIAGE

59. UMABALLAV
Age: 50
BW: 111 kg
BMI: 39
HTN: (+)
DM: (+)
ASTHMA: (+)
OA: (+)
Hypothyroidism: (+)
Hyperlipidmia: (+)

60. UMABALLAV
Age: 51
BW: 70 kg
BMI: 27
LOST 41 KGS

61. KISHANLAL
Age: 56
BW: 107 kg
BMI: 36.5
HTN: (+)
DM: (+)
ASTHMA: (+)
OA: (+)
Hypothyroidism: (+)
Hyperlipidmia: (+)

62. KISHANLAL
Age: 56
BW: 76 kg
BMI: 24.5
LOST 31 KGS

63. MAHUA
Age: 32
BW: 108 kg
BMI: 42
Hypothyroidism: (+)
Hyperlipidaemia: (+)

64. MAHUA
Age: 32
BW: 60 kg
BMI: 27
LOST 48 KGS

65. COMPLICATIONS
(n=50)
• 1.Leak – 1 case,P.O day 15,
GE junction > closed
abscess, Halitosis.
• Endoscopic Septotomy ,
NGT feeding- 6 wks.
• 2.GE stenosis – late – after 1
yr.
• Managed conservatively with
balloon dalatation.
• 3. Weight regain – after 2yrs
– SG > MGB

66. GE JUNCTION LEAK WITH A CLOSED ABSCESS

67. 2nd
Endoscopy

68. Final Endoscopy after 6 wks.

69. GE JUNCTION STENOSIS

70. Conclusion
In Bariatric Surgery
Everything is BIG!!!
Patient
Risks
Expectations.

71. Multidisciplinary teamMultidisciplinary team
And ProgramAnd Program

72. THE XXXTH ANNUAL
CONFERENCE OF ASI ODISHA
CHAPTER 2015
• DATE – 6-8 TH FEBRUARY 2015
• PLEASE BLOCK YOUR DATES
• 6TH
- 3D LAP. WORKSHOP- 1ST
TIME IN E.Z
• 7 & 8TH
– CONFERENCE
• VENUE- B.P.F,TV INSTITUTE, CUTTACK
• PLEASE REGISTER AT THE EARLIEST.

73. FOR YOUR PATIENT HEARING