OBJECTIVES

1. To know the pathophysiology of obesity

2. To know the physiologic consequences of the disease of obesity
3. To know the management options of obesity
4. To know which patient are candidates for bariatric surgery
5. To know the principles of bariatric surgery
Book Verbatim High-yield

I. OBESITY
▪ Refers to the condition of having excess body fat
▪ MORBID OBESITY
- 100 lbs above ideal body weight
- Twice ideal body weight
- BMI = 40 kg/m2
▪ 2013 American Medical Association (AMA) recognized obesity as a
disease
▪ 2014 AMA approved the resolution on evidence-based treatment for
obesity including surgical interventions
The Microbiome Theory
DEFINITION OF TERMS
▪ OVERWEIGHT ▪ Bacteria in the gut
- BMI for age and gender ≥85th percentile ▪ Obese individuals harbor microbes that are better at extracting food
▪ OBESE ▪ Obese individuals have microbes that signal the body to store energy
- BMI for age and gender ≥95th percentile as fat
▪ SEVERELY OBESE/MORBIDLY OBESE
- BMI for age and gender >120% of the 95th percentile Treating Obesity by Managing Microbiome
PATHOPHYSIOLOGY OF SEVERE OBESITY ▪ Genome is fixed
▪ Multifactorial ▪ Habits are hard to change
▪ Most important factors: ▪ Microbiome is changeable
- Lack of satiety ▪ Transplantation of intestinal microbiomes from obese
- Maintenance of hunger individuals increase adiposity in recipients
▪ Genetic predisposition ▪ Microbiome therapeutic interventions aimed at obesity
1. FTO gene 1. Prebiotics
2. MC4R deficiency gene 2. Probiotics
3. Synbiotics
Ghrelin and Leptin 4. Transplantation of fecal microbial communities

▪ GHRELIN
- Only known orexigenic gut hormone
- “hunger hormone”
- Secreted by P/D1 cells in the gastric fundus
- Actions:
• Stimulates release of various neuropeptides, such as
neuropeptide Y (NPY) and growth hormone from the
hypothalamus
• Increase appetite state (OREXIGENIC)
▪ LEPTIN
- Produced by adipose cells
- Anorexigenic (appetite diminishing)
- Acts via ObRb receptor in the hypothalamus
- Regulates/control food intake

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Complications of Obesity Medical Conditions Associated with Severe Obesity
Cardiovascular Hypertension
Sudden cardiac death myocardial infarction
Cardiomyopathy
Venous stasis disease
Deep venous thrombosis
Pulmonary hypertension
Right-sided heart failure
Pulmonary Obstructive sleep apnea
Hypoventilation syndrome of obesity
Asthma
Metabolic Metabolic syndrome (abdominal obesity,
hypertension, dyslipidemia, insulin
resistance)
Type 2 diabetes
Hyperlipidemia
Hypercholesterolemia
Nonalcoholic steatotic hepatitis (NASH) or
nonalcoholic fatty liver disease (NAFLD)
Gastrointestinal Gastroesophageal reflux disease
Cholelithiasis
Musculoskeletal Degenerative joint disease
Lumbar disk disease
Osteoarthritis
Ventral hernias
Genitourinary Stress urinary incontinence
End-stage renal disease (secondary to
Figure 27-3. Pathways through which obesity leads to major risk factors diabetes and hypertension)
and common chronic diseases. Common chronic diseases are shown in Gynecologic Menstrual irregularities
red boxes. The dashed arrows indicate an indirect association. Skin/Integumentary Fungal infections
System Boils, abscesses
Metabolic Syndrome Oncologic Cancer of the thyroid, prostate, esophagus,
▪ Central Obesity kidney, stomach, colon, rectum, gallbladder,
Women Waist circumference >35 inches pancreas, female cancers of the breast,
Men Waist circumference >40 inches ovaries, cervix, and endometrium
▪ Component: Neurologic/Psychiatric Pseudotumor cerebri
1. DM type 2 Depression
2. Dyslipidemia Low self-esteem
3. Hypertension Stroke
▪ Pathophysiologic mechanism: Social/Societal History of physical abuse
1. Impaired hepatic uptake of insulin History of sexual abuse
2. Systemic hyperinsulinemia Discrimination for employment
3. Tissue resistance to insulin Social discrimination
▪ High risk of cardiovascular death
MEDICAL VS SURGICAL THERAPY
▪ Absolute superiority of bariatric surgery over medical therapy for the
treatment of morbid obesity and its comorbidities

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BARIATRIC SURGERY BARIATRIC SURGERY
1. Caloric restriction
2. Nutrient malabsorption

Indications for Bariatric Surgery

Patients must meet the following criteria for consideration for bariatric
surgery:
▪ Body mass index (BMI) >40 kg/m2 or BMI >35 kg/m2 with an
associated medical comorbidity worsened by obesity
▪ Failed dietary therapy
▪ Psychiatrically stable without alcohol dependence or illegal drug
use
▪ Knowledgeable about the operation and its sequelae
▪ Motivated individual
▪ Medical problems not precluding probable survival from surgery

Multidisciplinary Team
▪ Surgeon
▪ Assisting surgeon
▪ Nutritionist
Adjustable Gastric Banding
▪ Anesthesiologist
▪ Operating room nurse ▪ Individualized adjustability
▪ Operating room scrub tech or nurse ▪ Adjustable port is anchored in the fascia
▪ Nurse care coordinator or educator
▪ Secretary/administrator
▪ Psychiatrist/psychologist
▪ Primary care physician
▪ Medical specialists for cardiac, pulmonary, gastrointestinal,
endocrine, musculoskeletal, and neurologic conditions as indicated

Preoperative Evaluation and Postoperative Care

Before the Clinic Documented, medically supervised diet
Visit Counseling and referral from the primary care
physician
Reading a comprehensive written brochure
and/or attendance at a seminar regarding
operative procedures, expected results, and
potential complications
Initial Clinic Visit Group presentation on information in the booklet
Group presentation on preoperative and Roux En Y Gastric Bypass
postoperative nutritional issues by the ▪ Loop of jejunum anastomosed to the gastric pouch
nutritionist ▪ Complication: bile reflux
Individual assessment by the surgeon’s team
Individual counseling session with the surgeon
Individual counseling session with the nutritionist
Screening blood tests
Subsequent Full psychological assessment and evaluation as
Events/Evaluations indicated
Medical specialist evaluations as indicated Biliopancreatic Diversion
Insurance approval for coverage of the ▪ Complications:
procedure - Marginal ulcers
Screening flexible upper endoscopy as indicated - Protein malnutrition
Screening ultrasound of the gallbladder (if - Iron Deficiency Anemia
present)
- Bone Demireralization
Arterial blood gas analysis as indicated
▪ Mechanism: malabsorption
Subsequent Clinic Counseling session with the surgeon (including
Visits selection of the date for surgery
Education session with the nurse educator
Preoperative evaluation by the anesthesiologist
Final paperwork by the preadmissions center

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 WHAT’S NEW?
Intragastric Balloon
▪ Nonsurgical weight loss procedure
▪ Mechanism:
- Occupy space
- Limit food carrying capacity
- Lessen caloric intake
- Temporary

Semaglutide
▪ Ozempic, Wegovy, Mounjard
Duodenal Switch ▪ Mechanism of action:
▪ Modification from BPD to lessen marginal ulcers - Incretin mimetic
▪ Same mechanism of weight loss as BPD (malabsorption) - Improves efficiency of incretin function by activating GLP-1
reactors
▪ Longer alimentary tract than BPD at 250 cm
▪ Major difference: Sleeve gastrectomy instead of hemigastrectomy

WHAT’S THE BEST OPTION?

▪ Overweight
- Diet
- Exercise
▪ Severe Obesity
- Diet
- Exercise
- Endoscopic weight loss procedure
- Bariatric surgery

Vertical Sleeve Gastrectomy

▪ Advantages:
1. Preservation of the pylorus
2. Metabolic reduction of ghrelin
3. No need for adjustment
4. Reduction of internal hernias
5. Reduction of malabsorption
6. Later modification to RYGB or OS

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