Stomach: Morbid Obesity

Basics

Weight Classification

  • BMI < 18.5 – Underweight
  • BMI ≥ 18.5 – Normal
  • BMI ≥ 25 – Overweight
  • BMI ≥ 30 – Obese, Class I
  • BMI ≥ 35 – Obese, Class II (Severe Obesity)
  • BMI ≥ 40 – Obese, Class III (Morbid Obesity)

Health Complications of Obesity

  • Diabetes
  • Cardiovascular Disease
  • Colorectal Cancer
  • Liver Disease
  • Sleep Apnea
  • Depression
  • Peripheral Arterial Disease

Obesity Hypoventilation Syndrome (Pickwickian Syndrome)

  • “Pickwickian Syndrome” Name Originates from a Character in Charles Dickens’ First Novel “The Pickwick Papers”
  • Decreased Ventilation Due to Obesity
  • Cause: Chest Wall Compression of Alveoli
    • Severity Not Correlated with Degree of Obesity
  • Complications: Pulmonary Hypertension & Right Heart Failure

Samuel Pickwick 1

Medical Management

Medical Management

  • Primary Interventions: Diet & Exercise
  • Indications for Drug Therapy: BMI > 30 or BMI > 27 with Comorbidities

Drugs

  • Liraglutide – GLP-1 Agonist (Stimulates Glucose-Dependent Insulin Secretion)
    • Typical First-Line Agent
  • Orlistat – Inhibits Lipase (Decreased Fat Absorption)
  • Phentermine – Release Norepinephrine (Appetite Suppressant)
  • Sibutramine – Blocks Serotonin Uptake (Increases Anorexic Effects)

Surgical Management

Criteria for Surgery

  • BMI:
    • > 40
    • > 35 With Comorbidities
  • Failed Nonsurgical Methods
  • No Alcohol or Drug Abuse
  • Psychiatric Stability
  • Able to Comply with Postoperative Requirements

Contraindications

  • Does Not Meet All Criteria for Surgery
  • Medically Unacceptable Risk
  • Unable to Ambulate
  • Prader-Willi Syndrome – Surgical Treatment Does Not Improve Constant Feelings of Hunger

Surgical Options

  • *See Stomach: Bariatric Surgery
  • Laparoscopic Adjustable Gastric Banding (LAGB)
    • Effect: Restriction
    • Lowest Weight Loss but Lowest Morbidity
  • Laparoscopic Vertical Sleeve Gastrectomy (LVSG)
    • Effect: Restriction
    • Most Common Bariatric Procedure for Weight Loss
  • Roux-en-Y Gastric Bypass (RYGB)
    • Effect: Combined Restriction & Malabsorption
    • Second Most Common Bariatric Procedure for Weight Loss
  • Duodenal Switch with Biliopancreatic Diversion
    • Effect: Malabsorption
    • Highest Weight Loss & DM Cure Rate
    • Higher Morbidity

Hormonal Effects After RYGB

  • Ghrelin – Decreased (Ghrelin Stimulates Hunger)
  • Leptin – Increased (Leptin Stimulates Satiety)

Surgery Outcomes

  • Expected Weight Loss at 2 Years (Of Excess Weight):
    • LAGB: 50%
    • LVSG: 55%
    • RNY-GB: 60%
    • Duodenal Switch: 70%
  • Lower All-Cause Mortality Compared to Intensive Medical Management
  • Overall Complication Rates Around 15%
  • Comorbidities Improved Postoperatively: Diabetes, Hypertension, Dyslipidemia & Sleep Apnea
    • Not Peripheral Arterial Disease
  • Diabetes Remission Rate at 3 Years:
    • Intensive Medical Therapy: 1.2%
    • LAGB: 24.9%
    • LVSG: 39.9%
    • RNY-GB: 58.4%
    • Duodenal Switch: 91.3%

LAGB 2

LVSG 2

RYGB 2

DS-BPD 2

References

  1. Clarke JC. 1889. Public Domain.
  2. Neff KJ, Olbers T, le Roux CW. Bariatric surgery: the challenges with candidate selection, individualizing treatment and clinical outcomes. BMC Med. 2013 Jan 10;11:8. (License: CC BY-2.0)