Surgical Treatment of Obesity

by

Abstract

Conservative treatment has been shown in long-term studies to be ineffective in morbid obesity. Surgical treatments break down into restrictive, malabsorptive, combined restrictive and malabsorptive or motility-reducing procedures. (Miller 1997, 280) Laparascopic implantation of an adjustable gastric band is an efficient restrictive measure for treating the majority of patients with this condition. The adjustable gastric band enables weight loss and food intake to be adapted to the individual patient's need. Eighty percent to 90% of these patients can expect to lose 55-70% of their excess weight. Vertical banded gastroplasty is losing ground among the restrictive options. Preliminary experiences are encouraging but the long term results are disappointing when assessed by the standard criteria. The biliopancreatic diversion with duodenal switch combines a sleeve gastrectomy with a duodenoileal switch to achieve maximum weight loss. Consistent excess weight loss between 70% is achieved with acceptable decreased long-term nutritional complications. The laparoscopic approach to this procedure has successfully created a surgical technique with optimum benefit and minimal morbidity, especially in the super obese patient. Intra-gastric stimulation is the least invasive surgical procedure at present. However, the excess weight loss is lowest with this method at only 32% in the first 2 years after the operation.

Abbreviations

BMI = Body Mass Index

RYGBP = Gastricbypass

BPD/DS = Biliopancreatic Diversion/Duodenal Switch

VBG = Vertical Banded Gastroplasty

AGB = Adjustable Gastric Band

MC = Momordica Charantia

ASBS = American Society for Bariatric Surgery

IFSO = International Federation of Surgery for Obesity

IGS = Implantable Gastric Stimulator

CLA = conjugated linoleic acid

PUFA = poly unsaturated fatty acids

PPAR = peroxisome proliferator activated receptor

MLT = Melatonin

EPA = eicosapentanoic acid

TEF = thermic effect of food

SNS = sympathetic nervous systems

UCP = uncoupling proteins

WAT = white adipose tissue

GERD = gastroesophageal reflux disease

STZ = streptozotocin

Table of Contents

SURGICAL TREATMENT OF OBESITYV

1. Introductionv

2. Surgical optionsv

3. Indication for surgeryvi

3.1. Pre-operative procedurevii

3.2. Peri-operative careviii

4. Gastric bypass (RYGBP)viii

5. Biliopancreatic diversion/duodenal switch (BPD/DS)ix

5.1. Two stage procedures ('sleeve' gastrectomy and RYGB or DS/BPD)xi

5.2. Vertical banded gastroplasty (VBG)xii

5.3 Adjustable gastric band (AGB)xiii

5.4 Gastric pacemakerxv

5.5. Weight loss and comorbidityxvii

6. Nutraceutical interventionxx

6.1 Conjugated linoleic acidxxi

6.2 Capsaicinxxii

6.3 Momordica charantia (MC)xxiii

6.4 Psyllium fiberxxv

7. Conclusionxxvi

REFERENCESXXVII

APPENDIXXLI

List of Figuresxli

List of Tablesxlv

Surgical Treatment of Obesity

1. Introduction

Morbid obesity is a chronic lifelong, multi-factorial, congenital disorder with excessive fat deposits and associated medical, psychological, physical, social and economic problems. (Cleator, 1994, 358-360). Etiological factors include the involvement of hereditary, biochemical, hormonal, environmental, behavioural, health and cultural elements. Extreme forms of obesity are hardly likely to respond to diet, behavioural therapy or medication.1 Obesity is directly correlated with type II diabetes and cardiovascular disease. (Sugerman, 1995, 91-96). and (Miller, 2003, 697-702). Non-surgical treatments for morbid obesity have relapse rates of up to 90% irrespective of the choice of conservative treatment. (Wittgrove , 2000, 56) and (Lönroth, 1996, 636-638). As early as 1991, the US National Institute of Health issued a statement recognising the known lack of success with conservative forms of treatment, noting that operations to constrict or bypass the stomach were justified for fully informed and consenting ...