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Sleeve Gastrectomy: Explained

Dec 30 | 2:00 PM

Bariatric surgery involves changing the patient's digestive system to help them lose weight and increase overall health. Sleeve gastrectomy reduces the patient's stomach by 15% of its original size. Dr. Narwaria, one of the country's leading bariatric surgeons and founder of Asian Bariatrics, will walk us through the Sleeve Gastrectomy procedure. Dr. Om Lakhani, an endocrinologist at Zydus Hospitals, will join him to discuss the broader significance of obesity surgeries. Join us live and exclusive on Medflix!

[Music] good evening to one and all netflix welcomes you today for this session on sleeve gastrectomy explain today we have with us uh dr mahindra naruvariya who's the senior bariatric surgeon but he's in an emergency surgery he'll be joining us soon he's one of the pioneers of bariatric surgery in india is the founder and chief bariatric and robotic surgeon at asian bariatrics ahmedabad he has obtained his post graduate degree in general surgery and then pursued his surgical gastroenterology and laparoscopic surgery he has an impressive 28 years of experience and has performed more than 2000 bariatric procedures to date he has done the first laparoscopic sleeve gastrectomy in india in 2004 followed by the first scarless slave gastric tummy in 2009. i think we have dr nirvariya with us welcome sir a very good evening good evening so dr narvaria has done the first laparoscopic sleeve gastric term in india in 2004 followed by the first carless sleeve gastrectomy as well in 2009 we are very glad to welcome such an eminent faculty we today also have with us dr om lakhani he is a consultant endocrinologist working at cyrus hospital ahmedabad he is a national board certified endocrinologist and also holds a specialty certificate in endocrinology and diabetes he was the winner of this celebrated endocrine society of india young scholar award and has also won the coveted av gandhi award for excellence in endocrinology research his areas of expertise include diabetes mellitus thyrotoxic causes pituitary disorders endocrine oncology and pediatric endocrinology welcome doctor ohm dr mom i would be starting okay so uh thank you for the kind introduction uh and uh good evening sir and good to see you today again uh so today we'll be discussing about uh well this is a two-part thing uh in the first part i'll be talking about how really weight loss happens with bariatric surgery or obesity surgery and uh doctor nanowrimo will be talking about the mechanics of the same and we'll be talking about the actual procedure in itself so uh what we're going to do is we're going to understand how obesity surgery works because ah it's been many years since this has been performed now but still there are a lot of you know interesting aspects of bariatric surgery or obesity surgery which are which are you know learning points for both uh surgeons as well as for uh endocrinologists and physicians so it's something which which isn't very interesting phenomena which will try to you know declutter and understand today in this talk okay so at this point of time in 2021 what are the options that we have for obesity and we know that obesity is a rising uh issue across the world especially in india where we now have a big uh you know middle class where food shortage is not a problem anymore and genetically perhaps we are at a disadvantage as we all know and because of that you know there is an increasing belly in the middle in our country and you know that's that's fueling a lot of metabolic problems including diabetes cardiovascular disease and so on so obviously you have three major options for obesity so you have the lifestyle measures which include you know dietary measures exercise and so on uh then you have medical therapy which is again fast emerging to be a viable option for obesity at this point of time the only approved obesity drug is only stacked but you have many of the anti-diabetic drugs which have potential to be used as obesity medications and which are now emerging you know there are trials emerging for the same and then you have obviously the obesity surgery and bariatric surgery of course you have certain minimally invasive procedures or endoscopic procedures as well but again you know that's somewhere in the middle and they're still emerging areas but mainly you have these three options as far as the management of obesity is concerned now one thing which you know we have learned over the time is that of all the three options that we have it seems that obesity surgery is the most effective or not only for initial weight loss but also for sustained weight loss now why is this so why is it that surgery is more effective than other forms including the lifestyle measures and medical therapy the reason is what we now realize is that surgery it has a multi-prong approach so there are multiple things which change following a surgery in terms of both physiology in terms of endocrinology in terms of anatomy and in terms of central nervous system as well and all these changes would lead to normally good initial weight loss but also sustained weight loss over a period of time whereas when you talk about a medications or lifestyle measure the issues with medications are that medications are very effective in the initial aspect but they do not sustain the weight loss for a long time the reason is that whatever medication you prescribe generally it acts on one pathway it acts on a single pathway whereas obesity is a multi-pronged disease it has multiple issues involved it has anatomical issues it has psychological issues it has psychosomatic issues it has endocrine issues it has microbiological issues as well as you'll understand from this talk so obesity surgery tends to be more effective over a long term because it tends to approach through multiple aspects it tends to cover multiple aspects of therapy and because of that you have a more sustained and effective weight loss perhaps in future just like in diabetes or hypertension we have we have you know drugs which act on multiple mechanisms and because of that you have good diabetes control with medications in the same way perhaps in future you will have oral medications or injectables which work in different mechanisms and perhaps because of that you will have a sustained weight loss with medical therapy as well but at this point of time obesity surgery continues to be the most effective form of obesity therapy now we know the basics of gi metabolism i'm not going to too much detail of this but you know for those who are interested you know this is a very nice cartoon which i could get and i think you know you could take a good screenshot of this perhaps you know it would be useful when we try and understand the mechanics of obesity surgery from uh our surgeon today okay so let's take the various pathways which get uh involved in a obesity surgery and how do they impact the weight so the first is a very obvious thing which is a mechanical pathway so these are the two most common commonly performed obesity surgeries worldwide so you have the road y gastric bypass and you have the sleeve gastrectomy so what happens is uh typically you know these are generally they are classified as either you know restrictive procedures or you know they are generally now called as more of a metabolic procedure so what happens in a slew gastrectomy is that a portion of the stomach is basically removed and it the stomach is made into a small pouch it you know is it used to be one component of a more detailed surgery which was done in the past but now you know they realize that just the initial sleeve gastrectomy part is also effective for weight loss so it's a simple straightforward procedure there is a ruin why gastric bypass is a male absorptive more uh you know advanced surgery in a sense where you have you have the bypass stomach as well you also bypass the deodorant and parts of the jejunum as well so it's a more uh it is definitely more effective in terms of weight loss but it is more potential complications and a much more uh you know extensive surgery compared to a sleep based return so what is the role of endocrine in this thing and how does a bariatric surgery so obviously you know you have portions of the gi tract which are bypassed and because you have these portions of gi tract which are bypass naturally that will lead to you know for example in a slew gastrectomy you know the the volume of the stomach is reduced so hence you know with some amount of food intake you know you feel satiety much faster similarly you know in case of a rnig rygb you tend to have you know uh you have bypass the deodorant where a lot of absorption takes place jejunum where a lot of absorption of nutrients takes place so this has been bypassed and actually this will lead to weight loss so there is clear anatomical reasons for weight loss but what we'll learn in the next few slides is that it's not as simple as that it's not just the anatomy which is involved but also there are endocrine changes which happen which lead to the weight loss so where does the endocrinology or where what what is the role of the hormones of the gi tract which really take up important role in this process so first of all you know there are neuro hormonal changes there are changes which occur at the central nervous system level and we'll see what these changes are now one very interesting thing is that what uh you know dr narvaria's patients may also you know come and tell you a lot of patients or underground barrier surgery come and tell us that after a period of time there is some alteration in taste sensation so that you know initially in the first few weeks after surgery there is in fact an increased craving for sugary and fatty food but over a long period of time there is reduced craving for sugary foods for fatty diet right there is some mechanism which occurs at the central nervous system uh perhaps at the mesolimbic and the orbital frontal pathways which lead to a reduction in alteration in taste sensation and over a long time this is hedonic changes we need to reduce reduce preference for sweet or fatty food uh both in terms of you know uh on a short term and long term exposure so the patients actually feel less craving for you know the kind of foods which are you know we feel a lot of craving for so this is one thing with changes and this is a very interesting phenomena to really explore and perhaps you know we have right now we are just understanding the basics of it uh perhaps in future we'll have more data on this and you know we'll understand this much better uh there are again multiple reasons why this could be happening again there could be neuro hormonal issues but also there is some propensity to think that there is some amount of dumping syndrome which happens uh after you know some of these surgeries and because of that there is a you know a negative response of which is created because of which patients tend to avoid sugary and fatty food so nonetheless the point is that there is definitely alteration in the sensation and there is definitely changes which occur in this taste uh pathways and the olfactory pathways which lead to uh the sustained weight loss one another interesting thing is that the reward pathway is disrupted so this is a very important aspect here to understand see food is the reason why food is a very important food plays a very important role in our life is because there is a reward pathway which is associated with the food so you know uh and it's like this that your body requires fuel to survive it requires energy it requires energy form of food to survive and when you consume this food there are uh you know signals which go to your central nervous system rewarding you for the food intake right you feel better after eating the meal let's say you're very hungry you are you are starving and then you have a meal you feel better there is definitely a sense of well-being which happens now this is the reward pathway and you know it will be so surprising that they have done animal studies uh where they've removed this reward pathway where they completely eliminated this reward pathway what they found is that if the reward pathway in a mice or a rat is removed there is foods sitting right in front of the mice and the mice will not bother to get up and eat that food right it simply it will starve to death it literally start to that this reward pathway is not there same thing has been seen in other mammals as well where you know for some reason by maybe an injury or something you know there is there is the reward pathway which is damaged and because of that you know uh literally they say that you know if the reward passing for a lion is cut off the line will not go and hunt the deer it will just sit under the shade of a tree all throughout the day and not do anything and literally starve to that right so this reward pathway is very very important uh for the you know uh body and it's very important that you know this this pathway remains intact uh otherwise you know the human beings actually do not eat food right so this is to some extent affected by a bariatric surgery or obesity surgery the reward pathway is is not completely cut off but the reward pathway is definitely dampened and because of this dampening of the reward pathway you know again the patients feel less uh you know reward for eating food and this again craving for food intake and other aspects they generally produce right a lot a lot of you you know may remember that there was a medication for obesity which was very effective which was called remona band and this rumor band was actually the you know drug which affected the reward pathway it actually cut off the reward pathway and this was a very effective anti-obesity drug patients lost significant weight it was thought to be a miraculous drug for weight loss but what did what happened as an unintended consequence of this drug was that there are a lot of people who were you know having depression having having suicidal tendencies and hence this drug was eventually withdrawn from the market and unfortunately because of this uh you know and there are a lot of uh you know cases also filed a lot of thoughts you know in u.s you know how systems work so because of that you know uh nobody really looked into this pathway again but the reward pathway is a very important pathway for food intake and i think you know it's very important for us as doctors to understand that this pathway is involved a lot of our patients who have altered relationships with food then of course you have so one is of course your central nervous system which plays a role but you have a big endocrine system in the gut in the gi tract right and this gut hormonal changes also have a impact on the system in fact this is a very very important role this plays a very important role in the sustained weight loss that happens after obesity surgery so you have this you know glp and peptide yy which are involved in this system now glp one a lot of you who are physicians or were you know uh dealing with metabolic disorders would be very well aware about glp one but glp one receptor anonymous are used for management of diabetes they are very effective drugs for management of diabetes initially they were available as injectable drugs but now you have uh you know oral sigma glutathione which is going to be available at the end of january which is the first oral drug for uh for glp as a glp1 receptor economist now glp one has two major actions grp one basically one what it does is whenever the food reaches the stomach there are some hormones which are released one is of course glp one from the gi tract from the intestine from the l cells of the intestine and this send a signal to the pancreas to tell them that the food has arrived keep the insulin ready so at that point of time the insulin is released by the pancreatic beta cell in preparation of the food intake so there is a automatic remote control system which is there and this remote control system is what really uh you know controls the uh you know keeps things ready uh before you know the food really is absorbed right so a lot of the time you know for example a lot of you might be having these fancy new cars where with with you know uh uh automatic uh mobile apps and all that you know so uh once you're leaving your clinic or your office you just click on the mobile app and the car is automatically activated the car is kept ready and you know maybe you can start on the air conditioner and all that it's something like this right so before even before your food is absorbed the pancreas keeps the system ready for able to metabolize and digest the food so this is the uh glp1 pathway the another interesting aspect of glp one is that attacks on the central nervous system and it produces satiety so it is again a signal to the body that you have had food now perhaps you are less hungry and you don't need to eat more right that's the system which is in play now this in terms of medical therapy we have started using glp1 receptor agonist which does the same thing which controls the diabetes very effectively but also reduces the food intake and satiety and because of that these patients typically lose weight and hence it's a very effective anti-diabetic drug as well as it's a very effective drug for obesity in fact uh glp1 decepticons is now approved for obesity in many of the western countries including united states and india also it is we often use this as an off label ah and it's a very effective drug for this very purpose now generally this peptide yy and the glp1 is released by a series of you know cells in the jejunum which are the uh l cells and this l cells are the one which release this uh hormone very important hormone now in a normal case these cells are obviously there in the body but in some patients with like especially patients with diabetes the effect of these system is actually dampened but if you undergo if a patient undergoes a sleeve gastrectomy what happens is that there is increase the the you know uh exposure of the food to the l cells of the intestine is actually increased because of the you know uh the food flows through a narrow tract and then they rapidly enter the intestine leading to more exposure to the l-cells and then when you do a roigb or rony you have directly bypassing a lot of system and giving a direct access to these l cells so because of this you have the activation of the glp one axis and this glp one axis like we discussed leads to weight loss as well as it leads to satiety and hence it's a very important axis and this axis actually can be mimicked by medical therapy as well so uh it's a very effective treatment in terms of medical therapy but also in terms of bariatric surgery it's a very effective therapy and hence you can see that this plays a major role in the weight loss especially from the gi tract then of course you have oxentomodulin which is another gi hormone which is released from uh in and this releases increasing patients with who tend to have uh under undergo bariatric surgery or obesity surgery uh what oxandromedulin does is that it increases insulin separation it promotes it reduces food intake and increases energy consumption it reduces ghrelin secretion and gastric emptying we'll see imports of berlin in a few minutes it increases the lag policies and adiponectin adiponectin reduces the insulin resistance uh increases fgf21 will see the mechanism as well and it also acts in the liver where it promotes the glucose you know utilization and promotion and also activates the fgf21 in the liver as well so oxentomodulin is another hormone uh unfortunately we this point of time we do not have any medical therapy uh for this hormone but i think in future perhaps uh with improved medical care we might be able to create uh medical therapies for this hormone as well and then of course we have the very famous duo the leptin and ghrelin right now ghrelin is an or exogenous hormone so oxygenate means it increases the food intake so when you have you know when you're hungry the ghrelin intake increases and there is uh this is the hormone which makes you hungry whereas leptin is exactly opposite to that leptin what it does is it is secreted by the adipose tissue and what leptin does is leptin produces satiety so it again is a signal to the body that you have enough food you don't need more right you don't need to overload the system so hence you tend to have leptin and trellis right now in uh you know before you eat so when you're hungry the leptin levels tend to be lower and the credit level needs to be higher but after you have had a food your adrenaline level tends to be low and the left hand level tends to be high so this is the basics of leptin and relent and these are very important hormones which play a key role in the weight loss weight maintenance and obesity so what happens to ghrelin after a obesity surgery or a bariatric surgery and what happens to leptin so typically it has been seen is that you know grilling levels so in the left you have the pre bariatric surgery and the right you have the post periodic surgery the grading levels tend to be lower post periodic surgery so the hormone which makes you hungry is less following the bariatric surgery if you see leptin levels unfortunately leptin levels are also low but this is the reason for this is that the leptin levels basically uh you have reduction of the adipose tissue over a long period of time and because of the reduction of adipose tissue this hormone which is produced by a disposed tissue is in a less quantity so overall you have both reduction of leptin as well as ghrelin but the predominantly grayling reduction is the one which is the one which leads to more satiety weight loss and reduce at a positive which leads to under secondary reduction in the leptin level as well so if you see this uh figure where you have what all you know from a gi tract is being done by one of these uh one or two of these surgeries that is rygbn uh you know sleep gastrectomy so what you can see is that the ghrelin levels are reduced in both rygb and uh sleep gastrectomy in fact the greater level reduction is much more prominent with new gastrectomy you have increase of bile acid secretion this plays a very important role and we'll see this in the next few slides uh the glp one and peptide wi-fi which we discussed is increased in both the surgeries but this increases more prominent with the rygb ah you have acentermodulin which is increased and then you have various other hormones like fgf19 fgf21 which are also impacted which we don't fully understand the role of these but uh you know we understand some parts of it and we'll discuss in the next few slides what this really do so what another important aspect which is now emerging and this is now emerging to be a very very important and key regulator for uh management in in situations of bariatric surgery is the role of bile acids and there is increased secretion of bile acid now for a long time it was thought that bile acid is just a carrier but it's not so pilates it plays a very important metabolic role also in the human body so uh you know i apologize for handwriting of mine in this you know this is the best way i could represent this so bile acid also increases glp one and peptide piy which leads to satiety it increases the effects are it acts on the fxr receptor which increases the brown adipose tissue now what's a brown added costume see brown adipose tissue is something where there is uncoupling uh in the mitochondrial axis where you have energy which is being dissipated but it is energy is not stored so brown eddy post issues are those people who have more brown adipose tissue they tend to be leaner they tend to be fitter right and this uh bile acid they increase the propensity to develop ground adipose tissue and you have another axis which is tgrf axis where you have fgf90 which is affected which impacts the society and you have fgf21 which is which impacts impacts the eating behavior so these two things are uh you know increased by bialysis and because of this bile acids also tend to have a role in the obesity mechanism so you know like we discussed what is the role of bile acid and like we discussed the bile acid on one hand they increase the glp one and increase the uh peptide leading to satiety they increase brown adipose tissue and they also lead to activation of tgr5 which in turn leads to activation of various other systems uh you know which which further lead to certain and adaptive adaptation of the code intake okay so these were all gut hormonal changes will summarize everything at the end for you to understand this much better but finally there's one more axis which is there which is very interesting and this accesses in fact you know this is an emerging area of research emerging area of understanding concept in not only in terms of you know bariatric surgery but also in terms of metabolics in terms of you know how the human beings interact with their immediate environment and this is the role of gut microbes now you know what is very interesting is you know uh what people have researched is that no what happens when you go to another planet you know like like mars you know you go outside the earth's atmosphere right now there are a lot of things we understand you know the oxygen will not be there you know you'll have to carry a food water etc but what we do not understand is that remember the human body is a carrier is a house is a home for millions and millions of bacteria which live within the human body right so the question is when you go on a on you know another planet what really happens to the people who are you know living rent free inside your human body we don't really understand this right the only thing you know they had they had some data from the you know uh people who went to the moon but you know they're not many of them right so we don't have much data there are you know they they do take uh samples from uh you know people are living on on these you know uh this space space uh what you know satellites over a time uh but you know we don't understand this and this is one of the concerns which has been there for a long time uh about space travel that what really happens to a gi tract uh the gut microbes in the gi tract and do they survive uh you know because they're housed within the human body or do they change and do they alter when we go uh on a space to right maybe to mars or maybe to some other planet right so this is something which we don't understand but what we do understand is that gut microbes definitely have a role in the you know gi tract uh what they have done is you know this is it sounds very uh but one of some of the earlier studies what they used to do was they used to take you know they used to take an obese mice and they used to take a lean mice and they used to you know uh clean the gut of the obese mice and they used to transplant the fecal matter from the uh lean mice to the obese mice and what they found was that the obs might also become thinner with the transplantation of the you know microbes from the lean mice and vice versa which is very interesting so that means that there is there are systems within your human body which is also impacting what happens to your metabolism and this is something which is really thing right so this is the kind of a picture of what are the normal cut microbes in the gi tract and there are many of them so i will not go into too much details of you know this anybody who's interested in this part of the research may be you know taking this up but what happens is that the diversity of this uh you know microbes the more diverse the microbes are the more likely you are to be leaner and fitter that is what we have seen over a period of time so if you see a normal person they'll be normal diversity but obese people tend to have less diversity of their gut microbes and because of this low diversity these people tend to be uh you know they need to have an impact on the way whereas when you do a gastric bypass what they found is and when they have taken samples of the gi tract they found they have to have very high diversity in their microbes this high diversity is perhaps you know has some relation with the overall uh you know likelihood of losing weight after obesity now what do these gut microbes really do now gut microbes also act on the increasing pathway leading to secretion of glp one they lead to production of short chain fatty acid in this short term fatty acid leads to you know again glp1 secretion but also give you a sense of satiety and fullness they increase the bile acid metabolism we already saw what bile myelitis does and it you know also has impact on the adipose tissue regulation leads to conversion of white adipose tissue to brown adipose tissue which is again like we discussed very very important so gut microbes also play a very very important role in your metabolism we often take this for granted now there are two very important uh microbes which are associated with obesity and fermi seeds uh fermi suits and pectoralis these are the two ones which are strongly associated with obesity again what they found is that post bariatric surgery uh these the you know the diversity the these uh you know bacteria tend to be lower in a lean person and perhaps again this could be is this a cause or is this the effect we don't know that's it's a chicken and neck thing but we do understand that they do play a key role in this system right so again you can see from this chart you know what happens uh in rygb and uh you know after uh sleeve gastrectomies again there are changes in these microbes and generally you know there is increase of diversity overall leading to a good metabolic health in these patients okay so let's summarize what we discussed today right so basically what we're trying to discuss is trying to demystify and try to understand how does an obesity surgery lead to weight loss now broadly speaking right uh this is a kind of a picture summary of this broadly there are multiple mechanisms by which it happens now one is obviously anatomical right so you are and by you know various bariatric surgeries what you're doing is you're bypassing certain aspects of the gi tract especially you know deodorant in certain cases you are making the stomach smaller leading to early satiety second is of course endocrine changes and endocrine changes can occur at two levels at the level of the central nervous system where you tend to have changes in terms of you have you know a reduction of the reward pathway and you have satiety you have alterations in taste sensation and so on and at the gut axis you have the very important pathway which is being activated that is the jlp one that is the including pathway which leads to early satiety and sustained weight loss and diabetes remission as well for a long period of time in these patients secondly of course there is there are other hormones which are also increased like oxygen to modulate which we understand that your fg of 21 and fgf 19 which are increased you need to increase production of brown adipose tissue and so on and so forth then of course you have uh increase of bile acids and these bile acids are you know again are they are not you know just uh you know waste carriers they are not sewage of a body they are in fact very very useful for the metabolic health they again activate various access leading to increased production of brown adipose tissue and so on and finally and most importantly and very interestingly there are changes in the gut microbes we don't really understand this fully we are trying to understand this better at this point of time what we understand is that uh post bariatric surgery there is basically uh you know increased diversity of the gut microbes this increased diversity of gut microbes often is associated and often linked with uh reduction in weight not only in you know people who have undergone obesity surgery but perhaps also in lean patients who are otherwise fit so overall this is there are the various mechanisms by which obesity really works and i think it is very very reason that you have so many mechanisms and because of that you tend to have uh you know obesity surgery which is more effective so i'll hand it over to sir now to take forward about the you know the actual surgery aspect you know uh of how what things are done and you know how you manage these patients in day-to-day practice thank you thank you so much doctor yes sir i will be starting your presentation thank you home for a wonderful presentation even i enjoyed a lot the pathophysiology of weight loss is very well explained i think the audience must about it i'll just take you through the surgical part of it and that to only a sleeve destructive because taking complete biotic process which are like almost 10 to 50 type of very variants we can't complete in one lecture so i will be just talking today about the benetic slew so if just to introduce you it benedict's sleeve gastrectomy is done in those who are having a bmi of more than 35 without obviously commodities in asian peasants and in america it is above 40 bmi or even western population we indians have changed this bmi at almost 2.5 bmi in 2008 in a consensus meeting in delhi and subsequently we did at a sl level at different international conferences so similarly we can offer uh this surgery to those who are having bmi of more than 32.5 with overstated com communities like blood pressure hyper diabetes or sleep apnea the preventive sleep gastrectomy is only to those people who uh are having like smoking habits because the chance of stomach ulcers are less in sleep dystectomy compared to blue and digestive bypass or mini gastric bypass we do it in pediatric age group because the growth is a major factor which can be affected due to gastric bypass and it is done in super obvious people when we can't do roanoke bypass because of the super obesity like bmi of more than 50 or 60 we sometimes cannot do and why so it is used as a stage processor in super obvious presence to reduce their weight and then we can do a definitely surgery later after some time so the contraindications of sleep gastric to me if you look at the general contraindications are like an accelerated when somebody is not fit for anesthesia we cannot do similarly those who are having contradicting laparoscopic surgery like unstable cardio um coronary artery disease presumed unable to tolerate the general assessor or inability to tolerate the new pattern like ielts incision lung disease or other problems and uncontrolled breathing disorders where we cannot do any surgery or again a contraindication and the other contraindication for bariatric surgery as such is substance abuse psychiatric illness that can mask the ability to understand the processor and may affect the compliance and regular follow-up and certain um persons who are having advanced malignancy we cannot offer biotic surgery the contagious sleep estimate itself if you look at the hydrocephalus for sleeve because sleeve will increase the chance of reflux on grd which can have bad quality of life and they cannot tolerate this surgery for the rest of life originally sleeve gastrin was used or started as a stage procedure as a stage processor in uh bpdds specials wherein those were high-risk persons they used to do sleep gastrectomy and subsequently after some weight loss they used to do a neutral switch which was a definitive surgery but and but they found in certain persons that there is no requirement of second surgery and gradually they modified it there was no there is no malabsorption in sleep gastrectomy and it is purely a restrictive component which also get improved or changed after two to three years they can have even good quantity of meal and they have risk of regaining weight if they don't change the quality of life this is the diagram of neutral switch bpd we do ds wherein as sleeve is a part of it you can see the sleeve and then the first part of deuteronomy after the progress and there is a common channel of about only 50 75 to 100 centimeter here there is a lot of male absorption and because of this reason this surgery is not that popular and not in not being performed worldwide maybe less than one percent people are opting for this surgery and less than one percent surgeons are offering this surgery so this sleeve gastrin which is a neutral switch variant of bpd relied mainly on the excision the greater the weights of the stomach and how to reduce the calorie intake the initial days the stomach was loosely calibrated in the sense that boozy size was about 54 to 60 friends um but due to compressive process and longer operating time super obvious persons were planned to have two-stage procedure just to reduce the complications of anesthesia and surgery and at that gastrectomies after a few weeks after initial weight loss once they become fit for anastasia and they were offered definitely like do not switch some obviously these slave persons who underwent sleeve gastrointestinal sustained weight loss after some time and they never required a second procedure and because of this surgeon notice that two sleeve after a sustained weight loss and they may not need any uh second process so why not to work it on it to have a standalone processor so progressively they change the book busy size from 60 friends to 40 friends to 38 friends and nowadays we use about 36 to 40 friends so two tightest leave has more risk of leak so usually we try to keep it more than 36 so in our practice we use since bhuji sorry 38 french boozy which has been routinely used in our country and larger the [ __ ] lesser the chance of leak but at the same time less have a chance of weight loss also so in these slave persons they experience as a good and sustained weight loss and with a very period of time so so this is the diagram sleeve wherein we look on our buji we place a buji which is which is a product and we remove a part of stomach i'll show it in so this is the diagram of sleeve i'll be explaining more and detail and the major effect of sleeve gastrectomy on diet is remission wherein we can achieve a calorie restriction we can achieve a weight loss and both of them can lead to reduced [Music] requirement of diabetic medications it also has effect on intraocular access and that is by glp one or gip py and hormones all these hormones almost already described and explained to you in more details i'll not take talk about these in what it is these are the mainly uh four hormones which are secreted in our bodies uh which are responsible for weight loss as well as insulin secretion that is growling glp1 gipp and pyy all these hormones and almost already explained so just to take you on the surgical side the we need to evaluate the person before surgery for which we do all written investigations for fitness of anesthesia and surgery body composition analysis is done on before surgery and subsequently we do it every three months just to know the laws which is there from the fat or muscles or so uh sleep study is done for those persons who are having symptoms of sleep apnea we do dexed on before surgery and subsequently every year just to monitor their born health because obese people are at positive porosis and bone mineral deficiencies and even subsequently after mal absorption sometimes they can have aggravation of [Music] osteoporosis there is nutritional evaluation done before surgery that is serum iron vitamin b12 vitamin d in albumin and we do diet counseling and we do appreciate endoscopy to exclude the pathology into the stomach to exclude the high test hernia and if we are doing a sleep gastrectomy because if there is high testosterone we should not offer them and we usually offer them plastic bypass so few people who are super rupees where the bmi is more than 50 or sometime more than 60 we advise very low calorie diet for almost three weeks just to reduce the weight as well as to reduce the liver size so that during surgery we can if effect and we can perform the surgery below the lever so we don't get much difficulty and would get a good exposure at the same time those who are in sleep apnea we usually advise cpap machine or biped that is non-invasive ventilators so that they improve their sleep apnea which most of time improve their lung capacity they reduce their edema and because of the gas exchange which occurs due to cpap machine and less co2 retention lead to some weight loss and those who are smokers we advise them to stop smoking at least three weeks before surgery low molecular hyperin that is collection of fragment or lmws which are prescribed to them before surgery we usually give it before 12 hours of surgery that is previous night and antibiotic prophylaxis will start about 30 ml before the skin incision and which we continue for um 48 hours if the person is staying with us otherwise usually 24 hours is what we are presently keeping persons for after surgery and we dissolve them so even two doses of antibiotic is sufficient to have a good control on any of any infection in ot preparation we need to have a good operation theater with benetic instruments that operation table can withstand weight of up to 300 kg which has capacity to change the position to reverse standard position or leg speed position the calibration tube should be always there in operation theater that is 36 to 38 french busy the dvd pump should be always there in the theater and after the surgery also to avoid the different thrombosis so we use dvt pump during surgery and these obese people they are having so much weight sometimes they can have um pressure on their back and muscles and they can develop repromises so we usually put them on pillows on the table table so that they don't get pressures [Music] injuries to muscles and to avoid the rebroad myosis and most of energy devices which are being used should be there in the operation theater and most of time we should have at least two devices available in theater that is harmony scalpel or lego silver and sealed the port placement usually is used i do this surgery in four ports the first entry is always by sub coastal links in the left side that is five millimeter incision using a optical view trokar through which we can see the layers of the abdomen wall and through which we can enter because obvious people you cannot use various needle or put other trochas because they have risk of um getting injury because we can't lift the abdominal wall so this pummers point left side port which is used is used for by the assistant then we have a 11 millimeter port which is for the camera which can be um like us if it is a female on uh those who are superb with large belly we use a supramelkin port about a palm length below the epic stream then we have five millimeter supposed to uh port on the right side and a 12 millimeter pararectal port on at the level of um like us on the right side of the surgeon's hand so that we have two uh ports which is which are being used by the surgeon and occasionally we use a biggest report to detect the lever or using the handsome retractor but i usually in my technique i avoid it and i usually don't use this port this is the poison supine next split and kind of and if you look at the steps usually by putting this process and getting a pneumocotin we look at the abdomen and we assess the whole abdomen we can call it a diagnostic laparoscopy because we need to see the liver whether it is serotic or sometimes we found liver cirrhosis in obese people because of the non alkali fatty hepatitis so we need to know the liver then we check the highest area we check the spleen and other organs sometimes any other pathology on the platonium sometimes we can find pattern modules or something which can be tuberculosis or malignancy we can abandon the procedure so a diagnostic electros we proceed for the pressure and then we start the dissection at the gastroesophageal junction and we dissect it till we expose the left leftness of the diaphragm and then we start division at the greater curvature and the momentum is separated or divided away from the greater curvature which is just opposite the incisor about three to five centimeter proximal to the pylorus and we open the retrogastic space and we bare the stomach along the lesser curvature till the left crust so the trogastic space is completely dissected and all the additions behind the stomach are separated and the city is their place uh which enter into the end drum and sometimes it can even enter the truth now so i'll just take you through the procedure this is how we enter this is g junction d section which is being done this is a gold finger which is used to dissect the jesus till reaches and then the stomach is lifted and momentum is separated at the greater curvature which is just opposite the incisura you can see we entered the lesser site now then the dissection goes further down till almost 5 centimeter proximal to the pylorus many people they do they sleep very close to the pilots but there is risk of developing anemia in these patients if we remove the part of the antrum then the puji is placed now after putting this boozy i lift the stomach up so we don't need liver attractor if we are doing by this technique this is my own technique usually most of people don't practice this and this is how the posted section is done till we reach the left crest of the diaphragm we divide the short casting vessels under direct vision then the stapling was started after firing the first cartridge only the bhooji is guided then you keep going up you see the staple line should be just on the lateral edge it should not have zigzag shape otherwise you have risk of high pressure into the tube and you have risk of leak so after putting after completely exercising this we start separating the momentum from the remnant stomach which need to be separated and taken out and usually this dissection i start from above downwards because we can hold every vessel by and one instrument and we keep dividing and going down so by this technique there is hardly any risk of breeding or even leak this the remnant stomach is then taken out through one of the 12 millimeter port then you look at the oozing part at this staple line and there is no bleeding we can always close the ports once the stomach is totally free from the post hydrogens the fundus has been completely mobilized subsequently the firing staple we've done from quarter to the panel end and there is a purple opening reload which are being used usually when we are using the johnson johnson staplers usually the green cartridge which is required because the antrum or stomach which close to the entrance having very [Music] thick wall which require a larger size of cartridges so in purple we have all the combination of green blue and white but in green load is the preferred load which can be used to reset the antrum or closer to the after the green firing we can use the gold which is slightly less thicker than the green cartridge and then we can use the blue cartridge subsequently when we are going upwards try to avoid narrowing at any stage it should not be too tight on the busy and we should try to avoid rotation at the surface we should not have zigzag type of sleeper line to avoid the leaks and bleeding hug the gct while firing toward that it should not be too tight it should not be firing at the gct once the vertical staples those are completely and that to be removed stomach is free from the momentum from above downwards specimen is liquid from the 12 millimeter port the most stress is stacked at the staple line as well as the momentum which is separated from the woman from the stomach leak test is done usually by the beginners i don't usually do because i don't experience any leak in sleeve gas technologistic bypass liver biopsy is only when person is having out of zero c one should take a liver type c which can be a very biopsy and 12 millimeter or 11 millimeter port should be closed using a port closure device and the common mistakes which usually people do is they don't mobilize the fundus adequately from behind or posted and they can have narrowing up or twisting at the incisor that is the junction of body and antrum and just opposite the raw food usually they make it narrow which can lead to twisting of the sleeve which can cause a lot of vomiting and even leak rotation deformities like twisted sleeve which can be there because of this technique staple line reinforcement is a personal preference people can use to take sutures on the staple line or we used to have a reinforcement material which is available which can be used to have good hemostasis but i usually don't use any of these because there is hardly any bleeding these are different publication this is a indian publication wherein our asia publication where they have done analysis of all asian papers on effect of sleeve gastrectomy on type of diabetes and you can see here the hp1c level of less than 6.5 or less than 6 we can have achieved in a short term about more than 50 percent of persons in most of these series and this is another international analysis meta-analysis wherein they achieved a short-term remission of type two diabetes in close to eighty percent of people this is again effect of type of diabetes uh after sleep gastrectomy uh on short term and long term but usually they found that diabetes of less than five year of duration or diabetes with only on oral medications are the better people who can respond to sleep gastrectomy and those who are on insulin should not be offered sleeve gastrectomy because the chances of long-term remission are reduced in these patients with this i conclude my talk and thank you very much for pressing sharing and we can take you soon if we have any yes thank you so much sir uh both of you very nice informative session thank you we have many positive comments that it was a good presentation they loved it is asking [Music] what is the cost of the surgery and is it having any indication in patients like obese patients with diabetes mellitus i think the course depends on the type of staplers which we use the setup we use there's so many factors which decide actually so it is very difficult but to an an average process i think it starts about 2.5 lakh rupees which includes the hospital stay the option theater and as i say also staplers and most of these things but stable is also a different variety which are very very expensive to use the different iron staples the cost may go high yes it can be used in diabetic person because diabetic person has more chances of long term remission by reducing the weight and as dr home has already explained that different hormonal change which occurs because of the surgery whether it is sleep western blue and digestive bypass they get better result with diabetes so this surgery should be offered to those who are having type 2 diabetes with obesity okay the next question is by dr narayan thawker what is the role of prebiotics and probiotics commercially available uh on our metabolism i think home content yeah so i think uh the understanding of gut microbes in terms of its role in metabolism we are just beginning to understand it at this point of time it's mainly you know what we're seeing what we're observing instead of you know offering any form of treatments which could definitely uh lead to positive outcomes so we are still far away from that uh though you know prebiotics and probiotic companies may like to advertise saying that you know it would lead to long-term weight loss and so on but in effect in clinical practice we have not seen that happen so uh at this point of time you know they obviously would have other benefits which i think there's no harm in taking it as such but i think you know to rely on them in terms of uh therapies for weight loss or any other metabolic issues it's not uh you know it's too early it's not recommended at this point of time but yes uh yeah it's an area of research and i think you know perhaps maybe uh maybe a decade from now we'll understand it much better so yeah i think there is no but yes there is no harm in touching it definitely benefit to the people or companies who are manufacturing it but the part of clinical trial is we can use it and we should observe and monitor and see the outcome all right thank you another question is that in case of patients with high risk for ga can the surgery be done under epidural or spinal or some centers do give segmental spinal for laparoscopic surgery so is it indicated here oh this should not be done in any of these patients because if there is a contaminant we should not do this surgery this surgery done in upper abdomen and there is definitely a compromise of the lung capacity due to obesity itself versus anaesthesia and after the laparoscopy we increase the interval of pressure which can further and decomposite their lung capacity and they can have more complication so one should not do this hardly any person who is having such problem i have not encountered any such person because those who are having difficulty we usually prepare them before surgery we can have medical management of weight loss for some time like in fact 10 15 kg weight loss can be achieved as dr home is suggested by different medicines and by using bypass cpa we can increase the lung capacity and we prepare them for surgery and then we do it but one should not try in regional or local anesthesia which is a disaster i have not asked my two years i have not done a single surgery by regional anesthesia okay so dr sanket would like to know more about the post-op complications uh management and discharge of patient see post-operative usually i start present working after two hours which usually make them immortally very stable and at the same time everybody is comfortable the risk of dvt goes down once they start walking and i start oral liquids after four hours of surgery this is my practice because of my 20 years experience but everybody should not do it most of people they start low oral liquids after 24 hours or maybe next day after doing a gastrographing study to check for the leak and any twisting and then once they don't have nausea vomiting or anything we can start the oral liquids in my practice i do it after four hours of my surgery the leak rate is less than one percent worldwide i don't have a single leak in any of my gastric bypass only in sleep gastrectomy i had four leaks in my first sunday surgeries but now i don't have leaks in the last the bleeding complication can be made because of the row area which is created at the greater curvature the staple line that all depends again using the different type of cartridges if you use a good size new cartridge with new staplers the chance of breeding is negligible and usually we evaluate during surgery and usually we apply clips or sutures at the time of surgery if there is any oozing at any staple line still the leak is close to one person if the bleeding rate is close to one to two percent in sleeve gastrectomy which can be managed uh by medical management or conservatively most of these patients the breeding can be inter aluminum which is through the into the human which can be managed by endoscopy and if it is extra luminal which is causing hypotension to some extent or the greater weight loss which significantly reduces the hemoglobin level then we should do uh relaproscopy in control these buildings long-term complications live vasectomy there is hardly any except these persons because of the reduced size of meal they need multivitamin supplements and mineral supplements till they lose their weight once they are static on their weight loss usually we can discontinue these multivitamins and that is usually up to two years all right so dr davin would like to ask this recently the lipotherapy which is becoming more popular so would you like to enlighten a bit on that see lipo therapy or liposuction they're two different things i don't know how there are multiple the new gadgets new devices news nomenclature which is being given to the these liposuction is one which is quite popular and being done since many years liposuction is wherein you can remove the subcutaneous fat by small small punches and that is usually done as a cosmetic procedure you need to understand that in our body we have fixed number of cells suppose we have one floor cells in our body and when obviously when there is obesity that is always the size of cell which increases not the number so once we remove the cells by liposuction we are not treating the obesity or calorie intake so these patients may increase their fat cells at some other area so those who are really obvious we cannot remove 30 40 kg fat from their body and the basal fat cannot be even touched so there is no indication or no benefit no benefit by liposuction okay all right next question is uh is there any special diet post surgery yes there is always because the stomach is stable the capacity is reduced we have g junction there is hormonal changes and many things so we usually train these peasants on diet usually to begin with we start clear liquids they tolerate we can have thicker liquids then we have a semi liquid dissolved which usually takes about four to six weeks to come back to normal diet that is what we usually advise many time they even don't tolerate uh soft normal diet after six weeks so we can again go back to subtitle liquid diet for some more time and then we can teach them we need to train these people on diet because the brain don't know what is the size of stomach because the brain size is already mapped and usually people try to eat much faster and they can have moisture vomiting so we educate them we give them the sample size of the vessels which are being used to eat advise them not to take a big size of this and try to complete this okay so i think the last question for today is what is the criteria for discharge see once the person is ambulatory tolerating a good amount of liquids for 24 hours with good output and immune stability and there is no pain we can discharge well sir i think we have answered all the questions that we had i would like to thank both of you for a very informative session on this much talked about topic nowadays bariatric surgery everyone has heard about it i am sure everyone has understood a bit more about it so thank you so much and we have this positive comment so you're so good and everything so i would like to say thank you to the audience as well and we would all we would see you all tomorrow thank you thank you for giving me supposedly thank you for thank you

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Dr. Murtuza Zozwala & 1336 others

SPEAKERS

dr. Mahendra Narwaria

Dr. Mahendra Narwaria

Founder & Senior Bariatric & Robotic Surgeon, Asian Bariatrics, Ahemdabad

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dr. Om Lakhani

Dr. Om Lakhani

Consultant Endocrinologist, Ahmedabad

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dr. Mahendra Narwaria

Dr. Mahendra Narwaria

Founder & Senior Bariatric & Robotic Surgeon,...

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dr. Om Lakhani

Dr. Om Lakhani

Consultant Endocrinologist, Ahmedabad

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