MORBID OBEZITE Cerrahi Tedavisi

1. MORBID OBEZITECerrahi Tedavisi Prof. Dr. Mustafa SAHIN S.Ü. Selçuklu Tip Fakültesi Genel cerrahi AD

2. OBEZITE NEDIR? Obezite; vucut agirliginin beklenen vucut agirligindan % 20 fazla olmasi veya VKI’nin 30’un üzerinde olmasidir. Yüksek morbiditesi ve mortalitesi olan ciddi bir hastaliktir. Birçok kronik hastalik için major risk faktörüdür (Colditz, Am J Clin Nutr, 1992) Obezite günümüzde kronik bir hastalik olarak kabul edilmektedir (Greenstein et al, Obesity Surgery, 1994)

3. TANIM Vücut Kitle Indeksi (VKI) =

4. TANIM Normal Aralik: VKI: 20 ? 25 Kilolu: VKI: > 25 ? 30 Obez: VKI: > 30 Morbid Obez: VKI: > 40 Süper Obez: VKI: > 50

5. Etiyoloji Ailesel Çevre ve Ortam Genetik Cinsiyet (K>E) Sosyal Psikolojik Depresyon

6. PREVELANS (40-60 yas, VKI ?30)

7. PREVELANS Avrupa’da orta yas grubunda her bes kisiden biri obez Fransa, Ingiltere ve Almanya gibi ülkelerin herbirinde yaklasik 5-10 milyon tedaviye ihtiyaç duyan obez var

8. PREVALENS ABD’de obezite bir ulusal saglik sorunu olarak kabul edilmektedir 1992 yili rakamlari ile ABD’de 97 milyon obez bulunmaktadir Bu populasyon içerisinde 4 milyon agir obez ve 1,5 milyon morbid obez hasta bulunmaktadir ABD’de insidens 1960 yilindan 1990 yilina kadar geçen sürede, %13’den %35’e kadar yükselmistir.

9. OBEZITEYE BAGLI MALIYET A- Direkt Maliyet Obezite ve beraberindeki hastaliklarin tedavisine bagli giderler B- Indirekt Maliyet Obez kisilerin daha az üretken olmalarina bagli toplumun yüklendigi giderler (Colditz, Am J Clin Nutr, 1992)

10. OBEZITEYE BAGLI MALIYET Obezite nedeni ile yapilan harcamalar gelismis ülkelerin toplam saglik harcamalari için ayirdigi bütçenin %3-8’ini olusturmaktadir (The Lancet, August 1997)

11. MORBID OBEZITE ILE BIRLIKTEGÖRÜLEN BOZUKLUKLAR Hipertansiyon Tromboembolism Pulmoner Yetersizlik Ani Ölüm Koroner Kalp Hastaligi Diabetes Mellitus Kanser (Endometrium, Kolon, Meme, vb.) Hipertrofik Kardiomiyopati Böbrek Hastaliklari Osteoartrit Dermatolojik Problemler(Mantar vb.) Ödem ve Hipostasis Infeksiyonlara Yatkinlik Infertilite Uyku Bozukluklari Hiperlipidemi Ameliyat Riskinde Artma

12. OBEZITENIN GENEL SAGLIK ÜZERINDEKI ETKILERI Safra kesesi hastaliklari gelisimi 6 kat Hipertansiyon gelisimi 5.6 kat Tip-2 diyabet gelisimi 5.4 kat Hiperkolesterolemi gelisimi 2.1 kat Osteoartrit gelisimi 2 kat daha sik görülmektedir Endometrium, safra kesesi, over, meme, prostat ve kolorektal karsinoma bagli ölümler artmaktadir Obezlerde venöz staz ve solunum problemleri de siklikla görülmektedir.

13. TEDAVI Obezitenin tedavisi neden gereklidir ? Bilinçli kilo verilmesi obeziteye bagli mortalite oranini azaltmaktadir

14. TEDAVI SEÇENEKLERI Medikal Tedavi Cerrahi Tedavi

15. MEDIKAL TEDAVI Diyet Davranis Düzenlemeleri Düzenli Fizik Egzersiz Ilaçlar, Hormonlar

16. MEDIKAL TEDAVI SONUÇLARI Medikal tedavi ile ancak %10 oraninda kilo kaybi olusurken, hastalarin %95’i diyet öncesindeki kilolarina geri dönmektedirler. (Adkinson et al., Am J Clin Nutr, 1994) 17 yillik süre içinde yapilan 3 büyük konsensus toplantisi sonucu; ”morbid obez hastalara uygulanan cerrahi disi tedavilerin basari sansi çok düsük” (Am J Clin Nutr, 1992)

17. MEDIKAL TEDAVI SONUÇLARI Hastalarin çogunda cerrahi disi yaklasimlarla kabul edilebilir derecede kilo kaybi saglansa da, en büyük handikap azaltilmis vücut agirliginin sürdürülmesindeki basarisizliktir

18. CERRAHI TEDAVI / TARIHÇE Ilk kez Kremen 1954 yilinda uç-uca yaptigi jejunoileostomi ile kilo kaybi varligini gözlemistir Mason ve Ito 1960’li yillarda gastrik by-pass yöntemini gelistirmislerdir Printen ve Mason 1971 yilinda gastroplasti teknigini tariflemislerdir Chelala ve Belachew 1992 yilinda laparoskopik ayarlanabilir gastrik band yöntemini tarif etmislerdir

19. Bariatrik cerrahi / tarihçe ‘‘ Bariatric’’ Yunanca bir kelime Baros = agirlik Iatrike = tedavi

20. BARIATRIK CERRAHININ HEDEFLERI Minimum komplikasyon ile en etkin tedavinin saglanmasi Kilo kaybi Yasam kalitesi Komplikasyon orani Maliyet Etkinligi Düsük Mortalite

21. MORBID OBEZITENIN CERRAHI TEDAVISINDE IDEAL YÖNTEM Kilo kaybinda en etkili Mide üzerine en az invaziv ? Gereginde geri dönüstürülebilir ? Hastanin kilo verip vermemesine göre yeni bir ameliyat yapmadan ayarlanabilir ? Morbidite ve Mortalitesi sifira yakin olmalidir

22. Yeterli kilo kaybi ne olmalidir? Uzun süreli takip sonuçlarinda kilo kaybinin mortalite artisi ile yakin iliskisi ortaya konmustur: Hafif kilo kayiplari obezlerdeki mortaliteyi azaltmaktadir, Kilo kayiplari arttikça mortalite oranlari da artmaktadir, Orta düzeydeki kilo kayiplarinin tercih edilebilecegi bildirilmektedir!

23. Yeterli kilo kaybi ne olmalidir? Kilo kaybini degerlendirmede “uygun”, “yeterli”, “saglikli” ve “ideal” ifadeleri kullanilmaktadir, Operasyon öncesi VKI>35-40 kg/m2 olan bir hasta için VKI<30 kg/m2 olmasi kabul edilebilir bir sonuç olmalidir.

24. CERRAHI IÇIN HASTA SEÇIMI BMI > 40 Cerrahi disi yöntemlerle kilo verilememesi (>2 yil süreyle) Obeziteye bagli yandas hastaliklar nedeniyle yüksek risk olusmasi Gebe olmamasi ve kilo verme sürecinde gebelik planlanmamasi Hastaya her konuda yeterli bilginin verilmis olmasi

25. CERRAHI TEDAVININ KESIN KONTRENDIKASYONLARI Gastrointestinal sistemin enflamatuar hastaliklari Yüksek operatif risk Üst gastrointestinal sistem kanamasi olusturabilecek nedenler (varisler, telanjiektaziler) Hamilelik Alkol veya ilaç bagimliligi Gastrointestinal sistem anomalileri (atrezi / stenoz) Aktif enfeksiyon varligi Uyum saglanamayacak hastalar Kullanilan materyallere reaksiyon gelisebilecek hastalar

26. CERRAHI TEDAVININ RELATIF KONTRENDIKASYONLARI 18 yasinin altindaki hastalar Kronik aspirin veya NSAID kullanan hastalar Alt özofagus sfinkterinin disfonksiyonuna bagli olarak agir derecede gastroözofageal reflü hastaligi varligi

27. AMELIYAT HAZIRLIGI Rutin biyokimya incelemeleri EKG Akciger grafisi Solunum fonksiyon testleri Batin USG (safra kesesinde tas?) Fotograf çekimi (4 cepheden) Arteriyel kan gazi ölçümü Boy - kilo ölçümü

28. AMELIYAT HAZIRLIGI Kardiyoloji Konsültasyonu Dahiliye Konsültasyonu (Diabet ve Endokrin Inceleme) Psikiyatri Konsültasyonu Anestezi Konsültasyonu Gögüs Hastaliklari Konsültasyonu

29. Cerrahi yöntemler Emilim bozucu girisimler, Hacim küçültücü girisimler, Kombine (restriktif / malabsorptif) islemler, Digerleri.

30. EMILIM BOZUCU GIRISIMLER Jejuno-kolik bypass Jejuno-ileal bypass Ileo-gastrostomy Bilio-intestinal bypass Duodeno-ileal bypass

31. Jejunoileal Bypass First series in 1969 of 80 patients; now a series of 153 JI bypasses reported 1973 Jejunum to ileum [note that this is end-to-side] 80 patients, with 5 deaths - one was from liver failure, 2 had PE, 2 had MI “14-4”; this was to replace the IC bypass; 16 year follow up; 153 JI bypasses done; 9% total mortality[6% blamed on bypass] noted that there was significant fatty change of the liver at the initial operation - this worsened w/ rapid weight loss. . . This was modified by Scott et al. in 1974; Note that the anastomosis is now end to end and the defunctionalized limb of distal ileum is drained into the transverse colon; note that the proximal jejunum sutured to the mesentery First series in 1969 of 80 patients; now a series of 153 JI bypasses reported 1973 Jejunum to ileum [note that this is end-to-side] 80 patients, with 5 deaths - one was from liver failure, 2 had PE, 2 had MI “14-4”; this was to replace the IC bypass; 16 year follow up; 153 JI bypasses done; 9% total mortality[6% blamed on bypass] noted that there was significant fatty change of the liver at the initial operation - this worsened w/ rapid weight loss. . . This was modified by Scott et al. in 1974; Note that the anastomosis is now end to end and the defunctionalized limb of distal ileum is drained into the transverse colon; note that the proximal jejunum sutured to the mesentery

32. Emilim bozucu girisimlerin komplikasyonlari Diare Kusma Yara enfeksiyonu Anal sorunlar Bypass enteriti Obstrüksiyon Protein malnütrisyonu Hipokalsemi Vitamin A D E yetersizligi Safra tasi Böbrek tasi Karaciger yetmezligi Anemi Alopesi Ödem Artralji

33. HACIM KÜÇÜLTÜCÜ GIRISIMLER Gastroplastiler Horizontal (yatay) gastroplasti (HGB) Anterior gastroplasti Vertikal band gastroplasti (VBG) Mide bandi Tüp (Sleeve) gastrektomi

34. Vertikal Band Gastroplasti

35. Horizontal Gastroplasty question was “why did it need to drain into the jejunum” -First used in 1971 by Mason; the first operation was the upper pouch was separated but in contnuity with the lower pouch; the pouches were separated by a un-reinforced stoma;the fundus was then more distensible and the operation failed This was re-popularized by Gomez in 1977 by reinforcing stoma on the greater curvature of the stomach. The pouch was 50cc, and the stoma was 12mm Good weight loss early on --> Gomez reported on his success in 1981 with 200 pts, but the follow up was only 18-24 months,-->there was 19% incidence of complications - including leaks, stenoses[2%], disruptions[7%], splenectomy, etc; 12% of these patients had to be revised; --->reported %EBWL was 63% at one year and then stayed at 64% for the next two years-----> everyone started doing it, then long termdata showed it did not work No safer – same amount of wound infections, etc Remember that the fundus is the most distensible portion of the stomachquestion was “why did it need to drain into the jejunum” -First used in 1971 by Mason; the first operation was the upper pouch was separated but in contnuity with the lower pouch; the pouches were separated by a un-reinforced stoma;the fundus was then more distensible and the operation failed This was re-popularized by Gomez in 1977 by reinforcing stoma on the greater curvature of the stomach. The pouch was 50cc, and the stoma was 12mm Good weight loss early on --> Gomez reported on his success in 1981 with 200 pts, but the follow up was only 18-24 months,-->there was 19% incidence of complications - including leaks, stenoses[2%], disruptions[7%], splenectomy, etc; 12% of these patients had to be revised; --->reported %EBWL was 63% at one year and then stayed at 64% for the next two years-----> everyone started doing it, then long termdata showed it did not work No safer – same amount of wound infections, etc Remember that the fundus is the most distensible portion of the stomach

36. Vertical Band Gastroplasti First used in 1980 Relatively easy, fast Physiologic; the duodenum is intact so the absorption of calcium and iron is maintained; Outlet reinforced with polypropylene mesh Avoid anastomosis No ulcers Access to stomach Reversible First used in 1980 Relatively easy, fast Physiologic; the duodenum is intact so the absorption of calcium and iron is maintained; Outlet reinforced with polypropylene mesh Avoid anastomosis No ulcers Access to stomach Reversible

37. Ayarlanabilir Stomali Mide Bandi

39. Sleeve Gastrektomi

40. Kombine yöntemler Biliopankreatik diversiyon (BPD) (Scopinaro; Kombine, restriktif + malabsorbtif) Duodenal switch (Hess, DeMeester; PKVST Gastrektomi + BPD = BPD+DS) Gastrik bypass VBG + DS

42. Gastrik Bypass

43. Gastric Bypass + Roux-en-Y University of Kentucky, First reported Randomized, prospective study of RYGB vs JI Bypass 32 pts in the GBP, 27 in the JI Bypass GBP associated with more EARLY complications, indicating that it is more technically demanding, yet there were more late complications with the JI bypass 56% had diarrhea and most of these pts needed anti-diarrheal meds . . . All patients had fatty livers to begin with by biopsy; Liver biopsies were done at 1 year in half of each group; the GBP group all showed no change or improvement, while 12/15 pts in the JI group got worse Also note that 10/27 required rehospitalization, 10/27 required reoperations in the JI group; the gastric bypass group had 4/32 rehospitalizations and no re-operations It was in this study(after the 7th GBP patient that the GBP evolved from the loop --> to the Roux configuration; stimulated by the bilious vomiting .. . The JI Bypass was done in the way advocated by Scott et al, the jejunum was transected 30cm distal to the ligament of Treitz and anastomosed to 25cm proximal to the cecum NO DIFFERENCE IN WEIGHT LOSS University of Kentucky, First reported Randomized, prospective study of RYGB vs JI Bypass 32 pts in the GBP, 27 in the JI Bypass GBP associated with more EARLY complications, indicating that it is more technically demanding, yet there were more late complications with the JI bypass 56% had diarrhea and most of these pts needed anti-diarrheal meds . . . All patients had fatty livers to begin with by biopsy; Liver biopsies were done at 1 year in half of each group; the GBP group all showed no change or improvement, while 12/15 pts in the JI group got worse Also note that 10/27 required rehospitalization, 10/27 required reoperations in the JI group; the gastric bypass group had 4/32 rehospitalizations and no re-operations It was in this study(after the 7th GBP patient that the GBP evolved from the loop --> to the Roux configuration; stimulated by the bilious vomiting .. . The JI Bypass was done in the way advocated by Scott et al, the jejunum was transected 30cm distal to the ligament of Treitz and anastomosed to 25cm proximal to the cecum NO DIFFERENCE IN WEIGHT LOSS

44. Laparoskopik Roux en-Y Gastrik ByPass (RYGBP)

47. Diger yöntemler Gastrik balon Distelleri (dental fiksasyon) Kusak (waist cord) Mide sarmalanmasi (gastric wrapping) Mide klibi ile gastroplasti Fobi-pos ameliyati Lateral hipotalamusun elektrokoagülasyonu Trunkal vagotomi

48. Bariatrik cerrahinin uygulanma sikligi Operasyon tipi Siklik % ABD Dünya Roux-en-Y gastric bypass 85 65 BPD/DS 12 4 Vertical banded gastroplasty 7 5 Adjustable gastric banding - 24 Gastric banding 5 Silastic ring gastroplasty 4 Laparoscopic bariatric surgery 3

49. Bariatrik cerrahinin uygulanma sikligi Dünyada bariatrik operasyonlardan; Gastric bypass’in % 55’i, Adjustable gastric banding’in % 100’ü, Duodenal switch’in % 30’u ve Vertical banded gastroplasty’nin %30’u, laparoskopik yöntemlerle yapilmaktadir.

50. Obezite cerrahisinin komplikasyonlari Mortalite hizi % 0.6 Morbidite hizi % 20 Majör komp. % 6.6 Gastroint. leaks % 0.8 Splenic yaralanma % 3 Pulmoner % 4.9 Tromboembolizm % 1 MOY % 0.8 Yara ayrilmasi % 0.4 Kanama % 0.9 Gastrik dilatasyon %0.3 Line sepsis % 0.9 Paralitik ileus %0.9 Myonecrosis % 0.1

51. Obezite cerrahisinin gastrointestinal komplikasyonlari Dumping Vitamin/mineral yetersizlikleri Kusma/bulanti Staple line failure Enfeksiyon Stenosis/bowel obstruction Ülserasyon Kanama Splenic injury Ölüm (perioperatively)

52. YANDAS HASTALIKLARIN DÜZELME SIKLIGI Diabet % Artroz % Hipertansiyon % Uyku apnesi %