Name: Dr M G Bhat Designation: Consultant Surgeon Affiliation: Manipal & Apollo Spectra Hospital Special Interest:Laparoscopy & Bariatric Surgery
When should we suggest Bariatric Surgery in PCOD? 17 June 2017 drmgbhat@gmail.com 2
17 June 2017 drmgbhat@gmail.com 3
Epidemiology of obesity 1,2,3 Billion Adults are overweight 312 Million are obese 3-4 Million die each year due to overweight and obesity Diabetes, IHD, Cancers 60% of women are overweight ( 25 kg/m2) US & Europe 30% of these are obese ( 30 kg/m2) 6% of these are morbidly obese ( 35 kg/m2) 1. Preventing and managing the global epidemic on Obesity WHO Report, 1997. 2. Obesity. Lancet 2005; 366: 1197-209.Haslam DW, James WP. 3. Improving reproductive performance in overweight/obese women with effective weight management. Norman RJ, Noakes M, Wu R, Davies MJ, Moran L, Wang JX. Hum Reprod Update 2004; 10:267-80. 17 June 2017 drmgbhat@gmail.com 4
The incidence of obesity is gradually increasing in India. 10-40% of urban population - Obese Punjab 40%. Karnataka 14%. 3 rd Obese Nation in the World 17 June 2017 drmgbhat@gmail.com 5
The impact of obesity on reproduction in women with polycystic ovary syndrome. Pasquali R et all: BJOG 2006; 113:1148 1159. ( Review Article) 17 June 2017 drmgbhat@gmail.com 6
Obesity and Women Obesity in infertile women is high 30-70% of PCOS are Obese Menstrual irregularities & infertility Risks in Pregnancy are increased Poor reproductive outcomes conceptions-in Both natural and assisted Weight Loss has beneficial effects 17 June 2017 drmgbhat@gmail.com 7
Measurement of Obesity Body Weight in Kg (Height in m) 2 = Kg m 2 Underweight - <18 Normal - 18-25 Overweight - >25 Obese - > 30 Morbidly Obese->40 Super Obese-> 50 17 June 2017 drmgbhat@gmail.com 8 8
The Reasons for Obesity Life Style Issue Eating more than required The weight gradually increases! 17 June 2017 drmgbhat@gmail.com 9
MENSTRUAL DISORDERS INFERTILITY HYPERANDROGENISM METABOLIC SYNDROME 17 June 2017 drmgbhat@gmail.com 10
Obesity and PCOS From: Pasquali R et all: BJOG 2006; 113:1148 1159 17 June 2017 drmgbhat@gmail.com 11
Prevent.. obesity? Diet & Exercise Weight Conscious Calorie Conscious Continuous Effort 17 June 2017 drmgbhat@gmail.com 12
Bariatric Procedures 17 June 2017 drmgbhat@gmail.com 13
Surgery for Obesity (Bariatric Surgery or Wt Loss Surgery ) Surgery to Reduce Food Intake or Decrease Absorption or Both It is not Fat Reducing Surgery. Loss of weight is gradual Diet Control is Essential and All Life 17 June 2017 drmgbhat@gmail.com 14
When to Suggest Surgery? Obese: BMI of >30 BMI of >25 with one or more obesity Related Health Conditions Others (failed attempts, psychological etc) 17 June 2017 drmgbhat@gmail.com 15
Laparoscopic Gastric Sleeve Resection Remove 80% Stomach Tube or Sleeve Like Stomach is left behind 70% Excess Weight Loss in 18 months Type 2 Diabetes Resolution in 70-80% Improves all other Co Morbidities 17 June 2017 drmgbhat@gmail.com 16
17 June 2017 drmgbhat@gmail.com 17
INSERT GASTRIC SLEEVE VIDEO 17 June 2017 drmgbhat@gmail.com 18
Intra Gastric Balloon Reduced Capacity Stomach Full Short Term / Temporary About 10-15kg Loss 3-6 months 17 June 2017 drmgbhat@gmail.com 19
Medical Problems Physical Social Psychological Economical 17 June 2017 drmgbhat@gmail.com 20
PCOS / Weight Loss / Pregnancy From: Pasquali R et all: BJOG 2006; 113:1148 1159 17 June 2017 drmgbhat@gmail.com 21
Role of Bariatric Surgery in PCOS Clin Endocriol Metab: 2005 Dec;90(12):6364-9. Escobar et all ( from Spain) The polycystic ovary syndrome associated with morbid obesity may resolve after weight loss induced by bariatric surgery. (n = 17) of PCOS patients with an average age of 30 years were followed prospectively 26 months after bariatric surgery. (12/17) regained normal menstrual function and (10/12) had documented spontaneous ovulation.. Follow up for more than 2 years showed that all women resumed normal menstrual cycles, HbA1C decreased from 8.2% to 5.1% in < 3 months. 78% saw improvement in metabolic syndrome & 48% showed improvement in PCOS 17 June 2017 drmgbhat@gmail.com 22
Defining the role of Bariatric Surgery in PCOS Patients Shaveta M Malik and Michael L Traub. World J Diabetes. 2012 April 15;3(4):71-79 (published online 10.4239/wjd.v3.i4.71) USA Bariatric surgery can be effective in achieving significant weight loss, restoration of the hypothalamic pituitary axis, reduction of cardiovascular risk and even in improving pregnancy outcomes. Bariatric surgery should be considered part of the treatment in PCOS women, especially in those with MS. 17 June 2017 drmgbhat@gmail.com 23
Large Maternal Weight Loss from Obesity Surgery Prevents transmission of Obesity to children who were followed for 2-18 yrs. Pediatrics - 20016 Dec;118(6):e 1644-9. Kral JG et all (USA) Transmission of obesity to offspring was reduced by 50% The risk of fetal macrosomia was reduced 17 June 2017 drmgbhat@gmail.com 24
THE SAFE TIMING OF PREGNANCY 12 months (1 year) after bariatric surgery Before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside. 17 June 2017 drmgbhat@gmail.com 25
Obesity Related Co-Morbidities Hyperlipidemia 60% Reflux Disease 98% Sleep Apnea 75% Type 2 Diabetes 95% Hypertension 97% Cardiac Function Improvement 97% Stress Incontinence 87% Depression 80% Menstrual Irregularity 50% Osteoarthritis 82% 17 June 2017 drmgbhat@gmail.com 26
Analysis of 114 Sleeve Resections 2009-2017 All except 3 have maintained weight loss 97/114 Women 20/97 were 23-35 years age 4 became pregnant and have live children 6 highly Diabetic Patients are without Insulin Shows Obesity is a Metabolic Disorder and thus Metabolic Surgery and Diabesity are coined 17 June 2017 drmgbhat@gmail.com 27
In Summary PCOS is highly prevalent and strongly associated with obesity and MS. PCOS develop coronary artery disease and Glucose abnormalities at a very young age and are therefore at risk for life threatening cardiac events. Bariatric surgery is a powerful tool that should not be overlooked simply because a woman is young or presents with PCOS and MS. Every woman with PCOS, MS and Obesity should be offered education and counseling regarding weight loss to reduce their illness. Bariatric surgery should be considered along with other medical and lifestyle alterations as first line therapy in PCOS women with obesity and MS. 17 June 2017 drmgbhat@gmail.com 28
In Summary Bariatric Surgery has a definite role in young women With PCOS 1. BMI >30 2. Failed Life Style Changes 3. BMI>25 with Co Morbid Conditions Literature Review confirms that weight reduction regulate hormones, improve ovulation and pregnancy rate 17 June 2017 drmgbhat@gmail.com 29
Thank you Dr. M G Bhat MS, FRCS(England & Edinburgh), FICS, DMLE (Law), DMIRCSEd (Informatics) Consultant Surgeon Laparoscopy and Bariatric Surgery Manipal Hospital Apollo Spectra Hospital, Koramangala Bangalore, India www.bariatricsurgerybangalore.com www.drmgbhat.com 17 June 2017 drmgbhat@gmail.com 30