مباحث:
چاقی چیست؟
مراقبتهای پس از عمل (درمان چاقی مفرط - Morbid obesity)
Definition of Obesity and Indications for Surgery
??WHY ARE WE SO OVERWEIGHT
چاقی چیست؟
چاقی یکی از بیماریهای شایع قرن حاضر است . شیوع چاقی و اضافه وزن در افراد بزرگسال در امریکا تا 35% و در اروپا بالای 20% است . در کشورهای پیشرفته تعداد افرادیکه سالانه با چاقی مرضی یا عوارض آن از دنیا می روند بیش از سه برابر مجموع بیماران سرطان روده بزرگ و پستان است. در بین بیماریهای قابل پیشگیری مرگ ناشی از چاقی مفرط بعد از مرگ ناشی از دخانیات رتبه دوم رادارد.در مجموع طول عمر افراد چاق در مقایسه با افراد غیر چاق بطور متوسط 5/10 سال کمتر است.
افزایش افراد چاق بیش از 4 برابر طی 30- 20 سال گذشته در غرب مبین تاثیر جنبه های محیطی بر چاقی است هرچند عوامل ارثی و فامیلی هم تاثیر غیر قابل انکاری بر چاقی دارند. احساس گرسنگی سیری ناپذیر در افراد چاق که تحت تاثیر ، CCKسروتونین، گرلین و نوراپی نفرین قرار دارد ، ممکن است مهمترین عامل در بروز این بیماری باشد.
چاقی چیست؟
در واقع هر وزن غیر مناسب و غیر ایده آل را اضافه وزن و یا چاقی می گوئیم که اگر در آقایان طول قد به سانتیمتر منهای عدد صد شود و در خانمها طول قد به سانتیمتر منهای عدد صد و پنج شود وزن مناسب تقریبی بدست می آید.
وزن مناسب آقایان = 100- طول قد به سانتیمتر
وزن مناسب خانمها = 105- طول قد به سانتیمتر
Body Mass Index) BMI) یا حجم توده بدن مساوی است با وزن به کیلو گرم تقسیم بر مجذور قد به متر
BMI = وزن به کیلوگرم / مجذور قد
و جز در بعضی موارد تقریب قابل قبولی از رابطه وزن و قد و نسبت مناسب آنها را نشان می دهد.
چاقی مرضی چیست؟
اگر BMI بین 40- 35 باشد و به همراه آن بیماریهای مرتبط با چاقی وجود داشته باشد و یا فقط وجود BMI بالای 40 را چاقی مفرط یا مرضی می گوییم وبعضا BMI بالای 50 را چاقی سوپر می نامند.
آیا چاقی نیاز به درمان دارد؟
شیوع بیماریهای همراه مثلا آسم در25% افراد چاق – پرفشاری خون در بیش از 30% افراد – بالا بودن قند خون در 20% افراد و بازگشت محتویات معده به مری ( رفلاکس ) در30- 20 درصد افراد – کاهش اعتماد به نفس این بیماران و نارضایتی از خودشان و از وضعیت ظاهر خود عواملی هستند که این افراد عواملی هستند که این افراد را به سمت درمان سوق می دهد.
درمان چاقی داروئی و رژیم غذایی است یا جراحی؟
علیرغم تلاش خود جوش یا سازمان یافته و علمی افراد چاق برای کاهش وزن و پیدا کردن وزن مناسب متاسفانه آمار نشان می دهد که فقط حدود 3% افرادیکه چاقی مرضی دارند با رژیم غذایی یا دارو می توانند BMI خود را زیر 35 نگه دارند ولی البته لازم است در همه افراد چاق ابتدا یک تا پنج سال برای کنترل چاقی به روش های غیر جراحی تلاش کرد و در صورت عدم موفقیت این روش ها و وجود انگیزه کافی و لازم در بیمار بعد به سراغ اعمال جراحی رفت .
دو داروی اصلی که امروزه در کنترل و درمان چاقی مصرف می شود عبارتند از : Orlistat ( که از طریق مهار لیپاز پانکراس باعث کاهش جذب چربی مصرفی تا 30% می شود ) و Sibutramine ( که از طریق مهار پیش سیناپسی گیرنده های نوراپی نفرین ، سرو تونین باعث تشدید بی اشتهایی در سیستم عصبی مرکزی می شود )
اعمال جراحی چاقی ( شرایط عمومی )
لازم به تاکید است که علاوه بر وجود انگیزه کافی و قوی برای همکاری و همراهی مادام العمر بایستی بیمار اطلاع کافی از نوع عمل ، فواید و عوارض آن داشته باشد و قبلا تلاش جدی برای تغییرات رفتاری و الگوی زندگی کرده باشد.
افراد زیر 18 سال یا بالای 60 سال و کسانی که ثبات روانی نداشته باشند کاندیداهای مناسبی برای جراحی نیستند.
انواع عمل جراحی
همه جراحی های چاقی را می توان به سه دسته کلی تقسیم کرد
1) اعمال جراحی محدود کننده حجم معده ( Restrictive )
2) اعمال جراحی کاهش دهنده جذب غذا ( Malabsorbtive )
3) اعمال جراحی ترکیبی که از دو حالت فوق باهم استفاده می شود
گروه اول شامل :
(VBG) Vertical Banded Gastroplasty
(AGB) Adjuctable Gastric Banding
(SG) Sleeve Gastrectomy
گروه دوم شامل :
(BPD) Bilio Pancreatic Diversion
B.P.D + Duodenal Switch
گروه سوم شامل :
Gastric By pass
می باشد.
مراقبتهای پس از عمل (درمان چاقی مفرط - Morbid obesity)
- 60-30 دقیقه برای هر غذا باید اختصاص داده شود
- هر لقمه 30 بار جویده شود
- لقمه ها باید کوچک باشد
- در حالت نشسته باید غذا میل شود
- به محض احساس سیری از غذا دست کشیده شود
علائم سیری:
- احساس پری یا فشار در ناحیه سر دل(پایین جناغ)
- تهوع
- احساس درد در شانه یا قفسه سینه
- 3 بار غذا در روز میل شود
- مایعات در فواصل بین غذاها میل شود
- آب،شیر کم چرب،نوشیدنی کم کالری،چای
- آب میوه حتی آب پرتقال هم کالری زیاد دارد و ترجیحاّ نباید میل شود
- نیم ساعت قبل و پس از غذا نباید مایعات میل شود
- مایعات باید مزه مزه و تدریجی و آرام میل شود
- مایعات پر کالری مانند شیر چرب،آب میوه و...... نباید میل شود
- مایعات شیرین نباید میل شود سبب نفخ می گردد.
Definition of Obesity and Indications for Surgery
A. Indications
Obesity is an excess of body fat that frequently results in a signifi cant impairment
of health. It is a chronic, lifelong, genetically related, life-threatening disease of
excessive fat storage. Obesity results when the size or number of fat cells in a
person’s body increases. A normal-sized person has 30 to 35 billion fat cells. When
a person gains weight, these fat cells fi rst increase in size and later in number. One
pound of body fat represents about 3,500 calories. The prevalence of overweight
and obesity in the United States make obesity a leading public health problem that
can have medical, social, psychological, and economic consequences. Obesity is
growing at an exponential rate: It is estimated that there are more than 150,000
bariatric operations performed each year in the United States.
Although “overweight” technically refers to an excess of body weight and
“obesity” to an excess of fat, these two words can be defi ned operationally in
terms of body mass index. The body mass index (BMI) is the most practical
way to evaluate the degree of obesity, although it does not take into account the
different ratios of adipose to lean tissue. Visceral fat (or central obesity) has a
much stronger correlation with certain diseases, such as cardiovascular disease,
than the BMI alone. The absolute waist circumference (>102 cm in men and
>88 cm in women) or waist–hip ratio (> 0.9 for men and > 0.85 for women) are
both used as measures of central obesity.
Another way to determine obesity is to assess the percent of body fat but
this can be a little challenging and often requires specialized equipment. The
most accurate measures are to weigh a person underwater or to use an X-ray
test called dual energy X-ray absorptiometry (DEXA). It is generally agreed that
men with more than 25% body fat and women with more than 30% body fat are
considered obese.
Bariatric surgeons use the BMI when evaluating candidates for potential
bariatric surgery. It is calculated from the height and weight as follows:
BMI = body weight (in kg) ÷ square of stature (height, in meters)
For example, a man who is 5¢ 10² (1.78 meters) tall and weighs 285 lbs (135 kg)
would have a BMI of 130/1.78 × 1.78 = 41.
Overweight is defi ned as a BMI between 25 and 30 kg/m2 and obesity as a
BMI greater than 30 kg/m2. The current defi nitions commonly in use establish
the following values, agreed in 1997 and published by the WHO in 2000 are
summarized in the following:
● A BMI less than 18.5 is underweight
● A BMI of 18.5–24.9 is normal weight
● A BMI of 25–29.9 is overweight
● A BMI of 30–39.9 is obese
● A BMI of equal to or greater than 40 is severely (or morbidly) obese
The latest estimates are that around 30% of adults in the United States are obese
and 5% are considered morbidly obese. Morbid obesity (or clinically severe obesity)
is recognized as a major public health risk throughout the world, and has been
clearly shown to reduce life expectancy. Certain comorbid conditions associated
with obesity are largely responsible for the mortality and morbidity of this disease.
Cardiac disease, diabetes mellitus type II, obstructive sleep apnea, hypertension,
dyslipidemia, gastroesophageal refl ux disease, stress urinary incontinence, arthritis
of the weight-bearing joints, infertility, and some cancers have all been linked to
obesity (Table 4.1). Bariatric surgery has proven to be an effective means to aid in
the management of these comorbidities. The previous chapter deals with the identifi
cation of these comorbid conditions and their management.
B. Indications for Operation
Medical management alone has a high failure rate to sustain greater than
10% weight loss in obese patients; and management of comorbidities is often
expensive and insuffi cient. The surgical treatment of morbid obesity has been
well established as being safe and effective. In addition, the short-term and longterm
improvement in comorbidities has been well documented. Surgery should
be only one part of a long-term multidisciplinary approach that should include
monitoring for nutritional and metabolic complications and dietary counseling to
prevent weight gain. Psychological and behavioral factors as well as an assessment
of perioperative risk and complications must be considered before bariatric
surgery. For these reasons, the NIH in 1991 issued a consensus statement and
acknowledged that “alone, objective clinical features is not suffi cient to make
a decision regarding surgery.” Although each potential surgical case should be
assessed for risks and benefi ts, the consensus statement offered the following
guidelines for patient selection:
● Patients should have a low likelihood of responding to traditional, nonsurgical
therapy. Often, these patients have previously tried medically
sound weight loss programs without success.
Table 4.1. Comorbidities associated with obesity.
Hypertension Certain carcinomas Venous stasis
Cardiovascular dysfunction Sexual hormone dysfunction Degenerative arthritis
Respiratory insuffi ciency Infectious complications Pseudotumor cerebri
GERD Hyperlipidemia Psychosocial impairment
Diabetes Heart disease Chronic lower back pain
Skin disorders Gout Sleep apena
Asthma Urinary stress incontinence
● Patients must be well informed and motivated and accept the operative
risks. They also need to be able to participate in and comply with treatment
and follow-up.
● Patients should have a BMI in excess of 40 kg/m2 or body weight greater
than 100 lbs above ideal body weight.
● Patients are candidates if they have a BMI between 35 and 40 kg/m2
along with more than one high-risk comorbid condition or body weight
greater than 80 lbs above ideal body weight with a comorbidity.
● An important conclusion of the 1991 National Institutes Consensus
Development Conference Statement on the surgical treatment of
obesity was that “patients judged by experienced clinicians to have a
low probability of success with non-surgical measures, as demonstrated,
for example, by failure in established weight control programs or
reluctance by the patient to enter such a program, may be considered
for surgical treatment.”
The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) therefore
recommends that surgical therapy should be considered for individuals who:
Have a body mass index (BMI) of greater than 40 kg/m2
OR
have a BMI greater than 35 kg/m2 with signifi cant comorbidities
AND
can show that dietary attempts at weight control have been ineffective
The indications for laparoscopic treatment of obesity are the same as for open
surgery.
Guidelines in the past also recommended that patients should be over the age
of 18 or under 60 years of age. There is not a lot of literature with regard to these
patients undergoing bariatric surgery, but a recent study indicates that it may
be safe for some of these individuals.
There are certain contraindications for bariatric surgery, including: no medical
management attempted, life-threatening diseases, lack of social support, inability
to follow up, substance abuse, and patients who have psychiatric disorders that
have been evaluated by a psychiatrist.
??WHY ARE WE SO OVERWEIGHT
• Consumption of foods high in calories
(excessive sugar and fat)
• Consumption of too much food (large
portions)
• Not enough exercise/sedentary lifestyle
• Inheriting “fat genes” from our
parents/relatives
Obesity has become one of the most
widespread health problems in the
world. Obesity is responsible for
causing many diseases such as
diabetes and high blood pressure. It
also leads to premature death in
individuals who are severely
overweight.
What is obesity? Who is
considered overweight?
Today, rather than using tables and “body
types” to determine who is overweight, we
use a simple calculation called Body Mass
Index or BMI. BMI relates a person’s
weight to their height.
How to calculate your BMI Body Mass Index = (BMI) Weight/Height 2
Obesity increases the chance that you will develop one of the following diseases:
• High blood pressure
• Diabetes mellitus
• Elevated Cholesterol
• Arthritis
• Sleep Apnea
• Gallstones
• Stroke or Heart Attack
• Cancer
– Uterus, cervix, prostate, colon/rectal, gallbladder, breast
Medical Treatment of Obesity
• Diet – low in calories, fat and carbohydrates
• Exercise – 40 minutes 5 times per week
• Behavior Modification – eat 3 sensible meals
per day, avoid snacking
• Drugs/Prescription medications
– Stimulants/appetite suppressants
– Antidepressants (Meridia ®)
– Reduce fat absorption (Xenical ®)
Disadvantages of medical treatment:
• Most patients (9597%)
regain most or all of the
weight that was lost within 25
years following
diet or drug treatment
• The average amount of weight loss is relatively
small 1040
pounds
• Drug therapy may be associated with severe
complications (FenPhen
and heart disease).
• Most insurance companies do not cover
costs associated with these programs
• Very difficult for most people to maintain
these programs in the long term
• “YoYo”
effect of many different programs
leads to significant weight fluctuations
The term “Bariatric Surgery”
Comes from the Greek words
baros – meaning weight
and
iatreia – meaning medical
treatment
Who Qualifies for Consideration for Surgery?
• Patients with a BMI of 40 or greater (roughly 100
pounds overweight)
• Patients with BMI of 35 (roughly 80 pounds
overweight) or greater who also suffer from a
severe medical condition related to obesity (sleep
apnea, diabetes, heart failure, high blood
pressure)
• A patient who is prepared and willing to commit to
the lifestyle changes that will be necessary
following surgery
Who is not eligible for surgery?
The following individuals are not eligible
to have weightloss
surgery:
– History of substance abuse, eating disorder,
or major psychiatric problem which is
untreated and/or unresolved
– Patients who are too ill or too high a risk for
surgery
– Women who may become pregnant soon
Types of Surgery
• Purely Restrictive
Horizontal
Gastroplasty
Silastic Ring
Gastroplasty
Vertical Banded
Gastroplasty
Laparoscopic Adjustable Gastric Band
• Mostly Restrictive
RouxenY
gastric bypass
• Mostly Malabsorptive
Biliopancreatic
Diversion with
Duodenal Switch
Longlimb
RouxenY
Gastric Bypass
Complications of Malabsorptive Procedures
• Leak at one of the staple lines or bowel
connections
• Abdominal infection or abscess
• Blood clot in the leg veins
• Pulmonary embolus (blood clot in the artery of
the lungs)
• Bowel Obstruction or blockage
• Wound problems Infection,
Hernia, Scar
• Narrowing of one of the intestinal connections
• Nausea and vomiting
• Severe Heartburn/reflux
• Death
Potential Complications of Gastric
Bypass Procedure
• Anemia / Malnutrition
• Injury to the spleen, stomach, or esophagus
• Pneumonia
• Depression
• Flatulence/gas
• Diarrhea
• Failure to Lose Weight
• Vitamin Deficiencies
• Ulcers
• Death
Benefits of Weight loss Surgery
• Prevention of debilitating diseases such as
arthritis, diabetes, and sleep apnea
• More energy and stamina
• Improved sense of wellbeing and selfesteem
• Extended lifespan
• Actually cures most existing related
medical problems such as diabetes, sleep
apnea, high blood pressure, etc