Morbid Obesity—A killer disease

Obesity today is recognized as a health problem of epidemic proportions. Overweight is detrimental for a person's, physical, social, psychological and emotional health. Obesity is responsible for Diabetes, Hypertension, Pulmonary problems, Obstructive sleep apnea, knee pains, Cancer of ovary, breast, uterus, prostate and many more problems. Obese people suffer from depression, lack of confidence, marital problems which are more agonizing but less visible.

An Obese Person Is.........

6 times more likely to develop gallbladder disease
5.6 times more likely to develop high blood pressure
3.8 times more likely to develop diabetes
2 times more likely to develop osteoarthritis
Higher rates of cancer have also been linked to obesity including prostate, breast, cervix, and ovarian cancers.

Losing weight will significantly reduce the many health risks that accompany obesity;

Now even growing children are getting obesity disorder due to excess indulgence of indoor games and watching T.V plus avoidance of outdoor games and exercise and premature obesity in later years can also become a cause of early death.

Why Surgery?
Although diet, exercise, behavior therapy and anti-obesity drugs are first-line treatment, but these medical solutions are only temporarily successful with the patient invariably regaining even more weight than the amount lost.

In this condition, Obesity Surgery (bariatric surgery) generally results in greater weight loss than conventional treatment, and leads to improvements in the quality of life and almost complete resolution of obesity related diseases like hypertension and diabetes. That is why obesity surgery is now being termed as Metabolic Surgery.

Am I Candidate
In order to determine if you are a candidate for weight-loss surgery, it is helpful to know your Body Mass Index or BMI. It is equal to your weight (in kilograms) divided by the square of your height (in meters). If your BMI is over 40 or BMI over 35 with comorbidities (Diabetes, hypertension, sleep apnea etc) and have been unsuccessful at dietary / behavioral approaches to weight loss, you may be a candidate for laparoscopic weight-loss surgery.

Surgery for morbid obesity

First of all, it must be clear that this is not a cosmetic procedure but an “fight for existence”. Main obesity surgery procedures are Laparoscopic Gastric Bypass surgery, Lap Band surgery, Laparoscopic Sleeve Gastrectomy surgery.


Laparoscopic Adjustable Gastric Banding
A silicon band is placed around the upper part of stomach, creating a small pouch that can hold only a small amount of food. The narrowed opening between the stomach pouch and the rest of the stomach controls how quickly food passes from the pouch to the lower part of the stomach. Connected to the band is tubing which is attached to a port, this part is placed under the skin in a muscle in the chest wall. The band can be tightened or loosened to meet your needs, on OPD basis.

Laparoscopic Roux-en-y Gastric Bypass:
Gastric bypass involves creating a small pouch by dividing the stomach. The small intestine is divided and brought up to join the new stomach pouch. This allows food to go straight from the stomach pouch into the small intestine, which causes it to bypass the lower stomach and the duodenum (the first segment of the small intestine). This reduces the amount of calories that the body absorbs.

Laparoscopic Sleeve Gastrectomy

The sleeve gastrectomy works by limiting the amount of food you’re able to eat. The surgeon will remove about 70-85% of your stomach. Your new stomach then takes on the shape of a banana thereby



reducing the storage capacity of stomach.

All these operations can be done laparoscopically so that the patient spends only one to two days in the hospital and can return to their daily routine in 1-2 weeks. Patients can lose 50-80% of their excess weight over 1-2 years


How does obesity surgery change your life?

Laparoscopic Bariatric / Metabolic surgery leads to definite & sustained loss of weight and reversal of

most of medical problems like diabetes and hypertension etc.

1 Lifestyle adjustments: Patient must learn to eat food in small amounts and to chew it well and slowly.
2 Weight loss starts soon after surgery and continues for atleast 2 years.
3 There is enhanced quality of life, with improved stamina, mood, self esteem and body image.
4 Almost complete resolution of DM, HPT, Sleep apnea, dyslipidemia etc.
5 Obesity surgery is not a cosmetic surgery




If you need any further information please contact:

Dr Puneet Gupta
MBBS, MS, DNB, FNB (MAS), FIAGES, MNAMS, DHA
Consultant–Minimal Access & Bariatric Surgery
SAHARA HOSPITAL
Viraj Khand, Gomti nagar, Lucknow
Email: drpgmas@yahoo.co.in
Mobile: 09919314819

Dr Shalin Dubey performed two port laparoscopic cholecystectomy on 62 yr old at wockhardt hospital,Vashi using conventional instruments
Article in DNA NAVI MUMBAI 17th MAY 2011 edition

Preservation of pancreatic tissue is an important goal during surgery for biliary and pancreatic diseases. The Whipple procedure is the standard of care and the procedure of choice for many malignant conditions of the pancreas , duodenum and the bile duct. It is also frequently performed for benign disorders that affects these organs. While in some patients, the extent and the nature of the disease may require a Whipple surgery, in some others, alternate procedure that preserves some of the tissues removed during the standard procedure may be an option. Some of these procedures include:
1) Duodenum preserving pancreatic head resection : This is offered to patients with chronic pancreatitis and non cancerous disorders of the head of the pancreas such as cystic neoplasm or small islet cell tumors which would otherwise require a Whipple operation. As the name suggests, this procedure preserves the duodenum. The head of the pancreas is removed. Postoperatively it is seen that the patients have rapid return of bowel function and less GI complications.
2) Central pancreatectomy- : This procedure is indicated for patients who have low grade malignant or benign tumors in the middle part of the pancreas which is also called the neck. Often this may require an extended Whipple procedure and a large portion of the normal pancreas has to be removed along with the tumor, but with the above mentioned alternative specialized technique, only the tumorous portion of the neck of the pancreas is removed.
3) Enucleation of pancreatic islet cell tumors : Insulinomas and gastrinomas are small functional pancreatic surface tumors. They have a lining around them that seperates them from the pancreas. During enucleation these tumors are shelled out from the pancreas without removing any pancreatic tissue. It is done laparoscopically.
4) Spleen preserving distal pancreatectomy : ThIs procedure is indicated for benign disorders or low grade malignancy of the last part or the tail of the pancreas. The purpose is to spare the spleen. Normally a standard distal pancreatectomy with spleen removal is done when in these cases there is often no indication for a splenectomy.
5) Wide resection of Ampulla of vater : For ampullary polyps or some benign disorders of the ampulla such as villous adenomas, the Whipple operation is offered when it is best to do a local resection of the ampulla . In this procedure the ampulla is widely removed and the cut ends of the bile duct and pancreatic duct is reimplanted into the duodenum.
6) Isolated resection of the third and fourth portion of the duodenum : This is also performed to avoid a Whipple surgery for tumors on the third and fourth portion of the duodenum. In this surgery only the third and fourth portion of the duodenum is removed and the cut ends of the intestine are then sutured together.
Pancreas plays an important role in the digestion of food and in the regulation of blood sugar. Loss of pancreatic tissue after surgery increases the risk of developing diabetes and malabsorption of food. It is therefore, very important that we try and preserve this vital organ as much and as far as possible even when there is a need for surgery.

Biologic Mesh
From SAGES Surgical Wiki
1 Introduction
2 Basic science of biologic meshes
3 Indications for use
3.1 Non contaminated setting
3.2 Bridging the gap
3.3 Reinforcement of the repair
3.4 Contaminated Setting
3.5 Prophylaxis during stoma creation
3.6 Hiatal Hernias
4 Conclusion
5 References


Introduction
Biologic mesh development resulted from a search for a biomaterial that could address the problems associated with permanent synthetic mesh, including chronic inflammation and foreign body reaction, stiffness and fibrosis, and mesh infection. Since the introduction of biologic mesh, the market has been rife with new biologic materials attached to largely unsupported claims of superiority and safety. With data comprised mainly from animal studies and Level III evidence, there has been little science regarding these materials, yet surgeons have been using these materials with increasing frequency driving a multi-million dollar market.

Basic science of biologic meshes
Most often derived from human or porcine dermis, these materials have been processed to acellular, porous extracellular matrix scaffolds of collagen and elastin. Some source growth factors remain and attract endothelial cells and subsequent fibroblasts into the mesh. These host cells release additional chemoattractants that signal the migration of other structural cells. The three-dimensional nature of the mesh and porosity allow cells to enter the mesh and adhere. What happens from there is a cycle of remodeling consisting of degradation of the biologic mesh and regeneration of the collagen scaffold with host tissue. The balance of this degradation and rebuilding process, and the speed with which it occurs, influences the ultimate strength and structure of the biologic mesh hernia repair.
The processing of the biologic mesh for production is by and large a proprietary procedure, making it difficult for surgeons to access information and answer several questions about the final products. These uncertain areas include decellularization, the sterilization process, the source of human dermis in terms of donor age and body part, and the crosslinking process. The cells are removed from the grafts in different ways: physical means such as dessication, chemical processes, or enzymatic reactions. Some of the products are terminally sterilized while others are not, resulting in variations in storage and pre-use hydration requirements. Sterilization options include gamma radiation, ethylene oxide, or hydrogen peroxide. Some companies instill chemicals, such as gluteraldehyde, into the biologic graft to induce additional crosslinking bonds in the graft to slow down the degradation process in the hope of leading to a stronger host collagen framework. However, this is a not a natural feature of the donor tissue and there is concern about the lack of remodeling in too heavily crosslinked grafts. This unintended feature could result in a poorly integrated graft and foreign body reaction, similar to some permanent synthetic meshes.
The advantage of crosslinked mesh versus non-crosslinked mesh remains a controversial area. Early investigation at Washington University presented at the 2009World Hernia Congress and the 2010 American Hernia Society Meeting showed increased stiffness for two crosslinked biologic mesh products (porcine dermis and bovine pericardium) compared to the non-crosslinked bovine pericardium mesh. 1-2 Greater cell infiltration was seen in the non-crosslinked mesh. Future investigation is warranted as to whether these characteristics are clinically important or if the crosslinked mesh poses an increased risk for infection by preventing collagen breakdown and macrophage migration.

Indications for use
The theoretical advantage of biologic mesh over synthetic mesh has appealed to surgeons, mostly in the United States. These meshes are not widely favored nor used in Europe and elsewhere due to the high cost of the biologic mesh over its cheaper and more widely applicable synthetic mesh counterpart. Over the last decade, surgeons have utilized biologic mesh in a variety of cases ranging from primary ventral and inguinal hernia repair in non-infected fields, recurrent hernias, reinforced hernia repair, hernia prophylaxis, and the most widely used application, hernia repair in the contaminated or potentially contaminated field.

Non contaminated setting
The use of biologic mesh in primary or recurrent ventral or inguinal herniorrhaphy in the noncontaminated and previously uninfected field is difficult to justify due to the high material cost without added benefit. There is very little data regarding the performance of biologic mesh in these settings.

Bridging the gap
The poor performance of the mesh in terms of laxity in a bridging repair makes this an unacceptable repair in the noncontaminated setting. Blatnik et al documented a recurrence rate of 80% for bridging repair with acellular dermal matrix at an average cost of $5,100 per patient, comparing the repair to an “expensive hernia sac.”3 The laxity associated with biologic mesh has been documented in other series.4

Reinforcement of the repair
The use of allograft or xenograft as reinforcement of a primary ventral hernia repair is felt to be a more sound approach. This fits with what we know of the science of biologic meshes in that placement in well-vascularized tissue is favorable for the ingrowth and remodeling process. Rosen’s group at Case Western investigated this and found a reduction in ventral hernia recurrence rate with a components separation midline repair reinforced with acellular dermal matrix (20%) compared to the 80% recurrence after bridging allograft repair.5

Contaminated Setting
The presence of contamination may limit the applicability of permanent synthetic mesh in some hernia repairs. Biologic mesh may be acceptable for this purpose or for placement in open wounds as a staged closure in complex abdominal wall reconstruction. There is limited data in both of these areas, with some noting a high risk of hernia recurrence and associated infection. The data is mostly limited to animal models and case series. 6,7 However, the lack of suitable alternatives has made biologic mesh attractive for contaminated field hernia repair.

Prophylaxis during stoma creation
The role of biologic mesh has been explored in prevention of parastomal hernias. An ongoing study of human dermis allograft placed at the time of construction of ileal conduits after cystectomy shows promising results with a decreased risk of hernia occurrence (30.4% v. 6.3%).8 Biologic mesh has also been used in the treatment of parastomal hernias where infection is a concern.9 With increasing reports of prophylactic synthetic mesh placement at the time of ostomy construction, the use of biologic mesh in this preventative setting may decline.

Hiatal Hernias
Biologic mesh has been utilized in the reinforcement of paraesophageal hernia repair. The randomized controlled trial of mesh repair for paraesophageal hernia lead by Oelschlager is the only Level I human study of biologic mesh.10 This study showed a decreased risk of hernia recurrence with mesh repair, from 24% to 9%. The recommendation for mesh reinforced hiatal repair is made with some caution; significant mesh complications, ranging from mesh erosion to esophageal stenosis and fibrosis, were documented in a follow-up study.11

Conclusion
In summary, biologic grafts represent a major advancement in complex hernia repair. Further investigation regarding the appropriate indications, performance of the grafts based on individual properties such as crosslinking, and potential complications is needed. Given the high cost of most of these materials and the limited available data, biologic mesh should be used judiciously and only when permanent synthetic mesh is inappropriate, such as in the contaminated field. The FDA reported complications of these materials warrant caution and sound surgical judgment.12,13




Biologic/bioresorbable graft comparison




Brand Name
Company
Type


AdditionallyCrosslinked?
Sterilized?

Alloderm®
LifeCell
Dermis
Human
No
No

Allomax™
CR Bard
Dermis
Human
No
Yes

Collamend™
CR Bard
Dermis
Porcine
Yes
Yes

FlexHD™
MTF
Dermis
Human
No
No

Periguard®
Synovis
Pericardium
Bovine
Yes
Yes

Permacol™
Covidien
Dermis
Porcine
Yes
Yes

Strattice®
LifeCell
Dermis
Porcine
No
Yes

Surgimend®
TEI
Dermis
Bovine fetal
No
Yes

Surgisis®
Cook
Intestinal submucosa
Porcine
No
Yes

Tutopatch®
Tutogen

Pericardium
Bovine
No
Yes

Veritas®
Synovis
Pericardium
Bovine
No
Yes

XenMatrix TM
CR Bard
Dermis
Porcine
No
Yes

BioA®
WL Gore
Synthetic bioabsorbable

N/A
Yes

TIGR®
Novus Scientific
Synthetic bioabsorbable


N/A
Yes





References
1. Melman L et al. Proceedings of World Hernia Congress. Berlin, Germany. 2009
2. Melman L et al. Histologic Evaluation of Crosslinked and Non-crosslinked Biologic Mesh Materials in a Porcine Model of Mature Ventral Incisional Hernia Repair. Proceedings of American Hernia Society: Hernia Repair 2010. Orlando, FL. 2010
3. Blatnik J, Jin J, Rosen M. Abdominal hernia repair with bridging acellular dermal matrix--an expensive hernia sac. Am J Surg. 2008 Jul;196(1):47-5
4. Bluebond-Langner R, Keifa ES, Mithani S, Bochicchio GV, Scalea T, Rodriguez ED. Recurrent abdominal laxity following interpositional human acellular dermal matrix. Ann Plast Surg. 2008 Jan;60(1):76-80.
5. Jin J, Rosen MJ, Blatnik J, McGee MF, Williams CP, Marks J, Ponsky J. Use of acellular dermal matrix for complicated ventral hernia repair: does technique affect outcomes? J Am Coll Surg. 2007 Nov;205(5):654-60.
6. Saettele TM, Bachman SL, Costello CR, Grant SA, Cleveland DS, Loy TS, Kolder DG, Ramshaw BJ. Use of porcine dermal collagen as a prosthetic mesh in a contaminated field for ventral hernia repair: a case report. Hernia. 2007 Jun;11(3):279-85.
7. Candage R, Jones K, Luchette FA, Sinacore JM, Vandevender D, Reed RL 2nd. Use of human acellular dermal matrix for hernia repair: friend or foe? Surgery. 2008 Oct;144(4):703-9.
8. Harold KL, et al. Early Results of a Prospective Randomized Study Using Acellular Human Dermal Matrix (Alloderm) to Prevent Parastomal Herniation. Proceedings of American Hernia Society: Hernia Repair 2010. Orlando, FL. 2010
9. Lo Menzo E, Martinez JM, Spector SA, Iglesias A, Degennaro V, Cappellani A. Use of biologic mesh for a complicated paracolostomy hernia. Am J Surg. 2008 Nov;196(5):715-9.
10. Oelschlager BK, Pellegrini CA, Hunter J, Soper N, Brunt M, Sheppard B, Jobe B, Polissar N, Mitsumori L, Nelson J, Swanstrom L. Biologic prosthesis reduces recurrence after laparoscopic
paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg. 2006 Oct;244(4):481-90.
11. Stadlhuber RJ, Sherif AE, Mittal SK, Fitzgibbons RJ Jr, Michael Brunt L, Hunter JG, Demeester TR, Swanstrom LL, Daniel Smith C, Filipi CJ. Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series. Surg Endosc. 2009 Jun;23(6):1219-26.
12. Rosen MJ. Biologic mesh for abdominal wall reconstruction: a critical appraisal. Am Surg. 2010 Jan;76(1):1-6.
13. Harth KC, Rosen MJ. Major complications associated with xenograft biologic mesh implantation in abdominal wall reconstruction. Surg Innov. 2009 Dec;16(4):324-9.
14. Gina Adrales, M.D. Biological Meshes – Indications and Shortcomings. Challenging Hernias Post-Graduate Course. 12thWorld Congress of Endoscopic Surgery. April 15, 2010

Colon cancer is the second leading cause of cancer deaths in America, specially in older women . Being overweight increases a woman's risk of developing colon cancer but where she stores the body fat determines how long she survives with the disease. Researchers followed about 1,000 post menopausal women with colon cancer for an average of 10 years and found that the women who were heavier before diagnosis were more likely to die from the disease, earlier than their thinner peers - yet another reason to avoid obesity throughout your life. Doing so increases the chances of survival if you are diagnosed with colon cancer.
Body weight refers to how you carry extra weight. You have heard about two body shapes- the ''apple" and the" pear". Apples tend to be apple shaped carrying excess weight in their chest and abdomen and look heavier on the top. Pears tend to be pear shaped and carry excess weight in their waist , butt and thighs and look heavier on the bottom. Dozens of studies show that having an apple shaped body increases the risk of heart disease, high blood pressure, diabetes, stroke and breast cancers. Scientists looked at data for weight, body mass index, waist size and waist to hip ratio and found that carrying extra weight at the waist and hip appeared to be more a factor in colon cancer deaths than overall weight or BMI. In other words a unhealthy waist hip ratio or adipose tissue distribution towards your bottom is a very important factor in colon cancer deaths. A waist to hip ratio of 0.80 or below is considered low risk. For instance, a woman with a waist of 27 inches and a hip of 36 inches has a waist to hip ratio of 0.75.
So maintaining a healthy body weight, life long body size , maintaining a healthy waist to hip ratio is a recommendation one can give for all post menopausal women.A waist circumference more than 40 inches, in men increases their risk of colon cancer also . So make sure you are only EATING apples and pears, not LOOKING like one !