Slide sem ttulo

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OBESIDADE MÓRBIDA INDICAÇÃO CIRÚRGICA X BALÃO
INTRAGÁSTRICO
Dr. José Afonso Sallet ( Clínica Sallet-SP)
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PRESENTATION OF THE BRAZILIAN BIB
PROTOCOL(BioEnterics Intragastric Balloon)
Coordinator Dr. José Afonso Sallet (SP)
Collaborators Dr. João Caetano Marchesini
(PR) Dr. Dyker Santos Paiva (MG)
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• INDICATIONS
• Super Obese Patients (BMI gt 50) and Associated
• diseases (S.A, Hypertension, DM)
• Minimize surgical risk (bariatric, orthopedic,
  cardio-vascular, general)
• Patients with BMI lt 40 with or without
• associated diseases
• Patients with 40 BMI lt 50 do not accept
• surgical indication or high risk of assoc.
  dis.
• (BIB test) - Lap-Band or other procedure
• BMI lt 35 in association with inter-disciplinary
• treatment (cosmetic).

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Multidisciplinary team evaluation
Private practice in São Paulo-Brazil - JA Sallet
et al
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• TECHNICAL PROCEDURE
• - With sedation and anesthetist (98)
• - General anesthetic ( 2)
• Sleep apnea
• Specific cases
• - Ambullatory procedure (82)
• discharge after two hours
• - Day hospital procedure (18)
• discharge 12 to 24 hours

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Redução Excesso de Peso 6 meses
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PROTOCOLO DE TRATAMENTO CIRÚRGICO DA OBESIDADE
SEVERA
Centro Integrado de Cirurgia da Obesidade HA -
H9J (C.I.C.O) Clínica Sallet
Dr. José Afonso Sallet
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Indications of Bariatric Surgery

• BMI ? 35, ass. diseases, clinical treatment
  failure
• BMI ? 40 clinical treatment failure,
  complications with obesity
• Sleep apnea (O.S.A)
• Difficulties with personal hygiene and movement
• Social and professional discrimination
• Associated diseases (hypertension, arthrosis,
  diabetes)

Private practice in São Paulo-Brazil - JA Sallet
et al
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Multidisciplinary team evaluation
Private practice in São Paulo-Brazil - JA Sallet
et al
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Patient selection protocol for bariatric surgery
fig. 1 Gastro-restrictive procedure LAGB
(Lap-band)
fig. 2 Gastroplastic with intestinal bypass. LGB
fig. 3 Biliopancreatic diversion LBPD
Private practice in São Paulo-Brazil - JA Sallet
et al
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Our experience with bariatric procedures May
1998-Feb 2003
(n1021)
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Sallet, JA Arruda, P Ribeiro, MLeal, J
Pisani, C Sallet, PC Private Pratices - SP - BR
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ADJUSTABLE GASTRIC BAND

• Analysis of results with 316 severely obese
  patients treated with this technique.
• Private practice in São Paulo-Brazil
• José Afonso Sallet M.D.

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LAGB selection process

• Ideal patient profile
• 35 ? BMI ? 50 male/female
• Determination to change behavior
• Motivated to physical activity
• Understanding acceptance of complete
  multidisciplinary program (psychological/
  nutritional/ surgical /physical )
• Non-acceptance of more invasive surgical
  procedures (GB/BPD)
• BIB test with good results
• Understanding that primary objective is health
  and quality of life esthetic considerations are
  secondary

Private practice in São Paulo-Brazil - JA Sallet
et al
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LAGB selection process

• Negative Patient Profile
• Compulsive nibbler
• Excessive sweet eaters
• High intake of hyper caloric liquids
• Resistance to physical activity and
  multidisciplinary control (orientation)

Private practice in São Paulo-Brazil - JA Sallet
et al
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LAGB (n250 pat. with 1 to 4 years after Lap-Band)
Statistics Analyses SPSS 10.0 version 2000
(Results to E.W.L.)
71
17
12
250
M61.97 S.D10.80
No. Patients
50
70
Excess weight loss
Private practice in São Paulo-Brazil - JA Sallet
et al
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Results (n 316)Later complications n18 (5,7)

• Port leakage - 2 patient (0,5)
• (Change port)
• Port infection - 4 patients (1,2 )
• (port remove)
• Slippage - 2 patient (0,5)
• Laparoscopic replacement of band)
• Band erosion - 12 patients (3,6)
• Early portal infection - 6 (2)
• Forced adjustment of band - 2 (0,4)
• Probable particular patient reaction - 4 (1,2)
• Pouch dilation - 0
• Esophagic dilation -0
• Mortality - 0

Private practice in São Paulo-Brazil - JA Sallet
et al
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BMI35 (EWL75)
BMI71
Private practice in São Paulo-Brazil - José
Afonso Sallet et al
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Adjustable Gastric BandFinal considerations

• Effective method for controlling obesity
• (60 to 70 of excess weight in 12 months)
• Control of co-morbidities (80 after 8th month)
• Benefits of minimal invasive surgery
• Low rate of major complications
• Learning curve
• (considered easy, with precise technical steps)
• Mortality -0
• Absolutely necessary
• Suitable patient triage
• Correct application of technical procedure
• Rigorous post-op control ( with multidisciplinary
  team to support motivate patient)

Private practice in São Paulo-Brazil - JA Sallet
et al
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PROTOCOLO DE TRATAMENTO CIRÚRGICO DA OBESIDADE
SEVERA
CIRURGIA DE FOBI-CAPELLA (n387)
TÉCNICA
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PROTOCOLO DE TRATAMENTO CIRÚRGICO DA OBESIDADE
SEVERA
CIRURGIA DE FOBI-CAPELLA (n387)
INDICAÇÕES

• ACESSO VIDEO-LAPAROSCÓPICO (85)
• SEXO FEMININO
• 35 ? IMC ? 60
• COMPULSIVOS PARA DOCES
• INGESTA DE LÍQUIDOS HIPERCALÓRICOS
• BELISCADORES COMPULSIVOS
• SEXO MASCULINO
• 35 ? IMC ? 50
• HABITO ALIMENTAR ACIMA CITADO
• AMBOS COM OBJETIVO ESTÉTICO
• DO PESO IDEAL

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PROTOCOLO DE TRATAMENTO CIRÚRGICO DA OBESIDADE
SEVERA
CIRURGIA DE FOBI-CAPELLA (n 387)
INDICAÇÕES

• ACESSO POR LAPAROTOMIA (15)
• SEXO FEMININO
• IMC gt 60
• SEXO MASCULINO
• IMC gt 50
• DOENÇAS ASSOCIADAS CONTRA-INDICANDO
• PNEUMOPERITÔNIO
• Pneumopatia restritiva grave
• ICO, Arritmia Cardíaca, etc.
• Laparotomia prévia de grande porte
• Custo da operação

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PROTOCOLO DE TRATAMENTO CIRÚRGICO DA OBESIDADE
SEVERA
CIRURGIA DE FOBI-CAPELLA (n 387)
COMPLICAÇÕES

• RELACIONADAS A CIRURGIA DE GRANDE PORTE
• DEISCÊNCIA DE ANASTOMOSE de 1 a 4
• MORTALIDADE de 0,5 a 1,5
• RUPTURA DE LINHA DE GRAMPEAMENTO
• 5 PAC (1,69)
• 2 TRAT. CONS. (0,84)
• 3 RE-OP (0,84)
• MORTALIDADE 2 PAC (0,51)
• 2 TEP (24PO e 32 PO)
• TOTAL CIR. n756 - MORT. 2 PAC. (0,26)

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RESULTADOS PERDA DE PESO
n 387
FOBI-CAPELLA - Perda () Excesso de Peso x Tempo
90-100
80
70
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36
? FALHA EM 1 PACIENTE (0,25)
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CIRURGIA DE FOBI-CAPELLA (n 387)
PRÉ-OP.
9º MÊS P.O
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PROTOCOLO DE TRATAMENTO CIRÚRGICO DA OBESIDADE
SEVERA
TÉC. DERIVAÇÃO BILIO PANCREÁTICA (n51)
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PROTOCOLO DE TRATAMENTO CIRÚRGICO DA OBESIDADE
SEVERA
TÉC. DERIVAÇÃO BILIO PANCREÁTICA (n 51)
INDICAÇÕES

• PACIENTES
• IMC gt 50
• NÃO ACEITAM PROCEDIMENTOS
• GASTRO-RESTRITIVOS
• DOENÇAS ASSOCIADAS DE DIFÍCIL
• CONTROLE

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PROTOCOLO DE TRATAMENTO CIRÚRGICO DA OBESIDADE
SEVERA
TÉC. DERIVAÇÃO BILIO PANCREÁTICA (n 51)
COMPLICAÇÕES

• RELACIONADAS A CIRURGIA DE GRANDE PORTE
• DEISCÊNCIA DE ANASTOMOSE de 0,5 a 1
• MORTALIDADE de 0,5 a 1
• 1 PAC (1,96) ESTENOSE DA G-E e HÉRNIA
  ENCARCERADA (PORTAL DO TROCÁRTER)
• DEGASTRECTOMIA POR V.L - BOA EVOL. P.O
• 1 PAC (1,96) ALTERAÇÃO HIDROELETROLITICA
• REPOSIÇÃO HE e CONTR. CLIN. DA DIARRÉIA

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PROTOCOLO DE TRATAMENTO CIRÚRGICO DA OBESIDADE
SEVERA
TÉC. DERIVAÇÃO BILIO PANCREÁTICA (n51)
COMPLICAÇÕES

• RELACIONADAS AO PROCESSO MALABSORTIVO
• DIST. METABÓLICO (ALT. HEPATO-RENAL)
• NECESSIDADE DE CONTROLE RIGOROSO
• DO ESTADO NUTRICIONAL, METABÓLICO E
• HIDRO-ELETROLÍTICO A LONGO PRAZO
• NECESSIDADE DE REOP. P/ CONTROLE
• CLÍNICO (3 - 8) DOS PACIENTES
• ESTEATOR. (EVAC. EXTREM. FÉTIDAS)

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RESULTADOS PERDA DE PESO
n51
DERIV. BILIO PANCREATICA - Perda () Excesso de
Peso x Tempo
75-85
70
54
42
30
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PROTOCOLO DE TRATAMENTO CIRÚRGICO DA OBESIDADE
SEVERA
CONCLUSÕES

• NÃO EXISTE UMA SÓ TÉCNICA PARA O
• TRATAMENTO DA OBESIDADE
• NECESSIDADE ABSOLUTA DE SEL. PACIENTES
• TRANSPARÊNCIA E HONESTIDADE NAS
• INFORMAÇÕES E NO RELAC. MÉDICO-PACIENTE
• DOMÍNIO DAS DIFERENTES TÉCNICAS
• CONSCIENTIZAÇÃO E MOTIVAÇÃO DO PACIENTE
• INTERAÇÃO EQUIPE INTERDISC. - PACIENTE.

Para sair, tecle Esc
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(No Transcript)
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BALÃO INTRAGÁSTRICO TÉCNICA E RESULTADOS
Dr. José Afonso Sallet (Clínica Sallet - SP)
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PRESENTATION OF THE BRAZILIAN BIB
PROTOCOL(BioEnterics Intragastric Balloon)
Coordinator Dr. José Afonso Sallet (SP)
Collaborators Dr. João Caetano Marchesini
(PR) Dr. Dyker Santos Paiva (MG)
34
Multidisciplinary team evaluation
Private practice in São Paulo-Brazil - JA Sallet
et al
35

• TECHNICAL PROCEDURE
• - With sedation and anesthetist (98)
• - General anesthetic ( 2)
• Sleep apnea
• Specific cases
• - Ambullatory procedure (82)
• discharge after two hours
• - Day hospital procedure
• discharge 12 to 24 hours

Vídeo
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PERSONAL EXPERIENCE
Nov, 2000 to Feb, 2003 (n265)
Male 44 Fem 56 min. age14 - max. age61
med. age50.6 BMI lt 35 67 pat. (37) -
cosmetic ind. 35 BMI lt 40 59 pat. (33) -
severe obesity 40 BMI lt 50 35 pat. (21) -
morbid obesity BMI gt 50 21 pat. (11) -
super obesity
Sallet, J.A.
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PERSONAL EXPERIENCE
Nov, 2000 to Feb, 2003 (n265)
min. BMI30 max. BMI110,5 min.
weight71 max. weight350 80 with associated
diseases (Hypertension, Arthrosis, SA, DM)
med. BMI45.32 kg/m2
med. weight141.06 kg
time of BIB use 4 - 6 months (n265)
Sallet, J.A.
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RESULTS

• Median excess weight loss by group
• BMI lt 35 - 52.06 EWL
• 35 BMI lt 40 - 37.09 EWL
• 40 BMI lt 50 - 30.11 EWL
• BMI gt 50 - 31.7 EWL

(n 265) Sallet, J.A.
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SUPER OBESE PATIENT
Sallet, J.A.
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RESULTS
Super Obese Patients (n21 pat)
Excess weight loss min12 max43 Total
Weight Loss (kg) min23 kg max48 kg BMI Loss
min7.2 max17.1
med31.7
med39 kg/pat
med14 kg/m2
(n 265) Sallet, J.A.
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RESULTS
Super Obese Patients Group (n21) Change surgical
risk
Pre BIB classification (ASA IV) Post BIB
classification (ASA II) Ease of control
Hypertension, DM Sleep Apnea before BIB 41.2/hr
- min. sat62 after BIB 15.4/hr - min.
sat88
(n 265) Sallet, J.A.
(failure2 pat. - Success in 90.5)
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ILLUSTRATIVE CASE
Sallet, J.A.
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ILLUSTRATIVE CASE
Sallet, J.A.
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ILLUSTRATIVE CASE
Sallet, J.A.
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ILLUSTRATIVE CASE
Sallet, J.A.
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ILLUSTRATIVE CASE
Sallet, J.A.
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RESULTS
Teenagers (n19 pat) Age between 12 - 16 years old
Initial BMI (before BIB) min38 max52 Total
Weight Loss (kg) min8 kg max35 kg BMI Loss
min4 max22
med45 kg/m2
med24 kg/pat
med16 kg/m2
(n 265) Sallet, J.A.
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TEENAGERS ILLUSTRATIVE CASE
Sallet, J.A.
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TEENAGERS ILLUSTRATIVE CASE
Marchesini, J.C.
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WEIGHT LOSS number of patients n143
Median final weight 89,39 Kg
Median initial weight 98,31Kg
Median final BMI 31,82 Kg/m2
Median initial BMI 35,3 Kg/m2
Final excess weight 18,74 Kg
Initial excess weight 31 Kg
BMI loss 3,54Kg/m2
Excess weight loss 39,47
All patients analysed irrespective of length of
accompaniment (median time 4.51 months)
Marchesini, J.C
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SIDE EFFECTS
n408 patients

• Nausea and vomiting - 42
• Stomach pains - 21
• Dehydration - (EV re-hydration 5)
• Early Intolerance - (BIB removal 4.2)
• Complications
• Minor GERD 12
• BIB valve likage 2

Sallet, J.A Marchesini, J.C
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SIDE EFFECTS
n408 patients
Major Gastric blockage BIB (2 pat - 0,49)
Gastric over-distention Endoscopic BIB removal
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SIDE EFFECTS
n408 patients
BIB deflation/migration (1 pat - 0,24)
Intestinal obstruction Laparotomy and
colonoscopic removal
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HOW TO MAXIMIZE BIB RESULTS
Suitable selection of patients (Psychiatrist)
Psychiatric Approach

• Good candidates for the BIB
• Voluntary decision reflection, post-surgical
  meeting w/ patient
• Self-control eat smaller quantities, more slowly
  and more frequently
• Absence of binge eating episodes ( BED, Bulimia)
  
• Socio-occupational functioning and self-esteem
  preserved
• Depressive states are not a counter indication,
  but should be treated before.

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POTENTIAL CONTROL DIFFICULTIES

• Nausea and vomiting
• post-placement (first three days)
• more powerful anti-emetics
• anti-spasmodic drugs
• Put patient in left side decubitus and massage
  balloon
• into gastric fund position
• Follow-up with cosmetic patients
• better selection
• closer contact between patients and
  inter-disciplinary
• team

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RESULTS

• Failure less than 10 loss of total weight
• less than 20 loss of excess weight
• Median excess weight loss
• Including 12 failure rate - 37.5 EWL
• excluding 12 failure rate - 41.2 EWL

(n408) Sallet, J.A.
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CONCLUSIONS

• Effective and transitory non-surgical technique
  for controlling
• obesity (app. 38 excess weight loss)
• No mortality and minimal risk of major
  complications
• MOST SUITABLE INDICATIONS
• Super obese patients (BMI gt 50) in pre-op.
• Teenagers
• BIB test for gastro-restrictive or other surgery
• Patient with BMI lt 35
• Failure in clinical treatment
• Diseases associated with obesity
• In an inter-disciplinary approach

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CONCLUSIONS
Our initial experience with the BIB Many
questions will still need to be answered
however, our initial impression is that this is a
very good technique which is especially effective
with super-obese patients, teenagers and
cosmetics indication.
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www.balaointragastricobib.com.br phone 55 11
3063-2414