Laparoscopic Bariatric Surgery

1. Laparoscopic Bariatric Surgery

2. Bariatric Surgery • Greek baros (weight) + iatrike (medicine, surgery) • A field of medicine encompassing the study of overweight, its causes, prevention, and treatment

3. Why Do Bariatric Surgery? • Major impact on morbidity and mortality • cures disease and saves lives! • preventative medicine? • Challenging • Very rewarding • Exceptional group of patients • A HAPPY specialty!

4. Obesity Is a Big Problem • Major public health problem worldwide • Affects 25% of industrialized world • American statistics: • 55% of adults are overweight • 25% of children are overweight • 300,000 deaths annually

5. <10% 10% to 15% >15% Prevalence of Obesity* among U.S. AdultsBRFSS, 1990 (*Approximately 30 pounds overweight) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

6. <10% 10% to 15% >15% Prevalence of Obesity* among U.S. AdultsBRFSS, 1991 (*Approximately 30 pounds overweight) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

7. <10% 10% to 15% >15% Prevalence of Obesity* among U.S. AdultsBRFSS, 1992 (*Approximately 30 pounds overweight) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

8. <10% 10% to 15% >15% Prevalence of Obesity* among U.S. AdultsBRFSS, 1993 (*Approximately 30 pounds overweight) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

9. <10% 10% to 15% >15% Prevalence of Obesity* among U.S. AdultsBRFSS, 1994 (*Approximately 30 pounds overweight) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

10. <10% 10% to 15% >15% Prevalence of Obesity* among U.S. AdultsBRFSS, 1995 (*Approximately 30 pounds overweight) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

11. <10% 10% to 15% >15% Prevalence of Obesity* among U.S. AdultsBRFSS, 1996 (*Approximately 30 pounds overweight) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

12. <10% 10% to 15% >15% Prevalence of Obesity* among U.S. AdultsBRFSS, 1997 (*Approximately 30 pounds overweight) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

13. <10% 10% to 15% >15% Prevalence of Obesity* among U.S. AdultsBRFSS, 1998 (*Approximately 30 pounds overweight) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

14. <10% 10% to 15% >15% Prevalence of Obesity* among U.S. AdultsBRFSS, 1999 (*Approximately 30 pounds overweight) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

15. Current Data Over 50% of Americans are obese and over 10% are morbidly obese

16. What Is Obesity? A life-long, progressive, life-threatening, costly, genetically-related, multi-factorial disease of excess fat storage ASBS

17. Body Mass Index (BMI) • BMI = weight (kg)_____ height (m) x height (m) WHO Classification BMI • Ideal weight 20–24.9 • Overweight 25–29.9 • Moderate obesity(class I) 30–34.9 • Severe obesity (class II) 35–39.9 • Morbid obesity (class III) 40–49.9 • (Super obesity) 50 +++

18. Exponential Mortality Risk

19. Diabetes Hypertension Hyperlipidemia Cardiac disease Respiratory disease sleep apnea Arthritis Depression Stress Incontinence Menstrual irregularity 14–20% 25–55% 35–53% 10–15% 10–20% 20–25% 70–90% 50% 50% Co-Morbid Medical Conditions

20. What Causes Obesity? • Energy in > energy out • Obesity is multifactorial: • genetic 25–30% • neuroendocrine • environmental • metabolic

21. Why Surgery? • Diet and exercise only works for 1 in 20 (5%) people who are obese • Surgery is safe and effective • Improves co-morbidities • Benefits of surgery outweigh the risks for the morbidly obese • risks of surgery • risks of staying morbidly obese

22. NIH Consensus Conference 1991 • Surgery is the only way to obtain consistent, permanentweight loss for obese patients • Surgery indicated in patients with: • BMI of 40 or over • BMI of 35 or over with significant co-morbidity • documented dietary attempts ineffective

23. How Does Surgery Work? • Malabsorption • jejunoileal bypass • biliopancreatic diversion  duodenal switch • Restriction • vertical banded gastroplasty • adjustable gastric banding • Hybrid of restriction and malabsorption • gastric bypass

24. Jejunoileal Bypass (JIB) • HISTORICAL • Bacterial overgrowth in blind limb: anemia, arthritis, cirrhosis, kidney stones, etc. • Diarrhea and malnutrition • No longer performed • Should be reversed graphics Courtesy of ASBS

25. Vertical Banded Gastroplasty (VBG) aka “Stomach Stapling” • On the way out • Restrictive • Minimal metabolic effects • Defeated by junk food diet, liquids • 40–60% loss EBW • Only 38% success • staple line failure graphics Courtesy of ASBS

26. Laparoscopic Adjustable Gastric Banding • Restrictive • Ongoing FDA studies • No long-term follow-up • Presence of a foreign body • Post operative adjustments required

27. Roux-en-Y Gastric Bypass • Most frequently performed bariatric procedure in the US • First done in 1967 • Some technical modifications since (stomach is divided) • Laparoscopically since 1993 graphics Courtesy of ASBS

28. Frantzides et al. Laparoscopic Gastric Stapling and Roux-en-Y Gastrojejunostomy for the treatment of Morbid obesity. J Laparoendosc Surg 1995

29. Laparoscopic Roux-en-Y(Minimally Invasive)

30. Planning

31. Laparoscopic Roux-en-Y(Minimally Invasive) • Six small puncture wounds (1/4 to ½ inch) •  A laparoscope, connected to a video camera, is inserted through the small incision into the abdomen

32. Advantages of Laparoscopy • Fewer wound complications • infection, hernia • Probably fewer cardiac and respiratory complications • Less pain and faster recovery • Surgeon has better view of the anatomy

33. Roux-en-YOpen vs. Laparoscopic Procedure • OPEN • Hospital stay of about 5 days. • Return to work in about 4 weeks. • More painful • Greater risk of infection LAPAROSCOPIC • Hospital stay is 1 to 3 days. • Patients usually return to work in 10 to 14 days. • Technically more demanding for the surgeon

34. Results of Our Lap Gastric Bypass Technique, 2003 • 711 Patients • Average BMI: 50 (range 35-91) • Conversions to open: 1 • Duration of Surgery: 90 min (range 37-180) • Hospital Stay: 2.0 days (range 1-4)

35. Author No. Patients Mean BMI Mean OR Time (MIN) Conversion (%) Hospital Stay (D) EBWL (Follow-up in months) Wtittgrove 500 NR 120 NR 2.6 73% (54) Higa 400 46 NR 3.0 1.6 69% (12) Schauer 275 48 247 1.0 2.6 77% (30) Champion 63 50 NR 1.6 2.5 82% (12) Frantzides 711 50 90 0.2 2.0 81% (12) Results of Lap Gastric Bypass, 2003

36. Frantzides et al. Triple Stapling Technique for Jejunojejunostomy in Laparoscopic Gastric Bypass. Arch Surg 2003

37. Post-Op Incisions

38. Post-OperativeNutrition and Diet • Most patients who have had gastric-bypass surgery begin . . . • A soft diet after the first week • A regular diet at one month • Nutritional and psychological counseling • A daily multi-vitamin with iron for life • Weekly sublingual vitamin B12 for life

39. Post-OperativeMaintenance • First post-operative visit is usually 7-10 days following surgery • Office visits are scheduled at 1, 3, 6 and 12 months after surgery, and yearly thereafter • Lab work is performed at all visits after the 1st postoperative visit

40. Post-Operative • Most patients lose up to and beyond 80% of excess weight …and keep it off.

41. Reduction in Co-Morbidities • All medical co-morbidities are resolved or improved in 80–100% of patients

42. Swedish Obesity Surgery Study

43. Pre-Operative Process • Medical History • You will need a detailed account of efforts to achieve weight loss by non-surgical methods. • Lists of specific comorbidities need to be identified. • Your current health status will need to be evaluated

44. Pre-Operative Process • Supporting Documentation • You will need a brief letter from any physicians that have treated any weight-related health conditions. • Any documentation from physicians stating the previous weight-loss efforts that you have made can be very valuable.

45. Pre-Operative Process • Medical Testing • Further medical testing may need to be completed in order to further clarify any existing comorbidities • A psychological evaluation may also be needed

46. Pre-Operative Process • Insurance Request • Depending on the type of health care benefits, a request is made for coverage of the surgery from the patient, as well as the surgeon. • If the Request is Denied • Some insurance companies will initially deny a request for coverage. An appeal from the patient can be made or the patient can choose to seek legal advice.

47. Frequently Asked Questions • Can gastric-bypass surgery be reversed? • Yes. The procedure is intended to be a permanent change, but because the stomach is bypassed, not removed, surgeons can undo the pouch.

48. Frequently Asked Questions Continued… • Will I need plastic surgery? • Many factors influence the need for plastic surgery, for example starting weight, the amount of weight lost, location of the excess weight and age. The younger patients have a greater amount of skin elasticity and therefore are less likely to need plastic surgery.

49. Frequently Asked Questions Continued… • Will I have gallstone complications? • Weight loss and diet will promote the production of gallstones. If a patient has has documented gallstones, the gallbladder will be removed at the time of surgery. • Gallstone dissolution medication

50. Frequently Asked Questions Continued… • Can I become pregnant after gastric-bypass surgery? • Yes, you can become pregnant after the surgery with out any related complications. Thousands of women have had successful pregnancies after the gastric-bypass surgery.