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Weight Loss Surgery: The First Step Toward a More Healthy Life

Weight Loss Surgery: The First Step Toward a More Healthy Life. Pre-operative Medications Post-operative Medications. Defining the Problem. The Problem. Prevalence of obesity in U.S. increased from 12% to 21% between 1991 and 2001 = 15 million people

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Weight Loss Surgery: The First Step Toward a More Healthy Life

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  1. Weight Loss Surgery:The First Step Toward a More Healthy Life

  2. Pre-operative Medications Post-operative Medications

  3. Defining the Problem

  4. The Problem • Prevalence of obesity in U.S. increased from 12% to 21% between 1991 and 2001 = 15 million people • Obesity is the 2nd most common cause of death from a modifiable behavioral risk factor • 111,909 excess deaths annually Mokdad AH et al.JAMA. 2003;289:76-79 Flegal KM et al. JAMA 2005;293:1861-1919

  5. Excess U.S. Medical Costs Related to Abnormal Body Weight Int J Obesity 2005;29:334-339

  6. Moderately increased Slightly increased Greatly increased (relative risk 2-3) (relative risk 1-2) (relative risk >>3) Cancer (breast cancer in Coronary heart disease Diabetes postmenopausal women, Osteoarthritis (knees) Gall bladder disease endometrial cancer, colon cancer) Hyperuricemia and Hypertension gout Reproductive hormone Dyslipidemia abnormalities Insulin resistance Polycystic ovary Breathlessness syndrome Sleep apnea Impaired fertility Low back pain Increased anesthetic risk Fetal defects arising from maternal obesity Relative risk of health problems associated withobesity

  7. 50 100 93 Men1 Women2 42 40 75 30 50 40 20 12 25 10 2.2 8.1 1.0 1.0 0 0 <23 25 31 <22 25 31 35 35 BMI The Effect of Obesity on the Development of Health Risks Age-adjusted relative risk of type 2 diabetes 1Chan JM et al. Diabetes Care 1994;17:961-969; 2Colditz G et al. Ann Intern Med 1995;122:481-486.

  8. Behavior Genetics Environment Causes of Obesity

  9. The Environment: Portion Size

  10. Non-operative Treatment of ObesityHow does it add up? • Diet • Exercise • Behavioral therapy • + Drug therapy . • ??????

  11. Fed up with how her diet is going Charlene takes a more serious aim at her target weight

  12. Surgical Treatment of Obesity: The Basics

  13. What is Body Mass Index ( BMI ) ?

  14. Surgical Treatment of Obesity: Indications and Surgical Options

  15. Patient Selection • Age 18 - 55 • AND • BMI ≥ 40 kg/m2 OR • BMI 35 - 40 kg/m2 with • High risk health problems OR • Obesity-induced physical problems NIH Consensus Development Conference

  16. Operative Approaches • Restrictive Procedures • Vertical banded gastroplasty ( VBGP ) • Adjustable silastic gastric banding (ASGB) • Malabsorptive Procedures • Biliopancreatic diversion ( BPD ) • Duodenal switch modification of BPD • Combined Procedures • Roux-en-Y gastric bypass ( GBP )

  17. The Gastrointestinal System

  18. General Features Pouch size: 1 oz Triple staple line Pouch opening: 0.5 in Average Weight Loss 50 % of excess weight Vertical Banded Gastroplasty (VBG)

  19. Vertical banded gastroplasty: Complications • Stomal narrowing with persistent vomiting • Staple line leak or disruption • Band erosion • Wound infection or hernia • Death 0.1% • Overall re-operation rate 43 %

  20. Adjustable Silastic Gastric Banding (ASGB): LapBandTM GENERAL FEATURES Inflatable balloon within the band orifice can be adjusted via a reservoir under the skin Average Weight loss 50% of excess weight

  21. Splenic injury Esophageal injury Wound infection Persistent vomiting Acid reflux Band slippage Reservoir leak/deflation Band erosion Death 0.3 % Re-operation 5 -20 % Adjustable Silastic Gastric Banding : Complications

  22. Biliopancreatic Diversion with Duodenal Switch (BPD-DS) • General Features • Gastric pouch size: • Standard: 14 oz (1.5 cups) • Three segments • Alimentary tract: 6.5 ft • Biliary tract: 13 ft • Common channel: 1.5 ft • Average Weight Loss • 80 % of excess weight

  23. Duodenal Switch (BPD-DS) : Complications • Protein malnutrition 15% • Anemia < 5 % • Marginal ulcer < 3 % • Peripheral neuropathy 1.3 % • Night Blindness 3 % • Osteoporosis 14 % • Renal stones • Nausea 65 % • Diarrhea 62 % • Vitamin deficiencies: A, D, E, K, B12 • Incisional hernia 10 % • Death 1.1 % First 6 mo

  24. Roux-en-Y Gastric Bypass (RYGBP) • General Features • Pouch size: 1 oz • Pouch opening: 0.5 in • Roux-en-Y limb • Standard: 2 ft • Average Weight Loss • 70 % of excess weight • “The Pouch-Tool”

  25. Early: Staple line leak 1-5% Acute gastric distention Roux-Y obstruction Death 0.5 % Late: Stomal narrowing /vomiting 15 % Marginal ulcer 13% Heartburn / inflammation of esophagus Anemia Folate deficiency Vitamin B12 deficiency Iron deficiency Calcium deficiency / osteoporosis Gallstones 10 % Gastric Bypass: Complications

  26. General Complications of Weight-Loss Surgery • Post-operative depression • Food issues • Changes in relationships • Hair loss • Usually temporary • Cause: protein, vitamin A, mineral • Excess skin

  27. Weight Maintenance after Bariatric Surgery Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26

  28. Conclusions • Bariatric surgery is an effective means to achieve clinically significant, permanent weight loss with low rates of complications. • Bariatric surgery results in significant improvement in health risks associated with obesity. • Surgical weight loss increases life-span. • Surgical therapy is cost-effective.

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