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

Pre-operative Medications Post-operative Medications

Defining the ProblemDefining the Problem

The ProblemThe 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;289:76-79Flegal KM et al. JAMA 2005;293:1861-1919

Excess U.S. Medical Costs Related Excess U.S. Medical Costs Related to Abnormal Body Weightto Abnormal Body Weight

Int J Obesity 2005;29:334-339

Diabetes

Gall bladder disease

Hypertension

Dyslipidemia

Insulin resistance

Breathlessness

Sleep apnea

Greatly increased(relative risk >>3)

Coronary heart disease

Osteoarthritis (knees)

Hyperuricemia and gout

Cancer (breast cancer in postmenopausal women, endometrial cancer, colon cancer)

Reproductive hormone abnormalities

Polycystic ovary syndrome

Impaired fertility

Low back pain

Increased anesthetic risk

Fetal defects arising from maternal obesity

Moderately increased(relative risk 2-3)

Slightly increased(relative risk 1-2)

Relative risk of health problems associated with obesity

1Chan JM et al. Diabetes Care 1994;17:961-969; 2Colditz G et al. Ann Intern Med 1995;122:481-486.

Age-adjusted relative risk of type 2 diabetes

The Effect of Obesity The Effect of Obesity on the Development on the Development of Health Risksof Health Risks

0

10

20

30

40

50

1.02.2

12

42

0

25

50

75

100

1.08.1

40

93

<23 25 31 35 <22 25 31 35

Men1 Women2

BMI

Causes of ObesityCauses of Obesity

Genetics Behavior

Environment

The Environment: Portion SizeThe Environment: Portion Size

Non-operative Treatment of ObesityNon-operative Treatment of ObesityHow does it add up?How does it add up?

Diet

Exercise

Behavioral therapy

+ Drug therapy .

??????

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

Surgical Treatment of Obesity: Surgical Treatment of Obesity: The BasicsThe Basics

What is Body Mass Index ( BMI ) ?What is Body Mass Index ( BMI ) ?

Surgical Treatment of Obesity: Surgical Treatment of Obesity: Indications and Surgical OptionsIndications and Surgical Options

Patient SelectionPatient 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

Operative ApproachesOperative 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 )

The Gastrointestinal SystemThe Gastrointestinal System

Vertical Banded Gastroplasty (VBG)Vertical Banded Gastroplasty (VBG)

General Features• Pouch size: 1 oz

• Triple staple line

• Pouch opening: 0.5 in

Average Weight Loss• 50 % of excess weight

Vertical banded gastroplasty: Vertical banded gastroplasty: ComplicationsComplications

• Stomal narrowing with persistent vomiting

• Staple line leak or disruption

• Band erosion

• Wound infection or hernia

• Death 0.1%

• Overall re-operation rate 43 %

Adjustable Silastic Gastric Banding Adjustable Silastic Gastric Banding (ASGB): LapBand(ASGB): LapBandTMTM

GENERAL FEATURES

• Inflatable balloon within the band orifice can be adjusted via a reservoir under the skin

Average Weight loss• 50% of excess weight

Adjustable Silastic Gastric Banding : ComplicationsAdjustable Silastic Gastric Banding : Complications

• Splenic injury

• Esophageal injury

• Wound infection

• Persistent vomiting

• Acid reflux

• Band slippage

• Reservoir leak/deflation

• Band erosion

• Death 0.3 %

Re-operation 5 -20 %

Biliopancreatic Diversion with Biliopancreatic Diversion with Duodenal Switch (BPD-DS)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

Duodenal Switch (BPD-DS) : Duodenal Switch (BPD-DS) : ComplicationsComplications

• Protein malnutrition15%

• 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

Roux-en-Y Gastric Bypass Roux-en-Y Gastric Bypass (RYGBP)(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”

Gastric Bypass: ComplicationsGastric Bypass: Complications

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 %

General Complications of General Complications of Weight-Loss SurgeryWeight-Loss Surgery

• Post-operative depression• Food issues

• Changes in relationships

• Hair loss• Usually temporary

• Cause: protein, vitamin A, mineral

• Excess skin

Weight Maintenance after Bariatric SurgeryWeight Maintenance after Bariatric Surgery

Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26

ConclusionsConclusions• 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.