Dr. Arif Ahmad MD, FACS, FRCS

A. Ahmad, J. Carleton, A. Agarwala, Z. Ahmad

John T. Mather Memorial Hospital, Port Jefferson, NY, USASt. Charles Hospital, Port Jefferson, NY, USA

Surgery for Morbid Obesity: A Retrospective Review of our Experience in a Community Hospital SettingDisclosureArif Ahmad MD

I have NO actual or potential conflict of interest in relation to this activity.

I do not have any relevant financial relationships with any commercial interests.

Disclosure InformationIn compliance with the guidelines established by ACCME, I have no actual or potential conflict of interest in relation. I have no relevant financial interest to this program or presentation. Venus of Willendorf

EvolutionThe Obesity EpidemicOne in five people in the United States is obeseThree in five Americans are either overweight or obeseIn the past 20 years, obesity among adults has doubledSource: The Surgeon Generals Call to Action to Prevent Overweight and Obesity.A Rapidly Expanding Problem

6Slide 6.According to the Surgeon Generals recent call to action, overweight and obesity have reached nationwide epidemic proportions.* In 1999, an estimated 61% of U.S. adults were overweight, along with 13% of children and adolescents. Obesity among adults has doubled since 1980, while overweight among adolescents has tripled. *The full text of The Surgeon Generals Call to Action to Prevent and Decrease Overweight and Obesity is available at http://www.surgeongeneral.gov/topics/obesity.Risks to Psychological & Social Well-BeingObesity Affects All Areas of Life35 to 39.940 or more30 to 34.9

18.5 to 24.925 to 29.9BMI*:Severely ObeseMorbidly ObeseNormal WeightOverweightObeseWith co-morbidityWith co-morbidity Lap-Band only**Lower BMI (30-34.9) may not be covered by insurance at this time.Who is a Candidate for Surgery?9Pulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndromeNonalcoholic fatty liver diseasesteatosissteatohepatitiscirrhosisCoronary heart disease Diabetes Dyslipidemia HypertensionGynecologic abnormalitiesabnormal mensesinfertilitypolycystic ovarian syndromeOsteoarthritisSkinGall bladder diseaseCancerbreast, uterus, cervixcolon, esophagus, pancreaskidney, prostatePhlebitisvenous stasisGoutPhysiological Impact of Obesity

Idiopathic intracranial hypertensionStrokeCataractsSevere pancreatitisNAASO Obesity Online1010Medical complication of obesityThis is why we treat obesity. No matter what the BMI is, is there is hardly a body systemthat is not affected by excess body fat. There was a study published early in this year inthe New England Journal of Medicine by Calle, from the American Cancer Societyshowing that obesity is second only to smoking in terms of a behavioral determinant ofcancer. That's pretty powerful data. These you all know well in terms of risks: sleepapnea, stroke, CHD, and particularly diabetes is a big player. These are the things, at leastin primary care, that gets people's attention. One of the take home messages I hope youget from my talk is that a lot of these things get better with a little bit of weight loss.We're not saying obesity is a cure for cancer. But for diabetes, dyslipidemia,hypertension, the data are very compelling that little bits of weight loss make a bigdifference.

Major Obesity Related DiseasesNIDDM ( Type 2 DM)HypertensionGERDCardiovascular Disease and HypercholesterolemiaPulmonary (Sleep Apnea)Degenerative Joint DiseaseUrinary Stress IncontinenceWeight Loss StrategiesDietary InterventionPhysical Activity AloneBehaviorModificationDrug TreatmentsWeight Loss Surgery and lifestyle changesDoes not always lead to weight lossRequires ongoing professional contact, and failure rate can be highWeight is typically regained when treatment endsThe most effective approach for long-term weight loss Weight Watchers, Jenny Craig, NutriSystem etc, does not work for 99% of Obese individuals long termWithout weight loss surgery 99.5% of Obese patients will regain their weight within 2 years12Most Common Procedures

AdjustableGastric BandRoux-En-Y Gastric Bypass

Sleeve GastrectomyOur Patient Selection CriteriaBody Mass Index (BMI) 40.0 or BMI of 35.0 39.9 with co-morbidities such as Type 2 diabetes, hypertension, sleep apnea, etc.

Failure of non-surgical control (diet, exercise, behavior modification)

Psychological stability

Patient Physician relationship

Weight loss prior to surgery

Free from alcohol, drugs, or smokingPreoperative Work-Up Standard pre-op labs and work-upNutrition assessment and educationUpper Endoscopy/UGI seriesUltrasound exam of the Gall BladderPsychological EvaluationPulmonary & Cardiac consults and clearanceMedical clearance from PCP Major Co-morbidities That Have Been Improved or Resolved by Bariatric SurgeryType 2 DiabetesHypertensionObstructive sleep ApneaObesity HypoventilationGERDNALD, NASHPseudotumor cerebriDepressionDyslipidemiaCoronary Artery DiseaseCardiac DysfunctionVenous Stasis DiseasePolycystic Ovarian SyndromeInfertilityCancersDegenerative Joint DiseaseQuality of Life1616Major obesity-related comorbidities that have been improved by bariatric surgery

Numerous comorbidities as listed above have been shown to resolve or markedly improve.

Reference:Sugerman HJ, Kral JG. Evidence-based medicine reports on obesity surgery: a critique. Int J Obes (Lond). 2005;29:735-45.Nonsurgical treatments are found ineffective for most morbidly obese patients

The American Academy for Clinical Endocrinologists, The Obesity Society, and the American Society for Metabolic & Bariatric Surgery have recommended that morbidly obese patients (BMI >40 or BMI >35 with a obesity related co morbidity) should be offered weight-loss surgery

American Diabetes Association: Weight-loss surgery should be considered for adults with BMI of 35 and type 2 diabetes, especially if the diabetes is difficult to control with lifestyle and pharmacologic therapyWeight-Loss Surgery is Now Recommended by the Top Medical SocietiesBariatric Surgery versus Intensive Medical Therapy for Diabetes:3-Year OutcomesCONCLUSION: Among obese patients with uncontrolled type 2 diabetes, 3 years of intensive medical therapy plus bariatric surgery resulted in glycemic control in significantly more patients than did medical therapy alone. Analyses of secondary end points, including body weight, use of glucose-lowering medications, and quality of life, also showed favorable results at 3 years in the surgical groups, as compared with the group receiving medical therapy alone.RESULTS: The mean (SD) age of the patients at baseline was 488 years, 68% were women, the mean baseline glycated hemoglobin level was 9.31.5%, and the mean baseline body-mass index (the weight in kilograms divided by the square of the height in meters) was 36.03.5. A total of 91% of the patients completed 36 months of follow-up. At 3 years, the criterion for the primary end point was met by 5% of the patients in the medical-therapy group, as compared with 38% of those in the gastric-bypass group (P