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  • 1. An Overview of Bariatric Surgery Kristin Dermody Angela Illing May 23, 2005

2. THE OBESITY EPIDEMIC 3. A Quick Background of Obesity

  • Derived from the Latin wordobesus to devour
  • Definition: having a very high amount of body fat in relation to lean body mass
  • Classifications using Body Mass Index (BMI)

4. BMI Categories

  • A BMI of : Classifies one as :
    • 40
      • BMI>35 + significant comorbidities
  • This therapy now referred to asBariatric Surgery

19. Types of Bariatric Surgery

  • Purely Restrictive
    • Gastric Balloons (not approved for use in USA)
    • Vertical-banded gastroplasty
    • Gastric adjustable banding (BWH)
  • Restrictive > Malabsorptive
    • Short-limb/Roux-en-Y gastric bypass (BWH)
    • Long-limb/distal Roux-en-Y gastric bypass
  • Malabsorptive > Restrictive
    • Biliopancreatic diversion (BPD)
    • BPD with duodenal switch
    • Very long limb Roux-en-Y gastric bypass
  • Purely Malabsorptive
    • Jejunoilieal bypass
    • Jejunocolonic bypass

20. A Brief History of Bariatric Surgery

  • First developed:
    • Pts with short bowel syndromeweight loss
  • First weight loss surgeries (ca. 1950s)
    • Intestinal bypass
      • Low-risk surgically BUT many patients developed serious and often fatal complications
    • Biliopancreatic diversion
      • Effective BUT with high risk and many complications

21. Evolution of the Roux-en-Y

  • Gastric partitioning(Roux-en-Y GBP)
    • Based on observations of weight loss in pts receiving subtotal gastric resections for other conditions
    • 1967 First performed
    • Continues to be studied and refined

22. Roux-en-Y

  • Open*
    • 2 hour procedure
    • 3 days in-house
    • 4 weeks Return to work
    • 60-70% EBW loss @ 2 yrs
    • 0.5-1.0% Risk of Death
    • Dumping Syndrome
  • Laparoscopic*
    • 2-4 hour procedure
    • 3 days in-house
    • 2-3 weeks Return to work
    • 60-70% EBW loss @ 2yrs
    • 0.5-1.0%Risk of Death
    • Dumping Syndrome

* Data based on averages. 23. Evolution of Gastric Banding

  • 1970s
    • Alternative to Roux-en-Y in Europe & Scandinavia
  • 1980s
    • Adjustable silicone band developed
  • 1990s
    • Laproscopic techniques for placement developed

24. Gastric Banding

  • Adjustable Lap Band
    • 1 hr procedure
    • 1 day in-house
    • 1 wk Return to work
    • 40-45% EBW loss @ 2 yrs
    • 1200mg/d) + D (10-20mg)
    • Folate (800-1000mcg) +B12
    • Iron (45-100mg elemental pre-menstrual)
    • Vitamin C (75-100mg)
    • Thiamin
  • Self-monitoring
  • Eating triggers/behaviors
  • Exercise

* Time line may vary among institutions 28. Post-Op Roux-En-Y Diet

  • Stage One (1 day)
    • Water and clear liquids
    • Non-caloric, non-carbonated, non-caffeinated liquids
    • Fluid goal: 28-32oz/d
  • Stage Two (14 days)
    • High protein, low sugar beverages
    • Fluid goal: 56oz
    • Protein goal: 60-70g/d
    • Chewable MVI + Ca

29. Post-Op Roux-En-Y Diet

  • Stage Three (4 weeks)
    • 5 2oz servings diced protein
    • Fluid goal: 56oz
    • Protein goal: 60-70g
    • Chewable MVI + Ca
  • Stage Four (4 months)
    • 3 meals, 2 snacks
    • 850kcal/d
    • Fluid goal: 56oz
    • Protein goal: 60-70g
    • Chewable MVI + Ca
  • Stage Five (ongoing)
    • Regular Meals
    • 1200-1500kcal
    • Fluid & Protein goals: same as above

30. Post-op Lap Band Diet

  • Stage One (1 day)
    • Water & Clear Liquids
    • Non-carbonated, non-caffeinated, non-caloric liquids
    • Fluid goal: 28-32oz/d
  • Stage Two (14 days)
    • 5-8oz servings of High Protein, low sugar Beverage
    • Fluid goal: 56oz
    • Protein goal: 50-60g
    • Chewable MVI + Ca

31. Post-op Lap Band Diet

  • Stage Three (14 days)
    • Pureed Foods, Semi solids
    • 2 small meals, 3 snacks
    • Fluid goal: 56oz
    • Protein goal: 50-60g
    • Chewable MVI + Ca
  • Stage Four (ongoing)
    • Regular meals: 3 meals,2 snacks (1000-1200)
    • Fluid goal: 56oz
    • Protein goal: 50-60g
    • Chewable MVI + Ca

32. Post-Surgical Nutrition& Exercise

  • RD seen frequently
    • 1m 3m 6m 1yr
  • Exercise
    • No heavy lifting or exercise 6-8wks post-op
    • Walking daily OK, encouraged
    • After cleared, strength training important to help skin stretch back
    • Helps with weight loss in the long run

33. When Surgery and Follow-Up Go Well 34. Efficacy of Bariatric Surgery for Weight Loss

  • Mean percentage excess weight loss:
    • 61.2% - All Patients
    • 47.5% - Gastric Banding
    • 61.6% - Gastric Bypass
    • 68.2% - Gastroplasty
    • 70.1% - BPD or duodenal switch
  • *Buchwald H, et al.Bariatric Surgery: A Systematic Review and Meta-analysis.JAMA, 14:1724-37, 2004

35.

  • Human body regulates nutrient intake over time by secreting hormones
  • Over 40 hormones play a role in regulation of feeding.

Roux-en-Y: Metabolic Sequelae 36. Roux-en-Y: Metabolic Sequelae

  • Two types :
    • Satiety hormones
      • Short-term
      • Help regulate meal size; daily intake
      • Secretion decreases meal size; reduces time to stop
      • Includes (among others) cholecystokinin, amylin, glucagon-like-peptide 1 (GLP-1), enterostatin, and bombesin
    • Adiposity hormones
      • Long-term
      • Related to energy stores
      • Secretion delays onset of beginning of meal
      • Includes insulin, leptin

37. Roux-en-Y: Metabolic Sequelae

  • Also of note isghrelin,the endogenous ligand for the growth hormone secretagogue receptor
  • Mostly secreted in the fundus of the stomach (part bypassed in RYGB)
  • Contrary to satiety hormones, ghrelin is orexigenic i.e., increases appetite (fasting increases levels)

38. Roux-en-Y: Metabolic Sequelae

  • Plasma ghrelin normally increases after non-surgical weight loss
    • This supports long-term w