Surgical treatment for morbid obesity

Ram Elazary, MDGeneral Surgery Department

Hadassah Medical CenterCampus Ein Kerem

General Surgery Department

Prevalence of obesity in Israel

• 60% of total population• Morbid obesity: 9% of women and 4% of men

Definitions

Body mass index (BMI) = Kg/Height2

• BMI > 40

• 35 < BMI < 39.9 and co-morbidity

Co-morbidity related to BMI

PE

RC

EN

T A

FF

LIC

TE

D

60%

4%

18%

7%

24%

15%

32%

26%

44%

23%

10%

14%

28%

16%

41%

51%

0%

10%

20%

30%

40%

50%

Diabetes Asthma Arthritis High BloodPressure

BMI < 25 25-30 30-40 BMI > 40

0

2

4

6

8

10

12

14

25 27 29 31 33 35 37 39 41 43 ≥45

BMI

YE

AR

S O

F L

IFE

LO

ST

20 30 40 50

Age

Morbid obesity and loss of years of life

Bariatric surgery (US)

Bariatric surgery (Hadassah)

Co-morbidity of Morbid Obesity• Hypertension• Type 2 Diabetes Mellitus• Hypercholesterolemia• Orthopedic disease (Osteoarthritis, Back pain)• Obstructive sleep apnea• Venous insufficiency• Fatty liver disease

Surgery at Hadassah

• Sleeve gastrectomy• Gastric bypass• Revision, conversion

and reverse surgery

Laparoscopic Surgery

Advantages of laparoscopy

Less pain, early mobilization, better cosmesis

Minutes post surgery…

Decision making (risk stratification)

Risk Benefit

Success rateWeight loss vs cure of co-morbidity

Side effects (vomiting, reflux)

•Gastric band <80%•Sleeve gastrectomy 90%•Gastric Bypass 90-95%

Sleeve Gastrectomy

• Low volume stomach• Reduces hunger• No malabsorption• Loss of 50-70% of

excess body weight• Relatively new

procedure• Morbidity 1-2%

Roux en Y Gastric Bypass

• Gold standard • Low volume pouch• Reduces hunger• No malabsorption• Loss of 50-70% of

excess body weight• More than 40 years of

experience• Morbidity 1-2%

Post operative course

• Admission for 3 days

• No urinary catheter or Naso-gatric tube

• Resuming fluids the day after surgery

• Discharged with liquid diet for 10 days

Candidates for surgery

• There is no age criteria• Failed previous weight loss diets• Strict BMI criteria• Compliance

Decision of which operation

• Patient preferences • Co-morbidity• Laboratory results• Imaging studies• Overall risk

Pre-operative studies

• Swallowing contrast study or endoscopy• Blood tests• Abdominal sonography• Chest X ray, EKG• Psychiatric evaluation• Dietician evaluation• Other studies tailored specifically to the

patient’s medical condition

Weight loss “slope” after surgery

• Different between patients• Relatively excessive during the first 3

months• Continues till 12-18 months post surgery

• Excess skin – plastic surgery

Follow up after surgery

• Multidisciplinary approach:Surgeon / Dietician / Psychologist

• 3 / 6 / 12 months regular follow up

• Designing a web/phone based follow up (emails, phone, Skype etc.)

• 39 yo M• 112 Kg, 173 cm BMI 37.4• Morbid obesity related co-morbidity:

• Hypertension• Type 2 Diabetes Mellitus• Hypertriglyceridemia• Fatty liver disease

Case presentation – gastric bypass

Aspirin 100mg q24hTritace 2.5mg q24hMetformin 850mg q12hNovorapid 10units q8hLantus 18units q24hLipitor 80mg q24h

Medications – prior to surgery

Fasting Glucose 134 mg/dlALT 71 unitsHbA1c 8 mg/dlLDL 160 mg/dlTG 178 mg/dl

Blood test result – prior to surgery

• Weight 112 84 Kg• BMI 37 28 • Morbid obesity related co-morbidity:

Hypertension curedType 2 Diabetes Mellitus curedHypertriglyceridemia improvedFatty liver disease cured

One year post surgery

Weight post surgery

HbA1c

HbA1c post surgery

Months post surgery

ALT post surgery

Aspirin 100mg q24hTritace 2.5mg Metformin 850mg Novorapid 10units Lantus 18units

Lipitor 40mg q24h

Medications one year post surgery

Case presentation – sleeve gastrectomy

• 36 yo M• 150 Kg, 184 cm• BMI 44.8

• Fasting GLU 104• HbA1c 6.6• Triglycerides 165

9 months post surgery – sleeve gastrectomy

• Weight 150 95 Kg• 150 Kg 184 cm• BMI 44.8

• Fasting GLU 104• HbA1c 6.6• Triglycerids 165