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 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

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

Int J Obesity 2005;29:334-339

Relative risk of health problems associated with obesity

Greatly increased (relative risk >>3)
Diabetes Gall bladder disease Hypertension Dyslipidemia

Moderately increased (relative risk 2-3)

Coronary heart disease Osteoarthritis (knees) Hyperuricemia and gout

Slightly increased (relative risk 1-2)

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

Insulin resistance
Breathlessness Sleep apnea

The Effect of Obesity on the Development of Health Risks

Age-adjusted relative risk of type 2 diabetes
50 40 30 50 20
12

Men1

100
42

Women2

93

75

40

10
2.2

25
8.1

0 <23

1.0

25

31

35

1.0

<22

25

31

35

BMI
1Chan

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

Causes of Obesity

Genetics

Behavior

Environment

The Environment: Portion Size

Non-operative Treatment of Obesity 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:

The Basics

What is Body Mass Index ( BMI ) ?

Surgical Treatment of Obesity:

Indications and Surgical Options

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

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 )

The Gastrointestinal System

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: Complications

Stomal narrowing with persistent vomiting Staple line leak or disruption Band erosion Wound infection or hernia Death 0.1% 43 %

Overall re-operation rate

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

Adjustable Silastic Gastric Banding : Complications

Splenic injury Esophageal injury Wound infection Persistent vomiting Acid reflux Band slippage Reservoir leak/deflation Band erosion

Re-operation 5 -20 %

Death

0.3 %

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

Duodenal Switch (BPD-DS) : Complications

Protein malnutrition Anemia Marginal ulcer Peripheral neuropathy Night Blindness Osteoporosis Renal stones Nausea First 6 mo Diarrhea Vitamin deficiencies: A, D, E, K, B12 Incisional hernia 15% <5% <3% 1.3 % 3% 14 % 65 % 62 % 10 %

Death

1.1 %

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

Gastric Bypass: Complications

Early:

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

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

Weight Maintenance after Bariatric Surgery

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

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.