Obesity

An excess of body fat; body mass index (BMI) >30 kg/m2 Affects ~30% adults in U.S.; $70Billion annual health cost Co-morbidities (CAD, HTN, DM II) affect increasing mortality risk in proportion to BMI

Body Mass Index -kg/m2 [Wt(lb) x 703/Ht (inches)2 ]

Underweight Normal Overweight Obese Severe (morbidly) obese <18.5 18.5-24.9 25-29.9 >30 >40

Obesity rates, 1991 vs 2000

Obesity defined as BMI>30. Data were obtained by calculating BMI from phone questionnaire on height and weight on 185000 participants >age 18. CDC study ,JAMA 2001;286,1195-1200

A typical fast food meal

Big Mac: 570 kcal Large Fries: 540 kcal 32 0z (large) soda: 400 kcal TOTAL 1510 kcal A 70 kg moderately active man requires 2100 kcal/day (3 meals).

Obesity co-morbidities
Metabolic syndrome: DM II (15% of all obese), HTN (40% of obese), & hyperlipidemia related to visceral adiposity and insulin resisitance Sleep apnea Cardiopulmonary failure Osteoarthritis Gallstones GERD NASH Breast cancer

Increases in obesity and diabetes 1991-2000

Medical management of obesity

Energy equation: wt stability when calories in = calories out Can therefore reduce by decreasing intake and/or increasing expenditure of calories

Medical management of obesity

Diet (according to ideal body weight for height) + exercise (30 min/d moderate 5d/wk) + behavioral modification = 510% wt loss in 6 months, most rebound. Very low calorie dieting (<900 kcal/d: works for many, but 99% rebound Pharmacological adjuncts: limited success

The super-obese (BMI 50 + )

Incidence in U.S. population: 2.1% (4.4 million) Increased risk of osteoarthritis, cardiopulmonary failure, sleep apnea, all consequences of metabolic syndrome (DM, NASH, HTN, hyperlipid) Medical treatment essentially hopeless, though met syndrome improves with 5-10% weight loss

Rationale for surgery for morbid obesity

>2x mortality with BMI>40 kg/m2 due to cardiopulmonary failure, sleep apnea, diabetes Poor results of all medical therapies to date Relative safety and efficacy of gastric bypass compared to older jejuno-ileal bypass procedure

Criteria for obesity surgery

BMI > 40, or >35 with significant comorbidities Documented failure of medical management (diet + exercise; pharm) Psychological ability to undergo surgery Absence of other chronic disease

What are the surgical options?

Restrictive: Adjustable gastric banding & Vertical band gastroplasty Malabsorptive: Roux-en-Y gastric bypass & Biliopancreatic diversion

 Adjustable gastric band

Vertical band gastroplasty

 RGB

BPD

BPD-DS

Estimated Number of Bariatric Operations Performed in the United States, 1992-2003

Steinbrook, R. N Engl J Med 2004;350:1075-1079

Laparoscopic Versus Open Gastric Bypass: A Randomized Study of Outcomes, Quality of Life, and Costs
Nguyen, Ninh T. MD*; Goldman, Charles MD*; Rosenquist, C. John MD; Arango, Andres BS*; Cole, Carol J. BS*; Lee, Steven J. MS* and; Wolfe, Bruce M. MD, FACS

 155 patients w/ BMI 40-60 randomly assigned to lap (79) or open (76)

Nguyen et al. Laparoscopic Versus Open Gastric Bypass: A Randomized Study of Outcomes, Quality of Life, and Costs. Ann Surg. 234, 2004. 279-91.

OUTCOMES

Nguyen et al. Laparoscopic Versus Open Gastric Bypass: A Randomized Study of Outcomes, Quality of Life, and Costs. Ann Surg. 234, 2004. 279-91.

OUTCOMES

Nguyen et al. Laparoscopic Versus Open Gastric Bypass: A Randomized Study of Outcomes, Quality of Life, and Costs. Ann Surg. 234, 2004. 279-91.

OUTCOMES

Nguyen et al. Laparoscopic Versus Open Gastric Bypass: A Randomized Study of Outcomes, Quality of Life, and Costs. Ann Surg. 234, 2004. 279-91.

OUTCOMES

Nguyen et al. Laparoscopic Versus Open Gastric Bypass: A Randomized Study of Outcomes, Quality of Life, and Costs. Ann Surg. 234, 2004. 279-91.

OUTCOMES

Nguyen et al. Laparoscopic Versus Open Gastric Bypass: A Randomized Study of Outcomes, Quality of Life, and Costs. Ann Surg. 234, 2004. 279-91.

CONCLUSIONS
Laparoscopic GBP is safe alternative to open GBP
Lap pt s benefited from dec EBL, shorter LOS & more rapid improvement in QOL than open GBP