New Patient Orientation for Bariatric Surgery St. Luke’s and Roosevelt Hospitals The Center of Excellence for Bariatric Surgery and Metabolic Disease

Bariatric Team Dr. Julio Teixeira, FACS – Director Dr. James McGinty Dr. Ninan Koshy Dr. Scott Belsley Christine Haufmann, FNP Aisling McGinty, RD Tricia Mah, RD

Why do people choose surgery for their obesity?

Facts on Obesity Obesity is a disease Multiple facts are related to obesity: -genetics -psychology -environment

A New Understanding Of Obesity “Genetics loads the gun—the environment pulls the trigger.” George Bray, 1996

A New Understanding Of Obesity “Genetics loads the gun—the environment pulls the trigger.” George Bray, 1996

Facts on Obesity Major public health problem worldwide Affects 25% of industrialized world American statistics: 55% (34 Million) adults are overweight (Body Mass Index > 25) 25% of children are overweight 5-11 million people are morbidly obese 6% of health care expenditures ($238 Billion / year) 300,000 deaths annually JAMA

Facts on Treatment of Obesity Medical treatment is an ineffective method of sustaining weight loss for individuals with a BMI >35 Bariatric surgery is the only effective method of sustaining weight loss for individuals with a BMI >35 (1991 NIH consensus)

Obesity and Mortality Risk 2.5 2.0 Mortality Ratio 1.5 1.0 Very Low Very High Moderate Low Moderate High 20 25 30 35 40 Body Mass Index (BMI) Gray DS. Med Clin North Am. 1989;73(1):1–13.

Obesity Related Co-Morbid Medical Conditions Co-Morbidities: Diabetes Hypertension Hyperlipidemia Cardiac disease Respiratory disease - sleep apnea Arthritis Depression Stress Incontinence Menstrual irregularity % of Occurrences: - 14–20% - 25–55% - 35–53% - 10–15% - 10–20% - 20–25% - 70–90% - 50% Table 7 Literature Review

Cancer and Obesity Common cancers associated with obesity: Esophageal Breast Uterine Ovarian Prostate Colon Cervical Herra 1999 Carrol 1998 Everhart 1993

Candidates for Weight Loss Surgery 18-70 years of age BMI >40 BMI 35 - 39 with associated medical conditions such as: Diabetes Hypertension Hyperlipidemia Cardiac disease Respiratory disease Arthritis Depression

Body Mass Index (BMI) Measure of body fat based on height and weight Calculate the person’s weight in kilograms divided by height in meters squared (Kg/m2) 20-25 normal 25-30 overweight 30-40 obese >40 severe obesity >50 super obesity

When should you have weight loss surgery ? Weight loss surgery should always be the last resort You must have attempted weight loss through other methods such as nutritional & medical therapy Medical support and/or clearance from your primary care physician

The Process for Weight Loss Surgery Attend a new patient orientation 1st Consultation: - evaluated by the surgeon - bariatric workup: -Nutritional evaluation -Psychological evaluation -Letter from your PCP: 6 months Letter of support Medical clearance -Blood work -Abdominal Ultrasound -2 bariatric support groups

The Process for Weight Loss Surgery 2nd Consultation: -Review bariatric work-up test results -Decide on your bariatric procedure -Set a surgery date -Begin the insurance approval process

The Weight Loss Surgery Options Laparoscopic Adjustable Gastric Band Laparoscopic Roux-en-Y Gastric Bypass Laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS) Laparoscopic Vertical Sleeve Gastrectomy (VSG)

Benefits of Doing Surgery Laparoscopically Less pain Smaller incisions Shorter hospital stay Avoiding post operative complications such as: -wound infection -hernia

How does these operations work? Restriction: restricts the volume of food consumed during each meal Malabsorption: decreases your ability to absorb ingested foods Lifestyle changes: helps you develop new eating habits and encourages lifestyle changes

The Surgical Options for Weight Loss Surgery

Adjustable Gastric Band

Adjustable Gastric Band Restrictive procedure Minimally invasive Good results in Europe and Australia Bioenterics Lap Band™ FDA approved 6/01 50% EWL

Facts on the Adjustable Gastric Band Operation time: 30-45 minutes Hospital stay: overnight Return to normal activity: 5-7 days Diet advancement: liquid-> puree->regular diet Post-op appointments: - 1, 2 weeks - 1, 2, 3, 4, 5, 6, 8, 10, 12 months - then as instructed for rest of life Adjustments: office or radiology Reversible Not effective in pts: who have a BMI >50 sweet or binge eaters

Risks and Complications related to the Adjustable Gastric Band - Bleeding - Pulmonary embolism - Nausea/Vomiting - Intestinal Obstruction - Hernias - Kidney/Gallstones - Nutritional and/or vitamin deficiencies 10-15% re-operative rate Mechanical Failure - Slippage - Migration - Erosion Death

Expected Weight loss with the Adjustable Gastric Band 20-30 lbs in the 1st month 1-2 lbs per week Average weight loss in 1 year = 60lbs 50% EWL in 3 years

Roux-en-Y Gastric Bypass Restrictive and mal-absorptive procedure Most frequently performed bariatric procedure in the US First done in 1967 Laparoscopic since 1993 75% EWL in 18-24 months 50% EWL is still maintained at a 14yr follow-up ASBS

Facts on Roux-en-Y Gastric Bypass Operation time: 1-3 hours Hospital stay: 2.5 days Return to normal activity: 7-10 days Diet advancement: liquid-> puree-> regular diet Post-op appointments: -1 wk, 1 month, 3 month, 6 months, 12 months -every 6 months for the next 2-3 years -than as instructed for the rest of your life Not Reversible

Expected weight loss with the Roux-en-Y Gastric Bypass 20-30 lbs in the first month 75-100 lbs in the first 6 months 75% of EWL in 18-24 months

Risks and Complications related to Roux-en-Y Gastric Bypass - Pulmonary Embolism - Leaks 0.5-2% - Strictures 3% - Bleeding - Perforation/injury to surrounding organs - Intestinal obstructions 2-3% - Hernias - Ulcers - Kidney/Gallstones - Nausea and vomiting - Dumping Syndrome - Malnutrition - Vitamin deficiencies - New addictions - Death

Biliopancreatic Diversion with Duodenal Switch (BPD/DS) Restrictive and mal-absorptive procedure Lesser degree of nutrient absorption 75-80% EWL 77% EWL at 5yr follow-up Scopinaro 1998

Facts on BPD/DS Operation time: 3-4 hours Hospital stay: 3 days Return to normal activity: 2 weeks Diet advancement: liquid-> puree-> regular diet Post-op appointments: - 1 week, 1 month, 3 months, 6 months, 12 months - every 6 months to a year for the rest of your life Larger pouch allows for bigger meal Complication rate: 15-20% Higher nutritional risk Excellent weight loss: 75-80% EWL

Risks and Complications related to BPD/DS Higher morbidity and mortality rate Pulmonary Embolism Cirrhosis Diarrhea Leaks Bleeding Ulcers Hernias Malnutrition Vitamin Deficiencies Death

Vertical Sleeve Gastrectomy (VSG) Restrictive procedure First done in US in 2001 Removing 60-85% stomach 30-50% EWL

Facts on Vertical Sleeve Gastrectomy Operation time: 1-2 hours Hospital stay: 2.5 days Return to normal activities: 7 days Diet advancement: liquid->puree->regular diet Post-op appointments: -1 week, 1 month, 3 month, 6 moths, 12 months - every 6 months for the next 2 years - than as instructed for rest of life Not reversible No intestinal bypass, only stomach reduction

Risks and Complications related to Vertical Sleeve Gastrectomy Gastric leaks and fistulas Blood clots Pulmonary embolism Bleeding Splenectomy Acute respiratory distress Pneumonia Small bowel obstruction Death

Mortality Rates Adjustable Gastric Band 0.1% Gastric Bypass 0.5% BPD/DS 1.1% Vertical Sleeve gastrectomy 0.25%

Post operative reasons that may cause death Pulmonary embolism (blood clots) Myocardial infarction (heart attack) Sepsis (overwhelming infection)

Post Operative Phases Recovery Exhaustion Adjustment Maintenance

Supplements after weight loss surgery Gastric Band: MVI Protein Gastric Bypass: Calcium Citrate + D Iron BPD/DS: -MVI -Calcium Citrate + D -Iron -Protein VSG:

Medical Co-Morbidities Resolved Sources: Bariatric Surgery: A Summary of the Literature, 1990 to 2001 Wittgrove AC,Clark GW. Laparoscopic Gastric bypass roux-n-y-500 patients. Obes Surg 2000. And others.

Outcomes after Surgery New England Journal of Medicine Study: 56% decrease in mortality from heart disease 70% decrease in cancer related mortality 90% decrease in diabetes related mortality

Can you have children after weight loss surgery? YES! Gastric Band and VSG: - Wait 1 year after surgery - Will need to see a High Risk OBGYN Gastric Bypass and BPD/DS: - Wait 2 years after surgery

What to do with the excess skin? Plastic surgery consultation is approximately at 18-24 months Weight must be stable for at least 6 months and there must be no evidence of malnutrition It may not be necessary for all patients, several facts impact on this need It may not be covered by insurance

Facts that play a role in the decision-making process Age Medical History Surgical History BMI Psychological Profile Nutritional Profile Lifestyle Personal choice