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 Diabetes Gall bladder disease Hypertension Dyslipidemia Insulin resistance Breathlessness Sleep apnea Greatly increased (relative risk >>3) Coronary heart disease Osteoarthritis (knees) Hyperuricemia and gout 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 Moderately increased (relative risk 2-3) Slightly increased (relative risk 1-2)

The Effect of Obesity on the Development of Health Risks Age-adjusted relative risk of type 2 diabetes 10 20 30 40 50 1.0 2.2 12 42 25 75 100 8.1 93 <23 31 35 <22 Men1 Women2 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 Behavior Eating (e.g. emotional eating) exercise

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 Malabsorptive 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% Overall re-operation rate 43 %

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 Death 0.3 % Re-operation 5 -20 %

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 15% Anemia < 5 % Marginal ulcer < 3 % Peripheral neuropathy 1.3 % Night Blindness 3 % Osteoporosis 14 % Renal stones Nausea 65 % Diarrhea 62 % Vitamin deficiencies: A, D, E, K, B12 Incisional hernia 10 % Death 1.1 % First 6 mo

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