Surgical treatment for morbid obesity General Surgery Department Surgical treatment for morbid obesity Ram Elazary, MD General Surgery Department Hadassah Medical Center Campus Ein Kerem

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 60% 28% 16% 41% 51% 50% 44% 40% 32% PERCENT AFFLICTED 30% 26% 24% 23% 10% 14% 20% 18% 15% 10% 7% 4% 0% Diabetes Asthma Arthritis High Blood Pressure BMI < 25 25-30 30-40 BMI > 40

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) Benefit

Success rate Weight 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.)

Case presentation – gastric bypass 39 yo M 112 Kg, 173 cm  BMI 37.4 Morbid obesity related co-morbidity: Hypertension Type 2 Diabetes Mellitus Hypertriglyceridemia Fatty liver disease

Medications – prior to surgery Aspirin 100mg q24h Tritace 2.5mg q24h Metformin 850mg q12h Novorapid 10units q8h Lantus 18units q24h Lipitor 80mg q24h

Blood test result – prior to surgery Fasting Glucose 134 mg/dl ALT 71 units HbA1c 8 mg/dl LDL 160 mg/dl TG 178 mg/dl

One year post surgery Weight 112 84 Kg BMI 37  28 Morbid obesity related co-morbidity: Hypertension cured Type 2 Diabetes Mellitus cured Hypertriglyceridemia improved Fatty liver disease cured

Weight post surgery

HbA1c post surgery HbA1c

ALT post surgery Months post surgery

Medications one year post surgery Aspirin 100mg q24h Tritace 2.5mg Metformin 850mg Novorapid 10units Lantus 18units Lipitor 40mg q24h

Case presentation – sleeve gastrectomy 36 yo M 150 Kg, 184 cm BMI 44.8 Fasting GLU 104 HbA1c 6.6 Triglycerides 165 אציג בפניכם חולה שעבר ניתוח שרוול קיבה ,בקבלתו בן 36 משקל 150 גובה 184 BMI 44.8 רמות סוכר 104 בדם HbA1c 6.6

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 9 חודשים לאחר הניתוח משקל 95.7 ירידה של 53 ק''ג מאז הניתוח בדיקות סוכר 75 5.4 HbA1c TG 80 אני חושב שזה הצלחה ל LDL 133

If all our allegations are true, there are possibly measures that could be taken in order to prevent this deleterious local and remote effects, for example by neutralizing the xanthine oxidase by oxygen radicals scavengers, or preventing this drastic portal vein blood flow reduction