1. Carle Bariatrics Weight Loss Surgery Seminar

2. Major public health problem worldwide Affects 30% of industrialized world American statistics: – 60% of adults are overweight – 30% of children are overweight – 15 million are morbidly obese – 6% of health care expenditures – 400 000 deaths annually Obesity Overview

3. BMI = weight in KG height in meters 2 The World Health Organization has used the BMI to categorize obesity and to predict risk of comorbidities. Body Mass Index (BMI)

4. Classification of Obesity ClassificationBMIRisk of Comorbidities Underweight<18.5Low Normal18.5 - 24.9Average Overweight25.0 - 29.9Increased Obese Class I30.0 - 34.9Moderate Obese Class II35.0 - 39.9Severe Obese Class III Super Obese 40.0 – 49.9 >/= 50.0 Very severe

5. Co-morbid Medical Conditions – Diabetes – Hypertension – Dyslipidemia – Cardiac disease – Obstructive Sleep Apnea – Stroke – Fatty liver disease – Depression – Stress Incontinence – Menstrual irregularity – GE reflux – Pseudotumor cerebri – Osteoarthritis – Restrictive lung disease – Asthma – Increased cancer risk – Gallstones – Infertility – Thromboembolism – Venous stasis disease

6. Exponential Mortality Risk

7. Options for Weight Loss Diet/Exercise/Behavior Modification Medications Surgery – Gastric bypass – Sleeve gastrectomy – Laparoscopic gastric banding

8. Roux-en-Y Gastric Bypass 60-80% average excess body weight lost 3 day hospital stay (laparoscopic) 2-3 week return to work Highest risk, most consistent weight loss ASBS

9. Bile duct Pancreas Descending duodenum Food absorbed Mouth Proximal gastric pouch To rest of bowel Jejunum

10. Gastric Bypass Results Resolution of medical conditions Diabetes 90% Dyslipidemia 70% Hypertension 65% Sleep apnea 90% Reflux 98%

11. Laparoscopic Adjustable Gastric Banding Around 50% EBWL at 3 years Outpatient Return to work in 1 week Evaluated every 6-8 weeks for gradual tightening if necessary Lowest risk, least consistent weight loss

12. Laparoscopic Adjustable Gastric Banding

13. Lap Banding Adjustability Filled Band Unfilled Band

14. Lap Banding Resolution of medical problems Diabetes 50% Dyslipidemia 50% Hypertension 60% Sleep Apnea 90%

15. Sleeve Gastrectomy Around 60% EBWL 2 days hospital stay Return to work approx. 2- 3 weeks Intermediate risk, intermediate weight loss consistency

16. Sleeve Gastrectomy Outcomes Diabetes 80% Dyslipidemia 60% Hypertension 60% Sleep apnea 95%

17. Dietary Lifestyle After Surgery No liquids with meals Unlimited non-calorie liquids between meals Liquids only for several weeks post-op Comfortably eat a small, selected solid meal Must chew thoroughly, eat slowly Must choose high protein foods Long term commitment to exercise

18. Risks- All Procedures Death Pulmonary embolus Bleeding Gastrointestinal injury or perforation Pneumonia Wound infections Hernias

19. Risks- Gastric Bypass Leak 1-4% Bowel obstruction 5% Stricture 2% Ulcer 9% Splenic injury <1%

20. Risks-Laparoscopic Banding Stomach slippage 2% Food obstruction 10% Erosion of the band 0.6% Stoma swelling 2% Port/mechanical complications 5% Source: Favretti, 500 patients.

21. Risks- Sleeve Gastrectomy Leaks 1-2% Strictures 1%

22. Side Effects Nausea/vomiting Difficulty swallowing Gallstones Pregnancy Vitamin/mineral deficiency Protein malnutrition Excess skin Emotional distress

23. Which operation is best? Issues to consider BMI Overall health Procedure risks-short and long term Procedure outcomes Follow up schedule

24. Surgery is not an “easy way out” Lifestyle changes Emotional Issues Discomfort Risks Side effects

25. Who Is a Surgical Candidate? Meets NIH criteria Acceptable operative risk Understands surgery, risks and aftercare Dedicated to life-style change and follow-up

26. Who is NOT a Candidate? Patients with: – Some previous gastric surgeries – Uncontrolled psychological conditions – Active drug or alcohol abuse – Active smoking habits – History of medical noncompliance

27. Thank You