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

2. 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

3. Why do people choose surgery for their obesity?

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

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

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

7. 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

8. 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)

9. 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.

10. 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

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

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

13. 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)
normal
overweight
obese
> severe obesity
> super obesity

14. 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

15. 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

16. 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

17. 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)

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

19. 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

20. The Surgical Options for Weight Loss Surgery

21. Adjustable Gastric Band

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

23. Facts on the Adjustable Gastric Band
Operation time: 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

24. 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

25. 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

26. 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 months
50% EWL is still maintained at a 14yr follow-up
ASBS

27. 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

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

29. 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

30. 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

31. 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

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

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

34. 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

35. 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

36. Mortality Rates Adjustable Gastric Band 0.1% Gastric Bypass 0.5%
BPD/DS %
Vertical Sleeve gastrectomy %

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

38. Post Operative Phases
Recovery
Exhaustion
Adjustment
Maintenance

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

40. 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 And others.

41. 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

42. 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

43. What to do with the excess skin?
Plastic surgery consultation is approximately at 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

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