1. Gastric Surgery for Severe Obesity David L. Gee, PhD Professor of Food Science and Nutrition Central Washington University

2. Carnie Wilson Gastroplasty, Aug 1999 weight loss ~ 150 lbs 2003 poses for Playboy 2005 delivers baby daughter (gained 70 pounds, lost ~ 40 pounds)

4. Charlie Weiss New England Patriots Offensive Coordinator Gastric Bypass Surgery Wt loss = 85 pounds Surgical complications: internal bleeding sepsis nerve damage to lower limbs

5. Bariatric Surgery Trends JAMA, 289(14): 1761 ‑ 1762, April 9, 2003 US Bariatric surgeries performed per year –2001: 47,000 –2002: 63,000 –2003 (projected): 98,000

6. Source: Health Affairs, July/Aug 2005

7. Criteria for Patient Selection Unlikely to lose weight with non- surgical procedure BMI > 40 Have high risk of obesity related problems not pregnant or planning pregnancy during weight loss Informed of risks, lifestyle effects

8. Surgical Mechanisms for Weight Loss Decrease food intake Decrease digestion and absorption of nutrients

9. Surgery to Decrease Food Intake Gastroplasty –Gastric banding –Vertical banded gastroplasty

10. Gastric Banding

11. Vertical Banded Gastroplasty

12. Weight Loss Outcomes of Gastroplasty 80% lose weight 30% achieve normal weight some regain some of lost weight improves obesity related conditions success depends on motivation and behaviors

13. Risks of Gastroplasty vomiting erosion of band, breakdown of staple line 10-20% require follow-up operations 1/3 develop gallstones

14. Surgery to Reduce Food Intake and Nutrient Absorption Gastric Bypass Surgery –Roux-en-Y Gastric Bypass

15. Roux-en-Y Gastric Bypass

16. Outcomes of Gastric Bypass Surgery produces more weight loss than gastroplasty generally lose 2/3rds of excess weight within 2 years

17. Risks of Gastric Bypass Surgery like gastroplasty chronic diarrhea nutritional deficiencies –vitamin B-12 –iron –calcium

18. Gastric Bypass Surgery Complications: 14-Year Followup Surgical Complications Number of Patients % of Patients Vitamin B 12 deficiency23939.9 Readmit for various reasons22938.2 Incisional hernia14323.9 Depression14223.7 Staple line failure 9015.0 Gastritis 7913.2 Cholecystitis 6811.4 Anastomotic problems 59 9.8 Dehydration, malnutrition 35 5.8 Dilated pouch 19 3.2 Data derived from source (Pories et al.) and modified based on personal communication. Source: Pories WJ, Swanson MS, MacDonald KG Jr, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222:339-350; discussion 350-352.

19. What are the dietary guidelines following bariatric surgery? JADA 104: 487-488 (2004) General guidelines –Eat for >20 min to allow for satiety –Well chewed, small volumes –Liquids ingested well before or after meals –Proteins eaten before fats and carbs Nutritional Considerations –Gastric banding: iron & B-12 deficiencies –Gastric bypass: iron, calcium, folate, B-12 deficiencies, dumping syndrome –Fat malabsorption and lactose intolerance –Dehydration –Vitamin/mineral supplements recommended

20. Early Mortality Among Medicare Beneficiaries Undergoing Bariatric Surgical Procedures Flum, D. et al. JAMA. 2005;294:1903-1908 Subjects: –All fee-for-service Medicare beneficiaries, 1997-2002 16,155 patients Mean age = 47.7 yrs (SD=11.3) 75.8% female Outcome Measures: –30 day, 90 day, 1 year mortality

21. Findings: 1. Overall mortality rate at 1 year = 4.6% 2. Mortality rate in men >> women (7.5% vs. 3.7%) 3. Mortality rate in >65 yr >> <65 yr (11.1% vs 3.9%)

22. Early Mortality Among Medicare Beneficiaries Undergoing Bariatric Surgical Procedures Flum, D. et al. JAMA. 2005;294:1903-1908 Conclusions Among Medicare beneficiaries, the risk of early death after bariatric surgery is considerably higher than previously suggested Risk of early death associated with advancing age, male sex, and lower surgeon volume of bariatric procedures Patients aged 65 years or older had a substantially higher risk of death within the early postoperative period than younger patients.

23. Conclusions Bariatric surgery generally results in – substantial weight loss –Marked improvement in health risks –Improved quality of life Bariatric surgery is not risk free –Mortality rate ~5% –Complications and further surgeries –High costs Permanent changes in eating/lifestyle –Risks of malnutrition