1. Obesity: Surgical Management Eric S. Hungness, M.D. Assistant Professor of Surgery Department of Surgery Northwestern University Feinberg School of Medicine Chicago, Illinois

2. Etiology of Obesity Familial Familial Genetic Genetic Gender (F>M) Gender (F>M) Social Social Psychologic (depression) Psychologic (depression) MULTIFACTORIAL

3. The Obesity Epidemic The weight gain cycle Eat too much Gain weight Can’tExercise GetDepressed

4. Normal Weight (BMI 18.5 to 24.9) Overweight (BMI 25 to 29.9) Obese (BMI 30 to 34.9) Severely Obese (BMI 35 to 39.9 ) Morbidly Obese (BMI > 40) Morbidly Obese (BMI > 40) Body Mass Index (BMI) Super Obese (BMI > 50) Super Obese (BMI > 50) BMI = weight (kg) / height (m) 2

5. Body Mass Index (BMI)

6. The Obesity Epidemic 66% of Americans >20 yrs are either overweight or obese (BMI > 25, ~ 133 million people) 66% of Americans >20 yrs are either overweight or obese (BMI > 25, ~ 133 million people) Increased from 45% in 1960 Increased from 45% in 1960 33% of Americans >20 yrs are obese (BMI > 30, ~ 66 million) 33% of Americans >20 yrs are obese (BMI > 30, ~ 66 million) 5% of Americans are morbidly obese (BMI > 40, ~ 10 million) 5% of Americans are morbidly obese (BMI > 40, ~ 10 million) 3.1% in men and 6.7% in women 3.1% in men and 6.7% in women Increasing by 1% per year Increasing by 1% per year Obesity is increasing in children (doubled in past 20 years) Obesity is increasing in children (doubled in past 20 years) 15% between the age of 6 and 19 15% between the age of 6 and 19 NHANES (2003-04) (n=4,431)

8. Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

9. Obesity Trends* Among U.S. Adults BRFSS, 1986 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

10. Obesity Trends* Among U.S. Adults BRFSS, 1987 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

11. Obesity Trends* Among U.S. Adults BRFSS, 1988 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

12. Obesity Trends* Among U.S. Adults BRFSS, 1989 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

13. Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

14. Obesity Trends* Among U.S. Adults BRFSS, 1991 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

15. Obesity Trends* Among U.S. Adults BRFSS, 1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

16. Obesity Trends* Among U.S. Adults BRFSS, 1993 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

17. Obesity Trends* Among U.S. Adults BRFSS, 1994 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

18. Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

19. Obesity Trends* Among U.S. Adults BRFSS, 1996 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

20. Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

21. Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

22. Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

23. Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

24. Obesity Trends* Among U.S. Adults BRFSS, 2001 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

25. (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) Obesity Trends* Among U.S. Adults BRFSS, 2002 No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

26. Obesity Trends* Among U.S. Adults BRFSS, 2003 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

27. Obesity Trends* Among U.S. Adults BRFSS, 2004 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

28. Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

29. Obesity Trends* Among U.S. Adults BRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

30. Why do we treat obesity?? Co-morbidities Co-morbidities Quality of life Quality of life Survival – Life Expectancy Survival – Life Expectancy

31. Co-morbidities Endocrine Endocrine Diabetes Diabetes Cardiovascular Cardiovascular Hypertension Hypertension Hyperlipidemia Hyperlipidemia Hypertriglyceridemia Hypertriglyceridemia Coronary and cerebral vascular disease Coronary and cerebral vascular disease Venous stasis Venous stasis Gynecology Infertility Menstrual irregularities Orthopedic DJD Arthralgia Low back pain Dermatology Fungal infection

32. Co-morbidities Pulmonary Pulmonary Sleep apnea Sleep apnea Asthma Asthma Hypoventilation Hypoventilation Pulmonary hypertension Pulmonary hypertension Gastrointestinal Gastrointestinal Cholelithiasis Cholelithiasis GERD GERD Fatty liver /dysfunction Fatty liver /dysfunction Socio-economic Discrimination Psychological Depression h/o abuse Cancer

33. 2 nd only to smoking as the leading cause of preventable death in the United States.† 2 nd only to smoking as the leading cause of preventable death in the United States.† > 110,000 deaths/year in the US are associated with obesity* > 110,000 deaths/year in the US are associated with obesity* Life Expectancy * Flegal KM et al. JAMA. 2005 Apr 20;293(15):1861-7. † CDC † CDC

34. Life Expectancy

35. Years of Life Lost (YLL) white male 10 years white male 10 years white female 7 years white female 7 years black male 11 years black male 11 years black female 3 years black female 3 years Life Expectancy Fontaine et al. JAMA 2003; 289:187-193

36. Medical Treatment Medications Medications Dietary Changes Dietary Changes Exercise Exercise Behavioral Therapy Behavioral Therapy Psychotherapy Psychotherapy Hypnosis Hypnosis Jaw-wiring Jaw-wiring UNSUCCESSFUL AT SIGNIFICANT OR SUSTAINED WEIGHT LOSS!

37. Trends In Surgery 1992 - 2003

38. Rationale for Surgery Long Term Outcome Data Long Term Outcome Data Sustained Weight Loss Sustained Weight Loss Improvement or Resolution of Co-morbidities Improvement or Resolution of Co-morbidities Improved long term survival Improved long term survival Minimally Invasive Surgery Minimally Invasive Surgery Public Awareness Public Awareness Obesity as a disease Obesity as a disease Celebrities Celebrities

39. Indications for Surgery BMI >40 kg/m 2, or >35 kg/m 2 with significant co- morbid illnesses BMI >40 kg/m 2, or >35 kg/m 2 with significant co- morbid illnesses Multiple failed weight loss attempts Multiple failed weight loss attempts Acceptable surgical risk Acceptable surgical risk Age 18-60 Age 18-60 Demonstrates commitment and understanding of weight loss following bariatric surgery Demonstrates commitment and understanding of weight loss following bariatric surgery

40. Preoperative Evaluation/Education Staff evaluation Staff evaluation Internist Internist Dietitian Dietitian Psychologist Psychologist Nurse Nurse Surgeon Surgeon Support group Support group Laboratory evaluationLaboratory evaluation – Blood – ECG, CXR – Stress Test – Sleep study – EGD – PFTs Consider an IVC filter for any patient with prior history of DVT/PE.

41. Surgical Treatment Restrictive Malabsorptive Horizontal gastroplasty Vertical banded gastroplasty (VBG) Roux-en-Y gastric bypass Adjustable gastric band Sleeve gastrectomy Jejunoilial bypass Biliopancreatic diversion (Scopinaro) Biliopancreatic diversion w/ duodenal switch

42. Surgical Treatment Restrictive Malabsorptive Horizontal gastroplasty Vertical banded gastroplasty (VBG) Roux-en-Y gastric bypass Adjustable gastric band Sleeve gastrectomy Jejunoilial bypass Biliopancreatic diversion (Scopinaro) Biliopancreatic diversion w/ duodenal switch

43. Horizontal Gastroplasty (HG) Gomez, Cesar. World Journal of Surgery, 1981

44. Mason E, Archives of Surgery, 1982 Polypropylene band Transgastric window Angle of His Vertical Banded Gastroplasty (VBG ) Gastric Pouch

45. Gastric Bypass + Roux-en-Y 75 – 150 cm ~ 40cm

46. Lap Adjustable Band

47. Sleeve gastrectomy

48. Jejunoileal Bypass Payne and Dewind, Archives of Surgery, 1973

49. Biliopancratic Diversion Marceau, et al. World Journal of Surgery, 1998 w/ duodenal switch w/o duodenal switch 75 – 100cm Common channel

50. Gastric Bypass vsLapBandvs Duodenal Switch

51. Safety Safety Complications Complications Overall Medical Condition Overall Medical Condition Age Age Effectiveness Effectiveness How Much Weight Do you need to lose How Much Weight Do you need to lose Expectations Expectations Long term results Long term results Vitamins Vitamins Anesthesia Type OR Time Hospital Stay Adjustable Maintenance Dumping Diabetes Multiple Prior Surgeries Hiatal Hernia/Reflux

52. Complications: General Anesthesia Blood Clot Blood Clot Heart Attack Heart Attack Pneumonia Pneumonia Stroke Stroke Death Death

53. Port displacement/tube break7%Port displacement/tube break7% Wound infection4%Wound infection4% Stoma obstruction2%Stoma obstruction2% Slippage2%Slippage2% Elective removal2%Elective removal2% Erosion<1%Erosion<1% Conversion to open<1%Conversion to open<1% Hemorrhage<1%Hemorrhage<1% Death<0.05%Death<0.05% Complications: Adjustable Gastric Banding

54. Complications: Roux-en-Y Gastric Bypass Complications: Roux-en-Y Gastric Bypass Leak 1-2% Leak 1-2% Bleeding Bleeding Infection Infection Dehydration Dehydration Stricture/ Ulcer 7% Stricture/ Ulcer 7% Conversion to open 1% Conversion to open 1% Death 0.2 - 0.5% Death 0.2 - 0.5%

55. Complications: BPD with Duodenal Switch Leak 1-2% Leak 1-2% Bleeding Bleeding Infection Infection Dehydration Dehydration Malnutrition5% Malnutrition5% Conversion to open 1% Conversion to open 1% Death 0.5 – 1.1% Death 0.5 – 1.1%

56. Weight Loss 5 yrs

57. Mortality%EBWL LB0.1%47.5 RYGB0.5%61.6 DS1.1%70.1 Buchwald et al. JAMA 2004; 292(14):1724-37

58. % Resolution of co-morbidity ↑ Chol/TGA Diabete s OSAHTN LB78.347.887.965.6 RYGB93.683.894.675.4 DS99.597.995.281.3 Buchwald et al. JAMA 2004; 292(14):1724-37

60. -Adams et al. NEJM 2007; 357:753-61

63. Summary Obesity – epidemic Obesity – epidemic Bariatric surgery Bariatric surgery Individual / tailored approach Individual / tailored approach Effective weight loss Effective weight loss Safe Safe Resolution of co-morbidities Resolution of co-morbidities Saves lives Saves lives