1. 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

2. Prevalence of obesity in Israel
60% of total population
Morbid obesity: 9% of women and 4% of men

3. Definitions Body mass index (BMI) = Kg/Height2 BMI > 40
35 < BMI < 39.9 and co-morbidity

5. 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

6. Morbid obesity and loss of years of life

7. Bariatric surgery (US)

8. Bariatric surgery (Hadassah)

9. Co-morbidity of Morbid Obesity
Hypertension
Type 2 Diabetes Mellitus
Hypercholesterolemia
Orthopedic disease (Osteoarthritis, Back pain)
Obstructive sleep apnea
Venous insufficiency
Fatty liver disease

10. Surgery at Hadassah Sleeve gastrectomy Gastric bypass
Revision, conversion and reverse surgery

11. Laparoscopic Surgery

13. Advantages of laparoscopy
Less pain, early mobilization, better cosmesis

14. Minutes post surgery…

15. Decision making (risk stratification)
Benefit

16. Success rate Weight loss vs cure of co-morbidity
Side effects (vomiting, reflux)
Gastric band <80%
Sleeve gastrectomy 90%
Gastric Bypass 90-95%

17. Sleeve Gastrectomy Low volume stomach Reduces hunger No malabsorption
Loss of 50-70% of excess body weight
Relatively new procedure
Morbidity 1-2%

18. 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%

19. 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

20. Candidates for surgery
There is no age criteria
Failed previous weight loss diets
Strict BMI criteria
Compliance

21. Decision of which operation
Patient preferences
Co-morbidity
Laboratory results
Imaging studies
Overall risk

22. 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

23. Weight loss “slope” after surgery
Different between patients
Relatively excessive during the first 3 months
Continues till months post surgery
Excess skin – plastic surgery

24. Follow up after surgery
Multidisciplinary approach:
Surgeon / Dietician / Psychologist
3 / 6 / 12 months regular follow up
Designing a web/phone based follow up ( s, phone, Skype etc.)

25. 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

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

27. 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

28. 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

29. Weight post surgery

30. HbA1c post surgery
HbA1c

31. ALT post surgery
Months post surgery

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

33. Case presentation – sleeve gastrectomy
36 yo M
150 Kg, 184 cm
BMI
Fasting GLU 104
HbA1c
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

34. 9 months post surgery – sleeve gastrectomy
Weight 150 95 Kg
150 Kg cm
BMI
Fasting GLU 104
HbA1c
Triglycerids
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

35. 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