1. Fight obesity with effective and guaranteed tools t Haitham Al-Khayat, MD Consultant general and bariatric surgeon New Dar Al-Shifa hospital

2. Obesity Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems. Obesity is the 2 nd most common cause of death from a modifiable behavioral risk factor

3. Obesity related comorbidity Type II DM Hypertension Cardiac diseases Strokes Hyperlipidemia Respiratory diseases Degenerative osteorthritis Depression GERD Nephrotic syndrome Infertility Venous stasis ulcers Pseudotumor cerebri

4. Causes of obesity Genetics Behavior Environment

5. Environment portion size

6. Nonoperative treatment how does it add up?? Diet Exercise Behavioral therapy + Drug therapy. ??????

7. Why Surgery? Diet and exercise are not effective long term in the morbidly obese Surgery is an accepted and effective approach Surgical risk is acceptable vs. risk of long-term obesity

8. Surgery is effective

9. Pre-operative Medications Post-operative Medications Surgery is effective

10. Surgical treatment of obesity Indication of surgical options

11. Patient selection BMI ≥ 40 kg/m 2 OR BMI 35 - 40 kg/m 2 with significant comorbidity High risk health problems Ineffective documented dietary attempt

12. The Gastrointestinal system

13. Operative approaches Restrictive Procedures Adjustable silastic gastric banding (ASGB) Sleeve gastrectomy Gastric plication Combined Procedures Roux-en-Y gastric bypass ( GBP )

14. Lap Band Restrictive Reversible 40-55% EBW loss

15. Lap sleeve gastrectomy Restrictive Very popular in Kuwait 60-70% EBW loss Relatively new with unknown long term consequences

16. Roux En Y gastric bypass First done in 1967 60-70% EBW 14 year followup

17. Results of bariatric surgery Weight loss Resolution or improvement in comorbidity Increased longevity Improved QOL  Health  Social  Personal  Work

18. General Complications of Weight-Loss Surgery Post-operative depression Food issues Changes in relationships Hair loss Usually temporary Cause: protein, vitamin A, mineral Excess skin

19. Weight loss program team Surgeon Nurse practitioner Dietitian Anesthesiologist Nurses Cardiologist SAFETY and RESULTS

20. Final words * Surgery is only a tool * Patients must commit to lifelong changes in diet and behavior * Think seriously about options * We are here to help

21. Defining the Problem

22. The Problem Prevalence of obesity in U.S. increased from 12% to 21% between 1991 and 2001 = 15 million people Obesity is the 2 nd most common cause of death from a modifiable behavioral risk factor 111,909 excess deaths annually Mokdad AH et al. JAMA. 2003;289:76-79 Flegal KM et al. JAMA 2005;293:1861-1919

23. Excess U.S. Medical Costs Related to Abnormal Body Weight Int J Obesity 2005;29:334-339

24. Diabetes Gall bladder disease Hypertension Dyslipidemia Insulin resistance Breathlessness Sleep apnea Greatly increased (relative risk >>3) Coronary heart disease Osteoarthritis (knees) Hyperuricemia and gout Cancer (breast cancer in postmenopausal women, endometrial cancer, colon cancer) Reproductive hormone abnormalities Polycystic ovary syndrome Impaired fertility Low back pain Increased anesthetic risk Fetal defects arising from maternal obesity Moderately increased (relative risk 2-3) Slightly increased (relative risk 1-2) Relative risk of health problems associated with obesity

25. 1 Chan JM et al. Diabetes Care 1994;17:961-969; 2 Colditz G et al. Ann Intern Med 1995;122:481-486. Age-adjusted relative risk of type 2 diabetes The Effect of Obesity on the Development of Health Risks 0 10 20 30 40 50 1.0 2.2 12 42 0 25 50 75 100 1.0 8.1 40 93 <232531  35 <222531  35 Men 1 Women 2 BMI

26. Fed up with how her diet is going Charlene takes a more serious aim at her target weight

27. Weight Maintenance after Bariatric Surgery Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26

28. Conclusions Bariatric surgery is an effective means to achieve clinically significant, permanent weight loss with low rates of complications. Bariatric surgery results in significant improvement in health risks associated with obesity. Surgical weight loss increases life-span. Surgical therapy is cost-effective.