1. Weight loss Surgery Kuldeep Singh, M.D., F.A.C.S., M.B.A.

2. Spectrum of the obesity Terms Used to Describe Various Levels of Body Fat 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 or more) This is where Surgical treatment is recommended

3. Health Risks Obese people have more risk for:Obese people have more risk for: Diabetes (type 2)Diabetes (type 2) Joint problems, backaches, disc Prolapse (e.g., arthritis)Joint problems, backaches, disc Prolapse (e.g., arthritis) High blood pressureHigh blood pressure Heart disease: coronary artery diseaseHeart disease: coronary artery disease Gallbladder problems, gallstonesGallbladder problems, gallstones Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity. Related Diseases and Health Problems

4. Health Risks (cont.) Related Diseases and Health Problems In addition, obese people have more risk for:In addition, obese people have more risk for: Certain types of cancer (breast, uterine, colon)Certain types of cancer (breast, uterine, colon) Digestive disorders (e.g. gastro-esophageal reflux disease, or GERD)Digestive disorders (e.g. gastro-esophageal reflux disease, or GERD) Breathing difficulties (e.g. sleep apnea, asthma).Breathing difficulties (e.g. sleep apnea, asthma). Psychological problems such as depression.Psychological problems such as depression. Problems with fertility and pregnancy.Problems with fertility and pregnancy. Stress Incontinence.Stress Incontinence. Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity.

5. Using Surgery to Treat Obesity Types of weight-loss surgeriesTypes of weight-loss surgeries Malabsorptive procedures shorten the digestive tract: BPD & BPD-DS Malabsorptive procedures shorten the digestive tract: BPD & BPD-DS Restrictive procedures reduce how much the stomach can hold: Lap Band & Sleeve Gastrectomy Restrictive procedures reduce how much the stomach can hold: Lap Band & Sleeve Gastrectomy Combined procedures shorten the digestive tract and reduce how much the stomach can hold: Gastric Bypass Combined procedures shorten the digestive tract and reduce how much the stomach can hold: Gastric Bypass

6. Using Surgery to Treat Obesity- Restrictive Techniques Sleeve Gastrectomy LAP-BAND System wo-pub2.med.cornell.edu/.../PublicA.woa/4/wa

7. Using Surgery to Treat Obesity- Malabsorptive Techniques Bilio-Pancreatic Diversion (BPD) We do not perform BPD, however we can refer you to surgeons in the area who perform this surgery

8. Mixed Techniques Roux-en-Y Gastric Bypass

9. Risk Benefit Ratio RISK Lap Band Sleeve Gastrectomy Roux –en-Y Gastric Bypass Bilio-Pancreatic Diversion HIGH LOW BENEFIT HIGH LOW Lap Band Sleeve Gastrectomy Roux –en-Y Gastric Bypass Bilio-Pancreatic Diversion Riskier the operation, the more effective it is

10. Expected Outcomes from the Surgery Improvement in health problems, including:Improvement in health problems, including: Diabetes (type 2): 80% cure possible.Diabetes (type 2): 80% cure possible. High blood pressure: 40% cureHigh blood pressure: 40% cure Asthma: marked improvementAsthma: marked improvement GERD (gastro-esophageal reflux disease):GERD (gastro-esophageal reflux disease): Sleep apnea: close to 100% cureSleep apnea: close to 100% cure Problems with fertility and pregnancyProblems with fertility and pregnancy Depression.Depression.

11. Laparoscopic Gastric Bypass Advantages Rapid initial weight loss Rapid initial weight loss Higher total average weight loss. Higher total average weight loss. Over 40 years of surgical experience in USA Over 40 years of surgical experience in USA Disadvantages Bigger operation and slower recovery. Bigger operation and slower recovery. Practically irreversible Practically irreversible Higher chances of nutritional problems such as Iron deficiency anemia and vitamin B 12 deficiency. Higher chances of nutritional problems such as Iron deficiency anemia and vitamin B 12 deficiency. Higher chances of ulcers at the junction of the stomach and the jejunum. Higher chances of ulcers at the junction of the stomach and the jejunum.

12. How the LAP-BAND System Works A silicone band is placed around the upper part of the stomachA silicone band is placed around the upper part of the stomach A small pouch is createdA small pouch is created Your stomach holds less foodYour stomach holds less food You feel full faster and longerYou feel full faster and longer

13. The LAP-BAND System Procedure Adjustable Band Adjustable Band Can be adjusted in office or operating room Can be adjusted in office or operating room No anesthesia needed. No anesthesia needed. On average 4-5 fills in first year On average 4-5 fills in first year 1 or 2 fills second year if needed. 1 or 2 fills second year if needed.

14. The LAP-BAND System Advantages Lowest mortality rateLowest mortality rate No stomach stapling or cutting, or intestinal re- routingNo stomach stapling or cutting, or intestinal re- routing AdjustableAdjustable Smaller operation, ReversibleSmaller operation, Reversible Lowest operative complication rateLowest operative complication rate Low malnutrition riskLow malnutrition risk Disadvantages Slower weight loss.Slower weight loss. Regular follow-up critical for optimal resultsRegular follow-up critical for optimal results Requires more commitment from the patient.Requires more commitment from the patient. Slippage or erosion and injury to the esophagus or stomach as possible complications.Slippage or erosion and injury to the esophagus or stomach as possible complications.

15. Arose from need to perform a safer yet effective operation in patients with high BMI (>50) and multiple co-morbidities.Arose from need to perform a safer yet effective operation in patients with high BMI (>50) and multiple co-morbidities. It is first stage of BPD-DS (Bilio- pancreatic diversion with Duodenal switch).It is first stage of BPD-DS (Bilio- pancreatic diversion with Duodenal switch). Designed as an separate staged procedure by Johnson in 1993.Designed as an separate staged procedure by Johnson in 1993. Sleeve Gastrectomy (SG)

16. Complications and outcomes are somewhere between Adjustable Laparoscopic gastric Banding and Gastric Bypass.Complications and outcomes are somewhere between Adjustable Laparoscopic gastric Banding and Gastric Bypass. Advantage of absence of Iron deficiency anemia, Marginal Ulcers, ability to perform upper endoscopic procedures and decrease the weight and co- morbidities to lead to any second staged procedure such as band, bypass or BPD.Advantage of absence of Iron deficiency anemia, Marginal Ulcers, ability to perform upper endoscopic procedures and decrease the weight and co- morbidities to lead to any second staged procedure such as band, bypass or BPD. Sleeve Gastrectomy

17. Who qualifies for the Bariatric Surgery? NIH criteriaNIH criteria 1.Weight: BMI more than 40 or 35 with two serious illnesses. 2.Free from untreated mental illnesses such as Bulimia and schizophrenia. 3.Documented evidence of weight loss attempts. In Maryland 6 months over the past two years. 4.Understanding by the patient that the surgery is only a tool to lose weight and need to have life style changes and exercise/ eating habits. Age: 18-60 years of ageAge: 18-60 years of age

18. Those who cannot walk.Those who cannot walk. Those who have severe heart disease.Those who have severe heart disease. Heart failure.Heart failure. Angina and coronary artery disease.Angina and coronary artery disease. With severe lung disease.With severe lung disease. In whom surgery is not possibleIn whom surgery is not possible Extreme obesity. Absolute weight matters to an extent. I will not operate patients over 500 lbs.Extreme obesity. Absolute weight matters to an extent. I will not operate patients over 500 lbs. Limited exercise tolerance. You should be able to walk with me to the parking lot (2 blocks) and back without severe shortness of breath.Limited exercise tolerance. You should be able to walk with me to the parking lot (2 blocks) and back without severe shortness of breath. Schizophrenia and Bulimia.Schizophrenia and Bulimia. Who does not qualifies for the Bariatric Surgery? These are our contraindication s

19. Bypass or Band?? How to choose? some guidelines Bypass Bypass Bigger operation, higher risk, more weight loss and rapid weight loss. Bigger operation, higher risk, more weight loss and rapid weight loss. More nutritional problems: anemia and ulcers. More nutritional problems: anemia and ulcers. My preference: severe obesity with lot of illnesses. My preference: severe obesity with lot of illnesses. Lap Band Lap Band Smaller and safer surgery, quick recovery. Smaller and safer surgery, quick recovery. Less nutritional problems, less anemia or ulcers. Less nutritional problems, less anemia or ulcers. Unique problems such as Slippage and Erosions. Unique problems such as Slippage and Erosions. Reversible. Reversible. My preference: BMI small with not so many diseases, women. My preference: BMI small with not so many diseases, women. Sleeve Gastrectomy Sleeve Gastrectomy BMI>60. BMI>60. Android Obesity Android Obesity

20. The process for the surgery 1.Make sure you meet the criteria for the surgery. 2.Call your insurance company to check coverage. 3.Make sure that we participate with your insurance or be willing to pay more out of Pocket expense. 4.See the dietician and the psychologist. 5.Fill all the forms and organize your folder into weight loss attempts, cardiac consult, Sleep Study and History and physical note form your doctor (whatever applies). 6.Call the office and make appointment to see the Doctor. 7.If you have questions whether you will qualify- Call the office to clarify.

21. Centers of Excellence Awarded COE by most of the Insurers in Maryland (Blue cross, Atena, United Healthcare and Cigna).Awarded COE by most of the Insurers in Maryland (Blue cross, Atena, United Healthcare and Cigna). Awarded COE by SRC (Surgical review Committee in June 2006 for full three years.Awarded COE by SRC (Surgical review Committee in June 2006 for full three years.

22. Bariatric Volumes and Market Share in Maryland DRG 288 & ICD-9 Procedure code definition FY02FY03FY04FY05FY06 Total Cases Market Share HOSPITAL Svc Area Total Total Total Total TotalFY02FY03FY04FY05FY06 ST. AGNES 1324751351533111743682294696%13%20%20%24% BAYVIEW6532214840281363063930415%14%18%17%15% GBMC000003118158331880.0%0.0%2.0%8.9%9.8% SINAI128314762160561885118423.9%7.6%3.9%10.6%9.6% HOLY CROSS 0338160062210231499.5%16.0%4.0%5.7%7.8% UMMS414727922422281304.0%2.7%1.4%1.2%6.8% SHADY GROVE 00062107214511050.0%0.6%7.0%8.2%5.5% PENINSULA REGIONAL 0025409819601020.0%5.4%6.4%5.4%5.3% WASHINGTON ADVENTIST 00010412721170910.0%1.0%8.3%6.6%4.7% HARFORD MEMORIAL 0000003601580.0%0.0%0.0%3.4%3.0% SAINT JOSEPH 13104522110189914570.9%4.5%7.2%5.6%3.0% FRANKLIN SQUARE 1369351461272116084719.8%14.6%4.7%3.4%2.4% UNION MEMORIAL 31316519185286373.7%5.1%1.2%1.6%1.9% SUBURBAN0000789022000.0%0.0%5.8%1.2%0.0% GOOD SAMARITAN 14502411530140000014.4%11.5%9.1%0.0%0.0% All Other 162280403001.7%2.8%0.3%0.2%0.0% Grand Total 673482151,0013091,5323321,7744131,921 100.0 %

23. Variable Average for Centers of Excellence (SRC) St. Agnes Program Washington State Data Number of patients 55 000 13003328 Mortality0.3%0.23%1.9% Morbidity10%8.5%NA Re-operations2.5%2%NA Re-admission4.5%4.5%NA Bowel obstruction 2.5%0.95%NA Marginal ulcer 5 % 0.99%NA EBWL % 1 year 65%65%NA Morbidity and Mortality of Gastric Bypass surgery at St. Agnes Hospital 2001-2007

24. Comparison of % EBWL of Gastric bypass and Lap. Band patients Chapman et al.; Surgery 135:326-351: 2004

25. Resolution of co-morbidities after 1 year in Gastric bypass patients with Insurance mandated diet Jamal et al., SOARD 2:122-127; 2006Variable Preoperative diet No diet P value HTN58%71%NS Diabetes93%79%NS Venous stasis 100%83%NS Sleep apnea NANANA GERD84%91%NS Joint pain 82%79%NS