1. Laparoscopic Bariatric Surgery

2. Bariatric Surgery Greek baros (weight) + iatrike (medicine, surgery) A field of medicine encompassing the study of overweight, its causes, prevention, and treatment

3. Why Do Bariatric Surgery? Major impact on morbidity and mortality cures disease and saves lives! preventative medicine? Challenging Very rewarding Exceptional group of patients A HAPPY specialty!

4. Obesity Is a Big Problem Major public health problem worldwide Affects 25% of industrialized world American statistics: 55% of adults are overweight 25% of children are overweight 300,000 deaths annually 300,000 deaths annually

5. Prevalence of Obesity* among U.S. Adults BRFSS, 1990 (*Approximately 30 pounds overweight) 15% Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

6. Prevalence of Obesity* among U.S. Adults BRFSS, 1991 (*Approximately 30 pounds overweight) 15% Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

7. Prevalence of Obesity* among U.S. Adults BRFSS, 1992 (*Approximately 30 pounds overweight) 15% Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

8. Prevalence of Obesity* among U.S. Adults BRFSS, 1993 (*Approximately 30 pounds overweight) 15% Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

9. Prevalence of Obesity* among U.S. Adults BRFSS, 1994 (*Approximately 30 pounds overweight) 15% Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

10. Prevalence of Obesity* among U.S. Adults BRFSS, 1995 (*Approximately 30 pounds overweight) 15% Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

11. Prevalence of Obesity* among U.S. Adults BRFSS, 1996 (*Approximately 30 pounds overweight) 15% Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

12. Prevalence of Obesity* among U.S. Adults BRFSS, 1997 (*Approximately 30 pounds overweight) 15% Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.

13. Prevalence of Obesity* among U.S. Adults BRFSS, 1998 (*Approximately 30 pounds overweight) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16. 15%

14. Prevalence of Obesity* among U.S. Adults BRFSS, 1999 (*Approximately 30 pounds overweight) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16. 15%

15. Current Data Over 50% of Americans are obese and over 10% are morbidly obese

16. What Is Obesity? multi- factorial A life-long, progressive, life-threatening, costly, genetically-related, multi- factorial disease of excess fat storage ASBS

17. Body Mass Index (BMI) BMI = weight (kg)_____ height (m) x height (m) WHO Classification BMI Ideal weight 20–24.9 Overweight 25–29.9 Moderate obesity(class I) 30–34.9 Severe obesity(class II) 35–39.9 Morbid obesity (class III) 40–49.9 (Super obesity) 50 +++

18. Exponential Mortality Risk

19. Co-Morbid Medical Conditions Diabetes Hypertension Hyperlipidemia Cardiac disease Respiratory disease sleep apnea Arthritis Depression Stress Incontinence Menstrual irregularity 14–20% 25–55% 35–53% 10–15% 10–20% 20–25% 70–90% 50%

20. What Causes Obesity? Energy in > energy out multifactorial Obesity is multifactorial: genetic 25–30% neuroendocrine environmental metabolic

21. Why Surgery? Diet and exercise only works for 1 in 20 (5%) people who are obese Surgery is safe and effective Improves co-morbidities Benefits of surgery outweigh the risks for the morbidly obese risks of surgery risks of staying morbidly obese

22. NIH Consensus Conference 1991 Surgery is the only way to obtain consistent, permanent weight loss for obese patients Surgery indicated in patients with: BMI of 40 or over BMI of 35 or over with significant co-morbidity documented dietary attempts ineffective

23. How Does Surgery Work? Malabsorption jejunoileal bypass biliopancreatic diversion  duodenal switch Restriction vertical banded gastroplasty adjustable gastric banding Hybrid of restriction and malabsorption gastric bypass

24. Jejunoileal Bypass (JIB) HISTORICAL Bacterial overgrowth in blind limb: anemia, arthritis, cirrhosis, kidney stones, etc. Diarrhea and malnutrition No longer performed Should be reversed graphics Courtesy of ASBS

25. Vertical Banded Gastroplasty (VBG) aka “Stomach Stapling” On the way out Restrictive Minimal metabolic effects Defeated by junk food diet, liquids 40–60% loss EBW Only 38% success staple line failure graphics Courtesy of ASBS

26. Laparoscopic Adjustable Gastric Banding Restrictive Ongoing FDA studies No long-term follow-up Presence of a foreign body Post operative adjustments required

27. Roux-en-Y Gastric Bypass Most frequently performed bariatric procedure in the US First done in 1967 Some technical modifications since (stomach is divided) Laparoscopically since 1993 graphics Courtesy of ASBS

28. Frantzides et al. Laparoscopic Gastric Stapling and Roux-en-Y Gastrojejunostomy for the treatment of Morbid obesity. J Laparoendosc Surg 1995

29. Laparoscopic Roux-en-Y (Minimally Invasive)

30. Planning

31. Laparoscopic Roux-en-Y (Minimally Invasive) Six small puncture wounds (1/4 to ½ inch) A laparoscope, connected to a video camera, is inserted through the small incision into the abdomen

32. Advantages of Laparoscopy Fewer wound complications infection, hernia Probably fewer cardiac and respiratory complications Less pain and faster recovery Surgeon has better view of the anatomy

33. Roux-en-Y Open vs. Laparoscopic Procedure LAPAROSCOPIC Hospital stay is 1 to 3 days. Patients usually return to work in 10 to 14 days. Technically more demanding for the surgeon OPEN  Hospital stay of about 5 days.  Return to work in about 4 weeks.  More painful  Greater risk of infection

34. Results of Our Lap Gastric Bypass Technique, 2003 711 Patients Average BMI: 50 (range 35-91) Conversions to open: 1 Duration of Surgery: 90 min (range 37- 180) Hospital Stay: 2.0 days (range 1-4)

35. Results of Lap Gastric Bypass, 2003 81% (12) 2.00.29050711Frantzides 82% (12) 2.51.6NR5063Champion 77% (30) 2.61.024748275Schauer 69% (12) 1.63.0NR46400Higa 73% (54) 2.6NR120NR500Wtittgrove EBWL (Follow-up in months) Hospital Stay (D) Conversio n (%) Mean OR Time (MIN) Mean BMINo. Patients Author

36. Frantzides et al. Triple Stapling Technique for Jejunojejunostomy in Laparoscopic Gastric Bypass. Arch Surg 2003

37. Post-Op Incisions

38. Post-Operative Nutrition and Diet Most patients who have had gastric- bypass surgery begin... A soft diet after the first week A regular diet at one month Nutritional and psychological counseling A daily multi-vitamin with iron for life Weekly sublingual vitamin B12 for life

39. Post-Operative Maintenance First post-operative visit is usually 7-10 days following surgery Office visits are scheduled at 1, 3, 6 and 12 months after surgery, and yearly thereafter Lab work is performed at all visits after the 1 st postoperative visit

40. Post-Operative Most patients lose up to and beyond 80% of excess weight …and keep it off.

41. Reduction in Co-Morbidities All medical co-morbidities are resolved or improved in 80–100% of patients

42. Swedish Obesity Surgery Study

43. Pre-Operative Process Medical History You will need a detailed account of efforts to achieve weight loss by non-surgical methods. Lists of specific comorbidities need to be identified. Your current health status will need to be evaluated

44. Pre-Operative Process Supporting Documentation You will need a brief letter from any physicians that have treated any weight-related health conditions. Any documentation from physicians stating the previous weight-loss efforts that you have made can be very valuable.

45. Pre-Operative Process Medical Testing Further medical testing may need to be completed in order to further clarify any existing comorbidities A psychological evaluation may also be needed

46. Pre-Operative Process Insurance Request Depending on the type of health care benefits, a request is made for coverage of the surgery from the patient, as well as the surgeon. If the Request is Denied Some insurance companies will initially deny a request for coverage. An appeal from the patient can be made or the patient can choose to seek legal advice.

47. Frequently Asked Questions Can gastric-bypass surgery be reversed? Yes. The procedure is intended to be a permanent change, but because the stomach is bypassed, not removed, surgeons can undo the pouch.

48. Frequently Asked Questions Continued… Will I need plastic surgery? Many factors influence the need for plastic surgery, for example starting weight, the amount of weight lost, location of the excess weight and age. The younger patients have a greater amount of skin elasticity and therefore are less likely to need plastic surgery.

49. Frequently Asked Questions Continued… Will I have gallstone complications? Weight loss and diet will promote the production of gallstones. If a patient has has documented gallstones, the gallbladder will be removed at the time of surgery. Gallstone dissolution medication

50. Frequently Asked Questions Continued… Can I become pregnant after gastric-bypass surgery? Yes, you can become pregnant after the surgery with out any related complications. Thousands of women have had successful pregnancies after the gastric-bypass surgery.

52. Pre-Op

53. Post-Op

54. Before

55. After

56. Pre-Op

57. Post-Op

58. Before

59. After

60. 12/13/02

61. 1/16/04

66. Conclusion “Only surgery has proven effective over the long term for most patients with clinically severe obesity” -National Institutes of Health Consensus Development Conference Statement

67. Chicago Institute of Minimally Invasive Surgery-St Francis Hospital