1. Weight Loss Surgery: The First Step Toward a More Healthy Life

3. Pre-operative Medications Post-operative Medications

4. Defining the Problem

5. The Problem
Prevalence of obesity in U.S. increased from 12% to 21% between 1991 and 2001 = 15 million people
Obesity is the 2nd 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:

6. Excess U.S. Medical Costs Related to Abnormal Body Weight
Int J Obesity 2005;29:

7. Relative risk of health problems associated with obesity
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)

8. The Effect of Obesity on the Development of Health Risks
Age-adjusted relative risk of type 2 diabetes 10 20 30 40 50
1.0
2.2 12 42 25 75
100
8.1 93
<23 31
35
<22
Men1
Women2
BMI
1Chan JM et al. Diabetes Care 1994;17: ; 2Colditz G et al. Ann Intern Med 1995;122:

9. Causes of Obesity Genetics Behavior Environment Behavior
Eating (e.g. emotional eating)
exercise

10. The Environment: Portion Size

11. Non-operative Treatment of Obesity How does it add up?
Diet
Exercise
Behavioral therapy
+ Drug therapy
??????

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

13. Surgical Treatment of Obesity: The Basics

14. What is Body Mass Index ( BMI ) ?

15. Surgical Treatment of Obesity: Indications and Surgical Options

16. Patient Selection Age 18 - 55 AND BMI ≥ 40 kg/m2 OR
BMI kg/m2 with
High risk health problems OR
Obesity-induced physical problems
NIH Consensus Development Conference

17. Operative Approaches Restrictive Procedures Malabsorptive Procedures
Vertical banded gastroplasty ( VBGP )
Adjustable silastic gastric banding (ASGB)
Malabsorptive Procedures
Biliopancreatic diversion ( BPD )
Duodenal switch modification of BPD
Combined Procedures
Roux-en-Y gastric bypass ( GBP )

18. The Gastrointestinal System

19. Vertical Banded Gastroplasty (VBG)
General Features
Pouch size: 1 oz
Triple staple line
Pouch opening: 0.5 in
Average Weight Loss
50 % of excess weight

20. Vertical banded gastroplasty: Complications
Stomal narrowing with persistent vomiting
Staple line leak or disruption
Band erosion
Wound infection or hernia
Death %
Overall re-operation rate 43 %

21. Adjustable Silastic Gastric Banding (ASGB): LapBandTM
GENERAL FEATURES
Inflatable balloon within the band orifice can be adjusted via a reservoir under the skin
Average Weight loss
50% of excess weight

22. Adjustable Silastic Gastric Banding : Complications
Splenic injury
Esophageal injury
Wound infection
Persistent vomiting
Acid reflux
Band slippage
Reservoir leak/deflation
Band erosion
Death 0.3 %
Re-operation %

23. Biliopancreatic Diversion with Duodenal Switch (BPD-DS)
General Features
Gastric pouch size:
Standard: 14 oz (1.5 cups)
Three segments
Alimentary tract: 6.5 ft
Biliary tract: 13 ft
Common channel: 1.5 ft
Average Weight Loss
80 % of excess weight

24. Duodenal Switch (BPD-DS) : Complications
Protein malnutrition 15%
Anemia < 5 %
Marginal ulcer < 3 %
Peripheral neuropathy 1.3 %
Night Blindness %
Osteoporosis 14 %
Renal stones
Nausea %
Diarrhea %
Vitamin deficiencies: A, D, E, K, B12
Incisional hernia 10 %
Death %
First 6 mo

25. Roux-en-Y Gastric Bypass (RYGBP)
General Features
Pouch size: oz
Pouch opening: 0.5 in
Roux-en-Y limb
Standard: 2 ft
Average Weight Loss
70 % of excess weight
“The Pouch-Tool”

26. Gastric Bypass: Complications
Early:
Staple line leak %
Acute gastric distention
Roux-Y obstruction
Death %
Late:
Stomal narrowing /vomiting %
Marginal ulcer %
Heartburn / inflammation of esophagus
Anemia
Folate deficiency
Vitamin B12 deficiency
Iron deficiency
Calcium deficiency / osteoporosis
Gallstones %

27. 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

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

29. 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.