1. Lap-Band for Weight Loss Marc Bessler, M.D. New York Presbyterian Center for Obesity Surgery FDA Approved

2. Obesity is a Disease 55% of Americans are overweight or obese These rates, already among the highest in the world, are increasing Patients suffer social and economic discrimination The Institute of Medicine calculated the health care cost to be more than $70 billion annually Mortality : 2-10 fold increase

3. What Causes Obesity ? Obesity develops when energy intake consistently exceeds energy output Complex disease involving: - genetics - physiology - metabolism- appetite regulation - environmental factors - psychosocial & cultural

4. Why Lose Weight ? Feel Better Quality of Life Look Better Be Healthier Avoid Discrimination Live Longer

5. Medical Problems from Obesity Many medical problems are caused by or worsened by obesity. Most get better or go away with significant weight loss. These medical problems are called comorbidities.

6. Obesity Comorbidities High Blood Pressure Diabetes High Cholesterol High Triglycerides Heart Disease Joint Pains Difficulty Breathing Sleep Apnea Heartburn Urine Incontinence Varicose Veins Difficulty Exercising Fatty Liver Increased Cancer Risk Frequent Headaches Sex Hormone Problems

7. Morbid Obesity 100 pounds over Ideal Body Weight Body Mass Index of 40 or greater 80 pounds over Ideal Body Weight if causing significant comorbidity Body Mass Index of 35 or greater if causing significant comorbidity

8. Ideal Body Weight Metropolitan Life Insurance Height-Weight Table, 1983 Height Women MenHeight Women Men 4’10” 1155’8” 143151 4’11” 1175’9” 146154 5’0” 1195’10” 149157 5”1” 1225’11” 152160 5’2” 1251366’0” 155163 5’3” 1281386’1”167 5’4” 1311406’2”171 5’6” 1341426’3”174 5’7” 1371456’4”179

9. Body Mass Index (BMI) A number that indicates degree of overweight. Eliminates height from consideration Calculated as 703 times weight in pounds divided by height in inches squared. Normal is 20-25

10. BMI Table Height in InchesHeight in InchesHeight in Inches Wt 57 59 61 63 65 67 69 71 73 75 Wt 57 59 61 63 65 67 69 71 73 75 Wt 57 59 61 63 65 67 69 71 73 75 154 33 31 29 27 26 24 23 22 20 19165 36 33 31 29 28 26 24 23 22 21176 38 36 33 31 29 28 26 25 23 22 187 40 38 35 33 31 29 28 26 25 24198 43 40 37 35 33 31 29 28 26 25209 45 42 40 37 35 33 31 29 28 26 220 48 44 42 39 37 35 33 31 29 28231 50 47 44 41 39 36 34 32 31 29243 52 49 46 43 40 38 36 34 32 30 254 55 51 48 45 42 40 38 35 34 32265 57 53 50 47 44 42 39 37 35 33276 59 56 52 49 46 43 41 39 37 35 287 62 58 54 51 48 45 42 40 38 36298 64 60 56 53 50 47 44 42 39 37309 67 62 58 55 51 48 46 43 41 39 320 69 64 60 57 53 50 47 45 42 40331 71 67 62 59 55 52 49 46 44 42342 74 69 65 61 57 54 51 48 45 43 353 76 71 67 63 59 55 52 49 47 44364 78 73 69 64 61 57 54 51 48 46375 81 76 71 66 62 59 56 52 50 47 386 83 78 73 68 64 61 57 54 51 48397 86 80 75 70 66 62 59 56 53 50408 88 82 77 72 68 64 60 57 54 51 419 90 84 79 74 70 66 62 59 56 53430 93 87 81 76 72 67 64 60 57 54441 95 89 83 78 73 69 65 62 58 55 452 98 91 85 80 75 71 67 63 60 57463 99 93 87 82 77 73 69 65 61 58

11. Risk of Death and Obesity BMI DEATHDEATH

12. Treatment Options Diets Exercise Behavior Modification Medication Surgery

13. Diets Don’t Work ! Almost anyone can lose weight dieting Almost no one can maintain long term weight loss 97% of patients 100 pounds or more overweight regain lost weight within 2 years Often gain more than was lost

14. Exercise Very important as part of any weight loss program Regular exercise causes more weight loss and keeps it off longer Length of time is more important than intensity Rarely enough as treatment alone

15. Medications Cause only modest weight loss 10-15% Need to be taken indefinitely Often cause side effects Expensive and often not covered by insurance Only work well in combination with diet and exercise

16. Surgery There are 2 safe and effective procedures commonly used in the US –Vertical Banded Gastroplasty –Gastric Bypass 20 year history and follow up Only proven long term effective treatment Patients should have failed other treatments

17. Vertical Banded Gastroplasty VBG commonly known as Stomach Stapling Small stomach pouch Staples partition stomach Plastic band controls outlet to rest of stomach

18. Vertical Banded Gastroplasty Advantages –Simple to perform –Bottom of stomach and duodenum can be easily examined –Low incidence of leaks –Normal absorption of nutrients –? lower risk of bowel obstruction

19. Problems with VBG Staple line can pull through (break) Band too tight for some causes vomiting Not adjustable Infection or erosion of band Can lead to poor dietary habits Failure in 25-50% of patients Has fallen out of favor in US

20. Gastric Bypass Small stomach pouch made from top of stomach Pouch empties directly to intestine Food and enzymes meet lower down in the intestine No plastic ring

21. Gastric Bypass Advantages No plastic ring Greater weight loss Causes avoidance of sweets and fats Most foods well tolerated Low failure rate Little weight regain

22. Problems with Gastric Bypass Higher rate of complications 1/2 - 1% death rate Vitamins and minerals poorly absorbed Laparoscopy may increase complications Difficult to reverse

23. Lap-Band System

24. System Components –Silastic band –Integrated bladder –Self locking buckle –Tubing –Port

25. Lap-Band

26. Lap-Band Port

27. Lap-Band the Operation

28. Lap Band Around the World Most common operation for obesity in Europe, Australia and South America. Over 50,000 implanted worldwide in past 9 years Extremely safe with good weight loss Recently FDA approval in the US

29. Lap-Band Placement

30. Lap Band Closure

31. Lap-Band Placement

32. Lap Band Placement

33. Lap-Band Fixation

34. Diet after Operation Fluids Pureed foods Soft food Regular food Meats, fresh breads and white rice come last and may not be well tolerated except in small amounts and well chewed

35. Office Visits 2 weeks after surgery 6 weeks after surgery –may have first band adjustment Monthly for first year –band adjustments as indicated Quarterly in second year Yearly for life

36. Band Adjustment

37. Lap-Band Inflation

38. Over Inflation

39. Components for Success Education –Nurse understand procedure care after operation –Nutritionist diet changes healthy balanced food choices Surgery Commitment –follow up –follow the rules

40. Weight Loss More Gradual than other operations Continues longer up to 2 years 1/3-2/3 of excess weight Depends on following rules –No Sweets –No Snacking –No liquids with calories A Tool not a Miracle

41. Complications Band Slippage 3-5% Band Erosion 1-3% Tubing Leak 2-3% Port Infection 1-2% Stomach Perforation <1% Esophageal Dilation ? Death <0.1% (less than 1/1000)

42. Summary Obesity is a significant health problem Non-surgical treatment is ineffective long term Gastric Bypass is currently most common in US Lap-Band most common in rest of World Lap-Band is safer than Gastric Bypass but may offer less weight loss on average Commitment to long term dietary change is key to success with Lap-Band

43. Thank You