1. MORBID OBESITY AMHE 2010 Convention Chateau Montebello Yvan Ducheine MD 310 Central Avenue East Orange NJ 07018

2. Obesity & Surgery GOALS & OBJECTIVES: Definition Definition Prevalence Prevalence Impact Impact Associated Illnesses Associated Illnesses Treatments (Surgical & Non-Surgical) Treatments (Surgical & Non-Surgical) Eligible Candidates Eligible Candidates Results of Surgery Results of Surgery

3. Obesity & Surgery DEFINITION: DEFINITION: National Institutes of Health Anyone with a body mass index of 30 or above is considered obese. A body mass index above 40 is considered morbidly obese. National Institutes of Health Anyone with a body mass index of 30 or above is considered obese. A body mass index above 40 is considered morbidly obese.

4. Obesity & Surgery PREVALENCE: PREVALENCE: Worldwide: 1.7 Billion Worldwide: 1.7 Billion 1.5 to 2 times higher in women 1.5 to 2 times higher in women USA 34% of Americans USA 34% of Americans 6% Morbidly Obese 6% Morbidly Obese 60% to 80% of African Americans (BET) 60% to 80% of African Americans (BET) Children 17%-33% Children 17%-33%

5. Obesity & Surgery It is the 2 nd most preventable cause of death after smoking It is the 2 nd most preventable cause of death after smoking Decrease life expectancy (2.4 years) Decrease life expectancy (2.4 years) Increased in co-morbid illnesses Increased in co-morbid illnesses

6. Obesity & Surgery Hypertension Hypertension Diabetes Diabetes Asthma Asthma Sleep Apnea Sleep Apnea Hyperlipidemia Hyperlipidemia Arthritis Arthritis Infertility Infertility Venous Stasis Venous Stasis Depression Depression Greater Cancer Risk Greater Cancer Risk Breast Cancer Breast Cancer Colon Cancer Colon Cancer Endometrial Cancer Endometrial Cancer *All cancers except pancreatic cancer & prostate cancer *All cancers except pancreatic cancer & prostate cancer

7. Obesity & Surgery TREATMENT OPTIONS TREATMENT OPTIONS Medicine 18% vs Surgery 30% to 80% Medicine 18% vs Surgery 30% to 80% J Am Coll Surg. 2003 Mar;196(3):379-84. J Am Coll Surg. 2003 Mar;196(3):379-84. A comparison of diet and exercise therapy versus laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity: a decision analysis model. Patterson EJ, Urbach DR, Swanstrom LL. Department of Minimally Invasive Surgery, Legacy Health System, Portland, OR, USA. CONCLUSIONS: In a decision analysis model, laparoscopic gastric bypass surgery for morbid obesity was associated with a substantially longer survival than diet and exercise therapy. Copyright 2003 by the American College of Surgeons A comparison of diet and exercise therapy versus laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity: a decision analysis model. Patterson EJ, Urbach DR, Swanstrom LL. Department of Minimally Invasive Surgery, Legacy Health System, Portland, OR, USA. CONCLUSIONS: In a decision analysis model, laparoscopic gastric bypass surgery for morbid obesity was associated with a substantially longer survival than diet and exercise therapy. Copyright 2003 by the American College of Surgeons Patterson EJUrbach DRSwanstrom LL Patterson EJUrbach DRSwanstrom LL

8. Obesity & Surgery BARIATRIC SURGERY WORLDWIDE BARIATRIC SURGERY WORLDWIDE Only effective therapy for morbid obesity Only effective therapy for morbid obesity 2002-2003 146,301Bariatric surgeries 2002-2003 146,301Bariatric surgeries 2839 Bariatric Surgeons 2839 Bariatric Surgeons 103,000 operations done in USA/Canada, increased to 112K (2007-08). 103,000 operations done in USA/Canada, increased to 112K (2007-08). 37.15% open, 65.85% laparoscopic 37.15% open, 65.85% laparoscopic

9. Obesity & Surgery ELIGIBILITY CRITERIA FOR SURGERY ELIGIBILITY CRITERIA FOR SURGERY Acceptable Medical Risk for Surgery Acceptable Medical Risk for Surgery Failed attempts @ non-surgical weight reductions (Diet & Exercise) Failed attempts @ non-surgical weight reductions (Diet & Exercise) BMI>40; BMI>40; BMI> 35 with obesity related comorbidities BMI> 35 with obesity related comorbidities No Psychiatric Contraindications No Psychiatric Contraindications Realistic Commitment and Expectations Realistic Commitment and Expectations

10. Obesity & Surgery FOOD ADDICTION Psychological Component Psychological Component Physical Component Physical Component Group Therapy & Support Group Therapy & Support BEHAVIOR MODIFICATION Eat 3 times per day Eat 3 times per day No Snacking Between Meals (Water Only) No Snacking Between Meals (Water Only) No Eating after 7:00 pm No Eating after 7:00 pm LIFESTYLE CHANGES Walk one half hour per day (Continuous) Walk one half hour per day (Continuous)

11. Obesity & Surgery GASTRIC BANDING GASTRIC BANDING Restrictive Restrictive 30% to 40% 30% to 40% Avoidance of gastrointestinal anastomosis Avoidance of gastrointestinal anastomosis Less Invasive Less Invasive Less Nutritional Px. Less Nutritional Px. GASTRIC BYPASS GASTRIC BYPASS Malabsorptive Malabsorptive 70%-80% 70%-80% Greater Weight Loss Greater Weight Loss More Invasive More Invasive Increased risk of nutritional deficiencies Increased risk of nutritional deficiencies

12. Obesity & Surgery LAP-BAND System

13. Obesity & Surgery GASTRIC BYPASS GASTRIC BYPASS Roux-en-Y Gastric Bypass

14. Obesity & Surgery SURGICAL COMPLICATIONS SURGICAL COMPLICATIONS Infections Infections Strictures Strictures Intestinal Leaks Intestinal Leaks Nausea & Vomiting Nausea & Vomiting Hernia Hernia Obstruction Obstruction Death <1% Death <1% METABOLIC COMPLICATIONS METABOLIC COMPLICATIONS Nutritional Deficiencies Nutritional Deficiencies Anemia Anemia Bone Disease Bone Disease Neuropathy Neuropathy Vit. A Deficiency Vit. A Deficiency Vit. D Deficiency Vit. D Deficiency

15. Obesity & Surgery RESULTS: RESULTS: Hypertension 62-73% Cured Hypertension 62-73% Cured Diabetes Mellitus 75-85% Cured Diabetes Mellitus 75-85% Cured Sleep Apnea 90% Cured Sleep Apnea 90% Cured GERD 90% Cured GERD 90% Cured Dyslipidemia 34% Cured (38% improved) Dyslipidemia 34% Cured (38% improved) Hypertension & Dyslipidemia = @ 10 yrs. Hypertension & Dyslipidemia = @ 10 yrs.

16. Obesity & Surgery RESULTS: Dramatic Reduction in Weight Dramatic Reduction in Weight Marked Quality of Life Improvement Depression, Self-esteem, eating pathology, Marked Quality of Life Improvement Depression, Self-esteem, eating pathology,

17. Obesity & Surgery RESULTS: (Non-Compliance with Behavior & Exercise) Depression 12% Depression 12% Sexual Concerns 4% Sexual Concerns 4% Relationship Problems 2% (>90%) Relationship Problems 2% (>90%) Medical Complications due to Surgery 9% Medical Complications due to Surgery 9% Lack of Exercise Being the Most Likely Area of Non-Compliance Lack of Exercise Being the Most Likely Area of Non-Compliance

18. Obesity & Surgery Obesity Obesity Prevalence (34% to 50%) Prevalence (34% to 50%) Co-morbidities Co-morbidities Eligible Candidates (BMI 35+ or BMI >40) Eligible Candidates (BMI 35+ or BMI >40) Types of Bariatric Surgeries Types of Bariatric Surgeries Success Rate in Weight Loss Success Rate in Weight Loss Success in Curing Diabetes, Hypertension Success in Curing Diabetes, Hypertension Complications Complications Change in Quality of Life and Life Expectancy Change in Quality of Life and Life Expectancy

19. Obesity & Surgery Cameron, JL: Current Therapy in Surgery 8 th Edition Cameron, JL: Current Therapy in Surgery 8 th Edition Seidell JC. Epidemiology of obesity. Seidell JC. Epidemiology of obesity. Seidell JC Seidell JC Mason ME, Jalagani H, Vinik AI Metabolic complications of bariatric surgery: diagnosis and management issues. Gastroenterol Clin North Am. 2005 Mar;34(1):25-33. Mason ME, Jalagani H, Vinik AI Metabolic complications of bariatric surgery: diagnosis and management issues. Gastroenterol Clin North Am. 2005 Mar;34(1):25-33. Mason MEJalagani HVinik AI Mason MEJalagani HVinik AI Buchwald H, Williams SE Bariatric surgery worldwide 2003. Obes Surg. 2004 Oct;14(9):1157-64. Buchwald H, Williams SE Bariatric surgery worldwide 2003. Obes Surg. 2004 Oct;14(9):1157-64. Buchwald HWilliams SE Buchwald HWilliams SE Elkins G, Whitfield P, Marcus J, Symmonds R, Rodriguez J, Cook T. Noncompliance with behavioral recommendations following bariatric surgery. Elkins G, Whitfield P, Marcus J, Symmonds R, Rodriguez J, Cook T. Noncompliance with behavioral recommendations following bariatric surgery. Elkins GWhitfield PMarcus JSymmonds RRodriguez JCook T Elkins GWhitfield PMarcus JSymmonds RRodriguez JCook T Dymek MP, le Grange D, Neven K, Alverdy J Quality of life and psychosocial adjustment in patients after Roux-en-Y gastric bypass: a brief report. Obes Surg. 2001 Feb;11(1):32-9. Dymek MP, le Grange D, Neven K, Alverdy J Quality of life and psychosocial adjustment in patients after Roux-en-Y gastric bypass: a brief report. Obes Surg. 2001 Feb;11(1):32-9. Dymek MPle Grange DNeven KAlverdy J Dymek MPle Grange DNeven KAlverdy J White S, Brooks E, Jurikova L, Stubbs RS Long-term outcomes after gastric bypass. Obes Surg. 2005 Feb;15(2):155-63. White S, Brooks E, Jurikova L, Stubbs RS Long-term outcomes after gastric bypass. Obes Surg. 2005 Feb;15(2):155-63. White SBrooks EJurikova LStubbs RS White SBrooks EJurikova LStubbs RS Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, Dahlgren S, Larsson B, Narbro K, Sjostrom CD, Sullivan M, Wedel H; Swedish Obese Subjects Study Scientific Group Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2005 Apr 7;352(14):1495-6; author reply 1495-6. Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, Dahlgren S, Larsson B, Narbro K, Sjostrom CD, Sullivan M, Wedel H; Swedish Obese Subjects Study Scientific Group Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2005 Apr 7;352(14):1495-6; author reply 1495-6. Sjostrom LLindroos AKPeltonen MTorgerson JBouchard CCarlsson BDahlgren SLarsson B Narbro KSjostrom CDSullivan MWedel HSwedish Obese Subjects Study Scientific GroupN Engl J Med. 2005 Apr 7;352(14):1495-6; author reply 1495-6. Sjostrom LLindroos AKPeltonen MTorgerson JBouchard CCarlsson BDahlgren SLarsson B Narbro KSjostrom CDSullivan MWedel HSwedish Obese Subjects Study Scientific GroupN Engl J Med. 2005 Apr 7;352(14):1495-6; author reply 1495-6. Patterson EJ, Urbach DR, Swanstrom LL. comparison of diet and exercise therapy versus laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity: a decision analysis model. J Am Coll Surg. 2003 Mar;196(3):379-84. Patterson EJ, Urbach DR, Swanstrom LL. comparison of diet and exercise therapy versus laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity: a decision analysis model. J Am Coll Surg. 2003 Mar;196(3):379-84. Patterson EJUrbach DRSwanstrom LL Patterson EJUrbach DRSwanstrom LL Craig BM, Tseng DS. Cost-effectiveness of gastric bypass for severe obesity. Am J Med. 2002 Oct 15;113(6):491-8. Craig BM, Tseng DS. Cost-effectiveness of gastric bypass for severe obesity. Am J Med. 2002 Oct 15;113(6):491-8.Craig BMTseng DSCraig BMTseng DS Fang J. The cost-effectiveness of bariatric surgery Am J Gastroenterol. 2003 Sep;98(9):2097-8. Fang J. The cost-effectiveness of bariatric surgery Am J Gastroenterol. 2003 Sep;98(9):2097-8. Fang J Fang J