1. Obesity & The Surgeon
Moises Jacobs, MD,FACS, Director Advanced Surgical Institute Mercy Hospital, Miami, FL.

2. Speaker Disclosure
Speaker discloses he is a consultant with Ethicon.

3. Gastric bypass Gastric band Duodenal switch Gastric sleeve
Four Operations
Gastric bypass
Gastric band
Duodenal switch
Gastric sleeve

4. Bariatric Surgery-USA
,000/year
,000
,000
,000
,000
,000
Schirmer, Laparoscopic Bariatric Surgery. Surg Endosc 2003

5. Bariatric Surgery-USA
It is estimated that by 2012, the number of cases will triple
It is estimated there are over one billion obese persons in the world today

6. Surgical Candidate NIH Consensus Conference 1991
BMI > >35 significant co-morbidity
No endocrine cause
Understand risks of surgery
Compliant with follow-up

7. Advantages of Gastric Sleeve
No dumping syndrome
No intestinal bypass
No intestinal obstruction
No anemia, vitamin deficiencies, no protein malnutrition, no osteoporosis
High BMI is not a contraindication

8. Sleeve vs Band
No foreign body ( no erosion, infection or revision of reservoir)
No adjustments
Second stage operation is an option if weight loss is inadequate

9. Downside? Gastric staple division, leaks can occur
Inadequate weight loss (soft calories)
Not reversible
Long term results are unknown

10. Inventing Something New?
Magenstrasse-Mill operation, Leeds UK
Lesser curvature tube, stomach is otherwise intact
Long term 60% EWL
Johnston, Obesity Surg 2003

11. Sleeve Gastrectomy-Results
Expected weight loss
40-60% EBW
6-18 months
1-2 day stay
Follow-up
Labs, nutrition
Assess compliance
Complications
Leak
DVT/PE
Pneumonia
Wound infection
Low rate,low mortality
Second stage
Gastric bypass
Duodenal switch

12. Agency for Healthcare Research and Quality
22% of bariatric surgery pts experienced a complication prior to discharge
Almost 40% experienced a complication within 180 days of discharge (?)
Dumping syndrome (19.5%)
Anastomotic problems (12.3%)
Abdominal hernia (7%)
Infection (5.7%)
Pneumonia (4.1%)
Encinosa;Medical Care 2006

13. Agency for Healthcare Research and Quality 2001-2002
6 month risk adjusted health care payments were $65,031 for those with 180 day readmission, compared with $27,125 for thos with readmissions
In a subset of 625 surgeries in centers with bariatric volume, no link was found between volume and the risk of complications, after adjusting for age,sex,and comorbidities