Transcript Slide 1

Weight loss Surgery
Kuldeep Singh, M.D., F.A.C.S., M.B.A.
Spectrum of the obesity
Terms Used to Describe Various Levels of
Body Fat
Normal Weight
(BMI 18.5 to 24.9)
Overweight
(BMI 25 to 29.9)
Obese
(BMI 30 to 34.9)
Severely Obese
(BMI 35 to 39.9 )
Morbidly Obese
(BMI 40 or more)
This is where
Surgical treatment is
recommended
Health Risks
Related Diseases and Health Problems
• Obese people have more risk for:
• Diabetes (type 2)
• Joint problems, backaches, disc Prolapse
(e.g., arthritis)
• High blood pressure
• Heart disease: coronary artery disease
• Gallbladder problems, gallstones
Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity.
Health Risks (cont.)
Related Diseases and Health Problems
• In addition, obese people have more risk for:
• Certain types of cancer (breast, uterine, colon)
• Digestive disorders (e.g. gastro-esophageal reflux
disease, or GERD)
• Breathing difficulties (e.g. sleep apnea, asthma).
• Psychological problems such as depression.
• Problems with fertility and pregnancy.
• Stress Incontinence.
Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity.
Using Surgery to Treat
Obesity
• Types of weight-loss surgeries
• Malabsorptive procedures shorten the
digestive tract: BPD & BPD-DS
• Restrictive procedures reduce how much the
stomach can hold: Lap Band & Sleeve
Gastrectomy
• Combined procedures shorten the digestive
tract and reduce how much the stomach can
hold: Gastric Bypass
Using Surgery to Treat ObesityRestrictive Techniques
Sleeve Gastrectomy
wo-pub2.med.cornell.edu/.../PublicA.woa/4/wa
LAP-BAND
System
Using Surgery to Treat ObesityMalabsorptive Techniques
We do not
perform BPD,
however we can
refer you to
surgeons in the
area who
perform this
surgery
Bilio-Pancreatic Diversion
(BPD)
Mixed Techniques
Roux-en-Y Gastric Bypass
Risk Benefit Ratio
LOW
LOW
Lap Band
Riskier the
operation, the
more effective it
is
Lap Band
Sleeve Gastrectomy
Sleeve Gastrectomy
Roux –en-Y Gastric
Bypass
Roux –en-Y Gastric
Bypass
Bilio-Pancreatic Diversion
HIGH
RISK
Bilio-Pancreatic Diversion
HIGH
BENEFIT
Expected Outcomes from the
Surgery
• Improvement in health problems,
including:
• Diabetes (type 2): 80% cure possible.
• High blood pressure: 40% cure
• Asthma: marked improvement
• GERD (gastro-esophageal reflux disease):
• Sleep apnea: close to 100% cure
• Problems with fertility and pregnancy
• Depression.
Laparoscopic Gastric Bypass
Advantages
• Rapid initial weight
loss
• Higher total average
weight loss .
• Over 40 years of
surgical experience
in USA
Disadvantages
• Bigger operation and slower
recovery.
• Practically irreversible
• Higher chances of
nutritional problems such
as Iron deficiency anemia
and vitamin B 12 deficiency.
• Higher chances of ulcers at
the junction of the stomach
and the jejunum.
How the LAP-BAND System
Works
• A silicone band is
placed around the
upper part of the
stomach
• A small pouch is
created
• Your stomach holds
less food
• You feel full faster
and longer
The LAP-BAND System
Procedure
• Adjustable Band
• Can be adjusted in
office or operating
room
• No anesthesia
needed.
• On average 4-5 fills
in first year
• 1 or 2 fills second
year if needed.
The LAP-BAND System
Advantages
• Lowest mortality rate
• No stomach stapling or
cutting, or intestinal rerouting
• Adjustable
• Smaller operation ,
Reversible
• Lowest operative
complication rate
• Low malnutrition risk
Disadvantages
• Slower weight loss.
• Regular follow-up critical for
optimal results
• Requires more commitment
from the patient.
• Slippage or erosion and injury
to the esophagus or stomach
as possible complications.
Sleeve Gastrectomy (SG)
• Arose from need to perform a safer yet
effective operation in patients with high
BMI (>50) and multiple co-morbidities.
• It is first stage of BPD-DS (Biliopancreatic diversion with Duodenal
switch).
• Designed as an separate staged
procedure by Johnson in 1993.
Sleeve Gastrectomy
• Complications and outcomes are
somewhere between Adjustable
Laparoscopic gastric Banding and
Gastric Bypass.
• Advantage of absence of Iron deficiency
anemia, Marginal Ulcers, ability to
perform upper endoscopic procedures
and decrease the weight and comorbidities to lead to any second
staged procedure such as band, bypass
or BPD.
Who qualifies for the
Bariatric Surgery?
•
NIH criteria
1.
2.
3.
4.
•
Weight: BMI more than 40 or 35 with two serious
illnesses.
Free from untreated mental illnesses such as Bulimia
and schizophrenia.
Documented evidence of weight loss attempts. In
Maryland 6 months over the past two years.
Understanding by the patient that the surgery is only a
tool to lose weight and need to have life style changes
and exercise/ eating habits.
Age: 18-60 years of age
Who does not qualifies for the Bariatric
Surgery?
• Those who cannot walk.
• Those who have severe heart disease.
These are our
contraindication
s
• Heart failure.
• Angina and coronary artery disease.
• With severe lung disease.
• In whom surgery is not possible
• Extreme obesity. Absolute weight matters to an extent. I will
not operate patients over 500 lbs.
• Limited exercise tolerance. You should be able to walk with
me to the parking lot (2 blocks) and back without severe
shortness of breath.
• Schizophrenia and Bulimia.
Bypass or Band?? How to choose?
some guidelines
• Bypass
• Bigger operation, higher risk, more weight loss and rapid
weight loss.
• More nutritional problems: anemia and ulcers.
• My preference: severe obesity with lot of illnesses.
• Lap Band
•
•
•
•
•
Smaller and safer surgery, quick recovery.
Less nutritional problems, less anemia or ulcers.
Unique problems such as Slippage and Erosions.
Reversible.
My preference: BMI small with not so many diseases, women.
• Sleeve Gastrectomy
• BMI>60.
• Android Obesity
The process for the surgery
1. Make sure you meet the criteria for the surgery.
2. Call your insurance company to check coverage.
3. Make sure that we participate with your insurance
or be willing to pay more out of Pocket expense.
4. See the dietician and the psychologist.
5. Fill all the forms and organize your folder into
weight loss attempts, cardiac consult , Sleep Study
and History and physical note form your doctor
(whatever applies).
6. Call the office and make appointment to see the
Doctor.
7. If you have questions whether you will qualify- Call
the office to clarify.
Centers of Excellence
• Awarded COE by most of the Insurers
in Maryland (Blue cross, Atena, United
Healthcare and Cigna).
• Awarded COE by SRC (Surgical review
Committee in June 2006 for full three
years.
Bariatric Volumes and Market Share in Maryland
DRG 288 & ICD-9 Procedure code
definition
FY02
HOSPITAL
Svc
Area
FY03
Total
Svc
Area
FY04
Total
Svc
Area
FY05
Total
Svc
Area
FY06
Total
Svc
Area
Total Cases Market Share
Total
FY02
FY03
FY04
FY05
FY06
13
24
75
135
153
311
174
368
229
469
6%
13%
20%
20%
24%
BAYVIEW
6
53
22
148
40
281
36
306
39
304
15%
14%
18%
17%
15%
GBMC
0
0
0
0
0
31
18
158
33
188
0.0%
0.0%
2.0%
8.9%
9.8%
SINAI
12
83
14
76
21
60
56
188
51
184
23.9%
7.6%
3.9%
10.6%
9.6%
HOLY CROSS
0
33
8
160
0
62
2
102
3
149
9.5%
16.0%
4.0%
5.7%
7.8%
UMMS
4
14
7
27
9
22
4
22
28
130
4.0%
2.7%
1.4%
1.2%
6.8%
SHADY GROVE
0
0
0
6
2
107
2
145
1
105
0.0%
0.6%
7.0%
8.2%
5.5%
PENINSULA REGIONAL
0
0
2
54
0
98
1
96
0
102
0.0%
5.4%
6.4%
5.4%
5.3%
WASHINGTON
ADVENTIST
0.0%
1.0%
8.3%
6.6%
0
0
0
10
4
127
2
117
0
91
HARFORD MEMORIAL
0
0
0
0
0
0
3
60
1
58
0.0%
0.0%
0.0%
3.4%
3.0%
SAINT JOSEPH
1
3
10
45
22
110
18
99
14
57
0.9%
4.5%
7.2%
5.6%
3.0%
13
69
35
146
12
72
11
60
8
47
19.8%
14.6%
4.7%
3.4%
2.4%
UNION MEMORIAL
3
13
16
51
9
18
5
28
6
37
3.7%
5.1%
1.2%
1.6%
1.9%
SUBURBAN
0
0
0
0
7
89
0
22
0
0
0.0%
0.0%
5.8%
1.2%
0.0%
14
50
24
115
30
140
0
0
0
0
14.4%
11.5%
9.1%
0.0%
0.0%
1
6
2
28
0
4
0
3
0
0
1.7%
2.8%
0.3%
0.2%
0.0%
67
348
215
1,001
309
1,532
332
1,774
413
1,921
100.0
%
100.0
%
100.0
%
100.0
%
100.0
%
ST. AGNES
FRANKLIN SQUARE
GOOD SAMARITAN
All Other
Grand Total
4.7%
Morbidity and Mortality of Gastric Bypass
surgery at St. Agnes Hospital 2001-2007
Variable
Average for
Centers of
Excellence
(SRC)
St. Agnes
Program
Washington
State Data
Number of
patients
55 000
1300
3328
Mortality
0.3%
0.23%
1.9%
Morbidity
10%
8.5%
NA
Re-operations
2.5%
2%
NA
Re-admission
4.5%
4.5%
NA
Bowel
obstruction
2.5%
0.95%
NA
Marginal ulcer 5 %
0.99%
NA
EBWL % 1
year
65%
NA
65%
Comparison of % EBWL of Gastric bypass and
Lap. Band patients
Chapman et al.; Surgery 135:326-351: 2004
Resolution of co-morbidities after 1 year in Gastric
bypass patients with Insurance mandated diet
Variable
Preoperative
diet
No diet
P value
HTN
58%
71%
NS
Diabetes
93%
79%
NS
Venous stasis
100%
83%
NS
Sleep apnea
NA
NA
NA
GERD
84%
91%
NS
Joint pain
82%
79%
NS
Jamal et al., SOARD 2:122-127; 2006