Transcript Lap-Band for Weight Loss

Lap-Band for Weight Loss
Marc Bessler, M.D.
New York Presbyterian Center for
Obesity Surgery
FDA Approved
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
What Causes Obesity ?
• Obesity develops when energy intake
consistently exceeds energy output
• Complex disease involving:
- genetics
- physiology
- metabolism
- appetite regulation
- environmental factors
- psychosocial & cultural
Why Lose Weight ?
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Feel Better
Quality of Life
Look Better
Be Healthier
Avoid Discrimination
Live Longer
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.
Obesity Comorbidities
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High Blood Pressure
Diabetes
High Cholesterol
High Triglycerides
Heart Disease
Joint Pains
Difficulty Breathing
Sleep Apnea
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Heartburn
Urine Incontinence
Varicose Veins
Difficulty Exercising
Fatty Liver
Increased Cancer Risk
Frequent Headaches
Sex Hormone Problems
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
Ideal Body Weight
Metropolitan Life Insurance Height-Weight Table, 1983
Height
4’10”
4’11”
5’0”
5”1”
5’2”
5’3”
5’4”
5’6”
5’7”
Women
115
117
119
122
125
128
131
134
137
Men
136
138
140
142
145
Height
5’8”
143
5’9”
146
5’10”
149
5’11”
6’0”
6’1”
6’2”
6’3”
6’4”
Women
151
154
157
152
155
Men
160
163
167
171
174
179
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
BMI Table
Height in Inches
Wt 57 59 61 63 65 67 69 71 73 75
154 33 31 29 27 26 24 23 22 20 19
187 40 38 35 33 31 29 28 26 25 24
220 48 44 42 39 37 35 33 31 29 28
254 55 51 48 45 42 40 38 35 34 32
287 62 58 54 51 48 45 42 40 38 36
320 69 64 60 57 53 50 47 45 42 40
353 76 71 67 63 59 55 52 49 47 44
386 83 78 73 68 64 61 57 54 51 48
419 90 84 79 74 70 66 62 59 56 53
452 98 91 85 80 75 71 67 63 60 57
Height in Inches
Wt 57 59 61 63 65 67 69 71 73 75
165 36 33 31 29 28 26 24 23 22 21
198 43 40 37 35 33 31 29 28 26 25
231 50 47 44 41 39 36 34 32 31 29
265 57 53 50 47 44 42 39 37 35 33
298 64 60 56 53 50 47 44 42 39 37
331 71 67 62 59 55 52 49 46 44 42
364 78 73 69 64 61 57 54 51 48 46
397 86 80 75 70 66 62 59 56 53 50
430 93 87 81 76 72 67 64 60 57 54
Height in Inches
Wt 57 59 61 63 65 67 69 71 73 75
176 38 36 33 31 29 28 26 25 23 22
209 45 42 40 37 35 33 31 29 28 26
243 52 49 46 43 40 38 36 34 32 30
276 59 56 52 49 46 43 41 39 37 35
309 67 62 58 55 51 48 46 43 41 39
342 74 69 65 61 57 54 51 48 45 43
375 81 76 71 66 62 59 56 52 50 47
408 88 82 77 72 68 64 60 57 54 51
441 95 89 83 78 73 69 65 62 58 55
463 99 93 87 82 77 73 69 65 61 58
Risk of Death and Obesity
300
D
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200
A
T
100
H
0
15
20
25
30
BMI
35
40
Treatment Options
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Diets
Exercise
Behavior Modification
Medication
Surgery
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
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
Medications
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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
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
Vertical Banded Gastroplasty
• VBG commonly known
as Stomach Stapling
• Small stomach pouch
• Staples partition stomach
• Plastic band controls
outlet to rest of stomach
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
Problems with VBG
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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
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
Gastric Bypass Advantages
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No plastic ring
Greater weight loss
Causes avoidance of sweets and fats
Most foods well tolerated
Low failure rate
Little weight regain
Problems with Gastric Bypass
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Higher rate of complications
1/2 - 1% death rate
Vitamins and minerals poorly absorbed
Laparoscopy may increase complications
Difficult to reverse
Lap-Band System
Lap-Band System
• System Components
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Silastic band
Integrated bladder
Self locking buckle
Tubing
Port
Lap-Band
Lap-Band Port
Lap-Band the Operation
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
Lap-Band Placement
Lap Band Closure
Lap-Band Placement
Lap Band Placement
Lap-Band Fixation
Diet after Operation
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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
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
Band Adjustment
Lap-Band Inflation
Over Inflation
Components for Success
• Education
– Nurse
• understand procedure
• care after operation
– Nutritionist
• diet changes
• healthy balanced food
choices
• Surgery
• Commitment
– follow up
– follow the rules
Weight Loss
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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
Complications
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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)
Summary
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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
Thank
You