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Weight Loss Surgery:
The First Step Toward a More Healthy Life
Pre-operative Medications
Post-operative Medications
Defining the Problem
The Problem
• Prevalence of obesity in U.S. increased from 12%
to 21% between 1991 and 2001 = 15 million
people
• Obesity is the 2nd most common cause of death
from a modifiable behavioral risk factor
• 111,909 excess deaths annually
Mokdad AH et al. JAMA. 2003;289:76-79
Flegal KM et al. JAMA 2005;293:1861-1919
Excess U.S. Medical Costs Related
to Abnormal Body Weight
Int J Obesity 2005;29:334-339
Relative risk of health problems
associated with obesity
Greatly increased
(relative risk >>3)
Moderately increased
(relative risk 2-3)
Diabetes
Coronary heart disease
Gall bladder disease
Osteoarthritis (knees)
Hypertension
Hyperuricemia and
gout
Dyslipidemia
Insulin resistance
Slightly increased
(relative risk 1-2)
Cancer (breast cancer in
postmenopausal women,
endometrial cancer, colon
cancer)
Reproductive hormone
abnormalities
Breathlessness
Polycystic ovary
syndrome
Sleep apnea
Impaired fertility
Low back pain
Increased anesthetic risk
Fetal defects arising
from maternal obesity
The Effect of Obesity on the Development
of Health Risks
Age-adjusted relative risk of type 2 diabetes
50
100
Men1
42
40
93
Women2
75
30
50
40
20
12
25
10
2.2
8.1
1.0
0
<23
25
31
35
0
1.0
<22
25
31
35
BMI
1Chan
JM et al. Diabetes Care 1994;17:961-969; 2Colditz G et al. Ann Intern Med 1995;122:481-486.
Causes of Obesity
Behavior
Genetics
Environment
The Environment: Portion Size
Non-operative Treatment of Obesity
How does it add up?
Diet
Exercise
Behavioral therapy
+ Drug therapy
??????
.
Fed up with how her diet is going Charlene
takes a more serious aim at her target weight
Surgical Treatment of Obesity:
The Basics
What is Body Mass Index ( BMI ) ?
Surgical Treatment of Obesity:
Indications and Surgical Options
Patient Selection
• Age 18 - 55
AND
• BMI ≥ 40 kg/m2
OR
BMI 35 - 40 kg/m2 with
• High risk health problems OR
• Obesity-induced physical problems
NIH Consensus Development Conference
Operative Approaches
Restrictive Procedures
• Vertical banded gastroplasty ( VBGP )
• Adjustable silastic gastric banding (ASGB)
Malabsorptive Procedures
• Biliopancreatic diversion ( BPD )
• Duodenal switch modification of BPD
Combined Procedures
• Roux-en-Y gastric bypass ( GBP )
The Gastrointestinal System
Vertical Banded Gastroplasty (VBG)
General Features
• Pouch size: 1 oz
• Triple staple line
• Pouch opening: 0.5 in
Average Weight Loss
• 50 % of excess weight
Vertical banded gastroplasty:
Complications
•
•
•
•
•
Stomal narrowing with persistent vomiting
Staple line leak or disruption
Band erosion
Wound infection or hernia
Death
0.1%
• Overall re-operation rate
43 %
Adjustable Silastic Gastric Banding
(ASGB): LapBandTM
GENERAL FEATURES
• Inflatable balloon within the
band orifice can be adjusted
via a reservoir under the skin
Average Weight loss
• 50% of excess weight
Adjustable Silastic Gastric Banding : Complications
•
•
•
•
•
•
•
•
Splenic injury
Esophageal injury
Wound infection
Persistent vomiting
Acid reflux
Band slippage
Reservoir leak/deflation
Band erosion
• Death
0.3 %
Re-operation 5 -20 %
Biliopancreatic Diversion with
Duodenal Switch (BPD-DS)
General Features
• Gastric pouch size:
• Standard: 14 oz (1.5 cups)
• Three segments
• Alimentary tract: 6.5 ft
• Biliary tract: 13 ft
• Common channel: 1.5 ft
Average Weight Loss
• 80 % of excess weight
Duodenal Switch (BPD-DS) :
Complications
•
•
•
•
•
•
•
•
•
•
•
Protein malnutrition
Anemia
Marginal ulcer
Peripheral neuropathy
Night Blindness
Osteoporosis
Renal stones
Nausea
First 6 mo
Diarrhea
Vitamin deficiencies: A, D, E, K, B12
Incisional hernia
• Death
15%
<5%
<3%
1.3 %
3%
14 %
65 %
62 %
10 %
1.1 %
Roux-en-Y Gastric Bypass
(RYGBP)
General Features
• Pouch size: 1 oz
• Pouch opening: 0.5 in
• Roux-en-Y limb
• Standard: 2 ft
Average Weight Loss
• 70 % of excess weight
“The Pouch-Tool”
Gastric Bypass: Complications
Early:
•
•
•
•
Late:
• Stomal narrowing /vomiting 15 %
Staple line leak 1-5%
• Marginal ulcer
13%
Acute gastric
• Heartburn / inflammation of
distention
esophagus
• Anemia
Roux-Y obstruction
• Folate deficiency
• Vitamin B12 deficiency
Death
0.5 %
• Iron deficiency
• Calcium deficiency / osteoporosis
• Gallstones
10 %
General Complications of
Weight-Loss Surgery
• Post-operative depression
• Food issues
• Changes in relationships
• Hair loss
• Usually temporary
• Cause: protein, vitamin A, mineral
• Excess skin
Weight Maintenance after Bariatric Surgery
Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26
Conclusions
• Bariatric surgery is an effective means to
achieve clinically significant, permanent
weight loss with low rates of complications.
• Bariatric surgery results in significant
improvement in health risks associated with
obesity.
• Surgical weight loss increases life-span.
• Surgical therapy is cost-effective.