CLINICALLY SEVERE

OBESITY

TIMOTHY CUSTER M.D., F.A.C.S

WHAT IS MORBID

OBESITY?

BMI CHART

Do You Know Your Own BMI?

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Definitions

Category BMI lbs overweight % US pop

Normal 25 0 30%

Overweight >25 0-35 30%

Obese >30 >35 35%

Morbidly Obese >40 >80 - 100 5% (15 million)

Morbid Obesity – a “disease”

• Clinically severe obesity = a point at which obesity becomes an independentdisease process and medical conditions occur as a result

this occures at about 100 lbs

over ideal body weight or BMI 40

OBESITY IS A WORLDWIDE EPIDEMIC

Consequences of Obesity

Consequences of Obesity

• Type II Diabetes 30%

• Hypertension 50%

• CAD/ CHF 20%

• Hyperlipidemia 50%

• Respiratory Insuff. 70%

- Sleep Apnea

- Obesity Hypovent Synd

- Asthma

• Intra-abdominal HTN

- GERD

- Stress Incontinence

- Venous Insufficiency

- DVT / PE

- Hernias

Consequences of Obesity

• Gallstones

• Arthritis 90%

• Infertility

• Hepatosteatosis

• Chronic Skin

Infections

• Pseudotumor Cerebri

• Cancer - 2-3x higher

- Breast

- Endometrial/Cervical

- Colon

- Prostate

• Depression

• Social Rejection

Clinically severe obesity

Risk of not Having Surgery

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Increasing BMI

Mortality of Obesity

• Shortens life by 8 yrs for women and 15 years for men

• Only one in seven with severe obesity reach a normal life span (77y)

• Carries a higher mortality than most cancers

• Current generation is the first to have shorter life expectancy than their parents in 100 yrs

OBESITY EPIDEMIC

• Obesity responsible for >$100 billion in

medical costs per yr

• US was first in life span in 1900, now

LAST among developed nations

• Current generation predicted to have 1/3

chance of developing DM

Consequences - Mortality

“Taken together, the diseases associated

with morbid obesity markedly reduce the

odds of attaining an average life span and

raise annual mortality tenfold or more.”

American College of Surgeons, Recommendations for facilities

performing bariatric surgery, ST-34, Bull Am Col Surg, 2000;85:

Consequences - Mortality

>300,000 people die each year secondary to

complications of obesity, making it our

2nd leading cause of preventable death

IV. Treatment of Obesity

Medical Options for Weight

Loss

• Dietary therapy

• Behavioral modification

• Exercise

• Medications

Medical Treatment

The bottom Line:

All Non-surgical weight loss attempts achieve at best modest and short termsuccess in the morbidly obese population, with about 10% wt loss, and regain in about 95% within two years

“ANYTHING LESS THAN A RADICAL AND PERMANENT TRANSFORMATION WILL RESULT IN FAILURE TO TREAT MORBID OBESITY”

Medical Weight Loss

1991 Concensus Conference on

Obesity

• Medical Therapy is Rarely successful

• Those who fail medical therapy should be treated surgically

• Criteria for surgical therapy:

- BMI > 40

- BMI > 35 with significant comorbidities

- failed attempts at medical wt loss

Procedures recommended = VBG and GBP

Surgical Options

• Gastric Band

• Sleeve Gastrectomy

• Gastric Bypass

• Biliopancreatic Diversion with Duodenal

Switch

How does surgery work?

Depending on the procedure:

1. Restriction (less volume in)

2. Malabsorbtion (less calories absorbed)

3. Hormonal Changes (less hunger, “cures”

several disease processes)

4. Dumping (less processed sugar in)

Ruox en Y Gastric Bypass

• First developed in the

1970s

• Procedure of choice in

the United States

• Best wt loss with the

lowest side effects

• 60 - 80% EWL in 12 - 18

mo (90% lose 70%)

• Maintained up to 15 yrs

post op

Gastric Bypass

Q : How does the GBP effect wt loss?

A : Four mechanisms

1. Restriction

2. Malabsorption

3. Dumping Syndrome

4. Hormonal Changes

The Roux-en-Y Procedure

• In the Roux-en-Y

Bypass procedure, a

small pouch

is formed along the

lesser curve, excluding

the fundus

• The fundus is the part

that can stretch out

The Roux-en-Y Procedure

• The small intestine is

divided about 20-50

cm beyond the lig of

trietz (beginning pt of

the jejunum)

The Roux-en-Y Procedure

• The small intestine (B), is brought up to the gastric pouch and these are attached

• The bilio-pancreatic limb (A) is hooked up to the Roux limb (B) 100 to 150 cm from the pouch

• The biliopancreatic limb delivers the bile and enzymes, so food in the roux limb is poorly digested

Dumping

The Roux limb does

not handle sugar well

and therefore eating

sweets will cause

nausea, cramping

and diarrhea

Decreased Hunger

• Ghrelin is a hormone that stimulates appetite

• Ghrelin levels are seen to drop within 24 hrs of surgery

and stay depressed

• Result = “I’m just not hungry”

• Not clear why this occurs

Benefits of GBP

• 90% of Patients lose 70% Excess Weight

• 90% of medical problems resolve or improve

• Longer Life (up to 89% reduced mortality)

• Improved energy

• Improved self-esteem, confidence, and relationships

Roux-en-Y

Open Procedure

• More pain

• Longer hosp stay

• Longer return to work

• Wound complications

- seroma (15%)

- infection (<5%)

- dehicsence (1%)

- hernia (20%)

• Technically much

easier

Laparoscopic Roux-en Y

• Less pain

• Shorter stay

• Less blood loss

• Faster return to

work

• Technically more

challenging

• More internal

hernias

“Restrictive” Surgery

LAP BAND

• Mechanism purely restrictive (no decreased appetite, dumping, or malabsorbtion)

• Injecting saline tightens the opening, decreasing flow out of the pouch

• Adjustments made based on symptoms, wt loss, about every 4 weeks for first several months

ADJUST, ADJUST, ADJUST!

• First adjustment at 6 wks post op

• Continues every 3 wks thereafter until in “green zone”

• Too tight = food gets stuck, nausea/ vomiting, GERD

• Too Loose = poor wt loss, hungry, tolleratebread / red meat, “large” meals

• Average adjustments - 5-6 first year and ever 6 - 12 months thereafter

LAP BAND

• Weight loss , generally , and

than with GBP

- Best studies = 30% 1 yr, 40% 2y, 50% 3y

- Some studies 20 -30% wt loss

- Some up to 60% wt loss

- overall about 50% pts lose 50% excess

weight

Lap Band Advantages

• Stomach and intestines not cut

• May have shorter recovery time

• Band is adjustable (going on a cruise is

not a reason to empty it!!)

• Surgery is “reversible” ( usually for

complications)

Lap Band Disadvantages

• Wt loss slower, less and more variable

• Persistently high rates of reoperation and

band removal (15 – 25%)

• Less Resolution medical problems

• Easier to “cheat”

• Requires Maintenance adjustments

forever (every 6 - 12 months)

Who should get a band?

Sleeve Gastrectomy

• BPD developed 1976

• BPD with DS 1998

• LS BPD w/ DS 2000

• Some restriction

• Mostly malabsorbtion

• Hormonal effect

• More complications,

higher risk

Sleeve Gastrectomy

“Two stage” LS BPD w/

DS proposed 2000

-LS Sleeve first

-Intestinal bypass after

initial wt loss

-FOUND THAT SOME

DID NOT NEED 2ND

SURGERY

Sleeve Gastrectomy

• 2005 – 2 studies of LS Sleeve as primary

procedure showing 53% and 83% EWL at

1 yr

• 2006 first large study (357pts) showing

62% EWL 12m and 67% EWL 2 yrs

• To date 36 studies (2,570 pts) showing

33 – 85% EWL at 5 yrs, AVERAGE 60%

Sleeve Gastrectomy

MECHANISM:

1.Restriction – 100 to 150 cc vs 30cc pouch

2.Hormonal Effect

- decreased grehlen 70%

- decreased hunger 75%

- significant effect on diabetes

3. No dumping, no malabsorbtion

COMPLICATIONS

LAP BAND GASTRIC BYPASS GASTRIC SLEEVE

Gastric Prolapse (slip) Anastomotic Leak Staple line Leak

Band Erosion Bowel Obstruction Bleeding

Esophageal Dialation Pulm Embolism Stricture

Port Problems Stricture/Marginal Ulcer Conversion to GBP

Death .1 - .5% Death .2 - .3% Death .2%

Is it worth it?

• Mortality - Cholecystectomy .2 - .5 %

- Hip Replacement .1 - .3 %

- Colon Resection 3 – 5 %

- LS Incisional Hernia 1 – 3%

- Hysterectomy .1 - .6%

Bariatric Surgery

• Major Life Changing event

• Not a “cure” for Morbid Obesity, but . . .

• Currently the best (and only) tool available

to manage the disease of Morbid obesity

• Will only be successful when

accompanied by of and

lifestyle changes