Viriato Fiallo, MD Ursula McMillian, MD

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1 Viriato Fiallo, MD Ursula McMillian, MD

2 Objectives Define obesity and effects on society and healthcare Define bariatric surgery Discuss recent medical management versus surgery research Evaluate different weight loss operations

3 Obesity Obesity is a chronic disease which has become a leading health problem More than 1/3(35.7%) of US adults are obese 17% of children and adolescents are obese

4 Obesity Mortality of obesity causes in excess of 112, ,000 deaths per year BMI 30-35: decreased life expectancy by 2-4 years BMI greater than 40 decreases life expectancy by 10 years Morbidity and mortality associated with specific obesity related diseases

5 Obesity Facts About 72 Million US adults Affect on children and adolescents (DM 2) Causes: Genetics (75% concordance), socioeconomic status, environment/culture Obesity significantly increases healthcare costs both directly and indirectly(decreased employability) Annual cost is $270 billion

6 What Causes Obesity? Obesity is the result of a combination of influences: The genes you inherited from your parents How well your body turns food into energy Your eating and exercising habits Your surroundings and the environment 11 BILLION DOLLARS SPENT ON ADVERTISING FOR FAST FOOD, SNACKS, AND SOFT DRINKS Psychological factors(depression/low self esteem)

7 Hunger Hormones Ghrelin Leptin Insulin PYY

11 Body Mass Index (BMI) BMI is a ratio between an individual s weight and the square of his height and is reported in kg/m2. It is the best measurement we have to determine how overweight a person may be BMI = Weight (pounds) x 703/Height (inches)2

Standard Obesity Classification OBESITY CLASS BMI UNDERWEIGHT < 19 NORMAL 19 24.

12 Standard Obesity Classification OBESITY CLASS BMI UNDERWEIGHT < 19 NORMAL OVERWEIGHT OBESITY I OBESITY II MORBID OBESITY III > 40

13 Co-Morbidities Related to Obesity Hypertension Type-2 Diabetes Sleep Apnea Cardiac Heart Disease Reflux High Cholesterol Depression Gallbladder Disease

14 Co-Morbidities (continued) Intertrigo Arthritis Urinary Stress Incontinence Fertility Problems (Pcos) Certain Types Of Cancers (Breast)

15 Psychosocial Implications of Obesity Low Self-Esteem Low Self-Confidence Reduced Employability, Less Pay, Decreased Opportunities For Promotions Decreased Libido Social Isolation (Movie Theaters, Travel, Amusement Park Rides, etc)

16 Non-Surgical Interventions Jenny Craig, Weight Watchers, Optifast, Medifast, etc., Do Not Achieve Long Term Weight Control And 95% of Dieters Regain Their Weight Drugs Produce a Modest Weight Loss of 4-22 Pounds, but Typically Plateaus After Six Months and Has Significant Regain Drugs and Diets Do Not Work on the Morbidly Obese Patient

17 Surgical Management of Obesity A LIFETIME TOOL FOR WEIGHT LOSS

18 Research 2 ground-breaking studies showing bariatric surgery being superior to medical management for treatment of diabetes (March 2012) Mingrone G, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes Schauer PR, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes

19 Research First paper from Italy looks at Gastric bypass and biliopancreatic diversion versus medical management Results: bariatric surgery patients had better glycemic control. Remission 75% and 95% at 2 years Remission of diabetes showed no correlation with weight loss unlike previous study

20 Research Second paper (Cleveland Clinic) evaluates intensive medical management for diabetes versus gastric bypass and sleeve gastrectomy Results: endpoint(blood glucose control) reached in 12% medical management, 37% sleeve gastrectomy, and 42% gastric bypass Medications for obesity related comorbidities decreased in surgery group but increased in medical management group

21 Surgical Management Open Roux-En-Y Gastric Bypass Laparoscopic Roux En-Y Gastric Bypass Laparoscopic Adjustable Banding Lap Sleeve Gastrectomy Duodenal Switch

22 Roux-en-Y Gastric Bypass

23 Benefits of Gastric Bypass surgery Large scale weight loss Improved health and well being Often produces remission of diabetes Resolution or significant improvement in obesity related comorbidities

24 Expected Outcomes for Gastric Bypass Surgery Average weight loss at 3 years postop of about 60 % excess body weight Chronic vitamin use post op Regular visits to your surgeon Possible excess skin and associated problems Dumping syndrome and possible increase bowel movements Smaller food portions Possible nausea or vomiting

25 Complications of Gastric Bypass Surgery Death Blood Clots to Lungs/Legs Infection Leak/Peritonitis Incisional Hernia Bowel Obstruction

26 Side Effects of Gastric Bypass Surgery Dumping Hair Loss Milk Intolerance Vitamin B-12 Deficiency Anemia Protein Deficiency Constipation Depression Vomiting Diarrhea Other Vitamin and Nutrient Deficiencies Excess Skin

27 Absorption of Vitamins and Minerals

29 Lap Band

30 Restrictive procedure Lap Band No changes to anatomy Slow and modest weight loss (40% at 3 yrs) Complications are slippage and erosion Requires strict adherence to diet and exercise

31 Lap Sleeve Gastrectomy

32 Sleeve Gastrectomy Restrictive procedure 80 % stomach removes Better hunger control with removal of ghrelin Pylorus still in tact also helps satiety Great weight loss (66% at 3 years) Doesn t require such strict adherence to diet and exercise

33 Risks of Sleeve Gastrectomy Leak Obstruction Gastroesophageal reflux Vomiting Bleeding

34 Duodenal Switch

35 Course of Postoperative care 1-3 days in the hospital Liquid diet for 2 weeks then slow advancement over 6 weeks to regular diet Regular follow up with surgeon and possibly dietician Occasional lab work to check vitamin levels Continuation of a high protein, low carb, low fat diet

36 Postoperative Care Progressive advancement of diet Monthly follow up for 3 months, then Q3 months, then yearly Vitamin supplementation Support groups Dietary and exercise counseling

37 Contraindications to Bariatric Surgery Physical health prohibits surgery Inflammatory bowel disease Severe liver disease or kidney disease Pregnancy Addiction to alcohol or drugs Current nicotine use Chronic steroid use Autoimmune connective tissue disease Severe mental illness

38 Thank You Questions?

SURGICAL MANAGEMENT OF OBESITY. Anne Lidor, MD, MPH Professor of Surgery Chief, Division of Minimally Invasive and Bariatric Surgery

SURGICAL MANAGEMENT OF OBESITY Anne Lidor, MD, MPH Professor of Surgery Chief, Division of Minimally Invasive and Bariatric Surgery Multi-Factorial Causes of Morbid Obesity include: Genetic Environmental