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

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

6 Multi-Factorial Causes of Morbid Obesity include: Genetic Environmental Cultural Psychological Socioeconomic

7 How does obesity impact our health?

8 Obesity-Related Comorbidities Type 2 Diabetes Obstructive sleep apnea High cholesterol Hypertension Heart Disease GERD (reflux/heart burn) Gallstones Degenerative joint disease Fatty liver disease Asthma Stress incontinence Birth defects Miscarriages Infertility Cancer Breast Cervical Endometrial Ovarian Colorectal Liver Pancreatic Esophageal Lung Prostate Kidney Lymphoma Multiple myeloma Leukemia

9 Available Treatment Options: Diet & Exercise Medication Behavioral modification Surgical management

10 Why Bariatric surgery? It s the most powerful tool in our tool box

11 Purpose of Bariatric Surgery To alleviate or eliminate obesity related medical diseases It is not cosmetic surgery!

12 Bariatric Surgery Patient Selection (Based On The 1991 NIH Guidelines) BMI > 40; or > 35 with obesity related morbidity Previous failed attempts at supervised weight reduction Realistic expectations No recent substance abuse Age limits (18 to 65 yrs old in most programs) Supportive family/friends Lifelong commitment to dietary change and follow-up

13 What is Body Mass Index? Classification of Obesity Body Mass Index (BMI) = wt (kg) / ht (m) 2 2 BMI (kg/m ) ~Excess body weight Non-obese < 30 lbs Obese > 30 > 30 lbs Morbid Obesity > 40 > 100 lbs Superobesity > 50 > 150 lbs

14 How much weight loss? Current weight: 250 pounds - (subtract) Ideal Body Weight: 150 pounds = Excess Body Weight: % Excess Body Weight = 50 to 75 pounds lost Example: A 300 lb individual may realize a lb weight loss A 400 lb individual may realize a lb weight loss

15 A normal BMI is not necessary for improved health OUR GOALS FOR YOU INCLUDE: Improved Co-morbid Conditions Type 2 Diabetes Obstructive sleep apnea High cholesterol Hypertension Improved Over-all Health Improved Quality of Life Longer Life

16 Bariatric Procedures RNY (Gastric Bypass) Sleeve

17 Laparoscopic Approach

18 Laparoscopic Approach Less pain Fewer infections Shorter length of stay Much less risk of developing a hernia at incision

19 Roux-en-Y Gastric Bypass Restrictive (small pouch size) Malabsorptive (skipping part of the intestine) Alters hunger hormones and insulin sensitivity little to no hunger Improved diabetes Hospital stay of 2 nights

20 Roux-en-Y Gastric Bypass

21 Gastric Bypass PROS CONS Proven long term weight loss Proven reduction of obesity related co-morbidities Best operation for patients with GERD Ulcers/stenosis Anemia Calcium deficiency Dumping syndrome Difficult to reverse Internal hernia

22 Pre-Op 22 BMI = 47 Weight = 306 lbs. Waist = 54 inches High Blood Pressure Diabetes PCOS Depression Back & Knee Pain Swelling of lower legs 7 prescriptions daily LRNY GBP, Johns Hopkins, 11/2008

23 5 years post-op 23 BMI = 25 Weight loss = 140 lbs. Waist = 37 inches Resolved Medical Problems High Blood Pressure Diabetes Depression PCOS Symptoms Improved Medical Problems Back & Knee Pain 1 Prescription Medication Just became pregnant!

24 Vertical Sleeve Gastrectomy Mostly a restrictive procedure Some altered hunger hormones and insulin sensitivity less hunger improved diabetes Hospital stay of 1-2 nights

25 Sleeve Gastrectomy

26 Sleeve Gastrectomy PROS CONS No malabsorption Proven long term weight loss and resolution of comorbidities Preserves pylorus (decreases risk of dumping) Can be converted to gastric bypass or duodenal switch Large portion of stomach removed (not reversible) Can worsen GERD Strictures

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28 Complications of surgery Bleeding Wound Infection DVT (blood clot) to Pulmonary Embolism Cardiac Event Leak Ulcers/Stricture/Stenosis Malabsorption Internal Hernia

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30 SG GBP Excess BMI loss 61% 68% Remission of DM, HTN, dyslipidemia Equivalent Equivalent GERD 33% better 66% better Early morbidity 0.9% 4.5% Total reoperations/interventions 15.8% 23% * Swiss study-217 with 95% follow up to 5 years

31 SG GBP % Excess Weight loss 50% 57% Remission of DM and dyslipidemia Anti-hypertensive meds Equivalent Early morbidity 9% 26% Total reoperations/interventions 10% 18% Equivalent Fewer meds * Finnish study-240 patients with 80% follow up at 5 years

32 Israeli study-retrospective cohort study with 8385 bariatric surgery patients and matched non surgical patients 100% follow up to 4 years Secondary analysis demonstrated improved weight loss, DM remission, and lower HTN/dyslipidemia.

33 Bariatric Budget Impact Calculator

34 Bariatric Budget Impact Calculator

35 The Path to Surgery Information gathering Pre-visit screening Assessments Work-up (tests/studies) Classes (ABC) Follow up visits + class D Pre-op visits and labs Surgery **CAN TAKE UP TO 7 MONTHS

36 Post-op follow-up Week 2 (after surgery) PA or Surgeon Dietitian Week 6 PA or Surgeon Dietitian Month 3 PA or Surgeon Dietitian Labs Month 6 PA or Surgeon Dietitian Labs Health Psychologist Month 12 (yearly thereafter) PA or Surgeon Dietitian Labs Health Psychologist

37 UW Health Hospital and Clinic UW Health Medical and Surgical Weight Management Program

38 Bariatric Surgery, UW Health at The American Center 4602 Eastpark Blvd, Madison

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40 Our Surgeons Michael Garren Jacob Greenberg Luke Funk Anne Lidor

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