Bariatric Surgery: Indications and Ethical Concerns

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1 Bariatric Surgery: Indications and Ethical Concerns Ramzi Alami, M.D. F.A.C.S Assistant Professor of Surgery American University of Beirut Medical Center Beirut, Lebanon

2 Nothing to Disclose

3 Determined by height and weight Comparison to ideal weight Waist circumference Body Mass Index (BMI) = kg/m 2 Body Fat Distribution Morbid Obesity Definition

4 Degrees of Obesity Body Mass Index NORMAL OVERWGT OBESE SEVERE LY OBESE MORBIDLY OBESE 40

5 What Causes Obesity? Genetic predisposition Twin studies Adopted children Obesity gene Physiologic Leptin/Ghrelin Decreased stretch receptors Loss of satiety mechanism (hypothalamus) Evolutionary- Thrifty Gene Behavioral Family tradition Food to comfort child Addiction Gender (80% women) Higher fat component Socioeconomic High/low income classes Cultural views Psychosocial Coping mechanism (i.e. stress, abuse) Societal Technology has decreased energy expenditure Elevators, power windows, food delivery, remote controls, computers, TV, cars

6 Medical Implications of Obesity Diabetes Hypertension Lipid disorders Heart disease Asthma Sleep apnea Gallstones NASH (non-alcoholic steatohepatitis) Urinary incontinence Gastroesophageal reflux Osteoarthritis and gout Infertility and menstrual problems Obstetric complications Low back pain DVT & thromboembolism Depression Immobility Cancer (breast, colorectal, prostate, endometrial, etc.) Venous/stasis ulcers Skin infections Psuedotumor cerebri Trauma

7

8 Exponentially Increased Death Risks of Morbid Obesity Mortality Ratio Mild Risk Moderate Risk High Risk BMI

9 Evolution of Obesity, the Modern Epidemic

10 The Obesity Epidemic A Rapidly Expanding Problem Three in five Americans are either overweight or obese In the past 20 years, adult obesity has doubled 300,000+ premature deaths annually 400,000 deaths/year from smoking, but is decreasing 90,000 deaths/year from colon and breast cancer combined 75% of obese children become morbidly obese adults Source: The Surgeon General s Call to Action to Prevent Overweight and Obesity.

11 Obesity and Bariatric Surgery About 15 million people or 1 in 50 adults in the U.S. are morbidly obese Obesity (BMI 30 or more) increased by 24%, morbid obesity (BMI 40 or more) increased by 50% and super obesity (BMI 50 or more) increased by 75%, according to a 2007 RAND study published in the Archives of Internal Medicine ~ 341,000 bariatric procedures worldwide in 2011

12 Bariatric Surgeries in 2011 Buchwald, Obes Surg 2013

13 High Attrition Rates of Commercial Weight Reduction % Attrition Rate Programs Weeks after commencement of program

14 Atkins Diet: NEJM, 2004

15 Ghrelin: Biological Cause of Post-Diet Weight Regain

16 Brief History-Bariatric Surgery Jejunoileal bypass mid 1954 Gastric bypass Mason mid 1967 Vertical Banded Gastroplasty, Mason 1982 Lap band 1990 Laparoscopic gastric bypass 1994 Biliopancreatic diversion Scopinaro 1996 Duodenal Switch Laparoscopic vertical sleeve gastrectomy, 2000 Laparoscopic Gastric Plication 2007

17 Most Popular

18 Most Popular

19 Bariatric Surgeries in 2011 Buchwald, Obes Surg 2013

20 Gastric Bypass and Diabetes Schauer NEJM 2014

21

22 The Obesity Epidemic A Rapidly Expanding Problem Three in five Americans are either overweight or obese In the past 20 years, adult obesity has doubled 300,000+ premature deaths annually 400,000 deaths/year from smoking, but is decreasing 90,000 deaths/year from colon and breast cancer combined 75% of obese children become morbidly obese adults Source: The Surgeon General s Call to Action to Prevent Overweight and Obesity.

23 Selection Criteria for Surgical Management 1991 NIH Consensus Conference Criteria BMI >40 kg/m 2 or BMI > 35 kg/m 2 with comorbidities Failure of nonsurgical methods Absence of endocrine disorder causing obesity Psychologic stability

24 Despite bariatric surgery s proven efficacy in managing obesity, its utilization in patients that meet the NIH guidelines in the USA is <1%

25 Today s Concerns Low peri-operative mortality. Overall now less than 0.5% Low perioperative morbidity Leak rates 2.5-4% Bleeding DVT/ PE Marginal Ulcer Stricture Bowel obstruction Wound infection Long Term Morbidity Nutritional Deficeincies Internal Hernias Failure Weight Regain: Up to 8+ percent with Roux en-y Gastric Bypass

26 Time for change?

27 Time for Change?

28 Concerns Bariatric Surgery Cosmetic Surgery 18 yoneeds to lose 10 kgs Unsatisfied with weight loss presenting for revision Psychological concerns Inherent failure of half measures Lap Band Intragastric Balloon Follow Up True Informed consent

29

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Surgical Therapy for Morbid Obesity. Janeen Jordan, PGY 5 Surgical Grand Rounds April 7, 2008

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