OBESITY AND WEIGHT LOSS SURGERY FOR THE PRIMARY CARE PHYSICIAN

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1 OBESITY AND WEIGHT LOSS SURGERY FOR THE PRIMARY CARE PHYSICIAN Nicole Basa, M.D., F.A.C.S., F.A.S.M.B.S Assistant Professor of Surgery Texas A&M Medical School Bariatric Medical Director- Cedar Park Regional Medical Center Cedar Park Surgeons, PLLC June 9, 2018

2 SPEAKER DISCLOSURE Dr. Basa has disclosed that she has no actual or potential conflict of interest in relation to this topic.

3 LEARNING OBJECTIVES By the end of this activity, the participant should be better able to: Identify patients who are good candidates for bariatric surgery and what premorbid conditions are exacerbated by obesity and improved with surgery. Decide what preoperative evaluation and/or interventions are needed before patients are scheduled for surgery. Review bariatric procedures, including what is being done and how well it works. Discuss postoperative care of the bariatric patient, including issues such as vitamin malabsorption, chronic need for vitamin supplements, issues with postoperative pill size, not drinking liquids with meals, and what foods can be problematic.

4 OBESITY PANDEMIC In the United States it is more common to be overweight than not. 2/3 of population BMI over 25 1/3 of population BMI over 30

5 WEIGHT LOSS METHODS DIET & EXERCISE SURGERY

6 DIETS STATISTICS 60 million Americans diet/year $50 billion spent On diet aids/year 95% regain weight After 3 years

7 BIGGEST LOSER CONTESTANTS Resting Metabolic Rate Baseline 2607 kcal/d After 30 week competition 1996 kcal/d After 6 years with weight regain 1900 kcal/d Why??? METABOLIC ADAPTATION

8 METABOLIC ADAPTATION Weight loss causes a slowing of Resting Metabolic Rate (RMR) Despite contestants losing more fat than muscle The RMR after weight loss < RMR predicted by body composition

9 Cause of Yo Yo Dieting? METABOLIC ADAPTATION CAUSE FOR SET POINT?

10 DIET AND EXERCISE VS. SURGERY Metabolic adaptation lasted for 6 years after the contestants lost weight Bariatric Surgery Roux en Y Gastric Bypass- Metabolic adaptation lasted for 6 months and then stopped

11 What does this mean? It is NOT normal for the body to lose weight! THE BODY WANTS TO REMAIN AT ITS SET POINT

12 BARIATRIC SET POINT SURGERY

13 LONG-TERM WEIGHT LOSS

14 COMORBIDITY RESOLUTION

15 BARIATRIC SURGERY CRITERIA BMI over 40 or BMI over 35 with at least one comorbidity Sleep Apnea Diabetes Mellitus Hypertension

16 PREOPERATIVE REQUIREMENTS Monthly medically supervised weight loss visits Psychological evaluations Cardiac clearance if with cardiac risk factors Dietitian visits optional per surgeon/insurance Weight loss preoperatively optional per surgeon

17 Gastric Bypass Sleeve Lap Band 75% Excess Wt. Loss 65% Excess Wt. Loss 40% Excess Wt. Loss Malabsorptive & Restrictive Restrictive

18 LAP BAND 2011 approximately 35% of weight loss surgeries 2015 less than 6%

19 SLEEVE GASTRECTOMY 2011 approximately 17.8% of weight loss surgeries %

20 ROUX EN Y GASTRIC BYPASS % of weight loss surgeries 2015 less than 23.1%

21 WHY DOES THE SLEEVE AND BYPASS WORK? Hormonal Control Change in Gut Flora Neurological Perception in Taste/Smell changes

22 HORMONAL CHANGES-SLEEVE AND BYPASS Ghrelin causes hunger decreases Peptide YY3-36 causes satiety Increases CCK causes satiety Increases postprandially

23 GLUCAGON LIKE PEPTIDE- 1 Post-prandial levels increase after surgery Improves insulin secretion Promotes satiety- centrally Diabetic medication currently as Liraglutide GLP-1 receptor agonist Improves Diabetes and causes weight loss

24 Sleeve Gastrectomy drives Persistent shifts in the gut microbiome MICE WITH SLEEVE GASTRECTOMY MICE WITH SHAM OPERATION DETECT BACTERIAL FLORA

25 CHANGES IN GUT FLORA Increases weight Decreases weight Increases weight

26 TASTE AND SMELL CHANGES Change in taste and smell occur by 2 months after sleeve/bypass Fat, fruits and meats were the foods that changed the most in taste/smell No difference between sleeve and bypass patients Improved weight loss with taste/smell change Surgery for Obesity and Related Diseases , S15-S16DOI: ( /j.soard )

27 REVISIONAL SURGERY Lap Band Removals Lap Band to Sleeve Lap Band to Bypass % of weight loss surgeries %

28 ROBOTIC SURGERY

29 ANTI-INFLAMMATORY USE Sleeve Gastrectomy OK Gastric Bypass Marginal ulceration may form in the Roux limb so life long commitment to: Stop anti-inflammatories for life No smoking

30 MEDICATION CHOICE AFTER BARIATRIC SURGERY For Sleeve and Gastric Bypass patients NO extended release medications Eliminate diuretic usage to prevent dehydration postoperatively Pills smaller than 8 mm

31 POSTOPERATIVE CONSIDERATIONS Patients must chew times after surgery before swallowing Low Carbohydrate, Protein approximately 1gm/kg, Low/Minimal Sugar less than 5 grams per meal No Straws No Carbonation Fluid Loading drinking 30 mins before and after a meal

32 VITAMIN SUPPLEMENTATION Gastric Bypass and Sleeve Gastrectomy Multivitamin that has greater than 100% of Vitamin K, Biotin, Zinc, Thiamine, Folic Acid, Iron and Copper Calcium Citrate with Vitamin D mg/day

33 VITAMIN SUPPLEMENTATION Iron Ferrous Fumarate or Ferrous Gluconate may be tolerated best Men and Postmenopausal women mg/day Premenopausal or Anemia mg/day Vitamin B12 Sublingual 500 mcg/day, 1000 ug IM injection monthly or weekly Cyanocobalamin Nasal Spray

34 FOODS TO AVOID Raw Celery Coconut Corn Dried Fruit Gum Hot Dog Skins

35 MORTALITY RATE Sleeve 0.08% Gastric Bypass 0.14% Gallbladder Surgery % Appendectomy 1.8%

36 COMPLICATIONS Sleeve and Gastric Bypass Leak 2.4 % Revisional Lap Band to Sleeve Leak 4-6 %

37 EMERGING TECHNOLOGIES

38 ENDOSCOPIC TREATMENTS Space-occupying devices Restrictive procedures Bypass liners Aspiration therapy Electrical stimulation

39 OBALON

40 FDA ALERT- FEB patients died within a month or less from placement Possible esophageal perforation or gastric perforation. Caution doctors to follow the patient closely due to risks of acute pancreatitis and spontaneous hyperinflation

41 ORBERA VS. RYGB Surgery for Obesity and Related Diseases , DOI: ( /j.soard )

42 CONCLUSIONS Gastric Sleeve and Bypass are effective at weight loss Allows the set point to be changed Hormonal changes occur to promote sustained weight loss Lap Band and Endoscopic treatments Currently Ineffective

43 CONCLUSIONS Bariatric Surgery with the aid of laparoscopic and robotic surgery are safe and effective tools for weight loss Low mortality and complication rate Quick recovery with patients ambulating within hours after surgery Discharge is done after overnight stay or as an outpatient for Sleeve Gastrectomies

44 THANK YOU

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