ADVANCE AT YOUR OWN PACE

ADVANCE AT YOUR OWN PACE

Welcome and Introductions Obesity and Its Impact on Health Surgeon Introduction Surgical Weight Loss Options AGENDA

OSVALDO ANEZ, MD 28 years of experience Performed approximately 5,000 bariatric surgeries Medical degree: National University of La Plata, Argentina Residency: Washington Hospital Center chief resident in general surgery Board Certified and Fellow of American College of Surgeons Member of the American Society for Metabolic & Bariatric Surgery

WE WILL DISCUSS Ideal Body Weight (IBW) Body Mass Index (BMI) Obesity Morbid Obesity Co-morbidities Indications for Surgery

IBW - WOMEN IBW - MEN Height Feet Inches Small Frame Medium Frame Large Frame Height Feet Inches Small Frame Medium Frame Large Frame 4' 10" 102-111 109-121 118-131 4' 11" 103-113 111-123 120-134 5' 0" 104-115 113-126 122-137 5' 1" 106-118 115-129 125-140 5' 2" 108-121 118-132 128-143 5' 3" 111-124 121-135 131-147 5' 4" 114-127 124-138 134-151 5' 5" 117-130 127-141 137-155 5' 6" 120-133 130-144 140-159 5' 7" 123-136 133-147 143-163 5' 8" 126-139 136-150 146-167 5' 9" 129-142 139-153 149-170 5' 10" 132-145 142-156 152-173 5' 11" 135-148 145-159 155-176 6' 0" 138-151 148-162 158-179 5' 2" 128-134 131-141 138-150 5' 3" 130-136 133-143 140-153 5'' 4" 132-138 135-145 142-156 5' 5" 134-140 137-148 144-160 5' 6" 136-142 139-151 146-164 5' 7" 138-145 142-154 149-168 5' 8" 140-148 145-157 152-172 5' 9" 142-151 148-160 155-176 5' 10" 144-154 151-163 158-180 5' 11" 146-157 154-166 161-184 6' 0" 149-160 157-170 164-188 6' 1" 152-164 160-174 168-192 6' 2" 155-168 164-178 172-197 6' 3" 158-172 167-182 176-202 6' 4" 162-176 171-187 181-207

BODY MASS INDEX (BMI) Base on weight and height

BMI RANGES Normal 18.5-24.9 Overweight 25.0-29.9 Obese 30.0-34.9 Severe Obesity* 35.0-39.9 * (with 1 or more co-morbidities) Morbid Obesity 40.0-49.9 Super-Morbid Obesity >50 BMI ranges indicated for surgery NHLBI 2000 (NIH), Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults

OBESITY: DISEASE OF EXCESS FAT STORAGE Multi-factorial Genetic Environmental Behavioral Costly Lifelong and progressive Causes multiple co-morbidities Life threatening

Genetic Environmental Behavioral

OBESITY: PROGRESSIVE

MORBID OBESITY The most extreme form of obesity Weight that increases the risk of developing medical conditions, such as: Type II Diabetes, Sleep Apnea, Hypertension, etc. >200% of ideal weight or >100lbs over weight BMI > 40 BMI > 35 with one or more severe co-morbidity Life threatening

OBESITY: ASSOCIATED CONDITIONS Type 2 Diabetes Hypertension Hyperlipidemia Respiratory Disease Sleep Apnea Depression Menstrual Irregularity Amenorrhea Dysmenorrhea Urinary Stress Incontinence Asthma/Pulmonary Disorder Gastroesophageal Reflux Disease (GERD) Degenerative Joint Disease (DJD) Heart Disease Gallstones Fatty Liver Disease Coronary Artery Disease Stroke Osteoarthritis Infertility Cancer

WHY SURGERY Only surgery has proven effective over the long term for most patients with clinically severe obesity NIH Consensus Conference Statement, 1991

INDICATIONS FOR SURGERY BMI >40 Or BMI 35-39 + one severe co-morbidity Obstructive sleep apnea Type 2 diabetes Uncontrolled hypertension (high blood pressure) Failed previous weight loss attempts Morbidly obese for at least 5 years At least 18 years of age 12% of the U.S. Adult Population (more than 20 million people) meet this criteria

The Digestive System Surgical Weight Loss Options

NORMAL DIGESTIVE SYSTEM - The first 200cm of small bowel is the jejunum ESOPHAGUS LOWER ESOPHAGEAL SPHINCTER (LES) STOMACH Capacity: average 1000 ml FUNDUS - Last 300cm of small bowel is the ileum - Jejunum + Ileum = 500 cm total small bowel length BODY THE DUODENUM The duodenum absorbs most: Calcium Iron Vitamins Micronutrients

RESTRICTIVE PROCEDURES Adjustable Gastric Banding Sleeve Gastrectomy

RESTRICTIVE Adjustable Gastric Banding Pure restriction Progressive slow compression to prevent hunger No stomach stapling Reversible Simple, lower risk procedure Stomach remains intact Low malnutrition or vitamin deficiency (<1%) Expect about 50% EWL at 3 yrs & only 30% at 1 yr Small 15-30 cc pouch Port Site

RISKS Migration of implant (band erosion) Band slippage Pouch dilation Tubing-related complications (port disconnection, tubing kinks) Port-site infection/displacement Esophageal spasm Gastroesophageal reflux disease (GERD) Inflammation of the esophagus or stomach

RESTRICTIVE Sleeve Gastrectomy Stomach reduced to 20-25% of original size Surgical removal of large portion of stomach Dramatically decreases ghrelin levels Average weight loss greater than gastric band, less than gastric bypass Not reversible

COMBINATION (RYGBP) Produced better weight loss, faster and more consistent long term Level of risk similar with any other general surgical procedure Higher resolution of diabetes Best control or cure of acid reflux Studied extensively and effectiveness and safety proven

Makes the stomach smaller (restriction) Causes food to bypass part of the small intestine decreasing absorption of food Dumping syndrome Done by mini incision or laparoscopy GASTRIC BYPASS (RYGBP)

DUMPING SYNDROME Dumping Syndrome appears to be due largely to rapid entrance of ingested food into the small bowel. Water flows in from the bowel wall, producing both intestinal distention and a reduction in plasma volume. Generalized vasodilation may be a factor.

About 4 incision About 35 TO 45 minutes, requiring less anesthesia 1-3 days hospital stay Reversible MINI INCISION RYGBP

LAPAROSCOPIC RYGBP 4-5 small incisions 1.5 to 3 hour 1 to 3 nights hospital stay Irreversible most of the time

MINI INCISION RYGBP LAPAROSCOPIC RYGBP

Mean co-morbidity resolution post RYGBP (www.ethicon.com)

POTENTIAL COMPLICATIONS Mortality 0.5% (0.3 to 2.3%) Pneumonias 0.1% Blood Clots (in veins or lungs) 0.03-0.5% Bleeding 1.4% Wound Infection 5% Hernias 3.3% (Internal 0.5%) Staple line breakdown, stretched pouch and/or outlet, 5-10% Gallstones 30% Obstruction of the intestines or pouch Protein Vitamins and mineral deficiencies if the supplements are not taken

QUESTIONS This is your journey and you are in charge of your success. We are here to assist you along the way! To schedule an appointment, call 703 956-6743.