surgical treatment of morbid obesity
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SURGICAL TREATMENT OF
MORBID OBESITYScott D. Steinberg, M.D.
St. Vincents Hospital and Medical Center
Grand Rounds, May 30, 2001
OVERVIEW• The problem of obesity
• Indications for bariatric surgery
• Evolution of bariatric surgery
• Results of bariatric surgery
• Conclusions
HOW BIG IS THE PROBLEM?
INTRODUCTION• More than 50% of US adults are
overweight (BMI > 25 kg/m2)
• The percentage of obese Americans (BMI > 30 kg/ m2) has increased by more than 50% in the last 20 years
• The number of overweight children has doubled over the last 20 years
JAMA, 282(16), 1504-1506
PREVALENCE OF OBESITY IN THE UNITED STATES
• The estimated number of annual deaths attributable to obesity among US adults is approximately 325,000
• More than 80% of these deaths occurred among individuals with a BMI of > 30 kg/m2
MORBID OBESITY
JAMA, 282(16), 1530-1538
BODY-MASS INDEX
(Height in meters) 2
BMI =Weight in kg
DEFINITIONSOVERWEIGHT BMI 25-29.9 kg/m2
OBESITY BMI 30-39.9 kg/m2
MORBID OBESITYBMI 40-49.9 kg/m2
SUPER OBESITY BMI > 50 kg/m2
100 lbs above ideal body weight
OR
BMI >40kg/m2
CLINICALLY SEVERE OBESITY
THE FRAMINGHAM STUDY
The first cohort to terminate because of demise of all participants was the morbidly obese
• Results from a complex interaction of genetic, behavioral, and environmental factors
• Second leading cause of preventable death, exceeded only by cigarette smoking
OBESITY
MORBID OBESITY• HTN• Diabetes• CAD• CHF• Cirrhosis• Osteoarthritis• Vascular disease
• Gallbladder disease• Sleep apnea• Breast cancer • Uterine cancer • Prostate cancer• Colon cancer• Psychiatric disease
• First treatment is lifestyle and dietary changes
• Only 5-10% of patients maintain weight loss for more than a few years
• When conservative measures fail, patients may consider surgery
MORBID OBESITY
Blue Cross/Blue Shield Medical Policy Manual, 1996
WHICH PATIENTS ARE CANDIDATES FOR BARIATRIC
SURGERY?
• Risk for M&M is proportional to the degree of overweight
• Pts with BMI > 40 (*35) are at highest risk and should be considered for bariatric surgery
• Diet and Drug therapy has limited success in the morbidly obese
• Endorsed VBG and Roux-en-Y gastric bypass
Gastrointestinal Surgery for Severe Obesity. NIH Consens Statement 1991 Mar 25-27;9(1):1-20.
• BMI > 40 kg/m2
• BMI > 35 kg/m2 with serious co-morbid medical conditions
• Repeated failure at conservative treatments • No history of significant psychiatric disorders
INDICATIONS FOR SURGERY
VBG
GASTROPLASTY
ADJUSTABLE BAND
RESTRICTIVE MALABSORPTIVE
JIB
SMALL BOWEL BYPASS
BPD/DS, ROUX-en-Y GASTRIC BYPASS
Dr. John Linner
1954
Jejuno-ileal bypass
THE BEGINNING
COMPLICATIONS OF JEJUNOILEAL BYPASS
• Electrolyte disturbances• Osteoporosis/osteomalacia• Protein malnutrition• Cholelithiasis• Diarrhea• Hair loss
• Arthritis• Liver failure• Steatosis• Renal calculi• Neuropathy• Anemia
Dr. Edward Mason
University of Iowa
1967 Gastric Bypass with
loop gastroenterostomy
GASTRIC BYPASS SHORT TERM • Anastomotic leak• Acute gastric dilatation• Roux-Y obstruction• Atelectasis• Wound infection
LONG TERM• Stomal stenosis• Anemia• Vit B12 deficiency• Calcium deficiency
GASTRIC BYPASS WITHROUX-en-Y LIMB
SUBSEQUENTLY MODIFIED
50 mL POUCH WITH A ROUXLIMB TO MINIMIZE BILEREFLUX
ROUX LIMB WAS LENGTHENEDTO INCREASE MALABSORPTIONAND IMPROVE WEIGHT LOSS
COMBINED RESTRICTIVEAND MALABSORPTIVE
Nicola Scopinaro
Biliopancreatic Diversion (BPD)
Any procedure that diverts bile and pancreatic secretions
Combined Restrictive and Malabsorptive surgery
1976“BPD”
COMPLICATIONS OF BPD
• Protein Malnutrition 15%
• Incisional Hernia 10%
• Intestinal obstruction 1%
• Acute biliopancreatic limb obstruction
• Stomal ulcer
1982VBG
Vertical-Banded
Gastroplasty
•Dr. Edward Mason
•Stapled opening in stomach
•Staple line along angle of His
•Polypropylene mesh around lesser curvature
1988BPD/DS
Dr. Doug Hess
•MODIFIED BPD
•Duodenal switch w/ sleeve gastric reduction
•Intact pylorus
•Eliminates dumping and ulcers
1994
AUGUST 1999 300 lbs DECEMBER 2000 143 lbs
CARNIE WILSON
MAY 2000: SAGES GUIDELINES FOR LAPAROSCOPIC
AND CONVENTIONAL SURGICAL TREATMENT OF MORBID OBESITY
ROUX-en-Y GASTRIC BYPASS
GOAL: To restrict the
gastric reservoir
ADVANTAGES
• Controls food intake
• Dumping reduces intake of sweets
• Reversible if indicatedRoux-en-Y Gastric
Bypass
ROUX-en-Y GASTRIC BYPASS
DISADVANTAGES
• Staple line failure
• Ulcers
• Blockage of stoma
• Vomiting if food eaten quickly Roux-en-Y Gastric
Bypass
LAPAROSCOPIC ROUX-en-Y
GASTRIC BYPASS
LAPAROSCOPIC ADJUSTABLE
GASTRIC BAND(LAP-BANDTM)
THE DATA…
• N=500• Excess weight loss of 80% in first year• 95% of significant pre-operative comorbidities well controlled
2000
Obesity Surgery, 2000 18:233-239
• N=1040
• Mean LOS 1.9 days
• Mean OR time 60 min
• No leaks
• 5 perioperative deaths
–3 PE, 1 asthma, 1 suicide
• Mean EWL 70% @ 1 yr
• N=275 (1997-2000)
• 1-31 month f/u
• One conversion
• One death (PE)
• 11 Wound infections
• Median LOS 2 days
• EWL
–83% @ 24 months
–77% @ 30 months
CONCLUSIONS• OBESITY IS A MAJOR PROBLEM IN
THE UNITED STATES
• CURRENT DIET AND DRUG THERAPY OFFERS LIMITED SUCCESS FOR THE MORBIDLY OBESE PATIENT
• BARIATRIC SURGERY OFFERS THE MORBIDLY OBESE LONG-TERM WEIGHT LOSS WITH IMPROVEMENT IN MORBIDITY AND MORTALITY
• LAPAROSCOPIC BARIATRIC SURGERY CAN BE PERFORMED SAFELY WITH EXCELLENT RESULTS
CONCLUSIONS
THANK YOU
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