Download - Surgical Options for Weight Loss
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The Surgical Management of Clinically Severe Obesity
Robert Bell, MD, MA, FACS
July 31, 2013
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Clinically Severe Obesity
• 65% of the US are Overweight or Obese
>86% by 2030
• 75% of obese children become obese adults
• Over 8 million Americans meet NIH criteria for weight loss surgery
• Compared to moderate obesity 2X growth rate of BMI >
40kg/m2
3X growth rate of BMI > 50 kg/m2
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Bariatric Surgery
• Goal of every bariatric procedure is to assist the patient in reducing daily calorie intake
• Exercise is key
Calories In > Calories Out Weight Gain
Calories In = Calories Out Weight Stable
Calories In < Calories Out Weight Loss
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Effect of Treatment on Obesity
Lifestyle Intervention = 3%
Medications = 1%
Surgery = 1%
Unmet = 95%
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Treating Obesity
• Diets, exercise, hypnosis, jaw-wiring and behavioral change
Up to 10% loss of excess body weight
Ineffective long-term: less than 5% sustain any significant weight loss
• Weight Loss Drugs Minimal sustained weight loss
• Weight Loss Surgery Average 55% loss of excess body
weight 85% long term success rate
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What is “Morbid” Obesity?
• The term originated when physicians had to communicate with insurance companies the disease aspect of treating obese patients (clinically severe obesity).
• Patients who weigh 100% over ideal weight.
• Patients with a BMI > 35
• Patients who develop disease states as a result of obesity.
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NIH guidelines
• BMI > 35 with co-morbidities.
• BMI > 40.
• Must have attempted and failed prior weight loss therapy.
• Must understand risks of operation.
• Must agree to lifelong follow up.
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Operations for Clinically Severe Obesity
Sleeve GastrectomyGastric Banding
Restrictive + hormonal
Gastric Bypass
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Surgery is the Un-Diet
Diet Surgery
Appetite
Hunger
Satiety
Reward-based eating
Energy expenditure
Stress response
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Adipocyte Secretions
IGF-1IGFBP
TNF-Interleukins
TGF-FGFEGF
Fatty acidsLysophospholipid
LactateAdenosine
ProstaglandinsGlutamine
Unknown Factors
Agouti Protein
Retinol
PAI-1
LeptinASPAngiotensin
ANG-II
Estrogen
Adipsin
Adiponectin
Resistin
Bone Morphogenic Protein
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Hormonal changes• Ghrelin
Produced by stomach Stimulates appetite Inhibits insulin secretion
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Weight Loss at One Year
0
2
4
6
8
10
12
14
16
18
Lap Band Sleeve Gastrectomy Gastric Bypass
BMIreduction
*Analysis of 28,616 patient at COE
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Long-term Weight Loss
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Diabetes: resolved or improved
0
10
20
30
40
50
60
70
80
90
Lap Band Sleeve Gastrectomy Gastric Bypass
%
*Analysis of 28,616 patient at COE
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Hypertension: resolved or improved
0
10
20
30
40
50
60
70
80
90
Lap Band Sleeve Gastrectomy Gastric Bypass
%
*Analysis of 28,616 patient at COE
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Roux-Y Gastric Bypass
• Advantages Excellent excess weight loss (60-75%)
Very good long-term results
Solid food well tolerated
• Disadvantages Potential vitamin deficiencies
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Personal Experience
• RYLGB 1015 1 year EWL
64.2% 2 year EWL
65.7% 3 year EWL
62.6% 4 year EWL
65.6%
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Complications
• Early Leak PE Pneumonia Bleeding
• Late SBO Stricture Stomal ulceration
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Sleeve (longitudinal) Gastrectomy
• Advantages Restrictive/hormonal 15% stomach capacity
Good excess weight loss (50%)
Solid food well tolerated
Used as bridge to bypass
• Disadvantages Long staple line
Not universal insurance approval
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Personal Experience
167 patients
Average BMI61.6
kg/m2 EWL at 12
months53.6%
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Laparoscopic bariatric surgey
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“Perioperative Safety in the Longitudinal Assessment of Bariatric Surgery”
• N Engl J Med 2009;361:445-54.
• 4,776 first-time bariatric surgery patients for 30 days 10 U.S. hospitals (3,412 gastric bypass patients and 1,198 gastric
band patients) between 2005 and 2007
• Risks of bariatric surgery are equal to gallbladder or hip replacement surgery
Mortality rate = 0.3% Total complication rate = 4.3%
• Risks are lower than the longer-term risk of dying from heart disease, diabetes and other consequences of obesity
Longitudinal Assessment of Bariatric Surgery (LABS) Consortium
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LONG-TERM SURVIVAL CANADA
6.17
0.68
0
1
2
3
4
5
6
7
% M
ort
ality
Control Bariatric
89% reduction in risk of89% reduction in risk ofdeath over 5 yearsdeath over 5 years
Christou et al. Ann Surg 2004;240:416-424
1035 surgical patients5746 controls Cohorts followed 5 years
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Results:Five Year Comorbidity
0 5 10 15 20 25 30 35 40
%
Cardiovascular
Endocrinological
Musculoskeletal
Infectious
Cancer
ControlBariatric
*
*
*
*
*
*p<0.001Christou et al. Ann Surg 2004;240:416-424
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2010 bariatric surgery2037 obese controlsMean 10.9 years f/u
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30% reduction in mortality
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7925 surgical patients7925 controlsMean f/u of 7.1 yearsGastric bypass reduced mortality by 40%
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Behavioral Aspects of Weight Loss Surgery
• Compliance with Diet
• Exercise
• Compliance with Nutritional Supplements
• Keeping follow-up appointments
• Support group attendance
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Behavioral Aspects of Weight Loss Surgery
• Compliance with Diet
• Exercise
• Compliance with Nutritional Supplements
• Keeping follow-up appointments
• Support group attendance
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Behavioral Aspects of Weight Loss Surgery
• Compliance with Diet
• Exercise
• Compliance with Nutritional Supplements
• Keeping follow-up appointments
• Support group attendance
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Behavioral Aspects of Weight Loss Surgery
• Compliance with Diet
• Exercise
• Compliance with Nutritional Supplements
• Keeping follow-up appointments
• Support group attendance
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Behavioral Aspects of Weight Loss Surgery
• Compliance with Diet
• Exercise
• Compliance with Nutritional Supplements
• Keeping follow-up appointments
• Support group attendance
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Behavioral Aspects of Weight Loss Surgery
• Compliance with Diet
• Exercise
• Compliance with Nutritional Supplements
• Keeping follow-up appointments
• Support group attendance
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5’ 7”360 lbs56.3 kg/m2
5’ 7”192 lbs30.0 kg/m290% EWL
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