obesity: surgical management eric s. hungness, m.d. assistant professor of surgery department of...

Obesity:Obesity:Surgical Surgical

ManagementManagement

Eric S. Hungness, M.D.Eric S. Hungness, M.D.

Assistant Professor of SurgeryAssistant Professor of Surgery

Department of SurgeryDepartment of Surgery

Northwestern University Feinberg School Northwestern University Feinberg School of Medicineof Medicine

Chicago, IllinoisChicago, Illinois

Etiology of ObesityEtiology of Obesity

FamilialFamilial GeneticGenetic Gender (F>M)Gender (F>M) SocialSocial Psychologic Psychologic

(depression)(depression)

MULTIFACTORIALMULTIFACTORIAL

The Obesity EpidemicThe Obesity EpidemicThe weight gain cycleThe weight gain cycle

Eat too muchEat too muchGain weightGain weight

Can’tCan’tExerciseExercise

GetGetDepressedDepressed

Normal Normal Weight Weight

(BMI 18.5 to (BMI 18.5 to 24.9)24.9)

OverweightOverweight(BMI 25 to 29.9)(BMI 25 to 29.9)

ObeseObese(BMI 30 to 34.9)(BMI 30 to 34.9)

Severely ObeseSeverely Obese(BMI 35 to 39.9 )(BMI 35 to 39.9 )

Morbidly ObeseMorbidly Obese(BMI (BMI >> 40) 40)

Body Mass Index (BMI)Body Mass Index (BMI)

Super ObeseSuper Obese(BMI (BMI >> 50 50))

BMI = weight (kg) / height (m)BMI = weight (kg) / height (m)22

Body Mass Index (BMI)Body Mass Index (BMI)

The Obesity EpidemicThe Obesity Epidemic 66% of Americans >20 yrs are either overweight or 66% of Americans >20 yrs are either overweight or

obese (BMI > 25, ~ 133 million people)obese (BMI > 25, ~ 133 million people) Increased from 45% in 1960Increased from 45% in 1960

33% of Americans >20 yrs are obese (BMI > 30, ~ 66 33% of Americans >20 yrs are obese (BMI > 30, ~ 66 million)million)

5% of Americans are morbidly obese (BMI > 40, ~ 10 5% of Americans are morbidly obese (BMI > 40, ~ 10 million)million)

3.1% in men and 6.7% in women3.1% in men and 6.7% in women Increasing by 1% per yearIncreasing by 1% per year

Obesity is increasing in children (doubled in past 20 Obesity is increasing in children (doubled in past 20 years)years)

15% between the age of 6 and 1915% between the age of 6 and 19

NHANES (2003-04) (n=4,431)NHANES (2003-04) (n=4,431)

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1985BRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Why do we treat obesity??Why do we treat obesity??

• Co-morbiditiesCo-morbidities

• Quality of lifeQuality of life

• Survival – Life ExpectancySurvival – Life Expectancy

Co-morbiditiesCo-morbidities

EndocrineEndocrine DiabetesDiabetes

CardiovascularCardiovascular HypertensionHypertension HyperlipidemiaHyperlipidemia HypertriglyceridemiHypertriglyceridemi

aa Coronary and Coronary and

cerebral vascular cerebral vascular diseasedisease

Venous stasisVenous stasis

GynecologyGynecology InfertilityInfertility Menstrual Menstrual

irregularitiesirregularities OrthopedicOrthopedic

DJDDJD ArthralgiaArthralgia Low back painLow back pain

DermatologyDermatology Fungal infectionFungal infection

Co-morbiditiesCo-morbidities

PulmonaryPulmonary Sleep apneaSleep apnea AsthmaAsthma HypoventilationHypoventilation Pulmonary Pulmonary

hypertensionhypertension

GastrointestinalGastrointestinal CholelithiasisCholelithiasis GERDGERD Fatty liver /dysfunctionFatty liver /dysfunction

Socio-economicSocio-economic DiscriminationDiscrimination

PsychologicalPsychological DepressionDepression h/o abuseh/o abuse

CancerCancer

22ndnd only to smoking as the leading cause only to smoking as the leading cause

of preventable death in the United of preventable death in the United

States.States.††

> 110,000 deaths/year in the US are > 110,000 deaths/year in the US are

associated with obesity*associated with obesity*

Life ExpectancyLife Expectancy

* Flegal KM et al. JAMA. 2005 Apr 20;293(15):1861-7. † † CDCCDC

Years of Life Lost Years of Life Lost (YLL)(YLL) white male 10 yearswhite male 10 years white female 7 yearswhite female 7 years black male 11 yearsblack male 11 years black female 3 yearsblack female 3 years


Fontaine et al. Fontaine et al. JAMAJAMA 2003; 289:187-193 2003; 289:187-193

Medical TreatmentMedical Treatment

Medications Medications Dietary ChangesDietary Changes ExerciseExercise Behavioral Behavioral

TherapyTherapy PsychotherapyPsychotherapy HypnosisHypnosis Jaw-wiringJaw-wiring

UNSUCCESSFUL AT SIGNIFICANT UNSUCCESSFUL AT SIGNIFICANT OR SUSTAINED WEIGHT LOSS!OR SUSTAINED WEIGHT LOSS!

Trends In Surgery 1992 - 2003Trends In Surgery 1992 - 2003

Rationale for SurgeryRationale for Surgery

Long Term Outcome DataLong Term Outcome Data Sustained Weight LossSustained Weight Loss Improvement or Resolution of Co-Improvement or Resolution of Co-

morbiditiesmorbidities Improved long term survivalImproved long term survival

Minimally Invasive SurgeryMinimally Invasive Surgery Public AwarenessPublic Awareness

Obesity as a diseaseObesity as a disease Celebrities Celebrities

Indications for SurgeryIndications for Surgery

BMI >40 kg/mBMI >40 kg/m22, or >35 kg/m, or >35 kg/m22 with with significant co-morbid illnessessignificant co-morbid illnesses

Multiple failed weight loss attemptsMultiple failed weight loss attempts

Acceptable surgical riskAcceptable surgical risk

Age 18-60Age 18-60

Demonstrates commitment and Demonstrates commitment and understanding of weight loss following understanding of weight loss following bariatric surgerybariatric surgery

Preoperative Preoperative Evaluation/EducationEvaluation/Education

Staff evaluationStaff evaluation InternistInternist DietitianDietitian PsychologistPsychologist NurseNurse SurgeonSurgeon Support groupSupport group

•Laboratory evaluationLaboratory evaluation– BloodBlood– ECG, CXR ECG, CXR – Stress TestStress Test– Sleep studySleep study– EGDEGD– PFTsPFTs

Consider an IVC filter for any patient with prior history of Consider an IVC filter for any patient with prior history of DVT/PE.DVT/PE.

Surgical TreatmentSurgical Treatment

RestrictiveRestrictive

MalabsorptiveMalabsorptive

Horizontal gastroplastyHorizontal gastroplastyVertical banded gastroplasty (VBG)Vertical banded gastroplasty (VBG)Roux-en-Y gastric bypassRoux-en-Y gastric bypassAdjustable gastric bandAdjustable gastric bandSleeve gastrectomySleeve gastrectomy

Jejunoilial bypassJejunoilial bypassBiliopancreatic diversion (Scopinaro)Biliopancreatic diversion (Scopinaro)Biliopancreatic diversion w/ duodenal switchBiliopancreatic diversion w/ duodenal switch

Horizontal Gastroplasty Horizontal Gastroplasty (HG)(HG)

Gomez, Cesar. Gomez, Cesar. World Journal of SurgeryWorld Journal of Surgery, 1981, 1981

Mason E, Mason E, Archives of SurgeryArchives of Surgery, , 19821982

Polypropylene Polypropylene bandband

Transgastric Transgastric windowwindow

Angle of HisAngle of His

Vertical Banded Gastroplasty Vertical Banded Gastroplasty (VBG(VBG))

Gastric PouchGastric Pouch

Gastric Bypass + Roux-en-Gastric Bypass + Roux-en-YY

75 – 150 cm75 – 150 cm

~ 40cm~ 40cm

Lap Adjustable BandLap Adjustable Band

Sleeve gastrectomySleeve gastrectomy

Jejunoileal BypassJejunoileal Bypass

Payne and Dewind, Payne and Dewind, Archives of SurgeryArchives of Surgery, 1973, 1973

Biliopancratic DiversionBiliopancratic Diversion

Marceau, et al. Marceau, et al. World Journal of SurgeryWorld Journal of Surgery, 1998, 1998

w/ duodenal switchw/ duodenal switchw/o duodenal switchw/o duodenal switch

75 – 100cm75 – 100cmCommon channelCommon channel

Gastric BypassGastric Bypass

vsvs

LapBandLapBand

vsvs

Duodenal SwitchDuodenal Switch

SafetySafety ComplicationsComplications Overall Medical Overall Medical

ConditionCondition AgeAge EffectivenessEffectiveness How Much Weight How Much Weight

Do you need to Do you need to loselose

ExpectationsExpectations

Long term resultsLong term results VitaminsVitamins

Anesthesia TypeAnesthesia Type OR TimeOR Time Hospital StayHospital Stay AdjustableAdjustable MaintenanceMaintenance DumpingDumping DiabetesDiabetes Multiple Prior Multiple Prior

SurgeriesSurgeries Hiatal Hernia/RefluxHiatal Hernia/Reflux

Complications:Complications:General AnesthesiaGeneral Anesthesia

Blood ClotBlood Clot Heart AttackHeart Attack PneumoniaPneumonia StrokeStroke DeathDeath

• Port displacement/tube breakPort displacement/tube break 7%7%• Wound infectionWound infection 4%4%• Stoma obstructionStoma obstruction 2%2%• SlippageSlippage 2%2%• Elective removalElective removal 2%2%• ErosionErosion <1%<1%• Conversion to openConversion to open <1%<1%• HemorrhageHemorrhage <1%<1%• DeathDeath <0.05%<0.05%

Complications:Complications: Adjustable Gastric BandingAdjustable Gastric Banding

Complications:Complications:Roux-en-Y Gastric BypassRoux-en-Y Gastric Bypass

Leak Leak 1-2%1-2% BleedingBleeding InfectionInfection DehydrationDehydration Stricture/ Ulcer Stricture/ Ulcer 7%7% Conversion to open Conversion to open 1%1% Death Death 0.2 - 0.2 -

0.5%0.5%

Complications:Complications:BPD with Duodenal SwitchBPD with Duodenal Switch

Leak Leak 1-2%1-2% BleedingBleeding InfectionInfection DehydrationDehydration MalnutritionMalnutrition 5%5% Conversion to open Conversion to open 1%1% Death Death 0.5 – 0.5 –

1.1%1.1%

Weight LossWeight Loss

5 yrs5 yrs

MortaliMortalityty

%EBW%EBWLL

LBLB 0.1%0.1% 47.547.5RYGRYGBB

0.5%0.5% 61.661.6

DSDS 1.1%1.1% 70.170.1Buchwald et al. JAMA 2004; 292(14):1724-37

% Resolution of co-morbidity% Resolution of co-morbidity

↑ ↑ Chol/TGChol/TG

AA

DiabeDiabetestes

OSAOSA HTNHTN

LBLB 78.378.3 47.847.8 87.987.9 65.665.6

RYGRYGBB

93.693.6 83.883.8 94.694.6 75.475.4

DSDS 99.599.5 97.997.9 95.295.2 81.381.3

Buchwald et al. JAMA 2004; 292(14):1724-37

-Adams et al. NEJM 2007; 357:753-61-Adams et al. NEJM 2007; 357:753-61

SummarySummary

Obesity – epidemicObesity – epidemic Bariatric surgeryBariatric surgery

Individual / tailored Individual / tailored approachapproach

Effective weight lossEffective weight loss SafeSafe Resolution of co-Resolution of co-

morbiditiesmorbidities Saves livesSaves lives

obesity: surgical management eric s. hungness, m.d. assistant professor of surgery department of...

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