Download Morbid Obesity

Obesity:
Surgical Management
Eric S. Hungness, M.D.
Assistant Professor of Surgery
Department of Surgery
Northwestern University Feinberg School of Medicine
Chicago, Illinois
Etiology of Obesity
MULTIFACTORIAL
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Familial
Genetic
Gender (F>M)
Social
Psychologic (depression)
The Obesity Epidemic
The weight gain cycle
Can’t
Exercise
Eat too much
Gain weight
Get
Depressed
Body Mass Index (BMI)
BMI = weight (kg) / height (m)2
Normal
Weight
(BMI 18.5 to
24.9)
Overweight
(BMI 25 to 29.9)
Obese
(BMI 30 to 34.9)
Severely Obese
(BMI 35 to 39.9 )
Morbidly Obese
(BMI > 40)
Super Obese
(BMI > 50)
Body Mass Index (BMI)
The Obesity Epidemic

66% of Americans >20 yrs are either overweight or obese (BMI
> 25, ~ 133 million people)
 Increased from 45% in 1960

33% of Americans >20 yrs are obese (BMI > 30, ~ 66 million)
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5% of Americans are morbidly obese (BMI > 40, ~ 10 million)
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3.1% in men and 6.7% in women
Increasing by 1% per year
Obesity is increasing in children (doubled in past 20 years)

15% between the age of 6 and 19
NHANES (2003-04) (n=4,431)
Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1986
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1987
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4”
person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1988
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1989
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1994
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1996
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 1998
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2002
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2003
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2004
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Why do we treat obesity??
• Co-morbidities
• Quality of life
• Survival – Life Expectancy
Co-morbidities
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Endocrine
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Diabetes
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Cardiovascular
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Hypertension
Hyperlipidemia
Hypertriglyceridemia
Coronary and cerebral
vascular disease
Venous stasis
Gynecology
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Orthopedic
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Infertility
Menstrual
irregularities
DJD
Arthralgia
Low back pain
Dermatology
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Fungal infection
Co-morbidities
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Pulmonary
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Sleep apnea
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Asthma
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Hypoventilation
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Pulmonary hypertension
Gastrointestinal
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Cholelithiasis
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GERD
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Fatty liver /dysfunction
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Socio-economic
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Discrimination
Psychological
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Depression

h/o abuse
Cancer
Life Expectancy

2nd only to smoking as the leading cause of
preventable death in the United States.†
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> 110,000 deaths/year in the US are associated with
obesity*
* Flegal KM et al. JAMA. 2005 Apr 20;293(15):1861-7.
† CDC
Life Expectancy
Life Expectancy
Years of Life Lost (YLL)
white male 10 years
 white female 7 years
 black male 11 years
 black female 3 years

Fontaine et al. JAMA 2003; 289:187-193
Medical Treatment
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Medications
Dietary Changes
Exercise
Behavioral Therapy
Psychotherapy
Hypnosis
Jaw-wiring
UNSUCCESSFUL AT SIGNIFICANT
OR SUSTAINED WEIGHT LOSS!
Trends In Surgery 1992 - 2003
Rationale for Surgery

Long Term Outcome Data
Sustained Weight Loss
 Improvement or Resolution of Co-morbidities
 Improved long term survival
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Minimally Invasive Surgery
Public Awareness
Obesity as a disease
 Celebrities
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Indications for Surgery
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BMI >40 kg/m2, or >35 kg/m2 with significant comorbid illnesses
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Multiple failed weight loss attempts
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Acceptable surgical risk

Age 18-60
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Demonstrates commitment and understanding of
weight loss following bariatric surgery
Preoperative Evaluation/Education
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Staff evaluation
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Internist
Dietitian
Psychologist
Nurse
Surgeon
Support group
•Laboratory evaluation
– Blood
– ECG, CXR
– Stress Test
– Sleep study
– EGD
– PFTs
Consider an IVC filter for any patient with prior history of
DVT/PE.
Surgical Treatment
Restrictive
Horizontal gastroplasty
Vertical banded gastroplasty (VBG)
Roux-en-Y gastric bypass
Adjustable gastric band
Sleeve gastrectomy
Malabsorptive
Jejunoilial bypass
Biliopancreatic diversion (Scopinaro)
Biliopancreatic diversion w/ duodenal switch
Surgical Treatment
Restrictive
Horizontal gastroplasty
Vertical banded gastroplasty (VBG)
Roux-en-Y gastric bypass
Adjustable gastric band
Sleeve gastrectomy
Malabsorptive
Jejunoilial bypass
Biliopancreatic diversion (Scopinaro)
Biliopancreatic diversion w/ duodenal switch
Horizontal Gastroplasty (HG)
Gomez, Cesar. World Journal of Surgery, 1981
Vertical Banded Gastroplasty (VBG)
Angle of His
Gastric Pouch
Polypropylene
band
Transgastric
window
Mason E, Archives of Surgery,
1982
Gastric Bypass + Roux-en-Y
75 – 150 cm
~ 40cm
Lap Adjustable Band
Sleeve gastrectomy
Jejunoileal Bypass
Payne and Dewind, Archives of Surgery, 1973
Biliopancratic Diversion
w/o duodenal switch
w/ duodenal switch
75 – 100cm
Common channel
Marceau, et al. World Journal of Surgery, 1998
Gastric Bypass
vs
LapBand
vs
Duodenal Switch
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Safety
Complications
Overall Medical
Condition
Age
Effectiveness
How Much Weight Do
you need to lose
Expectations
Long term results
Vitamins
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Anesthesia Type
OR Time
Hospital Stay
Adjustable
Maintenance
Dumping
Diabetes
Multiple Prior
Surgeries
Hiatal
Hernia/Reflux
Complications:
General Anesthesia
Blood Clot
 Heart Attack
 Pneumonia
 Stroke
 Death

Complications:
Adjustable Gastric Banding
•
•
•
•
•
•
•
•
•
Port displacement/tube break
Wound infection
Stoma obstruction
Slippage
Elective removal
Erosion
Conversion to open
Hemorrhage
Death
7%
4%
2%
2%
2%
<1%
<1%
<1%
<0.05%
Complications:
Roux-en-Y Gastric Bypass
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Leak
Bleeding
Infection
Dehydration
Stricture/ Ulcer
Conversion to open
Death
1-2%
7%
1%
0.2 - 0.5%
Complications:
BPD with Duodenal Switch
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Leak
Bleeding
Infection
Dehydration
Malnutrition
Conversion to open
Death
1-2%
5%
1%
0.5 – 1.1%
Weight Loss
5 yrs
Mortality %EBWL
LB
0.1%
47.5
RYGB
0.5%
61.6
DS
1.1%
70.1
Buchwald et al. JAMA 2004; 292(14):1724-37
% Resolution of co-morbidity
↑
Chol/TGA
Diabete
s
OSA
HTN
LB
78.3
47.8
87.9
65.6
RYGB
93.6
83.8
94.6
75.4
DS
99.5
97.9
95.2
81.3
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
-Adams et al. NEJM 2007; 357:753-61
Summary
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Obesity – epidemic
Bariatric surgery
Individual / tailored approach
 Effective weight loss
 Safe
 Resolution of co-morbidities
 Saves lives
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