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Weight Loss Surgery: The First Step Toward a More Healthy Life Pre-operative Medications Post-operative Medications Defining the Problem The Problem • Prevalence of obesity in U.S. increased from 12% to 21% between 1991 and 2001 = 15 million people • Obesity is the 2nd most common cause of death from a modifiable behavioral risk factor • 111,909 excess deaths annually Mokdad AH et al. JAMA. 2003;289:76-79 Flegal KM et al. JAMA 2005;293:1861-1919 Excess U.S. Medical Costs Related to Abnormal Body Weight Int J Obesity 2005;29:334-339 Relative risk of health problems associated with obesity Greatly increased (relative risk >>3) Moderately increased (relative risk 2-3) Diabetes Coronary heart disease Gall bladder disease Osteoarthritis (knees) Hypertension Hyperuricemia and gout Dyslipidemia Insulin resistance Slightly increased (relative risk 1-2) Cancer (breast cancer in postmenopausal women, endometrial cancer, colon cancer) Reproductive hormone abnormalities Breathlessness Polycystic ovary syndrome Sleep apnea Impaired fertility Low back pain Increased anesthetic risk Fetal defects arising from maternal obesity The Effect of Obesity on the Development of Health Risks Age-adjusted relative risk of type 2 diabetes 50 100 Men1 42 40 93 Women2 75 30 50 40 20 12 25 10 2.2 8.1 1.0 0 <23 25 31 35 0 1.0 <22 25 31 35 BMI 1Chan JM et al. Diabetes Care 1994;17:961-969; 2Colditz G et al. Ann Intern Med 1995;122:481-486. Causes of Obesity Behavior Genetics Environment The Environment: Portion Size Non-operative Treatment of Obesity How does it add up? Diet Exercise Behavioral therapy + Drug therapy ?????? . Fed up with how her diet is going Charlene takes a more serious aim at her target weight Surgical Treatment of Obesity: The Basics What is Body Mass Index ( BMI ) ? Surgical Treatment of Obesity: Indications and Surgical Options Patient Selection • Age 18 - 55 AND • BMI ≥ 40 kg/m2 OR BMI 35 - 40 kg/m2 with • High risk health problems OR • Obesity-induced physical problems NIH Consensus Development Conference Operative Approaches Restrictive Procedures • Vertical banded gastroplasty ( VBGP ) • Adjustable silastic gastric banding (ASGB) Malabsorptive Procedures • Biliopancreatic diversion ( BPD ) • Duodenal switch modification of BPD Combined Procedures • Roux-en-Y gastric bypass ( GBP ) The Gastrointestinal System Vertical Banded Gastroplasty (VBG) General Features • Pouch size: 1 oz • Triple staple line • Pouch opening: 0.5 in Average Weight Loss • 50 % of excess weight Vertical banded gastroplasty: Complications • • • • • Stomal narrowing with persistent vomiting Staple line leak or disruption Band erosion Wound infection or hernia Death 0.1% • Overall re-operation rate 43 % Adjustable Silastic Gastric Banding (ASGB): LapBandTM GENERAL FEATURES • Inflatable balloon within the band orifice can be adjusted via a reservoir under the skin Average Weight loss • 50% of excess weight Adjustable Silastic Gastric Banding : Complications • • • • • • • • Splenic injury Esophageal injury Wound infection Persistent vomiting Acid reflux Band slippage Reservoir leak/deflation Band erosion • Death 0.3 % Re-operation 5 -20 % Biliopancreatic Diversion with Duodenal Switch (BPD-DS) General Features • Gastric pouch size: • Standard: 14 oz (1.5 cups) • Three segments • Alimentary tract: 6.5 ft • Biliary tract: 13 ft • Common channel: 1.5 ft Average Weight Loss • 80 % of excess weight Duodenal Switch (BPD-DS) : Complications • • • • • • • • • • • Protein malnutrition Anemia Marginal ulcer Peripheral neuropathy Night Blindness Osteoporosis Renal stones Nausea First 6 mo Diarrhea Vitamin deficiencies: A, D, E, K, B12 Incisional hernia • Death 15% <5% <3% 1.3 % 3% 14 % 65 % 62 % 10 % 1.1 % Roux-en-Y Gastric Bypass (RYGBP) General Features • Pouch size: 1 oz • Pouch opening: 0.5 in • Roux-en-Y limb • Standard: 2 ft Average Weight Loss • 70 % of excess weight “The Pouch-Tool” Gastric Bypass: Complications Early: • • • • Late: • Stomal narrowing /vomiting 15 % Staple line leak 1-5% • Marginal ulcer 13% Acute gastric • Heartburn / inflammation of distention esophagus • Anemia Roux-Y obstruction • Folate deficiency • Vitamin B12 deficiency Death 0.5 % • Iron deficiency • Calcium deficiency / osteoporosis • Gallstones 10 % General Complications of Weight-Loss Surgery • Post-operative depression • Food issues • Changes in relationships • Hair loss • Usually temporary • Cause: protein, vitamin A, mineral • Excess skin Weight Maintenance after Bariatric Surgery Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26 Conclusions • Bariatric surgery is an effective means to achieve clinically significant, permanent weight loss with low rates of complications. • Bariatric surgery results in significant improvement in health risks associated with obesity. • Surgical weight loss increases life-span. • Surgical therapy is cost-effective.