bariatric surgery
DESCRIPTION
Bariatric SurgeryTRANSCRIPT
Weight Loss Surgery:Weight Loss Surgery: The First Step Toward a More Healthy LifeThe First Step Toward a More Healthy Life
Pre-operative Medications Post-operative Medications
Defining the ProblemDefining the Problem
The ProblemThe 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;289:76-79Flegal KM et al. JAMA 2005;293:1861-1919
Excess U.S. Medical Costs Related Excess U.S. Medical Costs Related to Abnormal Body Weightto Abnormal Body Weight
Int J Obesity 2005;29:334-339
Diabetes
Gall bladder disease
Hypertension
Dyslipidemia
Insulin resistance
Breathlessness
Sleep apnea
Greatly increased(relative risk >>3)
Coronary heart disease
Osteoarthritis (knees)
Hyperuricemia and gout
Cancer (breast cancer in postmenopausal women, endometrial cancer, colon cancer)
Reproductive hormone abnormalities
Polycystic ovary syndrome
Impaired fertility
Low back pain
Increased anesthetic risk
Fetal defects arising from maternal obesity
Moderately increased(relative risk 2-3)
Slightly increased(relative risk 1-2)
Relative risk of health problems associated with obesity
1Chan JM et al. Diabetes Care 1994;17:961-969; 2Colditz G et al. Ann Intern Med 1995;122:481-486.
Age-adjusted relative risk of type 2 diabetes
The Effect of Obesity The Effect of Obesity on the Development on the Development of Health Risksof Health Risks
0
10
20
30
40
50
1.02.2
12
42
0
25
50
75
100
1.08.1
40
93
<23 25 31 35 <22 25 31 35
Men1 Women2
BMI
Causes of ObesityCauses of Obesity
Genetics Behavior
Environment
The Environment: Portion SizeThe Environment: Portion Size
Non-operative Treatment of ObesityNon-operative Treatment of ObesityHow does it add up?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: Surgical Treatment of Obesity: The BasicsThe Basics
What is Body Mass Index ( BMI ) ?What is Body Mass Index ( BMI ) ?
Surgical Treatment of Obesity: Surgical Treatment of Obesity: Indications and Surgical OptionsIndications and Surgical Options
Patient SelectionPatient 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 ApproachesOperative 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 SystemThe Gastrointestinal System
Vertical Banded Gastroplasty (VBG)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: Vertical banded gastroplasty: ComplicationsComplications
• 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 Adjustable Silastic Gastric Banding (ASGB): LapBand(ASGB): LapBandTMTM
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 : ComplicationsAdjustable 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 Biliopancreatic Diversion with Duodenal Switch (BPD-DS)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) : Duodenal Switch (BPD-DS) : ComplicationsComplications
• Protein malnutrition15%
• Anemia < 5 %• Marginal ulcer < 3 %• Peripheral neuropathy 1.3 %• Night Blindness 3 %• Osteoporosis 14 %• Renal stones• Nausea 65 %• Diarrhea 62 %• Vitamin deficiencies: A, D, E, K, B12
• Incisional hernia 10 %
• Death 1.1 %
First 6 mo
Roux-en-Y Gastric Bypass Roux-en-Y Gastric Bypass (RYGBP)(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: ComplicationsGastric Bypass: Complications
Early:
• Staple line leak 1-5%
• Acute gastric distention
• Roux-Y obstruction
• Death 0.5 %
Late:• Stomal narrowing /vomiting 15
%• Marginal ulcer 13%• Heartburn / inflammation of
esophagus• Anemia
• Folate deficiency• Vitamin B12 deficiency • Iron deficiency
• Calcium deficiency / osteoporosis• Gallstones 10 %
General Complications of General Complications of Weight-Loss SurgeryWeight-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 SurgeryWeight Maintenance after Bariatric Surgery
Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26
ConclusionsConclusions• 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.