Weightloss Surgery The Five Ws
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Weightloss Surgery The Five Ws

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Weightloss Surgery The Five Ws Weightloss Surgery The Five Ws Presentation Transcript

  • New Patient Orientation for Bariatric Surgery St. Luke’s and Roosevelt Hospitals The Center of Excellence for Bariatric Surgery and Metabolic Disease
  • Bariatric Team
    • Dr. Julio Teixeira, FACS – Director
    • Dr. James McGinty
    • Dr. Ninan Koshy
    • Dr. Scott Belsley
    • Christine Haufmann, FNP
    • Aisling McGinty, RD
    • Tricia Mah, RD
  • Why do people choose surgery for their obesity?
  • Facts on Obesity
    • Obesity is a disease
    • Multiple facts are related to obesity:
    • -genetics
    • -psychology
    • -environment
    • “ Genetics loads the gun—the environment pulls the trigger.”
          • George Bray, 1996
    A New Understanding Of Obesity
    • “ Genetics loads the gun—the environment pulls the trigger.”
          • George Bray, 1996
    A New Understanding Of Obesity
  • Facts on Obesity
    • Major public health problem worldwide
    • Affects 25% of industrialized world
    • American statistics:
      • 55% (34 Million) adults are overweight (Body Mass Index > 25)
      • 25% of children are overweight
      • 5-11 million people are morbidly obese
      • 6% of health care expenditures ($238 Billion / year)
      • 300,000 deaths annually
    JAMA
  • Facts on Treatment of Obesity
    • Medical treatment is an ineffective method of sustaining weight loss for individuals with a BMI >35
    • Bariatric surgery is the only effective method of sustaining weight loss for individuals with a BMI >35 (1991 NIH consensus)
  • Body Mass Index (BMI) Gray DS. Med Clin North Am . 1989;73(1):1–13. Obesity and Mortality Risk 2.5 2.0 1.5 1.0 0 20 25 30 35 40 Mortality Ratio Moderate Very Low Low Moderate High Very High
  • Obesity Related Co-Morbid Medical Conditions
      • Co-Morbidities:
      • Diabetes
      • Hypertension
      • Hyperlipidemia
      • Cardiac disease
      • Respiratory disease
        • - sleep apnea
      • Arthritis
      • Depression
      • Stress Incontinence
      • Menstrual irregularity
      • % of Occurrences:
      • - 14–20%
      • - 25–55%
      • - 35–53%
      • - 10–15%
      • - 10–20%
      • - 20–25%
      • - 70–90%
    • - 50%
    • - 50%
    Table 7 Literature Review
  • Cancer and Obesity
    • Common cancers associated with obesity:
      • Esophageal
      • Breast
      • Uterine
      • Ovarian
      • Prostate
      • Colon
      • Cervical
    Herra 1999 Carrol 1998 Everhart 1993
  • Candidates for Weight Loss Surgery
    • 18-70 years of age
    • BMI >40
    • BMI 35 - 39 with associated medical conditions such as:
      • Diabetes
      • Hypertension
      • Hyperlipidemia
      • Cardiac disease
      • Respiratory disease
      • Arthritis
      • Depression
  • Body Mass Index (BMI)
    • Measure of body fat based on height and weight
    • Calculate the person’s weight in kilograms divided by height in meters squared (Kg/m2)
      • 20-25 normal
      • 25-30 overweight
      • 30-40 obese
      • >40 severe obesity
      • >50 super obesity
  • When should you have weight loss surgery ?
    • Weight loss surgery should always be the last resort
    • You must have attempted weight loss through other methods such as nutritional & medical therapy
    • Medical support and/or clearance from your primary care physician
  • The Process for Weight Loss Surgery
    • Attend a new patient orientation
    • 1 st Consultation:
    • - evaluated by the surgeon
    • - bariatric workup: -Nutritional evaluation
    • -Psychological evaluation
    • -Letter from your PCP: 6 months
      • Letter of support
      • Medical clearance
    • -Blood work
    • -Abdominal Ultrasound
    • -2 bariatric support groups
  • The Process for Weight Loss Surgery
    • 2nd Consultation:
    • -Review bariatric work-up test results
    • -Decide on your bariatric procedure
    • -Set a surgery date
    • -Begin the insurance approval process
  • The Weight Loss Surgery Options
    • Laparoscopic Adjustable Gastric Band
    • Laparoscopic Roux-en-Y Gastric Bypass
    • Laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
    • Laparoscopic Vertical Sleeve Gastrectomy (VSG)
  • Benefits of Doing Surgery Laparoscopically
    • Less pain
    • Smaller incisions
    • Shorter hospital stay
    • Avoiding post operative complications such as:
    • -wound infection
    • -hernia
  • How does these operations work?
    • Restriction : restricts the volume of food consumed during each meal
    • Malabsorption : decreases your ability to absorb ingested foods
    • Lifestyle changes : helps you develop new eating habits and encourages lifestyle changes
  • The Surgical Options for Weight Loss Surgery
  • Adjustable Gastric Band
  • Adjustable Gastric Band
    • Restrictive procedure
    • Minimally invasive
    • Good results in Europe and Australia
    • Bioenterics Lap Band™
    • FDA approved 6/01
    • 50% EWL
  • Facts on the Adjustable Gastric Band
    • Operation time: 30-45 minutes
    • Hospital stay: overnight
    • Return to normal activity: 5-7 days
    • Diet advancement: liquid-> puree->regular diet
    • Post-op appointments:
    • - 1, 2 weeks
    • - 1, 2, 3, 4, 5, 6, 8, 10, 12 months
    • - then as instructed for rest of life
    • Adjustments: office or radiology
    • Reversible
    • Not effective in pts: who have a BMI >50
    • sweet or binge eaters
  • Risks and Complications related to the Adjustable Gastric Band
    • - Bleeding
    • - Pulmonary embolism
    • - Nausea/Vomiting
    • - Intestinal Obstruction
    • - Hernias
    • - Kidney/Gallstones
    • - Nutritional and/or vitamin deficiencies
      • 10-15% re-operative rate
      • Mechanical Failure
      • - Slippage
      • - Migration
      • - Erosion
      • Death
  • Expected Weight loss with the Adjustable Gastric Band
    • 20-30 lbs in the 1 st month
    • 1-2 lbs per week
    • Average weight loss in 1 year = 60lbs
    • 50% EWL in 3 years
  • Roux-en-Y Gastric Bypass
    • Restrictive and mal-absorptive procedure
    • Most frequently performed bariatric procedure in the US
    • First done in 1967
    • Laparoscopic since 1993
    • 75% EWL in 18-24 months
    • 50% EWL is still maintained at a 14yr follow-up
    ASBS
  • Facts on Roux-en-Y Gastric Bypass
    • Operation time: 1-3 hours
    • Hospital stay: 2.5 days
    • Return to normal activity: 7-10 days
    • Diet advancement: liquid-> puree-> regular diet
    • Post-op appointments:
    • -1 wk, 1 month, 3 month, 6 months, 12 months
    • -every 6 months for the next 2-3 years
    • -than as instructed for the rest of your life
    • Not Reversible
  • Expected weight loss with the Roux-en-Y Gastric Bypass
    • 20-30 lbs in the first month
    • 75-100 lbs in the first 6 months
    • 75% of EWL in 18-24 months
  • Risks and Complications related to Roux-en-Y Gastric Bypass
    • - Pulmonary Embolism
      • - Leaks 0.5-2%
      • - Strictures 3%
      • - Bleeding
      • - Perforation/injury to surrounding organs
      • - Intestinal obstructions 2-3%
      • - Hernias
      • - Ulcers
      • - Kidney/Gallstones
      • - Nausea and vomiting
      • - Dumping Syndrome
      • - Malnutrition
      • - Vitamin deficiencies
      • - New addictions
      • - Death
  • Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
    • Restrictive and mal-absorptive procedure
    • Lesser degree of nutrient absorption
    • 75-80% EWL
    • 77% EWL at 5yr follow-up
    Scopinaro 1998
  • Facts on BPD/DS
    • Operation time: 3-4 hours
    • Hospital stay: 3 days
    • Return to normal activity: 2 weeks
    • Diet advancement: liquid-> puree-> regular diet
    • Post-op appointments:
    • - 1 week, 1 month, 3 months, 6 months, 12 months
    • - every 6 months to a year for the rest of your life
    • Larger pouch allows for bigger meal
    • Complication rate: 15-20%
    • Higher nutritional risk
    • Excellent weight loss: 75-80% EWL
  • Risks and Complications related to BPD/DS
      • Higher morbidity and mortality rate
      • Pulmonary Embolism
      • Cirrhosis
      • Diarrhea
      • Leaks
      • Bleeding
      • Ulcers
      • Hernias
      • Malnutrition
      • Vitamin Deficiencies
      • Death
  • Vertical Sleeve Gastrectomy (VSG)
    • Restrictive procedure
    • First done in US in 2001
    • Removing 60-85% stomach
    • 30-50% EWL
  • Facts on Vertical Sleeve Gastrectomy
    • Operation time: 1-2 hours
    • Hospital stay: 2.5 days
    • Return to normal activities: 7 days
    • Diet advancement: liquid->puree->regular diet
    • Post-op appointments:
    • -1 week, 1 month, 3 month, 6 moths, 12 months
    • - every 6 months for the next 2 years
    • - than as instructed for rest of life
    • Not reversible
    • No intestinal bypass, only stomach reduction
  • Risks and Complications related to Vertical Sleeve Gastrectomy
    • Gastric leaks and fistulas
    • Blood clots
    • Pulmonary embolism
    • Bleeding
    • Splenectomy
    • Acute respiratory distress
    • Pneumonia
    • Small bowel obstruction
    • Death
  • Mortality Rates
    • Adjustable Gastric Band 0.1%
    • Gastric Bypass 0.5%
    • BPD/DS 1.1%
    • Vertical Sleeve gastrectomy 0.25%
  • Post operative reasons that may cause death
    • Pulmonary embolism (blood clots)
    • Myocardial infarction (heart attack)
    • Sepsis (overwhelming infection)
  • Post Operative Phases
    • Recovery
    • Exhaustion
    • Adjustment
    • Maintenance
  • Supplements after weight loss surgery
    • Gastric Band:
      • MVI
      • Protein
    • Gastric Bypass:
      • MVI
      • Calcium Citrate + D
      • Iron
      • Protein
    • BPD/DS:
    • -MVI
    • -Calcium Citrate + D
    • -Iron
    • -Protein
    • VSG:
    • -MVI
    • -Protein
  • Medical Co-Morbidities Resolved Wittgrove AC,Clark GW. Laparoscopic Gastric bypass roux-n-y-500 patients. Obes Surg 2000. And others.
  • Outcomes after Surgery
    • New England Journal of Medicine Study:
      • 56% decrease in mortality from heart disease
      • 70% decrease in cancer related mortality
      • 90% decrease in diabetes related mortality
  • Can you have children after weight loss surgery?
    • YES!
    • Gastric Band and VSG:
    • - Wait 1 year after surgery
    • - Will need to see a High Risk OBGYN
    • Gastric Bypass and BPD/DS:
    • - Wait 2 years after surgery
    • - Will need to see a High Risk OBGYN
  • What to do with the excess skin?
    • Plastic surgery consultation is approximately at 18-24 months
    • Weight must be stable for at least 6 months and there must be no evidence of malnutrition
    • It may not be necessary for all patients, several facts impact on this need
    • It may not be covered by insurance
  • Facts that play a role in the decision-making process
    • Age
    • Medical History
    • Surgical History
    • BMI
    • Psychological Profile
    • Nutritional Profile
    • Lifestyle
    • Personal choice