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CLINICALLY SEVERE     OBESITY TIMOTHY CUSTER M.D., F.A.C.S
WHAT IS MORBID  OBESITY?
BMI CHART                Do You Know Your Own BMI?                                             Weight (lbs)               ...
DefinitionsCategory         BMI        lbs overweight   % US popNormal           25         0                30%Overweight...
Morbid Obesity – a “disease”• Clinically severe obesity = a point at  which obesity becomes an independent  disease proces...
OBESITY IS A WORLDWIDE EPIDEMIC
Consequences of Obesity
Consequences of Obesity•    Type II Diabetes 30%      • Intra-abdominal HTN•    Hypertension 50%           - GERD•    CAD/...
Consequences of Obesity• Gallstones            • Cancer - 2-3x higher• Arthritis 90%           - Breast• Infertility      ...
Clinically severe obesity  Risk of not Having Surgery                         4                         3       Mortality ...
Mortality of Obesity• Shortens life by 8 yrs for women and 15  years for men• Only one in seven with severe obesity  reach...
OBESITY EPIDEMIC• Obesity responsible for >$100 billion in  medical costs per yr• US was first in life span in 1900, now  ...
Consequences - Mortality“Taken together, the diseases associated with morbid obesity markedly reduce theodds of attaining ...
Consequences - Mortality>300,000 people die each year secondary to complications of obesity, making it our 2nd leading cau...
IV. Treatment of Obesity
Medical Options for Weight          Loss•   Dietary therapy•   Behavioral modification•   Exercise•   Medications
Medical Treatment         The bottom Line:All Non-surgical weight loss attemptsachieve at best modest and short termsucces...
Medical Weight Loss
1991 Concensus Conference on              Obesity• Medical Therapy is Rarely successful• Those who fail medical therapy sh...
Surgical Options•   Gastric Band•   Sleeve Gastrectomy•   Gastric Bypass•   Biliopancreatic Diversion with Duodenal    Swi...
How does surgery work?Depending on the procedure:1. Restriction (less volume in)2. Malabsorbtion (less calories absorbed)3...
Ruox en Y Gastric Bypass            • First developed in the              1970s            • Procedure of choice in       ...
Gastric BypassQ : How does the GBP effect wt loss?A : Four mechanisms   1. Restriction   2. Malabsorption   3. Dumping Syn...
The Roux-en-Y Procedure• In the Roux-en-Y  Bypass procedure, a  small pouch  is formed along the  lesser curve, excluding ...
The Roux-en-Y Procedure• The small intestine is  divided about 20-50  cm beyond the lig of  trietz (beginning pt of  the j...
The Roux-en-Y Procedure• The small intestine  (B), is brought up to  the gastric pouch and  these are attached• The bilio-...
DumpingThe Roux limb doesnot handle sugar welland therefore eatingsweets will causenausea, crampingand diarrhea
Decreased Hunger• Ghrelin is a hormone that stimulates appetite• Ghrelin levels are seen to drop within 24 hrs of surgery ...
Benefits of GBP•   90% of Patients lose 70% Excess Weight•   90% of medical problems resolve or improve•   Longer Life (up...
Roux-en-Y          Open Procedure• More pain• Longer hosp stay• Longer return to work• Wound complications - seroma (15%) ...
Laparoscopic Roux-en Y• Less pain• Shorter stay• Less blood loss• Faster return to  work• Technically more  challenging• M...
“Restrictive” Surgery
LAP BAND• Mechanism purely restrictive (no  decreased appetite, dumping, or  malabsorbtion)• Injecting saline tightens the...
ADJUST, ADJUST, ADJUST!• First adjustment at 6 wks post op• Continues every 3 wks thereafter until in  “green zone”• Too t...
LAP BAND• Weight loss          , generally   , and                  than with GBP - Best studies = 30% 1 yr, 40% 2y, 50% 3...
Lap Band Advantages• Stomach and intestines not cut• May have shorter recovery time• Band is adjustable (going on a cruise...
Lap Band Disadvantages• Wt loss slower, less and more variable• Persistently high rates of reoperation and  band removal (...
Who should get a band?
Sleeve Gastrectomy•   BPD developed 1976•   BPD with DS 1998•   LS BPD w/ DS 2000•   Some restriction•   Mostly malabsorbt...
Sleeve Gastrectomy“Two stage” LS BPD w/   DS proposed 2000-LS Sleeve first-Intestinal bypass after   initial wt loss-FOUND...
Sleeve Gastrectomy• 2005 – 2 studies of LS Sleeve as primary  procedure showing 53% and 83% EWL at  1 yr• 2006 first large...
Sleeve GastrectomyMECHANISM:1.Restriction – 100 to 150 cc vs 30cc pouch2.Hormonal Effect   - decreased grehlen 70%   - dec...
COMPLICATIONSLAP BAND                  GASTRIC BYPASS             GASTRIC SLEEVEGastric Prolapse (slip)   Anastomotic Leak...
Is it worth it?• Mortality -   Cholecystectomy .2 - .5 %            -   Hip Replacement .1 - .3 %            -   Colon Res...
Bariatric Surgery• Major Life Changing event• Not a “cure” for Morbid Obesity, but . . .• Currently the best (and only) to...
Seminar Powerpoint
Seminar Powerpoint
Seminar Powerpoint
Seminar Powerpoint
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Seminar Powerpoint

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Transcript of "Seminar Powerpoint"

  1. 1. CLINICALLY SEVERE OBESITY TIMOTHY CUSTER M.D., F.A.C.S
  2. 2. WHAT IS MORBID OBESITY?
  3. 3. BMI CHART Do You Know Your Own BMI? Weight (lbs) 120 130 140 150 160 170 180 190 200 210 220 230 240 250 260 270 28 29 300 0 0 50" 52"Height 54" 56" 58" 510" 60" 62" 64"
  4. 4. DefinitionsCategory BMI lbs overweight % US popNormal 25 0 30%Overweight >25 0-35 30%Obese >30 >35 35%Morbidly Obese >40 >80 - 100 5% (15 million)
  5. 5. Morbid Obesity – a “disease”• Clinically severe obesity = a point at which obesity becomes an independent disease process and medical conditions occur as a result this occures at about 100 lbs over ideal body weight or BMI 40
  6. 6. OBESITY IS A WORLDWIDE EPIDEMIC
  7. 7. Consequences of Obesity
  8. 8. Consequences of Obesity• Type II Diabetes 30% • Intra-abdominal HTN• Hypertension 50% - GERD• CAD/ CHF 20% - Stress Incontinence• Hyperlipidemia 50%• Respiratory Insuff. 70% - Venous Insufficiency - Sleep Apnea - DVT / PE - Obesity Hypovent Synd - Hernias - Asthma
  9. 9. Consequences of Obesity• Gallstones • Cancer - 2-3x higher• Arthritis 90% - Breast• Infertility - Endometrial/Cervical• Hepatosteatosis - Colon• Chronic Skin - Prostate Infections • Depression• Pseudotumor Cerebri • Social Rejection
  10. 10. Clinically severe obesity Risk of not Having Surgery 4 3 Mortality Ratio 2 1 0 20 25 30 35 40 Increasing BMI
  11. 11. Mortality of Obesity• Shortens life by 8 yrs for women and 15 years for men• Only one in seven with severe obesity reach a normal life span (77y)• Carries a higher mortality than most cancers• Current generation is the first to have shorter life expectancy than their parents in 100 yrs
  12. 12. OBESITY EPIDEMIC• Obesity responsible for >$100 billion in medical costs per yr• US was first in life span in 1900, now LAST among developed nations• Current generation predicted to have 1/3 chance of developing DM
  13. 13. Consequences - Mortality“Taken together, the diseases associated with morbid obesity markedly reduce theodds of attaining an average life span andraise annual mortality tenfold or more.” American College of Surgeons, Recommendations for facilities performing bariatric surgery, ST-34, Bull Am Col Surg, 2000;85:
  14. 14. Consequences - Mortality>300,000 people die each year secondary to complications of obesity, making it our 2nd leading cause of preventable death
  15. 15. IV. Treatment of Obesity
  16. 16. Medical Options for Weight Loss• Dietary therapy• Behavioral modification• Exercise• Medications
  17. 17. Medical Treatment The bottom Line:All Non-surgical weight loss attemptsachieve at best modest and short termsuccess in the morbidly obese population,with about 10% wt loss, and regain in about95% within two years“ANYTHING LESS THAN A RADICAL ANDPERMANENT TRANSFORMATION WILLRESULT IN FAILURE TO TREAT MORBIDOBESITY”
  18. 18. Medical Weight Loss
  19. 19. 1991 Concensus Conference on Obesity• Medical Therapy is Rarely successful• Those who fail medical therapy should be treated surgically• Criteria for surgical therapy: - BMI > 40 - BMI > 35 with significant comorbidities - failed attempts at medical wt lossProcedures recommended = VBG and GBP
  20. 20. Surgical Options• Gastric Band• Sleeve Gastrectomy• Gastric Bypass• Biliopancreatic Diversion with Duodenal Switch
  21. 21. How does surgery work?Depending on the procedure:1. Restriction (less volume in)2. Malabsorbtion (less calories absorbed)3. Hormonal Changes (less hunger, “cures” several disease processes)4. Dumping (less processed sugar in)
  22. 22. Ruox en Y Gastric Bypass • First developed in the 1970s • Procedure of choice in the United States • Best wt loss with the lowest side effects • 60 - 80% EWL in 12 - 18 mo (90% lose 70%) • Maintained up to 15 yrs post op
  23. 23. Gastric BypassQ : How does the GBP effect wt loss?A : Four mechanisms 1. Restriction 2. Malabsorption 3. Dumping Syndrome 4. Hormonal Changes
  24. 24. The Roux-en-Y Procedure• In the Roux-en-Y Bypass procedure, a small pouch is formed along the lesser curve, excluding the fundus• The fundus is the part that can stretch out
  25. 25. The Roux-en-Y Procedure• The small intestine is divided about 20-50 cm beyond the lig of trietz (beginning pt of the jejunum)
  26. 26. The Roux-en-Y Procedure• The small intestine (B), is brought up to the gastric pouch and these are attached• The bilio-pancreatic limb (A) is hooked up to the Roux limb (B) 100 to 150 cm from the pouch• The biliopancreatic limb delivers the bile and enzymes, so food in the roux limb is poorly digested
  27. 27. DumpingThe Roux limb doesnot handle sugar welland therefore eatingsweets will causenausea, crampingand diarrhea
  28. 28. Decreased Hunger• Ghrelin is a hormone that stimulates appetite• Ghrelin levels are seen to drop within 24 hrs of surgery and stay depressed• Result = “I’m just not hungry”• Not clear why this occurs
  29. 29. Benefits of GBP• 90% of Patients lose 70% Excess Weight• 90% of medical problems resolve or improve• Longer Life (up to 89% reduced mortality)• Improved energy• Improved self-esteem, confidence, and relationships
  30. 30. Roux-en-Y Open Procedure• More pain• Longer hosp stay• Longer return to work• Wound complications - seroma (15%) - infection (<5%) - dehicsence (1%) - hernia (20%)• Technically much easier
  31. 31. Laparoscopic Roux-en Y• Less pain• Shorter stay• Less blood loss• Faster return to work• Technically more challenging• More internal hernias
  32. 32. “Restrictive” Surgery
  33. 33. LAP BAND• Mechanism purely restrictive (no decreased appetite, dumping, or malabsorbtion)• Injecting saline tightens the opening, decreasing flow out of the pouch• Adjustments made based on symptoms, wt loss, about every 4 weeks for first several months
  34. 34. ADJUST, ADJUST, ADJUST!• First adjustment at 6 wks post op• Continues every 3 wks thereafter until in “green zone”• Too tight = food gets stuck, nausea/ vomiting, GERD• Too Loose = poor wt loss, hungry, tollerate bread / red meat, “large” meals• Average adjustments - 5-6 first year and ever 6 - 12 months thereafter
  35. 35. LAP BAND• Weight loss , generally , and than with GBP - Best studies = 30% 1 yr, 40% 2y, 50% 3y - Some studies 20 -30% wt loss - Some up to 60% wt loss - overall about 50% pts lose 50% excess weight
  36. 36. Lap Band Advantages• Stomach and intestines not cut• May have shorter recovery time• Band is adjustable (going on a cruise is not a reason to empty it!!)• Surgery is “reversible” ( usually for complications)
  37. 37. Lap Band Disadvantages• Wt loss slower, less and more variable• Persistently high rates of reoperation and band removal (15 – 25%)• Less Resolution medical problems• Easier to “cheat”• Requires Maintenance adjustments forever (every 6 - 12 months)
  38. 38. Who should get a band?
  39. 39. Sleeve Gastrectomy• BPD developed 1976• BPD with DS 1998• LS BPD w/ DS 2000• Some restriction• Mostly malabsorbtion• Hormonal effect• More complications, higher risk
  40. 40. Sleeve Gastrectomy“Two stage” LS BPD w/ DS proposed 2000-LS Sleeve first-Intestinal bypass after initial wt loss-FOUND THAT SOME DID NOT NEED 2ND SURGERY
  41. 41. Sleeve Gastrectomy• 2005 – 2 studies of LS Sleeve as primary procedure showing 53% and 83% EWL at 1 yr• 2006 first large study (357pts) showing 62% EWL 12m and 67% EWL 2 yrs• To date 36 studies (2,570 pts) showing33 – 85% EWL at 5 yrs, AVERAGE 60%
  42. 42. Sleeve GastrectomyMECHANISM:1.Restriction – 100 to 150 cc vs 30cc pouch2.Hormonal Effect - decreased grehlen 70% - decreased hunger 75% - significant effect on diabetes3. No dumping, no malabsorbtion
  43. 43. COMPLICATIONSLAP BAND GASTRIC BYPASS GASTRIC SLEEVEGastric Prolapse (slip) Anastomotic Leak Staple line LeakBand Erosion Bowel Obstruction BleedingEsophageal Dialation Pulm Embolism StricturePort Problems Stricture/Marginal Ulcer Conversion to GBPDeath .1 - .5% Death .2 - .3% Death .2%
  44. 44. Is it worth it?• Mortality - Cholecystectomy .2 - .5 % - Hip Replacement .1 - .3 % - Colon Resection 3 – 5 % - LS Incisional Hernia 1 – 3% - Hysterectomy .1 - .6%
  45. 45. Bariatric Surgery• Major Life Changing event• Not a “cure” for Morbid Obesity, but . . .• Currently the best (and only) tool available to manage the disease of Morbid obesity• Will only be successful when accompanied by of and lifestyle changes
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