On Line Seminar
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  • Slide 5. The ideal BMI ranges from 19 to 25. If your BMI is between 25 and 29.9, you are thought to be overweight. If it is between 30 and 39.9, you are obese. If your BMI is 40 or more, you are said to have morbid obesity. The term “morbid” obesity is used because this degree of excess weight may considerably reduce life expectancy and is associated with an increased risk of developing conditions or diseases such as diabetes, high blood pressure, joint problems, gallstones, stroke, heart disease, and psychosocial problems.
  • Slide 9. Over 80% of people with diabetes are overweight or obese.* Carrying excess weight around causes “wear and tear” on joints and can result in problems like arthritis. For every 2-pound increase in weight, the risk of developing arthritis is increased by 9% to 13%.* High blood pressure is twice as common in adults who are obese than in those who are of normal weight.* The risk of heart disease is increased in people whose BMI is more than 25.* People who are obese also have increased risk for developing gallbladder disease.* *The full text of The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity is available at http://www.surgeongeneral.gov/topics/obesity.
  • Slide 10. Overweight and obesity are associated with an increased risk for some types of cancer, including cancer of the lining of the uterus, colon cancer, cancer of the gallbladder, prostate cancer, kidney cancer, and postmenopausal breast cancer.* Gastroesophageal reflux disease (GERD), often commonly referred to as heartburn or indigestion, occurs more often in people who have excess body fat.* Sleep apnea (interrupted breathing while sleeping) and asthma are more common in obese people than in individuals of normal weight.* People who are obese are more likely to experience depression than people who are of normal weight.* Severe obesity can affect fertility. Women who are obese are likely to have irregular menstrual periods or have trouble becoming pregnant. When obese women do get pregnant, they have more risk of problems during pregnancy and childbirth.* Overweight and obesity are also associated with increased risk of incontinence.* *The full text of The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity is available at http://www.surgeongeneral.gov/topics/obesity.
  • Slide 14. If diets, exercise programs, and other nonsurgical methods have failed to help you achieve long-term weight loss, you may want to consider a weight loss operation. There are two basic kinds of surgery for obesity. One shortens the digestive tract, and the other reduces how much food the stomach can hold. Some surgeries are a combination of the two types.
  • Slide 15. The two most common obesity surgeries in the United States have been the Gastric Bypass (GBP) and the Vertical Banded Gastroplasty (VBG). The Gastric Bypass is both a restrictive and malabsorptive operation. With this procedure, the stomach is stapled to make a smaller pouch, then a part of the intestines is attached to it. The result is that you cannot eat as much, and you absorb fewer nutrients and calories from your food. The changes in your stomach and intestine are permanent. Vertical Banded Gastroplasty is a restrictive procedure. The surgeon uses staples to make a small stomach pouch. This reduces how much food the stomach can hold. You feel full sooner and eat less. What you eat is digested by the stomach in the normal way. There is another way to reduce how much food the stomach can hold. It is called the BioEnterics  LAP-BAND  System. Today, Vertical Banded Gastroplasty is being performed less frequently than in the past and is essentially being replaced with the LAP-BAND System because of its adjustability and more gentle approach.
  • Slide 25. Studies have shown that morbidly obese people who suffer from type 2 diabetes, high blood pressure, asthma, gastroesophageal reflux disease, sleep apnea, or problems with fertility and pregnancy often experience significant improvements when they lose weight with the LAP-BAND System. A large percentage of morbidly obese people who lose weight report that they feel better psychologically as well, and that their social interactions get better as they are able to do more.
  • Slide 16. People who have Gastric Bypass surgery lose weight very quickly right from the start. In fact, on the average, they lose more weight than people who have Vertical Banded Gastroplasty or LAP-BAND System surgery. Disadvantages of Gastric Bypass, however, are that the procedure requires cutting and stapling of the stomach and bowel, which can lead to more complications, and it is not adjustable.
  • Slide 18. Using the LAP-BAND System procedure, a surgeon places an adjustable band around the upper part of your stomach. As a result, you eat less food and feel full faster. The food you eat moves slowly from the small upper pouch, past the elastic band, and on to the lower part of your stomach, where it is digested normally. There is no cutting or stapling of the stomach needed in this procedure.
  • Slide 19. Instruments are placed through very small incisions, enabling the surgeon to insert the LAP-BAND System around the top of the stomach.
  • Slide 20. The LAP-BAND System is the least invasive surgery to reduce the amount of food your stomach can hold. The name “LAP-BAND” comes from the surgical technique used (laparoscopic, or “keyhole,” surgery) and the name of the product used (gastric band). LAP-BAND surgery does not result in permanent changes to your stomach or your intestines. The band can be removed, should that become necessary. When the band is removed, the stomach generally returns to its original form. In general, it is easier to remove the LAP-BAND than it is to reverse other kinds of surgical procedures for obesity. With the LAP-BAND, weight loss is slow and gentle—not as rapid from the start as with Gastric Bypass. Regular follow-up visits for nutrition and exercise education as well as for adjustments are necessary, however, for optimum results.
  • Slide 24. The LAP-BAND System is an aid to help you lose weight and keep it off. It will accomplish this by limiting how much you eat, reducing your appetite, slowing your digestion, and making you feel full longer. In addition, lifestyle changes are very important for success with the LAP-BAND System. The amount of weight you will lose depends both on the band and on your motivation and commitment to a new lifestyle and eating habits. You must be determined to stick to this new way of eating for the rest of your life. Exercise is just as important; it will not only help you in your battle against being overweight, it will also benefit your general health and well-being. Follow-up exams with the specialist who is treating you are very important. From time to time your band may need to be adjusted to help you keep losing weight.

On Line Seminar Presentation Transcript

  • 1. Weight loss Surgery Kuldeep Singh, M.D., F.A.C.S., M.B.A.
  • 2. Spectrum of the obesity
    • Terms Used to Describe Various Levels of Body Fat
    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 or more) This is where Surgical treatment is recommended
  • 3. Health Risks
    • Obese people have more risk for:
      • Diabetes (type 2)
      • Joint problems, backaches, disc Prolapse (e.g., arthritis)
      • High blood pressure
      • Heart disease: coronary artery disease
      • Gallbladder problems, gallstones
    Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity. Related Diseases and Health Problems
  • 4. Health Risks (cont.)
    • Related Diseases and Health Problems
    • In addition, obese people have more risk for:
      • Certain types of cancer (breast, uterine, colon)
      • Digestive disorders (e.g. gastro-esophageal reflux disease, or GERD)
      • Breathing difficulties (e.g. sleep apnea, asthma).
      • Psychological problems such as depression.
      • Problems with fertility and pregnancy.
      • Stress Incontinence.
    Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity.
  • 5. Using Surgery to Treat Obesity
    • Types of weight-loss surgeries
      • Malabsorptive procedures shorten the digestive tract: BPD & BPD-DS
      • Restrictive procedures reduce how much the stomach can hold: Lap Band & Sleeve Gastrectomy
      • Combined procedures shorten the digestive tract and reduce how much the stomach can hold: Gastric Bypass
  • 6. Using Surgery to Treat Obesity- Restrictive Techniques Sleeve Gastrectomy LAP-BAND System wo-pub2.med.cornell.edu/.../PublicA.woa/4/wa
  • 7. Using Surgery to Treat Obesity- Malabsorptive Techniques Bilio-Pancreatic Diversion (BPD) We do not perform BPD, however we can refer you to surgeons in the area who perform this surgery
  • 8. Mixed Techniques Roux-en-Y Gastric Bypass
  • 9. Risk Benefit Ratio RISK Lap Band Sleeve Gastrectomy Roux –en-Y Gastric Bypass Bilio-Pancreatic Diversion HIGH LOW BENEFIT HIGH LOW Lap Band Sleeve Gastrectomy Roux –en-Y Gastric Bypass Bilio-Pancreatic Diversion Riskier the operation, the more effective it is
  • 10. Expected Outcomes from the Surgery
    • Improvement in health problems, including:
      • Diabetes (type 2): 80% cure possible.
      • High blood pressure: 40% cure
      • Asthma: marked improvement
      • GERD (gastro-esophageal reflux disease):
      • Sleep apnea: close to 100% cure
      • Problems with fertility and pregnancy
      • Depression.
  • 11. Laparoscopic Gastric Bypass
    • Advantages
    • Rapid initial weight loss
    • Higher total average weight loss .
    • Over 40 years of surgical experience in USA
    • Disadvantages
    • Bigger operation and slower recovery.
    • Practically irreversible
    • Higher chances of nutritional problems such as Iron deficiency anemia and vitamin B 12 deficiency.
    • Higher chances of ulcers at the junction of the stomach and the jejunum.
  • 12. How the LAP-BAND System Works
    • A silicone band is placed around the upper part of the stomach
      • A small pouch is created
      • Your stomach holds less food
      • You feel full faster and longer
  • 13. The LAP-BAND System Procedure
    • Adjustable Band
      • Can be adjusted in office or operating room
      • No anesthesia needed.
      • On average 4-5 fills in first year
      • 1 or 2 fills second year if needed.
  • 14. The LAP-BAND System
    • Advantages
    • Lowest mortality rate
    • No stomach stapling or cutting, or intestinal re-routing
    • Adjustable
    • Smaller operation , Reversible
    • Lowest operative complication rate
    • Low malnutrition risk
    • Disadvantages
    • Slower weight loss.
    • Regular follow-up critical for optimal results
    • Requires more commitment from the patient.
    • Slippage or erosion and injury to the esophagus or stomach as possible complications.
  • 15.
    • Arose from need to perform a safer yet effective operation in patients with high BMI (>50) and multiple co-morbidities.
    • It is first stage of BPD-DS (Bilio-pancreatic diversion with Duodenal switch).
    • Designed as an separate staged procedure by Johnson in 1993.
    Sleeve Gastrectomy (SG)
  • 16.
    • Complications and outcomes are somewhere between Adjustable Laparoscopic gastric Banding and Gastric Bypass.
    • Advantage of absence of Iron deficiency anemia, Marginal Ulcers, ability to perform upper endoscopic procedures and decrease the weight and co-morbidities to lead to any second staged procedure such as band, bypass or BPD.
    Sleeve Gastrectomy
  • 17. Who qualifies for the Bariatric Surgery?
    • NIH criteria
      • Weight: BMI more than 40 or 35 with two serious illnesses.
      • Free from untreated mental illnesses such as Bulimia and schizophrenia.
      • Documented evidence of weight loss attempts. In Maryland 6 months over the past two years.
      • Understanding by the patient that the surgery is only a tool to lose weight and need to have life style changes and exercise/ eating habits.
    • Age: 18-60 years of age
  • 18.
    • Those who cannot walk.
    • Those who have severe heart disease.
      • Heart failure.
      • Angina and coronary artery disease.
    • With severe lung disease.
    • In whom surgery is not possible
      • Extreme obesity. Absolute weight matters to an extent. I will not operate patients over 500 lbs.
      • Limited exercise tolerance. You should be able to walk with me to the parking lot (2 blocks) and back without severe shortness of breath.
    • Schizophrenia and Bulimia.
    Who does not qualifies for the Bariatric Surgery? These are our contraindications
  • 19. Bypass or Band?? How to choose? some guidelines
    • Bypass
      • Bigger operation, higher risk, more weight loss and rapid weight loss.
      • More nutritional problems: anemia and ulcers.
      • My preference: severe obesity with lot of illnesses .
    • Lap Band
      • Smaller and safer surgery, quick recovery.
      • Less nutritional problems, less anemia or ulcers.
      • Unique problems such as Slippage and Erosions.
      • Reversible.
      • My preference: BMI small with not so many diseases, women.
            • Sleeve Gastrectomy
      • BMI>60.
      • Android Obesity
  • 20. The process for the surgery
    • Make sure you meet the criteria for the surgery.
    • Call your insurance company to check coverage.
    • Make sure that we participate with your insurance or be willing to pay more out of Pocket expense.
    • See the dietician and the psychologist.
    • Fill all the forms and organize your folder into weight loss attempts, cardiac consult , Sleep Study and History and physical note form your doctor (whatever applies).
    • Call the office and make appointment to see the Doctor.
    • If you have questions whether you will qualify- Call the office to clarify.
  • 21. Centers of Excellence
    • Awarded COE by most of the Insurers in Maryland (Blue cross, Atena, United Healthcare and Cigna).
    • Awarded COE by SRC (Surgical review Committee in June 2006 for full three years.
  • 22. Bariatric Volumes and Market Share in Maryland 100.0% 100.0% 100.0% 100.0% 100.0% 1,921 413 1,774 332 1,532 309 1,001 215 348 67 Grand Total 0.0% 0.2% 0.3% 2.8% 1.7% 0 0 3 0 4 0 28 2 6 1 All Other 0.0% 0.0% 9.1% 11.5% 14.4% 0 0 0 0 140 30 115 24 50 14 GOOD SAMARITAN 0.0% 1.2% 5.8% 0.0% 0.0% 0 0 22 0 89 7 0 0 0 0 SUBURBAN 1.9% 1.6% 1.2% 5.1% 3.7% 37 6 28 5 18 9 51 16 13 3 UNION MEMORIAL 2.4% 3.4% 4.7% 14.6% 19.8% 47 8 60 11 72 12 146 35 69 13 FRANKLIN SQUARE 3.0% 5.6% 7.2% 4.5% 0.9% 57 14 99 18 110 22 45 10 3 1 SAINT JOSEPH 3.0% 3.4% 0.0% 0.0% 0.0% 58 1 60 3 0 0 0 0 0 0 HARFORD MEMORIAL 4.7% 6.6% 8.3% 1.0% 0.0% 91 0 117 2 127 4 10 0 0 0 WASHINGTON ADVENTIST 5.3% 5.4% 6.4% 5.4% 0.0% 102 0 96 1 98 0 54 2 0 0 PENINSULA REGIONAL 5.5% 8.2% 7.0% 0.6% 0.0% 105 1 145 2 107 2 6 0 0 0 SHADY GROVE 6.8% 1.2% 1.4% 2.7% 4.0% 130 28 22 4 22 9 27 7 14 4 UMMS 7.8% 5.7% 4.0% 16.0% 9.5% 149 3 102 2 62 0 160 8 33 0 HOLY CROSS 9.6% 10.6% 3.9% 7.6% 23.9% 184 51 188 56 60 21 76 14 83 12 SINAI 9.8% 8.9% 2.0% 0.0% 0.0% 188 33 158 18 31 0 0 0 0 0 GBMC 15% 17% 18% 14% 15% 304 39 306 36 281 40 148 22 53 6 BAYVIEW 24% 20% 20% 13% 6% 469 229 368 174 311 153 135 75 24 13 ST. AGNES FY06 FY05 FY04 FY03 FY02 Total Svc Area Total Svc Area Total Svc Area Total Svc Area Total Svc Area HOSPITAL Total Cases Market Share FY06 FY05 FY04 FY03 FY02   DRG 288 & ICD-9 Procedure code definition
  • 23. Morbidity and Mortality of Gastric Bypass surgery at St. Agnes Hospital 2001-2007 NA 65% 65% EBWL % 1 year NA 0.99% 5 % Marginal ulcer NA 0.95% 2.5% Bowel obstruction NA 4.5% 4.5% Re-admission NA 2% 2.5% Re-operations NA 8.5% 10% Morbidity 1.9% 0.23% 0.3% Mortality 3328 1300 55 000 Number of patients Washington State Data St. Agnes Program Average for Centers of Excellence (SRC) Variable
  • 24. Comparison of % EBWL of Gastric bypass and Lap. Band patients Chapman et al.; Surgery 135:326-351: 2004
  • 25. Resolution of co-morbidities after 1 year in Gastric bypass patients with Insurance mandated diet Jamal et al., SOARD 2:122-127; 2006 NS 79% 82% Joint pain NS 91% 84% GERD NA NA NA Sleep apnea NS 83% 100% Venous stasis NS 79% 93% Diabetes NS 71% 58% HTN P value No diet Preoperative diet Variable
  • 26.