1. Update on Obesity managementUpdate on Obesity management
and surgical options.and surgical options.
Michael Baptista, MDMichael Baptista, MD
www.JaxSurgical.com

2. www.jaxsurgical.com
Are we facing an epidemic problem?Are we facing an epidemic problem?

3. www.jaxsurgical.com
Are we facing an epidemic problem?Are we facing an epidemic problem?

4. www.jaxsurgical.com
Are we facing an epidemic problem?Are we facing an epidemic problem?

5. www.jaxsurgical.com
Are we facing an epidemic problem?Are we facing an epidemic problem?

6. www.jaxsurgical.com
Are we facing an epidemic problem?Are we facing an epidemic problem?

7. What causes obesity?What causes obesity?
· GeneticsGenetics
· EnvironmentEnvironment
· HormonesHormones
· CultureCulture
· Kinds of food groupsKinds of food groups
· Lack of exerciseLack of exercise
· PsychologicalPsychological
· Et CeteraEt Cetera
www.JaxSurgical.com

8. What causes obesity?What causes obesity?
· GeneticsGenetics
· EnvironmentEnvironment
· HormonesHormones
· CultureCulture
· Kinds of food groupsKinds of food groups
· Lack of exerciseLack of exercise
· PsychologicalPsychological
· Et CeteraEt Cetera
www.JaxSurgical.com
It is not an anatomic variation of our gastrointestinal tract!!!It is not an anatomic variation of our gastrointestinal tract!!!

9. OBESITY IS A DISEASE!OBESITY IS A DISEASE!
Received official, FederalReceived official, Federal “DISEASE”“DISEASE” status in October 2004status in October 2004
American Medical Association recognized in June 2013American Medical Association recognized in June 2013
- 25% or less in the 1960s and 1970s;- 25% or less in the 1960s and 1970s;
- 50% during the 1980s and 1990s;- 50% during the 1980s and 1990s;
- 70% currently- 70% currently
US prevalence of overweight adults reached epidemic levels:US prevalence of overweight adults reached epidemic levels:

10. Success rates of differentSuccess rates of different
weight loss modalities…weight loss modalities…
6%6% 12%12% 60 - 90%60 - 90%8%8%

11. ““OnlyOnly surgerysurgery has proven effective overhas proven effective over
the long term for most patients withthe long term for most patients with
clinically severe obesity.”clinically severe obesity.”
National Institute of HealthNational Institute of Health
Consensus in 1992Consensus in 1992
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12. OBESITY…OBESITY…
Associated with many diseases such as:Associated with many diseases such as:
• HypertensionHypertension
• DyslipidemiaDyslipidemia
• Type 2 diabetesType 2 diabetes
• Coronary heart diseaseCoronary heart disease
• StrokeStroke
• Gallbladder diseaseGallbladder disease
• OsteoarthritisOsteoarthritis
• Sleep apnea and respiratory problemsSleep apnea and respiratory problems
• Cancers associated with 16 (endometrial, breast, and colon)Cancers associated with 16 (endometrial, breast, and colon)

13. OBESITY: THE AFFECT ON YOUR HEALTHOBESITY: THE AFFECT ON YOUR HEALTH
www.JaxSurgical.com

14. OBESITY: THE AFFECT ON YOUR HEALTHOBESITY: THE AFFECT ON YOUR HEALTH
www.JaxSurgical.com

15. Comorbidity Resolution:Comorbidity Resolution:
4 study results4 study results
1. Dixon JB, O’Brien PE. Health outcomes of severely obese type 2 diabetic subjects 1 year after laparoscopic adjustable gastric banding. Diabetes Care. 2002;25:358-363. 2. Dixon JB, Chapman L,
O’Brien P. Marked improvement in asthma after Lap-Band®
surgery for morbid obesity. Obes Surg. 1999;9:285-389 3. Dixon JB, Schachter LM, O’Brien PE. Sleep disturbance and obesity. Arch
Intern Med. 2001;161:102-106. 4. Dixon JB, O’Brien PE. Gastroesophageal reflux in obesity: the effect of Lap-Band placement. Obes Surg. 1999;9:527-531.

16. Risk of death in morbidly obeseRisk of death in morbidly obese
patients: surgery vs no surgerypatients: surgery vs no surgery
Survival rate atSurvival rate at
1 year1 year
Survival rate atSurvival rate at
3 years3 years
Survival rate atSurvival rate at
5 years5 years
99%99% 98%98% 97%97%
Survival rate at 1Survival rate at 1
yearyear
Survival rate at 3Survival rate at 3
yearsyears
Survival rate atSurvival rate at
5 years5 years
97%97% 88%88% 78%78%
PatientsPatients
seen atseen at
seminarseminar
SurgerySurgery
NoNo
surgerysurgery
Dr. Reinhold, Saint Raphael Hospital- New Haven – Connecticut.
www.JaxSurgical.com

17. What is “BMI” and what is theWhat is “BMI” and what is the
importance of BMI?importance of BMI?
Using Body Mass Index (BMI)Using Body Mass Index (BMI)
Measures obesity based on weightMeasures obesity based on weight
and height to standardizeand height to standardize
measurementsmeasurements
70% adults, 22% kids70% adults, 22% kids
30%30%
14%14%
8%8%

18. CHOOSING SURGERYCHOOSING SURGERY
• Surgery is a powerfulSurgery is a powerful tooltool, not a solution;, not a solution;
• No SurgeryNo Surgery can guarantee 100% success to all patients;can guarantee 100% success to all patients;
• Surgery is an option when other weight-loss therapies have failedSurgery is an option when other weight-loss therapies have failed
• Obesity surgery is not cosmetic; it is no different from cancerObesity surgery is not cosmetic; it is no different from cancer
or heart surgeryor heart surgery
• So, choose theSo, choose the safest, least invasive, lowest risk &safest, least invasive, lowest risk & successfulsuccessful
procedureprocedure

19. TYPES OF OBESITY SURGERYTYPES OF OBESITY SURGERY
RestrictiveRestrictive Reduce how much the stomach can holdReduce how much the stomach can hold
Horizontal GastroplastiesHorizontal Gastroplasties
Vertical Banded Gastroplasty (VGB)Vertical Banded Gastroplasty (VGB)
Silastic Ring Vertical Gastroplasty (SRVG)Silastic Ring Vertical Gastroplasty (SRVG)
Laparoscopic Sleeve Gastrectomy (LSG)Laparoscopic Sleeve Gastrectomy (LSG)
Laparoscopic Adjustable Gastric Banding (Realize Band & Lap Band)Laparoscopic Adjustable Gastric Banding (Realize Band & Lap Band)
MalabsorptiveMalabsorptive Shorten the digestive tractShorten the digestive tract
Jejunoileal Bypass (JIB)Jejunoileal Bypass (JIB)
Biliopancreatic Diversion (BPD)Biliopancreatic Diversion (BPD)
+/- Duodenal Switch+/- Duodenal Switch
Long Limb Gastric-BypassLong Limb Gastric-Bypass
CombinationCombination Laparoscopic Roux-en-Y Gastric Bypass (LRNYGB)Laparoscopic Roux-en-Y Gastric Bypass (LRNYGB)

20. TYPES OF OBESITY SURGERYTYPES OF OBESITY SURGERY
Gastric BypassGastric Bypass
(LRNYGB)(LRNYGB)
Gastric BandGastric Band
(REALIZE Band &(REALIZE Band &
Lap Band System)Lap Band System)
Vertical BandedVertical Banded
GastroplastyGastroplasty
(VBG)(VBG)
Bilio-PancreaticBilio-Pancreatic
DiversionDiversion
(BPD)(BPD)
MalabsorptiveMalabsorptive CombinedCombined
Restrictive,Restrictive,
FixedFixed
Restrictive,Restrictive,
AdjustableAdjustable
High complication rates,High complication rates,
poor long term weight losspoor long term weight loss
Historical operation stillHistorical operation still
done by somedone by some
High comp. rates (56.4%),High comp. rates (56.4%),
good long term weightgood long term weight
loss, major long termloss, major long term
malnutrition problemsmalnutrition problems
Technically veryTechnically very
demandingdemanding
AVOID mini-bypassAVOID mini-bypass 20 year experience;20 year experience;
FDA approved 2001FDA approved 2001
Restrictive,Restrictive,
FixedFixed
SleeveSleeve
GastrectomyGastrectomy
(LSG)(LSG)
Initially used as a first stepInitially used as a first step
surgery for other bariatricsurgery for other bariatric
surgery. Now stands as asurgery. Now stands as a
“new” technique. Long“new” technique. Long
results not available.results not available.

21. Open vs. Laparoscopic SurgeryOpen vs. Laparoscopic Surgery
Open SurgeryOpen Surgery
- Large incision, worse scar- Large incision, worse scar
- More pain- More pain
- More complications (hernias in- More complications (hernias in
20%)20%)
- Only 2 indications- Only 2 indications
• Can’t be done laparoscopicallyCan’t be done laparoscopically
• Insurance (eg. Tricare)Insurance (eg. Tricare)
Laparoscopic SurgeryLaparoscopic Surgery
- Small incisions, less scarring- Small incisions, less scarring
- Less pain, shorter hospital- Less pain, shorter hospital
stay, quicker return to workstay, quicker return to work
- Surgeon uses long, thin- Surgeon uses long, thin
instruments and videoinstruments and video
Single Site LapSingle Site Lap
- Even less scarring- Even less scarring
- Less pain, shorter hospital- Less pain, shorter hospital
stay, quicker return to workstay, quicker return to work
- Surgeon uses a special port- Surgeon uses a special port
to access the abdominal cavityto access the abdominal cavity
www.JaxSurgical.com

22. LAGB SurgeryLAGB Surgery
• RestrictiveRestrictive only…releases food slowly, providingonly…releases food slowly, providing SATIETYSATIETY
• Simple operation, easier re-operationSimple operation, easier re-operation
• Most done as same day surgeryMost done as same day surgery
• AdjustableAdjustable
• ReversibleReversible
• Low mortality vs. Fen-PhenLow mortality vs. Fen-Phen
• Few complications (2-3% overall)Few complications (2-3% overall)
• No malabsorptionNo malabsorption
• You are not as hungryYou are not as hungry
• Long term physician controlLong term physician control
• ““Normal” life, good maintenanceNormal” life, good maintenance
www.JaxSurgical.com

23. Laparoscopic Roux-en-YLaparoscopic Roux-en-Y
Gastric-Bypass SurgeryGastric-Bypass Surgery
• RestrictiveRestrictive && MalabsorptiveMalabsorptive
• Complex operation and re-operation,Complex operation and re-operation,
technically difficult, problematic to reversetechnically difficult, problematic to reverse
• 100% need to stay in the hospital100% need to stay in the hospital
• Lifelong protein-calorie malabsorptionLifelong protein-calorie malabsorption
requiring vitamin & mineral replacement forrequiring vitamin & mineral replacement for
the rest of your lifethe rest of your life
• Dumping syndrome (Bad diarrhea)Dumping syndrome (Bad diarrhea)
• Late weight regain, no adjustmentsLate weight regain, no adjustments
• 10-15% surgical complications10-15% surgical complications
• No post-op control physicianNo post-op control physician
• 1% Mortality1% Mortality
• Better life than obesity, BUTBetter life than obesity, BUT not normalnot normal
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24. Revision SurgeryRevision Surgery
• Complex re-operation, technically difficult due to scarring and changeComplex re-operation, technically difficult due to scarring and change
in anatomy;in anatomy;
• Need to stay in the hospital;Need to stay in the hospital;
• Must have a very careful evaluation for surgery:Must have a very careful evaluation for surgery:
• Access why the weight came back or why patient didn’t lose it.Access why the weight came back or why patient didn’t lose it.
• Technical problem with previous surgeryTechnical problem with previous surgery
• Patient needs to demonstrate ability to follow recommendations,Patient needs to demonstrate ability to follow recommendations,
since it will be the same with the next surgery;since it will be the same with the next surgery;
• Lack of long term data to prove efficacy;Lack of long term data to prove efficacy;
• Higher rate of surgical complications;Higher rate of surgical complications;
• Needs close follow up by the physicianNeeds close follow up by the physician
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25. SURGICAL OUTCOMESSURGICAL OUTCOMES
• Long-term Weight LossLong-term Weight Loss
 80-200 lbs in 12-18 months; goal achievement by 2 years80-200 lbs in 12-18 months; goal achievement by 2 years
 Life style changes + dietary recommendationsLife style changes + dietary recommendations
 Band + possible adjustmentsBand + possible adjustments
• Reduction of Co-morbiditiesReduction of Co-morbidities
 New-onset type 2 diabetes drops by 85%New-onset type 2 diabetes drops by 85%
 Sleep apneaSleep apnea →→ improvement in 86%;improvement in 86%;
 Increased intracranial pressureIncreased intracranial pressure →→ resolution in over 95%,resolution in over 95%,
 HypertensionHypertension →→ resolved in 60 – 74% of the patientsresolved in 60 – 74% of the patients
 Skin and cosmetic surgerySkin and cosmetic surgery
For morbidly obese patients, the risk of obesity far outweighsFor morbidly obese patients, the risk of obesity far outweighs
the risk of either surgery.the risk of either surgery.
www.JaxSurgical.com

26. It works….It works….
www.jaxsurgical.com

27. www.jaxsurgical.com
It works…It works…

28. www.jaxsurgical.com
The weight just falls…The weight just falls…

29. Thank you!Thank you!
www.JaxSurgical.comwww.JaxSurgical.com
Michael Baptista, MDMichael Baptista, MD