Information Session Surgical Weight Loss CDR Henry Lin, MC, USN LTC Scott Rehrig MD Phyllis Gottlieb RN
 
<ul><li>Why You are here </li></ul><ul><li>Indications for surgery </li></ul><ul><li>Pathway for surgery </li></ul><ul><li...
Scope of Problem <ul><li>Global epidemic </li></ul><ul><ul><li>300,000 US deaths per yr </li></ul></ul><ul><li>Economic im...
BMI and Risk Levels BMI Risk of Comorbidity Normal 18-24 Average Overweight 25-29 Increased Obesity class I 30-34 Moderate...
Obesity Comorbidities   <ul><ul><li>“ Once BMI values defining morbid obesity are reached, we are addressing a disease – a...
 
 
Diabetes <ul><li>Obesity primary risk factor  </li></ul><ul><ul><li>90% diabetics are obese </li></ul></ul><ul><li>Risk wi...
<ul><li>Every 2.2 lbs of weight loss equates to a 9% reduction in diabetes! </li></ul><ul><li>Jeffrey Sicat, MD </li></ul>...
Cardiovascular Risk <ul><li>HTN </li></ul><ul><ul><li>50%  adult BMI>30  </li></ul></ul><ul><ul><li>75%  all HTN is attrib...
Sleep Apnea <ul><li>Obesity  =  50% </li></ul><ul><li>Symptoms drowiness, inattentiveness, impaired job performance,  </li...
1991 National Institutes Health Patient Selection Criteria <ul><ul><li>BMI > 40 </li></ul></ul><ul><ul><li>BMI bwt 35 – 40...
Absolute Contraindications <ul><li>Inability to tolerate general anesthesia </li></ul><ul><ul><li>Severe non-correctable h...
WRAMC Specific Criteria <ul><li>18 y.o. <AGE < 65 y.o. </li></ul><ul><li>BMI:  < 50 kg/m 2 </li></ul><ul><li>NO  active du...
Initial Consult MTFs Phyllis Gottleib, RN (NNMC) Amanda (WRAMC) Filter Seminar (NNMC) Initial MD Appt (Lin) Out to Network...
Pathway to Surgery Information session General Surgery  Clinic appt Mental Health Medical Nutrition Exercise Physiology Pr...
Alternatives To Surgery
3 Surgical Options <ul><li>RNY GBP Sleeve  Band </li></ul>
Laparoscopic Gastric  Bypass
Weight loss <ul><li>About 100 lbs, or about 65% to 70% EBW and about 35% of the BMI. </li></ul><ul><li>Weight loss general...
Operative mortality (death) and morbidity (injury) <ul><li>Overall (30 day) mortality for gastric bypass when performed by...
Longterm complications <ul><li>internal hernias (bowel obstructions)  </li></ul><ul><ul><li>1-10% </li></ul></ul><ul><ul><...
Longterm complications <ul><li>Nutritional Deficiencies </li></ul><ul><ul><li>Permanent mineral and vitamin supplement for...
Laparoscopic Gastric Adjustable  Banding
Gastric Banding Contraindications |  Slide    <ul><li>Inflammation of the digestive tract, including ulcers, severe esopha...
Gastric Banding Contraindications – con’t. <ul><li>Infection of any type, anywhere in your body </li></ul><ul><li>Known al...
Risks Associated with Gastric Banding <ul><li>Migration of implant (band erosion, band slippage, port displacement)  </li>...
Risks Associated with Gastric Banding <ul><li>Migration of implant (band erosion, band slippage, port displacement)  </li>...
Weight Loss at Three Years  U.S. Clinical Study Results Overview |  Slide    %EWL At Three Years Number of Patients Percen...
|  Slide
|  Slide    <ul><li>Results </li></ul><ul><li>3yrs SAGB/LB </li></ul><ul><li>excess weight loss  56.36%/50.20%  </li></ul>...
Late Complications |  Slide    <ul><li>late slippage/migration  4.0% and 6.2% </li></ul><ul><li>pouch dilatation  1.7% to ...
Laparoscopic Sleeve Gastrectomy
 
 
 
 
Risk Effectiveness LAP BAND LAP GASTRIC SLEEVE  LAP GASTRIC BYPASS 0.5 % 0.1 % DEATH MORBIDITY 5.0 % %EWL 50 % 65-70 % 60 %
Summary <ul><li>Surgery NOT for everyone </li></ul><ul><li>NOT a Center of Excellence </li></ul><ul><li>?? About Future of...
Thank You! <ul><li>? </li></ul>
 
 
 
 
 
 
Welcome!
 
 
 
 
 
 
 
 
 
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Information Session Surgical Weight Loss

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Information Session Surgical Weight Loss

  1. 1. Information Session Surgical Weight Loss CDR Henry Lin, MC, USN LTC Scott Rehrig MD Phyllis Gottlieb RN
  2. 3. <ul><li>Why You are here </li></ul><ul><li>Indications for surgery </li></ul><ul><li>Pathway for surgery </li></ul><ul><li>Alternatives </li></ul><ul><li>Surgical Procedures </li></ul><ul><li>Risks and Benefits </li></ul>Overview
  3. 4. Scope of Problem <ul><li>Global epidemic </li></ul><ul><ul><li>300,000 US deaths per yr </li></ul></ul><ul><li>Economic impact </li></ul><ul><ul><li>$ 117 billion yr in US </li></ul></ul><ul><li>Negative Survival impact for BMI 45: </li></ul><ul><ul><li>White male 13yrs less </li></ul></ul><ul><ul><li>Black males 20yrs less </li></ul></ul><ul><ul><li>Black women 5yrs less </li></ul></ul><ul><ul><li>White women 8 yrs less </li></ul></ul>
  4. 5. BMI and Risk Levels BMI Risk of Comorbidity Normal 18-24 Average Overweight 25-29 Increased Obesity class I 30-34 Moderate Obesity class II 35-39 Severe Obesity class III 40 + Very Severe
  5. 6. Obesity Comorbidities <ul><ul><li>“ Once BMI values defining morbid obesity are reached, we are addressing a disease – a </li></ul></ul><ul><ul><li>life-shortening, </li></ul></ul><ul><ul><li>incapacitating, </li></ul></ul><ul><ul><li>malignant disease ” </li></ul></ul><ul><ul><li>Henry Buchwald MD PhD </li></ul></ul>
  6. 9. Diabetes <ul><li>Obesity primary risk factor </li></ul><ul><ul><li>90% diabetics are obese </li></ul></ul><ul><li>Risk with obesity </li></ul><ul><ul><li>BMI 30 = 50% </li></ul></ul><ul><ul><li>BMI 50 = 90% </li></ul></ul><ul><li>Nurses Health Study: (1980-1996) </li></ul><ul><ul><li>85,000 nurses noted that the risk of diabetes increased 40x as BMI increased from < 23 to > 35 </li></ul></ul>
  7. 10. <ul><li>Every 2.2 lbs of weight loss equates to a 9% reduction in diabetes! </li></ul><ul><li>Jeffrey Sicat, MD </li></ul><ul><li>Virginia Endocrinology and Osteoporosis Center </li></ul>
  8. 11. Cardiovascular Risk <ul><li>HTN </li></ul><ul><ul><li>50% adult BMI>30 </li></ul></ul><ul><ul><li>75% all HTN is attributed to obesity </li></ul></ul><ul><li>Dyslipidemia </li></ul><ul><ul><li>40-50% adult BMI>30 </li></ul></ul><ul><li>Cardiac and Peripheral Vascular Disease </li></ul><ul><ul><li>Primary risk factor </li></ul></ul><ul><ul><li>Secondary risk factor </li></ul></ul><ul><ul><ul><li>Impacts high blood pressure and hyperlipidemia </li></ul></ul></ul>
  9. 12. Sleep Apnea <ul><li>Obesity = 50% </li></ul><ul><li>Symptoms drowiness, inattentiveness, impaired job performance, </li></ul><ul><li>Men > women due higher incidence central obesity </li></ul>
  10. 13. 1991 National Institutes Health Patient Selection Criteria <ul><ul><li>BMI > 40 </li></ul></ul><ul><ul><li>BMI bwt 35 – 40 AND comorbidities related </li></ul></ul><ul><ul><ul><li>Functional limitations due to body size or joint disease </li></ul></ul></ul><ul><ul><li>After evaluation by a multidisciplinary team </li></ul></ul><ul><ul><ul><li>Have low probability of success with non-operative wt-loss measure </li></ul></ul></ul><ul><ul><ul><li>Be well informed with long and short term risks and benefits of surgery </li></ul></ul></ul><ul><ul><ul><li>Be highly motivated to lose weight through surgery </li></ul></ul></ul><ul><ul><ul><li>Have an accepted operative risk </li></ul></ul></ul><ul><ul><ul><li>Be willing to undergo lifelong medical surveillance </li></ul></ul></ul>
  11. 14. Absolute Contraindications <ul><li>Inability to tolerate general anesthesia </li></ul><ul><ul><li>Severe non-correctable heart or lung disease </li></ul></ul><ul><ul><li>Severe sleep apnea </li></ul></ul><ul><li>Liver disease with cirrhosis and gastric varices </li></ul><ul><li>Active peptic ulcer disease </li></ul><ul><ul><li>H. pylori infection </li></ul></ul><ul><li>Active malignancy (Cancer) </li></ul><ul><li>HIV infection </li></ul><ul><li>Any non-weight related condition with expected survival < 5 years! </li></ul>
  12. 15. WRAMC Specific Criteria <ul><li>18 y.o. <AGE < 65 y.o. </li></ul><ul><li>BMI: < 50 kg/m 2 </li></ul><ul><li>NO active duty </li></ul><ul><li>NEED a real PCM </li></ul><ul><li>- to coordinate your medical care </li></ul>
  13. 16. Initial Consult MTFs Phyllis Gottleib, RN (NNMC) Amanda (WRAMC) Filter Seminar (NNMC) Initial MD Appt (Lin) Out to Network Nutrition x 3 appts PCM Exercise Physiology Psychology Sleep Study Pulmonary? GI Pre-Op Appt (Lin) Surgery (WRAMC) Required Follow-Up Nutrition Surgeon Exercise Physiology PCM Bariatric Consult Flow Sleeve & Bypass: 3 months 6 months 9 months Every 6mo x 2 yrs Yearly Band: Monthly
  14. 17. Pathway to Surgery Information session General Surgery Clinic appt Mental Health Medical Nutrition Exercise Physiology Preop Counseling May require Additional f/u’s Up to 2 f/u’s <ul><li>H/P </li></ul><ul><li>Risk stratification </li></ul><ul><li>Medical consults </li></ul><ul><li>Setup endoscopy at NNMC </li></ul>TIME start 3-4 weeks 3-4 weeks 3-4 weeks DAY of Surgery WRAMC/NNMC <ul><li>Review consults </li></ul><ul><li>Agree on surgery type </li></ul><ul><li>Date/time </li></ul>3-4 weeks 4+ months
  15. 18. Alternatives To Surgery
  16. 19. 3 Surgical Options <ul><li>RNY GBP Sleeve Band </li></ul>
  17. 20. Laparoscopic Gastric Bypass
  18. 21. Weight loss <ul><li>About 100 lbs, or about 65% to 70% EBW and about 35% of the BMI. </li></ul><ul><li>Weight loss generally levels off in 1 to 2 years, and a regain of up to 20 lb or more is common in the longterm </li></ul>
  19. 22. Operative mortality (death) and morbidity (injury) <ul><li>Overall (30 day) mortality for gastric bypass when performed by skilled surgeons is about 0.5% </li></ul><ul><ul><li>High blood pressure, high BMI, bowel leak, blood clots to lung </li></ul></ul><ul><li>Overall Operative morbidity (eg, pulmonary emboli, anastomotic leak, bleeding, wound infection) is 5% </li></ul><ul><ul><li>Leak up to 5% - breakdown in the staple lines from cutting and formation of connections bwt intestine and stomach pouch </li></ul></ul><ul><ul><li>Bleeding up to 4% - this occurs at the staple lines after the stapling device cut the bowel </li></ul></ul><ul><ul><li>Blood clots up to 1% - but death from this complication accounts for 30-50% of patients </li></ul></ul>
  20. 23. Longterm complications <ul><li>internal hernias (bowel obstructions) </li></ul><ul><ul><li>1-10% </li></ul></ul><ul><ul><li>More common in laparoscopic technique </li></ul></ul><ul><ul><li>Difficult to diagnose with routine xrays leading to high rate of reoperation to make diagnosis </li></ul></ul><ul><li>stomal stenosis – opening to gastric pouch becomes too tight </li></ul><ul><ul><li>3-12% </li></ul></ul><ul><ul><li>Treatment require using a ballon to stretch the opening </li></ul></ul><ul><li>marginal ulcers - breakdown of connection between small intestine and gastric pouch </li></ul><ul><ul><li>1-16% </li></ul></ul><ul><ul><li>Alcohol and cigarrette smoking are major risk factor </li></ul></ul><ul><ul><li>NSAIDS contraindicated in bypass pts </li></ul></ul>
  21. 24. Longterm complications <ul><li>Nutritional Deficiencies </li></ul><ul><ul><li>Permanent mineral and vitamin supplement for the rest of natural life!! </li></ul></ul><ul><ul><ul><li>Can be very expensive cost out of pocket for patients! </li></ul></ul></ul><ul><ul><li>Anemias -- 54% </li></ul></ul><ul><ul><li>and nonreversible neurologic diseases </li></ul></ul><ul><ul><li>vitamin B12 </li></ul></ul><ul><ul><li>iron </li></ul></ul><ul><ul><li>folate </li></ul></ul><ul><ul><li>calcium </li></ul></ul>
  22. 25. Laparoscopic Gastric Adjustable Banding
  23. 26. Gastric Banding Contraindications | Slide <ul><li>Inflammation of the digestive tract, including ulcers, severe esophagitis, or Crohn’s disease </li></ul><ul><li>Severe heart or lung disease </li></ul><ul><li>Upper digestive tract bleeding conditions due to enlarged or fragile veins </li></ul><ul><li>Portal hypertension </li></ul><ul><li>Abnormal digestive tract anatomy </li></ul><ul><li>Cirrhosis of the liver </li></ul><ul><li>Chronic pancreatitis </li></ul>Situations where the risks are greater than the benefits that would be gained from surgery are contraindications. These include:
  24. 27. Gastric Banding Contraindications – con’t. <ul><li>Infection of any type, anywhere in your body </li></ul><ul><li>Known allergies to the implant materials </li></ul><ul><li>Using steroids for a long period of time or within 15 days of surgery </li></ul><ul><li>Currently pregnant </li></ul><ul><li>Younger than 18 years of age </li></ul><ul><li>Unwilling to make significant changes in eating and behavior patterns </li></ul><ul><li>Conditions or behaviors that would make it difficult to appropriately follow directions </li></ul>| Slide
  25. 28. Risks Associated with Gastric Banding <ul><li>Migration of implant (band erosion, band slippage, port displacement) </li></ul><ul><li>Tubing-related complications (port disconnection, tubing kinking) </li></ul><ul><li>Band leak </li></ul><ul><li>Esophageal spasm </li></ul><ul><li>Gastroesophageal reflux disease (GERD) </li></ul><ul><li>Inflammation of the esophagus or stomach </li></ul><ul><li>Port-site infection </li></ul>| Slide Note: Complications may result in re-operations. These complications are not usually life- threatening. Refer to the Realize™ Patient Guide for a full description of the risks and side effects.
  26. 29. Risks Associated with Gastric Banding <ul><li>Migration of implant (band erosion, band slippage, port displacement) </li></ul><ul><li>Tubing-related complications (port disconnection, tubing kinking) </li></ul><ul><li>Band leak </li></ul><ul><li>Esophageal spasm </li></ul><ul><li>Gastroesophageal reflux disease (GERD) </li></ul><ul><li>Inflammation of the esophagus or stomach </li></ul><ul><li>Port-site infection </li></ul>| Slide Note: Complications may result in re-operations. These complications are not usually life- threatening. Refer to the Realize™ Patient Guide for a full description of the risks and side effects.
  27. 30. Weight Loss at Three Years U.S. Clinical Study Results Overview | Slide %EWL At Three Years Number of Patients Percent of Patients Gained weight 5 2% 0% to 5% 6 3% 5% to 25% 41 18% 25% to 33% 33 14% 33% to 50% 63 28% 50% to 75% 56 25% 75% to 100% 24 10% Total: 228 100%
  28. 31. | Slide
  29. 32. | Slide <ul><li>Results </li></ul><ul><li>3yrs SAGB/LB </li></ul><ul><li>excess weight loss 56.36%/50.20% </li></ul><ul><li>resolution diabetes 61.45%/60.29% </li></ul><ul><li>hypertension 62.95%/43.58% </li></ul><ul><li>Adverse event (AE) rates appeared comparable </li></ul><ul><li>mortality was equivalent 0.1% </li></ul>
  30. 33. Late Complications | Slide <ul><li>late slippage/migration 4.0% and 6.2% </li></ul><ul><li>pouch dilatation 1.7% to 5.1% </li></ul>
  31. 34. Laparoscopic Sleeve Gastrectomy
  32. 39. Risk Effectiveness LAP BAND LAP GASTRIC SLEEVE LAP GASTRIC BYPASS 0.5 % 0.1 % DEATH MORBIDITY 5.0 % %EWL 50 % 65-70 % 60 %
  33. 40. Summary <ul><li>Surgery NOT for everyone </li></ul><ul><li>NOT a Center of Excellence </li></ul><ul><li>?? About Future of Program due to BRAC </li></ul>
  34. 41. Thank You! <ul><li>? </li></ul>
  35. 48. Welcome!
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