0
The Surgical Management of
Clinically Severe Obesity
Robert Bell, MD, MA, FACS
July 31, 2013
Clinically Severe Obesity
• 65% of the US are Overweight
or Obese

>86% by 2030
• 75% of obese children become
obese adul...
Bariatric Surgery
• Goal of every bariatric procedure is to
assist the patient in reducing daily
calorie intake
• Exercise...
Effect of Treatment on Obesity
Lifestyle Intervention = 3%
Medications = 1%
Surgery = 1%
Unmet = 95%
Treating Obesity
• Diets, exercise, hypnosis, jaw-wiring
and behavioral change

Up to 10% loss of excess body
weight

In...
What is “Morbid” Obesity?
• The term originated when physicians had to communicate with
insurance companies the disease as...
NIH guidelines
• BMI > 35 with co-morbidities.
• BMI > 40.
• Must have attempted and failed prior weight loss
therapy.
• M...
Operations for Clinically Severe
Obesity
Sleeve Gastrectomy
Gastric Banding
Restrictive + hormonal
Gastric Bypass
Surgery is the Un-Diet
Diet Surgery
Appetite  
Hunger  
Satiety  
Reward-based eating  
Energy expenditure  
Str...
Adipocyte Secretions
IGF-1
IGFBP
TNF-α
Interleukins
TGF-β
FGF
EGF
Fatty acids
Lysophospholipid
Lactate
Adenosine
Prostagla...
Hormonal changes
• Ghrelin

Produced by stomach

Stimulates appetite

Inhibits insulin secretion
Weight Loss at One Year
0
2
4
6
8
10
12
14
16
18
Lap Band SleeveGastrectomy Gastric Bypass
BMI
reduction
*Analysis of 28,6...
Long-term Weight Loss
Diabetes: resolved or improved
0
10
20
30
40
50
60
70
80
90
Lap Band SleeveGastrectomyGastric Bypass
%
*Analysis of 28,616...
Hypertension: resolved or improved
0
10
20
30
40
50
60
70
80
90
Lap Band SleeveGastrectomyGastric Bypass
%
*Analysis of 28...
Roux-Y Gastric Bypass
• Advantages

Excellent excess weight loss (60-75%)

Very good long-term results

Solid food well...
Personal Experience
• RYLGB 1015

1 year EWL 64.2%

2 year EWL 65.7%

3 year EWL 62.6%

4 year EWL 65.6%
Complications
• Early

Leak

PE

Pneumonia

Bleeding
• Late

SBO

Stricture

Stomal ulceration
Sleeve (longitudinal) Gastrectomy
• Advantages

Restrictive/hormonal

15% stomach capacity

Good excess weight loss (50...
Personal Experience

167 patients

Average BMI
61.6 kg/m2

EWL at 12
months
53.6%
Laparoscopic bariatric surgey
“Perioperative Safety in the Longitudinal
Assessment of Bariatric Surgery”
• N Engl J Med 2009;361:445-54.
• 4,776 first-t...
LONG-TERM SURVIVAL CANADA
6.17
0.68
0
1
2
3
4
5
6
7
%Mortality
Control Bariatric
89% reduction in risk of89% reduction in ...
Results:
Five Year Comorbidity
0 5 10 15 20 25 30 35 40
%
Cardiovascular
Endocrinological
Musculoskeletal
Infectious
Cance...
2010 bariatric surgery
2037 obese controls
Mean 10.9 years f/u
30% reduction in mortality
7925 surgical patients
7925 controls
Mean f/u of 7.1 years
Gastric bypass reduced mortality by 40%
Behavioral Aspects of Weight Loss Surgery
• Compliance with Diet
• Exercise
• Compliance with Nutritional
Supplements
• Ke...
Behavioral Aspects of Weight Loss Surgery
• Compliance with Diet
• Exercise
• Compliance with Nutritional
Supplements
• Ke...
Behavioral Aspects of Weight Loss Surgery
• Compliance with Diet
• Exercise
• Compliance with Nutritional
Supplements
• Ke...
Behavioral Aspects of Weight Loss Surgery
• Compliance with Diet
• Exercise
• Compliance with Nutritional
Supplements
• Ke...
Behavioral Aspects of Weight Loss Surgery
• Compliance with Diet
• Exercise
• Compliance with Nutritional
Supplements
• Ke...
Behavioral Aspects of Weight Loss Surgery
• Compliance with Diet
• Exercise
• Compliance with Nutritional
Supplements
• Ke...
5’ 7”
360 lbs
56.3 kg/m2
5’ 7”
192 lbs
30.0 kg/m2
90% EWL
Surgical Options for Weight Loss
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Surgical Options for Weight Loss

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Does being overweight or obese have a negative affect on your life? Learn how weight loss surgery can help you improve your health, feel better, and get your life back! Join us for a review of surgical options, including discussion about lifestyle changes to keep you on track with a healthy weight after weight loss surgery.

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Transcript of "Surgical Options for Weight Loss"

  1. 1. The Surgical Management of Clinically Severe Obesity Robert Bell, MD, MA, FACS July 31, 2013
  2. 2. Clinically Severe Obesity • 65% of the US are Overweight or Obese  >86% by 2030 • 75% of obese children become obese adults • Over 8 million Americans meet NIH criteria for weight loss surgery • Compared to moderate obesity  2X growth rate of BMI > 40kg/m2  3X growth rate of BMI > 50 kg/m2
  3. 3. Bariatric Surgery • Goal of every bariatric procedure is to assist the patient in reducing daily calorie intake • Exercise is key Calories In > Calories Out ⇒ Weight Gain Calories In = Calories Out ⇒ Weight Stable Calories In < Calories Out ⇒ Weight Loss
  4. 4. Effect of Treatment on Obesity Lifestyle Intervention = 3% Medications = 1% Surgery = 1% Unmet = 95%
  5. 5. Treating Obesity • Diets, exercise, hypnosis, jaw-wiring and behavioral change  Up to 10% loss of excess body weight  Ineffective long-term: less than 5% sustain any significant weight loss • Weight Loss Drugs  Minimal sustained weight loss • Weight Loss Surgery  Average 55% loss of excess body weight  85% long term success rate
  6. 6. What is “Morbid” Obesity? • The term originated when physicians had to communicate with insurance companies the disease aspect of treating obese patients (clinically severe obesity). • Patients who weigh 100% over ideal weight. • Patients with a BMI > 35 • Patients who develop disease states as a result of obesity.
  7. 7. NIH guidelines • BMI > 35 with co-morbidities. • BMI > 40. • Must have attempted and failed prior weight loss therapy. • Must understand risks of operation. • Must agree to lifelong follow up.
  8. 8. Operations for Clinically Severe Obesity Sleeve Gastrectomy Gastric Banding Restrictive + hormonal Gastric Bypass
  9. 9. Surgery is the Un-Diet Diet Surgery Appetite   Hunger   Satiety   Reward-based eating   Energy expenditure   Stress response  
  10. 10. Adipocyte Secretions IGF-1 IGFBP TNF-α Interleukins TGF-β FGF EGF Fatty acids Lysophospholipid Lactate Adenosine Prostaglandins Glutamine Unknown Factors Agouti Protein Retinol PAI-1 LeptinASP Angiotensin ANG-II Estrogen Adipsin Adiponectin Resistin Bone Morphogenic Protein
  11. 11. Hormonal changes • Ghrelin  Produced by stomach  Stimulates appetite  Inhibits insulin secretion
  12. 12. Weight Loss at One Year 0 2 4 6 8 10 12 14 16 18 Lap Band SleeveGastrectomy Gastric Bypass BMI reduction *Analysis of 28,616 patient at COE
  13. 13. Long-term Weight Loss
  14. 14. Diabetes: resolved or improved 0 10 20 30 40 50 60 70 80 90 Lap Band SleeveGastrectomyGastric Bypass % *Analysis of 28,616 patient at COE
  15. 15. Hypertension: resolved or improved 0 10 20 30 40 50 60 70 80 90 Lap Band SleeveGastrectomyGastric Bypass % *Analysis of 28,616 patient at COE
  16. 16. Roux-Y Gastric Bypass • Advantages  Excellent excess weight loss (60-75%)  Very good long-term results  Solid food well tolerated • Disadvantages  Potential vitamin deficiencies
  17. 17. Personal Experience • RYLGB 1015  1 year EWL 64.2%  2 year EWL 65.7%  3 year EWL 62.6%  4 year EWL 65.6%
  18. 18. Complications • Early  Leak  PE  Pneumonia  Bleeding • Late  SBO  Stricture  Stomal ulceration
  19. 19. Sleeve (longitudinal) Gastrectomy • Advantages  Restrictive/hormonal  15% stomach capacity  Good excess weight loss (50%)  Solid food well tolerated  Used as bridge to bypass • Disadvantages  Long staple line  Not universal insurance approval
  20. 20. Personal Experience  167 patients  Average BMI 61.6 kg/m2  EWL at 12 months 53.6%
  21. 21. Laparoscopic bariatric surgey
  22. 22. “Perioperative Safety in the Longitudinal Assessment of Bariatric Surgery” • N Engl J Med 2009;361:445-54. • 4,776 first-time bariatric surgery patients  for 30 days  10 U.S. hospitals (3,412 gastric bypass patients and 1,198 gastric band patients)  between 2005 and 2007 • Risks of bariatric surgery are equal to gallbladder or hip replacement surgery  Mortality rate = 0.3%  Total complication rate = 4.3% • Risks are lower than the longer-term risk of dying from heart disease, diabetes and other consequences of obesity Longitudinal Assessment of Bariatric Surgery (LABS) Consortium
  23. 23. LONG-TERM SURVIVAL CANADA 6.17 0.68 0 1 2 3 4 5 6 7 %Mortality Control Bariatric 89% reduction in risk of89% reduction in risk of death over 5 yearsdeath over 5 years Christou et al. Ann Surg 2004;240:416-424 1035 surgical patients 5746 controls Cohorts followed 5 years
  24. 24. Results: Five Year Comorbidity 0 5 10 15 20 25 30 35 40 % Cardiovascular Endocrinological Musculoskeletal Infectious Cancer Control Bariatric * * * * * *p<0.001 Christou et al. Ann Surg 2004;240:416-424
  25. 25. 2010 bariatric surgery 2037 obese controls Mean 10.9 years f/u
  26. 26. 30% reduction in mortality
  27. 27. 7925 surgical patients 7925 controls Mean f/u of 7.1 years Gastric bypass reduced mortality by 40%
  28. 28. Behavioral Aspects of Weight Loss Surgery • Compliance with Diet • Exercise • Compliance with Nutritional Supplements • Keeping follow-up appointments • Support group attendance
  29. 29. Behavioral Aspects of Weight Loss Surgery • Compliance with Diet • Exercise • Compliance with Nutritional Supplements • Keeping follow-up appointments • Support group attendance
  30. 30. Behavioral Aspects of Weight Loss Surgery • Compliance with Diet • Exercise • Compliance with Nutritional Supplements • Keeping follow-up appointments • Support group attendance
  31. 31. Behavioral Aspects of Weight Loss Surgery • Compliance with Diet • Exercise • Compliance with Nutritional Supplements • Keeping follow-up appointments • Support group attendance
  32. 32. Behavioral Aspects of Weight Loss Surgery • Compliance with Diet • Exercise • Compliance with Nutritional Supplements • Keeping follow-up appointments • Support group attendance
  33. 33. Behavioral Aspects of Weight Loss Surgery • Compliance with Diet • Exercise • Compliance with Nutritional Supplements • Keeping follow-up appointments • Support group attendance
  34. 34. 5’ 7” 360 lbs 56.3 kg/m2 5’ 7” 192 lbs 30.0 kg/m2 90% EWL
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