Central Ohio Bariatrics Presentation

8/14/2019 Central Ohio Bariatrics Presentation

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CLINICALLY SEVERE

OBESITY

TIMOTHY CUSTER M.D., F.A.C.S


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WHAT IS MORBID

OBESITY?


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BMI CHART

Do You Know Your Own BMI?

5'4"5'4"

Height

Height

Weight (lbs)Weight (lbs)

5'25'2""

5'0"5'0"

5'10"5'10"

5'8"5'8"

5'6"5'6"

6'0"6'0"

6'2"6'2"

120120130130 150150 160160170170180180190190 200200210210220220 230230240240250250140140 260260 2702702828

00

2929

00

300300

6'4"6'4"


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Definitions

Category BMI lbs overweight % US pop

Normal 25 0 30%

Overweight >25 0-35 30%

Obese >30 >35 35%

Morbidly Obese >40 >80 - 100 5% (15 million)


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Morbid Obesity a disease Clinically severe obesity = a point at

which obesity becomes an independent

disease processand medicalconditions occur as a result

this occures at about 100 lbs

over ideal body weight or BMI 40


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OBESITY IS A WORLDWIDE EPIDEMIC


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Consequences of Obesity


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Type II Diabetes 30% Hypertension 50% CAD/ CHF 20% Hyperlipidemia 50% Respiratory Insuff. 70%

- Sleep Apnea

- Obesity Hypovent Synd

- Asthma

Intra-abdominal HTN- GERD

- Stress Incontinence- Venous Insufficiency

- DVT / PE

- Hernias


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Gallstones Arthritis 90%

Infertility Hepatosteatosis

Chronic SkinInfections

Pseudotumor Cerebri

Cancer - 2-3x higher- Breast

- Endometrial/Cervical- Colon

- Prostate

Depression Social Rejection


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Clinically severe obesity

Risk of not Having Surgery

0

1

2

3

4

20 25 30 35 40

MortalityRatio

0

1

2

3

4

20 25 30 35 40

MortalityRatio

Increasing BMI


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Mortality of Obesity

Shortens life by 8 yrs for women and 15years for men

Only one in seven with severe obesityreach a normal life span (77y)

Carries a higher mortality than mostcancers

Current generation is the first to haveshorter life expectancy than their parentsin 100 yrs


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OBESITY EPIDEMIC

Obesity responsible for >$100 billion inmedical costs per yr

US was first in life span in 1900, nowLAST among developed nations Current generation predicted to have 1/3

chance of developing DM


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Consequences - Mortality

Taken together, the diseases associated

with morbid obesity markedly reduce theodds of attaining an average life span and

raise annual mortality tenfold or more.

American College of Surgeons, Recommendations for facilitiesperforming bariatric surgery, ST-34, Bull Am Col Surg, 2000;85:


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Consequences - Mortality

>300,000 people die each year secondary tocomplications of obesity, making it our

2ndleading cause of preventable death


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IV. Treatment of Obesity


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Medical Treatment

The bottom Line:All Non-surgical weight loss attempts achieveat best modest and short term success in the

morbidly obese population, with about 10%wt loss, and regain in about 95% within twoyears

ANYTHING LESS THAN A RADICALANDPERMANENT TRANSFORMATION WILLRESULT IN FAILURE TO TREAT MORBIDOBESITY


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Medical Weight Loss


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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


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Surgical Options


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Ruox en Y Gastric Bypass

First developed in the1970s

Procedure of choice inthe United States

Best wt loss with thelowest side effects

60 - 80% EWL in 12 - 18mo (90% lose 70%)

Maintained up to 15 yrspost op


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Gastric Bypass

Q : How does the GBP effect wt loss?

A : Four mechanisms

1. Restriction2. Malabsorption

3. Dumping Syndrome

4. Hormonal Changes


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The Roux-en-Y Procedure

In the Roux-en-YBypass procedure, asmall pouch

is formed along thelesser curve, excludingthe fundus

The fundus is the partthat can stretch out


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The small intestine isdivided about 20-50

cm beyond the lig oftrietz (beginning pt ofthe jejunum)


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The small intestine(B), is brought up tothe gastric pouch andthese are attached

The bilio-pancreaticlimb (A) is hooked upto the Roux limb (B)100 to 150 cm fromthe pouch

The biliopancreaticlimb delivers the bileand enzymes, so foodin the roux limb ispoorly digested


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Dumping

The Roux limb does

not handle sugar welland therefore eatingsweets will causenausea, cramping

and diarrhea


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Decreased Hunger

Ghrelin is a hormone that stimulates appetite Ghrelin levels are seen to drop within 24 hrs of surgery

and stay depressed Result = Im just not hungry Not clear why this occurs


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Benefits of GBP


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Roux-en-Y

Open Procedure More pain Longer hosp stay Longer return to work Wound complications

- seroma (15%)

- infection (


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Laparoscopic Roux-en Y

Less pain Shorter stay Less blood loss Faster return to

work

Technically morechallenging

More internalhernias


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Restrictive Surgery


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LAP BAND

Mechanism purely restrictive(nodecreased appetite, dumping, ormalabsorbtion)

Injecting saline tightens the opening,decreasing flow out of the pouch

Adjustments made based on symptoms,wt loss, about every 4 weeks for firstseveral months


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LAP BAND


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Lap Band Advantages

Stomach and intestines not cut May have shorter recovery time Band is adjustable (going on a cruise isnot a reason to empty it!!) Surgery is reversible ( usually for

complications)


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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 adjustmentsforever (every 6 - 12 months)


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Who should get a band?


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Sleeve Gastrectomy

BPD developed 1976 BPD with DS 1998 LS BPD w/ DS 2000 Some restriction Mostly malabsorbtion Hormonal effect More complications,

higher risk


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Sleeve Gastrectomy

Two stageLS BPD w/DS proposed 2000

-LS Sleeve first

-Intestinal bypass afterinitial wt loss

-FOUND THAT SOMEDID NOT NEED 2NDSURGERY


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Sleeve Gastrectomy

2005 2 studies of LS Sleeve as primaryprocedure showing 53% and 83% EWL at1 yr

2006 first large study (357pts) showing62% EWL 12m and 67% EWL 2 yrs

To date 36 studies (2,570 pts) showing33 85% EWL at 5 yrs, AVERAGE 60%


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Sleeve Gastrectomy

MECHANISM:

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


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COMPLICATIONS

LAP BAND GASTRIC BYPASS GASTRIC SLEEVE

Gastric Prolapse (slip) Anastomotic Leak Staple line Leak

Band Erosion Bowel Obstruction Bleeding

Esophageal Dialation Pulm Embolism Stricture

Port Problems Stricture/Marginal Ulcer Conversion to GBP

Death .1 - .5% Death .2 - .3% Death .2%


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Bariatric Surgery


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Documents

Central Ohio Bariatrics Presentation