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SURGICAL MANAGEMENT OF OBESITY
Anne Lidor, MD, MPH
Professor of Surgery
Chief, Division of Minimally Invasive and Bariatric Surgery
Multi-Factorial Causes of Morbid Obesity include:
• Genetic
• Environmental
• Cultural
• Psychological
• Socioeconomic
How does obesity impact our health?
Obesity-Related Comorbidities
Type 2 Diabetes
Obstructive sleep apnea
High cholesterol
Hypertension
Heart Disease
GERD (reflux/heart burn)
Gallstones
Degenerative joint disease
Fatty liver disease
Asthma
Stress incontinence
Birth defects
Miscarriages
Infertility
Cancer
Breast
Cervical
Endometrial
Ovarian
Colorectal
Liver
Pancreatic
Esophageal
Lung
Prostate
Kidney
Lymphoma
Multiple myeloma
Leukemia
Available Treatment Options:
Diet & Exercise
Medication
Behavioral modification
Surgical management
It’s the most powerful tool
in our tool box
Why Bariatric surgery?
Purpose of Bariatric Surgery
To alleviate or eliminate obesity related medical diseases
It is not cosmetic surgery!
Bariatric Surgery Patient Selection (Based On The 1991 NIH Guidelines)
BMI > 40; or > 35 with obesity related morbidity
Previous failed attempts at supervised weight reduction
Realistic expectations
No recent substance abuse
Age limits (18 to 65 yrs old in most programs)
Supportive family/friends
Lifelong commitment to dietary change and follow-up
What is Body Mass Index?
Classification of ObesityBody Mass Index (BMI) = wt (kg) / ht (m)
Non-obese 20 - 25 < 30 lbs
Obese > 30 > 30 lbs
Morbid Obesity > 40 > 100 lbs
Superobesity > 50 > 150 lbs
BMI (kg/m )~Excessbody weight
2
2
How much weight loss ?
Current weight: 250 pounds
- (subtract)
Ideal Body Weight: 150 pounds
__________________________
= Excess Body Weight: 100
50-75% Excess Body Weight = 50 to 75 pounds lost
Example:
A 300 lb individual may realize a 55 - 80 lb weight loss
A 400 lb individual may realize a 75-130 lb weight loss
A “normal” BMI is not necessary for improved health
OUR GOALS FOR YOU INCLUDE:
Improved Co-morbid Conditions Type 2 Diabetes
Obstructive sleep apnea
High cholesterol
Hypertension
Improved Over-all HealthImproved Quality of Life Longer Life
RNY (Gastric Bypass) Sleeve
Bariatric Procedures
Laparoscopic Approach
Laparoscopic Approach
• Less pain
• Fewer infections
• Shorter length of stay
• Much less risk of developing a hernia at incision
Roux-en-Y Gastric Bypass
Restrictive (small pouch size)
Malabsorptive (skipping part of the intestine)
Alters hunger hormones and insulin sensitivity
little to no hunger
Improved diabetes
Hospital stay of 2 nights
Roux-en-Y Gastric Bypass
Gastric Bypass
PROS
Proven long term weight loss
Proven reduction of obesity related co-morbidities
Best operation for patients with GERD
CONS
Ulcers/stenosis Anemia Calcium deficiency Dumping syndrome Difficult to reverse Internal hernia
Pre-Op
BMI = 47
Weight = 306 lbs.
Waist = 54 inches
High Blood Pressure
Diabetes
PCOS
Depression
Back & Knee Pain
Swelling of lower legs
7 prescriptions daily
22
LRNY GBP, Johns Hopkins, 11/2008
5 years post-op
BMI = 25
Weight loss = 140 lbs.
Waist = 37 inches
Resolved Medical Problems
High Blood Pressure
Diabetes
Depression
PCOS Symptoms
Improved Medical Problems
Back & Knee Pain
1 Prescription Medication
Just became pregnant!
23
Vertical Sleeve Gastrectomy
Mostly a restrictive procedure
Some altered hunger hormones and insulin sensitivity
less hunger
improved diabetes
Hospital stay of 1-2 nights
Sleeve Gastrectomy
Sleeve Gastrectomy
PROS
No malabsorption
Proven long term weight loss and resolution of co-morbidities
Preserves pylorus (decreases risk of dumping)
Can be converted to gastric bypass or duodenal switch
CONS
Large portion of stomach removed (not reversible)
Can worsen GERD Strictures
Complications of surgery
• Bleeding
• Wound Infection
• DVT (blood clot) to Pulmonary Embolism
• Cardiac Event
• Leak
• Ulcers/Stricture/Stenosis
• Malabsorption
• Internal Hernia
SG GBP
Excess BMI loss 61% 68%
Remission of DM, HTN,
dyslipidemia
Equivalent Equivalent
GERD 33% better 66% better
Early morbidity 0.9% 4.5%
Total
reoperations/interventions
15.8% 23%
* Swiss study-217 with 95% follow up to 5 years
* Finnish study-240 patients with 80% follow up at 5 years
SG GBP
% Excess Weight loss 50% 57%
Remission of DM and
dyslipidemia
Equivalent Equivalent
Anti-hypertensive meds Fewer meds
Early morbidity 9% 26%
Total
reoperations/interventions
10% 18%
Israeli study-retrospective cohort
study with 8385 bariatric surgery
patients and 22155 matched non
surgical patients
100% follow up to 4 years
Secondary analysis demonstrated
improved weight loss, DM
remission, and lower
HTN/dyslipidemia.
Bariatric Budget Impact Calculator
Bariatric Budget Impact Calculator
The Path to Surgery
Information gathering
Pre-visit screening
Assessments
Work-up (tests/studies)
Classes (ABC)
Follow up visits + class D
Pre-op visits and labs
Surgery
**CAN TAKE UP TO 7 MONTHS
Post-op follow-up
Week 2 (after surgery) PA or Surgeon
Dietitian
Week 6 PA or Surgeon
Dietitian
Month 3 PA or Surgeon
Dietitian
Labs
Month 6 PA or Surgeon
Dietitian
Labs
Health Psychologist
Month 12 (yearly thereafter)
PA or Surgeon
Dietitian
Labs
Health Psychologist
UW Health Hospital and Clinic
UW Health Medical and SurgicalWeight Management Program
Bariatric Surgery, UW Health
at The American Center
4602 Eastpark Blvd, Madison
Our Surgeons
Michael Garren Jacob Greenberg Luke Funk Anne Lidor
Other Success Stories…
41
Visit our website: www.uwhealth.org/weight-loss-surgery/bariatric-surgery