Information Session Surgical Weight Loss

Information SessionInformation SessionSurgical Weight LossSurgical Weight Loss

CDR Henry Lin, MC, USNCDR Henry Lin, MC, USN

LTC Scott Rehrig MDLTC Scott Rehrig MD

Phyllis Gottlieb RNPhyllis Gottlieb RN

• Why You are hereWhy You are here

• Indications for surgeryIndications for surgery

• Pathway for surgeryPathway for surgery

• AlternativesAlternatives

• Surgical ProceduresSurgical Procedures

• Risks and BenefitsRisks and Benefits

OverviewOverview

Scope of ProblemScope of Problem

• Global epidemicGlobal epidemic– 300,000 US deaths per yr300,000 US deaths per yr

• Economic impactEconomic impact– $ 117 billion yr in US$ 117 billion yr in US

• NegativeNegative Survival impact for BMI 45: Survival impact for BMI 45:– White male White male 13yrs less13yrs less– Black males Black males 20yrs less20yrs less– Black women Black women 5yrs less5yrs less– White women White women 8 yrs less8 yrs less

BMI and Risk LevelsBMI and Risk Levels

BMIBMI Risk of Risk of ComorbidityComorbidity

NormalNormal 18-2418-24 AverageAverage

OverweightOverweight 25-2925-29 IncreasedIncreased

Obesity class IObesity class I 30-3430-34 ModerateModerate

Obesity class IIObesity class II 35-3935-39 SevereSevere

Obesity class IIIObesity class III 40 +40 + Very SevereVery Severe

Obesity ComorbiditiesObesity Comorbidities

““Once BMI values defining morbid Once BMI values defining morbid obesity are reached, we are obesity are reached, we are addressing a disease – aaddressing a disease – a

life-shortening, life-shortening, incapacitating, incapacitating,

malignant diseasemalignant disease””

Henry Buchwald MD PhDHenry Buchwald MD PhD

DiabetesDiabetes

Obesity primary risk factor Obesity primary risk factor – 90% diabetics are obese90% diabetics are obese

Risk with obesityRisk with obesity– BMI 30 = 50%BMI 30 = 50%– BMI 50 = 90%BMI 50 = 90%

Nurses Health Study: (1980-1996) Nurses Health Study: (1980-1996) – 85,000 nurses noted that the risk of diabetes 85,000 nurses noted that the risk of diabetes

increased increased 40x40x as BMI increased from < 23 to > as BMI increased from < 23 to > 3535

Every 2.2 lbs of weight loss Every 2.2 lbs of weight loss equates to a 9% reduction in equates to a 9% reduction in

diabetes!diabetes!

Jeffrey Sicat, MDJeffrey Sicat, MD

Virginia Endocrinology and Virginia Endocrinology and Osteoporosis CenterOsteoporosis Center

Cardiovascular RiskCardiovascular Risk

1.1. HTNHTN• 50%50% adult BMI>30 adult BMI>30 • 75%75% all HTN is attributed to obesity all HTN is attributed to obesity

2.2. DyslipidemiaDyslipidemia• 40-50%40-50% adult BMI>30 adult BMI>30

3.3. Cardiac and Peripheral Vascular DiseaseCardiac and Peripheral Vascular Disease• Primary risk factor Primary risk factor • Secondary risk factorSecondary risk factor

• Impacts high blood pressure and hyperlipidemiaImpacts high blood pressure and hyperlipidemia

Sleep ApneaSleep Apnea

• Obesity = Obesity = 50%50%

• Symptoms drowiness, inattentiveness, Symptoms drowiness, inattentiveness, impaired job performance, impaired job performance,

• Men > women due higher incidence Men > women due higher incidence central obesitycentral obesity

1991 National Institutes Health 1991 National Institutes Health Patient Selection CriteriaPatient Selection Criteria

– BMI > 40BMI > 40– BMI bwt 35 – 40 BMI bwt 35 – 40 ANDAND comorbidities related comorbidities related

• FunctionalFunctional limitations due to body size or limitations due to body size or jointjoint disease disease– After evaluation by a multidisciplinary teamAfter evaluation by a multidisciplinary team

• Have Have low probabilitylow probability of success with of success with non-operativenon-operative wt-loss wt-loss measuremeasure

• Be Be well informedwell informed with long and short term risks and benefits with long and short term risks and benefits of surgeryof surgery

• Be Be highly motivatedhighly motivated to lose weight through surgery to lose weight through surgery• Have an accepted operative riskHave an accepted operative risk• Be willing to undergo Be willing to undergo lifelonglifelong medical surveillance medical surveillance

Absolute ContraindicationsAbsolute Contraindications

• Inability to tolerate general anesthesiaInability to tolerate general anesthesia– Severe non-correctable heart or lung diseaseSevere non-correctable heart or lung disease– Severe sleep apneaSevere sleep apnea

• Liver disease with cirrhosis and gastric Liver disease with cirrhosis and gastric varicesvarices

• Active peptic ulcer diseaseActive peptic ulcer disease– H. pylori infectionH. pylori infection

• Active malignancy (Cancer)Active malignancy (Cancer)• HIV infectionHIV infection• Any non-weight related condition with Any non-weight related condition with

expected survival < 5 years!expected survival < 5 years!

WRAMC Specific CriteriaWRAMC Specific Criteria

18 y.o. <AGE < 65 y.o.18 y.o. <AGE < 65 y.o.

BMI: < 50 kg/mBMI: < 50 kg/m22

NONO active duty active duty

NEED a NEED a real PCMreal PCM

- to coordinate your medical care- to coordinate your medical care

Initial ConsultInitial Consult

MTFsMTFs Phyllis Gottleib, RN (NNMC)

Phyllis Gottleib, RN (NNMC)

Amanda (WRAMC)Amanda

(WRAMC)

FilterFilter

Seminar (NNMC)Seminar (NNMC)

Initial MD Appt (Lin)

Initial MD Appt (Lin)

Out to NetworkOut to Network

Nutrition x 3 appts

Nutrition x 3 apptsPCMPCM Exercise

PhysiologyExercise

PhysiologyPsychologyPsychology Sleep StudySleep Study Pulmonary?Pulmonary? GIGI

Pre-Op Appt (Lin)

Pre-Op Appt (Lin)

Surgery (WRAMC)Surgery

(WRAMC)

Required Follow-Up

Required Follow-Up

NutritionNutrition SurgeonSurgeon Exercise PhysiologyExercise

Physiology PCMPCM

Bariatric Consult Flow

Sleeve & Bypass:3 months6 months9 monthsEvery 6mo x 2 yrsYearly

Band:Monthly

Pathway to SurgeryPathway to SurgeryInformation sessionInformation session

General Surgery General Surgery Clinic apptClinic appt

Mental HealthMental Health Medical NutritionMedical Nutrition Exercise PhysiologyExercise Physiology

Preop CounselingPreop Counseling

May requireMay requireAdditional f/u’sAdditional f/u’s

Up to 2 f/u’sUp to 2 f/u’s

•H/PH/P•Risk stratificationRisk stratification•Medical consults Medical consults •Setup endoscopy Setup endoscopy at NNMCat NNMC

TIMETIME

startstart

3-4 weeks3-4 weeks

3-4 weeks3-4 weeks

3-4 weeks3-4 weeks

DAY of SurgeryDAY of SurgeryWRAMC/NNMCWRAMC/NNMC

•Review consultsReview consults•Agree on surgery Agree on surgery typetype•Date/timeDate/time

3-4 weeks3-4 weeks

4+ months4+ months

Alternatives To Surgery

3 Surgical Options

• RNY GBP Sleeve Band

Laparoscopic Gastric BypassLaparoscopic Gastric Bypass

Weight lossWeight loss

• About 100 lbs, or about 65% to 70% EBW and about 35% of the BMI.

• 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

Operative mortality (death) and morbidity Operative mortality (death) and morbidity (injury)(injury)

• Overall (30 day) mortality for gastric bypass when performed by skilled surgeons is about 0.5%0.5%– High blood pressure, high BMI, bowel leak, blood clots to High blood pressure, high BMI, bowel leak, blood clots to

lunglung

• Overall Operative morbidity (eg, pulmonary emboli, anastomotic leak, bleeding, wound infection) is 5%5% – Leak up to 5%Leak up to 5% - breakdown in the staple lines from cutting and

formation of connections bwt intestine and stomach pouch

– Bleeding up to 4%Bleeding up to 4% - this occurs at the staple lines after the stapling device cut the bowel

– Blood clots up to 1%Blood clots up to 1% - but death from this complication accounts for 30-50% of patients

Longterm complicationsLongterm complications• internal hernias (bowel obstructions)

– 1-10%1-10%– More common in laparoscopic technique– Difficult to diagnose with routine xrays leading to high rate of

reoperation to make diagnosis• stomal stenosis – opening to gastric pouch becomes too

tight– 3-12%3-12%– Treatment require using a ballon to stretch the opening

• marginal ulcers - breakdown of connection between small intestine and gastric pouch– 1-16%1-16%– Alcohol and cigarrette smoking are major risk factor– NSAIDS contraindicated in bypass pts

Longterm complicationsLongterm complications

Nutritional Deficiencies– Permanent mineral and vitamin supplement for the

rest of natural life!! • Can be very expensive cost out of pocket for patients!

– Anemias -- 54%54%– and nonreversible neurologic diseases– vitamin B12 vitamin B12 – ironiron– folate folate – calcium calcium

Laparoscopic Gastric Adjustable Laparoscopic Gastric Adjustable BandingBanding

© 2007 Ethicon Endo-Surgery, Inc. All rights reserved. DSL #07-1742. REALIZETM and REALIZE mySUCCESSTM are trademarks of Ethicon Endo-Surgery, Inc.

| Slide 26

Gastric Banding Contraindications

• Inflammation of the digestive tract, including ulcers, severe esophagitis, or Crohn’s disease

• Severe heart or lung disease• Upper digestive tract bleeding conditions due to enlarged or

fragile veins• Portal hypertension• Abnormal digestive tract anatomy• Cirrhosis of the liver• Chronic pancreatitis

Situations where the risks are greater than the benefits that would be gained from surgery are contraindications. These include:


| Slide 27

Gastric Banding Contraindications – con’t.

• Infection of any type, anywhere in your body• Known allergies to the implant materials• Using steroids for a long period of time or within 15 days of

surgery• Currently pregnant• Younger than 18 years of age• Unwilling to make significant changes in eating and behavior

patterns• Conditions or behaviors that would make it difficult to

appropriately follow directions


| Slide 28

Risks Associated with Gastric Banding

• Migration of implant (band erosion, band slippage, port displacement)

• Tubing-related complications (port disconnection, tubing kinking)• Band leak• Esophageal spasm• Gastroesophageal reflux disease (GERD)• Inflammation of the esophagus or stomach• Port-site infection

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.


| Slide 29

Risks Associated with Gastric Banding

• Migration of implant (band erosion, band slippage, port displacement)

• Tubing-related complications (port disconnection, tubing kinking)• Band leak• Esophageal spasm• Gastroesophageal reflux disease (GERD)• Inflammation of the esophagus or stomach• Port-site infection

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.


| Slide 30

Weight Loss at Three Years U.S. Clinical Study Results Overview

%EWL At Three %EWL At Three YearsYears

Number of PatientsNumber of Patients Percent of PatientsPercent 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%


| Slide 31


| Slide 32

ResultsResults

3yrs SAGB/LB3yrs SAGB/LB• excess weight loss 56.36%/50.20% 56.36%/50.20% • resolution diabetes 61.45%/60.29%61.45%/60.29%• hypertension 62.95%/43.58%62.95%/43.58%

•Adverse event (AE) rates appeared comparable•mortality was equivalent 0.1%0.1%


Late ComplicationsLate Complications

| Slide 33

•late slippage/migration late slippage/migration 4.0% and 6.2%4.0% and 6.2%•pouch dilatation pouch dilatation 1.7% to 5.1% 1.7% to 5.1%

Laparoscopic Sleeve Laparoscopic Sleeve GastrectomyGastrectomy

Risk

Effectiveness

LAPBAND

LAPGASTRICSLEEVE

LAPGASTRICBYPASS

0.5 %0.1 %DEATH

MORBIDITY5.0 %

%EWL

50 % 65-70 %60 %

SummarySummary

• Surgery NOT for everyoneSurgery NOT for everyone

• NOT a Center of ExcellenceNOT a Center of Excellence

• ?? About Future of Program due to ?? About Future of Program due to BRACBRAC

Thank You!

??

Welcome!Welcome!

Health & Medicine

Information Session Surgical Weight Loss