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 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

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

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

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

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.

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.

Operations for Clinically Severe Obesity

Sleeve GastrectomyGastric Banding

Restrictive + hormonal

Gastric Bypass

Surgery is the Un-Diet

Diet Surgery

Appetite

Hunger

Satiety

Reward-based eating

Energy expenditure

Stress response

Adipocyte Secretions

IGF-1IGFBP

TNF-Interleukins

TGF-FGFEGF

Fatty acidsLysophospholipid

LactateAdenosine

ProstaglandinsGlutamine

Unknown Factors

Agouti Protein

Retinol

PAI-1

LeptinASPAngiotensin

ANG-II

Estrogen

Adipsin

Adiponectin

Resistin

Bone Morphogenic Protein

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 Sleeve Gastrectomy Gastric Bypass

BMIreduction

*Analysis of 28,616 patient at COE

Long-term Weight Loss

Diabetes: resolved or improved

0

10

20

30

40

50

60

70

80

90

Lap Band Sleeve Gastrectomy Gastric Bypass

%

*Analysis of 28,616 patient at COE

Hypertension: resolved or improved

0

10

20

30

40

50

60

70

80

90

Lap Band Sleeve Gastrectomy Gastric Bypass

%

*Analysis of 28,616 patient at COE

Roux-Y Gastric Bypass

• Advantages Excellent excess weight loss (60-75%)

Very good long-term results

Solid food well tolerated

• Disadvantages Potential vitamin deficiencies

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%)

Solid food well tolerated

Used as bridge to bypass

• Disadvantages Long staple line

Not universal insurance approval

Personal Experience

167 patients

Average BMI61.6

kg/m2 EWL at 12

months53.6%

Laparoscopic bariatric surgey

“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

LONG-TERM SURVIVAL CANADA

6.17

0.68

0

1

2

3

4

5

6

7

% M

ort

ality

Control Bariatric

89% reduction in risk of89% reduction in risk ofdeath over 5 yearsdeath over 5 years

Christou et al. Ann Surg 2004;240:416-424

1035 surgical patients5746 controls Cohorts followed 5 years

Results:Five Year Comorbidity

0 5 10 15 20 25 30 35 40

%

Cardiovascular

Endocrinological

Musculoskeletal

Infectious

Cancer

ControlBariatric

*

*

*

*

*

*p<0.001Christou et al. Ann Surg 2004;240:416-424

2010 bariatric surgery2037 obese controlsMean 10.9 years f/u

30% reduction in mortality

7925 surgical patients7925 controlsMean f/u of 7.1 yearsGastric bypass reduced mortality by 40%

Behavioral Aspects of Weight Loss Surgery

• Compliance with Diet

• Exercise

• Compliance with Nutritional Supplements

• Keeping follow-up appointments

• Support group attendance

Behavioral Aspects of Weight Loss Surgery

• Compliance with Diet

• Exercise

• Compliance with Nutritional Supplements

• Keeping follow-up appointments

• Support group attendance

Behavioral Aspects of Weight Loss Surgery

• Compliance with Diet

• Exercise

• Compliance with Nutritional Supplements

• Keeping follow-up appointments

• Support group attendance

Behavioral Aspects of Weight Loss Surgery

• Compliance with Diet

• Exercise

• Compliance with Nutritional Supplements

• Keeping follow-up appointments

• Support group attendance

Behavioral Aspects of Weight Loss Surgery

• Compliance with Diet

• Exercise

• Compliance with Nutritional Supplements

• Keeping follow-up appointments

• Support group attendance

Behavioral Aspects of Weight Loss Surgery

• Compliance with Diet

• Exercise

• Compliance with Nutritional Supplements

• Keeping follow-up appointments

• Support group attendance

5’ 7”360 lbs56.3 kg/m2

5’ 7”192 lbs30.0 kg/m290% EWL