CLINICALLY SEVERE OBESITY

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

WHAT IS MORBID OBESITY?

BMI CHART
Do You Know Your Own BMI?
Weight (lbs)
5'0" 5'2" 120 130 140 150 160 170 180 190 200 210 220 230 240 250 260 270 28 29 300 0 0

Height

5'4" 5'6" 5'8" 5'10" 6'0" 6'2" 6'4"

Definitions
Category Normal Overweight Obese Morbidly Obese BMI 25 >25 >30 >40 lbs overweight 0 0-35 >35 >80 - 100 % US pop 30% 30% 35% 5% (15 million)

Morbid Obesity a disease

! Clinically severe obesity = a point at which obesity becomes an independent disease process and medical conditions occur as a result this occures at about 100 lbs over ideal body weight or BMI 40

OBESITY IS A WORLDWIDE EPIDEMIC

Consequences of Obesity

Consequences of Obesity
! ! ! ! ! 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

Consequences of Obesity
! ! ! ! ! Gallstones Arthritis 90% Infertility Hepatosteatosis Chronic Skin Infections ! Pseudotumor Cerebri ! Cancer - 2-3x higher - Breast - Endometrial/Cervical - Colon - Prostate ! Depression ! Social Rejection

Clinically severe obesity

Risk of not Having Surgery
4 3
Mortality Ratio

2 1 0 20

Increasing BMI

25

30

35

40

Mortality of Obesity
! Shortens life by 8 yrs for women and 15 years for men ! Only one in seven with severe obesity reach a normal life span (77y) ! Carries a higher mortality than most cancers ! Current generation is the first to have shorter life expectancy than their parents in 100 yrs

OBESITY EPIDEMIC
! Obesity responsible for >$100 billion in medical costs per yr ! US was first in life span in 1900, now LAST among developed nations ! Current generation predicted to have 1/3 chance of developing DM

Consequences - Mortality
Taken together, the diseases associated with morbid obesity markedly reduce the odds of attaining an average life span and raise annual mortality tenfold or more.

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

Consequences - Mortality

>300,000 people die each year secondary to complications of obesity, making it our 2nd leading cause of preventable death

IV. Treatment of Obesity

Medical Options for Weight Loss

! ! ! ! Dietary therapy Behavioral modification Exercise Medications

Medical Treatment The bottom Line:

All Non-surgical weight loss attempts achieve at best modest and short term success in the morbidly obese population, with about 10% wt loss, and regain in about 95% within two years

ANYTHING LESS THAN A RADICAL AND PERMANENT TRANSFORMATION WILL RESULT IN FAILURE TO TREAT MORBID OBESITY

Medical Weight Loss

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 loss Procedures recommended = VBG and GBP

Surgical Options

How does surgery work?

Ruox en Y Gastric Bypass

! First developed in the 1970s ! Procedure of choice in the United States ! Best wt loss with the lowest side effects ! 60 - 80% EWL in 12 - 18 mo (90% lose 70%) ! Maintained up to 15 yrs post op

Gastric Bypass
Q : How does the GBP effect wt loss? A : Four mechanisms 1. Restriction 2. Malabsorption 3. Dumping Syndrome 4. Hormonal Changes

The Roux-en-Y Procedure

! In the Roux-en-Y Bypass procedure, a small pouch is formed along the lesser curve, excluding the fundus ! The fundus is the part that can stretch out

The Roux-en-Y Procedure

! The small intestine is divided about 20-50 cm beyond the lig of trietz (beginning pt of the jejunum)

The Roux-en-Y Procedure

! The small intestine (B), is brought up to the gastric pouch and these are attached ! The bilio-pancreatic limb (A) is hooked up to the Roux limb (B) 100 to 150 cm from the pouch ! The biliopancreatic limb delivers the bile and enzymes, so food in the roux limb is poorly digested

Dumping

The Roux limb does not handle sugar well and therefore eating sweets will cause nausea, cramping and diarrhea

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

Benefits of GBP

Roux-en-Y Open Procedure

! More pain ! Longer hosp stay ! Longer return to work ! Wound complications
- seroma (15%) - infection (<5%) - dehicsence (1%) - hernia (20%)

! Technically much easier

Laparoscopic Roux-en Y
! Less pain ! Shorter stay ! Less blood loss ! Faster return to work ! Technically more challenging ! More internal hernias

Restrictive Surgery

LAP BAND
! Mechanism purely restrictive (no decreased appetite, dumping, or malabsorbtion) ! Injecting saline tightens the opening, decreasing flow out of the pouch ! Adjustments made based on symptoms, wt loss, about every 4 weeks for first several months

ADJUST, ADJUST, ADJUST!

! First adjustment at 6 wks post op ! Continues every 3 wks thereafter until in green zone ! Too tight = food gets stuck, nausea/ vomiting, GERD ! Too Loose = poor wt loss, hungry, tollerate bread / red meat, large meals ! Average adjustments - 5-6 first year and ever 6 - 12 months thereafter

LAP BAND

Lap Band Advantages

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

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 adjustments forever (every 6 - 12 months)

Who should get a band?

Sleeve Gastrectomy
! ! ! ! ! ! ! BPD developed 1976 BPD with DS 1998 LS BPD w/ DS 2000 Some restriction Mostly malabsorbtion Hormonal effect More complications, higher risk

Sleeve Gastrectomy
Two stage LS BPD w/ DS proposed 2000 -LS Sleeve first -Intestinal bypass after initial wt loss -FOUND THAT SOME DID NOT NEED 2ND SURGERY

Sleeve Gastrectomy
! 2005 2 studies of LS Sleeve as primary procedure showing 53% and 83% EWL at 1 yr ! 2006 first large study (357pts) showing 62% EWL 12m and 67% EWL 2 yrs ! To date 36 studies (2,570 pts) showing 33 85% EWL at 5 yrs, AVERAGE 60%

Sleeve Gastrectomy
MECHANISM: 1.!Restriction 100 to 150 cc vs 30cc pouch 2.!Hormonal Effect - decreased grehlen 70% - decreased hunger 75% - significant effect on diabetes 3. No dumping, no malabsorbtion

COMPLICATIONS
LAP BAND Gastric Prolapse (slip) Band Erosion Esophageal Dialation Port Problems Death .1 - .5% GASTRIC BYPASS Anastomotic Leak Bowel Obstruction Pulm Embolism Stricture/Marginal Ulcer Death .2 - .3% GASTRIC SLEEVE Staple line Leak Bleeding Stricture Conversion to GBP Death .2%

Is it worth it?

Bariatric Surgery