Gastric Surgery for Severe Obesity

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Gastric Surgery for Severe Obesity

• David L. Gee, PhD
• Professor of Food Science and Nutrition
• Central Washington University

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Carnie WilsonGastroplasty, Aug 1999weight loss
150 lbs2003 poses for Playboy2005 delivers
baby daughter (gained 70 pounds, lost 40 pounds)
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(No Transcript)
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Charlie WeissNew England PatriotsOffensive
CoordinatorGastric Bypass SurgeryWt loss 85
poundsSurgical complicationsinternal
bleedingsepsisnerve damage to lower limbs
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Bariatric Surgery TrendsJAMA, 289(14)
1761-1762, April 9, 2003

• US Bariatric surgeries performed per year
• 2001 47,000
• 2002 63,000
• 2003 (projected) 98,000

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Source Health Affairs, July/Aug 2005
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Criteria for Patient Selection

• Unlikely to lose weight with non-surgical
  procedure
• BMI 40
• Have high risk of obesity related problems
• not pregnant or planning pregnancy during weight
  loss
• Informed of risks, lifestyle effects

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Surgical Mechanisms for Weight Loss

• Decrease food intake
• Decrease digestion and absorption of nutrients

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Surgery to Decrease Food Intake

• Gastroplasty
• Gastric banding
• Vertical banded gastroplasty

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Gastric Banding
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Vertical Banded Gastroplasty
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Weight Loss Outcomes of Gastroplasty

• 80 lose weight
• 30 achieve normal weight
• some regain some of lost weight
• improves obesity related conditions
• success depends on motivation and behaviors

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Risks of Gastroplasty

• vomiting
• erosion of band, breakdown of staple line
• 10-20 require follow-up operations
• 1/3 develop gallstones

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Surgery to Reduce Food Intake and Nutrient
Absorption

• Gastric Bypass Surgery
• Roux-en-Y Gastric Bypass

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Roux-en-Y Gastric Bypass
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Outcomes of Gastric Bypass Surgery

• produces more weight loss than gastroplasty
• generally lose 2/3rds of excess weight within 2
  years

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Risks of Gastric Bypass Surgery

• like gastroplasty
• chronic diarrhea
• nutritional deficiencies
• vitamin B-12
• iron
• calcium

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Gastric Bypass Surgery Complications 14-Year
Followup

• Surgical Complications Number of
  Patients of Patients
• Vitamin B12 deficiency 239 39.9
• Readmit for various reasons 229 38.2
• Incisional hernia 143 23.9
• Depression 142 23.7
• Staple line failure 90 15.0
• Gastritis 79 13.2
• Cholecystitis 68 11.4
• Anastomotic problems 59 9.8
• Dehydration, malnutrition 35 5.8
• Dilated pouch 19 3.2
• Data derived from source (Pories et al.) and
  modified based on personal communication.
• Source Pories WJ, Swanson MS, MacDonald KG Jr,
  et al. Who would have thought it?
• An operation proves to be the most effective
  therapy for adult-onset diabetes mellitus.
• Ann Surg. 1995222339-350 discussion 350-352.

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What are the dietary guidelines following
bariatric surgery?JADA 104 487-488 (2004)

• General guidelines
• Eat for 20 min to allow for satiety
• Well chewed, small volumes
• Liquids ingested well before or after meals
• Proteins eaten before fats and carbs
• Nutritional Considerations
• Gastric banding iron B-12 deficiencies
• Gastric bypass iron, calcium, folate, B-12
  deficiencies, dumping syndrome
• Fat malabsorption and lactose intolerance
• Dehydration
• Vitamin/mineral supplements recommended

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Early Mortality Among Medicare Beneficiaries
Undergoing Bariatric Surgical Procedures Flum,
D. et al. JAMA. 20052941903-1908

• Subjects
• All fee-for-service Medicare beneficiaries,
  1997-2002
• 16,155 patients
• Mean age 47.7 yrs (SD11.3)
• 75.8 female
• Outcome Measures
• 30 day, 90 day, 1 year mortality

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Findings 1. Overall mortality rate at 1 year
4.62. Mortality rate in men women (7.5 vs.
3.7)3. Mortality rate in 65 yr (11.1 vs 3.9)
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Early Mortality Among Medicare Beneficiaries
Undergoing Bariatric Surgical Procedures Flum,
D. et al. JAMA. 20052941903-1908

• Conclusions 
• Among Medicare beneficiaries, the risk of early
  death after bariatric surgery is considerably
  higher than previously suggested
• Risk of early death associated with advancing
  age, male sex, and lower surgeon volume of
  bariatric procedures
• Patients aged 65 years or older had a
  substantially higher risk of death within the
  early postoperative period than younger patients.

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Conclusions

• Bariatric surgery generally results in
• substantial weight loss
• Marked improvement in health risks
• Improved quality of life
• Bariatric surgery is not risk free
• Mortality rate 5
• Complications and further surgeries
• High costs
• Permanent changes in eating/lifestyle
• Risks of malnutrition