Obesity

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Obesity

• An excess of body fat body mass index (BMI) gt30
  kg/m2
• Affects 30 adults in U.S. 70Billion annual
  health cost
• Co-morbidities (CAD, HTN, DM II) affect
  increasing mortality risk in proportion to BMI

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Body Mass Index -kg/m2 Wt(lb) x 703/Ht
(inches)2

• Underweight lt18.5
• Normal 18.5-24.9
• Overweight 25-29.9
• Obese gt30
• Severe (morbidly) obese gt40

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Obesity rates, 1991 vs 2000
Obesity defined as BMIgt30. Data were obtained by
calculating BMI from phone questionnaire on
height and weight on 185000 participants gtage 18.
CDC study ,JAMA 2001286,1195-1200
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A typical fast food meal

• Big Mac 570 kcal
• Large Fries 540 kcal
• 32 0z (large) soda 400 kcal
• TOTAL 1510 kcal
• A 70 kg moderately active man requires 2100
  kcal/day (3 meals).

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Obesity co-morbidities

• Metabolic syndrome DM II (15 of all obese), HTN
  (40 of obese), hyperlipidemia related to
  visceral adiposity and insulin resisitance

• Sleep apnea
• Cardiopulmonary failure
• Osteoarthritis
• Gallstones
• GERD
• NASH
• Breast cancer

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Increases in obesity and diabetes 1991-2000
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Medical management of obesity

• Energy equation wt stability when calories in
  calories out
• Can therefore reduce by decreasing intake and/or
  increasing expenditure of calories

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Medical management of obesity

• Diet (according to ideal body weight for height)
  exercise (30 min/d moderate 5d/wk)
  behavioral modification 5-10 wt loss in 6
  months, most rebound.
• Very low calorie dieting (lt900 kcal/d works for
  many, but 99 rebound
• Pharmacological adjuncts limited success

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The super-obese (BMI 50 )

• Incidence in U.S. population 2.1 (4.4 million)
• Increased risk of osteoarthritis, cardiopulmonary
  failure, sleep apnea, all consequences of
  metabolic syndrome (DM, NASH, HTN, hyperlipid)
• Medical treatment essentially hopeless, though
  met syndrome improves with 5-10 weight loss

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Rationale for surgery for morbid obesity

• gt2x mortality with BMIgt40 kg/m2 due to
  cardiopulmonary failure, sleep apnea, diabetes
• Poor results of all medical therapies to date
• Relative safety and efficacy of gastric bypass
  compared to older jejuno-ileal bypass procedure

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Criteria for obesity surgery

• BMI gt 40, or gt35 with significant co-morbidities
• Documented failure of medical management (diet
  exercise pharm)
• Psychological ability to undergo surgery
• Absence of other chronic disease

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What are the surgical options?

• Restrictive Adjustable gastric banding
  Vertical band gastroplasty
• Malabsorptive Roux-en-Y gastric bypass
  Biliopancreatic diversion

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• Adjustable gastric band

• Vertical band gastroplasty

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• RGB

• BPD

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• BPD-DS

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Estimated Number of Bariatric Operations
Performed in the United States, 1992-2003
Steinbrook, R. N Engl J Med 20043501075-1079
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Laparoscopic Versus Open Gastric Bypass A
Randomized Study of Outcomes, Quality of Life,
and Costs

• Nguyen, Ninh T. MD Goldman, Charles MD
  Rosenquist, C. John MD Arango, Andres BS
  Cole, Carol J. BS Lee, Steven J. MS and
  Wolfe, Bruce M. MD, FACS

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• 155 patients w/ BMI 40-60 randomly assigned to
  lap (79) or open (76)

Nguyen et al. Laparoscopic Versus Open Gastric
Bypass A Randomized Study of Outcomes, Quality
of Life, and Costs. Ann Surg. 234, 2004. 279-91.
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OUTCOMES
Nguyen et al. Laparoscopic Versus Open Gastric
Bypass A Randomized Study of Outcomes, Quality
of Life, and Costs. Ann Surg. 234, 2004. 279-91.
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OUTCOMES
Nguyen et al. Laparoscopic Versus Open Gastric
Bypass A Randomized Study of Outcomes, Quality
of Life, and Costs. Ann Surg. 234, 2004. 279-91.
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OUTCOMES
Nguyen et al. Laparoscopic Versus Open Gastric
Bypass A Randomized Study of Outcomes, Quality
of Life, and Costs. Ann Surg. 234, 2004. 279-91.
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OUTCOMES
Nguyen et al. Laparoscopic Versus Open Gastric
Bypass A Randomized Study of Outcomes, Quality
of Life, and Costs. Ann Surg. 234, 2004. 279-91.
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OUTCOMES
Nguyen et al. Laparoscopic Versus Open Gastric
Bypass A Randomized Study of Outcomes, Quality
of Life, and Costs. Ann Surg. 234, 2004. 279-91.
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CONCLUSIONS

• Laparoscopic GBP is safe alternative to open GBP
• Lap pt s benefited from dec EBL, shorter LOS
  more rapid improvement in QOL than open GBP