Is weight- loss surgery the answer for you?

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Is weight-loss surgery the answer for you?
Dr. Terry Scarborough Dr. Sherman Yu
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What are you going to learn today?

• What is obesity?
• Your daily challenges
• What is obesity costing you?
• What are your surgical options?
• Summary
• What are your next steps?

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Welcome to TLC Surgery

• We are an entire practice dedicated to helping
  you succeed with weight loss surgery and living a
  longer, happier, healthier life!
• A multi-disciplinary Bariatric focused practice
• Lead by 2 fellowship trained, board certified
  Surgeons
• Nutritionists
• Psychologist
• Insurance Specialists

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How obesity can affect you
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Many factors influence obesity
OBESITY
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Obesity is

• a medical condition in which excess body fat has
  accumulated to the extent that it may have an
  adverse effect on health, leading to reduced life
  expectancy and/or increased health problems.
• It is also
• multi-factorial (many different factors can cause
  obesity)
• life-long
• progressive
• potentially life-threatening
• costly

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How do we measure obesity?

• According to the National Institute of Health
• Body Mass Index (BMI) is a measure of body fat
  based on
• height and weight that applies to both adult men
  and women

BMI Indicators Healthy Range 18.5
24.9 Overweight 25.0 29.9 Obese 30.0
34.9 Severe Obesity 35.0 39.9 Morbid
Obesity 40.0 49.9 Super-Morbid Obesity gt 50
NHLBI 2000 (NIH), Practical Guide
Identification, Evaluation and Treatment of
Overweight and Obesity in Adults
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Many serious illnesses are associated with
obesity

• Type-2 Diabetes1,3
• Hypertension1,3
• Hyperlipidemia1,3
• Respiratory disease1,3
• Sleep apnea1,2,3
• Depression3
• Menstrual irregularity2
• Amenorrhea2
• Dysmenorrhea2
• Urinary stress incontinence3
• Asthma/pulmonary disorder2,3
• Cancer1,3

• Gastroesophageal reflux disease (GERD)2,3
• Degenerative joint disease (DJD)3
• Heart disease 2
• Gallstones1,2,3
• Fatty liver disease2,3
• Coronary artery disease1,3
• Stroke1
• Osteoarthritis1,2
• Infertility2

• NHLBI 2000 (NIH), Practical Guide
  Identification, Evaluation and Treatment of
  Overweight and Obesity in Adults
• NIDDK 2006 (NIH), Understanding Adult Obesity.
• Schneider BE Mun EC. Diabetes Care. 2005
  28475-80

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Youre not alone

• More than 65 of adults are overweight or obese.1
  
• 32 of children are overweight.1
• 4.8 of adults are morbidly obese.1
• Total medical cost for obesity in 2003 was 75
  billion.2
• 325,000 obesity-related deaths occur annually.3

1. Wang, Y Beydoun, MA. Epidemiol Rev. 2007 29
   6-28.
2. Quick Facts Economic and Health Burden of
   Chronic Disease, CDC, updated 2007
3. Nordmann AJ et al., Arch Intern Med. 2006
   166285-93..

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DailyChallenges
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You face obstacles and prejudices every day

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High BMI can affect life expectancy

• In younger middle aged women men, increased
  BMI may increase the risk of dying prematurely1
• Teens entering adulthood with BMI gt40 die 8-13
  years earlier than the general population2

RELATIVE RISK OF ALL CAUSE MORTALITY
lt18.5
18.5 - 20.9
21.0 - 22.9
23.0 - 24.9
25.0 - 26.9
27.0 - 29.9
30.0 - 34.9
gt35.0
WOMEN MEN
BMI

1. Freedman DM et al. Int J of Obesity. 2006 30
   822-292.
2. Fontaine KR et al. JAMA. 2003 289 187-93.

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How much can obesityreally cost?
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What are the costs for you?

• Conventional treatments
• Type of Diet Completing One Year1
  Weight Loss
• at One Year1
• Atkins 21/40 (53)
  2.1 kg (5 lbs.)
• Zone 26/40 (65)
  3.2 kg (7 lbs.)
• Weight Watchers 26/40 (65)
  3.0 kg (7 lbs.)
• Ornish 20/40 (50) 3.3 kg (7
  lbs.)
• Day-to-day living
• Clothing, food
• 1. Dansinger, et al. JAMA 2005293(1).Atkins is
  a registered trademark of Atkins Nutritionals,
  Inc.Weight Watchers is a registered trademark of
  Weight Watchers International, Inc.

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Insurance costs go up as BMI goes up

• Percentage increase in costs comparing obese to
• non-obese (BMI lt25)

Body Mass Index (kg/m2)
Services 30 34.9 35 Physician
visits 14 25 Pharmacy 60 78 Laboratory 24
85 All outpatient services 21 37 All
inpatient services 33 70 Overall 25 44
Data from a 1993 health survey of members of a
large HMO (n 17,118) Quesenberry et al. Arch
Intern Med 1998158466
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What are your surgical options?
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Are you a candidate for weight-loss surgery?

• BMI gt35 with co-morbidities or gt40 without
• Healthy enough to undergo a major operation
• Failed attempts at medical weight loss
• Absence of drug and alcohol problems
• No uncontrolled psychological conditions
• Consensus by our multi-disciplinary team
• Understands surgery and risks
• Must be dedicated to a lifestyle change and
  lifetime follow-ups

From the NIH consensus conference in 1991
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Not all weight loss surgeries are the same

• Restrictive
• Malabsorptive
• Combination

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Restrictive Procedures

• The size of the stomach is reduced, which limits
  the amount of food patients can eat.
• The smaller stomach pouch fills quickly, helping
  patients feel satisfied with less food.
• Examples of restrictive bariatric procedures
• Gastric banding
• Sleeve gastrectomy

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Malabsorptive Procedures

• The small intestine is rerouted so that food
  skips a portion of it.
• Some calories and nutrients are not absorbed.
• Currently, surgeons rarely perform strictly
  malabsorptive procedures.
• Most procedures that involve malabsorption
  include restriction and are called combination
  procedures.

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Combination Procedures

• The surgeon creates a small pouch, limiting the
  amount of food a patient can eat.
• A section of the small intestine is rerouted,
  causing food to bypass a large portion of the
  small intestine.
• Bypassing a portion of the small intestine means
  the patients body absorbs fewer calories.
• Examples of combination bariatric procedures
• Gastric bypass
• Biliopancreatic diversion with duodenal switch

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Risks of abdominal surgery

• Bleeding
• Pain
• Shoulder pain
• Infection
• Pneumonia
• Complications due to anesthesia medications
• Deep vein thrombosis (Blood clot)
• Pulmonary embolism (Blood clot in lung)
• Injury to stomach, esophagus, or surrounding
  organs
• Death

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Risks of bariatric surgery

• Abdominal hernia
• Chest pain
• Collapsed lung
• Constipation or diarrhea
• Dehydration
• Enlarged heart
• Gallstones, pain from passing a gallstone,
  inflammation of the gallbladder, or surgery to
  remove the gallbladder

• Gastrointestinal inflammation or swelling
• Stoma obstruction
• Stretching of the stomach
• Surgical procedure repeated
• Vomiting and nausea

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Adjustable gastric banding is one type of
restrictive procedure

• Laparoscopic or Single Incision
• Second most frequently performedbariatric
  procedure in U.S.
• Mean excess weight loss at 1 yearof 50
• Requires implanted medical device
• Lowest rate of complications

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What are risks and complications of gastric
banding?

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

Note Your weight, age and medical history play a
significant role in determining your specific
risks. Your surgeon can inform you about your
specific risks for bariatric surgery.
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What can you expect after gastric banding?

• Recovery takes time and patience.
• The diet is strict.
• The capacity of the stomach has changed.
• You may experience discomfort and pain as your
  body heals.
• Length of time to return to normal activities can
  vary from patient to patient.
• Your healthcare team will advise you when to
  return to work and resume prior activities.
• Lifestyle changes are necessary to ensure success.

Reference From REALIZEband.com life with
REALIZE then recovery expectations.
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What can you expect after gastric banding?

• Recovery takes time and patience.
• Most patients are ready for their first
  adjustment after eating solid foods for the first
  week. The exact timing will depend on your
  progress.
• If you are losing 1-2 lbs. per week you may not
  need an adjustment at that time.

Reference From REALIZEband.com life with
REALIZE then recovery expectations.
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Vertical sleeve gastrectomy is another
restrictive option

• Laparoscopic or Single Incision
• A very good option between band and bypass.
• Mean excess weight loss at 1 yearof 592
• No implanted medical device
• No need for adjustments

• ASMBS, Position Statement on Sleeve Gastrectomy
  as a Bariatric Procedure. June 17, 2007.
• Lee CM, et al. Surg Endosc (2007) 21 18101816

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What are the risks and complicationsof a
vertical sleeve gastrectomy?

• Bleeding or infection
• Staple line leak
• Abdominal hernia
• Pulmonary Embolus
• Nausea and vomitting

Note Your weight, age and medical history play a
significant role in determining your specific
risks. Your surgeon can inform you about your
specific risks for bariatric surgery.
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A combination approach is most common
Roux-en-Y Gastric Bypass

• Laparoscopic
• Most frequently performedbariatric procedure
• Mean excess weight loss at 1 yearof 671
• No implanted medical device

1. Buchwald, H. et al., JAMA. 2004 2921724-37.
2. Buchwald H. 2004 ASBS Consensus Conference
   Statement, Bariatric surgery for morbid obesity
   Health implications for patients, health
   professionals, and third party payers. SOARD
   2005(1)371-8.

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What are the risks and complications of the
Roux-en-Y procedure?

• Dehiscence (separation of tissue that was
  stitched or stapled together)
• Leaks from staple lines
• Ulcers
• Internal hernia
• Dumping syndrome, an unpleasant side effect that
  may include vomiting, nausea, weakness, sweating,
  faintness, and diarrhea
• Inability to detect the stomach, duodenum, and
  parts of the small intestine using X-ray or
  endoscopy, should problems arise after surgery
  such as ulcers, bleeding, or malignancy

Note Your weight, age and medical history play a
significant role in determining your specific
risks. Your surgeon can inform you about your
specific risks for bariatric surgery.
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Duodenal Switch

• Weight loss 90 EBW
• More risk of protein and vitamin deficiency
• Requires maximum compliance with vitamins and
  protein
• Some patients have more frequent stools

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Gastric Plication

• Newest procedure
• No removal of stomach
• Not covered by insurance
• Results similar to gastric sleeve

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Summary
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Choosing the procedure thats right for you

• Considerations
• Age
• Health Risk (depending on comorbidities)
• Amount of weight to lose
• Lifestyle
• Eating behaviors
• Mutual decision between patient and surgeon
• Discuss with surgeon during initial consultation
• Discuss with family and friends

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Surgery can help you change your life

• Improves or resolves obesity-related illnesses
• Decreases mortality risk
• Reduces healthcare utilization and direct
  healthcare costs
• Remembersurgery is a tool that requires your
  strong commitment to a lifestyle change and
  lifetime of follow-up

Christou NV, Sampalis JS, Liberman M, et al.
Surgery Decreases Long-Term Mortality, Morbidity,
and Health Care Use in Morbidly Obese Patients.
Annals of Surgery 2004240(3)416-424.
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Resolving your co-morbid conditions

• Following bariatric surgery, most patients
  resolve or improve their co-morbid conditions

Buchwald, et al JAMA Oct 2004.
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What are your next steps?
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Youve already taken the first step

• Attend seminar (Complete!)
• Obtain referral from Primary Care Physician (PCP)
• Initial consultation with surgeon
• Psychological evaluation
• Nutritional evaluation counseling with one of
  our dieticians
• Verify benefits and obtain insurance
  authorization
• Pre-operative testing
• Surgery
• Lifelong follow-up appointments and support groups

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Questions?

• 1200 Binz Suite 950
• Houston, Tx 77004
• When (office hours) Mon-Thurs. 800-500, Fri.
  800-430
• Phone numbers [phone]
• Fax number [phone]
• Email tlc_at_tlcsurgery.com
• Web www.tlcsurgery.com

Texas Laparoscopic Consultants, LLP April 2009