P1251328620LFOjH

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Surgical Weight Loss
Information Seminar
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Obesity

• Obesity has become an epidemic
• Over 36 of the population of the state of Texas
  is morbidly obese
• Since 1980, the incidence of morbid obesity has
  quadrupled
• Obesity is now the second leading cause of
  preventable death in the U.S.

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Obesity

• Responsible for approximately 500,000 deaths
  per year
• 14 of all cancer deaths in men
• 20 of all cancer deaths in women

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Obesity

• Historically poorly defined
• Old definition Greater than 100 lbs. over
  ideal body weight
• Very difficult to compare scientific studies
  across the country / world

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Obesity

• Current definition
• Body Mass Index (BMI)
• Weight (Kg) / Height (m2)
• Normal 20 - 25
• Obese 25 - 35
• Morbidly Obese 35 - 50
• Super morbid obesity 50

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Weight Loss Options

• Diet
• Exercise
• Counseling
• Weight loss programs
• Jenny Craig, Weight Watchers, etc.

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Weight Loss Options

• Old mentality
• Gland Problem
• Lack of willpower
• Eating disorder
• Recognize ADDICTION in a large number of cases

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Weight Loss Options

• Dieting
• Extremely prominent in the media
• Notable absence of discussion of long-term
  results
• From a medical standpoint, dieting alone is
  almost uniformly ineffective in this patient
  population
• Patients typically regain all lost weight over
  their next five years
• Recent study Final average weight loss of only
  three pounds

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Dieting

• Define long-term success
• Realize that by this definition, 98 of diets
  ultimately fail
• Consequences of failure
• Depression, anxiety, irritability
• Decrease in overall quality of life
• Understand why diets fail

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Dieting

• Reasons for failure
• Hunger
• Hunger
• Hunger
• Hunger
• Hunger
• Hunger

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Grehlin

• Understand the mechanism of satiety in the human
  brain
• Grehlin
• Naturally produced hormone discovered shortly
  after the year 2000
• Produced in the stomach in response to a lack of
  food
• Acts in the brain by causing a feeling of satiety

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Grehlin
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Grehlin
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Grehlin
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Grehlin
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Grehlin Levels

• Essentially, gastric bypass equates to less
  hunger
• Greater degree of success with weight loss after
  gastric bypass due to this mechanism
• Higher compliance with post-op diet regimen due
  to this as well as positive reinforcement due to
  notable weight loss

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Medical Co-morbidities

• Metabolic
• Degenerative
• Psychological
• Neoplastic

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Metabolic Co-morbidities

• Type II Diabetes
• Hypertriglyceridemia
• Hypercholesterolemia
• Fatty infiltration of the liver
• Hypertension

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Degenerative / Anatomic

• DJD
• Sleep apnea
• Congestive heart failure
• Stress urinary incontinence
• GERD
• Long-term consequences of diabetes
• Renal failure, stroke, amputation, etc.

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Psychological

• Anxiety disorders
• Depression
• Social avoidance

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Neoplastic

• Breast
• Uterine
• Gastric
• Esophageal
• Pancreatic
• Hepatic
• Note Risk increases markedly at BMI 30-35

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Consequences

• Diminished quality of life
• Early death
• JAMA Jan 2003 study
• Example White male over 40 yrs old with BMI gt
  40 will experience a 22 reduction in remaining
  life span

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Who is a Surgical Candidate

• BMI of 35 or over with any co-morbidity
• BMI of 40 or greater
• Traditionally, age 18 to 60 years old
• Non-endocrine related cause of obesity
• Patients dedicated to permanent lifestyle changes
  and long-term follow-up

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Who is NOT a Surgical Candidate?

• Active substance abusers
• Noncompliant patients
• Patients with severe psychiatric disorders
• Schizophrenia
• Severe depression
• Borderline personality disorder

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Surgical Options

• Restrictive
• Lap-Band
• VBG
• Sleeve Gastrectomy
• Malabsorptive
• J-I Bypass
• Combination
• Roux-en-y bypass
• Biliary pancreatic diversion / duodenal switch

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Surgical Options

• Vertical Banded Gastroplasty

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Surgical Options

• Lap-Band

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Surgical Options

• Sleeve Gastrectomy

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Surgical Options
Click to edit Master title style

• Biliopancreatic Diversion

• Click to edit Master text styles
• Second level
• Third level
• Fourth level
• Fifth level

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Surgical Options

• Roux-en-Y Gastric Bypass

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Realistic Expectations

• Weight loss surgery is not a cure
• Surgery should be viewed as a tool to help with
  weight loss

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Risks and Complications

• Lap-Band
• Infection
• Erosion
• Slip
• Damage to stomach while placing band

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Risks and Complications

• Sleeve gastrectomy
• Leak
• Nausea
• Possible need for bypass in future

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Risks and Complications

• Gastric bypass
• Long-term
• Weight regain
• Anemia
• Vitamin / mineral deficiency

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Risks and Complications

• Gastric bypass
• Short-term
• Wound infection
• Hernia
• Pneumonia
• Heart attack
• Bleeding
• Blood clots (pulmonary embolism)
• Stricture
• Dumping syndrome

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Risks and Complications

• Gastric bypass
• Short-term
• Gallstones
• Hair loss
• Dietary intolerance
• Peripheral neuropathy
• Fistula
• Leak
• Death

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Risks and Complications

• Death from gastric bypass
• Most common cause is from pulmonary embolism
• Leaks play a major role as well
• Risk of death from gastric bypass across the
  country is 0.5
• Realize that gastric bypass reduces the mortality
  of morbidly obese patients by 89 over a
  five-year period when compared with morbidly
  obese patients who do not undergo significant,
  sustained weight loss

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Expectations

• Active aftercare participation
• Long-term follow up
• Daily vitamin supplementation after bypass
• Weekly B12 supplementation after bypass
• Band fills after Lap-Band

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Which Option Should I Choose?

• Patient choice
• IMPORTANT
• Lap-Band
• Technically lower risk
• On average 36-40 excess weight loss at one year
• Average of 60-65 excess weight loss at 3-5
  years
• Slower resolution of co-morbidities
• Importance of ongoing need for band fills for
  6-12 months
• Reversible
• Importance of realistic expectations

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Which Option Should I Choose?

• Sleeve gastrectomy
• Lower risk than gastric bypass
• Higher risk than Lap-Band
• Long- and short-term weight loss between Lap-Band
  and gastric bypass
• No dumping syndrome
• No need for band fills

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Which Option Should I Choose?

• Gastric bypass
• Technically higher risk
• On average 70-80 excess weight loss at one year
• Faster resolution of co-morbidities
• Non-reversible

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Conclusion

• Surgically induced weight loss
• Improves or resolves co-morbidities
• Decreases risk of early death from wide variety
  of causes
• Decreases risk of developing obesity related
  illnesses
• Reduces healthcare costs for patients
• Improves overall quality of life

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What Next?

• Generate Letter of Medical Necessity to
  insurance carrier
• Understand many insurance carriers are difficult
  to obtain approval from
• After response, schedule consult
• Schedule any necessary pre-op tests
• Surgery
• Post-op dietician consult
• Post-op physical therapy / exercise program
• Optional behavioral modification counseling
• Weekly / monthly support group meetings
• Follow-up at 2 wks, 6 wks, 6 mos, yearly

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Questions
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