surgical treatment of morbid obesity

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SURGICAL TREATMENT OF MORBID OBESITY Scott D. Steinberg, M.D. St. Vincents Hospital and Medical Center Grand Rounds, May 30, 2001

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Page 1: Surgical Treatment of Morbid Obesity

SURGICAL TREATMENT OF

MORBID OBESITYScott D. Steinberg, M.D.

St. Vincents Hospital and Medical Center

Grand Rounds, May 30, 2001

Page 2: Surgical Treatment of Morbid Obesity

OVERVIEW• The problem of obesity

• Indications for bariatric surgery

• Evolution of bariatric surgery

• Results of bariatric surgery

• Conclusions

Page 3: Surgical Treatment of Morbid Obesity

HOW BIG IS THE PROBLEM?

Page 4: Surgical Treatment of Morbid Obesity

INTRODUCTION• More than 50% of US adults are

overweight (BMI > 25 kg/m2)

• The percentage of obese Americans (BMI > 30 kg/ m2) has increased by more than 50% in the last 20 years

• The number of overweight children has doubled over the last 20 years

JAMA, 282(16), 1504-1506

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PREVALENCE OF OBESITY IN THE UNITED STATES

Page 6: Surgical Treatment of Morbid Obesity

• The estimated number of annual deaths attributable to obesity among US adults is approximately 325,000

• More than 80% of these deaths occurred among individuals with a BMI of > 30 kg/m2

MORBID OBESITY

JAMA, 282(16), 1530-1538

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BODY-MASS INDEX

(Height in meters) 2

BMI =Weight in kg

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DEFINITIONSOVERWEIGHT BMI 25-29.9 kg/m2

OBESITY BMI 30-39.9 kg/m2

MORBID OBESITYBMI 40-49.9 kg/m2

SUPER OBESITY BMI > 50 kg/m2

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100 lbs above ideal body weight

OR

BMI >40kg/m2

CLINICALLY SEVERE OBESITY

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THE FRAMINGHAM STUDY

The first cohort to terminate because of demise of all participants was the morbidly obese

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• Results from a complex interaction of genetic, behavioral, and environmental factors

• Second leading cause of preventable death, exceeded only by cigarette smoking

OBESITY

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MORBID OBESITY• HTN• Diabetes• CAD• CHF• Cirrhosis• Osteoarthritis• Vascular disease

• Gallbladder disease• Sleep apnea• Breast cancer • Uterine cancer • Prostate cancer• Colon cancer• Psychiatric disease

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• First treatment is lifestyle and dietary changes

• Only 5-10% of patients maintain weight loss for more than a few years

• When conservative measures fail, patients may consider surgery

MORBID OBESITY

Blue Cross/Blue Shield Medical Policy Manual, 1996

Page 16: Surgical Treatment of Morbid Obesity

WHICH PATIENTS ARE CANDIDATES FOR BARIATRIC

SURGERY?

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• Risk for M&M is proportional to the degree of overweight

• Pts with BMI > 40 (*35) are at highest risk and should be considered for bariatric surgery

• Diet and Drug therapy has limited success in the morbidly obese

• Endorsed VBG and Roux-en-Y gastric bypass

Gastrointestinal Surgery for Severe Obesity. NIH Consens Statement 1991 Mar 25-27;9(1):1-20.

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• BMI > 40 kg/m2

• BMI > 35 kg/m2 with serious co-morbid medical conditions

• Repeated failure at conservative treatments • No history of significant psychiatric disorders

INDICATIONS FOR SURGERY

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VBG

GASTROPLASTY

ADJUSTABLE BAND

RESTRICTIVE MALABSORPTIVE

JIB

SMALL BOWEL BYPASS

BPD/DS, ROUX-en-Y GASTRIC BYPASS

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Dr. John Linner

1954

Jejuno-ileal bypass

THE BEGINNING

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COMPLICATIONS OF JEJUNOILEAL BYPASS

• Electrolyte disturbances• Osteoporosis/osteomalacia• Protein malnutrition• Cholelithiasis• Diarrhea• Hair loss

• Arthritis• Liver failure• Steatosis• Renal calculi• Neuropathy• Anemia

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Dr. Edward Mason

University of Iowa

1967 Gastric Bypass with

loop gastroenterostomy

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GASTRIC BYPASS SHORT TERM • Anastomotic leak• Acute gastric dilatation• Roux-Y obstruction• Atelectasis• Wound infection

LONG TERM• Stomal stenosis• Anemia• Vit B12 deficiency• Calcium deficiency

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GASTRIC BYPASS WITHROUX-en-Y LIMB

SUBSEQUENTLY MODIFIED

50 mL POUCH WITH A ROUXLIMB TO MINIMIZE BILEREFLUX

ROUX LIMB WAS LENGTHENEDTO INCREASE MALABSORPTIONAND IMPROVE WEIGHT LOSS

COMBINED RESTRICTIVEAND MALABSORPTIVE

Page 26: Surgical Treatment of Morbid Obesity

Nicola Scopinaro

Biliopancreatic Diversion (BPD)

Any procedure that diverts bile and pancreatic secretions

Combined Restrictive and Malabsorptive surgery

1976“BPD”

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COMPLICATIONS OF BPD

• Protein Malnutrition 15%

• Incisional Hernia 10%

• Intestinal obstruction 1%

• Acute biliopancreatic limb obstruction

• Stomal ulcer

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1982VBG

Vertical-Banded

Gastroplasty

•Dr. Edward Mason

•Stapled opening in stomach

•Staple line along angle of His

•Polypropylene mesh around lesser curvature

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1988BPD/DS

Dr. Doug Hess

•MODIFIED BPD

•Duodenal switch w/ sleeve gastric reduction

•Intact pylorus

•Eliminates dumping and ulcers

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1994

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AUGUST 1999 300 lbs DECEMBER 2000 143 lbs

CARNIE WILSON

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MAY 2000: SAGES GUIDELINES FOR LAPAROSCOPIC

AND CONVENTIONAL SURGICAL TREATMENT OF MORBID OBESITY

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ROUX-en-Y GASTRIC BYPASS

GOAL: To restrict the

gastric reservoir

ADVANTAGES

• Controls food intake

• Dumping reduces intake of sweets

• Reversible if indicatedRoux-en-Y Gastric

Bypass

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ROUX-en-Y GASTRIC BYPASS

DISADVANTAGES

• Staple line failure

• Ulcers

• Blockage of stoma

• Vomiting if food eaten quickly Roux-en-Y Gastric

Bypass

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LAPAROSCOPIC ROUX-en-Y

GASTRIC BYPASS

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LAPAROSCOPIC ADJUSTABLE

GASTRIC BAND(LAP-BANDTM)

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THE DATA…

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• N=500• Excess weight loss of 80% in first year• 95% of significant pre-operative comorbidities well controlled

2000

Obesity Surgery, 2000 18:233-239

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• N=1040

• Mean LOS 1.9 days

• Mean OR time 60 min

• No leaks

• 5 perioperative deaths

–3 PE, 1 asthma, 1 suicide

• Mean EWL 70% @ 1 yr

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• N=275 (1997-2000)

• 1-31 month f/u

• One conversion

• One death (PE)

• 11 Wound infections

• Median LOS 2 days

• EWL

–83% @ 24 months

–77% @ 30 months

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CONCLUSIONS• OBESITY IS A MAJOR PROBLEM IN

THE UNITED STATES

• CURRENT DIET AND DRUG THERAPY OFFERS LIMITED SUCCESS FOR THE MORBIDLY OBESE PATIENT

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• BARIATRIC SURGERY OFFERS THE MORBIDLY OBESE LONG-TERM WEIGHT LOSS WITH IMPROVEMENT IN MORBIDITY AND MORTALITY

• LAPAROSCOPIC BARIATRIC SURGERY CAN BE PERFORMED SAFELY WITH EXCELLENT RESULTS

CONCLUSIONS

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THANK YOU