Surgical Weight Loss

1. Surgical Weight Loss Information Seminar

2. 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.

3. Obesity • Responsible for approximately 500,000 deaths per year • 14% of all cancer deaths in men • 20% of all cancer deaths in women 3

4. Obesity • Historically poorly defined • “Old” definition: Greater than 100 lbs. over “ideal” body weight • Very difficult to compare scientific studies across the country / world 4

5. 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 + 5

6. Weight Loss Options • Diet • Exercise • Counseling • Weight loss programs • Jenny Craig, Weight Watchers, etc. 6

7. Weight Loss Options • Old mentality • “Gland Problem” • “Lack of willpower” • “Eating disorder” • Recognize ADDICTION in a large number of cases 7

8. 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 8

9. 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 9

10. Dieting • Reasons for failure • Hunger • Hunger • Hunger • Hunger • Hunger • Hunger 10

11. 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 11

12. Grehlin 12

13. Grehlin 13

14. Grehlin 14

15. Grehlin 15

16. 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 16

17. Medical Co-morbidities • Metabolic • Degenerative • Psychological • Neoplastic 17

18. Metabolic Co-morbidities • Type II Diabetes • Hypertriglyceridemia • Hypercholesterolemia • Fatty infiltration of the liver • Hypertension 18

19. Degenerative / Anatomic • DJD • Sleep apnea • Congestive heart failure • Stress urinary incontinence • GERD • Long-term consequences of diabetes • Renal failure, stroke, amputation, etc. 19

20. Psychological • Anxiety disorders • Depression • Social avoidance 20

21. Neoplastic • Breast • Uterine • Gastric • Esophageal • Pancreatic • Hepatic • Note: Risk increases markedly at BMI 30-35 21

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

23. 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 23

24. Who is NOT a Surgical Candidate? • Active substance abusers • Noncompliant patients • Patients with severe psychiatric disorders • Schizophrenia • Severe depression • Borderline personality disorder 24

25. Surgical Options • Restrictive • Lap-Band • VBG • Sleeve Gastrectomy • Malabsorptive • J-I Bypass • Combination • Roux-en-y bypass • Biliary pancreatic diversion / duodenal switch 25

26. Surgical Options • Vertical Banded Gastroplasty 26

27. Surgical Options • Lap-Band 27

28. Surgical Options • Sleeve Gastrectomy 28

29. Surgical Options Click to edit Master title style • Biliopancreatic Diversion • Click to edit Master text styles • Second level • Third level • Fourth level • Fifth level 29 29

30. Surgical Options • Roux-en-Y Gastric Bypass 30

31. Realistic Expectations • Weight loss surgery is not a cure • Surgery should be viewed as a tool to help with weight loss 31

32. Risks and Complications • Lap-Band • Infection • Erosion • Slip • Damage to stomach while placing band 32

33. Risks and Complications • Sleeve gastrectomy • Leak • Nausea • Possible need for bypass in future 33

34. Risks and Complications • Gastric bypass • Long-term • Weight regain • Anemia • Vitamin / mineral deficiency 34

35. Risks and Complications • Gastric bypass • Short-term • Wound infection • Hernia • Pneumonia • Heart attack • Bleeding • Blood clots (pulmonary embolism) • Stricture • Dumping syndrome 35

36. Risks and Complications • Gastric bypass • Short-term • Gallstones • Hair loss • Dietary intolerance • Peripheral neuropathy • Fistula • Leak • Death 36

37. 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 37

38. Expectations • Active aftercare participation • Long-term follow up • Daily vitamin supplementation after bypass • Weekly B12 supplementation after bypass • Band fills after Lap-Band 38

39. 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 39

40. 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 40

41. 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 41

42. 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 42

43. 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 43

44. Questions 44