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SURGICAL MANAGEMENT OF OBESITY

Anne Lidor, MD, MPH

Professor of Surgery

Chief, Division of Minimally Invasive and Bariatric Surgery

Multi-Factorial Causes of Morbid Obesity include:

• Genetic

• Environmental

• Cultural

• Psychological

• Socioeconomic

How does obesity impact our health?

Obesity-Related Comorbidities

Type 2 Diabetes

Obstructive sleep apnea

High cholesterol

Hypertension

Heart Disease

GERD (reflux/heart burn)

Gallstones

Degenerative joint disease

Fatty liver disease

Asthma

Stress incontinence

Birth defects

Miscarriages

Infertility

Cancer

Breast

Cervical

Endometrial

Ovarian

Colorectal

Liver

Pancreatic

Esophageal

Lung

Prostate

Kidney

Lymphoma

Multiple myeloma

Leukemia

Available Treatment Options:

Diet & Exercise

Medication

Behavioral modification

Surgical management

It’s the most powerful tool

in our tool box

Why Bariatric surgery?

Purpose of Bariatric Surgery

To alleviate or eliminate obesity related medical diseases

It is not cosmetic surgery!

Bariatric Surgery Patient Selection (Based On The 1991 NIH Guidelines)

BMI > 40; or > 35 with obesity related morbidity

Previous failed attempts at supervised weight reduction

Realistic expectations

No recent substance abuse

Age limits (18 to 65 yrs old in most programs)

Supportive family/friends

Lifelong commitment to dietary change and follow-up

What is Body Mass Index?

Classification of ObesityBody Mass Index (BMI) = wt (kg) / ht (m)

Non-obese 20 - 25 < 30 lbs

Obese > 30 > 30 lbs

Morbid Obesity > 40 > 100 lbs

Superobesity > 50 > 150 lbs

BMI (kg/m )~Excessbody weight

2

2

How much weight loss ?

Current weight: 250 pounds

- (subtract)

Ideal Body Weight: 150 pounds

__________________________

= Excess Body Weight: 100

50-75% Excess Body Weight = 50 to 75 pounds lost

Example:

A 300 lb individual may realize a 55 - 80 lb weight loss

A 400 lb individual may realize a 75-130 lb weight loss

A “normal” BMI is not necessary for improved health

OUR GOALS FOR YOU INCLUDE:

Improved Co-morbid Conditions Type 2 Diabetes

Obstructive sleep apnea

High cholesterol

Hypertension

Improved Over-all HealthImproved Quality of Life Longer Life

RNY (Gastric Bypass) Sleeve

Bariatric Procedures

Laparoscopic Approach

Laparoscopic Approach

• Less pain

• Fewer infections

• Shorter length of stay

• Much less risk of developing a hernia at incision

Roux-en-Y Gastric Bypass

Restrictive (small pouch size)

Malabsorptive (skipping part of the intestine)

Alters hunger hormones and insulin sensitivity

little to no hunger

Improved diabetes

Hospital stay of 2 nights

Roux-en-Y Gastric Bypass

Gastric Bypass

PROS

Proven long term weight loss

Proven reduction of obesity related co-morbidities

Best operation for patients with GERD

CONS

Ulcers/stenosis Anemia Calcium deficiency Dumping syndrome Difficult to reverse Internal hernia

Pre-Op

BMI = 47

Weight = 306 lbs.

Waist = 54 inches

High Blood Pressure

Diabetes

PCOS

Depression

Back & Knee Pain

Swelling of lower legs

7 prescriptions daily

22

LRNY GBP, Johns Hopkins, 11/2008

5 years post-op

BMI = 25

Weight loss = 140 lbs.

Waist = 37 inches

Resolved Medical Problems

High Blood Pressure

Diabetes

Depression

PCOS Symptoms

Improved Medical Problems

Back & Knee Pain

1 Prescription Medication

Just became pregnant!

23

Vertical Sleeve Gastrectomy

Mostly a restrictive procedure

Some altered hunger hormones and insulin sensitivity

less hunger

improved diabetes

Hospital stay of 1-2 nights

Sleeve Gastrectomy

Sleeve Gastrectomy

PROS

No malabsorption

Proven long term weight loss and resolution of co-morbidities

Preserves pylorus (decreases risk of dumping)

Can be converted to gastric bypass or duodenal switch

CONS

Large portion of stomach removed (not reversible)

Can worsen GERD Strictures

Complications of surgery

• Bleeding

• Wound Infection

• DVT (blood clot) to Pulmonary Embolism

• Cardiac Event

• Leak

• Ulcers/Stricture/Stenosis

• Malabsorption

• Internal Hernia

SG GBP

Excess BMI loss 61% 68%

Remission of DM, HTN,

dyslipidemia

Equivalent Equivalent

GERD 33% better 66% better

Early morbidity 0.9% 4.5%

Total

reoperations/interventions

15.8% 23%

* Swiss study-217 with 95% follow up to 5 years

* Finnish study-240 patients with 80% follow up at 5 years

SG GBP

% Excess Weight loss 50% 57%

Remission of DM and

dyslipidemia

Equivalent Equivalent

Anti-hypertensive meds Fewer meds

Early morbidity 9% 26%

Total

reoperations/interventions

10% 18%

Israeli study-retrospective cohort

study with 8385 bariatric surgery

patients and 22155 matched non

surgical patients

100% follow up to 4 years

Secondary analysis demonstrated

improved weight loss, DM

remission, and lower

HTN/dyslipidemia.

Bariatric Budget Impact Calculator

Bariatric Budget Impact Calculator

The Path to Surgery

Information gathering

Pre-visit screening

Assessments

Work-up (tests/studies)

Classes (ABC)

Follow up visits + class D

Pre-op visits and labs

Surgery

**CAN TAKE UP TO 7 MONTHS

Post-op follow-up

Week 2 (after surgery) PA or Surgeon

Dietitian

Week 6 PA or Surgeon

Dietitian

Month 3 PA or Surgeon

Dietitian

Labs

Month 6 PA or Surgeon

Dietitian

Labs

Health Psychologist

Month 12 (yearly thereafter)

PA or Surgeon

Dietitian

Labs

Health Psychologist

UW Health Hospital and Clinic

UW Health Medical and SurgicalWeight Management Program

Bariatric Surgery, UW Health

at The American Center

4602 Eastpark Blvd, Madison

Our Surgeons

Michael Garren Jacob Greenberg Luke Funk Anne Lidor

Other Success Stories…

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Visit our website: www.uwhealth.org/weight-loss-surgery/bariatric-surgery