obesity: surgical management eric s. hungness, m.d. assistant professor of surgery department of...
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Obesity:Obesity:Surgical Surgical
ManagementManagement
Eric S. Hungness, M.D.Eric S. Hungness, M.D.
Assistant Professor of SurgeryAssistant Professor of Surgery
Department of SurgeryDepartment of Surgery
Northwestern University Feinberg School Northwestern University Feinberg School of Medicineof Medicine
Chicago, IllinoisChicago, Illinois
Etiology of ObesityEtiology of Obesity
FamilialFamilial GeneticGenetic Gender (F>M)Gender (F>M) SocialSocial Psychologic Psychologic
(depression)(depression)
MULTIFACTORIALMULTIFACTORIAL
The Obesity EpidemicThe Obesity EpidemicThe weight gain cycleThe weight gain cycle
Eat too muchEat too muchGain weightGain weight
Can’tCan’tExerciseExercise
GetGetDepressedDepressed
Normal Normal Weight Weight
(BMI 18.5 to (BMI 18.5 to 24.9)24.9)
OverweightOverweight(BMI 25 to 29.9)(BMI 25 to 29.9)
ObeseObese(BMI 30 to 34.9)(BMI 30 to 34.9)
Severely ObeseSeverely Obese(BMI 35 to 39.9 )(BMI 35 to 39.9 )
Morbidly ObeseMorbidly Obese(BMI (BMI >> 40) 40)
Body Mass Index (BMI)Body Mass Index (BMI)
Super ObeseSuper Obese(BMI (BMI >> 50 50))
BMI = weight (kg) / height (m)BMI = weight (kg) / height (m)22
The Obesity EpidemicThe Obesity Epidemic 66% of Americans >20 yrs are either overweight or 66% of Americans >20 yrs are either overweight or
obese (BMI > 25, ~ 133 million people)obese (BMI > 25, ~ 133 million people) Increased from 45% in 1960Increased from 45% in 1960
33% of Americans >20 yrs are obese (BMI > 30, ~ 66 33% of Americans >20 yrs are obese (BMI > 30, ~ 66 million)million)
5% of Americans are morbidly obese (BMI > 40, ~ 10 5% of Americans are morbidly obese (BMI > 40, ~ 10 million)million)
3.1% in men and 6.7% in women3.1% in men and 6.7% in women Increasing by 1% per yearIncreasing by 1% per year
Obesity is increasing in children (doubled in past 20 Obesity is increasing in children (doubled in past 20 years)years)
15% between the age of 6 and 1915% between the age of 6 and 19
NHANES (2003-04) (n=4,431)NHANES (2003-04) (n=4,431)
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1985BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1986BRFSS, 1986
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1987BRFSS, 1987
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1988BRFSS, 1988
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1989BRFSS, 1989
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1990BRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1991BRFSS, 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1992BRFSS, 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1993BRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1994BRFSS, 1994
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1995BRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1996BRFSS, 1996
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1997BRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1998BRFSS, 1998
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1999BRFSS, 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 2000BRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 2001BRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 2002BRFSS, 2002
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 2003BRFSS, 2003
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 2004BRFSS, 2004
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 2005BRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 2006BRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Why do we treat obesity??Why do we treat obesity??
• Co-morbiditiesCo-morbidities
• Quality of lifeQuality of life
• Survival – Life ExpectancySurvival – Life Expectancy
Co-morbiditiesCo-morbidities
EndocrineEndocrine DiabetesDiabetes
CardiovascularCardiovascular HypertensionHypertension HyperlipidemiaHyperlipidemia HypertriglyceridemiHypertriglyceridemi
aa Coronary and Coronary and
cerebral vascular cerebral vascular diseasedisease
Venous stasisVenous stasis
GynecologyGynecology InfertilityInfertility Menstrual Menstrual
irregularitiesirregularities OrthopedicOrthopedic
DJDDJD ArthralgiaArthralgia Low back painLow back pain
DermatologyDermatology Fungal infectionFungal infection
Co-morbiditiesCo-morbidities
PulmonaryPulmonary Sleep apneaSleep apnea AsthmaAsthma HypoventilationHypoventilation Pulmonary Pulmonary
hypertensionhypertension
GastrointestinalGastrointestinal CholelithiasisCholelithiasis GERDGERD Fatty liver /dysfunctionFatty liver /dysfunction
Socio-economicSocio-economic DiscriminationDiscrimination
PsychologicalPsychological DepressionDepression h/o abuseh/o abuse
CancerCancer
22ndnd only to smoking as the leading cause only to smoking as the leading cause
of preventable death in the United of preventable death in the United
States.States.††
> 110,000 deaths/year in the US are > 110,000 deaths/year in the US are
associated with obesity*associated with obesity*
Life ExpectancyLife Expectancy
* Flegal KM et al. JAMA. 2005 Apr 20;293(15):1861-7. † † CDCCDC
Years of Life Lost Years of Life Lost (YLL)(YLL) white male 10 yearswhite male 10 years white female 7 yearswhite female 7 years black male 11 yearsblack male 11 years black female 3 yearsblack female 3 years
Life ExpectancyLife Expectancy
Fontaine et al. Fontaine et al. JAMAJAMA 2003; 289:187-193 2003; 289:187-193
Medical TreatmentMedical Treatment
Medications Medications Dietary ChangesDietary Changes ExerciseExercise Behavioral Behavioral
TherapyTherapy PsychotherapyPsychotherapy HypnosisHypnosis Jaw-wiringJaw-wiring
UNSUCCESSFUL AT SIGNIFICANT UNSUCCESSFUL AT SIGNIFICANT OR SUSTAINED WEIGHT LOSS!OR SUSTAINED WEIGHT LOSS!
Rationale for SurgeryRationale for Surgery
Long Term Outcome DataLong Term Outcome Data Sustained Weight LossSustained Weight Loss Improvement or Resolution of Co-Improvement or Resolution of Co-
morbiditiesmorbidities Improved long term survivalImproved long term survival
Minimally Invasive SurgeryMinimally Invasive Surgery Public AwarenessPublic Awareness
Obesity as a diseaseObesity as a disease Celebrities Celebrities
Indications for SurgeryIndications for Surgery
BMI >40 kg/mBMI >40 kg/m22, or >35 kg/m, or >35 kg/m22 with with significant co-morbid illnessessignificant co-morbid illnesses
Multiple failed weight loss attemptsMultiple failed weight loss attempts
Acceptable surgical riskAcceptable surgical risk
Age 18-60Age 18-60
Demonstrates commitment and Demonstrates commitment and understanding of weight loss following understanding of weight loss following bariatric surgerybariatric surgery
Preoperative Preoperative Evaluation/EducationEvaluation/Education
Staff evaluationStaff evaluation InternistInternist DietitianDietitian PsychologistPsychologist NurseNurse SurgeonSurgeon Support groupSupport group
•Laboratory evaluationLaboratory evaluation– BloodBlood– ECG, CXR ECG, CXR – Stress TestStress Test– Sleep studySleep study– EGDEGD– PFTsPFTs
Consider an IVC filter for any patient with prior history of Consider an IVC filter for any patient with prior history of DVT/PE.DVT/PE.
Surgical TreatmentSurgical Treatment
RestrictiveRestrictive
MalabsorptiveMalabsorptive
Horizontal gastroplastyHorizontal gastroplastyVertical banded gastroplasty (VBG)Vertical banded gastroplasty (VBG)Roux-en-Y gastric bypassRoux-en-Y gastric bypassAdjustable gastric bandAdjustable gastric bandSleeve gastrectomySleeve gastrectomy
Jejunoilial bypassJejunoilial bypassBiliopancreatic diversion (Scopinaro)Biliopancreatic diversion (Scopinaro)Biliopancreatic diversion w/ duodenal switchBiliopancreatic diversion w/ duodenal switch
Surgical TreatmentSurgical Treatment
RestrictiveRestrictive
MalabsorptiveMalabsorptive
Horizontal gastroplastyHorizontal gastroplastyVertical banded gastroplasty (VBG)Vertical banded gastroplasty (VBG)Roux-en-Y gastric bypassRoux-en-Y gastric bypassAdjustable gastric bandAdjustable gastric bandSleeve gastrectomySleeve gastrectomy
Jejunoilial bypassJejunoilial bypassBiliopancreatic diversion (Scopinaro)Biliopancreatic diversion (Scopinaro)Biliopancreatic diversion w/ duodenal switchBiliopancreatic diversion w/ duodenal switch
Horizontal Gastroplasty Horizontal Gastroplasty (HG)(HG)
Gomez, Cesar. Gomez, Cesar. World Journal of SurgeryWorld Journal of Surgery, 1981, 1981
Mason E, Mason E, Archives of SurgeryArchives of Surgery, , 19821982
Polypropylene Polypropylene bandband
Transgastric Transgastric windowwindow
Angle of HisAngle of His
Vertical Banded Gastroplasty Vertical Banded Gastroplasty (VBG(VBG))
Gastric PouchGastric Pouch
Jejunoileal BypassJejunoileal Bypass
Payne and Dewind, Payne and Dewind, Archives of SurgeryArchives of Surgery, 1973, 1973
Biliopancratic DiversionBiliopancratic Diversion
Marceau, et al. Marceau, et al. World Journal of SurgeryWorld Journal of Surgery, 1998, 1998
w/ duodenal switchw/ duodenal switchw/o duodenal switchw/o duodenal switch
75 – 100cm75 – 100cmCommon channelCommon channel
SafetySafety ComplicationsComplications Overall Medical Overall Medical
ConditionCondition AgeAge EffectivenessEffectiveness How Much Weight How Much Weight
Do you need to Do you need to loselose
ExpectationsExpectations
Long term resultsLong term results VitaminsVitamins
Anesthesia TypeAnesthesia Type OR TimeOR Time Hospital StayHospital Stay AdjustableAdjustable MaintenanceMaintenance DumpingDumping DiabetesDiabetes Multiple Prior Multiple Prior
SurgeriesSurgeries Hiatal Hernia/RefluxHiatal Hernia/Reflux
Complications:Complications:General AnesthesiaGeneral Anesthesia
Blood ClotBlood Clot Heart AttackHeart Attack PneumoniaPneumonia StrokeStroke DeathDeath
• Port displacement/tube breakPort displacement/tube break 7%7%• Wound infectionWound infection 4%4%• Stoma obstructionStoma obstruction 2%2%• SlippageSlippage 2%2%• Elective removalElective removal 2%2%• ErosionErosion <1%<1%• Conversion to openConversion to open <1%<1%• HemorrhageHemorrhage <1%<1%• DeathDeath <0.05%<0.05%
Complications:Complications: Adjustable Gastric BandingAdjustable Gastric Banding
Complications:Complications:Roux-en-Y Gastric BypassRoux-en-Y Gastric Bypass
Leak Leak 1-2%1-2% BleedingBleeding InfectionInfection DehydrationDehydration Stricture/ Ulcer Stricture/ Ulcer 7%7% Conversion to open Conversion to open 1%1% Death Death 0.2 - 0.2 -
0.5%0.5%
Complications:Complications:BPD with Duodenal SwitchBPD with Duodenal Switch
Leak Leak 1-2%1-2% BleedingBleeding InfectionInfection DehydrationDehydration MalnutritionMalnutrition 5%5% Conversion to open Conversion to open 1%1% Death Death 0.5 – 0.5 –
1.1%1.1%
MortaliMortalityty
%EBW%EBWLL
LBLB 0.1%0.1% 47.547.5RYGRYGBB
0.5%0.5% 61.661.6
DSDS 1.1%1.1% 70.170.1Buchwald et al. JAMA 2004; 292(14):1724-37
% Resolution of co-morbidity% Resolution of co-morbidity
↑ ↑ Chol/TGChol/TG
AA
DiabeDiabetestes
OSAOSA HTNHTN
LBLB 78.378.3 47.847.8 87.987.9 65.665.6
RYGRYGBB
93.693.6 83.883.8 94.694.6 75.475.4
DSDS 99.599.5 97.997.9 95.295.2 81.381.3
Buchwald et al. JAMA 2004; 292(14):1724-37