New Patient New Patient Orientation for Orientation for

Bariatric SurgeryBariatric Surgery

St. Luke’s and Roosevelt HospitalsSt. Luke’s and Roosevelt HospitalsThe Center of Excellence for The Center of Excellence for

Bariatric Surgery and Metabolic Bariatric Surgery and Metabolic Disease Disease

Bariatric TeamBariatric Team

• Dr. Julio Teixeira, FACS – DirectorDr. Julio Teixeira, FACS – Director

• Dr. James McGintyDr. James McGinty

• Dr. Ninan Koshy Dr. Ninan Koshy

• Dr. Scott BelsleyDr. Scott Belsley

• Christine Haufmann, FNPChristine Haufmann, FNP

• Aisling McGinty, RDAisling McGinty, RD

• Tricia Mah, RDTricia Mah, RD

Why do people choose Why do people choose surgery for their obesity?surgery for their obesity?

Facts on ObesityFacts on Obesity

• Obesity is a diseaseObesity is a disease

• Multiple facts are related to obesity:Multiple facts are related to obesity:

-genetics-genetics

-psychology-psychology

-environment-environment

““Genetics loads the gun—the environment pulls the trigger.”Genetics loads the gun—the environment pulls the trigger.”

George Bray, 1996George Bray, 1996

A New Understanding Of Obesity

““Genetics loads the gun—the environment pulls the trigger.”Genetics loads the gun—the environment pulls the trigger.”

George Bray, 1996George Bray, 1996

A New Understanding Of Obesity

Facts on Obesity Facts on Obesity

• Major public health problem worldwideMajor public health problem worldwide • Affects 25% of industrialized worldAffects 25% of industrialized world• American statistics:American statistics:

– 55% (34 Million) adults are overweight (Body 55% (34 Million) adults are overweight (Body Mass Index > 25)Mass Index > 25)

– 25% of children are overweight25% of children are overweight– 5-11 million people are morbidly obese 5-11 million people are morbidly obese – 6% of health care expenditures ($238 Billion / 6% of health care expenditures ($238 Billion /

year)year)– 300,000 deaths annually300,000 deaths annually

JAMA

Facts on Treatment of Facts on Treatment of ObesityObesity

• Medical treatmentMedical treatment is an ineffective is an ineffective method of sustaining weight loss for method of sustaining weight loss for individuals with a BMI >35 individuals with a BMI >35

• Bariatric surgeryBariatric surgery is the only is the only effective method of sustaining effective method of sustaining weight loss for individuals with a BMI weight loss for individuals with a BMI >35 (1991 NIH consensus)>35 (1991 NIH consensus)

Body Mass Index (BMI)Gray DS. Med Clin North Am. 1989;73(1):1–13.

Obesity and Mortality Risk2.5

2.0

1.5

1.0

020 25 30 35 40

MortalityRatio

Moderate VeryLow Low Moderate HighHigh Very

High

Obesity Related Obesity Related Co-Morbid Medical ConditionsCo-Morbid Medical Conditions

Co-Morbidities:Co-Morbidities:– DiabetesDiabetes– HypertensionHypertension– HyperlipidemiaHyperlipidemia– Cardiac diseaseCardiac disease– Respiratory disease Respiratory disease

- sleep apnea- sleep apnea– ArthritisArthritis– DepressionDepression– Stress IncontinenceStress Incontinence– Menstrual irregularity Menstrual irregularity

% of Occurrences:% of Occurrences:

- 14–20%- 14–20%

- 25–55%- 25–55%

- 35–53%- 35–53%

- 10–15%- 10–15%

- 10–20%- 10–20%

- 20–25%- 20–25%

- 70–90%- 70–90%

- 50%- 50%

- 50%- 50%Table 7 Literature Review

Cancer and Obesity

• Common cancers associated with Common cancers associated with obesity:obesity:– EsophagealEsophageal– BreastBreast– UterineUterine– OvarianOvarian– ProstateProstate– ColonColon– CervicalCervical

Herra 1999Carrol 1998Everhart 1993

Candidates for Weight Loss Candidates for Weight Loss SurgerySurgery

• 18-70 years of age18-70 years of age• BMI >40BMI >40• BMI 35 - 39 with associated medical conditions such BMI 35 - 39 with associated medical conditions such

as:as:– DiabetesDiabetes– HypertensionHypertension– HyperlipidemiaHyperlipidemia– Cardiac diseaseCardiac disease– Respiratory diseaseRespiratory disease– ArthritisArthritis– DepressionDepression

Body Mass Index (BMI)Body Mass Index (BMI)

• Measure of body fat based on height and Measure of body fat based on height and weightweight

• Calculate the person’s weight in kilograms Calculate the person’s weight in kilograms divided by height in meters squared (Kg/m2) divided by height in meters squared (Kg/m2) – 20-25 normal20-25 normal– 25-30 overweight25-30 overweight– 30-40 obese30-40 obese– >40 severe obesity>40 severe obesity– >50 super obesity>50 super obesity

When should you have weight When should you have weight loss loss

surgery ?surgery ?• Weight loss surgery should always be Weight loss surgery should always be

the last resortthe last resort

• You must have attempted weight You must have attempted weight loss through other methods such as loss through other methods such as nutritional & medical therapynutritional & medical therapy

• Medical support and/or clearance Medical support and/or clearance from your primary care physicianfrom your primary care physician

The Process for The Process for Weight Loss Surgery Weight Loss Surgery • Attend a new patient orientation Attend a new patient orientation • 11stst Consultation: Consultation: - evaluated by the surgeon - evaluated by the surgeon - bariatric workup: -Nutritional evaluation- bariatric workup: -Nutritional evaluation -Psychological evaluation-Psychological evaluation -Letter from your PCP: 6 months -Letter from your PCP: 6 months

Letter of supportLetter of support Medical Medical

clearanceclearance

-Blood work-Blood work -Abdominal Ultrasound-Abdominal Ultrasound -2 bariatric support groups-2 bariatric support groups

The Process for The Process for Weight Loss Surgery Weight Loss Surgery

• 2nd Consultation:2nd Consultation:

-Review bariatric work-up test results-Review bariatric work-up test results

-Decide on your bariatric procedure -Decide on your bariatric procedure

-Set a surgery date-Set a surgery date

-Begin the insurance approval -Begin the insurance approval processprocess

The Weight Loss Surgery The Weight Loss Surgery Options Options

• Laparoscopic Adjustable Gastric BandLaparoscopic Adjustable Gastric Band

• Laparoscopic Roux-en-Y Gastric BypassLaparoscopic Roux-en-Y Gastric Bypass

• Laparoscopic Biliopancreatic Diversion with Laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS)Duodenal Switch (BPD/DS)

• Laparoscopic Vertical Sleeve Gastrectomy Laparoscopic Vertical Sleeve Gastrectomy (VSG)(VSG)

Benefits of Doing Surgery Benefits of Doing Surgery Laparoscopically Laparoscopically• Less painLess pain

• Smaller incisionsSmaller incisions

• Shorter hospital stayShorter hospital stay

• Avoiding post operative Avoiding post operative complications such as: complications such as:

-wound infection-wound infection

-hernia-hernia

How does these operations How does these operations work?work?• RestrictionRestriction: restricts the volume of food : restricts the volume of food

consumed during each meal consumed during each meal

• MalabsorptionMalabsorption: decreases your ability to : decreases your ability to absorb ingested foodsabsorb ingested foods

• Lifestyle changesLifestyle changes: helps you develop new : helps you develop new eating habits and encourages lifestyle eating habits and encourages lifestyle changeschanges

The Surgical Options for The Surgical Options for Weight Loss Surgery Weight Loss Surgery

Adjustable Gastric Band Adjustable Gastric Band

Adjustable Gastric BandAdjustable Gastric Band

• Restrictive procedureRestrictive procedure

• Minimally invasiveMinimally invasive

• Good results in Good results in Europe and AustraliaEurope and Australia

• Bioenterics Lap Bioenterics Lap Band™ Band™

FDA approved 6/01FDA approved 6/01

• 50% EWL50% EWL

Facts on the Facts on the Adjustable Gastric Band Adjustable Gastric Band• Operation time: 30-45 minutesOperation time: 30-45 minutes• Hospital stay: overnightHospital stay: overnight• Return to normal activity: 5-7 daysReturn to normal activity: 5-7 days• Diet advancement: liquid-> puree->regular dietDiet advancement: liquid-> puree->regular diet• Post-op appointments: Post-op appointments: - 1, 2 weeks - 1, 2 weeks - 1, 2, 3, 4, 5, 6, 8, 10, 12 months- 1, 2, 3, 4, 5, 6, 8, 10, 12 months - then as instructed for rest of life- then as instructed for rest of life• Adjustments: office or radiologyAdjustments: office or radiology• ReversibleReversible• Not effective in pts: who have a BMI >50Not effective in pts: who have a BMI >50 sweet or binge eaterssweet or binge eaters

Risks and Complications Risks and Complications related to the Adjustable related to the Adjustable

Gastric Band Gastric Band

- Bleeding- Bleeding

- Pulmonary embolism- Pulmonary embolism

- Nausea/Vomiting- Nausea/Vomiting

- Intestinal Obstruction- Intestinal Obstruction

- Hernias- Hernias

- Kidney/Gallstones- Kidney/Gallstones

- Nutritional and/or - Nutritional and/or vitamin deficiencies vitamin deficiencies

- 10-15% re-10-15% re-operative rateoperative rate

- Mechanical FailureMechanical Failure- Slippage- Slippage- Migration- Migration- Erosion- Erosion- DeathDeath

Expected Weight loss with the Expected Weight loss with the Adjustable Gastric BandAdjustable Gastric Band

• 20-30 lbs in the 120-30 lbs in the 1stst month month

• 1-2 lbs per week1-2 lbs per week

• Average weight loss in 1 year = 60lbsAverage weight loss in 1 year = 60lbs

• 50% EWL in 3 years50% EWL in 3 years

Roux-en-Y Gastric BypassRoux-en-Y Gastric Bypass• Restrictive and mal-Restrictive and mal-

absorptive procedureabsorptive procedure• Most frequently Most frequently

performed bariatric performed bariatric procedure in the USprocedure in the US

• First done in 1967First done in 1967• Laparoscopic since Laparoscopic since

19931993• 75% EWL in 18-24 75% EWL in 18-24

monthsmonths• 50% EWL is still 50% EWL is still

maintained at a 14yr maintained at a 14yr follow-upfollow-up ASBS

Facts on Roux-en-Y Gastric Facts on Roux-en-Y Gastric BypassBypass

• Operation time: 1-3 hours Operation time: 1-3 hours

• Hospital stay: 2.5 daysHospital stay: 2.5 days

• Return to normal activity: 7-10 daysReturn to normal activity: 7-10 days

• Diet advancement: liquid-> puree-> regular diet Diet advancement: liquid-> puree-> regular diet

• Post-op appointments: Post-op appointments:

-1 wk, 1 month, 3 month, 6 months, 12 months-1 wk, 1 month, 3 month, 6 months, 12 months

-every 6 months for the next 2-3 years-every 6 months for the next 2-3 years

-than as instructed for the rest of your life-than as instructed for the rest of your life

• Not ReversibleNot Reversible

Expected weight loss with the Expected weight loss with the Roux-en-Y Gastric BypassRoux-en-Y Gastric Bypass

• 20-30 lbs in the first month20-30 lbs in the first month

• 75-100 lbs in the first 6 months75-100 lbs in the first 6 months

• 75% of EWL in 18-24 months75% of EWL in 18-24 months

Risks and Complications Risks and Complications related related to Roux-en-Y Gastric to Roux-en-Y Gastric BypassBypass - Pulmonary Embolism- Pulmonary Embolism

- Leaks 0.5-2%- Leaks 0.5-2%- Strictures 3%- Strictures 3%- Bleeding - Bleeding - Perforation/injury to - Perforation/injury to

surrounding organssurrounding organs- Intestinal - Intestinal

obstructions 2-3%obstructions 2-3%- Hernias- Hernias- Ulcers- Ulcers

- - Kidney/GallstonesKidney/Gallstones

- Nausea and - Nausea and vomitingvomiting

- Dumping Syndrome- Dumping Syndrome

- Malnutrition- Malnutrition

- Vitamin deficiencies- Vitamin deficiencies

- New addictions- New addictions

- Death- Death

Biliopancreatic Diversion with Biliopancreatic Diversion with Duodenal Switch (BPD/DS)Duodenal Switch (BPD/DS)

• Restrictive and Restrictive and mal-absorptive mal-absorptive procedureprocedure

• Lesser degree of Lesser degree of nutrient nutrient absorptionabsorption

• 75-80% EWL75-80% EWL

• 77% EWL at 5yr 77% EWL at 5yr follow-upfollow-up Scopinaro 1998

Facts on BPD/DSFacts on BPD/DS

• Operation time: 3-4 hoursOperation time: 3-4 hours• Hospital stay: 3 daysHospital stay: 3 days• Return to normal activity: 2 weeksReturn to normal activity: 2 weeks• Diet advancement: liquid-> puree-> regular dietDiet advancement: liquid-> puree-> regular diet• Post-op appointments: Post-op appointments: - 1 week, 1 month, 3 months, 6 months, 12 months - 1 week, 1 month, 3 months, 6 months, 12 months - every 6 months to a year for the rest of your life- every 6 months to a year for the rest of your life• Larger pouch allows for bigger mealLarger pouch allows for bigger meal• Complication rate: 15-20%Complication rate: 15-20%• Higher nutritional riskHigher nutritional risk• Excellent weight loss: 75-80% EWLExcellent weight loss: 75-80% EWL

Risks and Complications Risks and Complications related related to BPD/DS to BPD/DS

– Higher morbidity and mortality rateHigher morbidity and mortality rate– Pulmonary EmbolismPulmonary Embolism– CirrhosisCirrhosis– DiarrheaDiarrhea– LeaksLeaks– BleedingBleeding– UlcersUlcers– HerniasHernias– MalnutritionMalnutrition– Vitamin DeficienciesVitamin Deficiencies– DeathDeath

Vertical Sleeve Gastrectomy Vertical Sleeve Gastrectomy (VSG)(VSG)

• Restrictive Restrictive procedureprocedure

• First done in US in First done in US in 20012001

• Removing 60-85% Removing 60-85% stomachstomach

• 30-50% EWL30-50% EWL

Facts on Facts on Vertical Sleeve Gastrectomy Vertical Sleeve Gastrectomy• Operation time: 1-2 hoursOperation time: 1-2 hours• Hospital stay: 2.5 daysHospital stay: 2.5 days• Return to normal activities: 7 daysReturn to normal activities: 7 days• Diet advancement: liquid->puree->regular dietDiet advancement: liquid->puree->regular diet• Post-op appointments:Post-op appointments: -1 week, 1 month, 3 month, 6 moths, 12 months-1 week, 1 month, 3 month, 6 moths, 12 months - every 6 months for the next 2 years- every 6 months for the next 2 years - than as instructed for rest of life- than as instructed for rest of life• Not reversibleNot reversible• No intestinal bypass, only stomach reductionNo intestinal bypass, only stomach reduction

Risks and Complications Risks and Complications related to related to Vertical Sleeve Gastrectomy Vertical Sleeve Gastrectomy• Gastric leaks and fistulasGastric leaks and fistulas• Blood clotsBlood clots• Pulmonary embolismPulmonary embolism• BleedingBleeding• SplenectomySplenectomy• Acute respiratory distressAcute respiratory distress• PneumoniaPneumonia• Small bowel obstructionSmall bowel obstruction• DeathDeath

Mortality RatesMortality Rates

• Adjustable Gastric Band 0.1%Adjustable Gastric Band 0.1%

• Gastric BypassGastric Bypass 0.5% 0.5%

• BPD/DSBPD/DS 1.1% 1.1%

• Vertical Sleeve gastrectomy 0.25% Vertical Sleeve gastrectomy 0.25%

Post operative reasons that Post operative reasons that may cause death may cause death

• Pulmonary embolism (blood clots)Pulmonary embolism (blood clots)

• Myocardial infarction (heart attack) Myocardial infarction (heart attack)

• Sepsis (overwhelming infection)Sepsis (overwhelming infection)

Post Operative PhasesPost Operative Phases

•RecoveryRecovery

•ExhaustionExhaustion

•AdjustmentAdjustment

•MaintenanceMaintenance

Supplements after weight loss Supplements after weight loss surgerysurgery

• Gastric Band:Gastric Band:– MVIMVI– ProteinProtein

• Gastric Bypass: Gastric Bypass: – MVIMVI– Calcium Citrate + DCalcium Citrate + D– IronIron– ProteinProtein

• BPD/DS:BPD/DS: -MVI-MVI

-Calcium Citrate + D-Calcium Citrate + D

-Iron-Iron

-Protein-Protein

• VSG:VSG: -MVI-MVI

-Protein-Protein

Medical Co-Morbidities Medical Co-Morbidities ResolvedResolved

Type 2 Diabetes 95%

Hypertension 92%

Cardiac Function Improvement

95%

Osteoarthritis 82%

Sleep Apnea 75%

GERD 98%

Stress Incontinence 87%

Cholesterol 97%

Wittgrove AC,Clark GW. Laparoscopic Gastric bypass roux-n-y-500 patients. Obes Surg 2000. And others.

Outcomes after SurgeryOutcomes after Surgery

• New England Journal of MedicineNew England Journal of Medicine Study:Study:– 56% decrease in mortality from heart 56% decrease in mortality from heart

diseasedisease– 70% decrease in cancer related 70% decrease in cancer related

mortalitymortality– 90% decrease in diabetes related 90% decrease in diabetes related

mortalitymortality

Can you have children after Can you have children after weight weight

loss surgery?loss surgery?• YES!YES!

• Gastric Band and VSG:Gastric Band and VSG:

- Wait 1 year after surgery- Wait 1 year after surgery

- Will need to see a High Risk OBGYN- Will need to see a High Risk OBGYN

• Gastric Bypass and BPD/DS:Gastric Bypass and BPD/DS:

- Wait 2 years after surgery- Wait 2 years after surgery

- Will need to see a High Risk OBGYN- Will need to see a High Risk OBGYN

What to do with the excess What to do with the excess skin?skin?

• Plastic surgery consultation is Plastic surgery consultation is approximately at 18-24 monthsapproximately at 18-24 months

• Weight must be stable for at least 6 Weight must be stable for at least 6 months and there must be no months and there must be no evidence of malnutritionevidence of malnutrition

• It may not be necessary for all It may not be necessary for all patients, several facts impact on this patients, several facts impact on this needneed

• It may not be covered by insuranceIt may not be covered by insurance

Facts that play a role in the Facts that play a role in the decision-making processdecision-making process

• AgeAge

• Medical HistoryMedical History

• Surgical HistorySurgical History

• BMIBMI

• Psychological ProfilePsychological Profile

• Nutritional ProfileNutritional Profile

• LifestyleLifestyle

• Personal choicePersonal choice