Transcript Slide 1

Weight loss Surgery at St. Agnes
Hospital
Andrew M. Averbach, M.D., FACS
Director of Bariatric and Minimally Invasive
Surgery
Spectrum of the obesity
Terms Used to Describe Various Levels of Body
Fat
Normal Weight
(BMI 18.5 to 24.9)
Overweight
(BMI 25 to 29.9)
Obese
(BMI 30 to 34.9)
Severely Obese
(BMI 35 to 39.9 )
Morbidly Obese
(BMI 40 or more)
Obesity Classification
Disease Stage by BMI
BMI
Class/Stage
Definition
Risk of DM II,
HTN, CAD,
Sleep apnea,
premature death
30-34.9
I
Obese
Increased
35-39.9
II
Severely obese
High
40—49.9
III
Morbidly
obese
Extremely high
50-59.9
IV
Mega obese
Extremely high
>60
IV
Mega-mega
obese
Extremely high
Health Risks
Related Diseases (Co-morbid conditions):
• Obese people have higher risk for:
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•
•
•
•
•
•
Diabetes Type II (adult onset)
Severe arthritis
High blood pressure (not controlled with medications)
Sleep apnea (disordered breathing during sleep)
Obesity related heart muscle weakness
High cholesterol (not controlled with diet and medications)
Fatty liver that can lead to cirrhosis
Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity.
Health Risks (cont.)
Related Diseases and Health Problems
• Obese people are at higher risk for:
• Certain types of cancer (breast, uterine, colon)
• Digestive disorders (e.g. gastro-esophageal reflux
disease, or GERD, gall bladder problems)
• Breathing difficulties (e.g. shortness of breath,
asthma).
• Psychological problems such as depression.
• Problems with fertility and pregnancy.
• Stress Incontinence.
Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity.
Types of Surgery to Treat
Obesity
• Types of weight-loss surgeries
• Malabsorptive procedures
shorten the digestive tract (Duodenal switch,
Biliopancreatic diversion)
• Restrictive procedures
reduce how much the stomach can hold
(Lap Band, Laparoscopic Sleeve Gastectomy)
• Combined procedures
shorten the digestive tract and reduce how much the
stomach can hold (Laparoscopic Gastric bypass)
Surgical procedures to Treat
Morbid Obesity
Gastric Bypass
(GBP)
LAP-BAND
System
Sleeve
Gastrectomy
Expected Outcomes from the
Surgery
• Improvement or resolution of:
• Diabetes (type 2): 80%
• High blood pressure: 80%
• Asthma: marked improvement
• GERD (gastro-esophageal reflux disease): 95%
• Sleep apnea: close to 100%
• High cholesterol: 80% improvement/resolution
• Infertility
• Depression.
Bariatric Surgery
Long-term outcomes
Bariatric Volumes in Maryland
DRG 288 & ICD-9 Procedure code
definition
FY02
HOSPITAL
Svc
Area
FY03
Total
Svc
Area
FY04
Total
Svc
Area
FY05
Total
Svc
Area
FY06
Total
Svc
Area
Total Cases Market Share
Total
FY02
FY03
FY04
FY05
FY06
13
24
75
135
153
311
174
368
229
469
6%
13%
20%
20%
26%
BAYVIEW
6
53
22
148
40
281
36
306
39
304
15%
14%
18%
17%
14%
GBMC
0
0
0
0
0
31
18
158
33
188
0.0%
0.0%
2.0%
8.9%
13%
SINAI
12
83
14
76
21
60
56
188
51
184
23.9%
7.6%
3.9%
10.6%
12%
HOLY CROSS
0
33
8
160
0
62
2
102
3
149
9.5%
16.0%
4.0%
5.7%
7.8%
UMMS
4
14
7
27
9
22
4
22
28
130
4.0%
2.7%
1.4%
1.2%
6.8%
SHADY GROVE
0
0
0
6
2
107
2
145
1
105
0.0%
0.6%
7.0%
8.2%
5.5%
PENINSULA REGIONAL
0
0
2
54
0
98
1
96
0
102
0.0%
5.4%
6.4%
5.4%
5.3%
WASHINGTON
ADVENTIST
0.0%
1.0%
8.3%
6.6%
0
0
0
10
4
127
2
117
0
91
HARFORD MEMORIAL
0
0
0
0
0
0
3
60
1
58
0.0%
0.0%
0.0%
3.4%
3.0%
SAINT JOSEPH
1
3
10
45
22
110
18
99
14
57
0.9%
4.5%
7.2%
5.6%
3.0%
13
69
35
146
12
72
11
60
8
47
19.8%
14.6%
4.7%
3.4%
2.4%
UNION MEMORIAL
3
13
16
51
9
18
5
28
6
37
3.7%
5.1%
1.2%
1.6%
1.9%
SUBURBAN
0
0
0
0
7
89
0
22
0
0
0.0%
0.0%
5.8%
1.2%
0.0%
14
50
24
115
30
140
0
0
0
0
14.4%
11.5%
9.1%
0.0%
0.0%
1
6
2
28
0
4
0
3
0
0
1.7%
2.8%
0.3%
0.2%
0.0%
67
348
215
1,001
309
1,532
332
1,774
413
1,921
100.0
%
100.0
%
100.0
%
100.0
%
100.0
%
ST. AGNES
FRANKLIN SQUARE
GOOD SAMARITAN
All Other
Grand Total
4.7%
ASBS/SRC COE requirements
• Surgeons: ABS certified, bariatric training, >50 cases/year,
>125 cases in the past, postop.management
• Hospital with >125 cases/year; bariatric surgery
credentialing and in-service education program
• Hospital with integrated multidisciplinary program (OR,
specialized nurses, dietician, psychologist, consultants,
critical care, radiology and etc.)
• Patients education and informed consent (indications,
surgery, alternative Tx, outcomes, risks, follow-up and etc)
• Bariatric team: Med.Director, coordinator,specialists, nurses
• Bariatric on call coverage
• Clinical pathways, standardized orders, procedures
• Support groups, outcome/long-term follow-up and database
Gastric bypass results
Variable
Average for
Centers of
Excellence
(US average)
Number of
patients
55 000 (140 000) 1500
750
Mortality
0.3% (2%)
0.25%
0%
Morbidity
10%
8.5%
8%
Re-operations
2.5% (5%)
2%
1.3%
Re-admission
4.5% (10%)
4.5%
4.4%
Bowel
obstruction
2.5% (4%)
0.95%
0.85%
Marginal ulcer
5%
(5-7%)
0.99%
0.73%
(NA)
67.6%
70%
EBWL % 1 year 65%
(30%)
St. Agnes
Program
Personal
results
Laparoscopic vs. Open Gastric Bypass
2004-2006
Outcomes
Lap.Gastric bypass
N= 16,357
Open Gastric Bypass
N=6,055
Odds ratio (95%CI)
Mean LOS (d) +SD
2.7+2.0
4.0+4.7
P<0.05
MORBIDITY
7.4%
13.0%
2.1
Pulmonary
0.7%
2.2%
3.05
Pneumonia
0.6%
1.2%
2.27
DVT/PE
0.3%
0.7%
3.06
Leak
1.4%
3.1%
2.24
Hemorrhage
1.7%
1.9%
1.33
Wound infection
0.5%
2.3%
5.07
30-day readmission
2.6%
4.7%
2.03
MORTALITY
0.1%
0.3%
3.44
Mean cost+SD
$13,743+6,873
$14,585+15,813
P<0.05
Nguyen et al., J Am Coll Surg.2007; 205:248-255
Laparoscopic Gastric Bypass
Advantages
• Rapid initial weight
loss
• Higher total average
weight loss .
• Higher rate of comorbidity
resolution
• Over 40 years of
surgical experience
in USA
Disadvantages
• Bigger operation and
somewhat slower recovery.
• Major surgery to reverse
• Possibility of nutritional
problems such as Iron
deficiency anemia and
vitamin B 12 deficiency
• 2-5% chances of ulcers at the
junction of the stomach and
the small bowel
The LAP-BAND System
Advantages
• Lowest mortality rate
• No stomach stapling or
cutting, or intestinal rerouting
• Adjustable
• Smaller operation , easily
reversible
• Lowest operative
complication rate
• Low malnutrition risk
Disadvantages
• Slower weight loss.
• Regular follow-up critical for
optimal results
• Requires more commitment from
the patient.
• Slippage or erosion and injury to
the esophagus or stomach as
possible complications.
• Possibility of mechanical
problems with device, infection
Band intolerance, poor weight
loss may result in Band removal
in about 5% of patients
Laparoscopic Sleeve Gastrectomy is an
alternative to:
• Roux-en-Y gastric bypass
Because:
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•
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•
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Lower risk of deficiencies
No risk of marginal ulcer
No or minimal “dumping”
No risk of intestinal obstruction
Easily converted to bypass for inadequate
weight loss
• Contraindications to bypass (chr.anemia,
Crohn’s disease etc.)
• Comparable long-term weight loss to
Gastric bypass
• Very effective as 1-st stage prior to Gastric
bypass in BMI>60
• Lap Band
Because:
• No risk of system
malfunctioning (slippage,
erosion, infection and etc.)
• No need for adjustment
• No foreign body/plastic
• Contraindications to Lap Band
(connective tissue disorders,
allergy)
• Need to take NSAIDs for
arthritis or heart disease
• Sleeve gastrectomy showed
superior weight loss at 3 years
Laparoscopic Sleeve Gastrectomy
Disadvantages:
• Potential for inadequate weight loss/ weight regain due to
sleeve dilatation
• People with BMI>60 may need 2-nd stage surgery (Gastric
Bypass) to achieve normal weight
• Sweet eaters, grazers, binge eaters have suboptimal results
• Potential complications with long staple line
• Not reversible
• May worsen reflux disease (heartburn)
• Not covered by any insurance
• Will have to take vitamins, B12, calcium, possibly antacids
• Mortality 0-0.5%, complications 2.5%, leaks 1%
Gastric Band Adjustment and
Follow-up
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Follow-up for life with bariatric surgeon
Follow-up at 2 and 6 weeks after surgery
First adjustment after 6 weeks
First adjustment in the office if possible or using X-ray
Subsequent adjustments done as needed
Patient-driven adjustment policy:
Despite your best effort (healthy eating and regular exercise) no weight loss for 2-3 weeks in a row
• Follow-up visit every 3 months during 1-2 year
• Annual Band adjustment under X-ray to look for optimal
restriction and to detect early potential problems with the band
St.Agnes Hospital outcomes
with Lap Band
Total for our program
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550 cases
Mortality 0%
Morbidity 3.2%
Re-operations 1.2% (stomach
laceration - 3; acute band
obstruction,port infection; band
intolerance)
Re-admission within 1 month 2%
(dehydration; atelectases; wound
infection).
Average LOS – 1 day (range 0-5)
Band slippage – 0.57%, no band
erosions
Band removal/gastric bypass – 1.2%
My personal results
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•
•
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275 cases
Mortality 0%
Morbidity 2.3%
Re-operations 1% (stomach
laceration)
• Re-admission 1.5%
• Average LOS 1 day
• No slips, erosions, infection or
band removal to date
Weight loss after gastric bypass
vs. Lap band
Jan et al., J.GI Surgery, 2007
% Excess Body Weight Loss by Procedure
St. Agnes Hospital
100
% Excess Body Weight Lost by Procedure
4/2005 - 12/2007
80
67.6
60
68.99
52.89
40
35.88
33.36
35.94
26.35
20
0
18.46
12.76
1 mon
20.33
3 mon
Bypass
6 mon
1 year
Lapband
2 year
% Weight Excess Body Loss by initial BMI
St.Agnes Hospital
Initial BMI Below 40, % EBWL 4/05 - 12/07
100
Initial BMI 40 - 49.9, % EBWL 4/05 - 12/07
100
86.01
80
60
80
78
73.83
72.27
60
50.97
71.65
57.03
44.8
40
38
23.97
20
0
20
3 mon
6 mon
Bypass
1 year
2 year
0
19.69
12.79
1 mon
Lapband
35.07
20.05
3 mon
6 mon
Bypass
Initial BMI 50 - 59.9, % EBWL 4/05 - 12/07
1 year
100
80
80
66.1
64.1
61.5
2 year
Lapband
Initial BMI Above 60, % EBWL 4/05 - 12/07
100
60
34.11
26.87
24.31
14.51
1 mon
39.21
40
30.56
60
53.2
46.8
40
20
0
31.7
29.1
17.7
16.9
32.8
26.6
21.2
20
11.1
1 mon
3 mon
Bypass
6 mon
1 year
Lapband
40.9
40
2 year
0
14.1
21.6
22.9
25.4
14.8
9.1
1 mon
3 mon
Bypass
6 mon
1 year
Lapband
2 year
Weight Loss Results by Surgeon
% Excess Body Weight Lost by
% Excess Body Weight Lost by Procedure,
Procedure, Singh - 4/2005 - 12/2007
Averbach - 4/2005 - 12/2007
100
100
80
68.6
60
72.8
66.9
60
53.5
40
80
40.6
36.1
52.3
40
35.6
30.4
20
0
19.3
18.7
3 mon
24
20
Bypass
6 mon
1 year
Lapband
35
33.8
27.8
12.4
1 mon
66.1
2 year
0
18.3
20.9
13
1 mon
3 mon
Bypass
6 mon
1 year
Lapband
2 year
Lap Band: Best results seen
• BMI 35-49
• No serious co-morbidities
• Good exercise tolerance; no disabling
arthritis
• Have a greater commitment to exercise
and good dietary choices then with
other procedures
Lap Band vs. Diet in BMI 30-35%
Laparoscopic Sleeve Gastrectomy
BMI decrease at 2 years
50
40
30
0 mo
12 m o
20
24 mo
10
0
Band
Bypass
Sleeve
Band or Bypass?
How patients choose?
• Lap Band (%)
• Lap Gastric Bypass
•
•
•
•
•
•
•
•
Low risk of surgery (85)
Quicker recovery (80)
“I felt it was better for me.”
6% less patients decide to
have Lap Band after seminar
and surgeons consult
• 50% choose Lap Band
More overall weight loss (92)
Quicker weight loss (79)
“I felt it was better for me.”
6% more switch to bypass
after seminar and surgeon
consult
• 50% choose Gastric bypass
What procedure to choose?
We will decide together.
Laparoscopic Gastric Bypass
•
•
•
•
Your choice
Procedure of choice for any BMI
Multiple co-morbidities requiring quick resolution
BMI >50
Laparoscopic Gastric Banding (Lap Band)
• Your choice.
• BMI 35-49
• No/few co-morbidities, no disabling arthritis, women who plan to have
children within a year
Laparoscopic Sleeve Gastrectomy
• Procedure of choice for any BMI
• BMI>50 and you do not want gastric bypass
• Your choice
Who qualifies for the
Bariatric Surgery?
•
NIH criteria
1.
2.
3.
4.
5.
•
Weight: BMI more than 40 or 35 with two serious illnesses.
Free from untreated mental illnesses such as Bulimia and
Schizophrenia, Bipolar disorder or Severe depression, Mental
retardation, Anorexia.
Documented evidence of weight loss attempts.
In Maryland 6 months over the past two years (varies by
insurance company).
Understanding by the patient that the surgery is only a tool
to lose weight.
Life style changes, exercise and eating habits are of
absolute importance.
Age: 18-60 years of age
Who does not qualifies for
the Bariatric Surgery?
• Those who have severe uncorrectable heart disease.
• Heart failure.
• Angina and coronary artery disease.
• Severe lung disease (home oxygen).
• Psychiatric illnesses
• In whom surgery is not feasible: UNWILLING & UNABLE
• Lack of understanding and willingness to learn how bariatric
surgery works for you.
• Unable or unwilling to make necessary life-style, eating habits
changes
• Limited exercise tolerance.
• Non-compliant with work-up, follow-up and recommendations
With ANY Bariatric Procedure
Best Outcomes are seen when:
•
HISTORY: You seriously tried to loose weight in the past; Surgery is not the
starting point
•
MOTIVATION: You leave all the excuses and get the job done.
•
INVOLVMENT: You are proactively participate in your care; Never say
“nobody told me that!” .
•
COMPLIANCE: You follow all recommendations, come for regular follow-up.
•
COMMITMENT: You exercise regularly and assume good eating habits.
•
SUPPORT: You have good social/family support or actively seek help when
needed, attend group support meetings.
When surgery might not work:
• You are waiting for weight loss - without exercising and changing
eating habits.
• You have an excuse why you are not exercising or eating right.
• “Cheating” with high calorie foods or drinks
• “Grazing” – continuous eating throughout the day
• You rely only on surgery for weight loss.
• You think that this is not a LIFELONG effort.
• You show up late or miss your appointment in doctor’s office!
• You are not coming for regular scheduled follow-up appointments
Your initial steps:
1. Make sure you meet the NIH criteria.
2. Check with insurance for coverage.
3. Make sure that we participate with your insurance
or be willing to cover the expense.
4. See the dietician and psychologist.
5. Fill all the forms and obtain copy of recent Physical,
consults, studies.
6. Make appointment to see Dr.Averbach.
7. If you have questions - Call the office.
If You are considering bariatric
surgery and think that:
• Safety
• Results
• Compassion
• Availability 24/7
• Professionalism
• Dedication
Are important you can call my office tomorrow
Thank you!
Questions?
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