Transcript Obesity and surgery - Iran Obesity Society

Davaei .M. MD. FACS
The Obesity Epidemic
 66% of Americans >20 yrs are either overweight or obese (BMI >
25, ~ 133 million people)
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Increased from 45% in 1960
 33% of Americans >20 yrs are obese (BMI > 30, ~ 66 million)
 5% of Americans are morbidly obese (BMI > 40, ~ 10 million)
 3.1% in men and 6.7% in women
 Increasing by 1% per year
 Obesity is increasing in children (doubled in past 20 years)
 15% between the age of 6 and 19
NHANES (2003-04) (n=4,431)
Body Mass Index (BMI)
BMI = weight (kg) / height (m)2
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)
Super Obese
(BMI > 50)
Why do we treat obesity??
• Co-morbidities
• Quality of life
• Survival – Life Expectancy
Rationale for Surgery
 Long Term Outcome Data
 Sustained Weight Loss
 Improvement or Resolution of Co-morbidities
 Improved long term survival
 Minimally Invasive Surgery
 Public Awareness
 Obesity as a disease
 Celebrities
Life Expectancy
 2nd only to smoking as the leading cause of preventable
death in the United States.†
 > 110,000 deaths/year in the US are associated with
obesity*
* Flegal KM et al. JAMA. 2005 Apr 20;293(15):1861-7.
† CDC
Life Expectancy
Potential Consequences of Obesity
 Obesity is associated with a rise in many comorbid
conditions, including:
Type 2 Diabetes
Hyperlipidemia
Hypertension
Obstructive Sleep Apnea
Heart Disease
Stroke
Asthma
Back and lower extremity weightbearing degenerative problems
 Cancer
 Depression
 AND MORE!
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Trends In Surgery 1992 - 2003
Who Is a Surgical Candidate?
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Meets NIH criteria
No endocrine cause of obesity
Acceptable operative risk
Understands surgery and risks
Absence of drug or alcohol problem
No uncontrolled psychological conditions
Consensus after bariatric team evaluation:
 Surgeon/Dietician/Psychologist/Consultant
 Dedicated to life-style change and follow-up
CONTRAINDICATIONS
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Untreated major depression or psychosis
Binge eating disorders
Current drug and alcohol abuse
Severe cardiac disease with prohibitive anesthetic risks
Severe coagulopathy
Inability to comply with nutritional requirements
including life-long vitamin replacement
Weight Loss Program Team
 Surgeon
 Nurse Practicioner
 Bariatric Coordinator
 Registered Dietician
 Clinical psychologist
 Exercise Specialist
 Office support staff
Preoperative Evaluation/Education
 Staff evaluation
 Internist
 Dietitian
 Psychologist
 Nurse
 Surgeon
 Support group
•Laboratory evaluation
– Blood
– ECG, CXR
– Stress Test
– Sleep study
– EGD
– PFTs
Consider an IVC filter for any patient with prior history of
DVT/PE.
Types of bariatric procedures
 Restrictive
 Vertical banded gastroplasty
 Laparoscopic adjustable gastric band
 Sleeve gastrectomy
 Malabsorptive
 Jejunoileal bypass
 Biliopancreatic diversion
 Biliopancreatic diversion with duodenal switch
 Combination of restrictive and malabsorptive
 Roux-en-Y gastric bypass
VERTICAL BANDING
from American Family Physician, 2006, 73(8): 1405.
LAP ADJUSTABLE BANDING
from American Family Physician, 2006, 73(8): 1405.
Sleeve gastrectomy
Jejunoileal Bypass
Payne and Dewind, Archives of Surgery, 1973
BPD & BPD w/ DUODENAL SWITCH
from www.utdol.com:Surgical Options for Obesity.
2006.
ROUX-EN-Y GASTRIC BYPASS
from American Family Physician, 2006, 73(8):
1404.
INTRAGASTRIC BALLOON
from www.obezitecerrahisi.com
POST-OP COMPLICATIONS
 Phase I: one to six weeks
 Phase II: seven to twelve weeks
 Phase III: thirteen wks to 12 months
Overall operative mortality = 1%
POST-OP COMPLICATIONS: PHASE I
Medical:
-pulmonary embolism
(1%)
-myocardial infarction
-respiratory failure
-pneumonia
-urinary tract infection
Surgical:
-anastomotic leak
(2-3%)
-postop bleeding
-bowel perforation
-bowel obstruction
-wound infections
POST-OP COMPLICATIONS PHASE II
RESTRICTIVE:
-staple line disruption or
band erosion
-stomal stenosis
-pouch/esophageal
dilatation
-port failure
-GERD/ulcers
-infection (foreign body)
ROUX-EN-Y:
-gastric remnant
distention  perf
-stomal stenosis
-wound infection
-cholelithiasis
-ventral hernia
-incisional hernia
POST-OP COMPLICATIONS PHASE III
-GERD/esophagitis/gastritis
-small bowel obstruction
-staple/band erosion
-dehydration due to severe constipation or freq
vomiting
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