SURGICAL TREATMENT OF

MORBID OBESITYScott D. Steinberg, M.D.

St. Vincents Hospital and Medical Center

Grand Rounds, May 30, 2001

OVERVIEW• The problem of obesity

• Indications for bariatric surgery

• Evolution of bariatric surgery

• Results of bariatric surgery

• Conclusions

HOW BIG IS THE PROBLEM?

INTRODUCTION• More than 50% of US adults are

overweight (BMI > 25 kg/m2)

• The percentage of obese Americans (BMI > 30 kg/ m2) has increased by more than 50% in the last 20 years

• The number of overweight children has doubled over the last 20 years

JAMA, 282(16), 1504-1506

PREVALENCE OF OBESITY IN THE UNITED STATES

• The estimated number of annual deaths attributable to obesity among US adults is approximately 325,000

• More than 80% of these deaths occurred among individuals with a BMI of > 30 kg/m2

MORBID OBESITY

JAMA, 282(16), 1530-1538

BODY-MASS INDEX

(Height in meters) 2

BMI =Weight in kg

DEFINITIONSOVERWEIGHT BMI 25-29.9 kg/m2

OBESITY BMI 30-39.9 kg/m2

MORBID OBESITYBMI 40-49.9 kg/m2

SUPER OBESITY BMI > 50 kg/m2

100 lbs above ideal body weight

OR

BMI >40kg/m2

CLINICALLY SEVERE OBESITY

THE FRAMINGHAM STUDY

The first cohort to terminate because of demise of all participants was the morbidly obese

• Results from a complex interaction of genetic, behavioral, and environmental factors

• Second leading cause of preventable death, exceeded only by cigarette smoking

OBESITY

MORBID OBESITY• HTN• Diabetes• CAD• CHF• Cirrhosis• Osteoarthritis• Vascular disease

• Gallbladder disease• Sleep apnea• Breast cancer • Uterine cancer • Prostate cancer• Colon cancer• Psychiatric disease

• First treatment is lifestyle and dietary changes

• Only 5-10% of patients maintain weight loss for more than a few years

• When conservative measures fail, patients may consider surgery

MORBID OBESITY

Blue Cross/Blue Shield Medical Policy Manual, 1996

WHICH PATIENTS ARE CANDIDATES FOR BARIATRIC

SURGERY?

• Risk for M&M is proportional to the degree of overweight

• Pts with BMI > 40 (*35) are at highest risk and should be considered for bariatric surgery

• Diet and Drug therapy has limited success in the morbidly obese

• Endorsed VBG and Roux-en-Y gastric bypass

Gastrointestinal Surgery for Severe Obesity. NIH Consens Statement 1991 Mar 25-27;9(1):1-20.

• BMI > 40 kg/m2

• BMI > 35 kg/m2 with serious co-morbid medical conditions

• Repeated failure at conservative treatments • No history of significant psychiatric disorders

INDICATIONS FOR SURGERY

VBG

GASTROPLASTY

ADJUSTABLE BAND

RESTRICTIVE MALABSORPTIVE

JIB

SMALL BOWEL BYPASS

BPD/DS, ROUX-en-Y GASTRIC BYPASS

Dr. John Linner

1954

Jejuno-ileal bypass

THE BEGINNING

COMPLICATIONS OF JEJUNOILEAL BYPASS

• Electrolyte disturbances• Osteoporosis/osteomalacia• Protein malnutrition• Cholelithiasis• Diarrhea• Hair loss

• Arthritis• Liver failure• Steatosis• Renal calculi• Neuropathy• Anemia

Dr. Edward Mason

University of Iowa

1967 Gastric Bypass with

loop gastroenterostomy

GASTRIC BYPASS SHORT TERM • Anastomotic leak• Acute gastric dilatation• Roux-Y obstruction• Atelectasis• Wound infection

LONG TERM• Stomal stenosis• Anemia• Vit B12 deficiency• Calcium deficiency

GASTRIC BYPASS WITHROUX-en-Y LIMB

SUBSEQUENTLY MODIFIED

50 mL POUCH WITH A ROUXLIMB TO MINIMIZE BILEREFLUX

ROUX LIMB WAS LENGTHENEDTO INCREASE MALABSORPTIONAND IMPROVE WEIGHT LOSS

COMBINED RESTRICTIVEAND MALABSORPTIVE

Nicola Scopinaro

Biliopancreatic Diversion (BPD)

Any procedure that diverts bile and pancreatic secretions

Combined Restrictive and Malabsorptive surgery

1976“BPD”

COMPLICATIONS OF BPD

• Protein Malnutrition 15%

• Incisional Hernia 10%

• Intestinal obstruction 1%

• Acute biliopancreatic limb obstruction

• Stomal ulcer

1982VBG

Vertical-Banded

Gastroplasty

•Dr. Edward Mason

•Stapled opening in stomach

•Staple line along angle of His

•Polypropylene mesh around lesser curvature

1988BPD/DS

Dr. Doug Hess

•MODIFIED BPD

•Duodenal switch w/ sleeve gastric reduction

•Intact pylorus

•Eliminates dumping and ulcers

1994

AUGUST 1999 300 lbs DECEMBER 2000 143 lbs

CARNIE WILSON

MAY 2000: SAGES GUIDELINES FOR LAPAROSCOPIC

AND CONVENTIONAL SURGICAL TREATMENT OF MORBID OBESITY

ROUX-en-Y GASTRIC BYPASS

GOAL: To restrict the

gastric reservoir

ADVANTAGES

• Controls food intake

• Dumping reduces intake of sweets

• Reversible if indicatedRoux-en-Y Gastric

Bypass

ROUX-en-Y GASTRIC BYPASS

DISADVANTAGES

• Staple line failure

• Ulcers

• Blockage of stoma

• Vomiting if food eaten quickly Roux-en-Y Gastric

Bypass

LAPAROSCOPIC ROUX-en-Y

GASTRIC BYPASS

LAPAROSCOPIC ADJUSTABLE

GASTRIC BAND(LAP-BANDTM)

THE DATA…

• N=500• Excess weight loss of 80% in first year• 95% of significant pre-operative comorbidities well controlled

2000

Obesity Surgery, 2000 18:233-239

• N=1040

• Mean LOS 1.9 days

• Mean OR time 60 min

• No leaks

• 5 perioperative deaths

–3 PE, 1 asthma, 1 suicide

• Mean EWL 70% @ 1 yr

• N=275 (1997-2000)

• 1-31 month f/u

• One conversion

• One death (PE)

• 11 Wound infections

• Median LOS 2 days

• EWL

–83% @ 24 months

–77% @ 30 months

CONCLUSIONS• OBESITY IS A MAJOR PROBLEM IN

THE UNITED STATES

• CURRENT DIET AND DRUG THERAPY OFFERS LIMITED SUCCESS FOR THE MORBIDLY OBESE PATIENT

• BARIATRIC SURGERY OFFERS THE MORBIDLY OBESE LONG-TERM WEIGHT LOSS WITH IMPROVEMENT IN MORBIDITY AND MORTALITY

• LAPAROSCOPIC BARIATRIC SURGERY CAN BE PERFORMED SAFELY WITH EXCELLENT RESULTS

CONCLUSIONS

THANK YOU