Surgical options for morbid obesity

Frank R. Ebert, MDFrank R. Ebert, MDUnion Memorial HospitalUnion Memorial Hospital

Baltimore, MarylandBaltimore, Maryland

TOTAL KNEE TOTAL KNEE

ARTHROPLASTYARTHROPLASTY

SURGICAL OPTIONS FOR MORBID SURGICAL OPTIONS FOR MORBID OBESITYOBESITY

DR ATUL N.C.PETERS Director - Institute Of Bariatric, Metabolic &

Minimal Access Surgery Fortis Hospital, Shalimar Bagh

New Delhi, India+91 - 9810048755

www.atulpeters.com

Why Say NO to Morbid ObesityMorbid Obesity and its

Treatment Options

What is Morbid Obesity

• Multi-factorial Disease of Excess Fat Storage with a Genetic Basis

• Associated with Several Serious Medical Problems

• Influenced by the Environment• Lifelong and Progressive

We are growing …We are growing …

Ours is the ‘heaviest’ generation and

we will most definitely be beaten by our children

Who can we blame for this?

We are made like that only

‘Thrifty genes’(Store fat for ‘need’)

Humans are genetically designed to ‘gain / maintain’ weight

Survival Advantage Thrifty

genes

Kaplan L. Body Weight Regulation and Obesity. Journal of Gastrointestinal Surgery 2003; 7(4): 443-451

Physical exercise guaranteed,

Food scarce

NOW =

Food Guaranteed

Exercise / Physical movement ‘Sometimes’

OBESITY

Even when food is in plenty, we are genetically designed to

store for ‘future’

Thrifty Genes Contribute to Morbid Thrifty Genes Contribute to Morbid ObesityObesity

• Humans are designed to maintain weight• Genetic factors account for 80% of a

person’s tendency to develop Obesity• Age old advantage of thrifty genes in our

unique environment is causing the disease

Kaplan L. Body Weight Regulation and Obesity. Journal of Gastrointestinal Surgery 2003; 7(4): 443-451

Ghrelin - Produced by the Stomach and Ghrelin - Produced by the Stomach and Controls Appetite Appetite

• Hormone secreted predominantly by gastric cells; recognized in 1999 as a mediator of growth hormone release

• Increases an hour or two before a meal and goes into a trough-like level after eating

• Weight loss of 17 percent of body weight from dieting is associated with a 24 percent increase in the 24-hour Ghrelin profile

• Weight loss of 36 percent of body weight following gastric bypass surgery resulted in a 77 percent decrease in Ghrelin levels from normal-weight controls and a 72 percent decrease in matched obese controls

Cummings, et al. NEJM 2002 May 23: 346(21); 623-30

“It is not the will power that fails the Obese to lose weight. Just that the hormonal drive to eat is very strong. And the hormones

determine their behavior ”

BMI – A measure of degree of ObesityBMI – A measure of degree of Obesity

• Best measure of Obesity• Will be able to tell the risk of developing Obesity-

related diseases

BMI =Weight (in kg)

Height (in mt) X Height (in mt)

Western Asian

Normal 21-25 18-22.5

Over-weight 25-30 22.5 – 27.5

Obese 30-40 27.5 – 37.5

Morbidly Obese >40 >37.5

BMI – A measure of degree of ObesityBMI – A measure of degree of Obesity

Asian

Normal 18-22.5

Over-weight 22.5 – 27.5

Obese 27.5 – 37.5

Morbidly Obese >37.5

Height (Ft & Inch)

WEIGHT (KGs)

Ideal BMI32.5

BMI37.5

4’11’’ 45 73 84

5’ 47 75 87

5’1’’ 49 78 90

5’2’’ 50 81 93

5’3’’ 52 83 96

5’4’’ 54 86 99

5’5’’ 55 89 102

5’6’’ 57 91 105

5’7’’ 59 94 109

5’8’’ 60 97 112 Ideal at BMI 20.25

Cleveland Clinic Journal of Medicine, Dec 2006

It’s a BIG Medical Problem

• 80% Diabetes is related to Obesity

• Obesity is the second biggest cause of Cancer after Smoking

Diabetes – A surgical perspective

Prevalence of Significant Morbidities per weight

Mokdad AH, et al. JAMA 2002:289:76.Centres for Disease Control, National Centre for Health and Nutrition Examination Survey*Increase in mortality rate from Cancers of all kinds compared to lowest risk group (BMI 25 – 30). From call EE, et al..Overweight, obesity and mortality from Cancer in a prospectively studies cohort of US adults. New Engl J Med 2003;348:1625

BMI

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

Obesity and Mortality Risk

2.5

2.0

1.5

1.0

020 25 30 35 40

MortalityRatio

ModerateVery

LowLow Moderate High

VeryHigh

The Mortality risk increases substantially with increase in the BMI

Impact of BMI on Longevity

HighVeryHigh

Example: Life expectancy of a 20 year old morbidly obese male is 13 years shorter than a normal – weight male of the same age.

Years of life lost due to Obesity: JAMA 2003;289:187

Weight Management Tools

• Diet• Exercise• Behavior Therapy• Medications• SURGERY

Being Overweight / Obese can be treated by Medical Intervention. Whereas Morbid Obesity requires Surgical Intervention

The weight loss curves for patients treated conservatively and surgically ( Adapted from Martin FL et al. Comparison of the costs associated with medical and surgical treatment of Obesity. Surgery 1995;118:599-607. used with permission)

National Institutes of Health 1991 Consensus Statement

Surgery is the only way to obtain consistent, permanent weight loss for morbidly obese patients.

Success Rate of Weight Loss Treatments for Morbid Obesity

Eliosoff 1997; Sjostrom NEJM 2004,Obrien J Laparoendose Adv Surg Tech A 2003 Aug; 13 (4): 265-70

Indications for Surgery• BMI greater than 32.5 with one or more significant obesity related

conditions including high blood pressure, diabetes, arthritis, sleep apnea, high cholesterol, and a family history of early coronary heart disease.

• BMI greater than 37.5, without any co – morbidities.

• Failure to loose weight through physical training / diet modifications / lifestyle changes or early regain / failure to sustain weight loss.

• Commitment to lifelong follow-up care and lifestyle changes

Institute of Minimal Access & Bariatric Surgery Chrysalis Healthcare

_____________________________________________________________________________BMI Range Eligible for Surgery Prioritised for Surgery_____________________________________________________________________________ <30 No No 30 – 35 YES-Conditional*** No 35 - 40 YES YES Conditional*** >40 YES YES_____________________________________________________________________________

* In all cases patients should have failed to lose weight and sustain significant weight loss through non surgical weight management programmes, and have type – II diabetes that has not responded adequately to lifestyle measures (+/-metformin) with a HbA1c <7%** Action points should be lowered by 2.5 BMI point levels for Asians.***HbA1c > 7.5 despite fully optimised conventional therapy, especially if weight is increasing, or other weight responsive co-morbidities not achieving targets on conventional therapies. For example blood pressure, dyslipidaemia and obstructive sleep apnea.

Eligibility and prioritisation for Bariatric Surgery on failed non – surgical weight loss therapy*, BMI, ethnicity** and disease control

Surgical Options• Restrictive Restrictive

LSG – Lap Sleeve GastrectomyLSG – Lap Sleeve GastrectomyLAGB - Lap Adjustable Gastric BandingLAGB - Lap Adjustable Gastric Banding


Combined Restrictive and Malabsorptive:

– RY-GB – Gastric Bypass– BPD_DS –Bilio Pancreatic diversion with Duodenal Switch – LMGB – Lap Mini-Gastric Bypass


Resolution of Co-morbidities following Surgery

Pories, et al. Ann Surg 1995, Sugerman, et al. Ann Surg 2003, Schauer, et al. Ann Surg 2003, Rasheid, et al. Obes Surg Pories, et al. Ann Surg 1995, Sugerman, et al. Ann Surg 2003, Schauer, et al. Ann Surg 2003, Rasheid, et al. Obes Surg 2003, George SM, et al. World J Surg 1998, Buchwald, et al JAMA Oct 2004 2003, George SM, et al. World J Surg 1998, Buchwald, et al JAMA Oct 2004

SCIENTIFIC VALIDATIONS

Miles to go before we stop…Miles to go before we stop…Institute of Minimal Access & Bariatric Surgery Chrysalis Healthcare


Thank you.