MORBID OBESITY AMHE 2010 Convention Chateau Montebello Yvan

MORBID OBESITY AMHE 2010 Convention Chateau Montebello Yvan Ducheine MD 310 Central Avenue East Orange NJ 07018

Obesity & Surgery GOALS & OBJECTIVES: l Definition l Prevalence l Impact l Associated Illnesses l Treatments (Surgical & Non-Surgical) l Eligible Candidates l Results of Surgery

Obesity & Surgery l l DEFINITION: National Institutes of Health Anyone with a body mass index of 30 or above is considered obese. A body mass index above 40 is considered morbidly obese.

Obesity & Surgery PREVALENCE: l Worldwide: 1. 7 Billion l 1. 5 to 2 times higher in women l USA 34% of Americans l 6% Morbidly Obese l 60% to 80% of African Americans (BET) l Children 17%-33% l

Obesity & Surgery It is the 2 nd most preventable cause of death after smoking l Decrease life expectancy (2. 4 years) l Increased in co-morbid illnesses l

Obesity & Surgery l l l l l Hypertension Diabetes Asthma Sleep Apnea Hyperlipidemia Arthritis Infertility Venous Stasis Depression l l l Greater Cancer Risk Breast Cancer Colon Cancer Endometrial Cancer *All cancers except pancreatic cancer & prostate cancer

Obesity & Surgery l l l TREATMENT OPTIONS Medicine 18% vs Surgery 30% to 80% J Am Coll Surg. 2003 Mar; 196(3): 379 -84. l A comparison of diet and exercise therapy versus laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity: a decision analysis model. Patterson EJ, Urbach DR, Swanstrom LL. Department of Minimally Invasive Surgery, Legacy Health System, Portland, OR, USA. CONCLUSIONS: In a decision analysis model, laparoscopic gastric bypass surgery for morbid obesity was associated with a substantially longer survival than diet and exercise therapy. Copyright 2003 by the American College of Surgeons

Obesity & Surgery BARIATRIC SURGERY WORLDWIDE l Only effective therapy for morbid obesity l 2002 -2003 146, 301 Bariatric surgeries l 2839 Bariatric Surgeons l 103, 000 operations done in USA/Canada, increased to 112 K (2007 -08). l 37. 15% open, 65. 85% laparoscopic l

Obesity & Surgery ELIGIBILITY CRITERIA FOR SURGERY l Acceptable Medical Risk for Surgery l Failed attempts @ non-surgical weight reductions (Diet & Exercise) l BMI>40; l BMI> 35 with obesity related comorbidities l No Psychiatric Contraindications l Realistic Commitment and Expectations l

Obesity & Surgery FOOD ADDICTION l Psychological Component l Physical Component l Group Therapy & Support BEHAVIOR MODIFICATION l Eat 3 times per day l No Snacking Between Meals (Water Only) l No Eating after 7: 00 pm LIFESTYLE CHANGES l Walk one half hour per day (Continuous)

Obesity & Surgery l l l GASTRIC BANDING Restrictive 30% to 40% Avoidance of gastrointestinal anastomosis Less Invasive Less Nutritional Px. l l l GASTRIC BYPASS Malabsorptive 70%-80% Greater Weight Loss More Invasive Increased risk of nutritional deficiencies

Obesity & Surgery LAP-BAND System

Obesity & Surgery l GASTRIC BYPASS Roux-en-Y Gastric Bypass

Obesity & Surgery l l l l SURGICAL COMPLICATIONS Infections Strictures Intestinal Leaks Nausea & Vomiting Hernia Obstruction Death <1% l l l l METABOLIC COMPLICATIONS Nutritional Deficiencies Anemia Bone Disease Neuropathy Vit. A Deficiency Vit. D Deficiency

Obesity & Surgery RESULTS: l Hypertension 62 -73% Cured l Diabetes Mellitus 75 -85% Cured l Sleep Apnea 90% Cured l GERD 90% Cured l Dyslipidemia 34% Cured (38% improved) l Hypertension & Dyslipidemia = @ 10 yrs. l

Obesity & Surgery RESULTS: l Dramatic Reduction in Weight l Marked Quality of Life Improvement Depression, Self-esteem, eating pathology,

Obesity & Surgery RESULTS: (Non-Compliance with Behavior & Exercise) l Depression 12% l Sexual Concerns 4% l Relationship Problems 2% (>90%) l Medical Complications due to Surgery 9% l Lack of Exercise Being the Most Likely Area of Non-Compliance

Obesity & Surgery l l l l l Obesity Prevalence (34% to 50%) Co-morbidities Eligible Candidates (BMI 35+ or BMI >40) Types of Bariatric Surgeries Success Rate in Weight Loss Success in Curing Diabetes, Hypertension Complications Change in Quality of Life and Life Expectancy

Obesity & Surgery l l l Cameron, JL: Current Therapy in Surgery 8 th Edition Seidell JC. Epidemiology of obesity. Mason ME, Jalagani H, Vinik AI Metabolic complications of bariatric surgery: diagnosis and management ME, Jalagani H, Vinik issues. Gastroenterol Clin North Am. 2005 Mar; 34(1): 25 -33. Buchwald H, Williams SE Bariatric surgery worldwide 2003. Obes Surg. 2004 Oct; 14(9): 1157 -64. H, Williams Elkins G, Whitfield P, Marcus J, Symmonds R, Rodriguez J, Cook T. Noncompliance with behavioral G, Whitfield P, Marcus J, Symmonds R, Rodriguez J, Cook T. Noncompliance recommendations following bariatric surgery. Dymek MP, le Grange D, Neven K, Alverdy J MP, le D, Neven K, Alverdy J Quality of life and psychosocial adjustment in patients after Roux-en-Y gastric bypass: a brief report. Obes Surg. 2001 Feb; 11(1): 32 -9. White S, Brooks E, Jurikova L, Stubbs RS S, Brooks E, Jurikova L, Stubbs RS Long-term outcomes after gastric bypass. Obes Surg. 2005 Feb; 15(2): 155 -63. Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, Dahlgren S, Larsson B, L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, Dahlgren S, Larsson B, Narbro K, Sjostrom CD, Sullivan M, Wedel H; Swedish Obese Subjects Study Scientific Group Lifestyle, K, Sjostrom CD, Sullivan M, Wedel H; Swedish Group Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2005 Apr 7; 352(14): 1495 -6; author reply 1495 -6. Patterson EJ, Urbach DR, Swanstrom LL. comparison of diet and exercise therapy versus laparoscopic EJ, Urbach DR, Swanstrom LL. comparison Roux-en-Y gastric bypass surgery for morbid obesity: a decision analysis model. J Am Coll Surg. 2003 Mar; 196(3): 379 -84. Craig Tseng DS. Cost-effectiveness of gastric bypass for severe obesity. Craig BM, Tseng DS. Cost-effectiveness Am J Med. 2002 Oct 15; 113(6): 491 -8. Fang J. The cost-effectiveness of bariatric surgery Am J Gastroenterol. 2003 Sep; 98(9): 2097 -8 J. The surgery Am J Gastroenterol. 2003 Sep; 98(9): 2097 -8. .