Obesity The Surgeon Moises Jacobs MD FACS Director

Obesity & The Surgeon Moises Jacobs, MD, FACS, Director Advanced Surgical Institute Mercy Hospital, Miami, FL.

Speaker Disclosure • Speaker discloses he is a consultant with Ethicon.

Four Operations Gastric bypass Gastric band Duodenal switch Gastric sleeve

Bariatric Surgery-USA • • • 1994 -1999 2000 2001 2002 2003 2004 10 -15, 000/year 22, 000 48, 000 75, 000 105, 000 140, 000 Schirmer, Laparoscopic Bariatric Surgery. Surg Endosc 2003

Bariatric Surgery-USA • It is estimated that by 2012, the number of cases will triple • It is estimated there are over one billion obese persons in the world today

Surgical Candidate • • • NIH Consensus Conference 1991 BMI > 40 >35 significant co-morbidity No endocrine cause Understand risks of surgery Compliant with follow-up

Advantages of Gastric Sleeve • • No dumping syndrome No intestinal bypass No intestinal obstruction No anemia, vitamin deficiencies, no protein malnutrition, no osteoporosis • High BMI is not a contraindication

Sleeve vs Band • No foreign body ( no erosion, infection or revision of reservoir) • No adjustments • Second stage operation is an option if weight loss is inadequate

Downside? • • Gastric staple division, leaks can occur Inadequate weight loss (soft calories) Not reversible Long term results are unknown

Inventing Something New? • Magenstrasse-Mill operation, Leeds UK • Lesser curvature tube, stomach is otherwise intact • Long term 60% EWL Johnston, Obesity Surg 2003

Sleeve Gastrectomy-Results • Expected weight loss – 40 -60% EBW – 6 -18 months • 1 -2 day stay • Follow-up – Labs, nutrition – Assess compliance • Complications – – Leak DVT/PE Pneumonia Wound infection • Low rate, low mortality • Second stage – Gastric bypass – Duodenal switch

Agency for Healthcare Research and Quality • 22% of bariatric surgery pts experienced a complication prior to discharge • Almost 40% experienced a complication within 180 days of discharge (? ) – Dumping syndrome (19. 5%) – Anastomotic problems (12. 3%) – Abdominal hernia (7%) – Infection (5. 7%) – Pneumonia (4. 1%) Encinosa; Medical Care 2006

Agency for Healthcare Research and Quality 2001 -2002 • 6 month risk adjusted health care payments were $65, 031 for those with 180 day readmission, compared with $27, 125 for thos with readmissions • In a subset of 625 surgeries in centers with bariatric volume, no link was found between volume and the risk of complications, after adjusting for age, sex, and comorbidities