Weight loss Surgery at St Agnes Hospital Andrew

Weight loss Surgery at St. Agnes Hospital Andrew M. Averbach, M. D. , FACS Director of Bariatric and Minimally Invasive Surgery

Spectrum of the obesity Terms Used to Describe Various Levels of Body Fat 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 or more)

Obesity Classification Disease Stage by BMI Class/Stage Definition Risk of DM II, HTN, CAD, Sleep apnea, premature death 30 -34. 9 I Obese Increased 35 -39. 9 II Severely obese High 40— 49. 9 III Morbidly obese Extremely high 50 -59. 9 IV Mega obese Extremely high >60 IV Mega-mega obese Extremely high

Health Risks Related Diseases (Co-morbid conditions): • Obese people have higher risk for: • • Diabetes Type II (adult onset) Severe arthritis High blood pressure (not controlled with medications) Sleep apnea (disordered breathing during sleep) Obesity related heart muscle weakness High cholesterol (not controlled with diet and medications) Fatty liver that can lead to cirrhosis Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity.

Health Risks (cont. ) Related Diseases and Health Problems • Obese people are at higher risk for: • Certain types of cancer (breast, uterine, colon) • Digestive disorders (e. g. gastro-esophageal reflux disease, or GERD, gall bladder problems) • Breathing difficulties (e. g. shortness of breath, asthma). • Psychological problems such as depression. • Problems with fertility and pregnancy. • Stress Incontinence. Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity.

Types of Surgery to Treat Obesity • Types of weight-loss surgeries • Malabsorptive procedures shorten the digestive tract (Duodenal switch, Biliopancreatic diversion) • Restrictive procedures reduce how much the stomach can hold (Lap Band, Laparoscopic Sleeve Gastectomy) • Combined procedures shorten the digestive tract and reduce how much the stomach can hold (Laparoscopic Gastric bypass)

urgical procedures to Treat Morbid Obesit Gastric Bypass (GBP) LAP-BAND System Sleeve Gastrectomy

Expected Outcomes from the Surgery • Improvement or resolution of: • Diabetes (type 2): 80% • High blood pressure: 80% • Asthma: marked improvement • GERD (gastro-esophageal reflux disease): 95% • Sleep apnea: close to 100% • High cholesterol: 80% improvement/resolution • Infertility • Depression.

Bariatric Surgery Long-term outcomes

Bariatric Volumes in Maryland DRG 288 & ICD-9 Procedure code definition FY 02 HOSPITAL Svc Area FY 03 Total Svc Area FY 04 Total Svc Area FY 05 Total Svc Area FY 06 Total Svc Area Total Cases Market Share Total FY 02 FY 03 FY 04 FY 05 FY 06 13 24 75 135 153 311 174 368 229 469 6% 13% 20% 26% BAYVIEW 6 53 22 148 40 281 36 306 39 304 15% 14% 18% 17% 14% GBMC 0 0 0 31 18 158 33 188 0. 0% 2. 0% 8. 9% 13% SINAI 12 83 14 76 21 60 56 188 51 184 23. 9% 7. 6% 3. 9% 10. 6% 12% HOLY CROSS 0 33 8 160 0 62 2 102 3 149 9. 5% 16. 0% 4. 0% 5. 7% 7. 8% UMMS 4 14 7 27 9 22 4 22 28 130 4. 0% 2. 7% 1. 4% 1. 2% 6. 8% SHADY GROVE 0 0 0 6 2 107 2 145 1 105 0. 0% 0. 6% 7. 0% 8. 2% 5. 5% PENINSULA REGIONAL 0 0 2 54 0 98 1 96 0 102 0. 0% 5. 4% 6. 4% 5. 3% WASHINGTON ADVENTIST 0. 0% 1. 0% 8. 3% 6. 6% 0 0 0 10 4 127 2 117 0 91 HARFORD MEMORIAL 0 0 0 3 60 1 58 0. 0% 3. 4% 3. 0% SAINT JOSEPH 1 3 10 45 22 110 18 99 14 57 0. 9% 4. 5% 7. 2% 5. 6% 3. 0% 13 69 35 146 12 72 11 60 8 47 19. 8% 14. 6% 4. 7% 3. 4% 2. 4% UNION MEMORIAL 3 13 16 51 9 18 5 28 6 37 3. 7% 5. 1% 1. 2% 1. 6% 1. 9% SUBURBAN 0 0 7 89 0 22 0 0 0. 0% 5. 8% 1. 2% 0. 0% 14 50 24 115 30 140 0 0 14. 4% 11. 5% 9. 1% 0. 0% 1 6 2 28 0 4 0 3 0 0 1. 7% 2. 8% 0. 3% 0. 2% 0. 0% 67 348 215 1, 001 309 1, 532 332 1, 774 413 1, 921 100. 0 % ST. AGNES FRANKLIN SQUARE GOOD SAMARITAN All Other Grand Total 4. 7%

ASBS/SRC COE requirements • • Surgeons: ABS certified, bariatric training, >50 cases/year, >125 cases in the past, postop. management Hospital with >125 cases/year; bariatric surgery credentialing and in-service education program Hospital with integrated multidisciplinary program (OR, specialized nurses, dietician, psychologist, consultants, critical care, radiology and etc. ) Patients education and informed consent (indications, surgery, alternative Tx, outcomes, risks, follow-up and etc) Bariatric team: Med. Director, coordinator, specialists, nurses Bariatric on call coverage Clinical pathways, standardized orders, procedures Support groups, outcome/long-term follow-up and database

Gastric bypass results Variable Average for Centers of Excellence (US average) Number of patients 55 000 (140 000) 1500 750 Mortality 0. 3% (2%) 0. 25% 0% Morbidity 10% 8. 5% 8% Re-operations 2. 5% (5%) 2% 1. 3% Re-admission 4. 5% (10%) 4. 5% 4. 4% Bowel obstruction 2. 5% (4%) 0. 95% 0. 85% Marginal ulcer 5% (5 -7%) 0. 99% 0. 73% (NA) 67. 6% 70% EBWL % 1 year 65% (30%) St. Agnes Program Personal results

Laparoscopic vs. Open Gastric Bypass 2004 -2006 Outcomes Lap. Gastric bypass N= 16, 357 Open Gastric Bypass N=6, 055 Odds ratio (95%CI) Mean LOS (d) +SD 2. 7+2. 0 4. 0+4. 7 P<0. 05 MORBIDITY 7. 4% 13. 0% 2. 1 Pulmonary 0. 7% 2. 2% 3. 05 Pneumonia 0. 6% 1. 2% 2. 27 DVT/PE 0. 3% 0. 7% 3. 06 Leak 1. 4% 3. 1% 2. 24 Hemorrhage 1. 7% 1. 9% 1. 33 Wound infection 0. 5% 2. 3% 5. 07 30 -day readmission 2. 6% 4. 7% 2. 03 MORTALITY 0. 1% 0. 3% 3. 44 Mean cost+SD $13, 743+6, 873 $14, 585+15, 813 P<0. 05 Nguyen et al. , J Am Coll Surg. 2007; 205: 248 -255

Laparoscopic Gastric Bypass Disadvantages Advantages • Bigger operation and • Rapid initial weight somewhat slower recovery. loss • Major surgery to reverse • Higher total average • Possibility of nutritional weight loss. problems such as Iron • Higher rate of codeficiency anemia and vitamin morbidity resolution B 12 deficiency • Over 40 years of • 2 -5% chances of ulcers at the surgical experience in junction of the stomach and USA the small bowel

The LAP-BAND System Advantages • Lowest mortality rate • No stomach stapling or cutting, or intestinal rerouting • Adjustable • Smaller operation , easily reversible • Lowest operative complication rate • Low malnutrition risk Disadvantages • Slower weight loss. • Regular follow-up critical for optimal results • Requires more commitment from the patient. • Slippage or erosion and injury to the esophagus or stomach as possible complications. • Possibility of mechanical problems with device, infection Band intolerance, poor weight loss may result in Band removal in about 5% of patients

Laparoscopic Sleeve Gastrectomy is an alternative to: Roux-en-Y gastric bypass Because: • • • Lower risk of deficiencies No risk of marginal ulcer No or minimal “dumping” No risk of intestinal obstruction Easily converted to bypass for inadequate weight loss Contraindications to bypass (chr. anemia, Crohn’s disease etc. ) Comparable long-term weight loss to Gastric bypass Very effective as 1 -st stage prior to Gastric bypass in BMI>60 Lap Band Because: • • No risk of system malfunctioning (slippage, erosion, infection and etc. ) No need for adjustment No foreign body/plastic Contraindications to Lap Band (connective tissue disorders, allergy) Need to take NSAIDs for arthritis or heart disease Sleeve gastrectomy showed superior weight loss at 3 years

Laparoscopic Sleeve Gastrectomy Disadvantages: • • • Potential for inadequate weight loss/ weight regain due to sleeve dilatation People with BMI>60 may need 2 -nd stage surgery (Gastric Bypass) to achieve normal weight Sweet eaters, grazers, binge eaters have suboptimal results Potential complications with long staple line Not reversible May worsen reflux disease (heartburn) Not covered by any insurance Will have to take vitamins, B 12, calcium, possibly antacids Mortality 0 -0. 5%, complications 2. 5%, leaks 1%

Gastric Band Adjustment and Follow-up • • Follow-up for life with bariatric surgeon Follow-up at 2 and 6 weeks after surgery First adjustment after 6 weeks First adjustment in the office if possible or using X-ray Subsequent adjustments done as needed Patient-driven adjustment policy: Despite your best effort (healthy eating and regular exercise) - no weight loss for 2 -3 weeks in a row Follow-up visit every 3 months during 1 -2 year Annual Band adjustment under X-ray to look for optimal restriction and to detect early potential problems with the band

St. Agnes Hospital outcomes with Lap Band Total for our program • • 550 cases Mortality 0% Morbidity 3. 2% Re-operations 1. 2% (stomach laceration - 3; acute band obstruction, port infection; band intolerance) Re-admission within 1 month 2% (dehydration; atelectases; wound infection). Average LOS – 1 day (range 0 -5) Band slippage – 0. 57%, no band erosions Band removal/gastric bypass – 1. 2% My personal results • • 275 cases Mortality 0% Morbidity 2. 3% Re-operations 1% (stomach laceration) Re-admission 1. 5% Average LOS 1 day No slips, erosions, infection or band removal to date

Weight loss after gastric bypass vs. Lap band Jan et al. , J. GI Surgery, 2007

% Excess Body Weight Loss by Procedure St. Agnes Hospital

% Weight Excess Body Loss by initial BMI St. Agnes Hospital

Weight Loss Results by Surgeon

Lap Band: Best results seen • • BMI 35 -49 No serious co-morbidities Good exercise tolerance; no disabling arthritis Have a greater commitment to exercise and good dietary choices then with other procedures

Lap Band vs. Diet in BMI 30 -35%

Laparoscopic Sleeve Gastrectomy BMI decrease at 2 years

Band or Bypass? How patients choose? • Lap Band (%) • Lap Gastric Bypass • Low risk of surgery (85) Quicker recovery (80) “I felt it was better for me. ” 6% less patients decide to have Lap Band after seminar and surgeons consult 50% choose Lap Band • More overall weight loss (92) Quicker weight loss (79) “I felt it was better for me. ” 6% more switch to bypass after seminar and surgeon consult 50% choose Gastric bypass • •

What procedure to choose? We will decide together. Laparoscopic Gastric Bypass • • Your choice Procedure of choice for any BMI Multiple co-morbidities requiring quick resolution BMI >50 Laparoscopic Gastric Banding (Lap Band) • Your choice. • BMI 35 -49 • No/few co-morbidities, no disabling arthritis, women who plan to have children within a year Laparoscopic Sleeve Gastrectomy • Procedure of choice for any BMI • BMI>50 and you do not want gastric bypass • Your choice

Who qualifies for the Bariatric Surgery? • NIH criteria 1. 2. 3. 4. 5. • Weight: BMI more than 40 or 35 with two serious illnesses. Free from untreated mental illnesses such as Bulimia and Schizophrenia, Bipolar disorder or Severe depression, Mental retardation, Anorexia. Documented evidence of weight loss attempts. In Maryland 6 months over the past two years (varies by insurance company). Understanding by the patient that the surgery is only a tool to lose weight. Life style changes, exercise and eating habits are of absolute importance. Age: 18 -60 years of age

Who does not qualifies for the Bariatric Surgery? • Those who have severe uncorrectable heart disease. • Heart failure. • Angina and coronary artery disease. • Severe lung disease (home oxygen). Psychiatric illnesses • In whom surgery is not feasible: UNWILLING & UNABLE • • Lack of understanding and willingness to learn how bariatric surgery works for you. • Unable or unwilling to make necessary life-style, eating habits changes • Limited exercise tolerance. • Non-compliant with work-up, follow-up and recommendations

With ANY Bariatric Procedure Best Outcomes are seen when: • HISTORY: You seriously tried to loose weight in the past; Surgery is not the starting point • MOTIVATION: You leave all the excuses and get the job done. • INVOLVMENT: You are proactively participate in your care; Never say “nobody told me that!”. • COMPLIANCE: You follow all recommendations, come for regular follow-up. • COMMITMENT: You exercise regularly and assume good eating habits. • SUPPORT: You have good social/family support or actively seek help when needed, attend group support meetings.

When surgery might not work: • You are waiting for weight loss - without exercising and changing eating habits. • You have an excuse why you are not exercising or eating right. • “Cheating” with high calorie foods or drinks • “Grazing” – continuous eating throughout the day • You rely on surgery for weight loss. • You think that this is not a LIFELONG effort. • You show up late or miss your appointment in doctor’s office! • You are not coming for regular scheduled follow-up appointments

Your initial steps: 1. 2. 3. 4. 5. 6. 7. Make sure you meet the NIH criteria. Check with insurance for coverage. Make sure that we participate with your insurance or be willing to cover the expense. See the dietician and psychologist. Fill all the forms and obtain copy of recent Physical, consults, studies. Make appointment to see Dr. Averbach. If you have questions - Call the office.

If You are considering bariatric surgery and think that: Safety • Results • Compassion • Availability 24/7 • Professionalism • Dedication Are important you can call my office tomorrow •

Thank you! Questions? To view this presentation again and obtain additional information Visit our website www. mdlapbarisurge. com