Information Session Surgical Weight Loss

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Information SessionSurgical Weight Loss

• CDR Henry Lin, MC, USN
• LTC Scott Rehrig MD
• Phyllis Gottlieb RN

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Overview

• Why You are here
• Indications for surgery
• Pathway for surgery
• Alternatives
• Surgical Procedures
• Risks and Benefits

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Scope of Problem

• Global epidemic
• 300,000 US deaths per yr
• Economic impact
• 117 billion yr in US
• Negative Survival impact for BMI 45
• White male 13yrs less
• Black males 20yrs less
• Black women 5yrs less
• White women 8 yrs less

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BMI and Risk Levels
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Obesity Comorbidities

• Once BMI values defining morbid obesity are
  reached, we are addressing a disease a
• life-shortening,
• incapacitating,
• malignant disease
• Henry Buchwald MD PhD

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Diabetes

• Obesity primary risk factor
• 90 diabetics are obese
• Risk with obesity
• BMI 30 50
• BMI 50 90
• Nurses Health Study (1980-1996)
• 85,000 nurses noted that the risk of diabetes
  increased 40x as BMI increased from lt 23 to gt 35

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• Every 2.2 lbs of weight loss equates to a 9
  reduction in diabetes!
• Jeffrey Sicat, MD
• Virginia Endocrinology and Osteoporosis
  Center

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Cardiovascular Risk

• HTN
• 50 adult BMIgt30
• 75 all HTN is attributed to obesity
• Dyslipidemia
• 40-50 adult BMIgt30
• Cardiac and Peripheral Vascular Disease
• Primary risk factor
• Secondary risk factor
• Impacts high blood pressure and hyperlipidemia

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Sleep Apnea

• Obesity 50
• Symptoms drowiness, inattentiveness, impaired job
  performance,
• Men gt women due higher incidence central obesity

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1991 National Institutes Health Patient Selection
Criteria

• BMI gt 40
• BMI bwt 35 40 AND comorbidities related
• Functional limitations due to body size or joint
  disease
• After evaluation by a multidisciplinary team
• Have low probability of success with
  non-operative wt-loss measure
• Be well informed with long and short term risks
  and benefits of surgery
• Be highly motivated to lose weight through
  surgery
• Have an accepted operative risk
• Be willing to undergo lifelong medical
  surveillance

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Absolute Contraindications

• Inability to tolerate general anesthesia
• Severe non-correctable heart or lung disease
• Severe sleep apnea
• Liver disease with cirrhosis and gastric varices
• Active peptic ulcer disease
• H. pylori infection
• Active malignancy (Cancer)
• HIV infection
• Any non-weight related condition with expected
  survival lt 5 years!

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WRAMC Specific Criteria

• 18 y.o. ltAGE lt 65 y.o.
• BMI lt 50 kg/m2
• NO active duty
• NEED a real PCM
• - to coordinate your medical care

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Bariatric Consult Flow
Initial Consult
MTFs
Phyllis Gottleib, RN (NNMC)
Amanda (WRAMC)
Out to Network
Filter
Seminar (NNMC)
Initial MD Appt (Lin)
Nutrition x 3 appts
PCM
Exercise Physiology
Psychology
Sleep Study
Pulmonary?
GI
Pre-Op Appt (Lin)
Surgery (WRAMC)
Required Follow-Up
Nutrition
Surgeon
Exercise Physiology
PCM
Sleeve Bypass 3 months 6 months 9 months Every
6mo x 2 yrs Yearly
Band Monthly
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Pathway to Surgery
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Alternatives To Surgery
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3 Surgical Options

• RNY GBP Sleeve Band

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Laparoscopic Gastric Bypass
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Weight loss

• About 100 lbs, or about 65 to 70 EBW and about
  35 of the BMI.
• Weight loss generally levels off in 1 to 2 years,
  and a regain of up to 20 lb or more is common in
  the longterm

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Operative mortality (death) and morbidity (injury)

• Overall (30 day) mortality for gastric bypass
  when performed by skilled surgeons is about 0.5
• High blood pressure, high BMI, bowel leak, blood
  clots to lung
• Overall Operative morbidity (eg, pulmonary
  emboli, anastomotic leak, bleeding, wound
  infection) is 5
• Leak up to 5 - breakdown in the staple lines
  from cutting and formation of connections bwt
  intestine and stomach pouch
• Bleeding up to 4 - this occurs at the staple
  lines after the stapling device cut the bowel
• Blood clots up to 1 - but death from this
  complication accounts for 30-50 of patients

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Longterm complications

• internal hernias (bowel obstructions)
• 1-10
• More common in laparoscopic technique
• Difficult to diagnose with routine xrays leading
  to high rate of reoperation to make diagnosis
• stomal stenosis opening to gastric pouch
  becomes too tight
• 3-12
• Treatment require using a ballon to stretch the
  opening
• marginal ulcers - breakdown of connection between
  small intestine and gastric pouch
• 1-16
• Alcohol and cigarrette smoking are major risk
  factor
• NSAIDS contraindicated in bypass pts

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Longterm complications

• Nutritional Deficiencies
• Permanent mineral and vitamin supplement for the
  rest of natural life!!
• Can be very expensive cost out of pocket for
  patients!
• Anemias -- 54
• and nonreversible neurologic diseases
• vitamin B12
• iron
• folate
• calcium

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Laparoscopic Gastric Adjustable Banding
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Gastric Banding Contraindications
Situations where the risks are greater than the
benefits that would be gained from surgery are
contraindications. These include

• Inflammation of the digestive tract, including
  ulcers, severe esophagitis, or Crohns disease
• Severe heart or lung disease
• Upper digestive tract bleeding conditions due to
  enlarged or fragile veins
• Portal hypertension
• Abnormal digestive tract anatomy
• Cirrhosis of the liver
• Chronic pancreatitis

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Gastric Banding Contraindications cont.

• Infection of any type, anywhere in your body
• Known allergies to the implant materials
• Using steroids for a long period of time or
  within 15 days of surgery
• Currently pregnant
• Younger than 18 years of age
• Unwilling to make significant changes in eating
  and behavior patterns
• Conditions or behaviors that would make it
  difficult to appropriately follow directions

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Risks Associated with Gastric Banding

• Migration of implant (band erosion, band
  slippage, port displacement)
• Tubing-related complications (port disconnection,
  tubing kinking)
• Band leak
• Esophageal spasm
• Gastroesophageal reflux disease (GERD)
• Inflammation of the esophagus or stomach
• Port-site infection

Note Complications may result in re-operations.
These complications are not usually life-
threatening. Refer to the Realize Patient Guide
for a full description of the risks and side
effects.
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Risks Associated with Gastric Banding

• Migration of implant (band erosion, band
  slippage, port displacement)
• Tubing-related complications (port disconnection,
  tubing kinking)
• Band leak
• Esophageal spasm
• Gastroesophageal reflux disease (GERD)
• Inflammation of the esophagus or stomach
• Port-site infection

Note Complications may result in re-operations.
These complications are not usually life-
threatening. Refer to the Realize Patient Guide
for a full description of the risks and side
effects.
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Weight Loss at Three Years U.S. Clinical Study
Results Overview
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• Results
• 3yrs SAGB/LB
• excess weight loss 56.36/50.20
• resolution diabetes 61.45/60.29
• hypertension 62.95/43.58
• Adverse event (AE) rates appeared comparable
• mortality was equivalent 0.1

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Late Complications

• late slippage/migration 4.0 and 6.2
• pouch dilatation 1.7 to 5.1

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Laparoscopic Sleeve Gastrectomy
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Risk
DEATH
0.5
0.1
MORBIDITY
5.0
LAP GASTRIC SLEEVE
LAP GASTRIC BYPASS
LAP BAND
EWL
50
65-70
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Effectiveness
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Summary

• Surgery NOT for everyone
• NOT a Center of Excellence
• ?? About Future of Program due to BRAC

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Thank You!

• ?

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Welcome!
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