Laparoscopic Bariatric Surgery

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Laparoscopic Bariatric Surgery

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Bariatric Surgery

• Greek baros (weight) iatrike (medicine,
  surgery)
• A field of medicine encompassing the study of
  overweight, its causes, prevention, and treatment

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Why Do Bariatric Surgery?

• Major impact on morbidity and mortality
• cures disease and saves lives!
• preventative medicine?
• Challenging
• Very rewarding
• Exceptional group of patients
• A HAPPY specialty!

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Obesity Is a Big Problem

• Major public health problem worldwide
• Affects 25 of industrialized world
• American statistics
• 55 of adults are overweight
• 25 of children are overweight
• 300,000 deaths annually

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Prevalence of Obesity among U.S. Adults BRFSS,
1990
(Approximately 30 pounds overweight)
Source Mokdad AH, et al. J Am Med Assoc
199928216.
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Prevalence of Obesity among U.S. Adults BRFSS,
1991
(Approximately 30 pounds overweight)
Source Mokdad AH, et al. J Am Med Assoc
199928216.
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Prevalence of Obesity among U.S. Adults BRFSS,
1992
(Approximately 30 pounds overweight)
Source Mokdad AH, et al. J Am Med Assoc
199928216.
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Prevalence of Obesity among U.S. Adults BRFSS,
1993
(Approximately 30 pounds overweight)
Source Mokdad AH, et al. J Am Med Assoc
199928216.
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Prevalence of Obesity among U.S. Adults BRFSS,
1994
(Approximately 30 pounds overweight)
Source Mokdad AH, et al. J Am Med Assoc
199928216.
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Prevalence of Obesity among U.S. Adults BRFSS,
1995
(Approximately 30 pounds overweight)
Source Mokdad AH, et al. J Am Med Assoc
199928216.
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Prevalence of Obesity among U.S. Adults BRFSS,
1996
(Approximately 30 pounds overweight)
Source Mokdad AH, et al. J Am Med Assoc
199928216.
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Prevalence of Obesity among U.S. Adults BRFSS,
1997
(Approximately 30 pounds overweight)
Source Mokdad AH, et al. J Am Med Assoc
199928216.
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Prevalence of Obesity among U.S. Adults BRFSS,
1998
(Approximately 30 pounds overweight)
Source Mokdad AH, et al. J Am Med Assoc
199928216.
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Prevalence of Obesity among U.S. Adults BRFSS,
1999
(Approximately 30 pounds overweight)
Source Mokdad AH, et al. J Am Med Assoc
199928216.
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Current Data
Over 50 of Americans are obese and over 10 are
morbidly obese
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What Is Obesity?

• A life-long, progressive, life-threatening,
  costly, genetically-related, multi-factorial
  disease of excess fat storage
• ASBS

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Body Mass Index (BMI)

• BMI weight (kg)_____
• height (m) x height (m)
• WHO Classification BMI
• Ideal weight 2024.9
• Overweight 2529.9
• Moderate obesity(class I) 3034.9
• Severe obesity (class II) 3539.9
• Morbid obesity (class III) 4049.9
• (Super obesity) 50

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Exponential Mortality Risk
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Co-Morbid Medical Conditions

• Diabetes
• Hypertension
• Hyperlipidemia
• Cardiac disease
• Respiratory disease
• sleep apnea
• Arthritis
• Depression
• Stress Incontinence
• Menstrual irregularity

• 1420
• 2555
• 3553
• 1015
• 1020
• 2025
• 7090
• 50
• 50

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What Causes Obesity?

• Energy in gt energy out
• Obesity is multifactorial
• genetic 2530
• neuroendocrine
• environmental
• metabolic

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Why Surgery?

• Diet and exercise only works for 1 in 20 (5)
  people who are obese
• Surgery is safe and effective
• Improves co-morbidities
• Benefits of surgery outweigh the risks for the
  morbidly obese
• risks of surgery
• risks of staying morbidly obese

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NIH Consensus Conference 1991

• Surgery is the only way to obtain consistent,
  permanent weight loss for obese patients
• Surgery indicated in patients with
• BMI of 40 or over
• BMI of 35 or over with significant co-morbidity
• documented dietary attempts ineffective

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How Does Surgery Work?

• Malabsorption
• jejunoileal bypass
• biliopancreatic diversion ? duodenal switch
• Restriction
• vertical banded gastroplasty
• adjustable gastric banding
• Hybrid of restriction and malabsorption
• gastric bypass

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Jejunoileal Bypass (JIB)

• HISTORICAL
• Bacterial overgrowth in blind limb anemia,
  arthritis, cirrhosis, kidney stones, etc.
• Diarrhea and malnutrition
• No longer performed
• Should be reversed

graphics Courtesy of ASBS
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Vertical Banded Gastroplasty (VBG) aka Stomach
Stapling

• On the way out
• Restrictive
• Minimal metabolic effects
• Defeated by junk food diet, liquids
• 4060 loss EBW
• Only 38 success
• staple line failure

graphics Courtesy of ASBS
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Laparoscopic Adjustable Gastric Banding

• Restrictive
• Ongoing FDA studies
• No long-term follow-up
• Presence of a foreign body
• Post operative adjustments required

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Roux-en-Y Gastric Bypass

• Most frequently performed bariatric procedure in
  the US
• First done in 1967
• Some technical modifications since (stomach is
  divided)
• Laparoscopically since 1993

graphics Courtesy of ASBS
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• Frantzides et al. Laparoscopic Gastric Stapling
  and Roux-en-Y Gastrojejunostomy for the treatment
  of Morbid obesity. J Laparoendosc Surg 1995

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Laparoscopic Roux-en-Y(Minimally Invasive)
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Planning
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Laparoscopic Roux-en-Y(Minimally Invasive)

• Six small puncture wounds (1/4 to ½ inch)
•  A laparoscope, connected to a video camera, is
  inserted through the small incision into the
  abdomen

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Advantages of Laparoscopy

• Fewer wound complications
• infection, hernia
• Probably fewer cardiac and respiratory
  complications
• Less pain and faster recovery
• Surgeon has better view of the anatomy

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Roux-en-YOpen vs. Laparoscopic Procedure

• LAPAROSCOPIC
• Hospital stay is 1 to 3 days.
• Patients usually return to work in 10 to 14 days.
• Technically more demanding for the surgeon

• OPEN
• Hospital stay of about 5 days.
• Return to work in about 4 weeks.
• More painful
• Greater risk of infection

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Results of Our Lap Gastric Bypass Technique, 2003

• 711 Patients
• Average BMI 50 (range 35-91)
• Conversions to open 1
• Duration of Surgery 90 min (range 37-180)
• Hospital Stay 2.0 days (range 1-4)

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Results of Lap Gastric Bypass, 2003
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• Frantzides et al. Triple Stapling Technique for
  Jejunojejunostomy in Laparoscopic Gastric Bypass.
  Arch Surg 2003

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Post-Op Incisions
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Post-OperativeNutrition and Diet

• Most patients who have had gastric-bypass surgery
  begin . . .
• A soft diet after the first week
• A regular diet at one month
• Nutritional and psychological counseling
• A daily multi-vitamin with iron for life
• Weekly sublingual vitamin B12 for life

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Post-OperativeMaintenance

• First post-operative visit is usually 7-10 days
  following surgery
• Office visits are scheduled at 1, 3, 6 and 12
  months after surgery, and yearly thereafter
• Lab work is performed at all visits after the 1st
  postoperative visit

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Post-Operative

• Most patients lose up to and beyond 80 of excess
  weight
• and keep it off.

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Reduction in Co-Morbidities

• All medical co-morbidities are resolved or
  improved in 80100 of patients

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Swedish Obesity Surgery Study
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Pre-Operative Process

• Medical History
• You will need a detailed account of efforts to
  achieve weight loss by non-surgical methods.
• Lists of specific comorbidities need to be
  identified.
• Your current health status will need to be
  evaluated

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Pre-Operative Process

• Supporting Documentation
• You will need a brief letter from any physicians
  that have treated any weight-related health
  conditions.
• Any documentation from physicians stating the
  previous weight-loss efforts that you have made
  can be very valuable.

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Pre-Operative Process

• Medical Testing
• Further medical testing may need to be completed
  in order to further clarify any existing
  comorbidities
• A psychological evaluation may also be needed

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Pre-Operative Process

• Insurance Request
• Depending on the type of health care benefits, a
  request is made for coverage of the surgery from
  the patient, as well as the surgeon.
• If the Request is Denied
• Some insurance companies will initially deny a
  request for coverage. An appeal from the patient
  can be made or the patient can choose to seek
  legal advice.

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Frequently Asked Questions

• Can gastric-bypass surgery be reversed?
• Yes. The procedure is intended to be a permanent
  change, but because the stomach is bypassed, not
  removed, surgeons can undo the pouch.

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Frequently Asked Questions Continued

• Will I need plastic surgery?
• Many factors influence the need for plastic
  surgery, for example starting weight, the amount
  of weight lost, location of the excess weight and
  age. The younger patients have a greater amount
  of skin elasticity and therefore are less likely
  to need plastic surgery.

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Frequently Asked Questions Continued

• Will I have gallstone complications?
• Weight loss and diet will promote the production
  of gallstones. If a patient has has documented
  gallstones, the gallbladder will be removed at
  the time of surgery.
• Gallstone dissolution medication

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Frequently Asked Questions Continued

• Can I become pregnant after gastric-bypass
  surgery?
• Yes, you can become pregnant after the surgery
  with out any related complications. Thousands of
  women have had successful pregnancies after the
  gastric-bypass surgery.

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Pre-Op
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Post-Op
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Before
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After
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Pre-Op
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Post-Op
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Before
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After
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12/13/02
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1/16/04
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Conclusion

• Only surgery has proven effective over the long
  term for most patients with clinically severe
  obesity -National Institutes of Health
  Consensus Development Conference Statement

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Chicago Institute of Minimally Invasive
Surgery-St Francis Hospital