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 bypassGastric band

Duodenal switchGastric sleeve

Bariatric Surgery-USA

• 1994-1999 10-15,000/year• 2000 22,000• 2001 48,000• 2002 75,000 • 2003 105,000• 2004 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