Surgical treatment for morbid obesity Ram Elazary, MD General Surgery Department Hadassah Medical...
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Transcript of Surgical treatment for morbid obesity Ram Elazary, MD General Surgery Department Hadassah Medical...
Surgical treatment for morbid obesity
Ram Elazary, MDGeneral Surgery Department
Hadassah Medical CenterCampus Ein Kerem
General Surgery Department
Prevalence of obesity in Israel
• 60% of total population• Morbid obesity: 9% of women and 4% of men
Definitions
Body mass index (BMI) = Kg/Height2
• BMI > 40
• 35 < BMI < 39.9 and co-morbidity
Co-morbidity related to BMI
PE
RC
EN
T A
FF
LIC
TE
D
60%
4%
18%
7%
24%
15%
32%
26%
44%
23%
10%
14%
28%
16%
41%
51%
0%
10%
20%
30%
40%
50%
Diabetes Asthma Arthritis High BloodPressure
BMI < 25 25-30 30-40 BMI > 40
0
2
4
6
8
10
12
14
25 27 29 31 33 35 37 39 41 43 ≥45
BMI
YE
AR
S O
F L
IFE
LO
ST
20 30 40 50
Age
Morbid obesity and loss of years of life
Bariatric surgery (US)
Bariatric surgery (Hadassah)
Co-morbidity of Morbid Obesity• Hypertension• Type 2 Diabetes Mellitus• Hypercholesterolemia• Orthopedic disease (Osteoarthritis, Back pain)• Obstructive sleep apnea• Venous insufficiency• Fatty liver disease
Surgery at Hadassah
• Sleeve gastrectomy• Gastric bypass• Revision, conversion
and reverse surgery
Laparoscopic Surgery
Advantages of laparoscopy
Less pain, early mobilization, better cosmesis
Minutes post surgery…
Decision making (risk stratification)
Risk Benefit
Success rateWeight loss vs cure of co-morbidity
Side effects (vomiting, reflux)
•Gastric band <80%•Sleeve gastrectomy 90%•Gastric Bypass 90-95%
Sleeve Gastrectomy
• Low volume stomach• Reduces hunger• No malabsorption• Loss of 50-70% of
excess body weight• Relatively new
procedure• Morbidity 1-2%
Roux en Y Gastric Bypass
• Gold standard • Low volume pouch• Reduces hunger• No malabsorption• Loss of 50-70% of
excess body weight• More than 40 years of
experience• Morbidity 1-2%
Post operative course
• Admission for 3 days
• No urinary catheter or Naso-gatric tube
• Resuming fluids the day after surgery
• Discharged with liquid diet for 10 days
Candidates for surgery
• There is no age criteria• Failed previous weight loss diets• Strict BMI criteria• Compliance
Decision of which operation
• Patient preferences • Co-morbidity• Laboratory results• Imaging studies• Overall risk
Pre-operative studies
• Swallowing contrast study or endoscopy• Blood tests• Abdominal sonography• Chest X ray, EKG• Psychiatric evaluation• Dietician evaluation• Other studies tailored specifically to the
patient’s medical condition
Weight loss “slope” after surgery
• Different between patients• Relatively excessive during the first 3
months• Continues till 12-18 months post surgery
• Excess skin – plastic surgery
Follow up after surgery
• Multidisciplinary approach:Surgeon / Dietician / Psychologist
• 3 / 6 / 12 months regular follow up
• Designing a web/phone based follow up (emails, phone, Skype etc.)
• 39 yo M• 112 Kg, 173 cm BMI 37.4• Morbid obesity related co-morbidity:
• Hypertension• Type 2 Diabetes Mellitus• Hypertriglyceridemia• Fatty liver disease
Case presentation – gastric bypass
Aspirin 100mg q24hTritace 2.5mg q24hMetformin 850mg q12hNovorapid 10units q8hLantus 18units q24hLipitor 80mg q24h
Medications – prior to surgery
Fasting Glucose 134 mg/dlALT 71 unitsHbA1c 8 mg/dlLDL 160 mg/dlTG 178 mg/dl
Blood test result – prior to surgery
• Weight 112 84 Kg• BMI 37 28 • Morbid obesity related co-morbidity:
Hypertension curedType 2 Diabetes Mellitus curedHypertriglyceridemia improvedFatty liver disease cured
One year post surgery
Weight post surgery
HbA1c
HbA1c post surgery
Months post surgery
ALT post surgery
Aspirin 100mg q24hTritace 2.5mg Metformin 850mg Novorapid 10units Lantus 18units
Lipitor 40mg q24h
Medications one year post surgery
Case presentation – sleeve gastrectomy
• 36 yo M• 150 Kg, 184 cm• BMI 44.8
• Fasting GLU 104• HbA1c 6.6• Triglycerides 165
9 months post surgery – sleeve gastrectomy
• Weight 150 95 Kg• 150 Kg 184 cm• BMI 44.8
• Fasting GLU 104• HbA1c 6.6• Triglycerids 165