Update on Obesity Management & Surgical Options

Update on Obesity management Update on Obesity management and surgical options.and surgical options.

Michael Baptista, MDMichael Baptista, MD

www.JaxSurgical.com

www.jaxsurgical.com

Are we facing an epidemic problem?Are we facing an epidemic problem?

What causes obesity?What causes obesity?· GeneticsGenetics· EnvironmentEnvironment· HormonesHormones· CultureCulture· Kinds of food groupsKinds of food groups· Lack of exerciseLack of exercise· PsychologicalPsychological· Et CeteraEt Cetera

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What causes obesity?What causes obesity?· GeneticsGenetics· EnvironmentEnvironment· HormonesHormones· CultureCulture· Kinds of food groupsKinds of food groups· Lack of exerciseLack of exercise· PsychologicalPsychological· Et CeteraEt Cetera

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It is not an anatomic variation of our gastrointestinal tract!!!It is not an anatomic variation of our gastrointestinal tract!!!

OBESITY IS A DISEASE!OBESITY IS A DISEASE! Received official, FederalReceived official, Federal “DISEASE” “DISEASE” status in October 2004status in October 2004

American Medical Association recognized in June 2013American Medical Association recognized in June 2013

- 25% or less in the 1960s and 1970s;- 25% or less in the 1960s and 1970s;- 50% during the 1980s and 1990s;- 50% during the 1980s and 1990s;- 70% currently- 70% currently

US prevalence of overweight adults reached epidemic levels:US prevalence of overweight adults reached epidemic levels:

Success rates of different Success rates of different weight loss modalities…weight loss modalities…

6%6% 12%12% 60 - 90%60 - 90%8%8%

““Only Only surgerysurgery has proven effective over has proven effective over the long term for most patients with the long term for most patients with

clinically severe obesity.”clinically severe obesity.”

National Institute of HealthNational Institute of HealthConsensus in 1992Consensus in 1992

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OBESITY…OBESITY…

Associated with many diseases such as:Associated with many diseases such as:• HypertensionHypertension• DyslipidemiaDyslipidemia• Type 2 diabetesType 2 diabetes• Coronary heart diseaseCoronary heart disease• StrokeStroke• Gallbladder diseaseGallbladder disease• OsteoarthritisOsteoarthritis• Sleep apnea and respiratory problemsSleep apnea and respiratory problems• Cancers associated with 16 (endometrial, breast, and colon)Cancers associated with 16 (endometrial, breast, and colon)

OBESITY: THE AFFECT ON YOUR HEALTHOBESITY: THE AFFECT ON YOUR HEALTH

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Comorbidity Resolution: Comorbidity Resolution: 4 study results4 study results

1. Dixon JB, O’Brien PE. Health outcomes of severely obese type 2 diabetic subjects 1 year after laparoscopic adjustable gastric banding. Diabetes Care. 2002;25:358-363. 2. Dixon JB, Chapman L, O’Brien P. Marked improvement in asthma after Lap-Band® surgery for morbid obesity. Obes Surg. 1999;9:285-389 3. Dixon JB, Schachter LM, O’Brien PE. Sleep disturbance and obesity. Arch Intern Med. 2001;161:102-106. 4. Dixon JB, O’Brien PE. Gastroesophageal reflux in obesity: the effect of Lap-Band placement. Obes Surg. 1999;9:527-531.

Risk of death in morbidly obese Risk of death in morbidly obese patients: surgery vs no surgerypatients: surgery vs no surgery

Survival rate at Survival rate at 1 year1 year

Survival rate at Survival rate at 3 years3 years


99%99% 98%98% 97%97%

Survival rate at 1 Survival rate at 1 yearyear

Survival rate at 3 Survival rate at 3 yearsyears


97%97% 88%88% 78%78%

Patients Patients seen at seen at seminarseminar

SurgerySurgery

NoNosurgerysurgery

Dr. Reinhold, Saint Raphael Hospital- New Haven – Connecticut.

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What is “BMI” and what is the What is “BMI” and what is the importance of BMI?importance of BMI?

Using Body Mass Index (BMI)Using Body Mass Index (BMI)Measures obesity based on weight Measures obesity based on weight and height to standardize and height to standardize measurementsmeasurements

70% adults, 22% kids70% adults, 22% kids30%30%14%14%8%8%

CHOOSING SURGERYCHOOSING SURGERY

• Surgery is a powerfulSurgery is a powerful tooltool, not a solution;, not a solution;• No Surgery No Surgery can guarantee 100% success to all patients;can guarantee 100% success to all patients;

• Surgery is an option when other weight-loss therapies have failedSurgery is an option when other weight-loss therapies have failed

• Obesity surgery is not cosmetic; it is no different from cancer Obesity surgery is not cosmetic; it is no different from cancer or heart surgeryor heart surgery• So, choose theSo, choose the safest, least invasive, lowest risk & safest, least invasive, lowest risk & successfulsuccessful procedureprocedure

TYPES OF OBESITY SURGERYTYPES OF OBESITY SURGERYRestrictiveRestrictive Reduce how much the stomach can holdReduce how much the stomach can hold

Horizontal GastroplastiesHorizontal Gastroplasties

Vertical Banded Gastroplasty (VGB)Vertical Banded Gastroplasty (VGB)

Silastic Ring Vertical Gastroplasty (SRVG)Silastic Ring Vertical Gastroplasty (SRVG)

Laparoscopic Sleeve Gastrectomy (LSG)Laparoscopic Sleeve Gastrectomy (LSG)

Laparoscopic Adjustable Gastric Banding (Realize Band & Lap Laparoscopic Adjustable Gastric Banding (Realize Band & Lap Band)Band)

MalabsorptiveMalabsorptive Shorten the digestive tractShorten the digestive tract

Jejunoileal Bypass (JIB)Jejunoileal Bypass (JIB)

Biliopancreatic Diversion (BPD)Biliopancreatic Diversion (BPD)

+/- Duodenal Switch+/- Duodenal Switch

Long Limb Gastric-BypassLong Limb Gastric-Bypass

CombinationCombination Laparoscopic Roux-en-Y Gastric Bypass (LRNYGB)Laparoscopic Roux-en-Y Gastric Bypass (LRNYGB)

TYPES OF OBESITY SURGERYTYPES OF OBESITY SURGERY

Gastric BypassGastric Bypass(LRNYGB)(LRNYGB)

Gastric BandGastric Band(REALIZE Band & (REALIZE Band & Lap Band System)Lap Band System)

Vertical BandedVertical BandedGastroplastyGastroplasty

(VBG)(VBG)

Bilio-Pancreatic Bilio-Pancreatic DiversionDiversion

(BPD)(BPD)

MalabsorptiveMalabsorptive CombinedCombinedRestrictive, Restrictive,

FixedFixedRestrictive, Restrictive, AdjustableAdjustable

High complication rates, High complication rates, poor long term weight losspoor long term weight loss

Historical operation still Historical operation still done by somedone by some

High complication rates, High complication rates, poor long term weight losspoor long term weight loss

Historical operation still Historical operation still done by somedone by some

High comp. rates (56.4%), High comp. rates (56.4%), good long term weight good long term weight loss, major long term loss, major long term

malnutrition problemsmalnutrition problemsTechnically very Technically very

demandingdemanding

High comp. rates (56.4%), High comp. rates (56.4%), good long term weight good long term weight loss, major long term loss, major long term

malnutrition problemsmalnutrition problemsTechnically very Technically very

demandingdemanding

AVOID mini-bypassAVOID mini-bypassAVOID mini-bypassAVOID mini-bypass 20 year experience;20 year experience;FDA approved 2001FDA approved 200120 year experience;20 year experience;FDA approved 2001FDA approved 2001

Restrictive, Restrictive, FixedFixed

SleeveSleeveGastrectomyGastrectomy

(LSG)(LSG)

Initially used as a first step Initially used as a first step surgery for other bariatric surgery for other bariatric surgery. Now stands as a surgery. Now stands as a “new” technique. Long “new” technique. Long results not available.results not available.

Initially used as a first step Initially used as a first step surgery for other bariatric surgery for other bariatric surgery. Now stands as a surgery. Now stands as a “new” technique. Long “new” technique. Long results not available.results not available.

Open vs. Laparoscopic SurgeryOpen vs. Laparoscopic Surgery

Open SurgeryOpen Surgery- Large incision, worse scar- Large incision, worse scar

- More pain- More pain

- More complications (hernias in - More complications (hernias in 20%)20%)

- Only 2 indications- Only 2 indications• Can’t be done Can’t be done laparoscopicallylaparoscopically• Insurance (eg. Tricare)Insurance (eg. Tricare)

Laparoscopic SurgeryLaparoscopic Surgery- Small incisions, less scarring- Small incisions, less scarring

- Less pain, shorter hospital - Less pain, shorter hospital stay, quicker return to workstay, quicker return to work

- Surgeon uses long, thin - Surgeon uses long, thin instruments and videoinstruments and video

Laparoscopic SurgeryLaparoscopic Surgery- Small incisions, less scarring- Small incisions, less scarring


- Surgeon uses long, thin - Surgeon uses long, thin instruments and videoinstruments and video

Single Site LapSingle Site Lap- Even less scarring- Even less scarring


- Surgeon uses a special port - Surgeon uses a special port to access the abdominal cavityto access the abdominal cavity

Single Site LapSingle Site Lap- Even less scarring- Even less scarring


- Surgeon uses a special port - Surgeon uses a special port to access the abdominal cavityto access the abdominal cavity

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LAGB SurgeryLAGB SurgeryLAGB SurgeryLAGB Surgery• RestrictiveRestrictive only…releases food slowly, providing only…releases food slowly, providing SATIETYSATIETY• Simple operation, easier re-operationSimple operation, easier re-operation• Most done as same day surgeryMost done as same day surgery• AdjustableAdjustable• ReversibleReversible• Low mortality vs. Fen-PhenLow mortality vs. Fen-Phen• Few complications (2-3% overall)Few complications (2-3% overall)• No malabsorptionNo malabsorption• You are not as hungryYou are not as hungry• Long term physician controlLong term physician control• ““Normal” life, good maintenanceNormal” life, good maintenance

• RestrictiveRestrictive only…releases food slowly, providing only…releases food slowly, providing SATIETYSATIETY• Simple operation, easier re-operationSimple operation, easier re-operation• Most done as same day surgeryMost done as same day surgery• AdjustableAdjustable• ReversibleReversible• Low mortality vs. Fen-PhenLow mortality vs. Fen-Phen• Few complications (2-3% overall)Few complications (2-3% overall)• No malabsorptionNo malabsorption• You are not as hungryYou are not as hungry• Long term physician controlLong term physician control• ““Normal” life, good maintenanceNormal” life, good maintenance

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Laparoscopic Roux-en-YLaparoscopic Roux-en-YGastric-Bypass SurgeryGastric-Bypass Surgery

Laparoscopic Roux-en-YLaparoscopic Roux-en-YGastric-Bypass SurgeryGastric-Bypass Surgery

• RestrictiveRestrictive & & MalabsorptiveMalabsorptive• Complex operation and re-operation, Complex operation and re-operation,

technically difficult, problematic to reversetechnically difficult, problematic to reverse• 100% need to stay in the hospital100% need to stay in the hospital• Lifelong protein-calorie malabsorption Lifelong protein-calorie malabsorption

requiring vitamin & mineral replacement for requiring vitamin & mineral replacement for the rest of your lifethe rest of your life

• Dumping syndrome (Bad diarrhea)Dumping syndrome (Bad diarrhea)• Late weight regain, no adjustmentsLate weight regain, no adjustments• 10-15% surgical complications10-15% surgical complications• No post-op control physicianNo post-op control physician• 1% Mortality1% Mortality• Better life than obesity, BUT Better life than obesity, BUT not normalnot normal

• RestrictiveRestrictive & & MalabsorptiveMalabsorptive• Complex operation and re-operation, Complex operation and re-operation,

technically difficult, problematic to reversetechnically difficult, problematic to reverse• 100% need to stay in the hospital100% need to stay in the hospital• Lifelong protein-calorie malabsorption Lifelong protein-calorie malabsorption

requiring vitamin & mineral replacement for requiring vitamin & mineral replacement for the rest of your lifethe rest of your life

• Dumping syndrome (Bad diarrhea)Dumping syndrome (Bad diarrhea)• Late weight regain, no adjustmentsLate weight regain, no adjustments• 10-15% surgical complications10-15% surgical complications• No post-op control physicianNo post-op control physician• 1% Mortality1% Mortality• Better life than obesity, BUT Better life than obesity, BUT not normalnot normal

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Revision SurgeryRevision SurgeryRevision SurgeryRevision Surgery• Complex re-operation, technically difficult due to scarring and change Complex re-operation, technically difficult due to scarring and change

in anatomy;in anatomy;• Need to stay in the hospital;Need to stay in the hospital;• Must have a very careful evaluation for surgery:Must have a very careful evaluation for surgery:

• Access why the weight came back or why patient didn’t lose it.Access why the weight came back or why patient didn’t lose it.• Technical problem with previous surgeryTechnical problem with previous surgery• Patient needs to demonstrate ability to follow recommendations, Patient needs to demonstrate ability to follow recommendations,

since it will be the same with the next surgery; since it will be the same with the next surgery; • Lack of long term data to prove efficacy;Lack of long term data to prove efficacy;• Higher rate of surgical complications;Higher rate of surgical complications;• Needs close follow up by the physicianNeeds close follow up by the physician

• Complex re-operation, technically difficult due to scarring and change Complex re-operation, technically difficult due to scarring and change in anatomy;in anatomy;

• Need to stay in the hospital;Need to stay in the hospital;• Must have a very careful evaluation for surgery:Must have a very careful evaluation for surgery:

• Access why the weight came back or why patient didn’t lose it.Access why the weight came back or why patient didn’t lose it.• Technical problem with previous surgeryTechnical problem with previous surgery• Patient needs to demonstrate ability to follow recommendations, Patient needs to demonstrate ability to follow recommendations,

since it will be the same with the next surgery; since it will be the same with the next surgery; • Lack of long term data to prove efficacy;Lack of long term data to prove efficacy;• Higher rate of surgical complications;Higher rate of surgical complications;• Needs close follow up by the physicianNeeds close follow up by the physician

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SURGICAL OUTCOMESSURGICAL OUTCOMES• Long-term Weight LossLong-term Weight Loss

80-200 lbs in 12-18 months; goal achievement by 2 years80-200 lbs in 12-18 months; goal achievement by 2 years Life style changes + dietary recommendationsLife style changes + dietary recommendations Band + possible adjustmentsBand + possible adjustments

• Reduction of Co-morbiditiesReduction of Co-morbidities New-onset type 2 diabetes drops by 85%New-onset type 2 diabetes drops by 85% Sleep apnea Sleep apnea →→ improvement in 86%; improvement in 86%; Increased intracranial pressure Increased intracranial pressure → → resolution in over 95%,resolution in over 95%, Hypertension Hypertension → → resolved in 60 – 74% of the patientsresolved in 60 – 74% of the patients

Skin and cosmetic surgerySkin and cosmetic surgery

For morbidly obese patients, the risk of obesity far outweighs For morbidly obese patients, the risk of obesity far outweighs the risk of either surgery.the risk of either surgery.

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It works….It works….

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www.jaxsurgical.com

It works…It works…

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The weight just falls…The weight just falls…

Thank you!Thank you!

www.JaxSurgical.comwww.JaxSurgical.com

Michael Baptista, MDMichael Baptista, MD

Update on Obesity Management & Surgical Options

Healthcare

Transcript of Update on Obesity Management & Surgical Options