Laparoscopic Bariatric Surgery
Bariatric Surgery
Greek baros (weight) + iatrike (medicine, surgery)
A field of medicine encompassing the study of overweight, its causes, prevention, and treatment
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!
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 annually300,000 deaths annually
Prevalence of Obesity* among U.S. AdultsPrevalence of Obesity* among U.S. Adults BRFSS, 1990BRFSS, 1990
(*Approximately 30 pounds overweight)
<10% 10% to 15% >15%
Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.
Prevalence of Obesity* among U.S. AdultsPrevalence of Obesity* among U.S. Adults BRFSS, 1991BRFSS, 1991
(*Approximately 30 pounds overweight)
<10% 10% to 15% >15%
Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.
Prevalence of Obesity* among U.S. AdultsPrevalence of Obesity* among U.S. Adults BRFSS, 1992BRFSS, 1992
(*Approximately 30 pounds overweight)
<10% 10% to 15% >15%
Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.
Prevalence of Obesity* among U.S. AdultsPrevalence of Obesity* among U.S. Adults BRFSS, 1993BRFSS, 1993
(*Approximately 30 pounds overweight)
<10% 10% to 15% >15%
Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.
Prevalence of Obesity* among U.S. AdultsPrevalence of Obesity* among U.S. Adults BRFSS, 1994BRFSS, 1994
(*Approximately 30 pounds overweight)
<10% 10% to 15% >15%
Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.
Prevalence of Obesity* among U.S. AdultsPrevalence of Obesity* among U.S. Adults BRFSS, 1995BRFSS, 1995
(*Approximately 30 pounds overweight)
<10% 10% to 15% >15%
Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.
Prevalence of Obesity* among U.S. AdultsPrevalence of Obesity* among U.S. Adults BRFSS, 1996BRFSS, 1996
(*Approximately 30 pounds overweight)
<10% 10% to 15% >15%
Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.
Prevalence of Obesity* among U.S. AdultsPrevalence of Obesity* among U.S. Adults BRFSS, 1997BRFSS, 1997
(*Approximately 30 pounds overweight)
<10% 10% to 15% >15%
Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.
Prevalence of Obesity* among U.S. AdultsPrevalence of Obesity* among U.S. Adults BRFSS, 1998BRFSS, 1998
(*Approximately 30 pounds overweight)
Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.
<10% 10% to 15% >15%
Prevalence of Obesity* among U.S. AdultsPrevalence of Obesity* among U.S. Adults BRFSS, 1999BRFSS, 1999
(*Approximately 30 pounds overweight)
Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.
<10% 10% to 15% >15%
Current Data
Over 50% of Americans are obese and over 10% are morbidly obese
What Is Obesity?
A life-long, progressive, life-threatening, costly, genetically-related, multi-factorialmulti-factorial disease of excess fat storage
ASBS
Body Mass Index (BMI)
BMI = weight (kg)_____ height (m) x height (m)
WHO Classification BMI Ideal weight 20–24.9 Overweight 25–29.9 Moderate obesity(class I) 30–34.9 Severe obesity (class II) 35–39.9 Morbid obesity (class III) 40–49.9 (Super obesity) 50 +++
Exponential Mortality Risk
Co-Morbid Medical Conditions
Diabetes Hypertension Hyperlipidemia Cardiac disease Respiratory disease
sleep apnea Arthritis Depression Stress Incontinence Menstrual irregularity
14–20% 25–55% 35–53% 10–15% 10–20%
20–25% 70–90% 50% 50%
What Causes Obesity?
Energy in > energy out Obesity is multifactorialmultifactorial:
genetic 25–30% neuroendocrine environmental metabolic
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
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
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
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
Vertical Banded Gastroplasty (VBG) aka “Stomach Stapling”
On the way out Restrictive Minimal metabolic
effects Defeated by junk
food diet, liquids 40–60% loss EBW Only 38% success
staple line failure
graphics Courtesy of ASBS
Laparoscopic Adjustable Gastric Banding
Restrictive Ongoing FDA studies No long-term
follow-up Presence of a
foreign body Post operative
adjustments required
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
Frantzides et al. Laparoscopic Gastric Stapling and Roux-en-Y Gastrojejunostomy for the treatment of Morbid obesity. J Laparoendosc Surg 1995
Laparoscopic Roux-en-Y(Minimally Invasive)
Planning
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
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
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
OPENHospital stay of about 5 days.
Return to work in about 4 weeks.
More painful
Greater risk of infection
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)
Results of Lap Gastric Bypass, 2003
81%(12)
2.00.29050711Frantzides
82%(12)
2.51.6NR5063Champion
77%(30)
2.61.024748275Schauer
69% (12)
1.63.0NR46400Higa
73%(54)
2.6NR120NR500Wtittgrove
EBWL(Follow-up in months)
Hospital Stay (D)
Conversion (%)
Mean OR Time (MIN)
Mean BMINo. Patients
Author
Frantzides et al. Triple Stapling Technique for Jejunojejunostomy in Laparoscopic Gastric Bypass. Arch Surg 2003
Post-Op Incisions
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
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
Post-Operative
Most patients lose up to and beyond 80% of excess weight
…and keep it off.
Reduction in Co-Morbidities
All medical co-morbidities are resolved or improved in 80–100% of patients
Swedish Obesity
Surgery Study
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
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.
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
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.
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.
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.
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
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.
Pre-Op
Post-Op
Before
After
Pre-Op
Post-Op
Before
After
12/13/02
1/16/04
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
Chicago Institute of Minimally Invasive Surgery-St Francis
Hospital
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