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Bariatric Surgery for the Internist Gordon Wisbach, MD, FACS Director, Bariatric Surgery Program Naval Medical Center

Bariatric Surgery for the Internist Gordon Wisbach, MD, FACS Director, Bariatric Surgery Program Naval Medical Center San Diego. NMCSD Bariatric Team Gordon Wisbach, MD, Eva Brzezinski, MS, RD, David Gallus, MD, Karen Hanna, MD, Thomas Nelson, MD, Deborah Romero, MSN, FNP.

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Bariatric Surgery for the Internist Gordon Wisbach, MD, FACS Director, Bariatric Surgery Program Naval Medical Center

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  1. Bariatric Surgery for the Internist Gordon Wisbach, MD, FACS Director, Bariatric Surgery Program Naval Medical Center San Diego

  2. NMCSD Bariatric Team Gordon Wisbach, MD, Eva Brzezinski, MS, RD, David Gallus, MD, Karen Hanna, MD, Thomas Nelson, MD, Deborah Romero, MSN, FNP

  3. Obesity Epidemic • World epidemic encompasses 1.7 billion people • Highest in the U.S. • Approximately 2/3 of Americans are overweight, and almost half are obese • BMI subgroups of >35 and >40 are experiencing most rapid growth Buchwald et al. Jama 2004

  4. Obesity Epidemic • World epidemic encompasses 1.7 billion people • Highest in the U.S. • Approximately 2/3 of Americans are overweight, and almost half are obese • BMI subgroups of >35 and >40 are experiencing most rapid growth Buchwald et al. Jama 2004

  5. Obesity Epidemic • Rise in the prevalence of obesity is associated with rises in prevalence of obesity related comorbidities • Comorbidities responsible for 2.5 million deaths per year worldwide • Loss of life expectancy is profound • 25 year-old morbidly obese male has 22% reduction in lifespan, representing a loss of 12 years of life Buchwald et al. Jama 2004

  6. Obesity Trends Among U.S. AdultsBRFSS,1990, 1999, 2009 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 1999 1990 2009 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

  7. Obesity Data per County

  8. Obesity Data per Race/Ethnicity Hispanic White/Non-Hispanic Black/Non-Hispanic

  9. Obesity Epidemic • Diet therapy, with and without support organizations, is ineffective long term • Currently, there are no effective pharmaceutical agents to treat obesity, especially morbid obesity North American Association for the Study of Obesity. NIH 2000

  10. Definition of Obesity according to BMI BMI = W(kg)/H (m²)

  11. BMI • Calculated as follows: Weight(kg)/Height(m2) • Lowest mortality = BMI < 25kg/m2 • Highest mortality = BMI > 40kg/m2 • BMI > 40 = approximately 100lbs. over ideal body weight

  12. WhyOperate?

  13. Medical Complications of Obesity Idiopathic intracranial hypertension Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Stroke Cataracts Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Coronary heart disease Diabetes Dyslipidemia Hypertension Severe pancreatitis Gall bladder disease Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Phlebitis venous stasis Skin Gout

  14. Medical Co-morbidities • Metabolic •  Mechanical •  Degenerative •  Neoplastic •  Psychological

  15. Medical Co-morbidities Metabolic •  Diabetes mellitus, type II •  Hypertriglyceridemia •  Hypercholesterolemia •  Hypertension • Gallstones • Fatty liver disease (NASH) • Pancreatitis • Central sleep apnea • Hypercoagulable • Infertility

  16. Metabolic Syndrome Abdominal obesity Hyperinsulinemia High fasting plasma glucose Impaired glucose tolerance Hypertriglyceridemia Low HDL-cholesterol Hypertension

  17. Medical Co-morbidities Mechanical/Anatomic • Obstructive sleep apnea • GERD • GERD - associated asthma • Urinary stress incontinence • Pseudotumor cerebri • Venous stasis • DVT / PE • Fungal skin infections • Decubitus ulcers • Accidental injuries

  18. Medical Co-morbidities Degenerative • Cardiovascular disease • Complications of diabetes • CHF • DJD • Vertebral disc disease • NASH related cirrhosis

  19. Medical Co-morbidities Neoplastic • Breast Cancer • Ovarian Cancer • Endometrial Cancer • Prostate Cancer • Colorectal Cancer • Renal Cell Carcinoma • NHL • Esophageal Cancer • Gastric Cancer • Pancreatic Cancer

  20. Medical Co-morbidities Psychological • Anxiety disorders • Depression • Binge eating disorders • Reactive bulimia • Trauma

  21. Indications for Surgery • BMI > 40 kg/m2 • BMI > 35 kg/m2 with co-morbidities • Comorbidities: • Hypertension • Diabetes • Hyperlipidemia • Sleep apnea • Severe arthrosis NIH Consensus Conference Ann Intern Med 1991

  22. Indications for Surgery • Age > 18 or < 60 • Failure of diet > 6 months • Obesity history > 5 years • Low risk for surgery • No endocrinological disease • Psychologically sound NIH Consensus Conference Ann Intern Med 1991

  23. Goals of Surgery • Effective: Loss > 50% of Excess Weight • Low operative morbidity • Well tolerated • No long term complications

  24. Preoperative Preparation • Cardiac • Pulmonary • Endocrine • Psychiatric • Gastro-intestinal • Dietician • Weight Loss

  25. Nutritionist Wrong expectations Poor compliance Poor outcome Yes 1

  26. History of Bariatric Surgery • Realization that some patients with Gastric Surgery would lose weight • Observation that ileal resection caused improved fatty acid and cholesterol profile

  27. History of Bariatric Surgery • J-I Bypass: Kremen, Linner, Nelsen, Dragstedt • Gastric Bypass: Mason • BPD: Scopinaro • Gastric Banding: Kuzmak • Gastric Pacing: Cigiana

  28. Surgical Procedures • Restrictive procedures • Gastric Banding • Vertical Banded Gastroplasty • Vertical Gastrectomy • Malabsorptive procedure • Biliopancreatic Diversion • Scopinaro • Duodenal-Switch BPD • Hybrid procedure • Roux-en-Y Gastric Bypass

  29. Surgical Procedures(International Registry of Bariatric Surgery 2002)

  30. Vertical Banded Gastroplasty Mac Lean Mason

  31. Vertical Banded Gastroplasty • Developed in 1982 by Dr. Mason • Most widely used between 1982 and 1992 • 78% of patients are successful at decreasing co-morbidities • Staple line failure can occur up to 20% per year • Band erosion

  32. Bilio-pancreatic diversion Withduodenalswitch Scopinaro

  33. Bilio-Pancreatic Diversion • Developed by Scopinaro in 1979 • Excellent weight-loss results • Excellent results with resolution of co-morbidities • Technically demanding • Higher complication rate

  34. Vertical Gastrectomy

  35. Vertical Gastrectomy • Developed in 1987 by Dr. Johnston called the Magenstrasse and Mill operation • Derived from VBG • Restrictive component of BPD with DS • Advantages include no anastomosis or prosthetic implant making it technically easier in higher BMI patients

  36. Roux-en-Y GastricBypass

  37. History of Gastric Bypass • 1967 – first described gastric bypass by Mason and Ito • 1994 - first report of laparoscopic gastric bypass by Wittgrove & Clark • Mirroring the open technique, the laparoscopic approach was initially described retrocolic, retrogastric • Currently, there are multiple variations of each major aspect of the operation without a standardizedapproach

  38. How does it work ? Gastric Bypass ? Loss of appetite Ghrelin Restriction Small pouch (approx 30 cc) Small anastomosis (approx. 1.5 cm) Malabsorption Alimentary Limb Between 100 to 200cm Biliopancreatic Limb Between 50 to 75 cm

  39. Gastric Bypass: Technique • Biliary Limb • 15 to 100cm • Roux Limb • BMI<50: does not matter • BMI>50: 150cm Choban Obesity Surg 2002 Brolin Ann Surg 1992

  40. Gastric Bypass: Follow Up • Clinical Pathway • 2 weeks, 1 month, 3 months, 6 months, 9 months, 1 year, 18 months and yearly • Nutritionist • Vitamins • Labs • Aggressive follow up is the key to good outcomes

  41. Roux-en-Y Gastric Bypass • Excess weight loss (EWL): 60%- 80% after 12 months • Mean EWL at 5 years: 50-60% • Morbidity: 16% • Mortality: 0.2% Brolin, Surg Clin North Am; 2001

  42. Roux-en-Y Gastric Bypass • Co-morbidities Resolved/Improved • Respiratory dysfunction(up to 99%) resolved • Hypertension (up to 95%) improved • Cardiac dysfunction (up to 95%) improved • Diabetes (up to 90%) resolved • Arthritis (up to 85%) improved • Hyperlidemia (up to 95%) resolved • Gastro-esophageal Reflux (up to 99%) resolved

  43. Surgical Outcomes: Comorbidities • Resolution or improvement in a substantial number of patients after gastric bypass • Buchwald et. al JAMA 2004; 292; 1724

  44. Roux-en-Y Gastric Bypass:Complications • Overall: 16% • Leak • Hemorrhage • P.E. • Stomal stenosis • Marginal ulcer • Internal hernia • Incisional hernia • Vit B12 deficiency • Iron Deficiency • Mortality: 0.2%

  45. Unfilled Band Filled Band GastricBanding

  46. Gastric Banding • Developed by Dr. Kuzmak in 1982 • No staples • Ability to adjust stoma size • Completely reversible • U.S. Clinical trial began in 1990 • International experience • Over 2,000 ASGB implantations ’91-’94 • ASGB results comparable to VBG results

  47. Laparoscopic Gastric BandingResults FDA Study’s outcomes : (www.fdcdrh/pdf/POOOOO8b.pdf) • 178 pts • 36 months f.u. • EWL: 36% at 36 months • 82% overall adverse event incidence

  48. Laparoscopic Gastric BandingResults • Change in technique – pars flaccida rather then peri-gastric • Product improvements • Decreased complications – slippage, erosion • Increased results – EBWL 50-60% - studies range • Requires f/u for 3-4 yrs

  49. “Laparoscopic Adjustable Gastric Banding 1,014 Consecutive Cases • Ponce, et al. • 1014 consecutive cases • 82% women, mean age 42, BMI 47.7 kg/m2 • %EBWL at 3 years 62+-21% • Slip rate 1.4% (pars flaccida) to 21% (perigastric) • 2 cases (0.2%) erosion • 85% follow-up J Am Coll Surg. Vol 701, No. 4, 2005 p 529-535

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