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Obesity: Surgical Management

Obesity: Surgical Management. Eric S. Hungness, M.D. Assistant Professor of Surgery Department of Surgery Northwestern University Feinberg School of Medicine Chicago, Illinois. Etiology of Obesity. MULTIFACTORIAL. Familial Genetic Gender (F>M) Social Psychologic (depression).

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Obesity: Surgical Management

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  1. Obesity:Surgical Management Eric S. Hungness, M.D. Assistant Professor of Surgery Department of Surgery Northwestern University Feinberg School of Medicine Chicago, Illinois

  2. Etiology of Obesity MULTIFACTORIAL • Familial • Genetic • Gender (F>M) • Social • Psychologic (depression)

  3. The Obesity Epidemic The weight gain cycle Eat too much Gain weight Can’t Exercise Get Depressed

  4. Body Mass Index (BMI) BMI = weight (kg) / height (m)2 Normal Weight (BMI 18.5 to 24.9) Overweight(BMI 25 to 29.9) Obese(BMI 30 to 34.9) Severely Obese(BMI 35 to 39.9 ) Morbidly Obese(BMI > 40) Super Obese(BMI > 50)

  5. Body Mass Index (BMI)

  6. The Obesity Epidemic • 66% of Americans >20 yrs are either overweight or obese (BMI > 25, ~ 133 million people) • Increased from 45% in 1960 • 33% of Americans >20 yrs are obese (BMI > 30, ~ 66 million) • 5% of Americans are morbidly obese (BMI > 40, ~ 10 million) • 3.1% in men and 6.7% in women • Increasing by 1% per year • Obesity is increasing in children (doubled in past 20 years) • 15% between the age of 6 and 19 NHANES (2003-04) (n=4,431)

  7. Obesity Trends* Among U.S. AdultsBRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

  8. Obesity Trends* Among U.S. AdultsBRFSS, 1986 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

  9. Obesity Trends* Among U.S. AdultsBRFSS, 1987 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

  10. Obesity Trends* Among U.S. AdultsBRFSS, 1988 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

  11. Obesity Trends* Among U.S. AdultsBRFSS, 1989 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

  12. Obesity Trends* Among U.S. AdultsBRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

  13. Obesity Trends* Among U.S. AdultsBRFSS, 1991 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

  14. Obesity Trends* Among U.S. AdultsBRFSS, 1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

  15. Obesity Trends* Among U.S. AdultsBRFSS, 1993 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

  16. Obesity Trends* Among U.S. AdultsBRFSS, 1994 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

  17. Obesity Trends* Among U.S. AdultsBRFSS, 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

  18. Obesity Trends* Among U.S. AdultsBRFSS, 1996 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

  19. Obesity Trends* Among U.S. AdultsBRFSS, 1997 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

  20. Obesity Trends* Among U.S. AdultsBRFSS, 1998 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

  21. Obesity Trends* Among U.S. AdultsBRFSS, 1999 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

  22. Obesity Trends* Among U.S. AdultsBRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

  23. Obesity Trends* Among U.S. AdultsBRFSS, 2001 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

  24. Obesity Trends* Among U.S. AdultsBRFSS, 2002 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

  25. Obesity Trends* Among U.S. AdultsBRFSS, 2003 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

  26. Obesity Trends* Among U.S. AdultsBRFSS, 2004 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

  27. Obesity Trends* Among U.S. AdultsBRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

  28. Obesity Trends* Among U.S. AdultsBRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

  29. Why do we treat obesity?? • Co-morbidities • Quality of life • Survival – Life Expectancy

  30. Endocrine Diabetes Cardiovascular Hypertension Hyperlipidemia Hypertriglyceridemia Coronary and cerebral vascular disease Venous stasis Gynecology Infertility Menstrual irregularities Orthopedic DJD Arthralgia Low back pain Dermatology Fungal infection Co-morbidities

  31. Pulmonary Sleep apnea Asthma Hypoventilation Pulmonary hypertension Gastrointestinal Cholelithiasis GERD Fatty liver /dysfunction Socio-economic Discrimination Psychological Depression h/o abuse Cancer Co-morbidities

  32. Life Expectancy • 2nd only to smoking as the leading cause of preventable death in the United States.† • > 110,000 deaths/year in the US are associated with obesity* * Flegal KM et al. JAMA. 2005 Apr 20;293(15):1861-7. † CDC

  33. Life Expectancy

  34. Life Expectancy Years of Life Lost (YLL) • white male 10 years • white female 7 years • black male 11 years • black female 3 years Fontaine et al. JAMA 2003; 289:187-193

  35. Medical Treatment • Medications • Dietary Changes • Exercise • Behavioral Therapy • Psychotherapy • Hypnosis • Jaw-wiring UNSUCCESSFUL AT SIGNIFICANT OR SUSTAINED WEIGHT LOSS!

  36. Trends In Surgery 1992 - 2003

  37. Rationale for Surgery • Long Term Outcome Data • Sustained Weight Loss • Improvement or Resolution of Co-morbidities • Improved long term survival • Minimally Invasive Surgery • Public Awareness • Obesity as a disease • Celebrities

  38. Indications for Surgery • BMI >40 kg/m2, or >35 kg/m2 with significant co-morbid illnesses • Multiple failed weight loss attempts • Acceptable surgical risk • Age 18-60 • Demonstrates commitment and understanding of weight loss following bariatric surgery

  39. Preoperative Evaluation/Education • Staff evaluation • Internist • Dietitian • Psychologist • Nurse • Surgeon • Support group • Laboratory evaluation • Blood • ECG, CXR • Stress Test • Sleep study • EGD • PFTs Consider an IVC filter for any patient with prior history of DVT/PE.

  40. Surgical Treatment Restrictive Horizontal gastroplasty Vertical banded gastroplasty (VBG) Roux-en-Y gastric bypass Adjustable gastric band Sleeve gastrectomy Malabsorptive Jejunoilial bypass Biliopancreatic diversion (Scopinaro) Biliopancreatic diversion w/ duodenal switch

  41. Surgical Treatment Restrictive Horizontal gastroplasty Vertical banded gastroplasty (VBG) Roux-en-Y gastric bypass Adjustable gastric band Sleeve gastrectomy Malabsorptive Jejunoilial bypass Biliopancreatic diversion (Scopinaro) Biliopancreatic diversion w/ duodenal switch

  42. Horizontal Gastroplasty (HG) Gomez, Cesar. World Journal of Surgery, 1981

  43. Vertical Banded Gastroplasty (VBG) Angle of His Gastric Pouch Polypropylene band Transgastric window Mason E, Archives of Surgery, 1982

  44. Gastric Bypass + Roux-en-Y 75 – 150 cm ~ 40cm

  45. Lap Adjustable Band

  46. Sleeve gastrectomy

  47. Jejunoileal Bypass Payne and Dewind, Archives of Surgery, 1973

  48. Biliopancratic Diversion w/o duodenal switch w/ duodenal switch 75 – 100cm Common channel Marceau, et al. World Journal of Surgery, 1998

  49. Gastric Bypass vs LapBand vs Duodenal Switch

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