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BARIATIC SURGERYFOR OBESITY

boon or bane

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One of the most widespread health

problems in the world.

Responsible for causing many diseases.

Leads to premature death

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The Obesity EpidemicThe Obesity EpidemicThe weight gain cycleThe weight gain cycle

Eat too muchEat too much

Gain weightGain weight

CantCant

ExerciseExercise

GetGet

DepressedDepressed

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1998

Obesity Trends* Among U.S. Adults

BRFSS, 1990, 1998, 2006(*BMI u30, or about 30 lbs. overweight for 54 person)

2006

1990

No Data

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MORE THAN

1 IN 4

CHILDREN IS

OVERWEIGHT

or OBESE!!

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NormalNormal

WeightWeight(BMI 18.5 to(BMI 18.5 to

24.9)24.9)

OverweightOverweight

(BMI 25 to 29.9)(BMI 25 to 29.9)

ObeseObese

(BMI 30 to 34.9)(BMI 30 to 34.9)

Severely ObeseSeverely Obese

(BMI 35 to 39.9 )(BMI 35 to 39.9 )

Morbidly ObeseMorbidly Obese

(BMI(BMI >> 40)40)

Body Mass Index (BMI)

Super ObeseSuper Obese

(BMI(BMI >> 5050))

BMI = weight (kg) / height (m)BMI = weight (kg) / height (m)22

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BMI and mortality

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The Risks of Overweight

Coronary heart disease

Metabolic syndrome:hypertension, diabetes mellitus,high cholesterol

Breast cancer, prostate cancer,colon cancer, uterine cancer

Stroke

Osteoarthritis

Gallbladder disease

Sleep apnea, respiratoryproblems

Work, educational, and socialdiscrimination

Depression

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To Cut or Not To Cut

Medical Therapy 5-10% excess weight

loss

Pharmacologic Intervention 8-10% EWL

Bariatric Surgery 60-80% EWL

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Disadvantages of medical

treatmentMost patients (95-97%) regainmost or all of the weight thatwas lost within 2-5 years.

Relatively small -- 10-40pounds

Associated with severecomplications.

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Not this!

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Why would anyone have surgery to

lose weight?

Most people are not successful losing weight with diets (up to97% are unsuccessful)

As someone becomes more overweight, the risk of developing

other serious diseases dramatically increases

Surgery has proven to be the MOST effective method to treatsevere obesity

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NIH Criteria for surgery:

1. Patients with a BMI of 40 or greater

2. Patients with BMI of 35 or greater who also sufferfrom a severe medical condition related to obesity

(sleep apnea, diabetes, heart failure, high bloodpressure)

3. A patient who is prepared and willing to commit to thelifestyle changes that will be necessary following

surgery

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Surgery

2001 47,0002003 98,0002008 344,221

No. of surgery done in INDIA in 2008 -1,216.

Over 90% (91.4%) of world bariatricsurgery was performed laparoscopically.

Henry Buchwald, Danette M. Oien.Metabolic/Bariatric Surgery Worldwide 2008.Obes Surg 19(12)

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Types of Bariatric Procedures

Restrictive:Vertical banded gastric bypass

Laproscopic adjustable gastric banding

Restrictive and Malabsorptive:Roux-en Y gastric bypass

Distal gastric bypass with DS

Malabsorptive:

Jejuno-ileal bypassBiliopancreatic Diversion

Duodenal Switch (DS), no bypass

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The most common procedures, 86.6% of the

total number of procedures were

1.Laparoscopic AGB (32.3%),

2.laparoscopic RYGB (39.7%; open plus

laparoscopic RYGB 49.3%), and

3.laparoscopic SG (5.1%).

y Henry Buchwald, Danette M. Oien,.

Metabolic/Bariatric Surgery Worldwide 2008.

Obesity Surgery; 19(12)

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Laproscopic Adjustable

Banding This type of surgery is

performed with the

laparoscope.

This surgery

restricts

consumption but

does not cause

malabsorption.

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Advantages of the Lap Band

Less invasive, shorter surgery, and shorter hospital

stay.

After 3 years weight loss is about the same asRoux-en-Y in some studies.

Adjustable - customized per patient.

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Reversible

Lowest operative complication rate - noleaks

Low malnutrition risk

Satiety-including procedure

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Surgical Advantages of Pure Gastric

Restriction

50% excess weight loss at 1 year

Minimal nutrition complications

Can be used in populations that are

high risk for RYGB

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MOSTLY RESTRICTIVE PROCEDURES

Most commonly

performed surgery in

USA

Weight loss by

restricting food intake.

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Roux-en Y Gastric Bypass

Best weight

reduction surgery

according to NIH.

Surgeons create a

pouch from the

upper part of thestomach.

It becomes a

Reservoir for food.

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Roux-en-Y Surgery

Very effective in obtaining and maintaininglong-term weight loss.

At 10 years, the average patient will have lostabout 70% of their excess weight.

Seems to be more effective in patients whose

BMI is 50 or less.

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Malabsorptive Procedure Facts

The largest weight loss is usually seen withthis procedure.

At 10 years, the average excess weight lossis about 80%.

Heavier patients (BMI > 50) appear to have

better results with this operation in the longterm than other weight-loss procedures

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Surgical Advantages of Combined Gastric

Restriction & Malabsorption

Advantages of Gastric Bypass :60% of excess weight lost in year 1

Maintains a weight loss of 50% for 25 years

Rapid resolution of metabolic syndromeImprovement in obesity-related complications

Advantages of the Duodenal Switch :

60-80% of excess weight lost in year 1

Most effective therapy for super obese

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Weight Loss Benefits vs. Nutritional Risk

0

10

20

30

40

50

60

70

Band Gastroplasty GBP DS

EWL

Mortality

B12 def

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Anti-obesity Surgery and Co-morbidities

0

20

40

60

80

100

120

Hype

rtens

ion

Diab

etes

Lipid

s

Asthma

HeartF

ailure

Slee

pApn

ea

Improve

Cure

J Kral 1995, >1000 patients

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The mean glucose levels in the surgical

group fell from 187 mg/dl preoperatively

and remained less than 140 mg/dl for up

to 10 years of follow-up.

Macdonald KGJ, Long SD, Swanson MS, et al. The

gastric bypass operation reduces the progression

and mortality of non-insulin-dependent diabetes

mellitus. J Gastrointest Surg 1997;1:213-20.

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Gastric bypass is now established as

effective & safe therapy for morbid

obesity& its associated comorbidities.

No other therapy has produced such

durable & complete control of diabetes

mellitus.

Pories WJ, Swanson MS, MacDonald KG et al. Who

would have thought it? An Operation Proves to be

most effective therapy for adult onset diabetes

mellitus. Ann Surg 1995; 222: 339-50

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Bariatric surgery is effective for decreasing the useof medications for obesity-related diabetes,hypertension, and hyperlipidemia.

The clinical and economic benefits of reducedmedication requirements should be consideredwhen making decisions about the effects ofbariatric surgery.

Jodi BS , Jeanne MC, Andrew DS, et al. Prompt Reduction inUse of Medications for Comorbid Conditions After BariatricSurgery. Obes Surg 2009; 19(12):1646-56

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LGBRY can be done safely in patients over60 years of age in an experienced bariatricprogram, even in patients with relatively high riskbased on their comorbid conditions preoperatively.

Resolution of associated comorbidities farexceeds that found with any other treatmentmodality.

Alan CW, Tracy M. Laparoscopic Gastric Bypass in Patients60 Years and Older: Early Postoperative Morbidity andResolution of Comorbidities. Obes Surg 2009; 19(11) 1472-76

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Behavior modification techniques produce asmuch as 8% to 10% weight loss.

Weight regain after a period of initial weight losswas seen in virtually all studies that involved

behavioral approaches.

Volume 70, No. 6 : 2009 GASTROINTESTINALENDOSCOPY 1167

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Pharmacotherapy

Use of pharmacologic agents for patients with

severe obesity is limited by their modest efficacy,

weight regain after cessation of therapy,adverse-effect profile, and uncertainty of long-

term safety.

Volume 70, No. 6 : 2009 GASTROINTESTINAL ENDOSCOPY 1168

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Weight loss 1 year after gastric bypass

was significant and led to an improvement

of quality of life.

Health-related quality of life improves

dramatically 1 year after gastric bypass.

Jennifer K, Zoltan P, Ileana I, et al. Relationship

between Quality ofLife and Weight Loss 1 Year after

Gastric Bypass. Digestive surgery 2009; 26(5):

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The operative 30-day mortality rates of

0.1% for the restrictive procedures, 0.5%

for gastric bypass, and 1.1% for

biliopancreatic diversion or duodenal

switch compare favorably with the

accepted operative mortality rates for

other major surgical procedures.

Buchwald H, Avidor Y, Braunwald E, et al. Bariatic

surgery : a systematic review and Meta analysis.

JAMA 2004;292(14):1724-37

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Benefits of Bariatric Surgery

Improved glycemic control

Improved BP

Improved ventricular function

Improvement in symptoms of Osteoarthritis

Improved quality of life

Reduction in depressive symptoms

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In addition to the effective weight loss

achieved by patients undergoing bariatric

surgical procedures, a substantial majority

of patients with diabetes, hyperlipidemia,

hypertension, and obstructive sleep apnea

experienced complete resolution or

improvement of their comorbid condition.

Buchwald H, Avidor Y, Braunwald E, et al. Bariatic

surgery : a systematic review and Meta analysis.

JAMA 2004;292(14):1724-37

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Weight-loss surgery significantly

decreases overall mortality as well as

the development of new health-

related conditions in morbidly obese

patients.

Christou NV, Sampalis JS, Liberman M, et al

Surgery Decreases Long-term Mortality,

Morbidity, and Health Care Use in Morbidly

Obese Patients. Ann Surg 2004;240:416-23

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Severely obese patients

who lost 43 kg through

gastric bypassdemonstrated improved

quality of life scores to such

an extent that their post-

weight loss scores wereequal to or even better than

population norms.2009

J La State Med Soc .2005; 157 (1): S42-49.

Endocrinol Metab Clin N Am. 2003; 32: 761-

786.

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Non surgical treatment have limited success inachieving substantial weight loss for morvidly obesepatients

There is sufficient evidence to conclude that surgeryimproves health outcomes for patients with morbidobesity as compared with non surgical treatment.

Blue Cross Blue Shield Association. Special report: Therelationship between weight loss & changes in morbidity following

bariatic surgery for morbid obesity. Technol Eval Center AssesProg Exec Summ 2003;18(9):1-25

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Bariatic surgery is more effective than nonsurgical treatment & clearly results insustained weight loss & comorbidity control.

Also stated that at this stage an RCT thatcompares medical & surgical therapies is notwarranted given the known superiority of thelatter.

Shekelle PG, Morton SC, Maglione MA et al.Pharmacological & Surgical treatment of Obesity.AHRQ Publication #04-E028-2, 2004

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CONCLUSION

Surgical therapies are themost efficacious and durable

weight-loss options forpatients with MORBIDobesity.

Volume 70, No. 6 : 2009GASTROINTESTINALENDOSCOPY 1174

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THANK YOU