Roux-en-Y Gastric Bypass

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1 Roux-en-Y Gastric Bypass Restrictive and malabsorptive procedure Most frequently performed bariatric procedure in the US First done in 1967 Laparoscopic since % EWL in months 50% EWL is still maintained at a 14yr follow-up ASBS

2 Facts on Roux-en-Y Gastric Bypass Operation time: 1-3 hours Hospital stay: 2.5 days Return to normal activity: 7-10 days Diet advancement: liquid-> puree-> regular diet Not Reversible

3 Expected weight loss with the Roux-en-Y Gastric Bypass lbs in the first month lbs in the first 6 months 75% of EWL in months

4 - Bleeding Risks and Complications related to Roux-en-Y Gastric Bypass - Pulmonary embolism - MI - Intestinal Obstruction - Hernias - Kidney/Gallstones - Nutritional and/or vitamin deficiencies - Death - Leaks % - Strictures 3 % - Ulcers - Dumping Syndrome - Malnutrition

5 Vertical Sleeve Gastrectomy (VSG) Restrictive procedure First done in US in 2001 Removing 60-85% stomach 30-50% EWL

6 Facts on Vertical Sleeve Gastrectomy Operation time: 1-2 hours Hospital stay: 2.5 days Return to normal activities: 7 days Diet advancement: liquid->puree->regular diet Not reversible No intestinal bypass, only stomach reduction

7 Risks and Complications related to Vertical Sleeve Gastrectomy - Bleeding - Pulmonary embolism - MI - Intestinal Obstruction Gastric leaks and fistulas Injury to Spleen /Splenectomy Stricture - Hernias - Kidney/Gallstones - Nutritional and/or vitamin deficiencies - Death

8 Comparison of attributes of the principal bariatric procedures Attribute Gastric band RYGB Sleeve gastrectomy Safe Effective Durable + +++? Side effects Reversible easily Yes No No Minimally invasive Controllable/adjusta ble Yes No No Low revision rate NO YES? Requires follow up Metabolic Impact LOW HIGH HIGH

9 What is the Mortality Rate? Cholecystectomy?

10 Mortality Rates Adjustable Gastric Band 0.1% Gastric Bypass 0.5% Vertical Sleeve Gastrectomy 0.25%

11 Post operative reasons that may cause death Pulmonary embolism (blood clots) Myocardial infarction (heart attack)

12 Extreme Obesity Intraop Management: Airway Brodsky JB: Anesth Analg, Volume 96(6) June

13 Facts that play a role in the decision-making process Age Medical History Surgical History BMI Psychological Profile Nutritional Profile Lifestyle Personal choice

14 Post Operative Phases Surgical Recovery Diet Modification Life Stile Adjustment Health Maintenance

15 Supplements after weight loss Gastric Band: MVI Protein surgery VSG: -MVI -Protein Gastric Bypass: MVI Protein Calcium Citrate + D Iron

16 Expected Risks and Outcomes

17 Risk Benefit Ratio Risk of Obesity Risk of surgery Life Lost : BMI > 45 / year old White men: lose 13 years White women: lose 8 years African American men: 20 years African American women: 5 years LAGB mortality: 0.1% RGBP mortality: 0.5%

18 Estimated Number of Bariatric Operations Performed in the United States, , , , , ,000 80,000 60,000 40,000 20, Modified from Steinbrook, R. N Engl J Med 2004;350: using ASMBS estimates

19 Bariatric Procedures at PENN HUP HUP

20 Effects of bariatric surgery on mortality in Swedish obese subjects Percent Weight Change during a 15-Year Period Sjöström et al. NEJM 357 (8): 741, 2007

21 Outcomes after Surgery New England Journal of Medicine Study: 56% decrease in mortality from heart disease 70% decrease in cancer related mortality 90% decrease in diabetes related mortality

22 Effects of bariatric surgery on mortality in Swedish obese subjects Cumulative Mortality. Sjöström et al. NEJM 357 (8): 741, 2007

23 Medical Co-Morbidities Resolved Cholesterol 97% Type 2 Diabetes 95% Hypertension 92% GERD 98% Cardiac Function Improvement 95% Stress Incontinence 87% Osteoarthritis 82% Sleep Apnea 75% Wittgrove AC,Clark GW. Laparoscopic Gastric bypass roux-n-y-500 patients. Obes Surg And others.

24

25 Bariatric surgery: a systematic review and meta-analysis OSA Hypertension Hyperlipidemia Diabetes 0% 20% 40% 60% 80% 100% 120% Diabetes Hyperlipidemia Hypertension OSA Resolution 77% 62% 84% Improvement 85% 97% 79% 86% Buchwald, H. et al. JAMA 2004;292:

26 Table 10: Improvement of Comorbidities After Bariatric Surgery Operation Diabetes resolved (%) Hypercholesterol improved (%) Hypertension resolved (%) Sleep apnea resolved (%) AGB RYGB BPD ± DS LSG Dumon et al. Surg. Clin North America 2011 Dec; 91(6):

27 Mean values from a meta-analysis of 22,094 patients Restrictive (AGB) Malabsorptive (BPD) Combined (RYGB) EWL % Type 2 diabetes Hypertension Hyperlipidemia (improved) Sleep apnea Operative mortality Reviewed in Vetter, Dumon et al., 2012

28 Bariatric Surgery Patients HUP Bariatric Surgery Patients (n = 1007) Age (yr) 45 +/- 14 Female (%) 86 % Preop BMI (kg/m 2 ) /- 8.4 Preop weight (lb) 298 +/- 124 Previous abdominal Surgery 26% Co-morbidity requiring medication 78 %

29 Penn Program: Effects of RYGB on Medical Conditions Prevalence (%) Cured Improved HTN Diabetes Dyslipidemia

30 Penn Program: Effects of RYGB on Medical Conditions Prevalence (%) Cured Improved Asthma Heart failure 10 Sleep apnea

31 Why do we do it? It works! Co-morbidity improvement & resolution DM, HTN, CV dysfunction, OA, OSA, GERD, hyperlipidemia, Stress incontinence Extension of life expectancy Improved quality of life I can cross my legs I can play with my children I can climb stairs w/o getting short of breath My knee pain is gone I ve gone from size 3x to size 14 I have so much more energy!

32 Conclusions

33 KEY LEARNING POINTS Bariatric surgery is safe Specific criteria must be met and the patient must be motivated and fully informed. Most obesity comorbidity is durably (>10 years) improved after surgery mortality is less than after nonsurgical care

34 KEY LEARNING POINTS After bariatric surgery most patients do not reach normal weight; however, the weightloss induced by surgery is sufficient to improve morbidity and mortality A dedicated, comprehensive team is needed to assess, educate and manage the patient before and after surgery

35 KEY LEARNING POINTS Laparoscopic Roux-en Y gastric bypass and Sleeve Gastrectomy are the two most common operative procedures. Obesity surgery may be considered for adolescent obese patients. Patients require long-term follow-up to ensure success and appropriate support.

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37 290 pounds

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39 411 lbs 170 lbs

40

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42 Thank You! Our Team.

43 Thank You! Our Team.

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