Bariatric Surgery: What the Internist Needs to Know

Transcription

1 Bariatric Surgery: What the Internist Needs to Know Richard Stahl, MD, FACS Assistant Professor of Surgery Medical Director of Bariatric Surgery

2 Disclosures None (sadly)

3 Objectives Describe several myths and facts related to obesity treatment. Identify the indications and contraindications for bariatric surgery and the process for approval. Describe the current common bariatric surgical procedures, and compare their benefits, risks, and outcomes. Describe several potential complications of bariatric surgery.

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5 NEJM 368;5 January 31, 2013

6 Presumptions Skipping breakfast leads to obesity because people eat more later Just eating fruits and vegetables will lead to weight loss Weight cycling (i.e., yo-yo dieting) increases mortality Snacking inherently leads to weight gain

7 Myths Increasing activity modestly yields large weight loss over time Setting unrealistic weight loss goals is detrimental PE classes lead to weight loss Sex burns kcal yielding weight loss

8 Facts Heritabiltiy is not destiny Diets are effective; simply recommending one is not Exercise is important for health; very vigorous exercise is required for weight loss Obesity is a chronic condition; treatment must be also Bariatric surgery is effective

9 Degrees of Obesity NORMAL BMI OVERWEIGHT BMI Class I Obesity BMI Class II Obesity BMI Class III Obesity BMI 40

10 Impact of BMI on Mortality and Years of Life Lost UAB Bariatric Surgery Graph represents years of life lost for white men. Fontaine KR, Redden DT, et al. Years of life lost due to obesity. JAMA 2003;289:187.

11 Indications for Weight Loss Surgery 1. Initial attempt at nonsurgical weight loss 2. Bariatric surgery for motivated, appropriate risk patients 3. Multi-disciplinary team management 4. Surgeon and facility with appropriate experience and support 5. Life long follow up

12 How are we doing? 70% of US adults are overweight 34% are obese (i.e., BMI 30) 6% are morbidly obese (BMI 40) 18 million people age are morbidly obese About 113,000 cases are done annually* 159 years to operate on all of these * Am J Surg September ; 200(3):

13 90% feel obesity is a serious chronic medical condition and should be discussed with patients 75% agree even 10% reduction in weight is beneficial 50% would spend more time managing weight issues if reimbursed and feel comfortable doing so 22% feel long term weight loss management is possible 23% would refer patients for bariatric surgery if patients met criteria OBESITY RESEARCH Vol. 11 No. 10 October 2003

14 Pre-certification Requirements Age 18 years BMI with comorbidities BMI 40 regardless of comorbidities At least 3 years duration Acceptable for major elective abdominal surgery 6 month PCP directed diet

15 Current Topics in Weight Loss Surgery THE OPERATIONS

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19 Weight Loss Bypass vs Band Nguyen et. al. Ann Surg Aug 27

20 Weight Loss: Bypass vs Sleeve

21 Remission of Co-Morbidities

22 Mortality and Morbidity Bypass Band Sleeve Mortality 0.5% 0.1% 0.4% from H. Buchwald, J Am Coll Surg 2005;200: Laparoscopic Appendectomy Mortality 0.1% 0.3% Laparoscopic Cholecystectomy From Manish M. Tiwari, Surg Endosc Oct 7. [Epub ahead of print]

23 Risks Band Sleeve Bypass Slippage Leak Leak Erosion Stricture Stricture Port / band infection Reflux Ulcer Leakage Small bowel obstruction / internal hernia Port dislodgement Esophageal motility / dilitation Vitamin / micronutrient deficiencies: especially iron, calcium, Vitamins B1, B12, and D

24 Current Topics in Weight Loss Surgery MECHANISMS

25 How do they work? Patients eat less!! Why do they eat less?

26 Does Size Matter?

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28 Is it Malabsorption?

29 Is it Malabsorption?

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31 Could it be Better Choices? Mason EE, et.al. Intl J of Obesity (1981) 5:

32 Maybe the patients got really motivated to eat right! Sleeve gastrectomy rats decreased their consumption of calorie dense foods on their own volition

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34 Long Term Care / Considerations Vitamins / supplements Pills, tablets, crushed? Altered medication absorption? Alcohol Hypoglycemia

35 Anemia Wernicke's encephalopathy Abdominal pain Failure / Recidivism

36 Bariatric surgery is the most effective treatment of morbid obesity It is indicated in appropriate risk patients with BMI 40 (or 35 with co-morbidities Gastric bypass and sleeve gastrectomy yield better results than bands Mortality and morbidity risk is commensurate with other common GI operations