Roux-en-Y Gastric Bypass Restrictive and malabsorptive procedure Most frequently performed bariatric procedure in the US First done in 1967 Laparoscopic since 1993 75% EWL in 18-24 months 50% EWL is still maintained at a 14yr follow-up ASBS
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
Expected weight loss with the Roux-en-Y Gastric Bypass 20-30 lbs in the first month 75-100 lbs in the first 6 months 75% of EWL in 18-24 months
- 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 0.5 2 % - Strictures 3 % - Ulcers - Dumping Syndrome - Malnutrition
Vertical Sleeve Gastrectomy (VSG) Restrictive procedure First done in US in 2001 Removing 60-85% stomach 30-50% EWL
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
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
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
What is the Mortality Rate? Cholecystectomy?
Mortality Rates Adjustable Gastric Band 0.1% Gastric Bypass 0.5% Vertical Sleeve Gastrectomy 0.25%
Post operative reasons that may cause death Pulmonary embolism (blood clots) Myocardial infarction (heart attack)
Extreme Obesity Intraop Management: Airway Brodsky JB: Anesth Analg, Volume 96(6) June 2003.1841-1842
Facts that play a role in the decision-making process Age Medical History Surgical History BMI Psychological Profile Nutritional Profile Lifestyle Personal choice
Post Operative Phases Surgical Recovery Diet Modification Life Stile Adjustment Health Maintenance
Supplements after weight loss Gastric Band: MVI Protein surgery VSG: -MVI -Protein Gastric Bypass: MVI Protein Calcium Citrate + D Iron
Expected Risks and Outcomes
Risk Benefit Ratio Risk of Obesity Risk of surgery Life Lost : BMI > 45 / 20-30 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%
Estimated Number of Bariatric Operations Performed in the United States, 1992-2005 180,000 160,000 140,000 120,000 100,000 80,000 60,000 40,000 20,000 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Modified from Steinbrook, R. N Engl J Med 2004;350:1075-1079 using ASMBS estimates
Bariatric Procedures at PENN 500 450 400 350 300 250 200 150 100 50 0 HUP 1998 2000 2002 2004 2006 2008 HUP
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
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
Effects of bariatric surgery on mortality in Swedish obese subjects Cumulative Mortality. Sjöström et al. NEJM 357 (8): 741, 2007
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 2000. And others.
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;292:1724-1737.
Table 10: Improvement of Comorbidities After Bariatric Surgery Operation Diabetes resolved (%) Hypercholesterol improved (%) Hypertension resolved (%) Sleep apnea resolved (%) AGB 50 70 40 95 RYGB 85 95 75 85 BPD ± DS 95 99 80 95 LSG 75 60 70 85 Dumon et al. Surg. Clin North America 2011 Dec; 91(6):1313-38
Mean values from a meta-analysis of 22,094 patients Restrictive (AGB) Malabsorptive (BPD) Combined (RYGB) EWL % 50 70 65 Type 2 diabetes 50 95 85 Hypertension 40 80 75 Hyperlipidemia (improved) 70 100 95 Sleep apnea 95 95 90 Operative mortality 0.1 1.1 0.5 Reviewed in Vetter, Dumon et al., 2012
Bariatric Surgery Patients HUP Bariatric Surgery Patients (n = 1007) Age (yr) 45 +/- 14 Female (%) 86 % Preop BMI (kg/m 2 ) 47.5 +/- 8.4 Preop weight (lb) 298 +/- 124 Previous abdominal Surgery 26% Co-morbidity requiring medication 78 %
Penn Program: Effects of RYGB on Medical Conditions Prevalence (%) Cured Improved HTN 25-60 60-66 80-90 Diabetes 25-35 85-95 100 Dyslipidemia 25-40 70 95
Penn Program: Effects of RYGB on Medical Conditions Prevalence (%) Cured Improved Asthma 10-15 Heart failure 10 Sleep apnea 81 90-95 90-100 60 90 40-80 90-95
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!
Conclusions
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
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
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.
290 pounds
411 lbs 170 lbs
Thank You! Our Team.
Thank You! Our Team.