Laparoscopic Bariatric Surgery

Bariatric Surgery

Greek baros (weight) + iatrike (medicine, surgery)

A field of medicine encompassing the study of overweight, its causes, prevention, and treatment

Why Do Bariatric Surgery?

Major impact on morbidity and mortality cures disease and saves lives! preventative medicine?

Challenging Very rewarding Exceptional group of patients A HAPPY specialty!

Obesity Is a Big Problem Major public health problem worldwide Affects 25% of industrialized world American statistics:

55% of adults are overweight 25% of children are overweight 300,000 deaths annually300,000 deaths annually

Prevalence of Obesity* among U.S. AdultsPrevalence of Obesity* among U.S. Adults BRFSS, 1990BRFSS, 1990

(*Approximately 30 pounds overweight)

<10% 10% to 15% >15%

Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16.



<10% 10% to 15% >15%


Current Data

Over 50% of Americans are obese and over 10% are morbidly obese

What Is Obesity?

A life-long, progressive, life-threatening, costly, genetically-related, multi-factorialmulti-factorial disease of excess fat storage

ASBS

Body Mass Index (BMI)

BMI = weight (kg)_____ height (m) x height (m)

WHO Classification BMI Ideal weight 20–24.9 Overweight 25–29.9 Moderate obesity(class I) 30–34.9 Severe obesity (class II) 35–39.9 Morbid obesity (class III) 40–49.9 (Super obesity) 50 +++

Exponential Mortality Risk

Co-Morbid Medical Conditions

Diabetes Hypertension Hyperlipidemia Cardiac disease Respiratory disease

sleep apnea Arthritis Depression Stress Incontinence Menstrual irregularity

14–20% 25–55% 35–53% 10–15% 10–20%

20–25% 70–90% 50% 50%

What Causes Obesity?

Energy in > energy out Obesity is multifactorialmultifactorial:

genetic 25–30% neuroendocrine environmental metabolic

Why Surgery?

Diet and exercise only works for 1 in 20 (5%) people who are obese

Surgery is safe and effective Improves co-morbidities Benefits of surgery outweigh the risks

for the morbidly obese risks of surgery risks of staying morbidly obese

NIH Consensus Conference 1991

Surgery is the only way to obtain consistent, permanent weight loss for obese patients

Surgery indicated in patients with: BMI of 40 or over BMI of 35 or over with significant co-

morbidity documented dietary attempts ineffective

How Does Surgery Work?

Malabsorption jejunoileal bypass biliopancreatic diversion duodenal

switch Restriction

vertical banded gastroplasty adjustable gastric banding

Hybrid of restriction and malabsorption gastric bypass

Jejunoileal Bypass (JIB) HISTORICAL Bacterial

overgrowth in blind limb: anemia, arthritis, cirrhosis, kidney stones, etc.

Diarrhea and malnutrition

No longer performed

Should be reversed graphics Courtesy of ASBS

Vertical Banded Gastroplasty (VBG) aka “Stomach Stapling”

On the way out Restrictive Minimal metabolic

effects Defeated by junk

food diet, liquids 40–60% loss EBW Only 38% success

staple line failure

graphics Courtesy of ASBS

Laparoscopic Adjustable Gastric Banding

Restrictive Ongoing FDA studies No long-term

follow-up Presence of a

foreign body Post operative

adjustments required

Roux-en-Y Gastric Bypass Most frequently

performed bariatric procedure in the US

First done in 1967 Some technical

modifications since (stomach is divided)

Laparoscopically since 1993

graphics Courtesy of ASBS

Frantzides et al. Laparoscopic Gastric Stapling and Roux-en-Y Gastrojejunostomy for the treatment of Morbid obesity. J Laparoendosc Surg 1995

Laparoscopic Roux-en-Y(Minimally Invasive)

Planning

Laparoscopic Roux-en-Y(Minimally Invasive)

Six small puncture wounds (1/4 to ½ inch)

A laparoscope, connected to a video camera, is inserted through the small incision into the abdomen

Advantages of Laparoscopy

Fewer wound complications infection, hernia

Probably fewer cardiac and respiratory complications

Less pain and faster recovery Surgeon has better view of the

anatomy

Roux-en-YOpen vs. Laparoscopic

Procedure

LAPAROSCOPIC Hospital stay is 1 to 3 days.

Patients usually return to work in 10 to 14 days.

Technically more demanding for the surgeon

OPENHospital stay of about 5 days.

Return to work in about 4 weeks.

More painful

Greater risk of infection

Results of Our Lap Gastric Bypass Technique, 2003

711 Patients Average BMI: 50 (range 35-91) Conversions to open: 1 Duration of Surgery: 90 min (range

37-180) Hospital Stay: 2.0 days (range 1-4)

Results of Lap Gastric Bypass, 2003

81%(12)

2.00.29050711Frantzides

82%(12)

2.51.6NR5063Champion

77%(30)

2.61.024748275Schauer

69% (12)

1.63.0NR46400Higa

73%(54)

2.6NR120NR500Wtittgrove

EBWL(Follow-up in months)

Hospital Stay (D)

Conversion (%)

Mean OR Time (MIN)

Mean BMINo. Patients

Author

Frantzides et al. Triple Stapling Technique for Jejunojejunostomy in Laparoscopic Gastric Bypass. Arch Surg 2003

Post-Op Incisions

Post-OperativeNutrition and Diet

Most patients who have had gastric-bypass surgery begin . . .

A soft diet after the first week A regular diet at one month Nutritional and psychological

counseling A daily multi-vitamin with iron for life Weekly sublingual vitamin B12 for life

Post-OperativeMaintenance

First post-operative visit is usually 7-10 days following surgery

Office visits are scheduled at 1, 3, 6 and 12 months after surgery, and yearly thereafter

Lab work is performed at all visits after the 1st postoperative visit

Post-Operative

Most patients lose up to and beyond 80% of excess weight

…and keep it off.

Reduction in Co-Morbidities

All medical co-morbidities are resolved or improved in 80–100% of patients

Swedish Obesity

Surgery Study

Pre-Operative Process

Medical History

You will need a detailed account of efforts to achieve weight loss by non-surgical methods.

Lists of specific comorbidities need to be identified.

Your current health status will need to be evaluated


Supporting Documentation

You will need a brief letter from any physicians that have treated any weight-related health conditions.

Any documentation from physicians stating the previous weight-loss efforts that you have made can be very valuable.


Medical Testing

Further medical testing may need to be completed in order to further clarify any existing comorbidities

A psychological evaluation may also be needed

Pre-Operative Process Insurance Request

Depending on the type of health care benefits, a request is made for coverage of the surgery from the patient, as well as the surgeon.

If the Request is Denied

Some insurance companies will initially deny a request for coverage. An appeal from the patient can be made or the patient can choose to seek legal advice.

Frequently Asked Questions

Can gastric-bypass surgery be reversed?

Yes. The procedure is intended to be a permanent change, but because the stomach is bypassed, not removed, surgeons can undo the pouch.

Frequently Asked Questions Continued…

Will I need plastic surgery?

Many factors influence the need for plastic surgery, for example starting weight, the amount of weight lost, location of the excess weight and age. The younger patients have a greater amount of skin elasticity and therefore are less likely to need plastic surgery.


Will I have gallstone complications?

Weight loss and diet will promote the production of gallstones. If a patient has has documented gallstones, the gallbladder will be removed at the time of surgery.

Gallstone dissolution medication


Can I become pregnant after gastric-bypass surgery?

Yes, you can become pregnant after the surgery with out any related complications. Thousands of women have had successful pregnancies after the gastric-bypass surgery.

Pre-Op

Post-Op

Before

Pre-Op

Post-Op

Before

12/13/02

1/16/04

Conclusion

“Only surgery has proven effective over the long term for most patients with clinically severe obesity” -National Institutes of Health Consensus

Development Conference Statement

Chicago Institute of Minimally Invasive Surgery-St Francis

Hospital

Laparoscopic Bariatric Surgery

Documents

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