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Obesity & The Surgeon

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  1. Obesity &The Surgeon Moises Jacobs, MD,FACS, Director Advanced Surgical Institute Mercy Hospital, Miami, FL.

  2. Speaker Disclosure • Speaker discloses he is a consultant with Ethicon.

  3. Four Operations Gastric bypass Gastric band Duodenal switch Gastric sleeve

  4. Bariatric Surgery-USA • 1994-1999 10-15,000/year • 2000 22,000 • 2001 48,000 • 2002 75,000 • 2003 105,000 • 2004 140,000 Schirmer, Laparoscopic Bariatric Surgery. Surg Endosc 2003

  5. Bariatric Surgery-USA • It is estimated that by 2012, the number of cases will triple • It is estimated there are over one billion obese persons in the world today

  6. Surgical Candidate • NIH Consensus Conference 1991 • BMI > 40 >35 significant co-morbidity • No endocrine cause • Understand risks of surgery • Compliant with follow-up

  7. Advantages of Gastric Sleeve • No dumping syndrome • No intestinal bypass • No intestinal obstruction • No anemia, vitamin deficiencies, no protein malnutrition, no osteoporosis • High BMI is not a contraindication

  8. Sleeve vs Band • No foreign body ( no erosion, infection or revision of reservoir) • No adjustments • Second stage operation is an option if weight loss is inadequate

  9. Downside? • Gastric staple division, leaks can occur • Inadequate weight loss (soft calories) • Not reversible • Long term results are unknown

  10. Inventing Something New? • Magenstrasse-Mill operation, Leeds UK • Lesser curvature tube, stomach is otherwise intact • Long term 60% EWL Johnston, Obesity Surg 2003

  11. Expected weight loss 40-60% EBW 6-18 months 1-2 day stay Follow-up Labs, nutrition Assess compliance Complications Leak DVT/PE Pneumonia Wound infection Low rate,low mortality Second stage Gastric bypass Duodenal switch Sleeve Gastrectomy-Results

  12. Agency for Healthcare Research and Quality • 22% of bariatric surgery pts experienced a complication prior to discharge • Almost 40% experienced a complication within 180 days of discharge (?) • Dumping syndrome (19.5%) • Anastomotic problems (12.3%) • Abdominal hernia (7%) • Infection (5.7%) • Pneumonia (4.1%) Encinosa;Medical Care 2006

  13. Agency for Healthcare Research and Quality 2001-2002 • 6 month risk adjusted health care payments were $65,031 for those with 180 day readmission, compared with $27,125 for thos with readmissions • In a subset of 625 surgeries in centers with bariatric volume, no link was found between volume and the risk of complications, after adjusting for age,sex,and comorbidities