Dr. Terry Scarborough & Dr. Sherman Yu Is weight- loss surgery the answer for you?

Dr. Terry Scarborough & Dr. Sherman Yu

Is weight-loss surgery the answer for you?

September 26, 2008

Texas Laparoscopic Consultants, LLP April 2009

What are you going to learn today?

• What is obesity?• Your daily challenges• What is obesity costing you?• What are your surgical options?• Summary• What are your next steps?

September 26, 2008


Welcome to TLC Surgery

• We are an entire practice dedicated to helping you succeed with weight loss surgery and living a longer, happier, healthier life!

• A multi-disciplinary Bariatric focused practice• Lead by 2 fellowship trained, board certified Surgeons• Nutritionists• Psychologist• Insurance Specialists

How obesity can affect you

September 26, 2008

Many factors influence obesity


OBESITY

September 26, 2008

Obesity is…

…a medical condition in which excess body fat has accumulated to the extent that it may have an

adverse effect on health, leading to reduced life expectancy and/or increased health problems.

It is also…• multi-factorial (many different factors can cause obesity)• life-long• progressive• potentially life-threatening• costly


September 26, 2008

How do we measure obesity?

According to the National Institute of Health –

Body Mass Index (BMI) is a measure of body fat based on

height and weight that applies to both adult men and women


NHLBI 2000 (NIH), Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults

BMI Indicators

Healthy Range 18.5 – 24.9

Overweight 25.0 – 29.9

Obese 30.0 – 34.9

Severe Obesity 35.0 – 39.9

Morbid Obesity 40.0 – 49.9

Super-Morbid Obesity > 50

September 26, 2008

Many serious illnesses are associated with obesity

• Type-2 Diabetes1,3

• Hypertension1,3

• Hyperlipidemia1,3

• Respiratory disease1,3 • Sleep apnea1,2,3

• Depression3

• Menstrual irregularity2

• Amenorrhea2

• Dysmenorrhea2

• Urinary stress incontinence3

• Asthma/pulmonary disorder2,3

• Cancer1,3

• Gastroesophageal reflux disease (GERD)2,3

• Degenerative joint disease (DJD)3

• Heart disease 2 • Gallstones1,2,3

• Fatty liver disease2,3

• Coronary artery disease1,3 • Stroke1

• Osteoarthritis1,2

• Infertility2


1. NHLBI 2000 (NIH), Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults2. NIDDK 2006 (NIH), Understanding Adult Obesity.3. Schneider BE & Mun EC. Diabetes Care. 2005; 28:475-80

September 26, 2008

You’re not alone

• More than 65% of adults are overweight or obese.1

• 32% of children are overweight.1

• 4.8% of adults are morbidly obese.1

• Total medical cost for obesity in 2003 was $75 billion.2

• 325,000 obesity-related deaths occur annually.3


1. Wang, Y & Beydoun, MA. Epidemiol Rev. 2007; 29: 6-28.2. “Quick Facts: Economic and Health Burden of Chronic Disease,” CDC, updated 20073. Nordmann AJ et al., Arch Intern Med. 2006; 166:285-93..

DailyChallenges

September 26, 2008

You face obstacles and prejudices every day


September 26, 2008

High BMI can affect life expectancy

• In younger & middle aged women & men, increased BMI may increase the risk of dying prematurely1

• Teens entering adulthood with BMI >40 die 8-13 years earlier than the general population2


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BMI

1. Freedman DM et al. Int J of Obesity. 2006; 30: 822-292.2. Fontaine KR et al. JAMA. 2003; 289: 187-93.

<18.5

WOMEN MEN

18.5 - 20.9

21.0 - 22.9

23.0 - 24.9

25.0 - 26.9

27.0 - 29.9

30.0 - 34.9

>35.0

1

2

3

How much can obesityreally cost?

September 26, 2008

What are the costs for you?

Conventional treatmentsType of Diet Completing One Year1 Weight Loss

at One Year1

Atkins® 21/40 (53%) 2.1 kg (5 lbs.)Zone 26/40 (65%) 3.2 kg (7 lbs.)Weight Watchers ® 26/40 (65%) 3.0 kg (7 lbs.)Ornish 20/40 (50%) 3.3 kg (7 lbs.)

Day-to-day livingClothing, food

• 1. Dansinger, et al. JAMA 2005;293(1).Atkins is a registered trademark of Atkins Nutritionals, Inc.Weight Watchers is a registered trademark of Weight Watchers International, Inc.


September 26, 2008

Insurance costs go up as BMI goes up

Percentage increase in costs comparing obese to

non-obese (BMI <25)


Services 30 – 34.9 ≥ 35

Physician visits +14% +25%

Pharmacy +60% +78%

Laboratory +24% +85%

All outpatient services +21% +37%

All inpatient services +33% +70%

Overall +25% +44%

Body Mass Index (kg/m2)

Data from a 1993 health survey of members of a large HMO (n = 17,118) Quesenberry et al. Arch Intern Med 1998;158:466

What are your surgical options?

September 26, 2008

Are you a candidate for weight-loss surgery?

• BMI >35 with co-morbidities or >40 without*• Healthy enough to undergo a major operation• Failed attempts at medical weight loss• Absence of drug and alcohol problems • No uncontrolled psychological conditions• Consensus by our multi-disciplinary team• Understands surgery and risks

Must be dedicated to a lifestyle change and lifetime follow-ups


*From the NIH consensus conference in 1991

September 26, 2008


Not all weight loss surgeries are the same

1. Restrictive

2. Malabsorptive

3. Combination

September 26, 2008


Restrictive Procedures

•The size of the stomach is reduced, which limits the amount of food patients can eat.

•The smaller stomach pouch fills quickly, helping patients feel satisfied with less food.

•Examples of restrictive bariatric procedures:• Gastric banding• Sleeve gastrectomy

September 26, 2008


Malabsorptive Procedures

•The small intestine is rerouted so that food skips a portion of it.

•Some calories and nutrients are not absorbed.

•Currently, surgeons rarely perform strictly malabsorptive procedures.

•Most procedures that involve malabsorption include restriction and are called combination procedures.

September 26, 2008


Combination Procedures

•The surgeon creates a small pouch, limiting the amount of food a patient can eat.

•A section of the small intestine is rerouted, causing food to bypass a large portion of the small intestine.

•Bypassing a portion of the small intestine means the patient’s body absorbs fewer calories.

•Examples of combination bariatric procedures:• Gastric bypass• Biliopancreatic diversion with duodenal switch

September 26, 2008


Risks of abdominal surgery

• Bleeding• Pain• Shoulder pain• Infection• Pneumonia• Complications due to anesthesia & medications• Deep vein thrombosis (Blood clot)• Pulmonary embolism (Blood clot in lung)• Injury to stomach, esophagus, or surrounding organs• Death

September 26, 2008


Risks of bariatric surgery

• Abdominal hernia• Chest pain• Collapsed lung• Constipation or diarrhea• Dehydration• Enlarged heart• Gallstones, pain from passing a

gallstone, inflammation of the gallbladder, or surgery to remove the gallbladder

• Gastrointestinal inflammation or swelling

• Stoma obstruction• Stretching of the stomach• Surgical procedure repeated• Vomiting and nausea

September 26, 2008

Adjustable gastric banding is one type of restrictive procedure

• Laparoscopic or Single Incision

• Second most frequently performedbariatric procedure in U.S.

• Mean excess weight loss at 1 yearof 50%

• Requires implanted medical device

• Lowest rate of complications


September 26, 2008


September 26, 2008

What are risks and complications of gastric banding?

• Migration of implant (band erosion, band slippage, port displacement) • Tubing-related complications (port disconnection, tubing kinking) • Band leak • Port-site infection • Esophageal spasm • Gastroesophageal reflux disease (GERD) • Inflammation of the esophagus or stomach


Note: Your weight, age and medical history play a significant role in determining your specific risks. Your surgeon can inform you about your specific risks for bariatric surgery.

September 26, 2008

What can you expect after gastric banding?

Recovery takes time and patience.• The diet is strict. • The capacity of the stomach has changed.• You may experience discomfort and pain as your body heals. • Length of time to return to normal activities can vary from patient to

patient. • Your healthcare team will advise you when to return to work and

resume prior activities.• Lifestyle changes are necessary to ensure success.


Reference: From REALIZEband.com; life with REALIZE then recovery expectations.

September 26, 2008


Recovery takes time and patience.• Most patients are ready for their first adjustment after eating solid foods

for the first week. The exact timing will depend on your progress.

• If you are losing 1-2 lbs. per week you may not need an adjustment at that time.

What can you expect after gastric banding?

Reference: From REALIZEband.com; life with REALIZE then recovery expectations.

September 26, 2008

Vertical sleeve gastrectomy is another restrictive option

• Laparoscopic or Single Incision

• A very good option between band and bypass.

• Mean excess weight loss at 1 yearof 59%2

• No implanted medical device

• No need for adjustments


1. ASMBS, Position Statement on Sleeve Gastrectomy as a Bariatric Procedure. June 17, 2007.

2. Lee CM, et al. Surg Endosc (2007) 21: 1810–1816

September 26, 2008


September 26, 2008

What are the risks and complicationsof a vertical sleeve gastrectomy?

• Bleeding or infection• Staple line leak• Abdominal hernia • Pulmonary Embolus• Nausea and vomitting

Texas Laparoscopic Consultants, LLP April 2009G


September 26, 2008

A combination approach is most common

• Laparoscopic

• Most frequently performedbariatric procedure

• Mean excess weight loss at 1 yearof 67%1

• No implanted medical device


1. Buchwald, H. et al., JAMA. 2004; 292:1724-37.2. Buchwald H. 2004 ASBS Consensus Conference Statement, Bariatric surgery for morbid obesity: Health implications for

patients, health professionals, and third party payers. SOARD 2005;(1):371-8.

Roux-en-Y Gastric Bypass

September 26, 2008


September 26, 2008

What are the risks and complications of the Roux-en-Y procedure?

• Dehiscence (separation of tissue that was stitched or stapled together)

• Leaks from staple lines • Ulcers• Internal hernia • Dumping syndrome, an unpleasant side effect that may include

vomiting, nausea, weakness, sweating, faintness, and diarrhea • Inability to detect the stomach, duodenum, and parts of the small

intestine using X-ray or endoscopy, should problems arise after surgery such as ulcers, bleeding, or malignancy



September 26, 2008

Duodenal Switch

• Weight loss: 90% EBW• More risk of protein and vitamin deficiency• Requires maximum compliance with vitamins and protein• Some patients have more frequent stools

September 26, 2008

Gastric Plication

• Newest procedure• No removal of stomach• Not covered by insurance• Results similar to gastric sleeve

Summary

September 26, 2008

Choosing the procedure that’s right for you

Considerations• Age• Health Risk (depending on comorbidities)• Amount of weight to lose• Lifestyle• Eating behaviors

Mutual decision between patient and surgeon• Discuss with surgeon during initial consultation• Discuss with family and friends


September 26, 2008

Surgery can help you change your life

• Improves or resolves obesity-related illnesses• Decreases mortality risk• Reduces healthcare utilization and direct healthcare costs

Remember…surgery is a tool that requires your strong commitment to a lifestyle change and lifetime of follow-up


* Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality, Morbidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery 2004;240(3):416-424.

September 26, 2008

Resolving your co-morbid conditions

62%

86%86%79%

84%

72%77%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Diabetes Hypertension Sleep Apnea HighCholesterol*

Resolved

Resolved/Improved


•Following bariatric surgery, most patients resolve or improve their co-morbid conditions

Buchwald, et al JAMA Oct 2004.

What are your next steps?

September 26, 2008


You’ve already taken the first step

Attend seminar (Complete!)

• Obtain referral from Primary Care Physician (PCP)

• Initial consultation with surgeon

• Psychological evaluation

• Nutritional evaluation & counseling with one of our dieticians

• Verify benefits and obtain insurance authorization

• Pre-operative testing

• Surgery

• Lifelong follow-up appointments and support groups

Questions?

1200 Binz Suite # 950

Houston, Tx 77004• When (office hours): Mon-Thurs. 8:00-5:00, Fri. 8:00-4:30

• Phone numbers: (713) 493-7700 • Fax number: (281) 971-4065• Email: [email protected]• Web: www.tlcsurgery.com


mailto:[email protected]

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Dr. Terry Scarborough & Dr. Sherman Yu Is weight- loss surgery the answer for you?