Weight loss SurgeryWeight loss Surgery

Kuldeep Singh, M.D., F.A.C.S., M.B.A.Kuldeep Singh, M.D., F.A.C.S., M.B.A.

Spectrum of the Spectrum of the obesityobesity

Terms Used to Describe Various Levels of Body FatTerms Used to Describe Various Levels of Body Fat

Normal Weight (BMI 18.5 to 24.9)

Overweight(BMI 25 to 29.9)

Obese(BMI 30 to 34.9)

Severely Obese(BMI 35 to 39.9 )

Morbidly Obese(BMI 40 or more)

This is where Surgical

treatment is recommended

Health Risks Health Risks

• Obese people have more risk for:Obese people have more risk for:• Diabetes (type 2)Diabetes (type 2)

• Joint problems, backaches, disc Prolapse Joint problems, backaches, disc Prolapse (e.g., arthritis)(e.g., arthritis)

• High blood pressureHigh blood pressure

• Heart disease: coronary artery diseaseHeart disease: coronary artery disease

• Gallbladder problems, gallstonesGallbladder problems, gallstones

Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity.

Related Diseases and Health Related Diseases and Health ProblemsProblems

Health Risks Health Risks (cont.)(cont.)

Related Diseases and Health ProblemsRelated Diseases and Health Problems• In addition, obese people have more risk for:In addition, obese people have more risk for:

• Certain types of cancer (breast, uterine, colon)Certain types of cancer (breast, uterine, colon)

• Digestive disorders (e.g. gastro-esophageal reflux Digestive disorders (e.g. gastro-esophageal reflux disease, or GERD)disease, or GERD)

• Breathing difficulties (e.g. sleep apnea, asthma).Breathing difficulties (e.g. sleep apnea, asthma).

• Psychological problems such as depression.Psychological problems such as depression.

• Problems with fertility and pregnancy.Problems with fertility and pregnancy.

• Stress Incontinence.Stress Incontinence.

Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity.

Using Surgery to Treat Using Surgery to Treat ObesityObesity

• Types of weight-loss surgeriesTypes of weight-loss surgeries• MalabsorptiveMalabsorptive procedures shorten the procedures shorten the

digestive tract: digestive tract: BPD & BPD-DSBPD & BPD-DS• RestrictiveRestrictive procedures reduce how procedures reduce how

much the stomach can hold: much the stomach can hold: Lap Band & Lap Band & Sleeve GastrectomySleeve Gastrectomy

• CombinedCombined procedures shorten the procedures shorten the digestive tract and reduce how much digestive tract and reduce how much the stomach can hold: the stomach can hold: Gastric BypassGastric Bypass

Using Surgery to Treat Using Surgery to Treat Obesity- Restrictive Obesity- Restrictive

TechniquesTechniques

Sleeve Gastrectomy LAP-BANDSystem

wo-pub2.med.cornell.edu/.../PublicA.woa/4/wa

Using Surgery to Treat Using Surgery to Treat Obesity- Malabsorptive Obesity- Malabsorptive

TechniquesTechniques

Bilio-Pancreatic Diversion(BPD)

We do not perform BPD, however we can refer you to surgeons in the area who perform this

surgery

Mixed TechniquesMixed TechniquesRoux-en-Y Gastric BypassRoux-en-Y Gastric Bypass

Risk Benefit RatioRisk Benefit Ratio

RISK

Lap Band

Sleeve Gastrectomy

Roux –en-Y Gastric Bypass

Bilio-Pancreatic Diversion

HIGH

LOW

BENEFIT

HIGH

LOW

Lap Band

Sleeve Gastrectomy

Roux –en-Y Gastric Bypass

Bilio-Pancreatic Diversion

Riskier the operation, the

more effective it is

Expected Outcomes Expected Outcomes from the Surgeryfrom the Surgery

• Improvement in health problems, Improvement in health problems, including:including:• Diabetes (type 2): 80% cure possible.Diabetes (type 2): 80% cure possible.

• High blood pressure: 40% cureHigh blood pressure: 40% cure

• Asthma: marked improvementAsthma: marked improvement

• GERD (gastro-esophageal reflux disease): GERD (gastro-esophageal reflux disease):

• Sleep apnea: close to 100% cureSleep apnea: close to 100% cure

• Problems with fertility and pregnancyProblems with fertility and pregnancy

• Depression. Depression.

Laparoscopic Gastric Laparoscopic Gastric Bypass Bypass

AdvantagesAdvantages• Rapid initial Rapid initial

weight lossweight loss• Higher total Higher total

average weight average weight loss .loss .

• Over 40 years Over 40 years of surgical of surgical experience in experience in USAUSA

DisadvantagesDisadvantages• Bigger operation and Bigger operation and

slower recovery.slower recovery.• Practically irreversiblePractically irreversible• Higher chances of Higher chances of

nutritional problems nutritional problems such as Iron deficiency such as Iron deficiency anemia and vitamin B anemia and vitamin B 12 deficiency.12 deficiency.

• Higher chances of Higher chances of ulcers at the junction ulcers at the junction of the stomach and of the stomach and the jejunum.the jejunum.

How the How the LAP-BANDLAP-BAND System WorksSystem Works

• A siliconeA silicone band is band is placed around the placed around the upper part of the upper part of the stomachstomach• A small pouch is A small pouch is

createdcreated• Your stomach Your stomach

holds less foodholds less food• You feel full faster You feel full faster

and longerand longer

The LAP-BAND System The LAP-BAND System ProcedureProcedure

• Adjustable Band Adjustable Band • Can be adjusted Can be adjusted

in office or in office or operating roomoperating room

• No anesthesia No anesthesia needed.needed.

• On average 4-5 On average 4-5 fills in first yearfills in first year

• 1 or 2 fills second 1 or 2 fills second year if needed.year if needed.

The LAP-BAND SystemThe LAP-BAND System

AdvantagesAdvantages• Lowest mortality rateLowest mortality rate• No stomach stapling or No stomach stapling or

cutting, or intestinal re-cutting, or intestinal re-routingrouting

• AdjustableAdjustable• Smaller operation , Smaller operation ,

ReversibleReversible• Lowest operative Lowest operative

complication ratecomplication rate• Low malnutrition riskLow malnutrition risk

DisadvantagesDisadvantages• Slower weight loss.Slower weight loss.• Regular follow-up critical Regular follow-up critical

for optimal resultsfor optimal results• Requires more Requires more

commitment from the commitment from the patient.patient.

• Slippage or erosion and Slippage or erosion and injury to the esophagus or injury to the esophagus or stomach as possible stomach as possible complications.complications.

• Arose from need to perform a safer yet Arose from need to perform a safer yet effective operation in patients with effective operation in patients with high BMI (>50) and multiple co-high BMI (>50) and multiple co-morbidities.morbidities.

• It is first stage of BPD-DS (Bilio-It is first stage of BPD-DS (Bilio-pancreatic diversion with Duodenal pancreatic diversion with Duodenal switch).switch).

• Designed as an separate staged Designed as an separate staged procedure by Johnson in 1993.procedure by Johnson in 1993.

Sleeve Gastrectomy (SG)Sleeve Gastrectomy (SG)

• Complications and outcomes are Complications and outcomes are somewhere between Adjustable somewhere between Adjustable Laparoscopic gastric Banding and Laparoscopic gastric Banding and Gastric Bypass. Gastric Bypass.

• Advantage of absence of Iron deficiency Advantage of absence of Iron deficiency anemia, Marginal Ulcers, ability to anemia, Marginal Ulcers, ability to perform upper endoscopic procedures perform upper endoscopic procedures and decrease the weight and co-and decrease the weight and co-morbidities to lead to any second staged morbidities to lead to any second staged procedure such as band, bypass or BPD.procedure such as band, bypass or BPD.

Sleeve GastrectomySleeve Gastrectomy

Who qualifies for the Who qualifies for the Bariatric Surgery?Bariatric Surgery?

• NIH criteriaNIH criteria1.1. Weight: BMI more than 40 or 35 with two serious Weight: BMI more than 40 or 35 with two serious

illnesses.illnesses.

2.2. Free from untreated mental illnesses such as Free from untreated mental illnesses such as Bulimia and schizophrenia.Bulimia and schizophrenia.

3.3. Documented evidence of weight loss attempts. Documented evidence of weight loss attempts. In Maryland 6 months over the past two years.In Maryland 6 months over the past two years.

4.4. Understanding by the patient that the surgery is Understanding by the patient that the surgery is only a tool to lose weight and need to have life only a tool to lose weight and need to have life style changes and exercise/ eating habits.style changes and exercise/ eating habits.

• Age: 18-60 years of ageAge: 18-60 years of age

• Those who cannot walk.Those who cannot walk.• Those who have severe heart disease.Those who have severe heart disease.

• Heart failure.Heart failure.• Angina and coronary artery disease.Angina and coronary artery disease.

• With severe lung disease.With severe lung disease.• In whom surgery is not possibleIn whom surgery is not possible

• Extreme obesity. Absolute weight matters to an Extreme obesity. Absolute weight matters to an extent. I will not operate patients over 500 lbs.extent. I will not operate patients over 500 lbs.

• Limited exercise tolerance. You should be able to Limited exercise tolerance. You should be able to walk with me to the parking lot (2 blocks) and back walk with me to the parking lot (2 blocks) and back without severe shortness of breath. without severe shortness of breath.

• Schizophrenia and Bulimia.Schizophrenia and Bulimia.

Who does not qualifies for the Who does not qualifies for the Bariatric Surgery? Bariatric Surgery?

These are our contraindicatio

ns

Bypass or Band?? How to Bypass or Band?? How to choose?choose?

some guidelinessome guidelines• BypassBypass• Bigger operation, higher risk, more weight loss and rapid Bigger operation, higher risk, more weight loss and rapid

weight loss.weight loss.• More nutritional problems: anemia and ulcers.More nutritional problems: anemia and ulcers.• My preference: severe obesity with lot of illnessesMy preference: severe obesity with lot of illnesses..

• Lap BandLap Band• Smaller and safer surgery, quick recovery.Smaller and safer surgery, quick recovery.• Less nutritional problems, less anemia or ulcers.Less nutritional problems, less anemia or ulcers.• Unique problems such as Slippage and Erosions.Unique problems such as Slippage and Erosions.• Reversible.Reversible.• My preference: BMI small with not so many diseases, women.My preference: BMI small with not so many diseases, women.

• Sleeve GastrectomySleeve Gastrectomy• BMI>60.BMI>60.• Android ObesityAndroid Obesity

The process for the The process for the surgerysurgery

1.1. Make sure you meet the criteria for the surgery.Make sure you meet the criteria for the surgery.2.2. Call your insurance company to check coverage.Call your insurance company to check coverage.3.3. Make sure that we participate with your insurance Make sure that we participate with your insurance

or be willing to pay more out of Pocket expense.or be willing to pay more out of Pocket expense.4.4. See the dietician and the psychologist.See the dietician and the psychologist.5.5. Fill all the forms and organize your folder into Fill all the forms and organize your folder into

weight loss attempts, cardiac consult , Sleep weight loss attempts, cardiac consult , Sleep Study and History and physical note form your Study and History and physical note form your doctor (whatever applies).doctor (whatever applies).

6.6. Call the office and make appointment to see the Call the office and make appointment to see the Doctor.Doctor.

7.7. If you have questions whether you will qualify- If you have questions whether you will qualify- Call the office to clarify.Call the office to clarify.

Centers of ExcellenceCenters of Excellence

• Awarded COE by most of the Insurers Awarded COE by most of the Insurers in Maryland (Blue cross, Atena, United in Maryland (Blue cross, Atena, United Healthcare and Cigna).Healthcare and Cigna).

• Awarded COE by SRC (Surgical review Awarded COE by SRC (Surgical review Committee in June 2006 for full three Committee in June 2006 for full three years.years.

Bariatric Volumes and Market Share in Bariatric Volumes and Market Share in MarylandMaryland

DRG 288 & ICD-9 Procedure code DRG 288 & ICD-9 Procedure code definitiondefinition

   FY02FY02 FY03FY03 FY04FY04 FY05FY05 FY06FY06 Total Cases Market ShareTotal Cases Market Share

HOSPITALHOSPITALSvc Svc AreaArea TotalTotal

Svc Svc AreaArea TotalTotal

Svc Svc AreaArea TotalTotal

Svc Svc AreaArea TotalTotal

Svc Svc AreaArea TotalTotal FY02FY02 FY03FY03 FY04FY04 FY05FY05 FY06FY06

ST. AGNES ST. AGNES 1313 2424 7575 135135 153153 311311 174174 368368 229229 469469 6%6% 13%13% 20%20% 20%20% 24%24%

BAYVIEWBAYVIEW 66 5353 2222 148148 4040 281281 3636 306306 3939 304304 15%15% 14%14% 18%18% 17%17% 15%15%

GBMCGBMC 00 00 00 00 00 3131 1818 158158 3333 188188 0.0%0.0% 0.0%0.0% 2.0%2.0% 8.9%8.9% 9.8%9.8%

SINAISINAI 1212 8383 1414 7676 2121 6060 5656 188188 5151 184184 23.9%23.9% 7.6%7.6% 3.9%3.9% 10.6%10.6% 9.6%9.6%

HOLY CROSSHOLY CROSS 00 3333 88 160160 00 6262 22 102102 33 149149 9.5%9.5% 16.0%16.0% 4.0%4.0% 5.7%5.7% 7.8%7.8%

UMMSUMMS 44 1414 77 2727 99 2222 44 2222 2828 130130 4.0%4.0% 2.7%2.7% 1.4%1.4% 1.2%1.2% 6.8%6.8%

SHADY GROVESHADY GROVE 00 00 00 66 22 107107 22 145145 11 105105 0.0%0.0% 0.6%0.6% 7.0%7.0% 8.2%8.2% 5.5%5.5%

PENINSULA REGIONALPENINSULA REGIONAL 00 00 22 5454 00 9898 11 9696 00 102102 0.0%0.0% 5.4%5.4% 6.4%6.4% 5.4%5.4% 5.3%5.3%

WASHINGTON WASHINGTON ADVENTISTADVENTIST 00 00 00 1010 44 127127 22 117117 00 9191

0.0%0.0% 1.0%1.0% 8.3%8.3% 6.6%6.6%4.7%4.7%

HARFORD MEMORIALHARFORD MEMORIAL 00 00 00 00 00 00 33 6060 11 5858 0.0%0.0% 0.0%0.0% 0.0%0.0% 3.4%3.4% 3.0%3.0%

SAINT JOSEPHSAINT JOSEPH 11 33 1010 4545 2222 110110 1818 9999 1414 5757 0.9%0.9% 4.5%4.5% 7.2%7.2% 5.6%5.6% 3.0%3.0%

FRANKLIN SQUAREFRANKLIN SQUARE 1313 6969 3535 146146 1212 7272 1111 6060 88 4747 19.8%19.8% 14.6%14.6% 4.7%4.7% 3.4%3.4% 2.4%2.4%

UNION MEMORIALUNION MEMORIAL 33 1313 1616 5151 99 1818 55 2828 66 3737 3.7%3.7% 5.1%5.1% 1.2%1.2% 1.6%1.6% 1.9%1.9%

SUBURBANSUBURBAN 00 00 00 00 77 8989 00 2222 00 00 0.0%0.0% 0.0%0.0% 5.8%5.8% 1.2%1.2% 0.0%0.0%

GOOD SAMARITANGOOD SAMARITAN 1414 5050 2424 115115 3030 140140 00 00 00 00 14.4%14.4% 11.5%11.5% 9.1%9.1% 0.0%0.0% 0.0%0.0%

All OtherAll Other 11 66 22 2828 00 44 00 33 00 00 1.7%1.7% 2.8%2.8% 0.3%0.3% 0.2%0.2% 0.0%0.0%

Grand TotalGrand Total 6767 348348 215215 1,0011,001 309309 1,5321,532 332332 1,7741,774 413413 1,9211,921100.0100.0

%%100.0100.0

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VariableVariable Average for Average for Centers of Centers of Excellence Excellence (SRC)(SRC)

St. Agnes St. Agnes ProgramProgram

Washington Washington State DataState Data

Number of Number of patientspatients

55 00055 000 13001300 33283328

MortalityMortality 0.3%0.3% 0.23%0.23% 1.9%1.9%

MorbidityMorbidity 10%10% 8.5%8.5% NANA

Re-Re-operationsoperations

2.5%2.5% 2%2% NANA

Re-Re-admissionadmission

4.5%4.5% 4.5%4.5% NANA

Bowel Bowel obstructionobstruction

2.5%2.5% 0.95%0.95% NANA

Marginal Marginal ulcerulcer

5 %5 % 0.99%0.99% NANA

EBWL % 1 EBWL % 1 yearyear

65%65% 65%65% NANA

Morbidity and Mortality of Gastric Morbidity and Mortality of Gastric Bypass surgery at St. Agnes Bypass surgery at St. Agnes

Hospital 2001-2007Hospital 2001-2007

Comparison of % EBWL of Gastric Comparison of % EBWL of Gastric bypass and Lap. Band patientsbypass and Lap. Band patients

Comparison of % EBWL of Gastric Comparison of % EBWL of Gastric bypass and Lap. Band patientsbypass and Lap. Band patients

Chapman et al.; Surgery 135:326-351: 2004

Resolution of co-morbidities after 1 year Resolution of co-morbidities after 1 year in Gastric bypass patients with Insurance in Gastric bypass patients with Insurance

mandated dietmandated diet

Jamal et al., SOARD 2:122-127; 2006

VariableVariable Preoperative Preoperative dietdiet

No dietNo diet P valueP value

HTNHTN 58%58% 71%71% NSNS

DiabetesDiabetes 93%93% 79%79% NSNS

Venous stasisVenous stasis 100%100% 83%83% NSNS

Sleep apneaSleep apnea NANA NANA NANA

GERDGERD 84%84% 91%91% NSNS

Joint painJoint pain 82%82% 79%79% NSNS