The Time is Now For Weight Loss Surgery

The Time Is Now For Bariatric
Surgery
Presented By
Dr. Joseph Martin
The
St. Elizabeth and St. Joseph Surgical Weight Loss
Center
Center of Excellence In Bariatric Surgery
330-480-2866
St. Elizabeth and St. Joseph Surgical Weight Loss Center
452 Broadway Street
Youngstown, OH
Weighing Your Options
Overview of obesity
Treatment of obesity
 Different Types of Weight Loss Surgery
 Bariatric Diets and Supplements
 Surgical Weight Loss Center of
Excellence Program
 Questions and Answers?


Definition of Obesity
 Ideal
Body Weight
– Obesity is about 30 pounds over ideal
body weight
– Morbid Obesity defined as 100
pounds or more over ideal body
weight
 Excess
Body Weight
– Difference between ones ideal weight
and their actual weight
1
IDEAL BODY WEIGHT
Metropolitan Life Insurance Company Height/Weight Chart
Woman
Revised 1983
Men
Height
Feet Inches
4' 10"
4' 11"
5' 0"
5' 1"
5' 2"
5' 3"
5' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5' 10"
5' 11"
6' 0"
Small
Frame
102-111
103-113
104-115
106-118
108-121
111-124
114-127
117-130
120-133
123-136
126-139
129-142
132-145
135-148
138-151
Medium
Frame
109-121
111-123
113-126
115-129
118-132
121-135
124-138
127-141
130-144
133-147
136-150
139-153
142-156
145-159
148-162
Height
Feet Inches
5' 2"
5' 3"
5'' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5' 10"
5' 11"
6' 0"
6' 1"
6' 2"
6' 3"
6' 4"
Large
Frame
118-131
120-134
122-137
125-140
128-143
131-147
134-151
137-155
140-159
143-163
146-167
149-170
152-173
155-176
158-179
Small
Frame
128-134
130-136
132-138
134-140
136-142
138-145
140-148
142-151
144-154
146-157
149-160
152-164
155-168
158-172
162-176
Medium
Frame
131-141
133-143
135-145
137-148
139-151
142-154
145-157
148-160
151-163
154-166
157-170
160-174
164-178
167-182
171-187
Large
Frame
138-150
140-153
142-156
144-160
146-164
149-168
152-172
155-176
158-180
161-184
164-188
168-192
172-197
176-202
181-207
Definition of Obesity


BMI = Weight (kg) / Height (m2)
Definition of Obesity based on BMI
– Normal
– Overweight
– Obesity
– Morbid Obesity
-BMI
-BMI
-BMI
-BMI
20-25
26-29
30-39
> 40
Obesity rates:
Current and projected
USA
England
Mauritius
50
40
Australia
Population
percentage with 30
BMI > 30 kg/m2 20
Brazil
10
2030
2020
0
2010
2000
1990
1980
1970
1960
2
Frequency of Obesity by State
2004 vs 2013 CDC Data
#1 Mississippi
(Obese state)
#2 Alabama
#3 West Virginia
#11 Ohio
#19 Pennsylvania
#50 Vermont
#51 Massachusetts
#52 Colorado
(Thinnest state)
- 29.4%
#1 Mississippi and West
Virginia (Tied)
- 35.1% (Obese state)
-
#2 Arkansas
- 34.6%
#3 Tennessee
- 33.7%
#15 Ohio
-30.4%
#17 Pennsylvania
- 30.0 %
#40 Massachusetts
- 22.7%
#41Hawaii
- 21.8%
#42 Colorado
- 21.3% (Thinnest state)
28.8%
27.6%
25.2%
24.2%
18.6%
18.3%
16.7%
Note: Data included District of Columbia (D.C.), Puerto Rico,
& Virgin Islands and no data available on Hawaii so 52 “states” listed
Impact of Obesity
Comorbid Diseases
Quality of Life
Disability
Obesity
 Mortality
 Medical Cost
Obesity Related Co-Morbidities






Diabetes Mellitus
Hypertension
Elevated Cholesterol
and Triglycerides
Sleep Apnea
GERD
Coronary Artery
(Heart) Disease






Degenerative Joint
Disease
Urinary Incontinence
(Leakage of Urine)
Peripheral Edema
Chronic Venous
Insufficiency
Depression
Asthma
3
Scope of Problem of Obesity
Incidence
1/3 of the US Adult Population is obese (34.9% or 78.6 million
U.S. Adults are Obese)
15% morbidly obese
17% of children and adolescents are obese (12.5 Million)
•
•
•
400,000 die annually from obesity related
comorbidities
$147 billion annual cost in health care and
lost productivity
Etiology of Obesity
 Factors
related to obesity
• Genetic
• Hormonal
• Environmental


Increase availability and decreased cost of food
Decrease activity
Energy Balance
Intake is More
Expenditure Less
=
Weight Gain
Intake is Less
Expenditure is More
=
Weight Loss
Intake = Expenditure
Weight Maintenance
4
10% Weight Loss



Improves Overall Health
Blood Cholesterol
Blood Glucose
Blood Pressure
A Guide to Selecting Treatment
Treatment
25-26.9 27-29.9 30-34.9 35-39.9 > 40
Diet, Physical Activity,
and Behavior Therapy
With CoMorbidity
Pharmacotherapy
Surgery
+
+
+
+
With CoMorbidity
+
+
+
With CoMorbidity
+
Brief History of Weight Loss
Surgery











1954
1967
1978
1979
1979
1982
1993
1993
2001
2002
2003
- Jejunal-ileal bypass
- Gastric bypass
- Biliopancreatic diversion
- Gastric partitioning
- Roux-en-Y Gastric Bypass (RYGB)
- Vertical banding gastroplasty
- Duodenal switch procedure
- Laparoscopic RYGB
– Laparoscopic Gastric Band
- Gastric Stimulator (Experimental)
– Laparoscopic Sleeve Gastrectomy
5
Criteria for Eligibility for
Bariatric Surgery
 National
Institute of Health (NIH)
Criteria based on 1991 consensus
statement
– BMI > 40
 Patient failed medical therapy
 Patient aware of the significant risk of
the surgery, required changes in diet,
and desires surgery
– BMI >35 & < 40
 In addition to the above, patient has 2
“significant” obesity related comorbidities
Currently Performed
Weight Loss Surgeries
 Roux-en-Y
Gastric Bypass –
most common
 Laparoscopic
Gastric Band
 Laparoscopic
Sleeve Gastrectomy -
newest treatment
Before gastric bypass surgery
After gastric bypass surgery
Carnie Wilson – Singer (RYGB 1999)
6
Al Roker
NBC Today morning weatherman
2002 Gastric Bypass Surgery
Randy Jackson
American Idol judge
2003 Gastric Bypass Surgery
Mechanism of Action of
Bariatric Surgical Procedures
•
Restriction of Functional Capacity of the
Stomach
•
Malabsorption of food ingested
•
Combination of above
Roux-en-Y Gastric Bypass or RYGB
(1979)

The most
widely
performed
and
accepted
bariatric
surgical
procedure
in the U.S.
7
Roux-en-Y Gastric Bypass or RYGB
(1979)

Severe
Gastric
restriction

Malabsorption
Behavioral
Modification –
Dumping
Syndrome

8
St. Joseph Health Care
Center
Warren, Ohio
Laparoscopic RYGB (1994)


5 small incisions
Advantages

24 Hour Observation
Hospital Stay

– Less pain and
wound
complications
– Quicker recovery
75% EBWL
Lap Band (2001)




Laparoscopic
procedure,
wrapping the lap
band around
upper stomach to
form a 30 ml to
50 ml pouch
Band connected
to a port under
the skin to inject
or withdraw fluid
to inflate or
deflate band
Purely restrictive
procedure, no
malabsorption
50% EBWL
9
Laparoscopic Sleeve Gastrectomy




Removal of the
remaining stomach
Pouch 3oz. to 4oz.
in size
Purely restrictive
procedure, no
malabsorption
50 - 60% EBWL
Process for Evaluation &
Scheduling for Weight Loss
Surgery at SWLC


Schedule Initial Consultation Visit and Fill
Out Necessary Paperwork
At the Initial Consultation
– Meet with the Bariatric Nurse
– Meet with the surgeon who performs
History & Physical and explains the
different surgeries right for you.
– Based on patient needs further testing
will be scheduled at this time.
Process for Evaluation &
Scheduling for Weight Loss
Surgery at SWLC









Nutrition Consultation with the Surgical Weight Loss
Bariatric Dietitian
Insurance Companies Dietary Requirements needs met
Psychological Evaluation
Upper GI Endoscopy (scope test)
Ultrasound of the Gallbladder (if still present)
Cardiac Clearance
Pulmonary Clearance – (Based on Past Medical History)
Medical Clearance
Insurance Submission and Approval
10
Process for Evaluation &
Scheduling for Weight Loss
Surgery at SWLC
2
Hour Nutrition Class
H & P (within 30 days
of surgery)
 Preadmission Testing (within 10 to
14 days of surgery)
 Surgery is 24 Hour Observation
 Preoperative
Before Surgery Dietary
Requirements:




10% of Excess Body Weight Lost Before Surgery
Super Morbidly Obese patients need to work with
RD/LD to maintain a healthier weight before surgery.
Some Insurance companies require 6 months weight
loss and exercise program prior to surgery
Before surgery patients must purchase a 3 month
supply of Bariatric Approved Vitamins, Calcium and
Protein Supplements to be used after surgery.
The Difference

Purely Restrictive
– Laparoscopic Gastric
Band
– Laparoscopic Sleeve
Gastrectomy

Restrictive,
Malabsorption and
Behavior
Modification
– Roux-en-Y Gastric
Bypass Surgery
11
Create a Small Pouch Restriction
Patients have to learn that they need
“To eat to live” after bariatric surgery
not “Live to eat”.
 The first realization is that they can only
eat a very small volume of food and
that this is okay and satisfying.
 Control of hunger and fullness.
 This is the biggest obstacle

RYGB Lifestyle for Eating
Mechanisms of Weight Loss
Create a Small Pouch
Malabsorption
Dumping Syndrome
Malabsorption

If patients choose to have the Roux-enY Gastric Bypass Surgery. They have
the benefit of not absorbing all the
calories, fat, protein, vitamins, minerals
and nutrients that they consume for the
first 18 – 24 months post-op.
12
Dumping Syndrome – Behavior
Modification
Sugar –
Fats
Symptoms
Prevention
Rules of 2
PROTEIN - 60-80 Grams

Importance of Protein

Protein Deficiency

Protein Supplementation
Lifestyle Habits after
Bariatric Surgery








6 small meals daily
 1200 calories daily
3oz. to 4oz. portions daily
25gms. - 35gms. fat daily
60gms. - 80gms. protein daily - Males 80gms.
64oz. - 90oz. fluid daily
Chew 30-35 times per bite
Add 1 new food item at a time
13
Diet Progression
Bariatric Clear Liquid Diet
Bariatric Full Liquid Diet
Bariatric Puree Diet
Bariatric Soft Diet
Regular 1200 Calorie Diet
Behavior Modification
Lactose Intolerant
Red Meats, Doughy and Fibrous Foods
 Carbonated Beverages
 Decaffeinated Coffee, Decaffeinated
Tea
 Alcoholic Beverages
 Juices
 Low Sugar, Low Fat Diet


Supplements






Bariatric Approved Multi-Vitamins Daily (2 to 4 times)
1500 - 1800 mg Calcium Citrate with 1000iu of
Vitamin D
Gastric Sleeve patients will also take an additional
Vitamin B 12 supplement
If your Multi-Vitamin does not contain Iron you will
take an additional Iron Supplement
Vitamin D3 – 5,000iu every other day
Iron Supplements as needed
 Check Labs - 2wk, 6wk, 3m, 6m, 1 yr, 18m, Yearly
14
Difficulties:
Excess Salvia -Food Getting Stuck
Food Bezoar
 Delayed Dumping Syndrome - Reactive
Hypoglycemia
 Constipation
 Gas - Floating Stools
 Weight Regain - 18 months post-op


Bariatric Surgery
20%
Clinical
80 % Patient
Behavior Change

Alternative to Eating

Stress Management

Regular Physical Activity
15
Lifestyle Change





This is a diet patients will need to follow for a life
time.
Patients will always need to watch calories, fat
intake, and portion control.
Patients will always need to exercise.
Patients will always need to take vitamins and
supplements
Patients will need to return for routine follow-up
yearly
Advantages and Outcomes of
Bariatric Surgery
•
•
Effective weight loss in morbidly obese
patients
Improvement in obesity related comorbidities – Diabetes, High Blood Pressure,
High Cholesterol, High Triglycerides, Sleep Apnea Resolve
•
•
Improved Quality of Life
Decreased Long-term Health Care Cost
St. Elizabeth and St. Joseph Surgical Weight Loss
Center Surgery Cases - Since 2002 - 2015

Total Surgery Number is 1,555

Monthly Bariatric Surgeries – 10.36

Yearly Average Surgeries – 119.61
16
Weight Loss After RYGB
Surgery
Weight Loss- varies from patient to
patient
• Approximately 90% of patients will loose at
least 50% of their excess weight.
• Expected rate of excess weight loss
•
•
•
33% at 3 months
65% at 12 months
75% at 18 months
Weight Loss Results at
St E/St J SWLC
Wt. Lost
Benchmark % EBWL (Lbs.)
3
months 33%
12
months 65%
18
months 75%
41%
60
73%
107
75%
111
SWLC Weight Loss Results
Reduction in BMI – 242 cases
30 Days
6 Months
1 Year
2 Year
SWLC
Nat.
Data
SWLC
Nat.
Data
SWLC
Nat.
Data
SWLC
Nat.
Data
45.09
45.14
45.57
45.38
45.61
45.51
45.87
45.55
42.35
42.12
34.27
36.57
31.97
33.07
31.77
33.01
Note: In Red is the SWLC BMI
reduction data and you can see
where we are ahead of the national
average.
17
Obesity Related Co-Morbidities






Diabetes Mellitus
Hypertension
Elevated Cholesterol
and Triglycerides
Sleep Apnea
GERD
Coronary Artery
(Heart) Disease






Degenerative Joint
Disease
Urinary Incontinence
(Leakage of Urine)
Peripheral Edema
Chronic Venous
Insufficiency
Depression
Asthma
Improvements in Obesity-Related CoMorbidities, St E / St J SWLC
Average 12.8 month
F/U
Preop
Incidence
Resolved
Improved
HTN
241
(60%)
66%
26%
Hypercholest
erolemia
170
(42%)
61%
19%
Diabetes
120
(30%)
70%
30%
Obstructive
Sleep Apnea
96 (24%) 75%
21%
SWLC Leak Rate – 327 Cases
30 Days
SWLC
0.8%
6 Months
Nat. Data SWLC
0.3%
0%
1 Year
Nat.
Data
0.1%
SWLC
0%
2 Year
Nat.
Data
0%
SWLC
Nat.
Data
0%
%
Note: In Red is the SWLC Leak Rate data and you can see
where we are ahead of the national average. Our Average
leak rate is 0.3% and you want you leak rate to be less
than 1.0% in order to be a Center of Excellence.
18
SWLC
Improvement in Quality of Life
FOLLOWUP
No.
pts.
6 wks
Change in QOL Compared to Preop
Greatly
improved
Improved
Same
Diminished
Greatly
diminished
376
35%
46%
14%
4%
1%
3 mos
363
63%
33%
3%
1%
0%
6 mos
320
77%
20%
1.5%
1%
0.5%
12 mos
235
82%
15%
2%
1%
0%
18 mos
140
87%
10%
1%
2%
0%
24 mos
60
80%
11%
7%
2%
0%
Ht – 5’1”
Wt – 302 lbs
Excess BW –
177 lbs
BMI - 57
1 year after
RYGB
Wt lost – 124 lbs
EBWL – 72%
BMI 33
55 year-old female
Ht - 5’1”
Wt - 200 lbs
Excess BW – 94 lbs
BMI 38
12 mo follow-up
Wt – 110 lbs
Wt lost – 90 lbs
%EBWL 96%
BMI - 21
19
Ht – 6’0”
Wt – 309 lbs
Excess BW –
121 lbs
BMI - 42
1 year after
RYGB
Wt lost –
113 lbs
EBWL – 93%
BMI 26
Off CPAP
HTN resolved
Knee pain
resolved
Back pain
improved
34 year-old female
Height – 5’5”
Weight – 268 lbs
BMI – 44
Excess BW-128 lbs
31 months after
RYGB
Weight – 143 lbs
Wt. Loss – 126 lbs
%EBWL – 98%
BMI – 23
45 year-old female
Height – 4’11”
Wt – 202 lbs
BMI – 40
Excess BW – 92 lbs
24 months after RYGB
Wt – 119 lbs
Wt. Loss – 81 lbs
%EBWL – 90 %
BMI – 24
Resolved:
HTN, DM, & high
chole/trig
20
49 year-old female
Height – 5’3”
Weight – 307
BMI –54
Excess BW - 160 lbs
10 months after
RYGB
Weight – 187
Wt. Loss – 120 lbs
%EBWL – 75%
BMI –33
Medical Problems
Improved:
HTN, OA, LBP,
GERD
Ht – 5’4”, Wt – 274 lbs
Excess BW – 136 lbs
BMI - 47
2 years after RYGB
Wt – 156 lbs
Wt lost – 118 lbs
EBWL – 87%
BMI 27
33 year-old female
Height – 5’3”
Weight – 284 lbs
BMI – 50
Excess BW - 149 lbs
1 yr after RYGB
Weight – 151 lbs
Wt. Loss – 133 lbs
%EBWL – 89%
BMI – 26
21
49 year-old male
Height – 5’10”
Weight – 300 lbs
BMI – 43
Excess BW-116 lbs
1 yr after RYGB
Weight – 189 lbs
Wt. Loss – 114 lbs
%EBWL – 96%
BMI – 27
Before
2 ½ years after RYGB
Weight – 182 lbs

Wt. Loss – 121 lbs
%EBWL – 104%
BMI – 26
50 year-old female
Ht - 5’5”
Wt - 311 lbs
BMI 52
Sleep apnea with
tracheostomy
RYGB 5/19/2003
3 month follow-up
Wt lost - 69 lbs
Tracheostomy
removed and
sleep apnea
resolved
18 mo follow-up
Wt – 184 lbs
Wt lost – 127 lbs
%EBWL 75%
BMI - 31
22
Ht – 5’5”,
Wt – 282 lbs
Excess BW – 152 lbs
BMI - 47
1 year after RYGB
Wt – 170 lbs
Wt lost – 112 lbs
EBWL – 74%
BMI 28
35 year-old female
Ht - 5’3”
Wt - 237 lbs
Excess BW – 107 lbs
BMI 42
6 mo follow-up
Wt – 158 lbs
Wt lost – 88 lbs
%EBWL – 75%
BMI - 28
60 year-old female
Ht - 5’3”
Wt - 230 lbs
Excess BW – 109 lbs
BMI 41
6 mo follow-up
Wt – 138 lbs
Wt lost – 92 lbs
%EBWL – 83%
BMI - 25
23
41 year-old female
Height – 5’1”
Weight – 259 lbs
BMI – 49
Excess BW- 139 lbs
3 years after
RYGB
Weight – 147 lbs
Wt. Loss – 113 lbs
%EBWL – 81%
BMI – 28
Decreased:
•Arthritic pain
•Dyspnea
Ht – 5’1”
Wt – 252 lbs
Excess BW –
127 lbs
BMI - 48
18 months
after RYGB
Wt lost –
121 lbs
EBWL – 95%
BMI 25
Sleep apnea
resolved
Decreased
back pain
Increased
energy
41 year-old female
Height – 5’7”
Weight – 277 lbs
Excess BW – 130 lbs
BMI – 43
3 years after RYGB
Weight – 146 lbs
Wt. Loss – 131 lbs
%EBWL – 101%
BMI – 22
24
39 year-old male
Height – 5’1 ½”; Weight – 350 lbs
Excess BW- 165 lbs; BMI – 48
1 year after RYGB
Weight – 232 lbs; Wt. Loss – 118 lbs
%EBWL – 73% ; BMI – 32
51 year-old female
Height – 5’7”
Weight – 254 lbs
Excess BW – 116 lbs
BMI – 40
2 years after RYGB
Weight – 155 lbs
Wt. Loss – 99 lbs
%EBWL – 85%
BMI – 24
27 year-old female
Height – 5’5”
Weight – 224 lbs
BMI – 37
Excess BW- 97 lbs
1 year after RYGB
Weight – 132 lbs
Wt. Loss – 5 lbs
%EBWL – 95%
BMI – 22
Resolved:
•HTN
•Hypercholesterolemia
•Hypertriglyceridemia
25
30 year-old male
Ht - 5’10”
Wt - 378 lbs
Excess BW – 198 lbs
BMI 54
1 year after RYGB
Wt – 191 lbs
Wt lost – 187 lbs
%EBWL 94%
BMI – 27
Sleep apnea resolved
off CPAP
HTN resolved
No back pain
Better energy
35 year-old female
Height – 5’7”
Weight – 330 lbs
BMI – 52
Excess BW- 185 lbs
1 year after RYGB
Weight – 185 lbs
Wt. Loss – 40 lbs
%EBWL – 78%
BMI – 29
Thank You
Presented By The
St. Elizabeth and St. Joseph Surgical Weight
Loss Center
Center of Excellence In Bariatric
Surgery
330-480-2866
26