1. CLINICALLY SEVERE
OBESITY
TIMOTHY CUSTER M.D., F.A.C.S

2. WHAT IS MORBID
OBESITY?

3. BMI CHART
Do You Know Your Own BMI?
Weight (lbs)
120 130 140 150 160 170 180 190 200 210 220 230 240 250 260 270 28 29 300
0 0
5'0"
5'2"
Height
5'4"
5'6"
5'8"
5'10"
6'0"
6'2"
6'4"

5. Definitions
Category BMI lbs overweight % US pop
Normal 25 0 30%
Overweight >25 0-35 30%
Obese >30 >35 35%
Morbidly Obese >40 >80 - 100 5% (15 million)

6. Morbid Obesity – a “disease”
• Clinically severe obesity = a point at
which obesity becomes an independent
disease process and medical
conditions occur as a result
this occures at about 100 lbs
over ideal body weight or BMI 40

7. OBESITY IS A WORLDWIDE EPIDEMIC

8. Consequences of Obesity

10. Consequences of Obesity
• Type II Diabetes 30% • Intra-abdominal HTN
• Hypertension 50% - GERD
• CAD/ CHF 20%
- Stress Incontinence
• Hyperlipidemia 50%
• Respiratory Insuff. 70%
- Venous Insufficiency
- Sleep Apnea - DVT / PE
- Obesity Hypovent Synd - Hernias
- Asthma

11. Consequences of Obesity
• Gallstones • Cancer - 2-3x higher
• Arthritis 90% - Breast
• Infertility - Endometrial/Cervical
• Hepatosteatosis - Colon
• Chronic Skin - Prostate
Infections • Depression
• Pseudotumor Cerebri • Social Rejection

12. Clinically severe obesity
Risk of not Having Surgery
4
3
Mortality Ratio
2
1
0
20 25 30 35 40
Increasing BMI

13. Mortality of Obesity
• Shortens life by 8 yrs for women and 15
years for men
• Only one in seven with severe obesity
reach a normal life span (77y)
• Carries a higher mortality than most
cancers
• Current generation is the first to have
shorter life expectancy than their parents
in 100 yrs

14. OBESITY EPIDEMIC
• Obesity responsible for >$100 billion in
medical costs per yr
• US was first in life span in 1900, now
LAST among developed nations
• Current generation predicted to have 1/3
chance of developing DM

15. Consequences - Mortality
“Taken together, the diseases associated
with morbid obesity markedly reduce the
odds of attaining an average life span and
raise annual mortality tenfold or more.”
American College of Surgeons, Recommendations for facilities
performing bariatric surgery, ST-34, Bull Am Col Surg, 2000;85:

16. Consequences - Mortality
>300,000 people die each year secondary to
complications of obesity, making it our
2nd leading cause of preventable death

17. IV. Treatment of Obesity

18. Medical Options for Weight
Loss
• Dietary therapy
• Behavioral modification
• Exercise
• Medications

19. Medical Treatment
The bottom Line:
All Non-surgical weight loss attempts
achieve at best modest and short term
success in the morbidly obese population,
with about 10% wt loss, and regain in about
95% within two years
“ANYTHING LESS THAN A RADICAL AND
PERMANENT TRANSFORMATION WILL
RESULT IN FAILURE TO TREAT MORBID
OBESITY”

20. Medical Weight Loss

21. 1991 Concensus Conference on
Obesity
• Medical Therapy is Rarely successful
• Those who fail medical therapy should be
treated surgically
• Criteria for surgical therapy:
- BMI > 40
- BMI > 35 with significant comorbidities
- failed attempts at medical wt loss
Procedures recommended = VBG and GBP

22. Surgical Options
• Gastric Band
• Sleeve Gastrectomy
• Gastric Bypass
• Biliopancreatic Diversion with Duodenal
Switch

23. How does surgery work?
Depending on the procedure:
1. Restriction (less volume in)
2. Malabsorbtion (less calories absorbed)
3. Hormonal Changes (less hunger, “cures”
several disease processes)
4. Dumping (less processed sugar in)

24. Ruox en Y Gastric Bypass
• First developed in the
1970s
• Procedure of choice in
the United States
• Best wt loss with the
lowest side effects
• 60 - 80% EWL in 12 - 18
mo (90% lose 70%)
• Maintained up to 15 yrs
post op

25. Gastric Bypass
Q : How does the GBP effect wt loss?
A : Four mechanisms
1. Restriction
2. Malabsorption
3. Dumping Syndrome
4. Hormonal Changes

26. The Roux-en-Y Procedure
• In the Roux-en-Y
Bypass procedure, a
small pouch
is formed along the
lesser curve, excluding
the fundus
• The fundus is the part
that can stretch out

27. The Roux-en-Y Procedure
• The small intestine is
divided about 20-50
cm beyond the lig of
trietz (beginning pt of
the jejunum)

28. The Roux-en-Y Procedure
• The small intestine
(B), is brought up to
the gastric pouch and
these are attached
• The bilio-pancreatic
limb (A) is hooked up
to the Roux limb (B)
100 to 150 cm from
the pouch
• The biliopancreatic
limb delivers the bile
and enzymes, so food
in the roux limb is
poorly digested

29. Dumping
The Roux limb does
not handle sugar well
and therefore eating
sweets will cause
nausea, cramping
and diarrhea

30. Decreased Hunger
• Ghrelin is a hormone that stimulates appetite
• Ghrelin levels are seen to drop within 24 hrs of surgery
and stay depressed
• Result = “I’m just not hungry”
• Not clear why this occurs

31. Benefits of GBP
• 90% of Patients lose 70% Excess Weight
• 90% of medical problems resolve or improve
• Longer Life (up to 89% reduced mortality)
• Improved energy
• Improved self-esteem, confidence, and
relationships

32. Roux-en-Y
Open Procedure
• More pain
• Longer hosp stay
• Longer return to work
• Wound complications
- seroma (15%)
- infection (<5%)
- dehicsence (1%)
- hernia (20%)
• Technically much
easier

33. Laparoscopic Roux-en Y
• Less pain
• Shorter stay
• Less blood loss
• Faster return to
work
• Technically more
challenging
• More internal
hernias

34. “Restrictive” Surgery

35. LAP BAND
• Mechanism purely restrictive (no
decreased appetite, dumping, or
malabsorbtion)
• Injecting saline tightens the opening,
decreasing flow out of the pouch
• Adjustments made based on symptoms,
wt loss, about every 4 weeks for first
several months

36. ADJUST, ADJUST, ADJUST!
• First adjustment at 6 wks post op
• Continues every 3 wks thereafter until in
“green zone”
• Too tight = food gets stuck, nausea/
vomiting, GERD
• Too Loose = poor wt loss, hungry, tollerate
bread / red meat, “large” meals
• Average adjustments - 5-6 first year and
ever 6 - 12 months thereafter

37. LAP BAND
• Weight loss , generally , and
than with GBP
- Best studies = 30% 1 yr, 40% 2y, 50% 3y
- Some studies 20 -30% wt loss
- Some up to 60% wt loss
- overall about 50% pts lose 50% excess
weight

38. Lap Band Advantages
• Stomach and intestines not cut
• May have shorter recovery time
• Band is adjustable (going on a cruise is
not a reason to empty it!!)
• Surgery is “reversible” ( usually for
complications)

39. Lap Band Disadvantages
• Wt loss slower, less and more variable
• Persistently high rates of reoperation and
band removal (15 – 25%)
• Less Resolution medical problems
• Easier to “cheat”
• Requires Maintenance adjustments
forever (every 6 - 12 months)

40. Who should get a band?

41. Sleeve Gastrectomy
• BPD developed 1976
• BPD with DS 1998
• LS BPD w/ DS 2000
• Some restriction
• Mostly malabsorbtion
• Hormonal effect
• More complications,
higher risk

42. Sleeve Gastrectomy
“Two stage” LS BPD w/
DS proposed 2000
-LS Sleeve first
-Intestinal bypass after
initial wt loss
-FOUND THAT SOME
DID NOT NEED 2ND
SURGERY

43. Sleeve Gastrectomy
• 2005 – 2 studies of LS Sleeve as primary
procedure showing 53% and 83% EWL at
1 yr
• 2006 first large study (357pts) showing
62% EWL 12m and 67% EWL 2 yrs
• To date 36 studies (2,570 pts) showing
33 – 85% EWL at 5 yrs, AVERAGE 60%

44. Sleeve Gastrectomy
MECHANISM:
1.Restriction – 100 to 150 cc vs 30cc pouch
2.Hormonal Effect
- decreased grehlen 70%
- decreased hunger 75%
- significant effect on diabetes
3. No dumping, no malabsorbtion

45. COMPLICATIONS
LAP BAND GASTRIC BYPASS GASTRIC SLEEVE
Gastric Prolapse (slip) Anastomotic Leak Staple line Leak
Band Erosion Bowel Obstruction Bleeding
Esophageal Dialation Pulm Embolism Stricture
Port Problems Stricture/Marginal Ulcer Conversion to GBP
Death .1 - .5% Death .2 - .3% Death .2%

46. Is it worth it?
• Mortality - Cholecystectomy .2 - .5 %
- Hip Replacement .1 - .3 %
- Colon Resection 3 – 5 %
- LS Incisional Hernia 1 – 3%
- Hysterectomy .1 - .6%

47. Bariatric Surgery
• Major Life Changing event
• Not a “cure” for Morbid Obesity, but . . .
• Currently the best (and only) tool available
to manage the disease of Morbid obesity
• Will only be successful when
accompanied by of and
lifestyle changes