Obesity: Surgical Treatment The Science Past The Billboards

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Obesity Surgical TreatmentThe Science Past The
Billboards
Ara Keshishian, MD, FACS, FASMBS Glendale,
California
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Objectives

• Define obesity
• Why is it important? Public Health
• Causes of obesity
• You are what you eat
• Genetic
• Environment
• Current Surgical Options
• Advantages and Disadvantages
• The Decision to Undergo Surgery
• Conclusion

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The term Bariatric Surgery

• Comes from the Greek words
• baros meaning weight
• and
• iatreia meaning medical treatment

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Changing Perceptions of the Seriously Overweight

• Past
• Obesity seen as a weakness or failure of
  individual
• Diet and exercise were prescribed treatments
• Weight loss surgery viewed as dangerous and
  extreme- weak persons easy way out
• Present
• Obesity is considered a disease and the cause of
  many serious health conditions
• Surgery has gained acceptance as a proven method
  to treat this disease
• But surgical treatment is not for all obese
  patients

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Why are We Overweight?

• Consumption of foods high in calories (excessive
  sugar and fat)
• Consumption of too much food (large portions)
• Not enough exercise/sedentary lifestyle
• Inheriting fat genes from our parents/relatives

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Scale-Severity of Obesity

• Using the Body Mass Index (BMI)1-3
• Used to determine if you qualify for surgery
• Measures obesity based on weight
  and height

Height (ft/in) Height (ft/in) Height (ft/in) Height (ft/in) Height (ft/in) Height (ft/in) Height (ft/in) Height (ft/in) Height (ft/in) Height (ft/in) Height (ft/in) Height (ft/in)
49 411 51 53 55 57 59 511 61 63
154 33 31 29 27 26 24 23 22 20 19
165 36 33 31 29 28 26 24 23 22 21
176 38 36 33 31 29 28 26 25 23 22
187 40 38 35 33 31 29 28 26 25 24
198 43 40 37 35 33 31 29 28 26 25
209 45 42 40 37 35 33 31 29 28 26
220 48 44 42 39 37 35 33 31 29 28
231 50 47 44 41 39 36 34 32 31 29
243 52 49 46 43 40 38 36 34 32 30
254 55 51 48 45 42 40 38 35 34 32
265 57 53 50 47 44 42 39 37 35 33
276 59 56 52 49 46 43 41 39 37 35
287 62 58 54 51 48 45 42 40 38 36
298 64 60 56 53 50 47 44 42 39 37
309 67 62 58 55 51 48 46 43 41 39
320 69 64 60 57 53 50 47 45 42 40
Weight (lbs)
Weight Category BMI (kg/m2)
Healthy Weight 18.5-24.9
Overweight 25-29.9
Obese 30-34.9
Severely Obese 35-39.9
Morbidly Obese 40
Please note BMI does not distinguish between
fat and muscle. A heavily muscled person could
have a BMI in excess of 25 without having any
increased health risks.
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Causes of Obesity

• Just eat healthy and exercise and every thing
  will be fine... is not the answer- it does not
  work.
• Height, hair color, eye color, bone structure,
  physical abilities, all dictated by genetics- so
  is weight.
• Surgery outcomes always follow the data !
• Diets do not fail
• Patient do not fail

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Complex Disease

• Obesity is
• Multifactorial
• comprehensive solution to address all components
• Not a simple answer
• Long term approach needed

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Animal Model for genetic basis

• Mutant Mouse agouti is
• Fat, with yellow fur. It has a mutant protein
  that binds to Melanocortin Receptor-1 (MCR-1) and
  hinders pigment production.
• This protein also binds to MCR-3, and MCR-4
  protein that quell feeding.
• University of Arizona- Levine
• Blocked the MCR-1 receptor and ended up with
  thin, dark fur, mouse!
• Human studies in phase 3 trials
• Palatin researchers ...increased blood flow to
  genitalia noted
• Perfect ! Loose weight, get a tan and boost your
  sex life!

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GI Hormones
Gastrointestinal Hormones and their Relationship
to Bariatric Surgery April 2009 by Daniel J.
Rosen, MD and Alfons Pomp, MD, FACS

• AGB

Gastric Bypass- RNY
Sleeve Gastrectomy
Duodenal Switch
Diet !
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Health Risks and Increased Risk of Mortality

• Diabetes
• Hypertension
• Sleep apnea
• Depression
• Joint pain
• Infertility
• Cancer
• GERD
• Asthma

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Relative Mortality
2.5
2.0
1.5
Relative mortality
1.0
VeryLow
VeryHigh
Moderate
Low
Moderate
High
0
20
25
30
35
40
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BMI
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Who Qualifies for Weight Loss Surgery?

• Clinical Terms Used to Describe Various Levels of
  Body Fat1

Normal Weight (BMI 18.5 to 24.9)
Overweight(BMI 25 to 29.9)
Obese (Class I)(BMI 30 to 34.9)
Obese (Class II)(BMI 35 to 39.9 )
Extremely Obese (Class III)(BMI 40 or more)
BMI (Body Mass Index) A measurement of an
individuals weight in relation to height (kg/m2).
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1. National Institutes of Health/National Heart,
Lung and Blood Institute Clinical Guidelines
Evidence Report. NIH Publication 98-4083,
September 1998.
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Diseases Attributable to Obesity
Relative Risk of Developing Certain Diseases Over
the Next Decade For Men With BMI gt351
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Weight Loss Strategies

• Dietary Intervention
• About 10 of body weight can be healthfully lost
  in 6 months,1 but diets are prone to failure for
  many reasons2
• Physical Activity1
• Increased activity can improve general health but
  may have little impact on total body weight in
  morbid obesity
• Behavior Modification1
• Can contribute to overall weight loss program,
  but requires ongoing professional contact
  and failure rate can be high
• Drug Treatments1
• Short-term use not recommended since weight is
  typically regained when treatment ends and there
  is modest difference from placebo long-term
• Weight Loss Surgery in the Severely Obese1
• The most effective approach for long-term weight
  loss

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Medical - Surgical Treatments (SOS)
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Normal Anatomy
CHO
FAT
Protein
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AGB (Lap Band, Realize band)
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Duodenal Switch (DS, GRDS, BPD-DS)
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Gastric Bypass
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Science- maybe not!
1-800-
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Facts not fiction
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Facts not fiction
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Duodenal Switch
TBL- Total Bowel Length
Alimentary Limb 40 of the TBL
Bilio-pancreatic Limb 40-50 of the TBL
Common Channel 10 of the TBL
TBL- Total Bowel Length
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Comparing Weight Loss Results
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Outcomes data
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Outcomes

• Needs to be reproducible
• Needs to be predictable
• Get past punch lines
• Reversible, Minimally invasive, Low Risk (single,
  cumulative)
• This is a disease process that needs treated

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Questions?

• Thank you

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