BARIATIC SURGERY

FOR OBESITY
“ boon or bane ”
• One of the most widespread health
problems in the world.

• Responsible for causing many diseases.

• Leads to premature death

 The Obesity Epidemic
The weight gain cycle

Eat too much

Gain weight

Can’t
Exercise

Get
Depressed
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1998, 2006
(*BMI 30, or about 30 lbs. overweight for 5’4” person)

1990 1998

2006

CDC-2007

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

 MORE THAN
1 IN 4
CHILDREN IS
OVERWEIGHT
or OBESE!!
 Body Mass Index (BMI)
BMI = weight (kg) / height (m)2

Normal
Weight Overweight Obese Severely Obese Morbidly Obese Super Obese
(BMI 18.5 to (BMI 25 to 29.9) (BMI 30 to 34.9) (BMI 35 to 39.9 ) (BMI > 40) (BMI > 50)
24.9)
BMI and mortality
The Risks of Overweight
Coronary heart disease
Metabolic syndrome:
hypertension, diabetes mellitus,
high cholesterol
Breast cancer, prostate cancer,
colon cancer, uterine cancer
Stroke
Osteoarthritis
Gallbladder disease
Sleep apnea, respiratory
problems
Work, educational, and social
discrimination
Depression
 “To Cut or Not To Cut”

• Medical Therapy 5-10% excess weight loss

• Pharmacologic Intervention 8-10% EWL

• Bariatric Surgery 60-80% EWL

Disadvantages of medical
treatment
Not this!
Why would anyone have surgery to
lose weight?
 NIH Criteria for surgery:
1. Patients with a BMI of 40 or greater

2. Patients with BMI of 35 or greater who also suffer

from a severe medical condition related to obesity
(sleep apnea, diabetes, heart failure, high blood
pressure)

3. A patient who is prepared and willing to commit to the

lifestyle changes that will be necessary following
surgery
 Surgery
2001 47,000
2003 98,000
2008 344,221

No. of surgery done in INDIA in 2008 -

1,216.

Over 90% (91.4%) of world bariatric

surgery was performed laparoscopically.
 Henry Buchwald, Danette M. Oien.
Metabolic/Bariatric Surgery Worldwide 2008.
Obes Surg 19(12)
Types of Bariatric Procedures
• Restrictive:
Vertical banded gastric bypass
Laproscopic adjustable gastric banding
• Restrictive and Malabsorptive:
Roux-en Y gastric bypass
Distal gastric bypass with DS
• Malabsorptive:
Jejuno-ileal bypass
Biliopancreatic Diversion
Duodenal Switch (DS), no bypass
The most common procedures, 86.6% of the
total number of procedures were
1.Laparoscopic AGB (32.3%),
2.laparoscopic RYGB (39.7%; open plus
laparoscopic RYGB 49.3%), and
3.laparoscopic SG (5.1%).

 Henry Buchwald, Danette M. Oien,.
Metabolic/Bariatric Surgery Worldwide 2008.
Obesity Surgery; 19(12)
 Laproscopic Adjustable
Banding
• This type of surgery is
performed with the
laparoscope.

• This surgery
restricts
consumption but
does not cause
malabsorption.
 Advantages of the Lap Band

• Less invasive, shorter surgery, and shorter hospital

stay.

• After 3 years weight loss is about the same as

Roux-en-Y in some studies.

•Adjustable - customized per patient.

• Reversible

• Lowest operative complication rate - no leaks

• Low malnutrition risk

• Satiety-including procedure
 Surgical Advantages of Pure Gastric
Restriction

• 50% excess weight loss at 1 year

• Minimal nutrition complications

• Can be used in populations that are

high risk for RYGB
 MOSTLY RESTRICTIVE PROCEDURES

• Most commonly
performed surgery in
USA

• Weight loss by
restricting food intake.
 Roux-en Y Gastric Bypass

• “Best” weight
reduction surgery
according to NIH.
• Surgeons create a
pouch from the upper
part of the stomach.
• It becomes a
Reservoir for food.
Roux-en-Y Surgery
Malabsorptive Procedure Facts
The largest weight loss is usually seen with
this procedure.

At 10 years, the average excess weight loss is

about 80%.

Heavier patients (BMI > 50) appear to have

better results with this operation in the long
term than other weight-loss procedures

 Society Americas Gastrointestinal Endoscopic Surgeons

 Surgical Advantages of Combined Gastric
Restriction & Malabsorption

• Advantages of Gastric Bypass :

60% of excess weight lost in year 1
Maintains a weight loss of
50% for 25 years Rapid resolution of metabolic
syndrome Improvement in obesity-related
complications
• Advantages of the Duodenal Switch :
60-80% of excess weight lost in year 1
Most effective therapy for super obese
Weight Loss Benefits vs. Nutritional Risk

70

60

50

40 EWL
Mortality
30
B12 def
20

10

0
Band Gastroplasty GBP DS
 Anti-obesity Surgery and Co-morbidities
120
100
80
Improve
60
Cure
40
20
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J Kral 1995, >1000 patients

• The mean glucose levels in the surgical group fell
from 187 mg/dl preoperatively and remained less
than 140 mg/dl for up to 10 years of follow-up. 

» Macdonald KGJ, Long SD, Swanson MS, et al. The gastric

bypass operation reduces the progression and mortality of non-
insulin-dependent diabetes mellitus. J Gastrointest Surg
1997;1:213-20.
• Gastric bypass is now established as effective &
safe therapy for morbid obesity& its associated
comorbidities.
• No other therapy has produced such durable &
complete control of diabetes mellitus.

» Pories WJ, Swanson MS, MacDonald KG et al. Who would have

thought it? An Operation Proves to be most effective therapy for
adult onset diabetes mellitus. Ann Surg 1995; 222: 339-50
• Bariatric surgery is effective for decreasing the
use of medications for obesity-related diabetes,
hypertension, and hyperlipidemia.

• The clinical and economic benefits of reduced

medication requirements should be considered
when making decisions about the effects of
bariatric surgery.

» Jodi BS , Jeanne MC, Andrew DS, et al. Prompt Reduction in

Use of Medications for Comorbid Conditions After Bariatric
Surgery. Obes Surg 2009; 19(12):1646-56
• LGBRY can be done safely in patients over
60 years of age in an experienced bariatric
program, even in patients with relatively high risk
based on their comorbid conditions preoperatively.

• Resolution of associated comorbidities far

exceeds that found with any other treatment
modality.

» Alan CW, Tracy M. Laparoscopic Gastric Bypass in Patients

60 Years and Older: Early Postoperative Morbidity and
Resolution of Comorbidities. Obes Surg 2009; 19(11) 1472-76
Pharmacotherapy
• Weight loss 1 year after gastric bypass was significant
and led to an improvement of quality of life.

• Health-related quality of life improves dramatically 1

year after gastric bypass.

» Jennifer K, Zoltan P, Ileana I, et al. Relationship between Quality of Life

and Weight Loss 1 Year after Gastric Bypass. Digestive surgery 2009;
26(5):
• The operative 30-day mortality rates of 0.1% for the
restrictive procedures, 0.5% for gastric bypass, and
1.1% for biliopancreatic diversion or duodenal
switch compare favorably with the accepted
operative mortality rates for other major surgical
procedures.

» Buchwald H, Avidor Y, Braunwald E, et al. Bariatic surgery : a

systematic review and Meta analysis. JAMA 2004;292(14):1724-37
 Benefits of Bariatric Surgery
• Improved glycemic control

• Improved BP

• Improved ventricular function

• Improvement in symptoms of Osteoarthritis

• Improved quality of life

• Reduction in depressive symptoms

• In addition to the effective weight loss achieved by
patients undergoing bariatric surgical procedures,
a substantial majority of patients with diabetes,
hyperlipidemia, hypertension, and obstructive
sleep apnea experienced complete resolution or
improvement of their comorbid condition.
» Buchwald H, Avidor Y, Braunwald E, et al. Bariatic surgery : a
systematic review and Meta analysis. JAMA 2004;292(14):1724-
37
• Weight-loss surgery significantly
decreases overall mortality as well as
the development of new health-related
conditions in morbidly obese patients.

» Christou NV, Sampalis JS, Liberman M, et al

Surgery Decreases Long-term Mortality,
Morbidity, and Health Care Use in Morbidly
Obese Patients. Ann Surg 2004;240:416-23
• Severely obese patients
who lost 43 kg through
gastric bypass
demonstrated improved
quality of life scores to such
an extent that their post-
weight loss scores were
equal to or even better than
population norms.
J La State Med Soc .2005; 157 (1): S42-49. 2009
Endocrinol Metab Clin N Am. 2003; 32: 761-786.
• Non surgical treatment have limited success in
achieving substantial weight loss for morvidly obese
patients

• There is sufficient evidence to conclude that surgery

improves health outcomes for patients with morbid
obesity as compared with non surgical treatment.

» Blue Cross Blue Shield Association. Special report: The

relationship between weight loss & changes in morbidity following
bariatic surgery for morbid obesity. Technol Eval Center Asses
Prog Exec Summ 2003;18(9):1-25
• Bariatic surgery is more effective than non
surgical treatment & clearly results in
sustained weight loss & comorbidity control.

• Also stated that at this stage an RCT that

compares medical & surgical therapies is not
warranted given the known superiority of the
latter.

» Shekelle PG, Morton SC, Maglione MA et al.

Pharmacological & Surgical treatment of Obesity. AHRQ
Publication #04-E028-2, 2004
CONCLUSION
THANK YOU