Post on 02-Apr-2015
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Options for Obesity and Long-Term ResultsBariatric Surgery
Mark Kligman, M.D.Assistant Professor, Surgery
Director, Center for Weight Management & WellnessUniversity of Maryland, School of Medicine
The Problem
The BIG Secret !
Current Surgical Management
Indications
Standard Criteria
Age 18 – 65 years
+
BMI ≥ 40 kg/m2
Standard Criteria
Age 18 – 65 years
+
BMI ≥ 40 kg/m2
Special Criteria
Age 18 - 65
+
BMI 35 - 40 kg/m2
+
High risk health problems
Special Criteria
Age 18 - 65
+
BMI 35 - 40 kg/m2
+
High risk health problems
The Surgery Timeline
1 2 3 4 5 6 7 8 9 10
Educational Seminar
Initial Office Visit• Bariatric surgery
booklet
Dietician Evaluation• 6 month supervised diet• Nutrition education
Submit Request for Preauthorization
Preoperative Office Visit• Consent• Written examination
Preoperative Workshop
Initial Contact OR
• Laboratory evaluation• CBC, Chem, LFT, cholesterol, triglycerides• Vit D, Vit B12, TFT, adrenal function tests
• Pulmonary evaluation: CXR, sleep study, PFT, ABG• EKG, Stress test, echocardiogram• UGI, GB U/S, EGD, Colonoscopy• Pap, Mammogram
• Consultation: • psychologist / psychiatrist• Cardiology• Anesthesia• Pulmonary• Gastroenterology• Endocrine
Current Operative Approaches
More Weight Loss Less
More Risks Less
Malabsorption Restriction
Biliopancreatic Diversion with Duodenal Switch
Roux-en-Y Gastric Bypass
Adjustable Gastric Banding
Sleeve Gastrectomy
Biliopancreatic Diversion with Duodenal Switch (BPD-DS)
General Features• Gastric pouch size:
• Standard: 300 mL
• Three segments• Alimentary tract: 200-250cm• Biliary tract: 250 cm• Common channel: 50-150 cm
Average Weight Loss• 70 - 90 % of excess weight
Risks Associated with Duodenal Switch
•Protein malnutrition 15%•Anemia < 5 %•Marginal ulcer < 3 %•Peripheral neuropathy 1.3 %•Night Blindness 3 %•Osteoporosis 14 %•Renal stones•Nausea 65 %•Diarrhea 62 %
•Vitamin deficiencies: A, D, E, K, B12
•Bowel obstruction•Incisional hernia 10 %
•Death 1.1%
Adjustable Gastric Banding (AGB)
Fill Port
Portion of Band which wraps around stomach
Realize™LapBand™
Adjustable Gastric Banding
GENERAL FEATURES
• Inflatable balloon can be adjusted using a port under the skin
Average Weight loss
• 30 - 50% of excess weight
Band Adjustment
Deflated Post-Adjustment
Risks Associated with Gastric Banding
• Injury to esophagus, stomach, spleen• Migration of implant (band erosion, band slippage, port displacement)*• Tubing-related complications (port disconnection, tubing kinking) *• Band leak• Esophageal spasm• Gastroesophageal reflux disease (GERD)• Port-site infection
• Death 0.1 %
* Re-operation 5 -20 %
Vertical sleeve gastrectomy
•May be an option for carefullyselected patients, including high-risk or super-super-obese patients1.
•Use:
• Primary operation
• Staged operation
•Mean %EWL at 1 yr: 59%2
•No implanted medical device
1. ASMBS, Position Statement on Sleeve Gastrectomy as a Bariatric Procedure. June 17, 2007.
2. Lee CM, et al. Surg Endosc (2007) 21: 1810–1816
Risks Associated with Sleeve Gastrectomy
• Leak * 2.2 %• Stricture * 0.6 %• Gastroesophageal reflux disease (GERD)• Delayed gastric emptying 0.2 %• Wound infection
• Re-operation 6 %
• Death 0.19 %
Obesity Surgery 2007, 17:962-969Obesity Surgery 2009, 19:1672–1677Surg Obes Relat Dis 2010; 6: 1–5
Sleeve Gastrectomy: Unresolved Issues
• Standardization of operation• Optimal sleeve diameter• Location of the sleeve termination
• Durability as a primary operation
Roux-en-Y Gastric Bypass (RYGBP)
General Features• Pouch size: 15 – 30 ml
• Pouch opening: 10 mm• Roux-en-Y limb
70-150 cm
Average EWL: 60 – 80%
Risks Associated with Gastric Bypass
Early:• Staple line leak <1 %• Acute gastric distention • Roux-Y obstruction
Late:• Stomal Stenosis <5 %• Marginal ulcer ~5 %• Anemia
• Folate deficiency• Vitamin B12 deficiency • Iron deficiency
• Calcium deficiency / osteoporosis• Gallstones 10 %
Death : ~ 0.1 %
Which Operation?Roux-en-Y Gastric
BypassSleeve
GastrectomyAdjustable Gastric
Banding
Weight Loss(% EWL)
80 50 40
Time to achieve maximal weight loss (years)
~1 ~1 2-3
Number of Office visits (1st year)
4 4 6-8
Improvement of obesity-associated health problems
Excellent Very Good Very Good
Reversibility + / ─ ─ +
Safety Excellent Excellent Excellent
Risk of nutritional complications
Moderate (easily correctable)
Minimal Minimal
Measuring Success
Measuring Success — Part 1
Impact of surgery on:• Weight • Co-morbidities • Mortality
Weight Maintenance 10 Years after Bariatric SurgeryThe SOS Study
Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26
Effect of Gastric Bypass on Cardiac Risk Factors
Preoperative Postoperative
BMI (kg/m2) 46.9 ± 5.8 28.7 ± 4*
Cholesterol (mg/dl) 202 ± 37 165 ± 29*
LDL-Cholesterol (mg/dl) 118 ± 33 97 ± 26*
HDL –Cholesterol (mg/dl) 45 ± 11 51 ± 11*
Systolic BP (mmHg) 143 ± 20 123 ± 18*
Diastolic BP (mmHg) 81 ± 10 71 ± 11*
* p <0.0001
Kligman MD et al. Surgery 2008;143:533
Impact of Gastric Bypass on Cardiac Risk
10-year Risk of Cardiac Event (%)
Pre-operative Post-operative
Vogel 2007 6 3
Torquati 2007 5.4 2.7
Kligman 2008 6.7 3.2
Vogel et al. Am J Cardiol 2007;99:222-26.Torquati et al. J Am Coll Surg 2007;204:776-82.Kligman et al. Surgery 2008;143:533
Impact of Bariatric Surgery on MortalityDeath Rates
Adams et al. N Engl J Med 2007 357 753
Impact of Bariatric Surgery on MortalityThe SOS Study
Sjöström et al. N Engl J Med 2007;357:41
Measuring Success — Part 2
Comparison to Medical Therapy
Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes
Schauer et al. N Engl J Med 2012;366:1567-76.
Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes
Schauer et al. N Engl J Med 2012;366:1567-76.
Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes
Schauer et al. N Engl J Med 2012;366:1567-76.
Measuring Success—Part 3
Weight LossTraditional approach•Final BMI:
• <35 for morbid obesity (starting BMI < 49)• <40 for superobesity
(Starting BMI > 50)•Percent EWL:
• Excellent ≥75%• Good 50-74%• Fair 25-49%• Poor <25%
Co-morbidity ResolutionCurrent approach•The “real” goal of bariatric surgery is the reduction of life-threatening co-morbidity
Biron S et al. Obes Surg 2004; 14: 160-164Reinholt RB Surg Gynecol Obstet 1982; 155: 385-394
Remission Rate of Type 2 Diabetes is Associated with Greater Weight Loss
Following Gastric Bypass
Kadera BE et al. Surg Obes Relat Dis 2009; 5:305–309
Remission Rate of Type 2 Diabetes is Associated with Greater Weight Loss Following
Sleeve Gastrectomy
Surg Obes Relat Dis 2009; 5: 429-434.
EW
L (
%)
Does the Type of Procedure Influence the Improvement in Co-morbidities?
Gastric Banding
Gastric Bypass BPD±DS
EWL (%) 47.5 61.6 70.1
Remission DM (%) 47.9 83.7 98.9
Buchwald et al. JAMA 2004;292:1724-1737
“[Weight loss] isn't everything, it's the only thing” --Vince Lombardi