Transcript obesity surgery at jhbmc

Bariatric Surgery for
the Treatment of
Obesity and Metabolic
Disease
JHI Partners Forum 10/2/2012
Thomas Magnuson MD
Associate Professor of Surgery
Johns Hopkins University
School of Medicine ([email protected])
Disclosure
Nothing to disclose
OBESITY SURGERY
OVERVIEW
• Indications for surgery and patient selection
• Current surgical procedures to treat obesity
• Outcomes of surgery: Benefits and risks
• “Metabolic surgery” and impact on diabetes and
cardiometabolic risk
Why are we talking about Obesity Surgery today?
1) Rapid rise in prevalence of obesity
2) Recognition of Obesity as a Disease
3) Better operations for Obesity
and public/physician awareness
4) Increased focus on improvement/
resolution of metabolic disease
Treatment of Obesity
• Diet & Exercise
• Medications
• Behavioral modification
• Surgical management
Explosion in Bariatric
Surgery
Over 200,000 procedures in the U.S. in 2010
Purpose of Bariatric Surgery
• To alleviate or
eliminate obesity
related medical
diseases
• It is not cosmetic
surgery and
patients may still
be overweight after
plateau in weight
loss postop
Bariatric Surgery Patient Selection
(Based On The 1991 NIH Guidelines)
• BMI > 40; or > 35 with obesity related morbidity
• Previous failed attempts at supervised weight
reduction
• Realistic expectations; no recent substance abuse
• Age limits (18 to 70 yrs old in most programs)
• Supportive family/friends
• Lifelong commitment to dietary change and followup
• Pre-op evaluation by dietician and psychologist
Obesity Surgery
Patient Selection
Additional Considerations
• Adolescents (? informed consent, compliance)
• Age > 70yo (higher risk, less medical benefit,
? Improved quality of life)
• “End stage obesity” (severe CHF, home oxygen, nonambulatory, BMI>100)
• Bridge to other procedures (transplantation; joint
replacement)
• Patients post-transplant (liver; kidney)
• Lower BMI patients (30-35) with diabetes/htn
Obesity Surgery
Pre-Operative Evaluation
• Insurance approval (most require 6 month dietary
program/counseling within previous 2 years)
• Mandatory Dietary and Psych evaluation/counseling
• Cardiac/pulmonary “clearance” if significant history
• Sleep apnea testing/treatment if high risk
• In select patients- EGD, UGI, IVC filter
• Stop smoking and estrogen products (BCP’s) prior to
surgery (high risk for VTE)
• Most Bariatric Surgery is performed at “Centers of
Excellence” certified by the ACS and ASMBS
OBESITY SURGERY
OPERATIONS FOR MORBID OBESITY
RESTRICTIVE OPERATIONS
Adjustable Gastric Banding (ABG)
Vertical Sleeve Gastrectomy (VSG)
Gastric Bypass (GBP) (also malabsorptive)
MALABSORPTIVE OPERATIONS
Gastric Bypass (GBP)
Duodenal Switch-biliopancreatic diversion (DS-BPD)
Roux-en-Y Gastric Bypass
• Small gastric
pouch (20-30 ml)
(remainder of
stomach left in)
• ~100 cm of small
bowel bypassed
creating nutrient
malabsorption
Laparoscopic Gastric Bypass
Gastric Bypass
PROS
• Durable weight loss: 60 to
70% excess wt loss at 2 yrs
• Proven reduction of obesity
related medical problems
• Risk of death low if done by
experienced team (<0.5%)
• Most common operation in
US with the most follow-up
data
CONS
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Marginal Ulcer
Stomal stenosis
Anemia
Calcium deficiency
Nutrition/vitamin defic.
Difficult to reverse
Laparoscopic Gastric Band
• Laparoscopic procedure
that is less invasive than
gastric bypass
• Adjustable, depending
on desired wt. loss
• Weight loss less than
gastric bypass (40%
excess wt. loss at 1yr
post-op)
Adjustable Gastric Band
PROS
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Reversible
Least invasive
Lowest risk of Death
No malabsorption
Adjustable
40 to 50 % excess
weight loss at 2
years
CONS
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Foreign body / erosion
Esophageal dilation
GERD
Breakage/slippage
Failure to lose weight
Slower weight loss
30-50% reoperation
rate/removal long term
Laparoscopic Vertical
Sleeve Gastrectomy
Vertical Sleeve Gastrectomy
Laparoscopic Vertical Sleeve
Gastrectomy
• Does not involve intestinal rearrangement
• Restrictive only; 50-60% excess weight loss
• May be used as a first step operation in high
risk patients to induce weight loss before
performing duodenal switch or gastric
bypass
• Currently considered for weight loss in lower
BMI morbidly obese patients who do not
want an adjustable band or a malabsorptive
operation
Duodenal Switch
• Partial stomach resection
• All of the bowel bypassed
except 150-200 cm of
distal small bowel
• Primarily malabsorptive:
risk of malnutrition, vitamin
deficiency, diarrhea
Duodenal Switch w/ BPD
PROS
• Best wt loss (80%
excess weight)
• Best resolution of
metabolic disease
• Pylorus preserved
• Less restriction than
GBP
CONS
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•
•
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Malabsorption
Anemia
Calcium deficieincy
10 % may need
revision
• Diarrhea/malodorous
stools
• Protein malnutrition
• ? Liver disease
Summary of Obesity
Surgery
• Gastric bypass (60-70% of all procedures)
• Laparoscopic adjustable gastric band (LAGB)
(20-30%)
• Lap Sleeve Gastrectomy (15-25%)
• Duodenal Switch w/ biliopancreatic diversion
(5%)
The Johns Hopkins Center for Bariatric Surgery
Over 3,000 bariatric procedures since 1997
Analysis of 1000 gastric bypass procedures:
Age = 41 yo (18 - 74 yrs)
Female = 77 %
Pre-Op weight = 349 lbs (210 - 740 lbs)
Pre-Op Body Mass Index (BMI) = 55.3 (39 - 101)
Hospital stay (median) = 2 days (lap=2; open=3)
Pre-Op obesity related disease:
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Osteoarthritis = 83 %
Hypertension = 47 %
GERD = 40 %
Diabetes = 27 %
Sleep Apnea (requiring CPAP) = 22 %
Obesity Surgery At Johns Hopkins
Weight Loss
Excess body wt. loss
12 months =
120 lbs
61%
24 months =
134 lbs
67%
36 months =
133 lbs
66%
48 months =
133 lbs.
62%
60 months =
128 lbs.
64%
Impact on Medical Disease (by 1 year post-op)
Hypertension
73% resolution
Diabetes
75% resolution
GERD
91% resolution
Sleep Apnea
93 % resolution
WEIGHT LOSS
350
325
POUNDS
300
275
250
225
200
0
6
12
18
24
30
MONTHS POST-OP
36
42
48
OBESITY SURGERY AT JHBMC
POST-OP COMPLICATIONS
(1000 gastric bypass pts.)
Mortality = 0.2 %
Morbidity = 13 %
Wound infection =
Pulmonary embolus =
Reoperation (< 30 days) =
Decubitus ulcers =
Anastamotic leak =
Bowel obstruction =
Readmission =
6.5 %
0.9 %
1.2 %
0.6 %
0.2 %
0.6 %
8%
OBESITY SURGERY
Evidence based analysis
Is bariatric surgery effective?
• Buchwald 2004 (meta-analysis):
% excess wt loss
Gastric Band
Gastric Bypass
DS/BPD
49%
61%
70%
Resolution of
DM
HTN
48%
83%
98%
43%
67%
83%
OBESITY SURGERY
Evidence based analysis
Is bariatric surgery effective?
• Buchwald 2004 (meta-analysis):
% excess wt loss
Gastric Band
Gastric Bypass
DS/BPD
49%
61%
70%
Resolution of
DM
HTN
48%
83%
98%
43%
67%
83%
• Swedish Obese Subjects Study (SOS) 2007
Longitudinal matched-control cohort study; over 10 yr f/u of 2,010 pts.
- Sustained weight loss in the surgical cohort with
reductions in diabetes, dyslipidemia, and HTN
compared to matched controls
Mean % Weight Change over 15 Years
Swedish Obesity Study
Control
Bands
VBG’s
30%
RYGB
Sjostrom: NEJM 2007;357:741-
Diabetes Remission after Bariatric surgery
Ann Intern Med. 2009;150(2):94-103.
N Engl J Med. 2012.
• Compared the efficacy of three treatments for
patients with T2DM and BMI between 27-42 kg/m2:
1.Intensive Medical Therapy*
2.Intensive Medical Therapy* + Laparoscopic Sleeve
Gastrectomy
3.Intensive Medical Therapy* + Gastric Bypass
• Primary Endpoint: Proportion of patients with a
glycated hemoglobin level of 6.0% or less at 12
months after treatment.
45%
Patients at Glycemic Control, 12
months
40%
N Engl J Med. 2012
42%
35%
37%
30%
25%
20%
15%
10%
12%
5%
0%
Med therapy
GBP
Sleeve
Medication Utilization and Annual Health Care
Costs in Patients With Type 2 Diabetes Mellitus
Before and After Bariatric Surgery
Makary, et al
Archives of Surgery, 2010
• Large multistate insurance claims dataset
• Jan 2002 – Dec 2005
• 2235 patients with diabetes undergoing
bariatric surgery
• at least 1 year pre-op and post-op follow up
Results
Diabetes resolution: 1669 (74.7%) of 2235 pts at 6 months
1489 (80.6%) of 1847 pts at 12 months
906 (84.5%) of 1072 pts at 2 years
Prompt Reduction in Use of Medications for Comorbid Conditions After
Bariatric Surgery Segal et al, Obesity Surgery, 2009
-6025 pts. undergoing
bariatric surgery
-Early post-op reduction
in HTN, DM, and lipidlowering medications
Effect of Surgery on Long-term Mortality
Compared to
Non-Operated Controls
Study
Procedure
F/U
Mortality
Reduction
MacDonald,1997
RYGB
9 yrs
88%
Flum, 2004
RYGB
4.4yrs
33%
Christou, 2004
RYGB
5 yrs
89%
Sowemimo, 2007
RYGB
4.4 yrs
50%
O’brien, 2006
LAGB
12 yrs
73%
Adams, 2007
RYGB
8.4 yrs
40%
Sjostrom (SOS), 2007
VBG/RYGB
14 yrs
31%
“Metabolic Surgery”
Future directions:
• Patient selection based more on metabolic
disease as opposed to weight (? BMI of 30-35
or lower)
• Better understanding of metabolic and
hormonal effects of surgery
• Development of less invasive procedures or
drugs which achieve the desired
physiologic/metabolic effects
Weight Loss Procedures in Development
Endoluminal Surgery
Gastric/vagus n. pacing
Gastric balloon
EndoBarrier
-Endoscopically placed plastic “sleeve” allowing
nutrients to avoid contact with duodenal mucosa
-Designed to achieve diabetes resolution by altering
GI hormone production and islet cell stimulation
OBESITY SURGERY
Summary
-Bariatric surgery is relatively safe with an expected
mortality of <0.5% and morbidity of 10-15%
-Surgery results in sustained weight loss and
favorably impacts obesity related medical disease
and reduces long term mortality
-Further clinical trials are needed to help determine
which operation is best for which patient
The End