Transcript Bariatric Surgery

Bariatric Surgery
Taewan Kim MD
Assistant Professor of Surgery
Introduction
Obesity is a complex chronic disease process that is associated with
increased morbidity, mortality and health care costs as well as a
decreased quality of life
The pathway to obesity is multifactorial and involves biologic,
genetic, emotional, social and cultural factors
Obesity has reached epidemic proportions in the United States
1950s Burger, french fries, coke –
590 calories
Today –1500 calories
25% of children ( watch > 4hrs of
television per day)
Decreased Physical education
participation
NIH/ASBS Classification of Obesity
BMI
18–25
25–30
> 30
30–35
35–40
40-60
> 60
Healthy weight
Overweight
Obese
Class I
Class II
Morbidly Obese
Super/Super obese
BMI correlates with the risk of hypertension, diabetes, dyslipidemia and
overall mortality. It is correlated with body fatness and is not a measure of
body composition.
Weight (kg)
BMI =
Weight (lbs)
=
Height (m2)
x 705
Height (in2)
BMI=42
BMI=14
Introduction
Nearly 97 million adults in the US have a BMI > 25 kg/m2
15 to 20% of American children are obese
In 2000, 56 million American adults met the criteria for obesity (BMI
> 30 kg/m2)
15 million American Adults suffer from morbid obesity (BMI > 40
kg/m2, 100 lbs over normal body weight)
Summary of an Epidemic
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Total medical cost for obesity in 2003 was
$75 billion.
Obesity is estimated to cause 280,000 deaths
annually in the United States.
9.1 percent of annual medical spending was for
direct costs of overweight and obese patients
• Finkelstein, Jan/2004 Obesity Research
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BMI of 30 to 40 (56 million Americans)
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Had healthcare costs of 36 percent greater than
normal-weight individuals
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Had pharmacy costs of 77 percent greater than
normal-weight individuals
• Sturm, Ph.D. Archives of Medicine
Co-Morbidities Associated with Obesity
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Atherosclerotic CV Disease
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Hypertension
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Asthma
•
Hyperlipidemia
•
Sleep Apnea
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Obesity Hypoventilation Syndrome
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Steatohepatitis ( Fatty Liver)
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GERD
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Gout
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Cholelithiasis
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Soft Tissue Infections
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Joint and Back Disease
•
Stress Incontinence
•
Amenorrhea / Infertility
•
Cardiomyopathy
•
Diabetes (type 2)
•
Stress Urinary Incontinence
•
Malignancies (uterine, breast, colon)
•
Pseudotumor cerebri
•
Low self esteem
•
Depression
•
Physical / Sexual Abuse
Prevalence of Significant
Morbidities per Weight
60%
52%
51%
50%
PERCENT AFFLICTED
44%
41%
40%
32%
30%
28%
26%
23%
24%
18%
20%
15%
16%
14%
15%
10%
10%
7%
4%
3%
0%
0%
Diabetes
Asthma
BMI < 25
Arthritis
25-30
30-40
High Blood
Pressure
Cancer*
BMI > 40
Mokdad AH, et al. JAMA 2002;289:76.
Centers for Disease Control, National Center for Health Statistics, National Health and Nutrition Examination Survey
* Increase in mortality rate from cancers of all kinds compared to lowest risk group (BMI 25-30). From: Call EE, et al.
Overweight, obesity and mortality from cancer in a prospectively studies cohort of US adults. New Engl J Med
2003;348:1625.
National Institutes of Health 1991
Consensus Statement
Surgery is the only way to obtain consistent, permanent
weight loss for morbidly obese patients
Who Is a Surgical Candidate?
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Meets National Institutes of Health Criteria:
100 pounds over ideal body weight, BMI > 40
(or > 35 with co-morbidities)
Age 18 to 60 years old
Adolescent and senior patients deserve
special consideration
Failed medically supervised weight loss attempts
Understands surgery and risks
Acceptable operative risks (patient and procedure)
Stable psychological condition:
interview, psychotherapy, support groups as
indicated
Patients who smoke may not be candidates without
stopping for some period of time prior to surgery
Exponential Growth
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10 million individuals in the US
are morbidly obese
>50 million are obese
20% of children or adolescents
160,000
Increased prevalence of comorbidities
100,000
Media and celebrity influence
Laparoscopic or robotic
techniques
Increase in number of trained
bariatric surgeons
140,000
Bariatric surgery
volume trend
120,000
80,000
60,000
40,000
20,000
0
1992 1997 2001 2004
Surgical Evaluation
Educate the patient regarding the surgical procedure and review the
potential risks and benefits
History and physical examination

GI disorders
• Colitis, IBD, guaiac positivity, PUD, gallstones, “irritable
bowel”
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Previous abdominal operations and ventral hernias
• acquire all operative reports
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Smoking
Coordinate preop and postop care with PCP and subspecialists
Nutrition Evaluation
Essential component of the preoperative evaluation
Nutrition/diet history
Current eating habits
Review changes after surgery
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How frequently to eat
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What to eat
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Vitamin and mineral supplements
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Follow-up every 1-2 months for the first year and every 2-3
months for the second year
Behavioral Health Evaluation
The etiology of obesity is multifactorial
Many individuals develop dysfunctional behavior as a consequence of
their obesity
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depression
- low self-esteem
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paranoid ideation
- anxiety
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psychoses
- somatization
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obsessions/compulsions
Certain eating and lifestyle issues may not be conducive to a good
outcome after surgery
Behavioral Health Evaluation
A comprehensive psychological evaluation is essential prior to
undertaking a life altering surgical procedure:
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Living situation
Work situation
Family relationships
Childhood history - abuse
Life stresses
Substance abuse history/Suicide history
Patients with abusive or self-destructive habits are usually eliminated
from consideration
Current Bariatric
Surgical Procedures
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Restrictive
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Vertical Banded Gastroplasty
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Laparoscopic Adjustable Gastric Banding
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Sleeve gastrectomy
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Malabsorptive
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Duodenal Switch/Biliopancreatic Diversion
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Restrictive and Malabsorptive
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Roux-en-Y Gastric Bypass
Vertical Banded Gastroplasty
A restrictive procedure that
creates a small pouch
The pouch empties into the
rest of the stomach
through a small opening
Weight loss is about 50
percent of excess weight
The risk of surgery is
about the same as for
gastric bypass surgery
Malabsorptive Procedures
Advantages:
• Greater sustained
weight loss that is less
dependent on dietary
compliance
Disadvantages:
• Increased risk of
malnutrition and vitamin
deficiencies
• Intermittent diarrhea
and steatorrhea
• Technically complex
Complications (BPD/ DS)
• Buchwald et al
– Leak rate 1.8%
– Reop rate 4.2%
– Mortality 1.1%
• Protein Malnutrition (11.9%)
• Metabolic effects- low iron and Ca levels
• Malabsorption of fat soluble vitamins
Current Most-Used
Bariatric Techniques
Roux-en-Y Gastric Bypass
Weight loss procedure that combines
malabsorption involving a bypass
of the small intestine and restriction
with the creation of a small
(15-30cc) pouch.
Sleeve gastrectomy
Restrictive weight loss surgery
works by reducing the amount
of food consumed at one time; it
does not, however, interfere with
the normal absorption (digestion)
of food.
Roux-en-Y Gastric Bypass
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Restriction and
malabsorption
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Considered the gold
standard
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85 percent of
procedures
performed in the U.S.
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140,600 procedures
in U.S. in 2004
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Death rate, 0.5
percent
Roux-en-Y Gastric Bypass
Open RYGB
Laparoscopic RYGB
Roux-en-Y Gastric Bypass
Contrast Study post-surgery
“Pouch”
Anastomosis
Small intestine
(jejunum)
New Entrants
Barriers to Entry
5%
Mortality
1%
<20 Procedures
>250 Procedures
Surgeon Experience
Open vs. Laparoscopic Approach
Mortality and complication rates are the same or better
with laparoscopic surgery
Recovery time with laparoscopic surgery:
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Hospitalization is shorter (two nights)
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Time until back to work is shorter (two to
three weeks)
Decrease in adhesions with less risk of bowel
obstruction in the future with laparoscopic surgery
Roux-en-Y Gastric Bypass
Results
Control of Weight After
Gastric Bypass Surgery
100
90
80
70
Excess Body
Weight Loss
60
50
Body Mass
Index
40
30
20
10
0
2
5
10
14
Years After Gastric Bypass
Pories, et al. Ann Surg 1995.
•
Complications
Liu et al
– Independent Predicators of Complications
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Male Gender
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Presence of Co-morbidity
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Low volume hospitals
– Open RnY
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20% incidence of incisional hernias
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Leak rate 1-3%
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GI Bleeding 2-4%
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Pulmonary Embolism (1% for open RnY)
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Stenosis of gastrojejunostomy (2-14%)
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Internal Hernias
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Marginal Ulcer
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Metabolic Issues (B12 and Iron deficiency)
Sleeve Gastrectomy
 Sleeve or vertical gastrectomy removes 70-80% of the
stomach.
 Essentially changes the shape of the stomach from a cresent to
a long tube preserving the pylorus.
 One stage vs part of a multistage procedure.
 Advantages
 Technically easier than a bypass
 No foreign body.
 No need for adjustments
 Disadvantages
 Irreversible
 No long term results( >10 yrs)
 Increased operative risk compared to banding
Laparoscopic Adjustable Gastric Band
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Introduced in Australia in 1994,
over 5,000 placed
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Laparoscopic placement of a
silicone band around the
cardia of the stomach – 1 cm
below GE junction
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Access port is secured to the
anterior rectus sheath
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Saline is used to adjust the
band as needed
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FDA approved in 2001
Laparoscopic Adjustable
Gastric Banding
Advantages of the Lap-Band:
• Maintain GI continuity
• Easy to place
• Short operative time
• Requires no alteration in
absorption of micronutrients
• Adjustable
• Requires frequent follow-up visits
Laparoscopic Adjustable Gastric Band
• Long term followup ( O’brien et al, 2013)
– Total 3227 patients ( 714 long term followup -10 years)
• 47% EWL at 15 years
• Revisional surgery
– Proximal enlargement ( 26%)
– Erosion (3.4 %)
– Port and tubing problems ( 21%)
– Band explanted 5.6%
– Revision rate 40% within first 10 years
The Good, The Bad and The Ugly About
Bariatric Surgery
Summary of Outcomes
Treatment
%Total Avg. Wt. Loss %Excess Wt. Loss @
5Years
Placebo
4-6
0
Diet/Behavior
8-12
1.6
Drug Tx
<10
10
RYGB
65-85
60
LAGB
45-50
56
Sjostrom, NEJM 2004
O’Brien JLAST 2003
Summary of Outcomes
Operations for Morbid Obesity
% excess weight loss over time
2 yr
Operation
VBG
Lap Band
Open RYGB
Lap RYGB
BPD
Sleeve**
49%
51%
70%
83%
73%
5 yr
10 yr
14 yr
48%
56%
60%
65%
75%
40%
50%
50%
57%
76%
49%
77% ( 3 yrs)
53% ( 6yrs)
** Himpens et al, 2010 Ann Surg
Weight Loss and Resolution of Comorbid Conditions
Outcome
Gastric
Banding
Gastric Bypass
BPD or DS
Total
Excess Weight
Loss
47%
62%
70%
61%
Resolution of
Diabetes
48%
84%
99%
77%
Resolution of
hyperlipidemia
59%
97%
99%
79%
Resolution of
Htn
43%
68%
83%
62%
Resolution of
sleep apnea
95%
80%
92%
86%
Buchwald et al, 2004, JAMA
Complications of
Gastric Bypass Surgery
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Early complications
 Nausea and vomiting
 Intestinal leakage
 Acute gastric remnant dilatation
 Internal hernia/Obstruction
 Cardiopulmonary
• Myocardial infarction
• Pulmonary embolism
• Pneumonia
• Atelectasis
 Late complications
 Anastomotic stricture (5 percent to
10 percent)
 Anemia, vitamin B12 deficiency,
calcium deficiency
 Gallstones
Chapin 1996
Surgery Reduces Long-term
Morbidity, Mortality, and Healthcare
Use in Morbidly Obese Patients
Study goal: assess impact of bariatric surgery on:
• Mortality
• Healthcare utilization and healthcare costs
• Morbidity
Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality,
Morbidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery
2004;240(3):416-424.
Methods: Study Design
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Observational two-cohort study
Subjects: 1,035 morbidly obese patients treated with
bariatric surgery at the McGill University Health
Centre, Montreal
Controls:
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5,746 matched morbidly obese patients who had
not undergone surgery
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Controls matched for age, BMI, date of first
diagnosis of M/O, gender, and disease status
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Inception time for bariatric cohort was surgery
date
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Inception time for controls was date of surgery of
their match
Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality,
Morbidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery
2004;240(3):416-424.
Procedure Type
Majority of Procedures: Gastric Bypass
Surgeries
800
700
NUMBER OF CASES
600
500
400
300
200
100
0
VBG
GASTRIC BANDING
OPEN GASTRIC
BYPASS
LAP. GASTRIC
BYPASS
Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality,
Morbidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery
2004;240(3):416-424.
Baseline Cohorts
Baseline Characteristics
BARIATRIC CONTROLS
Number of
Subjects
1,035
5,746
Mean Age (SD)
45.1 (11.6)
46.7 (13.1)
Male Gender N
(%)
356 (34.4%)
2,068 (36.0%)
2.5 (1.4)
2.6 (1.5)
Mean Followup (SD)
Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality,
Morbidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery
2004;240(3):416-424.
Surgical Weight Loss Outcomes
Bariatric Cohort Weight Loss (and SD)
Initial Weight (kg)
136 (28)
Initial BMI
50 (9)
Final Weight
89 (23)
Final BMI
32 (7)
% EWL*
67 (24)
Follow-up (yrs)
5.3 (3.8)
* % of excess weight loss is the standard measure of weight loss following surgery.
Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality,
Morbidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery
2004;240(3):416-424.
Significant Reduction in
Co-morbidity Incidences
at Five Years
Reduction in Incidence of
Co-morbidities at Five Years
Cancer
Control
Bariatric
*
Infectious
*
Musculoskeletal
*
Endocrinological
*
Cardiovascular
*
0
10
20
30
40
%
* p < 0.001
Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality,
Morbidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery
2004;240(3):416-424.
5-Year Mortality Reduction
Surgical Patients Had Nine Times Lower Risk of
Dying Within the Study Period
7.0%
6.17%
MORTALITY
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.68%
0.0%
BARIATRIC*
CONTROLS
p-value 0.001
* Includes perioperative (30-day) mortality of 0.4%
Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality,
Morbidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery
2004;240(3):416-424.
Reduction in Healthcare Utilization
Five-Year Healthcare Utilization
Hospitalizations
Hospital Days
Physician Visits
BARIATRIC
CONTROLS
MEAN (SD)
MEAN (SD)
PVALUE
2.75 (3.44)
3.17 (3.22)
0.001
21.05 (38.97)
36.59 (25.41)
0.001
9.62 (15.8)
17.00 (21.74)
0.001
Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality,
Morbidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery
2004;240(3):416-424.
Summary
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Mortality rate of the bariatric surgery cohort was 0.68
percent, compared to 6.17 percent in controls
The bariatric surgery patients were nine times less
likely to die in the five-year follow-up period
Bariatric surgery patients had significant risk
reductions for developing all major categories of
chronic conditions
Surgery patients had significantly fewer
hospitalizations, in-hospital days, and outpatient
physician visits
Direct healthcare costs were significantly lower in
the surgery cohort
Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality,
Morbidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery
2004;240(3):416-424.
Bariatric Surgery: A Systematic
Review of the Literature and
Meta-analysis
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Study goals: assess impact of bariatric
surgery on:
• Diabetes
• Obstructive sleep apnea
• Hypertension
• Hyperlipidemia
Buchwald H, Avidor Y, Braunwald E, et al. Bariatric Surgery–
A Systematic Review of the Literature and Meta-analysis.
Journal of the American Medical Association 2004 Oct 13;292(14).
Surgical Therapy for
Morbid Obesity
Resolution of Co-morbidities
Following Gastric Bypass Surgery
95%
100%
90%
84%
80%
80%
68%
70%
60%
50%
40%
30%
20%
10%
0%
Diabetes
Hypertension
Sleep Apnea
High
Cholesterol*
* Refers to % resolution and/or improvement
Pories, et al. Ann Surg 1995, Sugerman, et al. Ann Surg 2003,
Schauer, et al. Ann Surg 2003, Rasheid, et al. Obes Surg 2003,
George SM, et al. World J Surg 1998, Buchwald, et al JAMA Oct 2004.
GHRELIN
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