Obesity When to Recommend Surgery. Lily Chang, MD September 27, 2013

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1 Obesity When to Recommend Surgery Lily Chang, MD September 27, 2013

2 Obesity BMI >30 Trends Among U.S. Adults Source: Behavioral Risk Factor Surveillance System, CDC, 2012

3 Obesity Related Co-Morbidities Diabetes Hypertension Hyperlipidemia Cardiac disease Pulmonary HTN Heart failure Respiratory disease Obstructive sleep apnea Asthma Arthritis Depression Urinary stress Incontinence PCOS

4 What Can We Do? Diet, exercise, behavior modification for anyone with BMI >25 Initiate medication when BMI >30, or BMI> 27 with comorbidities Expectations: 10-15% weight loss considered good response Concerns about medication safety, efficacy and weight regain after medication is stopped Discuss surgery for BMI > 40, or BMI > 35 with comorbidities

5 Why Surgery? Diet and exercise and medications are not effective long term in the morbidly obese Surgery is an accepted and effective approach Improves obesity related co-morbidities Benefits of surgery are greater than the risks of surgery or the risks of remaining morbidly obese

6 Bariatric Surgery Surgical Approaches Restrictive Vertical Banded Gastroplasty Gastric Banding Sleeve Gastrectomy (+/-) Malabsorptive Jejuno-ileal bypass Combination or Metabolic Biliopancreatic Diversion with Duodenal Switch Roux-en-y Gastric Bypass Three most common procedures: Gastric Banding Sleeve Gastrectomy Gastric Bypass

7 Restrictive Procedures A small pouch is created, which limits the amount of food patients can eat. The smaller stomach pouch fills quickly, helping patients feel satisfied with less food. If patients eat too much or too fast, they will have severe chest pain or vomit or both. Examples of restrictive bariatric procedures: Vertical banded gastroplasty Gastric banding Sleeve gastrectomy Metabolic

8 Vertical Banded Gastroplasty (VBG) Restrictive No metabolic effects > 50% EBW 5yr follow-up 40% re-op rate for weight loss failure, vomiting Complications: Obstruction Ulceration Staple line breakdown No longer performed Balsiger 2000, Kolanowski 1997, Rogers 1992, Cheah 1998, Scheen 2000 Greve 2000

9 Adjustable gastric banding Restrictive procedure replaced VBG Mean excess weight loss at 1 year of 42% 1, 50% 5 yrs Frequent f/u and adjustments No malabsorption, dumping or marginal ulcers Low rate of operative complications Increased long-term complications and weight loss failure(>25-50%) 20-25% require revision or removal 1. Buchwald, H. et al., JAMA. 2004; 292:

10 Lap Band Complications Symptoms: Nausea/vomiting Dysphagia (esp solids) Regurgitation/foaming Acid reflux/heartburn Pain Port site redness/fever

11 Lap Band Erosion

12 Lap Band Removal

13 Lap sleeve gastrectomy cc volume Restrictive procedure with metabolic effects Initially developed as first stage procedure for BPD-DS Increased acceptance as primary operation Mean excess weight loss at 1 year of 59% % 5 year Insurance coverage variable 1. ASMBS, Position Statement on Sleeve Gastrectomy as a Bariatric Procedure. June 17, Lee CM, et al. Surg Endosc (2007) 21:

14 Sleeve Gastrectomy Advantages No anastomosis No marginal ulcer Preserved antrum/pylorus No dumping syndrome No malabsorption (+/-) No implant or adjustments

15 Sleeve Gastrectomy Complications Leak 2.2% Bleed 2.0% Stricture <1% Acid reflux 20% Mortality 0.19% Brethauer et al. SOARD 5 (2009)

16 Gastric Sleeve leak

17 Gastric Sleeve Leak Symptoms Back & left shoulder pain Epigastric /Right upper pain Nausea and vomiting Diaphoresis Dyspnea Signs Tachycardia Fever Leukocytosis Elevated CRP Diagnosis CT / UGI EGD

18 Gastric Sleeve Leak Management Antibiotics PPI Nutrition TPN NJT JT Drainage Percutaneous Operative Surgical or Endoscopic treatment Leaks are difficult to manage

19

20 Malabsorptive Procedures The proximal small intestine is bypassed Some calories and nutrients are not absorbed Currently, strictly malabsorptive procedures are rarely performed Jejunal-ileal bypass Most procedures that involve malabsorption include restriction and are called combination procedures

21 Jejunal ileal bypass Complications: Bacterial overgrowth/ diarrhea Vitamin/Protein/Calorie deficiency Kidney stones Liver failure Death We don t do this operation anymore!

22 Combination Metabolic Procedures Restrictive: small gastric pouch is created limiting the amount of food and speed at which a patient can eat. Malabsorptive: stomach and/or the proximal intestine is bypassed Fewer calories are absorbed Examples of metabolic bariatric procedures: Biliopancreatic diversion with duodenal switch Roux-en-Y Gastric bypass

23 BPD with Duodenal Switch Gastric sleeve Preserve pylorus 250 cm alimentary limb Short common channel cm Duodenal ileostomy Technically difficult operation Complications: Significant malabsorption Nutritional deficiency common Dumping Marginal ulcers 77% EBW 5yr follow-up >90 % diabetes resolution Scopinaro 1998

24 Roux-en-Y Gastric Bypass Most frequently performed bariatric procedure Mean excess weight loss at 1 year of 67%, 50-70% at 5 yrs Restrictive Malabsorptive

25 Laparoscopic Gastric Bypass Complications Bleeding (< 1% transfusion) Infection (< 1%) Leak (1%) DVT (1%) Stricture (5-10%) Weight Loss Failure (<5%) Weight Regain (5-10%) Death (< 1%) Marginal ulcer (2-5%) Nutritional deficiency (5-20%) B-1, B-12, calcium, Iron Dumping syndrome Small Bowel Obstruction (3%) Advantages Technically feasible laparoscopically No foreign body Few reoperations or revisions No adjustments Better compliance Seems to offer the best weight loss results

26 Results after Surgery

27 Resolution of comorbidities Following bariatric surgery (all types), most patients resolve or improve their comorbid conditions 100% 90% 80% 70% 60% 77% 86% 62% 79% 86% 84% 72% 50% 40% 30% 20% 10% 0% Resolved Diabetes Hypertension Sleep Apnea High Cholesterol* Resolved/Improved Buchwald, et al JAMA Oct 2004.

28 Metabolic Effects Incompletely understood Not just related to weight loss, restriction or malabsorption Gastric bypass alters gut hormone secretion resulting in Sustained reductions in food intake and increased satiety Increased Postprandial peptide YY Increased GLP-1 Enhanced insulin secretion Increased GLP-1 Weight loss leads to increased sensitivity of insulin receptors Critical area of research

29 Life after Bariatric Surgery Diet Guidelines ½ cup per meal, 3 meals/day, 2 snacks Small bites, chew well, swallow slowly High protein Low sugar Avoid liquids with meals Avoid carbonation Avoid alcohol

30 Life after Bariatric Surgery Nutritional Supplements MVI (with Iron) 1-2 chewable/day B-12/B complex Sublingual dot/drops (500 mcg B12/day) Calcium Citrate (with Vit D/Magnesium) 1200 mg/day (chewable or liquid) Iron (with Vit C) 325 mg ferrous sulfate/day (chewable/liquid) Medications Elixir or crushed pills Avoid long acting/sustained release XT,XR Avoid NSAIDS, ASA Monitor levels Variable absorption

31 Recommending Surgery BMI 35 with obesity-related comorbidities, or BMI 40 with or without comorbidities Failure of non-operative attempts at weight loss Lack of severe comorbidities that preclude safe general anesthesia (unstable CAD, severe pulmonary disease, portal hypertension) Motivated patient with the mental capacity to understand the surgery and its side effects Insurance coverage

32 Which surgery to choose? Insurance coverage Big three: Gastric bypass Sleeve gastrectomy Gastric band Patient education and preference Consultation with bariatric expert Virginia Mason Bariatric Surgery Clinic Jeffrey Hunter, MD, Bariatric Surgeon Anthony Burden, MD, Medical Bariatrician NorthStar Multispecialty Clinic

33 Those who benefit most Younger patients Age limit for VM is 70 years Able to exercise Non-smokers Comorbidities still potentially reversible Self-motivated

34 Surgery is NOT for everyone Nothing magical It s hard work Difficult transition in the beginning No guarantee, crystal ball Possibility for weight regain NOT reversible

35 But it s the only thing that works

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