Dealing with weight regain after Rouxen-Y gastric bypass: surgical approach

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1 Dealing with weight regain after Rouxen-Y gastric bypass: surgical approach Robin Blackstone, MD, FACS Masters of Minimally Invasive Bariatric Surgery April 5, 2013 Orlando, Florida

2 Disclosures PI Enteromedics VBLOC and Recharge Trials Consulting Johnson and Johnson/Ethicon Surgical

3 Changing Semantics Remission of weight Partial Remission of weight Weight regain ELIMINATE THE WORD FAILURE.

4 Number of Patients 50% 100% Weight Loss after RYGB is Widely and Normally Distributed 150 n= % Excess Body Weight Loss at 1 year Hatoum IJ et al. Obesity 2009; 17(1):98-9.

5 Adams T. et al. JAMA September 19, 2012

6 Bariatric Surgery Evidence for Physiological Mechanisms 1. Dramatic effects on hunger and satiety 2. Few patients become underweight after surgery 3. Transient weight gain during pregnancy 4. Little or no weight loss in thin patients or animals 5. Changes in GI endocrine markers ghrelin, PYY, GLP-1, amylin 6. Increased energy expenditure (bypass procedures) 7. Ability to reverse effects of surgery with drugs and genetic manipulation

7 Anatomic Dissection of RYGB

8 Gastric Bypass: Five Operations 5. Partial vagotomy

9 Gastric Bypass: Five Operations 1. Isolation of gastric cardia

10 Gastric Bypass: Five Operations 2. Exclusion of distal stomach

11 Gastric Bypass: Five Operations 3. Exclusion of duodenum and proximal jejunum 3 ELS 10 cm 4

12 Gastric Bypass: Five Operations 4. Exposure of distal intestine to undigested nutrients

13 kcal / 24 hours Altering the Set Point with Gastric Post-op Energy Intake Post-op Energy Expenditure Surgery Baseline Energy Intake Baseline Energy Expenditure Body Mass Index (kg/m 2 )

14 kcal / 24 hours RYGB: Resolution of the Overfed State Post-op Energy Intake Post-op Energy Expenditure Overfed state Body Mass Index (kg/m 2 )

15 RYGB Mimics the Overfed State Resolution of the overfed state Body Weight (g) Overfed Control Food Restricted Days

16 RYGB Mimics the Overfed State Resolution of the overfed state Body Weight (g) OLD model of RYGB CURRENT model of RYGB Overfed Control Food Restricted Days

17 Fat Mass Set Point Set Point and Weight Regain Aging and environmental influences (no intervention) Surgery Environmental influences and aging Time (years)

18 RYGB Induces Weight Loss in Mice 120 % Preoperative Body Weight Sham RYGB Time after Surgery (Weeks) Stylopoulos N et al. Obesity 2009; 17(10):

19 Cumulative Food Intake (kcal) RYGB Reduces Nutrient Intake RYGB Sham Time (Weeks) Stylopoulos N et al. Obesity 2009; 17(10):

20 RYGB Selectively Reduces Body Fat 60 Body Composition (Grams) Fat Mass Lean Body Mass 0 Sham RYGB Stylopoulos N et al. Obesity 2009; 17(10):

21 Nutrient Absorption (%) RYGB Does Not Alter Caloric Absorption Stool Calorimetry Before RYGB After RYGB Stylopoulos N et al. Obesity 2009; 17(10):

22 TEE - VO 2 (ml/hr/kg.75 ) REE - VO 2 (ml/hr/kg.75 ) RYGB Increases Energy Expenditure RYGB Sham Weight-matched p<0.05 p<0.001 Stylopoulos N et al. Obesity 2009; 17(10):

23 GI Endocrine Responses to RYGB GLP-1 PYY Amylin Active GLP-1 (pg/ml) min mixed meal # RYGB Sham Lean PYY (pg/ml) min mixed meal RYGB Sham Lean Active Amylin (pg/ml) min mixed meal Time after start of meal (min) Time after start of meal (min) Time after start of meal (min) Ghrelin GIP Acylated Ghrelin (pg/ml) 5 min mixed meal 300 RYGB Sham 250 Lean Time after start of meal (min) GIP (pg/ml) min mixed meal Time after start of meal (min) Shin AC et al. Endocrinology 2010; 151(4):

24 GLP-1 levels in human after RYGB Peterli R et al. Ann Surg 2009; 250(2):

25 Endocrine Effects of GI Manipulations Ghrelin GLP-1 PYY GIP Gastric Banding Sleeve gastrectomy Gastric Bypass Decreased Initially BPD/DS Post-prandial

26 Clinical Predictors of RYGB Weight Loss Associations with more modest weight loss Increased preoperative BMI Presence of T2DM Duration of T2DM? Relationship with b-cell failure Lack of physical activity Increased patient age Inadequate surgical restriction Pouch size Diameter of gastro-jejunal anastomosis Lack of patient follow-up / compliance None of these predictors is sufficiently powerful to determine clinical practice

27 Carbohydrate eating leads to weight regain When a post GBP patient eats any simple sugar (carbohydrates: rice, pasta, bread, potatoes) then evoke a very strong GLP1 response The GLP1 drives the release of insulin which outlasts the simple sugar in the blood causing a relative low blood sugar which drives eating This occurs over and over all day with subsequent weight regain

28 Intensive Medical/Behavioral Therapy STOP eating any carbs except in green vegetables Need to increase energy expenditure and drive body fat percent below 30% in order to reengage the LEPTIN coupling with metabolism (good evidence for Leptin resistance at Body Fat >30%) Get the original set of parameters to work for the patient

29 So what is there to revise? Possible options: Revise the gastrojejunostomy Take out the distal remnant (decrease ghrelin) Lengthen the Roux limb Convert to Sleeve/ Duodenal switch

30 THANK YOU

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