Bariatric Surgery. Beth A. Ryder, MD FACS. Assistant Professor of Surgery The Miriam Hospital Warren Alpert Medical School of Brown University

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1 Bariatric Surgery Beth A. Ryder, MD FACS Assistant Professor of Surgery The Miriam Hospital Warren Alpert Medical School of Brown University April 30, 2013

2 Why surgery? Eligibility criteria Most commonly performed operations Outcomes Weight loss Resolution of medical comorbidities

3 Why surgery? The only proven method for long-term weight control in morbidly obese patients when all other therapies have failed Improvement in medical comorbidities

4 Who is eligible? BMI 40 or 35 with significant weight-related comorbidities Obstructive sleep apnea Hypertension, Coronary Artery Disease Diabetes Mellitus Previous failed weight loss attempts No reversible medical cause for obesity No active substance abuse No uncontrolled psychiatric illness AACE/TOS/ASMBS Bariatric Surgery Guidelines, Endocr Pract. 2008;14(3)

5 Most important Ability to understand & comply with post-op care Cannot be emphasized enough Without commitment to change in lifestyle, surgery will ultimately be unsuccessful

6 Historical background 1954 Jejuno-Ileal Bypass 1963 Jejuno-Colic Bypass 1967 Gastric Bypass 1971 Gastroplasty 1978 Gastric Banding 1979 Biliopancreatic Bypass 1980 Jaw Wiring 1983 Intestinal Interpositioning 1986 Adjustable Gastric Banding Malabsorptive Severe medical complications some progress 1990 Laparoscopic Adjustable Banding 1993 Laparoscopic Gastric Bypass 2001 Lap Adjustable Banding in USA (FDA approval) 2005 Laparoscopic Sleeve Gastrectomy

7 Common Laparoscopic Operations Restrictive Decrease food intake Promote feeling of fullness (satiety) Adjustable Gastric Band Sleeve Gastrectomy Combination Restrictive component PLUS Decrease absorptive surface exposed to food (malabsorptive) Roux-en-Y Gastric Bypass (RYGB)

8 Laparoscopic Adjustable Gastric Band band port

9 Laparoscopic Adjustable Gastric Band PROS: Purely restrictive Reversible Adjustable make it your own Low operative risk CONS: * High rate of revisional surgery (10-30%) slower weight loss

10 Laparoscopic Sleeve Gastrectomy

11 Laparoscopic Sleeve Gastrectomy PROS: Purely restrictive No implanted device Can use as bridge to bypass More reliable early wt loss CONS: Can t reverse Risk of leak (staple line) 1-3% Long term (>5yr) results just emerging

12 Laparoscopic Roux-en-Y Gastric Bypass FOOD Inge, T. H. et al. Pediatrics 2004;114: DIGESTIVE JUICES

13 Laparoscopic Roux-en-Y Gastric Bypass FOOD PROS: Usually laparoscopic Immediate weight loss Immediate improvement for DMII Dumping syndrome (pro and con) DIGESTIVE JUICES CONS: Difficult to reverse Higher rate of serious complications leak, deficiencies, internal hernia, etc. Requires lifelong supplementation Inge, T. H. et al. Pediatrics 2004;114:

14 Which operation? Patient choice Medical comorbidities Operative risk (high BMI, etc.) Diabetics & gastric bypass Eating patterns: snackers, sweet eaters Willingness to alter anatomy Family/spouse/MD impact

15 Our pre-op process: 6-12 months Information session Meet with surgeon, select procedure Generally require pre-insurance approval tests Mandatory nutrition education/ counseling Psychological screening emotional eating Once insurance approved, testing: OSA screening, upper GI, cardiopulm assessment as needed Attend 2 support groups Quit smoking Pre-op class Meet with primary care physician

16 Outcomes Weight loss Comorbidities Mortality

17 Weight loss Excess weight loss = [weight lost (pre-op weight ideal body weight)] x 100% Gastric Bypass 60-80% excess weight loss in 1.5 years 55-70% excess weight loss in 5 years After years still 50% excess weight loss Gastric Banding 35-50% excess weight loss in 3-5 years controversial durability of wt loss Gastric Sleeve 40-50% excess weight loss 1-3 years Data from multiple sources

18 Outcomes Weight loss Comorbidities Mortality

19 Outcomes: Comorbidities Meta-analysis, , > 22K patients 3873 gastric band, 7074 gastric bypass Pooled outcomes resolved or resolved/improved Hypertension 61.7% 78.5% Sleep apnea 85.7% 83.6% Type II Diabetes 76.8% 86% Hyperlipidemia 70% Buchwald, H. et al. JAMA 2004;292:

20 With successful surgery, Reduced need for medications Reduced # MD visits Reduced costs to health care system and to society Missed work, disability due to weight-related illnesses/conditions

21 Outcomes Weight loss Comorbidities Mortality

22 Outcomes: Mortality The average bariatric surgery patient is Female (about 80%) Caucasian (about 80%) years old BMI MORBIDLY OBESE (Class III Obesity) BMI 40

23 Outcomes: Mortality Retrospective cohort gastric bypass patients ( ) Matched age, gender, BMI controls from Utah DMV registry Controlled for guess weights on license Average age 40, mean follow-up 7 years Mortality decreased by 40%» CAD 56%, DM 92%, cancer 60% Adams et al, NEJM 357(8), 2007.

24 Summary Obesity is (and will remain) a major health problem in the United States More than 20,000 Rhode Island adults have BMI 40 Surgery is an effective modality to improve health

25 Bariatric Surgery Appropriate patient selection and preparation can lead to long-term weight loss and associated improvements in health

26

27 My Colleagues Dieter Pohl (RWH) Siva Vithiananthan (TMH) Jeannine Giovanni (RWH) G. Dean Roye (TMH)

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