Surgical Treatment of Obesity: A Surgeon s View

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1 Surgical Treatment of Obesity: A Surgeon s View Jenny J. Choi, MD Director of Bariatrics Associate Director of Clinical Affairs Assistant Professor of Surgery Albert Einstein School of Medicine Montefiore Medical Center Bronx, New York

2 Jenny Choi, M.D. No relevant financial relationship reported

3 What Causes Obesity? Obesity is a disease that develops when calorie intake is greater than calorie use This is a complex disease involving multiple factors: - Genetics - Physiology - Metabolism - Appetite regulation - Environmental - Psychosocial & cultural

4 Obesity Co-morbidities High Blood Pressure Diabetes High Cholesterol High Triglycerides Heart Disease Joint Pains Sleep Apnea Heartburn Urine Incontinence Varicose Veins Fatty Liver Frequent Headaches Infertility Some Cancers

5 Body Mass Index (BMI) BMI > 35 with medical comorbidities BMI > 40 based on weight alone

6 Comparison of Weight Loss Surgeries Adjustable Gastric Banding Sleeve Gastrectomy Roux-en-Y Gastric Bypass BPD with Duodenal Switch Place implantable device around upper most part of stomach Resect approximately 80 85% of the stomach Bypasses most of the stomach and a portion of the small intestine. Sleeve and Bypass most of the small intestine.

7 Mechanisms of Bariatric Surgery Surgery was believed to be either Restrictive or Malabsorptive but that is NOT the case Anatomic Model Calorie Restriction Decreased Fat Absorption Small Pouch Small Stoma Physiologic Model Intestinal hormonal signaling Changes in Vagal nerve signaling Bile Acid Signaling Impact on the Microbiome

8 Mechanisms: Gut Hormones Satiety Hormones GLP-1 Reduces hepatic gluconeogenesis Blunts effect of glucagon Decreases appetite Increases glucose dependent insulin secretion PYY Slows gastric emptying and intestinal transit ileal brake Leptin CCK Hunger Hormones Ghrelin Produced in the fundus Stimulates food intake Increases gastric emptying

9 Hormonal and Neural Pathways That Regulate Food Intake and Body-Fat Mass Korner and Leibel, N Engl J Med 2003;349:

10 System Components Adjustable band Tubing Port Gastric Band Lap Band AP Realize C Band

11 Adjustable Band Placement Esophagus Pouch Band Stomach

12 Adjustable Gastric Banding Advantages Safest operation in the short term 30%-50% EWL Adjustable Reversible Outpatient surgery Disadvantages Food intolerance/vomiting Most dependent on following dietary rules Highest long-term complication and reoperation rate Lowest average weight loss Implanted foreign object

13 Sleeve Gastrectomy Removes most of stomach Leaves a narrow tube of stomach

14 Sleeve Gastrectomy Advantages Most foods tolerated well Less vitamin and mineral supplementation than gastric bypass or duodenal switch Fewer long-term complications than others No foreign object Disadvantages Outcomes at 10 years and more not known Irreversible May cause or aggravate reflux Less weight loss than Bypass or Duodenal Switch

15 Gastric Bypass Small pouch made from the top of the stomach Limits volume Intestine re-connected to the pouch Changes digestion Changes hormonal response to a meal

16 Gastric Bypass Advantages Average 70% excess weight loss May help you avoid sweets and fats Most foods well tolerated Low failure rate Little weight regain No foreign device Reversible Disadvantages More vitamin and mineral deficiencies Higher rate of early postoperative complications than Band or Sleeve Gastrectomy Intestinal Obstruction Marginal Ulcer

17 Duodenal Switch Sleeve + Intestinal Bypass Removes most of stomach Bypasses most of the intestine

18 Duodenal Switch Advantages Greatest weight loss 80% EWL Least weight regain No foreign object Disadvantages Most risk for malnutrition Highest surgical risk Needs most vitamin and mineral supplementation More frequent, looser bowel movements

19 Obesity in the U.S. Over 35 million obese adults 12 million morbidly obese 200k bariatric procedures Over 98% get no effective long term therapy Why??? Blame themselves Fear

20 Price of Surgery General anesthesia Pain Fear Peri-operative complications Long term complications But most effective LONG TERM weight loss

21 Incisions

22 Obesity Care Continuum ENDOLUMENAL Less Invasive Unmet Needs More Invasive Pharmaceuticals Gastric Banding Gastric Bypass What are the Goals?

23 Endoluminal Bariatrics Procedures may be: Revisional Reduce stoma or pouch size Repair fistulas Short-term devices for weight loss Preparation for a definitive procedure For a specific event, transplant Cosmetic?? Primary providing durable weight loss?? All except perhaps balloon are of unproven efficacy/safety!

24 Technologies Suturing Balloons Barriers Elimination Obstruction

25 Intragastric Balloon: Orbera

26 Orbera Balloon Apollo Endosurgery 33.9% 6 months (n=2215) Avg. BMI=44.4 CE Mark certified; commercially available in more than 40 countries FDA approved and now available in US Must be removed at 6 month

27 Reshape Duo 25.1% 6 mo Multi chamber design Marketed in EU since 2007 FDA approved and REDUCE Trial

28 Obalon Balloon Balloon swallowed in a capsule Multiple balloons can be implanted 50.2% 3 months (n=110)

29 Baronova Gastric Position: Moves freely within the stomach Transpyloric Position: Delays gastric emptying

30 Endo Barrier Procedure Courtesy of GI Dynamics

31 Aspire Assist 49% EWL 1yr, 55% at 2 yr lb wt loss 1-2 yr PMA study completed enrollment Pending FDA Submission

32 Summary Most morbidly obese individuals do not get effective treatment but surgery is currently the most effective long term therapy Endolumenal therapy holds promise to fill a void between medication and surgery Many new approaches are being developed and evaluated Randomized, controlled, IRB approved trials are ongoing The safety and degree as well as duration of weight loss will determine the role of these therapies

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