Learning Objectives. What Is Morbid Obesity? Presenter Disclosure Information

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1 3:45 4:45pm The Skinny on Bariatric Surgery: From Pre-op Evaluation to Long Term Post-op Complications SPEAKER Nestor de la Cruz-Munoz, MD, FACS Presenter Disclosure Information The following relationships exist related to this presentation: Nestor de la Cruz-Munoz, MD, FACS, FASMBS, has no financial relationships to disclose. Off-Label/Investigational Discussion In accordance with pmicme policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations. Learning Objectives Bariatric Surgery: From Pre-op Evaluation to Long Term Post-op Complications Nestor de la Cruz-Muñoz, MD FACS Associate Professor of Surgery Chief, Division of Laparoendoscopic and Bariatric Surgery University of Miami/ Miller School of Medicine 1. Describe the most common bariatric surgical procedures and their relative impacts on weight loss in patients with obesity. 2. Interpret data showing how bariatric surgery affects mortality and different comorbid conditions, including diabetes, hypertension, dyslipidemia, and sleep apnea. 3. Discuss common complications of bariatric surgery and how they can be managed. What Is Morbid Obesity? What Is Morbid Obesity? Multifactorial disease of excess fat storage with a genetic basis Associated with multiple serious medical problems Influenced by the environment Lifelong and progressive

2 Thrifty Genes Contribute to Morbid Obesity Genetic factors account for 80 percent of a person s tendency to develop obesity. These thrifty genes are designed to protect us from starvation by allowing us to store large amounts of energy in the form of fat when food is abundant. This is the first time in human history that food has been so abundant. The age-old advantage of thrifty genes has been influenced by our unique environment to cause disease. Hormones Control Appetite Genes code for hormones that are important in metabolism, appetite, and satiety regulation. Hormones made by the cells in the stomach and intestines act on the brain. These hormones regulate body weight by controlling appetite (Ghrelin), satiety (GLP-1, PYY,CCK), and body metabolism (Leptin, Melanocortin). Kaplan L. Journal of Gastrointestinal Surgery 2003;7(4): Cummings DE, Schwartz MW. Annu Rev Med 2003;54: Medical Complications of Obesity Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Gall bladder disease Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Skin Gout Idiopathic intracranial hypertension Stroke Cataracts Coronary heart disease Diabetes Dyslipidemia Hypertension Severe pancreatitis Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis Prevalence of Significant Morbidities per Weight PERCENT AFFLICTED 60% 50% 40% 30% 20% 10% 7% 4% 0% 15% 26% 10% 14% 23% 18% 24% 32% 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: % 16% 28% 41% Diabetes Asthma Arthritis High Blood Pressure BMI < BMI > 40 51% 3% 0% 15% Cancer* 52% Obesity Kills Over 300,000 deaths per year Second leading cause of preventable death Obesity markedly lessens life expectancy Morbidly obese die 10 to 15 years earlier that averageweight persons Impact of Obesity on Mortality and Years of Life Lost Treatment of Morbid Obesity RTI International. Center for Consumer Freedom.

3 Guide for Selecting Obesity Treatment BMI Category (kg/m 2 ) Treatment >40 Diet, Exercise, Behavior Tx* Pharmacotherapy Surgery *medical follow-up necessary With comorbidities With comorbidities + Who Is a Surgical Candidate? 1991 National Institutes of Health Criteria: BMI > 40 (or BMI > 35 with co-morbidities) Age 16 years old and above 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 *eg, community weight loss program, referral to a dietician. National Institutes of Health. October NIH publication Gastrointestinal Surgery for Severe Obesity (1991) National Institutes of Health Consensus Development Conference Statement March 25-27;9(1):1-20, Accessed January 15, Current Common Bariatric Surgical Procedures Restrictive Laparoscopic Adjustable Gastric Banding Metabolic Sleeve Gastrectomy Roux-en-Y Gastric Bypass Duodenal Switch/Biliopancreatic Diversion Comparing Weight-Loss Results 1 year 2 years 5 years Band 31% 40% 45% Sleeve 51% 47% 50% Bypass 69% 70% 60% Average Percent Excess Weight Loss University of Miami Data, accessed January 15, 2015 Effect on Long-term Mortality Compared to Non-Operated Controls HOW DOES BARIATRIC SURGERY IMPACT DISEASE CAUSED BY OBESITY? Study Procedure F/U Mortality Reduction MacDonald,1997 RYGB 9 yrs 88% Flum, 2004 RYGB 4.4yrs 33% Christou, 2004 RYGB 5 yrs 89% Sowemimo, 2007 RYGB 4.4 yrs 50% O brien, 2006 LAGB 12 yrs 73% Adams, 2007 RYGB 8.4 yrs 40% Sjostrom, 2007 VBG/other 14 yrs 31% Roux-en-y Gastric Bypass (RYGB) Laparoscopic Adjustable Gastric Bypass (LAGB) Vertical Banded Gastroplasty (VBG)

4 Impact of Bariatric Surgery on Diabetes Impact of Bariatric Surgery on Sleep Apnea THE MAJORITY OF MORBIDLY OBESE DIABETICS EXPERIENCE RESOLUTION OF DIABETES AFTER BARIATRIC SURGERY. Banding, Biliopancreatic Diversion, and Duodenal Switch; Normal Ranges: HbA1c < 6.0 percent, Fasting glucose = mmol/l, Fasting insulin = pmol/l t = number of studies or treatment groups; n = number of patients with this characteristic; N = number of patients evaluated; Diabetes resolved Numerator = discontinued treatment or condition disappeared; denominator includes patients evaluated for resolution. 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 ;292(14). SLEEP APNEA RESOLVES IN MOST PATIENTS FOLLOWING BARIATRIC SURGERY. Banding, Biliopancreatic Diversion, and Duodenal Switch. ** Apnea-hypopnea index normal range is < 5 events per hour of sleep. t = number of studies or treatment groups; n = number of patients with this characteristic; N = number of patients evaluated; OSA resolved numerator = discontinuation of treatment/medication; denominator includes patients evaluated for resolution. Meta-analysis. Journal of the American Medical Association 2004 Oct 13;292(14). Impact of Bariatric Surgery on Hypertension Impact of Bariatric Surgery on Hyperlipidemia HYPERTENSION IS RESOLVED OR IMPROVED IN MOST PATIENTS FOLLOWING BARIATRIC SURGERY. Banding, Biliopancreatic Diversion, and Duodenal Switch. t = number of studies or treatment groups; n = number of patients with this characteristic; N = number of patients evaluated; Hypertension resolved numerator = discontinued treatment or condition disappeared; denominator includes patients evaluated for resolution. Meta-analysis. Journal of the American Medical Association 2004 Oct 3;292(14). HYPERLIPIDEMIA AND HYPERCHOLESTEROLEMIA IMPROVE IN MOST PATIENTS FOLLOWING BARIATRIC SURGERY. Banding, Biliopancreatic Diversion, and Duodenal Switch. t = number of studies or treatment groups; n = number of patients with this characteristic; N = number of patients evaluated; Patients Improved numerator includes patients described by study authors as having improved by virtue of elimination or reduction in therapy and patients reported to have improved lipid parameters. Meta-analysis. Journal of the American Medical Association 2004 Oct 13;292(14). Comparing Comorbidity Resolution Band Sleeve Bypass Arthritis 30% 40% 41% Cholesterol 78% 90% 95% Heartburn 58% 24% 72% Hypertension 63% 82% 78% Sleep Apnea 71% 91% 94% Diabetes 67% 85% 92% Meta-analysis. Journal of the American Medical Association 2004 Oct 13;292(14). Caring for the Postoperative Patient Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient update: Cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery Mechanick, et al. Surgery for Obesity and Related Diseases 9;(2) Mar 2013; Chang S, Stoll C, Song J, et al. The Effectiveness and Risks of Bariatric Surgery. An Updated Systematic Review and Meta-analysis, JAMA Surg. 2014;149(3);

5 Complications Please refer patient to, or contact, surgeon: Abdominal Pain Vomiting Food intolerance Anemia Weight regain Significant fatigue Hypoglycemic episodes Dietary questions Recommended Vitamin Supplementation Gastric Bypass/Sleeve MVI with Iron BID Calcium Citrate mg/d iu/d vit D Vit B12 >350 micrograms orally daily or 1000 micrograms monthly IM Menstruating women should have 40-65mg of Iron daily Surgery for Obesity and Related Diseases 9(2);2013: Recommended Biochemical Surveillance of Nutritional Status Gastric Bypass (every 3-6 months, first year, then yearly) CBC SMA20 Iron Studies, Ferritin Vit B12 LFT s Lipid Profile 25-hydroxyvitamin D Optional: intact PTH, Thiamine, RBC Folate Ulcerogenic Medications Increased consideration secondary to increased concentration within smaller pouch (no primary literature) ASA (case-by-case basis) NSAIDs (case-specific PPIs) Salicylates Oral bisphosphonates > Follow bone density closely > Alternative forms of therapy: calcitonin nasal spray, synthetic parathyroid hormone, raloxifene Surgery for Obesity and Related Diseases 9(2);2013: Surgery for Obesity and Related Diseases 9(2);2013: Multidisciplinary Follow up Support Groups Usually run by bariatric surgical programs Psychological Individual or group therapy Nutritional Complications No specific diet, but special tips for using the surgery are reinforced. Exercise Lifestyle Medical

6 Number of Hospitals performing operation National Average Mortality ( %) Average Hospital caseloads Median Mortality rates following common operations in U.S. hospitals Aortic Aneurysm Coronary Artery Bypass Grafting Craniotomy Esophageal Resection Hip Replacement Pancreatectomy Pediatric Heart Surgery SRC: Bariatric Surgery Mortality 0.3% (46,190 patients). 106 Hospitals reporting Average Case Load: 312 cases/year. Complications of Gastric Bypass/ Gastric Sleeve UM > Pneumonia 0.12% > Infections 0.50% > DVT 0.32% > Pulmonary Embolus 0.13% > Anastomotic leak 0.5% > Bleeding 1.3% > Bowel Obstruction 0.5% > Stricture 1.5% > Nutritional- Anemia, Electrolyte, vitamin and mineral deficiencies, protein malnutrition > Conversion rate 0.1% > Mortality > Overall 0.057% [ Dimick JB, Welch HG, Birkmeyer JD. JAMA 2004,292, Laparoscopic Adjustable Gastric Band Vomiting Abdominal pain Reflux Symptoms Wound Infection In the ER Before hydration Give 100mg IV Thiamine to prevent acute Thiamine def if the patient has been vomiting. Then, Rally Pack (QD) and give and additional 1000mg Vit B12 and 1 mg Folic Acid. Anastamotic Leak 2 nd most common cause of death after a gastric bypass % in most studies Up to 5% during learning curve of 75 cases Complications: Intermediate Ulcer Stricture Depression

7 Cholecystitis Complications: Late Bowel Obstruction Internal Hernia Adhesions Intussusception Normal Human Pathology Gastro-Gastric Fistula Symptoms of an Internal Hernia Nonspecific abdominal discomfort Episodes of severe, crampy periumbilical pain (esp postprandially) (CT insensitive) Nausea Intestinal Obstruction (CT >85% sen) Malnutrition Anemia Vitamin Deficiency Protein Malnutrition Small Bowel Obstruction Diagnosis Cannot be based on Upper Gastrointentinal Series. Cannot rely on Nasogastric Tube to decompress the gastric remnant! GastroGastric Fistulas Usually present with pain. A marginal ulcer develops at the gastrojejunal anastomosis due to the stomach acid (refluxed up from the remnant) in the pouch. Weight Regain Dilation of pouch or GJ anastamosis Eating behaviors Psychological problems GG Fistula