Bariatric Surgery Claire Vial Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5 4 person) 1990 2000 Men 36% Women 36% 2010 2010 NHANES Data No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% 1
Parallel epidemics of obesity and diabetes Obesity (BMI 30 kg/m 2 ) 1994 2000 2009 Diabetes No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0% www.diabetes.org (2011) 1994 2000 Men 12% Women 11% 2009 No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% >9.0% http://www.cdc.gov/diabetes/statistics 2
Bariatric Surgery in USA 250000 200000 150000 100000 50000 0 1997 2002 2003 2004 2007 2008 Beaumont Indications For Bariatric Surgery BMI 40 or higher BMI 35-39.9 with medical complications Age 18-70 years old Failed dietary therapy Psychologically stable Knowledge about operation Motivated individual No medical contraindications Most insurance companies mandate monthly medical supervised weight loss attempt 3
Laparoscopic Bariatric Surgery Gastric Bypass Gastric Sleeve Lap-Band Gastric Bypass (Roux-en-Y Gastric Bypass) 4
How Gastric Bypass Surgery Works Restrictive component- Small pouch Malabsorption component Bypassed portion of bowel Physiologic changes augmenting enforced behavioral modification Dumping Ghrelin GLP-1 Gastric Bypass Results Typically weight loss exceeds 100 pounds 65-70% excess body weight Results vary Weight loss typically levels off in 1 year Signori C, Zalesin KC, Franklin B, Miller WM, McCulloughPA. Obes Surg 2010 Jamcollsurg.2005.10.039 5
Lap-BAND Lap-BAND Gradual weight loss Loss of 1-2 pounds per week 40% excess weight loss first year May take 3 years to maximum End result: 45-60% excess weight loss Results marginal if BMI over ~50 Surgical Revision Up to 10-20% of patients will require operative repairs Up to 10% of patients will choose revision to gastric bypass for lack of weight loss or complications of the device 6
Lap-BAND Advantages: Simple procedure Low leak rate Normal nutrient absorption Band is reversible with surgery Disadvantages: Solid food may be difficult to swallow Requires adjustments, every 6 weeks to few months the first year May create problems with heartburn Slower, less predictable weight loss *Complications of Lap-BAND Early Nausea/vomiting Heartburn Late Malfunction of port Band slippage Band erosion Esophageal dilatation Gallstones *Mostly related to mechanical failure of the device 7
Gastric Sleeve Unique features Restriction only No foreign body No adjustments No malabsorption Less vitamin and mineral deficiencies 8
Unique features Irreversibility Higher surgical leak rate, up to ~2.5% Unproven durability beyond 5-years Not covered by all insurances Medicare now covers as of February 2013 Complications Early: Leakage of new connections (Sleeve or Bypass) Dumping syndrome (Bypass-only) Nausea/vomiting (all) Blood clot (all) Late: Stomach ulcers (Bypass) Heartburn and reflux (Sleeve and Band) Kidney stones (Calcium oxalate) (Bypass) Gallstones (all) Gout flare (all) Poor nutrition (all) Vitamin/Mineral deficiencies (all) Hair shedding(all) Stomal narrowing/stricture (Bypass) Lap-band positional changes or device complications 9
Mortality Rates with Bariatric Surgery Gastric Bypass 0.14% Lap-BAND 0.05% Gastric Sleeve 0.11% Ann Surg 2011;254;410-422 Results Excess Weight Loss Lap-BAND 48% (41%-54%) Gastric Sleeve 55% (33%-85%) Gastric bypass 62 % (57%-67%) JAMA, October 13,2004-Vol292, No.14 Obesity surgery 201020(8):1171-7 10
Clev. Clin J of med: 73, Nov.2006 Changes in Quality of Life Greatly Improved 58% Improved 37% No Change 5% Diminished 0% Greatly Diminished 0% Follow-up at least one year post-op Schauer, Ann Surg 232;529-529 :2001 11
Eating for Healing Gastric Bypass and Sleeve Stage I: Clear Liquid diet Day 2 Stage II: Full Liquid diet Day 3-13 Stage III: Pureed Food diet Day 14-27 Stage IV: Soft Food diet Day 28-41 5 gram sugar restriction at meals to prevent dumping reaction With bypass Medication/Vitamin Use after Gastric Bypass and Sleeve Multivitamin twice daily (life-long) Calcium plus vitamin D twice daily (life-long) Ursodiol twice daily during rapid weight loss (exception if gallbladder has been removed) Omeprazole (stomach acid) 1 year with bypass 12
Medication Considerations Drug absorption affected by solubility, surface area for absorption, blood flow to the tissue RYGB: Decreased HCl secretion, less surface area by bypassing portion of small intestine Lifelong restriction of NSAIDS (ASA risk:benefit) Delayed or enteric formulations Medication Considerations Caution with bisphosphonates Effectiveness of oral contraceptives Perioperatively: Hormones, SERMS, immune suppressants, anticoagulants 13
Case Studies Mr. JF, 53 yo male, manager of Tool and Die company. Works 10-17 hours per day 1/2/13 concerned re: weight regain and general health RYGB 2007 Max Wt: 586 pounds Min Wt: 210 (as adult) Height 6 1 Lost 150 pounds or more after surgery Mr. JF Weight at 260 pounds in 2009, had excess skin removal abdomen and chest Weight regain 2011 due to stress. 40 pound gain from Thanksgiving to end of year 2012 PMH: DMS, HTN, gout, edema, asthma (resolved after wt. loss), OSA (resolved after wt. loss), dyslipidemia, cellulitis LE, LBP. 14
Mr. JF cont. Knee pain, DOE BP: 178/108 WC: 48 inches PLAN: Diet: 4 plus one, group support, vasotec 20 mg Jan 9: wt down 13 pounds, BP 152/88 Jan 23: wt down 9 pounds more, 130/81 Plan: multidisciplinary intervention ongoing Case Study: MrFC 67 yo male presented 12/1/10 Initial wt 272; Ht: 5 8, BMI 41.4 BP: 115/70 PMH: Type 2 DM, Htn, CAD (with stent age 59), dylipidemia. HBA1C: 10.1 Meds: metformin, actos, glyburide, simvastatin, levothyroxine, lisinopril, metoprolol, plavix RYGB 6/24/11 15
Mr. FC 1/23/13: Wt 178 pounds (loss of 94 pounds) BMI: 27.3 HBAIC: 7.1 on metformin, off actos and off glyburide BP: 101/65: off lisinopril, on metoprolol Lipids: optimal on simvastatin 40 mg No further CV events or DM complications LAGB: Ms. JS 34 yo female. LAGB 1/24/12 BMI: 42, wt: 237 PMH: T2 DM, HTN, dyslipidemia, OSA, GERD, IBS, PCOS, LBP, depression, renal calculi Meds: metformin 500 mg qd, omeprazole, atenolol, naproxen, oxybutinin, hydrocodone LDL-108, HDL-39, TG-146, HBAIC-5.9% 16
MS JF 1/4/13 wt: 153 (84 pounds lost). Has had 3 band fills. Feels great! Off metformin, atenolol, oxybutinin. Off CPAP No GERD, menses have returned to normal Exercises 3/7, uses fitness pal AIC-5.2%, HDL-58, LDL-127, TG-69 Ms. DR 41 yo female, August 2008 LAGB 11/12 Band slippage, gastric prolapse Initial wt: 262 pounds, BMI 41 Current wt: 181, (loss 81 #), BMI 28.3 PMH: HTN, dyslipidemia, OA, DOE PSH: Skin removal arms and pannus 9/12 Plan: Band revision soon 17