Options for Obesity and Long-Term ResultsBariatric Surgery

Mark Kligman, M.D.Assistant Professor, Surgery

Director, Center for Weight Management & WellnessUniversity of Maryland, School of Medicine

The Problem

The BIG Secret !

Current Surgical Management

Indications

Standard Criteria

Age 18 – 65 years

+

BMI ≥ 40 kg/m2

Standard Criteria

Age 18 – 65 years

+

BMI ≥ 40 kg/m2

Special Criteria

Age 18 - 65

+

BMI 35 - 40 kg/m2

+

High risk health problems

Special Criteria

Age 18 - 65

+

BMI 35 - 40 kg/m2

+

High risk health problems

The Surgery Timeline

1 2 3 4 5 6 7 8 9 10

Educational Seminar

Initial Office Visit• Bariatric surgery

booklet

Dietician Evaluation• 6 month supervised diet• Nutrition education

Submit Request for Preauthorization

Preoperative Office Visit• Consent• Written examination

Preoperative Workshop

Initial Contact OR

• Laboratory evaluation• CBC, Chem, LFT, cholesterol, triglycerides• Vit D, Vit B12, TFT, adrenal function tests

• Pulmonary evaluation: CXR, sleep study, PFT, ABG• EKG, Stress test, echocardiogram• UGI, GB U/S, EGD, Colonoscopy• Pap, Mammogram

• Consultation: • psychologist / psychiatrist• Cardiology• Anesthesia• Pulmonary• Gastroenterology• Endocrine

Current Operative Approaches

More Weight Loss Less

More Risks Less

Malabsorption Restriction

Biliopancreatic Diversion with Duodenal Switch

Roux-en-Y Gastric Bypass

Adjustable Gastric Banding

Sleeve Gastrectomy

Biliopancreatic Diversion with Duodenal Switch (BPD-DS)

General Features• Gastric pouch size:

• Standard: 300 mL

• Three segments• Alimentary tract: 200-250cm• Biliary tract: 250 cm• Common channel: 50-150 cm

Average Weight Loss• 70 - 90 % of excess weight

Risks Associated with Duodenal Switch

•Protein malnutrition 15%•Anemia < 5 %•Marginal ulcer < 3 %•Peripheral neuropathy 1.3 %•Night Blindness 3 %•Osteoporosis 14 %•Renal stones•Nausea 65 %•Diarrhea 62 %

•Vitamin deficiencies: A, D, E, K, B12

•Bowel obstruction•Incisional hernia 10 %

•Death 1.1%

Adjustable Gastric Banding (AGB)

Fill Port

Portion of Band which wraps around stomach

Realize™LapBand™

Adjustable Gastric Banding

GENERAL FEATURES

• Inflatable balloon can be adjusted using a port under the skin

Average Weight loss

• 30 - 50% of excess weight

Band Adjustment

Deflated Post-Adjustment

Risks Associated with Gastric Banding

• Injury to esophagus, stomach, spleen• Migration of implant (band erosion, band slippage, port displacement)*• Tubing-related complications (port disconnection, tubing kinking) *• Band leak• Esophageal spasm• Gastroesophageal reflux disease (GERD)• Port-site infection

• Death 0.1 %

* Re-operation 5 -20 %

Vertical sleeve gastrectomy

•May be an option for carefullyselected patients, including high-risk or super-super-obese patients1.

•Use:

• Primary operation

• Staged operation

•Mean %EWL at 1 yr: 59%2

•No implanted medical device

1. ASMBS, Position Statement on Sleeve Gastrectomy as a Bariatric Procedure. June 17, 2007.

2. Lee CM, et al. Surg Endosc (2007) 21: 1810–1816

Risks Associated with Sleeve Gastrectomy

• Leak * 2.2 %• Stricture * 0.6 %• Gastroesophageal reflux disease (GERD)• Delayed gastric emptying 0.2 %• Wound infection

• Re-operation 6 %

• Death 0.19 %

Obesity Surgery 2007, 17:962-969Obesity Surgery 2009, 19:1672–1677Surg Obes Relat Dis 2010; 6: 1–5

Sleeve Gastrectomy: Unresolved Issues

• Standardization of operation• Optimal sleeve diameter• Location of the sleeve termination

• Durability as a primary operation

Roux-en-Y Gastric Bypass (RYGBP)

General Features• Pouch size: 15 – 30 ml

• Pouch opening: 10 mm• Roux-en-Y limb

70-150 cm

Average EWL: 60 – 80%

Risks Associated with Gastric Bypass

Early:• Staple line leak <1 %• Acute gastric distention • Roux-Y obstruction

Late:• Stomal Stenosis <5 %• Marginal ulcer ~5 %• Anemia

• Folate deficiency• Vitamin B12 deficiency • Iron deficiency

• Calcium deficiency / osteoporosis• Gallstones 10 %

Death : ~ 0.1 %

Which Operation?Roux-en-Y Gastric

BypassSleeve

GastrectomyAdjustable Gastric

Banding

Weight Loss(% EWL)

80 50 40

Time to achieve maximal weight loss (years)

~1 ~1 2-3

Number of Office visits (1st year)

4 4 6-8

Improvement of obesity-associated health problems

Excellent Very Good Very Good

Reversibility + / ─ ─ +

Safety Excellent Excellent Excellent

Risk of nutritional complications

Moderate (easily correctable)

Minimal Minimal

Measuring Success

Measuring Success — Part 1

Impact of surgery on:• Weight • Co-morbidities • Mortality

Weight Maintenance 10 Years after Bariatric SurgeryThe SOS Study

Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26

Effect of Gastric Bypass on Cardiac Risk Factors

Preoperative Postoperative

BMI (kg/m2) 46.9 ± 5.8 28.7 ± 4*

Cholesterol (mg/dl) 202 ± 37 165 ± 29*

LDL-Cholesterol (mg/dl) 118 ± 33 97 ± 26*

HDL –Cholesterol (mg/dl) 45 ± 11 51 ± 11*

Systolic BP (mmHg) 143 ± 20 123 ± 18*

Diastolic BP (mmHg) 81 ± 10 71 ± 11*

* p <0.0001

Kligman MD et al. Surgery 2008;143:533

Impact of Gastric Bypass on Cardiac Risk

10-year Risk of Cardiac Event (%)

Pre-operative Post-operative

Vogel 2007 6 3

Torquati 2007 5.4 2.7

Kligman 2008 6.7 3.2

Vogel et al. Am J Cardiol 2007;99:222-26.Torquati et al. J Am Coll Surg 2007;204:776-82.Kligman et al. Surgery 2008;143:533

Impact of Bariatric Surgery on MortalityDeath Rates

Adams et al. N Engl J Med 2007 357 753

Impact of Bariatric Surgery on MortalityThe SOS Study

Sjöström et al. N Engl J Med 2007;357:41

Measuring Success — Part 2

Comparison to Medical Therapy

Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes

Schauer et al. N Engl J Med 2012;366:1567-76.

Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes

Schauer et al. N Engl J Med 2012;366:1567-76.

Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes

Schauer et al. N Engl J Med 2012;366:1567-76.

Measuring Success—Part 3

Weight LossTraditional approach•Final BMI:

• <35 for morbid obesity (starting BMI < 49)• <40 for superobesity

(Starting BMI > 50)•Percent EWL:

• Excellent ≥75%• Good 50-74%• Fair 25-49%• Poor <25%

Co-morbidity ResolutionCurrent approach•The “real” goal of bariatric surgery is the reduction of life-threatening co-morbidity

Biron S et al. Obes Surg 2004; 14: 160-164Reinholt RB Surg Gynecol Obstet 1982; 155: 385-394

Remission Rate of Type 2 Diabetes is Associated with Greater Weight Loss

Following Gastric Bypass

Kadera BE et al. Surg Obes Relat Dis 2009; 5:305–309

Remission Rate of Type 2 Diabetes is Associated with Greater Weight Loss Following

Sleeve Gastrectomy

Surg Obes Relat Dis 2009; 5: 429-434.

EW

L (

%)

Does the Type of Procedure Influence the Improvement in Co-morbidities?

Gastric Banding

Gastric Bypass BPD±DS

EWL (%) 47.5 61.6 70.1

Remission DM (%) 47.9 83.7 98.9

Buchwald et al. JAMA 2004;292:1724-1737

“[Weight loss] isn't everything, it's the only thing” --Vince Lombardi