Gastrointestinal and Metabolic Complications of Bariatric ...
Bariatric and Metabolic Institute · Bariatric and Metabolic Institute June 3, 2008 Philip Schauer...
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Bariatric and Metabolic Institute June 3, 2008 Philip Schauer MD Professor of Surgery Cleveland Clinic Lerner College of Medicine
Transcript of Bariatric and Metabolic Institute · Bariatric and Metabolic Institute June 3, 2008 Philip Schauer...
Bariatric and Metabolic Institute
June 3, 2008Philip Schauer MDProfessor of SurgeryCleveland Clinic Lerner College of Medicine
Cleveland ClinicBariatric and Metabolic Institute (BMI)
www.ccf.org/bariatricsurgery
Comprehensive obesity treatment integrating sub-specialty medical care
Inter-nationally ranked Cleveland Clinic Specialties–Endocrinology–Cardiology–Gastroenterology–Nutrition–Sleep Medicine–Orthopedics–Plastic Surgery–Neurology
Cleveland Clinic Bariatric and Metabolic Institute
–Emphasizes minimally invasive surgical approach promoting speedy recovery while minimizing complications
–>97% of cases are performed laparoscopically
–Adolescent bariatric surgery–Specialize in higher risk patients–Expertise in re-operative surgery
BMI Surgeons
Philip Schauer, MD Bipan Chand, MD Stacy Brethauer, MD
BMI Team
State-of-the-art inpatient/outpatient unit
Obesity Research CollaboratorsLoutfi Aboussouan, M.D.
Matthew Barber, M.D.
Deepak Bhatt, M.D.
Gordon Blackburn, Ph.D.
Carol Blixen, Ph.D.
Charles Bae, M.D.
Tracey Bonfield, Ph.D.
Stacy Brethauer, M.D.
William Carey, M.D.
Bipan Chand, M.D.
Silas Chikunguwo, M.D.
Leslie Cho, M.D.
Karen Cooper, D.O.
Susan Curtas, R.N., M.S.
Gary Falk, M.D.
Nancy Foldvary-Schaefer, D.O.
Zhenghong Fu, Ph.D.
John Fung, M.D., Ph.D.
Joseph Golish, M.D.
Heather Gornik, M.D.
Eileen Groh, R.N., M.S.N.
Cindy Hamilton, M.S., R.D.
J. Michael Henderson, M.D.
Amir Jaffer, M.D.Ruth Jerkins, R.N., C
Sangeeta Kashyap, M.D.
Roop Kaw, M.D.
Dympna Kelly, M.D.
Allan Klein, M.D.
Matthew Metz, M.D.
Annitta Morehead
Marie Fidela Paraiso, M.D.Tracy Pitt, M.D..
Stanley Hazen, M.D., Ph.D.
Steven Nissen, M.D.
Carrie Geither, R.N. Ofer Reizes, Ph.D.Kitty Ribar, R.N., M.S.N.
Tomasz Rogula, M.D.
Ellen Rome, M.D., M.P.H.
Samuel Rossi, M.D.
Douglas Seidner, M.D.
Daniel Sessler, M.D.
Allan Siperstein, M.D.Glennys Smith
Laura Smolenak, R.N.
Ezra Steiger, M.D.
John Vargo, M.D., M.P.H.
Tammy Wade, L.P.N. Esteban Walker, Ph.D.
R. Matthew Walsh, M.D.
Amy Windover, Ph.D.
Massarat Zutshi, M.D.
James Young, M.D.
Keith Rosenbaum
Bariatric and Metabolic Institute l l 12
OBESITY ICEBERG: US Population = 300 Million
Morbidly Obese: 15 mil
Obese: 85 mil
Over Weight: 100 mil
Normal Weight: 100 mil
Bariatric and Metabolic Institute l l 13
Obesity is a Metabolic Disease
Liver disease
Gallbladder disease
OsteoarthritisGout
Asthma
Heart disease
Menstrual/
Infertility problems
Type 2 diabetes
High blood pressure
Sleep apnea
GERD
Bariatric and Metabolic Institute l l 14
Obesity Treatment Pyramid
Surgery
Pharmacotherapy
Lifestyle Modification
Diet Physical Activity
BMI
Operations for Severe Obesity
BPD10%
RY-Gastric Bypass75%
BPD2%
RY-Gastric Bypass73%
Gastric Banding15%
Gastric Banding25%
Laparoscopic Open
Heath Economics of Obesity l July 8, 2008 l 17
Bariatric SurgeryA Systematic Review and Meta-analysis: 136 studies, 22,094 patients
• Excess Weight Loss– All Patients: 61.2% (58.1%-64.4%) – Gastric Banding 47.5% (40.7%-54.2%) – Gastric bypass 61.6% (56.7%-66.5%)– Gastroplasty 68.2% (61.5%-74.8%)– BPD/DS 70.1% (66.3%-73.9%)
• Operative mortality ( 30 days)– Restrictive procedures 0.1%– Gastric bypass 0.5% – BPD/DS 1.1%
• Comorbidity Resolution– Diabetes 76.8% – Hyperlipidemia 70.0% (improved not resolved)– Hypertension 61.7% – Obstructive sleep apnea 85.7%
Buchwald et al. JAMA. 2004;292:1724-1737
Heath Economics of Obesity l July 8, 2008 l 18
Comparative Mortality
Craniotomy Esophagectomy Pancreatectomy
Peds
HeartAortic
Aneurysm CABG Hip Replacement
10.7% 9.1% 8.3% 5.4% 3.9% 3.5% 0.3%
BARTIATRIC SURGERY
0.28%
**Adopted from Dimiek et al. JAMA 2004;292:847Adopted from Dimiek et al. JAMA 2004;292:847--851.851.
Bariatric and Metabolic Institute 2007 Outcomes l July 8, 2008 l 20
Bariatric and Metabolic InstituteSurgical Cases
404133
0
25
50
75
100
High Risk Super Obesity Diabetes Cases
%
High Risk - Cases with BMI > or = to 55 and age > 60, N= 663Super Obesity > BMI 50Diabetes Cases - 2006
Source: ORIS/EPIC, 2004-2007
Bariatric and Metabolic Institute 2007 Outcomes l July 8, 2008 l 21
Bariatric and Metabolic Institute2007 Length of Stay
Source: 2007 TSI data
ICU Cases (%) Days Number of Cases
Lap Gastric Bypass 1.6% 3.3 252
Lap Adjustable Gastric Band 1.5% 1.8 66
Bariatric and Metabolic Institute 2007 Outcomes l July 8, 2008 l 22
Two years and greater post surgery (N=116)
70
0
25
50
75
100
Excess Weight LossLosing > 50% of excess body weight
%
Bariatric and Metabolic InstituteExcessive Weight Loss
Source: ORIS/EPIC, 2004-2005
Bariatric and Metabolic Institute 2007 Outcomes l July 8, 2008 l 23
Bariatric and Metabolic Institute
Source: 2004 -2007 ORIS/EPIC
Resolution of Diabetes (N=248)
53
0
25
50
75
100
% Resolved by Cessation of Diabetic Medications
%
Bariatric and Metabolic Institute 2007 Outcomes l July 8, 2008 l 24
Bariatric and Metabolic InstituteSurgical Cases
404133
0
25
50
75
100
High Risk Super Obesity Diabetes Cases
%
High Risk - Cases with BMI > or = to 55 and age > 60, N= 663Super Obesity > BMI 50Diabetes Cases - 2006
Source: ORIS/EPIC, 2004-2007
Bariatric and Metabolic Institute 2007 Outcomes l July 8, 2008 l 25
Bariatric and Metabolic Institute2007 Length of Stay
Source: 2007 TSI data
ICU Cases (%) Days Number of Cases
Lap Gastric Bypass 1.6% 3.3 252
Lap Adjustable Gastric Band 1.5% 1.8 66
Bariatric and Metabolic Institute 2007 Outcomes l July 8, 2008 l 26
Two years and greater post surgery (N=116)
70
0
25
50
75
100
Excess Weight LossLosing > 50% of excess body weight
%
Bariatric and Metabolic InstituteExcessive Weight Loss
Source: ORIS/EPIC, 2004-2005
Bariatric and Metabolic Institute 2007 Outcomes l July 8, 2008 l 27
Bariatric and Metabolic Institute
Source: 2004 -2007 ORIS/EPIC
Resolution of Diabetes (N=248)
53
0
25
50
75
100
% Resolved by Cessation of Diabetic Medications
%
BARIATRIC SURGERY
Overall Mortality
Effect on Long-term Mortality Compared to Non-Operated Controls
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%
How would You manage this Patient?
• Obesity• Hypertension• Dyslipidemia• Diabetes/impaired GT• Insulin resistance
• Central obesity• Visceral obesity• Nonalcoholic steatohepatitis
(NASH)• Obstructive sleep apnea • Left ventricular hypertrophy
Before and After Bariatric Surgery
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Before After
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Before After
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Before After
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Before After
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Before After
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Before After
