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![Page 1: Bariatric Surgery for the Treatment of Obesity and Metabolic Disease Thomas Magnuson MD Associate Professor of Surgery Johns Hopkins University School.](https://reader035.fdocuments.us/reader035/viewer/2022062409/56649d955503460f94a7dfe1/html5/thumbnails/1.jpg)
Bariatric Surgery for the Treatment of Obesity and Metabolic Disease
Thomas Magnuson MD
Associate Professor of Surgery
Johns Hopkins UniversitySchool of Medicine ([email protected])
JHI Partners Forum 10/2/2012
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Disclosure
Nothing to disclose
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OBESITY SURGERYOVERVIEW
• Indications for surgery and patient selection
• Current surgical procedures to treat obesity
• Outcomes of surgery: Benefits and risks
• “Metabolic surgery” and impact on diabetes and cardiometabolic risk
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Why are we talking about Obesity Surgery today?
1) Rapid rise in prevalence of obesity
2) Recognition of Obesity as a Disease
3) Better operations for Obesity and public/physician awareness
4) Increased focus on improvement/ resolution of metabolic disease
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Treatment of Obesity
• Diet & Exercise
• Medications
• Behavioral modification
• Surgical management
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Explosion in Bariatric Surgery
Over 200,000 procedures in the U.S. in 2010
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Purpose of Bariatric Surgery
• To alleviate or eliminate obesity related medical diseases
• It is not cosmetic surgery and patients may still be overweight after plateau in weight loss postop
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Bariatric Surgery Patient Selection
(Based On The 1991 NIH Guidelines)
• BMI > 40; or > 35 with obesity related morbidity• Previous failed attempts at supervised weight
reduction• Realistic expectations; no recent substance abuse• Age limits (18 to 70 yrs old in most programs) • Supportive family/friends• Lifelong commitment to dietary change and follow-
up• Pre-op evaluation by dietician and psychologist
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Obesity Surgery Patient Selection
Additional Considerations
• Adolescents (? informed consent, compliance)• Age > 70yo (higher risk, less medical
benefit, ? Improved quality of life)• “End stage obesity” (severe CHF, home oxygen, non-
ambulatory, BMI>100)• Bridge to other procedures (transplantation; joint
replacement)• Patients post-transplant (liver; kidney)• Lower BMI patients (30-35) with diabetes/htn
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Obesity Surgery
Pre-Operative Evaluation
• Insurance approval (most require 6 month dietary program/counseling within previous 2 years)
• Mandatory Dietary and Psych evaluation/counseling• Cardiac/pulmonary “clearance” if significant history• Sleep apnea testing/treatment if high risk• In select patients- EGD, UGI, IVC filter• Stop smoking and estrogen products (BCP’s) prior to
surgery (high risk for VTE)• Most Bariatric Surgery is performed at “Centers of
Excellence” certified by the ACS and ASMBS
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OBESITY SURGERY
OPERATIONS FOR MORBID OBESITY
RESTRICTIVE OPERATIONS
Adjustable Gastric Banding (ABG)Vertical Sleeve Gastrectomy (VSG)Gastric Bypass (GBP) (also malabsorptive)
MALABSORPTIVE OPERATIONS
Gastric Bypass (GBP)Duodenal Switch-biliopancreatic diversion (DS-BPD)
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Roux-en-Y Gastric Bypass
• Small gastric pouch (20-30 ml) (remainder of stomach left in)
• ~100 cm of small bowel bypassed creating nutrient malabsorption
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Laparoscopic Gastric Bypass
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Gastric Bypass
• Durable weight loss: 60 to 70% excess wt loss at 2 yrs
• Proven reduction of obesity related medical problems
• Risk of death low if done by experienced team (<0.5%)
• Most common operation in US with the most follow-up data
• Marginal Ulcer• Stomal stenosis• Anemia• Calcium deficiency• Nutrition/vitamin defic.• Difficult to reverse
PROS CONS
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Laparoscopic Gastric Band
• Laparoscopic procedure that is less invasive than gastric bypass
• Adjustable, depending on desired wt. loss
• Weight loss less than gastric bypass (40% excess wt. loss at 1yr post-op)
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Adjustable Gastric Band
• Reversible • Least invasive• Lowest risk of Death• No malabsorption• Adjustable• 40 to 50 % excess
weight loss at 2 years
• Foreign body / erosion• Esophageal dilation• GERD• Breakage/slippage• Failure to lose weight• Slower weight loss• 30-50% reoperation
rate/removal long term
PROS CONS
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Laparoscopic Vertical Sleeve Gastrectomy
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Vertical Sleeve Gastrectomy
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Laparoscopic Vertical Sleeve Gastrectomy
• Does not involve intestinal rearrangement• Restrictive only; 50-60% excess weight loss• May be used as a first step operation in high
risk patients to induce weight loss before performing duodenal switch or gastric bypass
• Currently considered for weight loss in lower BMI morbidly obese patients who do not want an adjustable band or a malabsorptive operation
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Duodenal Switch
• Partial stomach resection
• All of the bowel bypassed except 150-200 cm of distal small bowel
• Primarily malabsorptive: risk of malnutrition, vitamin deficiency, diarrhea
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Duodenal Switch w/ BPD
• Best wt loss (80% excess weight)
• Best resolution of metabolic disease
• Pylorus preserved• Less restriction than
GBP
• Malabsorption • Anemia• Calcium deficieincy• 10 % may need revision• Diarrhea/malodorous stools• Protein malnutrition• ? Liver disease
PROS CONS
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Summary of Obesity Surgery
• Gastric bypass (60-70% of all procedures)
• Laparoscopic adjustable gastric band (LAGB) (20-30%)
• Lap Sleeve Gastrectomy (15-25%)
• Duodenal Switch w/ biliopancreatic diversion (5%)
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The Johns Hopkins Center for Bariatric Surgery Over 3,000 bariatric procedures since 1997
Age = 41 yo (18 - 74 yrs)Female = 77 %Pre-Op weight = 349 lbs (210 - 740 lbs)Pre-Op Body Mass Index (BMI) = 55.3 (39 - 101)Hospital stay (median) = 2 days (lap=2; open=3)
Pre-Op obesity related disease:• Osteoarthritis = 83 %• Hypertension = 47 %• GERD = 40 %• Diabetes = 27 %• Sleep Apnea (requiring CPAP) = 22 %
Analysis of 1000 gastric bypass procedures:
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Obesity Surgery At Johns Hopkins
Weight Loss Excess body wt. loss
12 months =120 lbs 61% 24 months = 134 lbs 67% 36 months = 133 lbs 66% 48 months = 133 lbs. 62% 60 months = 128 lbs. 64%Impact on Medical Disease (by 1 year post-op) Hypertension 73% resolution Diabetes 75% resolution GERD 91% resolution Sleep Apnea 93 % resolution
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0 6 12 18 24 30 36 42 48200
225
250
275
300
325
350
WEIGHT LOSS
MONTHS POST-OP
PO
UN
DS
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OBESITY SURGERY AT JHBMC
POST-OP COMPLICATIONS(1000 gastric bypass pts.)
Mortality = 0.2 %
Morbidity = 13 %
Wound infection = 6.5 % Pulmonary embolus = 0.9 % Reoperation (< 30 days) = 1.2 % Decubitus ulcers = 0.6 % Anastamotic leak = 0.2 % Bowel obstruction = 0.6 % Readmission = 8 %
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OBESITY SURGERY Evidence based analysis
Is bariatric surgery effective?
• Buchwald 2004 (meta-analysis): Resolution of
% excess wt loss DM HTN Gastric Band 49% 48% 43% Gastric Bypass 61% 83% 67% DS/BPD 70% 98% 83%
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OBESITY SURGERY Evidence based analysis
Is bariatric surgery effective?
• Buchwald 2004 (meta-analysis): Resolution of
% excess wt loss DM HTN Gastric Band 49% 48% 43% Gastric Bypass 61% 83% 67% DS/BPD 70% 98% 83%
• Swedish Obese Subjects Study (SOS) 2007 Longitudinal matched-control cohort study; over 10 yr f/u of 2,010 pts.
- Sustained weight loss in the surgical cohort with reductions in diabetes, dyslipidemia, and HTN compared to matched controls
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Mean % Weight Change over 15 Years Swedish Obesity Study
Sjostrom: NEJM 2007;357:741-52
Control
Bands
VBG’s
RYGB30%
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Ann Intern Med. 2009;150(2):94-103.
Diabetes Remission after Bariatric surgery
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N Engl J Med. 2012.
• Compared the efficacy of three treatments for patients with T2DM and BMI between 27-42 kg/m2:
1.Intensive Medical Therapy*
2.Intensive Medical Therapy* + Laparoscopic Sleeve Gastrectomy
3.Intensive Medical Therapy* + Gastric Bypass
• Primary Endpoint: Proportion of patients with a glycated hemoglobin level of 6.0% or less at 12 months after treatment.
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0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
12%
42%
37%
Patients at Glycemic Control, 12 months
Med therapy GBP Sleeve
N Engl J Med. 2012
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Medication Utilization and Annual Health Care Costs in Patients With Type 2 Diabetes Mellitus Before and After Bariatric Surgery
Makary, et alArchives of Surgery, 2010
• Large multistate insurance claims dataset
• Jan 2002 – Dec 2005
• 2235 patients with diabetes undergoing bariatric surgery
• at least 1 year pre-op and post-op follow up
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Results
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Diabetes resolution: 1669 (74.7%) of 2235 pts at 6 months 1489 (80.6%) of 1847 pts at 12 months 906 (84.5%) of 1072 pts at 2 years
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Prompt Reduction in Use of Medications for Comorbid Conditions After Bariatric Surgery Segal et al, Obesity Surgery, 2009
-6025 pts. undergoing bariatric surgery
-Early post-op reductionin HTN, DM, and lipid-lowering medications
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Effect of Surgery 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 (SOS), 2007 VBG/RYGB 14 yrs 31%
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“Metabolic Surgery”
Future directions:• Patient selection based more on metabolic
disease as opposed to weight (? BMI of 30-35 or lower)
• Better understanding of metabolic and hormonal effects of surgery
• Development of less invasive procedures or drugs which achieve the desired physiologic/metabolic effects
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Weight Loss Procedures in Development
Gastric balloonGastric/vagus n. pacing
Endoluminal Surgery
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-Endoscopically placed plastic “sleeve” allowing nutrients to avoid contact with duodenal mucosa -Designed to achieve diabetes resolution by altering GI hormone production and islet cell stimulation
EndoBarrier
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OBESITY SURGERY Summary
-Bariatric surgery is relatively safe with an expected mortality of <0.5% and morbidity of 10-15%
-Surgery results in sustained weight loss and favorably impacts obesity related medical disease and reduces long term mortality
-Further clinical trials are needed to help determine which operation is best for which patient
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The End