Bariatric Surgery in the Transplant Population
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Bariatric Surgery in the Transplant Population
Guilherme M. Campos, MD, FACS, FASMBSAssociate Professor of Surgery
University of Wisconsin – [email protected]
5th Annual Wisconsin Chapter Transplant Symposium
Transplant: Sharing and Caring
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1. Overview of Bariatric Surgery1. Indications2. Type of procedures3. Peri-operative and long term-outcomes4. Beyond Caloric Restriction, why does it work
2. Bariatric Surgery & Organ Transplantation1. UCSF Data2. CRF (with or without dialysis / pre Kidney Tx)3. Post Kidney Tx4.Before, during and after Liver Tx
Bariatric Surgery Before and After Organ Transplantation
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Surgery for Severe ObesityN
o. o
f Ba
ria
tric
Sx.
in th
e U
S
Recent trends in bariatric surgery case volume in the United States.Kohn GP, Galanko JA, Overby DW, Farrell TM.Surgery 2009 146: 375-80
1. Increasing prevalence and recognition Health Hazard
2. Poor outcomes with nonsurgical management
3. Good outcomes with Bariatric Surgery
4. Introduction of Laparoscopic Techniques
Surgery for Severe ObesitySteinbrook RN Eng J Med 2004 350: 1075-79
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• Failure supervised weight loss program
• Well-informed and motivated patients
• Acceptable operative risks
• BMI > 40 or BMI 35-40 with high risk comorbidities
Surgery for Severe Obesity
PATIENT SELECTION
NIH Consensus Statement – March 25-27, 1991 Nutrition 1996; 12: 397-402
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LaparoscopicGastric Bypass
LaparoscopicGastric Banding
60% 25%
LaparoscopicSleeve Gastrectomy
20%
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1. Low perioperative and long-term complication rate.
2. Significant and Long Term Weight Loss
3. Improvement/Cure Obesity Associated Comorbidities
4. Improvement Quality of Life
5. Reduces Mortality
Bariatric Surgery Overview O U T C O M E S
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• A prospective, multicenter, observational study of 30-day outcomes in consecutive patients
undergoing bariatric surgical procedures at 10 clinical sites in the US from 2005 - 2007.
• 4,340 patients who had a first-time bariatric procedure
1. Open RYGB - 899 patients (21%) - BMI 51
2. Laparoscopic RYGB - 2243 patients (51%) - BMI 47
3. Laparoscopic Band - 1198 patients (28%) - BMI 44
Significant Differences in between all groups/p<0.01/ for BMI and Co-existing Conditions
(Other procedures - 166 patients, not included in the analysis)
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1. Low perioperative and long-term complication rate.
2. Significant and Long Term Weight Loss
3. Improvement/Cure Obesity Associated Comorbidities
4. Improvement Quality of Life
5. Reduces Mortality
Bariatric Surgery Overview O U T C O M E S
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Effects of Bariatric Surgery on Mortality in Swedish Obese SubjectsSjöström et al. NEJM. 2007; 357 (8):741-52
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1. Low perioperative and long-term complication rate.
2. Significant and Long Term Weight Loss
3. Improvement/Cure Obesity Associated Comorbidities
4. Improvement Quality of Life
5. Reduces Mortality
Bariatric Surgery Overview O U T C O M E S
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% R
eso
lutio
n C
omor
bid
ityResolution of Obesity Associated Diseases after
Gastric Bypass
Buchwald H. et al. JAMA. 2004; 292(14):1724-37
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48%
75%80%
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12 Studies, 576 patients, RYGB, 2cd Biopsy ~ 17 mo
STEATOSIS INFLAMMATION FIBROSIS
Improvement 100% 80% 80%
No Change - 10% 10%
Worse/New Onset - 10% (Portal) 10%
OUTCOME HISTOLOGY 2cd BIOPSY
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• Ralph, 45 y/o, 394 lbs• On Disability for Back Pain• High Blood Pressure (3 meds.)• Diabetes• Sleep Apnea• Venous Disease
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1. Low perioperative and long-term complication rate.
2. Significant and Long Term Weight Loss
3. Improvement/Cure Obesity Associated Comorbidities
4. Improvement Quality of Life
5. Reduces Mortality
Bariatric Surgery Overview O U T C O M E S
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Original Article Long-Term Mortality after Gastric Bypass Surgery
Ted D. Adams, Ph.D., M.P.H., et alUniversity of Utah School of Medicine
Salt Lake City, UT
N Engl J MedVolume 357(8):753-761
August 23, 2007
Original Article Effects of Bariatric Surgery on Mortality in Swedish
Obese SubjectsLars Sjöström, M.D., Ph.D., et al.
Swedish Obese Subjects (SOS) StudySahlgrenska University Hospital, Gothenburg, Sweden,
N Engl J MedVolume 357(8):741-752
August 23, 2007
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Distribution of Deaths and Death Rates per 10,000 Person-Years, According to Study Group
Adams TD et al. N Engl J Med 2007;357:753-761
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Cause of Death
Sjostrom L et al. N Engl J Med 2007;357:741-752
5% 6.3%
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• Failure supervised weight loss program
• Well-informed and motivated patients
• Acceptable operative risks
• BMI > 40 or BMI 35-40 with high risk comorbidities
Surgery for Severe Obesity
PATIENT SELECTION
NIH Consensus Statement – March 25-27, 1991 Nutrition 1996; 12: 397-402
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Beyond Caloric Restriction, why does it work?
Surgery for Severe Obesity
• Well-informed and motivated patients
NIH Consensus Statement – March 25-27, 1991 Nutrition 1996; 12: 397-402
• Change in Hunger-Satiety Mechanisms
• Change in Endocrine and Gluco-regulatory
Mechanisms
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Cummings D.E. et al.
Ghrelin Secretion before & after Weight Loss
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Cummings D.E. et al.
Ghrelin Secretion before & after GBP
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BAGGIO LL & DRUCKER DJ Gastroenterology 2007;132:2131–2157
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GLP-1 LEVELS AFTER A MEAL
Campos GM, et al.Journal of Gastrointestinal Surgery, Jan; 14 (1):15-23, 2010
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Campos GM, et al.Journal of Gastrointestinal Surgery, Jan; 14 (1):15-23, 2010.
* P=0.01
GLP-1 LEVELS AFTER A MEAL
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INSULIN LEVELS AFTER A MEAL
Campos GM, et al.Journal of Gastrointestinal Surgery, Jan; 14 (1):15-23, 2010.
* P=0.01
- Gastric Bypass Group
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BAGGIO LL & DRUCKER DJ Gastroenterology 2007;132:2131–2157
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1. UCSF Data2. CRF (with or without dialysis / pre Kidney Tx)3. Post Kidney Tx4. Before and after Heart Tx5. Before and after Lung Tx6. Before, during and after Liver Tx
Bariatric Surgery Before and After Organ Transplantation
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4%
35%
4%
33%
18%
8%
0
5
10
15
20
25
30
35
40
< 18.5 18.5 - 24.9 25 - 29.9 30 - 34.9 35 - 39.9 > 40
BMI
Prevalence of Obesity in Patients Awaiting Kidney or Liver Transplant at UCSF - 2006
6%
18%
34%
8%
3%
32%
0
5
10
15
20
25
30
35
40
< 18.5 18.5 - 24.9 25 - 29.9 30 - 34.9 35 - 39.9 > 40
BMI
32% (n = 248) > 306% (n = 33) > 40
30% (n = 1,076) > 304% (n = 222) > 40
Liver (n = 986)Liver (n = 986)Kidney (n =4,144)Kidney (n =4,144)
Background%
of
patie
nts
% o
f pa
tient
s
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Gore JL, et al. Am J of Transplantation 2006Pischon T, et al. Neph Dail Transplant 2001
• More post-op wound, pulmonary and cardiovascular complications
• Higher rate of primary graft non-function
• Longer length of hospitalization
• 30% higher cost of hospitalization
• Higher mortality
• More post-op wound, pulmonary and cardiovascular complications
• Higher rate of primary graft non-function
• Longer length of hospitalization
• 30% higher cost of hospitalization
• Higher mortality
KIDNEYKIDNEY LIVERLIVER
Nair S, et al. AJG 2001, Hepatol 2002Sawyer RG, et al. Clin Trans 1999
BackgroundMorbidity after Transplant - UNOS
• Higher rate of delayed graft function
• Higher rate of early graft loss
• Higher rate of acute rejection
• Higher rate of overall graft failure
• Longer length of hospitalization
• Higher mortality
• Higher rate of delayed graft function
• Higher rate of early graft loss
• Higher rate of acute rejection
• Higher rate of overall graft failure
• Longer length of hospitalization
• Higher mortality
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Background
• Most transplant centers have implemented BMI limits beyond which patients are considered unsuitable for
transplantation.
• Bariatric surgery is the most effective treatment for morbid obesity, but is not offered routinely to this patient
population.
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Laparoscopic Bariatric Surgery Improves Transplant Candidacy In Morbidly Obese
Patients
Takata M, Campos G, Ciovica R, Rogers S, Cello J, Ascher N, Posselt A
Bariatric Surgery Program
University of California San Francisco, USA
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Objectives
• Evaluate the safety and efficacy of:– Laparoscopic gastric bypass - ESRD.– Laparoscopic sleeve cirrhosis and ESLD.
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Patients and Methods
• Selected patients ineligible for a kidney, liver, or lung transplant because of their BMI.
• UCSF BMI limits for transplantation– Kidney: 40kg/m2
– Liver: 40kg/m2 (relative contraindication) and 50kg/m2 (absolute contraindication).
– Lung: 40kg/m2
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ResultsOperative and Perioperative Outcomes
ESRD (n=19) Cirrhosis (n=14) ESLD (n=4)
Operation LGBP LSG LSG
Total O.R. time (min) 189 (148 - 222) 141 (120 - 176) 147 (90 & 213)
Mean EBL, ml 64 58 50
Complications 4 4 2
LOS, days 3.0 (3 - 3) 4.2 (2 - 8) 4.0 (3 & 5)
Follow-up, months 36 (6 - 36) 21 (3 - 21) 18 (9 - 18)
Bariatric Surgery Program
University of California San Francisco, USA
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ResultsLGBP in Patients With ESRD
25
30
35
40
45
50
55
60
65
Preop 1 3 6 9 12
Time since Surgery (months)
BMI
25
30
35
40
45
50
55
60
65
Preop 1 3 6 9 12
Time since Surgery (months)
BMI
BMI Cutoff for Transplant
Transplant candidate at 12 months11/12
Bariatric Surgery Program
University of California San Francisco, USA
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ResultsLSG in Patients With Cirrhosis / ESLiverD
25
30
35
40
45
50
55
60
Preop 1 3 6 9 12
Time since surgery (months)
BMI
25
30
35
40
45
50
55
60
Preop 1 3 6 9 12
Time since surgery (months)
BMI
BMI Cutoff for Transplant
Transplant candidate at 12 months6/9
Bariatric Surgery Program
University of California San Francisco, USA
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1. CRF (with or without dialysis / pre Kidney Tx)2. Post Kidney Tx
32 patients CRF, RYGB, no Tx9 patients CRF, RYGB, Kidney Tx10 patients Post kidney, RYGB
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1. Before Heart Tx
N=2Lap Sleeve
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1. After Liver Tx
N=12 months after Liver TxBiliary reconstruction and Open SleeveBMI 37 to 30, 6 months post-op
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1. After Liver Tx
N=21. BMI 65 to 48, 3 years post-op2. BMI 63 to 43, 18 mo post-op
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1. CRF (with or without dialysis / pre Kidney Tx)2. Post Kidney Tx3. Before and after Heart Tx4. Before and after Lung Tx5. Before, during and after Liver Tx
Bariatric Surgery Before and After Organ Transplantation
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LaparoscopicGastric Bypass
LaparoscopicGastric Banding
60% 25%
LaparoscopicSleeve Gastrectomy
20%
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LaparoscopicGastric Bypass
LaparoscopicSleeve Gastrectomy
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Patient Selection – Initial Procedure
1. for patients considered high-risk
2. for transplant candidates
3. for morbidly obese patients with Met Syndrome
4. for pts. BMI 30-35 and comorbidities
5. for pts. with Inflammatory Bowel Disease
6. adolescent morbidly obese patients
7. for elderly morbidly obese patients
LSG is a valid option
96%
96%
91%
95%
86%
77%
100%
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Bariatric Surgery in the Transplant Population
Guilherme M. Campos, MD, FACS, FASMBSAssociate Professor of Surgery
University of Wisconsin – [email protected]
5th Annual Wisconsin Chapter Transplant Symposium
Transplant: Sharing and Caring