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September 26, 2008

Bariatric Surgery: Where We’ve Been & Where We’re GoingCalifornia Academy of Physician Assistants 37th Annual ConferenceRenaissance Hotel Palm Springs California October 5th 2013

September 26, 2008

Outline

• The obesity epidemic and associated morbidities• Treatment approaches• Surgical options and outcomes• Surgical impact on obesity related morbidities• Reconstructive procedures (excess skin removal)• Issues for PCPs in post op care

September 26, 2008

What is Morbid Obesity?

• Multifactorial disease of excess fat storage with a genetic basis

• Associated with multiple serious medical problems• Influenced by the environment• Lifelong and progressive

September 26, 2008

Body Mass Index (BMI)

•

or

• An objective measure of obesity• Central vs. peripheral obesity

Agency for Healthcare Research and Quality. Screening for obesity in adults. Accessed June 22, 2010 from http://www.ahrq.gov/clinic/3rduspstf/obesity/obeswh.htm

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September 26, 2008

BMI and Obesity

Normal 18.5 – 24.9

Overweight 25.0-29.9

Obese ≥ 30

• Class I 30-34.9

• Class II 35-39.9

• Class III ≥40

Morbid Obesity > 100 lbs. overweight or BMI ≥ 40

Agency for Healthcare Research and Quality. Screening for obesity in adults. Accessed June 22, 2010 from http://www.ahrq.gov/clinic/3rduspstf/obesity/obeswh.htmDugdale DC. Obesity. MedlinePlus. Accessed June 22, 2010 from http://www.nlm.nih.gov/medlineplus/ency/article/007297.htm

September 26, 2008

Various Levels of BMIWhat does obesity look like? *based on female 5’4” tall

Normal Weight (BMI 19 to 24.9)

130#BMI 22

Overweight(BMI 25 to 29.9)

152#BMI 26

Obese (Class I)(BMI 30 to 34.9)

175#BMI 30

Obese (Class II)(BMI 35 to 39.9 )

205#BMI 35

Morbidly Obese(BMI 40 or more)

234#BMI 40

Agency for Healthcare Research and Quality. Screening for obesity in adults. Accessed June 22, 2010 from http://www.ahrq.gov/clinic/3rduspstf/obesity/obeswh.htmDugdale DC. Obesity. MedlinePlus. Accessed June 22, 2010 from http://www.nlm.nih.gov/medlineplus/ency/article/007297.htm

AF4

September 26, 2008

Central Obesity

September 26, 2008

Obesity* Trends Among U.S. Adults 1991 and 2008

Source: Centers for Disease Control and Prevention. US Obesity Trends, trends by state 1985-2008. Accessed May 20, 2010 from http://www.cdc.gov/obesity/downloads/obesity_trends_2008.ppt

* BMI ≥30 or ~ 30 lbs. overweight for 5’ 4” person

1991 2008

No Data < 10% 10%-14% 15%-19% 20%-24% 25%-29% ≥ 30%

Slide 6

AF4 Brian Ruble's comment: Need reference material cited to support data aboveAlexander Feng, 7/23/2010

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September 26, 2008

Morbid Obesity: An “Epidemic within an Epidemic”

Sturm R. “Increases in morbid obesity in the USA: 2000-2005.” Public Health (2007) 121, 492-496.

September 26, 2008

Many factors influence obesity

OBESITY

September 26, 2008

Effect of a “snack food” diet provided in addition to standard laboratory chow on body weight in adult female rats over the first 50 days of feeding (filled circles). Animals offered the snack foods (which included such items as sugared cereal, marshmallows, salami, bananas, and a sweetened liquid formula) gained weight rapidly and became obese, as compared to controls (open circles) fed only the standard chow. When the snack food-fed rats were returned to a diet of chow only, they rapidly lost weight to the level maintained by the animals fed chow continuously. (From Gale, S.K., and Van Itallie, T.B., unpublished observations.)

CHOW DIET

September 26, 2008

SF Chronicle February 18, 2004

The Obesity Epidemic

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September 26, 2008 September 26, 2008

Table 3 – Intrapair correlations for Monozygotic (MZ) and Dizygotic (DZ) Twin Pairs and Heritability (G) with its SE

Induction MZ DZ G SE

Height .9055 .5077 .7956 .0344

Weight .8494 .4591 .7806 .0367

Body Mass Index .8096 .4238 .7716 .0390

25 year follow –up

Height .8826 .4823 .8006 .0350

Weight .7447 .3379 .8136 .0436

Body Mass Index .6655 .2444 .8422 .0481

Loehlin, J.C. & Nichols, R.C. Heredity, Environment and Personality (Univ. of Texas Press, Austin, Texas, 1976)

[(1-r2

MZ)2 1-r2 DZ)2

]SE = 2 + 1/2

NMZ NDZ

Formula for SE is derived from Falconer20 and Loehlin and Nichols21.

September 26, 2008

Obesity: Genetic Correlation

• Both parents obese: 70% of children will be obese

• One parent obese: 40% of children will be obese

• Neither parent obese: < 10% of children will be obese

September 26, 2008

HESS FAMILY—BEFORE & AFTER LapDS

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“Genetics loads the gun—the environment pulls the trigger.”George Bray, 1996

A new understanding of obesity

September 26, 2008

Hormonal Effectors• Glucagon-like peptide-1 (GLP-1): released by distal illeum; delays gastric emptying, CNS induced satiety, increases insulin (incretin)

• Glucose-dependent insulinotropic peptide (GIP): released by proximal gut; increases insulin

• Peptide YY (PYY): distal illeum; delays gastric emptying, increases satiety

• Ghrelin: gastric fundus / proximal intestine; hypothalamic effect to increase appetite

September 26, 2008

CO-MORBIDITIES

• Physical• Economic• Psychological• Medical

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September 26, 2008

Physical

September 26, 2008

Economic

September 26, 2008

Psychological

September 26, 2008

Medical Co-Morbidities

• NAFLD• Diabetes• Hypertension• Coronary artery disease• Sleep apnea• Degenerative joint

disease• Depression• Hyperlipidemia

• Asthma• Urinary stress incontinence• Infertility• Skin infections (psoriasis)• GE reflux• Increased malignancies• Increased mortality

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September 26, 2008

Prevalence of Significant Morbidities per Weight

Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA 2003;289:76."* Increase in mortality rate from cancers of all kinds compared to lowest risk group (BMI 25-30). From Calle EE, Rodriguez C, Walker-Thurmond K,et al. Overweight, obesity and mortality from cancer in a prospectively studies cohort of US adults. New Engl J Med 2003;348:1625."

September 26, 2008

Metabolic Syndrome

Hyper-Insulinemia

Dyslipidemia Hypertension

Heart Disease

Central Morbid Obesity

Insulin Resistance

Type 2 Diabetes

Complex interaction between genetic, metabolic, and environmental factors

Recent studies suggest metabolic syndrome may be an

inflammatory state.

Adapted from Lee YH, Pratley RE. The evolving role of inflammation in obesity and the metabolic syndrome. Curr Diab Rep. 2005;5:70-75.

September 26, 2008

Impact of BMI on LongevityImpact of Obesity on Mortality and Years of Life Lost

Graph represents years of life lost for white men.Fontaine KR, Redden DT, et al. Years of life lost due to obesity. JAMA 2003;289:187.

September 26, 2008

Leave the GourmandizingKnow the Grave Doth Gape for TheeThrice Wider Than For Other Men

-William Shakespeare

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September 26, 2008

Obesity Treatment Options

September 26, 2008

Weight Management Techniques• Lifestyle Modifications

• Standardized meal plans instructed by RDs• 1200–1500 Kcal, 25%–30% fat - women• 1500–1800 Kcal, 25%–30% fat - men• ADA (food exchanges) with diabetes or PCOS

• Daily food logs for 4-6 weeks• Weekly weigh-in• “Occurrence” exercise program• Water intake (no liquid calories)• Behavior modification lessons

September 26, 2008DaysObese subjects were maintained seven days on 3500-calorie diet, then 24 days on 450 calories.

At end of month, oxygen consumption had declined significantly more than body weight,

suggesting metabolic adaptation to caloric restriction. (Data of G. Bray)

Diet & Metabolism

September 26, 2008

Comparison of Atkins®, Ornish, Weight Watchers®, and Zone Diets • Randomized trial of 160 patients with average BMI of 35

(enrollment 2000 to 2002)• Medically supervised• Each diet reduced the LDL/HDL ratio by 10 percent

Dansinger ML, Gleason JI, Griffith JL, et al. Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease reduction. JAMA 2005;293(1)43-53.Atkins is a registered trademark of Atkins Nutritionals, Inc.Weight Watchers is a registered trademark of Weight Watchers International, Inc.

Type of Diet Completing One Year Weight Loss at One Year

Atkins® 21/40 (53%) 2.1 kg (4 lbs.)

Zone 26/40 (65%) 3.2 kg (7 lbs.)

Weight Watchers® 26/40 (65%) 3.0 kg (6 lbs.)

Ornish 20/40 (50%) 3.3 kg (7 lbs.)

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September 26, 2008

The Effect of 30 Minutes of Daily Exercise

Walking Rapidly 175 1 ½

Jogging 225 2

Running 450 3 ½

Swimming 340 3

Roller-skating 325 2 2/3

Bicycling 250 2

Tennis 250 2

Calories expended

Pounds lost per month

September 26, 2008

% P

atie

nts R

emai

ning

Red

uced

Wei

ght

Although many obese individuals can accomplish initial weight loss, few are able to maintain reduced body weight. In study of 102 obese subjects D. Johnson and E.J. Drenick found that only about 6% maintained weight loss for nine years.

Maintaining Excess Weight Loss with Traditional Methods

Months after Weight Reduction

September 26, 2008

Medications for Weight LossorlistatXenical1

orlistatAlli2

phentermineAdipex3

Mechanism of Action

blocks fat absorption

blocks fat absorption induces satiety

Dosage 120 mg TID 60 mg TID 15-37.5 mg QD

Average Weight Loss

5.7 lbsat 1 year

5-10 lbs at 6 months

7.92 lbsat 1 year

ConcernsGI symptoms,

risk of liver damage

GI symptoms, risk of liver

damage

Monitor blood pressure

Reference 16

September 26, 2008

Weight Loss of Various Treatments for Morbid Obesity

* Average Weight Loss from baseline; meta-analysis of various studies up to 4 years in length.

1Bray GA. Lifestyle and pharmacologic approaches to weight loss: Efficacy and safety. J Clin Endocrinol Metab, 2008; 93(11): 581-588.2Buchwald H, Avidor Y, Braunwald E et al. Bariatric surgery: A review and meta-analysis. JAMA 2004; 292(14):1724-1737. Meta-analysis of studies with at least 30 days of follow-up, with the majority of followup at two years or less.3Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Surg Obes Relat Dis. 2009;5:469-475. Meta-analysis of studies from 3 to 60 months follow up.

TreatmentExcess

Weight Loss

Lifestyle / Pharmacologic Treatments1

(Diets, lifestyle programs, sibutramine, orlistat, rimonabant)<10%*

Laparoscopic Adjustable Gastric Banding2 48%

Sleeve Gastrectomy3 74% / 55%

Gastric Bypass Surgery2 62%

Duodenal Switch 91%

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September 26, 2008

Effects of Bariatric Surgery on Mortality in Swedish Obese SubjectsSjostrom et al, Univ of Gothenburg NEJM 357:741-752

• Prospective cohort study• Surgery n=2010 / medical therapy n=2037• Average follow-up 10.9 years• Deaths: 101 (surgery) vs 129 (medical)• 10 yr weight loss from baseline (medical < 2%)

Gastric bypass: 25%VBG: 16%Lap Band: 14%

September 26, 2008

Long Term Mortality after Gastric Bypass SurgeryAdams et al University of Utah NEJM 357:753-761

• Retrospective matched cohort (1984-2002)• 9949 gastric bypass / 9628 severely obese

(7925/7925)• Average follow-up: 7.1 years

• Mortality decrease: All cause 40% (37.6 vs 57.1 deaths/10,000 person years; p<0.001)

• Cancer related mortality decrease: 60%• Diabetes related mortality decrease: 92%

September 26, 2008

Reduction of Premature Death89% reduction in risk of death over 5 years

* Includes perioperative (30-day) mortality of 0.4% p-value 0.001

Observational 2-cohort study. Treatment cohort (n=1035) included patients having undergone bariatric surgery. Control group (n=5746) included age and gender matched severely obese patients who had not undergone weight reduction surgery

Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality, Morbidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery 2004;240(3):416-424

September 26, 2008

Surgery is Currently the Most Effective Treatment for Morbid Obesity

“Bariatric surgery can result in long-term weight loss and significant reductions in cardiac and other risk factors for some severely obese adults.”- American Heart Association (AHA), 201120

“Bariatric surgery should be considered for adults with BMI ≥ 35 kg/m2 and type 2 diabetes, especially if the diabetes is difficult to control with lifestyle and pharmacologic therapy.”

- ADA “The Standards of Medical Care in Diabetes,” 200921

“Weight-loss surgery is the most effective treatment for morbid obesity producing durable weight loss, improvement or remission of comorbid conditions, and longer life.”- Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), 200922

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September 26, 2008

Treatments Prescribed for Morbid Obesity

September 26, 2008

Who is a Surgical Candidate?• Meets National Institutes of Health Criteria: BMI ≥ 40 (80-100 pounds or

more above ideal body weight) or ≥ 35 with significant obesity-related co-morbiditiesor 30-39 for LapBand• Failed medical weight loss attempts• Understands surgery and risks• Acceptable operative risk (patient and procedure)• Stable psychological condition: interview, psychotherapy, support

group participation• Tobacco, alcohol, & drug free

September 26, 2008

JAW WIRING

September 26, 2008

Surgical OptionsMalabsorption• Jejuno-Ileal Bypass (1960’s/1970’s)

Restriction• Gastroplasty (1980’s)• Roux-en-Y Gastric Bypass (1980’s - current)• Adjustable Gastric Band (“Lap Band”) (2001 - current)• Vertical (‘Sleeve’) Gastrectomy (2004 - current)

Combined• Biliopancreatic Diversion (1980’s - current in Europe)• Duodenal Switch (1990’s - current)

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September 26, 2008

Jejuno-Ileal Bypass (1960s-1970s)Construction: 90% of the small intestine bypassed and

inactive.

Mechanism: Severe malabsorption.

Meals: Greatly increased volume and caloric intake.

Bowel habits: Loose liquid stools, often immediate after each meal.

Weight loss: Good to fair.

Advantages: Technically simple operative procedure.

Weaknesses: Severe diarrhea, excessive losses of fluids and electrolytes. Vitamin and mineral malabsorption. Kidney stones. 10% incidence of mortality from liver and kidney failure.

Summary: First widely employed surgical weight loss procedure. Associated severe metabolic complications and significant mortality. No longer performed in the US.

September 26, 2008

Gastroplasty (1980s)Construction: ½ to 1 ounce upper stomach pouch with

constricting plastic band or ring to restrict flow. Recently developed adjustable bands can be resized without re-operation.

Mechanism: Exclusively restriction; pain or vomiting when food intake exceeds pouch capacity.

Meals: Portions limited by pouch size. Diet often shifts to liquid high calorie foods which can empty more quickly from the pouch (ice cream).

Bowel habits: Variable, may be constipated due to lack of fiber.

Weight loss: Unpredictable and unsustained. May plateau early with weight regain as diet changes.

Advantages: Shorter operative time (about 1 hour), much lower complexity.

Weaknesses: Band ring too loose causes inadequate weight loss or too tight: obstruction and vomiting. Band / ring is a foreign body and may migrate and may erode through the stomach wall. Staple line disruption can result in weight regain.

Summary: Least complex procedure. Shorter anesthesia time, reduced operative risk. Least potential for metabolic complications. Diminished quality of eating with pain or vomiting if pouch volume exceeded. High revision rate. Weight loss unsatisfactory.

September 26, 2008

Current Bariatric Surgical Procedures• Restrictive

• Laparoscopic Adjustable Gastric Banding• Sleeve Gastrectomy

• Restrictive and Malabsorptive• Roux-en-Y Gastric Bypass (malabsorptive for minerals

only, not calories)• Duodenal Switch / Biliopancreatic Diversion

September 26, 2008

Restrictive

Dissect approximately three-fourths of

the stomach

Malabsorptive(for MINERALS ONLY) & Restrictive

Bypass a portion of the small intestine and create a

15-30cc stomach pouch

Vertical Sleeve Gastrectomy

Current Most-Used Bariatric TechniquesAdjustable Gastric

BandingRoux-en-Y Gastric

Bypass

Restrictive

Place implantable device around upper most part of stomach

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September 26, 2008

Adjustable Gastric Banding• Laparoscopic• Least invasive• Restrictive• Second most frequently performed

bariatric procedure1

• Mean excess weight loss of 48%2

• Requires implanted medical device• Ongoing maintenance required

• Adjustments/Fills

1. Buchwald H. Consensus conference statement – Bariatric surgery for morbid obesity: health implications forpatients, health professionals, and payers Surgery for Obesity and Related Diseases 2005; 1:371-381.2. Buchwald, H, Avidor Y, Braunwald E, et al. Bariatric surgery: A systematic review and meta-analysis. JAMA.2004; 292:1724-37.

September 26, 2008

Potential Risks and Complications of Gastric Banding

• Anorexia• Band erosion / slippage• Band leak / malfunction• Esophageal spasm • Gastroesophageal reflux disease

(GERD) • Gastric perforation• Inflammation of the esophagus or

stomach • Migration of implant (band erosion,

band slippage, port displacement)• Outlet obstruction

• Pouch dilation • Port-site hernia or infection • Reservoir leakage / twisting• Tubing-related complications (port

disconnection, tubing kinking)

Note: Risks are in addition to the general risks of surgery. Patient weight, age and medical history play a significant role in determining specific risks.

September 26, 2008

Vertical Sleeve Gastrectomy

• Laparoscopic• Restrictive• May be an option as a first-

stage procedure for high-risk patients1

• Mean excess weight loss of 55%2

• No implanted medical device

1. ASMBS, Updated Position Statement on Sleeve Gastrectomy as a Bariatric Procedure. Surgery for Obesity and Related Diseases 2010;6(1):1-5.2. Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric Procedure. Surg Obes Relat Dis. 2009;5:469-‐475.

September 26, 2008

Risks and Complications of Vertical Sleeve Gastrectomy

• Abdominal hernia • Chest pain • Collapsed lung • Constipation or diarrhea • Dehydration • Dyspepsia• Esophageal dysmotility• Fistula• Gallstones, biliary colic,

cholecystitis

• Gastric leakage• Gastrointestinal inflammation

or swelling• Staple line leak• Stomach dilation• Ulcers• Vomiting and nausea

Note: Risks are in addition to the general risks of surgery. Patient weight, age and medical history play a significant role in determining specific risks.

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September 26, 2008

Roux-en-Y Gastric Bypass

• Routinely laparoscopic• Restrictive/malabsorptive

(minerals)• Most frequently performed

bariatric procedure• Mean excess weight loss at 1

year of 62%1

• No implanted medical device• Bypasses proximal small

intestine: metabolic syndrome beneficial impact

1. Buchwald, H, Avidor Y, Braunwald E, et al. Bariatric surgery: A systematic review and meta-analysis. JAMA. 2004; 292:1724-37.

Roux-en-Y Gastric Bypass

September 26, 2008

Potential Risks and Complications of Roux-en-Y Gastric Bypass

• Anastomotic/staple line leak • Bowel obstruction• Cholecystitis• Chronic anemia• Diagnostic challenges due to

potential difficulty in detecting the stomach, duodenum, or parts of the small intestine

• Dumping syndrome• Fistula• Gastric pouch dilation

• Internal hernia• Intestinal irritation• Marginal ulcers • Nutritional deficiencies • Osteoporosis• Pancreatitis• Stricture• Vitamin deficiency

Note: Risks are in addition to the general risks of surgery. Patient weight, age and medical history play a significant role in determining specific risks.

September 26, 2008

Biliopancreatic Diversion (1980s; Europe)Construction: Removal of lower 2/3 of stomach, 50 cm

common limb. Food separated from bile and pancreatic enzymes via Roux-en-y outflow.

Mechanism: Hybrid, combining moderately reduced stomach capacity (8 ounces) and short common limb producing more severe malabsorption.

Meals: Volume and caloric value of meals frequently twice as large as preoperative values.

Bowel habits: Loose, liquid, often immediate after each meal, stool odor dependent on diet.

Weight loss: Good, sometimes excessive. Stable long term.

Advantages: Normal eating pattern. No “blind loop” of intestine.

Weaknesses: Significant incidence of excessive weight loss, associated with vitamin, mineral, and protein malabsorption. Potential for anastamotic marginal ulcers with bleeding or perforation. Higher complexity. Dumping.

General: Lactose intolerance common. Requires close, careful long-term support.

Summary: Sustained weight loss, complex procedure, more common in Europe. Associated significant metabolic problems in some patients.

September 26, 2008

Evolution of the Duodenal Switch Procedure

Biliopancreatic Diversion

Long Loop Gastroplasty

Duodenal Switch Procedure

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September 26, 2008

Duodenal Switch (1989-present)Construction: Tube shaped stomach, distal Roux-en-y.Mechanism: Reduced stomach capacity provides initial

weight loss. Roux-en-y malabsorption component suppresses weight regain.

Meals: Reduced volume immediately post-op, increases as stomach stretches. No absolute food restriction. Significant lactose intolerance.

Bowel Habits: 1-3x/day, generally morning only, odor dependent upon fat and spices in the diet. First stool is formed / second is loose within 30 to 60 minutes.

Weight loss: Excellent, stable long term.Advantages: Normal eating habits, normally stomach

emptying, no dumping. No marginal ulcers since there is no gastroenteric anastomosis. Thus, aspirin and NSAIDS permissible. No “blind pouch”. Entire stomach accessible to UGI x-ray or endoscopy.

Weaknesses: Increased operative time and complexity. General: Lactose intolerance similar to RGB and BPD.

Daily multivitamin and calcium supplements recommended. Oral iron recommended for menstrual losses.

Summary: Combines moderate intake restriction with moderate malabsorption. Normal eating pattern, no dumping, no marginal ulceration. Excellent, sustained weight loss.

September 26, 2008

Human Digestive System

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September 26, 2008

Post DS Digestive System

September 26, 2008

Laparoscopic Duodenal Switch Technique Intracorporeal Port Placement

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September 26, 2008

Laparoscopic Duodenal Switch Technique Hand Assisted

September 26, 2008

Incisional Healing

6 weeks post-op 6 months post-op

September 26, 2008

Laparoscopic Duodenal Switch: Percent Excess Weight Lost*

* Based on an ideal BMI of 24 September 26, 2008

Laparoscopic Duodenal Switch: Reduction in BMI

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September 26, 2008

Weight Loss of Various Treatments for Morbid Obesity

* Average Weight Loss from baseline; meta-analysis of various studies up to 4 years in length.

1Bray GA. Lifestyle and pharmacologic approaches to weight loss: Efficacy and safety. J Clin Endocrinol Metab, 2008; 93(11): 581-588.2Buchwald H, Avidor Y, Braunwald E et al. Bariatric surgery: A review and meta-analysis. JAMA 2004; 292(14):1724-1737. Meta-analysis of studies with at least 30 days of follow-up, with the majority of followup at two years or less.3Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Surg Obes Relat Dis. 2009;5:469-475. Meta-analysis of studies from 3 to 60 months followup.

TreatmentExcess

Weight Loss

Lifestyle / Pharmacologic Treatments1

(Diets, lifestyle programs, sibutramine, orlistat, rimonabant)<10%*

Laparoscopic Adjustable Gastric Banding2 48%

Sleeve Gastrectomy3 74% / 55%

Gastric Bypass Surgery2 62%

Duodenal Switch 91%

September 26, 2008

LAPDS Co-Morbidity Resolution

* All results with exception of diabetes and hypercholesterolemia based on a random 40-person sample. Diabetes and hypercholesterolemia results based on laboratory analysis.

September 26, 2008

Co-Morbidity ResolutionMeta-analysis Comparison

Co-Morbidity Band RNY DSDiabetes 48% 84% 98%Hyperlipidemia 59% 97% 99%Hypertension 43% 68% 83%Sleep Apnea --- 80% 92%Operative mortality 0.1% 0.5% 1.1%

PacLap < 0.5%

September 26, 2008

LapDS EWL Maintenance (PACLAP)Year 1 2 3 4 5%EWL 85% 94% 95% 94% 91%

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September 26, 2008

Bariatric Literature : DS Long-term Weight Loss Maintenance

• Biron: Laval University Quebec, Canada• Hess: Bowling Green, Ohio• Anthone: USC Los Angeles, CA

Ten year excess weight loss maintenance: 75% - 85%

September 26, 2008

Co-Morbidity Resolution at Five Years (PACLAP)

Co-Morbidity Resolved Unchanged Worse

Depression 81% 17% 2%

Diabetes mellitus 94% 6% 0%

Hypercholesterolemia 93% 5% 2%

Hypertension 94% 4% 2%

Sleep apnea (symptoms) 100% 0% 0%

Asthma 95% 5% 0%

GERD 77% 17% 6%

Arthritis/DJD 79% 16% 5%

Low back pain 90% 3% 7%

Headaches 80% 12% 8%

September 26, 2008

Pre vs. Post Quality of Life: 5 YearsPreop QOL 4

Postop QOL 9

September 26, 2008

Weight Loss, Cardiovascular Risk Factors, and Quality of Life After Gastric Bypass and Duodenal SwitchSovik et al, Ann Intern Med. 2011;155:281-291

• Randomized gastric bypass (31) vs duodenal switch (29)• Two academic ctrs (Norway/Sweden); no DS experience• BMI 50 – 60 w/ two year follow-up• Mean EWL/BMI reduction: 50.6 kg/17.3 vs 73.5 kg/24.8• BMI > 40 @ 2 yrs: 8/31 vs 0/27• Total chol decrease mmol/l: 0.24 vs 1.07 (LDL .26 vs .78)• Decrease in trig, BP, FBS, CRP, insulin & increase HDL =• Quality of life assessments similar• Adverse events: 10/31 (32%) vs 18/29 (62%)• Inadequate vitamin & mineral supp / surgical technique

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September 26, 2008

Many Weight Loss Surgical Procedures Need RevisionPrevious failed procedures include:gastroplasties, bands, gastric bypasses, sleeve gastrectomies

Reasons for revision include: inadequate weight loss, weight regainpersistent nausea/vomiting/food intolerancegastro-esophageal reflux, dumping symptomsstrictures, ulcers

September 26, 2008

Results with Conversionto the Duodenal Switch (DSC)

Rabkin, et al.49 patients converted to the DS (DSC)Retrospective chart review, interview, physical exam and

lab studies for up to 10 years Factors examined included:outcome of primary procedureability of the DSC to reduce or eliminate surgical

morbidities related to the primary procedureBMI reduction & %EWL measured at routine intervals following the DSCcomplications and re-operations following the DSC

September 26, 2008

Reconstructive Surgery

• After weight loss has stabilized (average 12 to 18 months) • Document complications from excess skin such as rashes,

skin breakdown, back pain, etc. and treatments for these issues with both PCP and surgeon’s office

• Insurance companies often authorize

September 26, 2008

Reconstructive Procedures

• Brachioplasty (arms)• Abdominoplasty/paniculectomy (‘tummy tuck’)• Thighplasty (thighs)• Breasts (lift/augmentation)• Circumferential lipectomy (‘lower body lift’)

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September 26, 2008

Abdominoplasty / Panniculectomy: Before

September 26, 2008

Abdominoplasty / Panniculectomy: After

September 26, 2008

Pre LapDS BMI: 40

September 26, 2008

Abdominoplasty/Panniculectomy: 100 lb Weight Loss at 18 months

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September 26, 2008

Post-Operative Management of Bariatric Surgery Patients

September 26, 2008

• Post-operative pneumonia / atelectasis• Deep venous thrombosis / pulmonary embolism• Wound infections• Nausea / vomiting• Anastomotic & staple line leak

Acute Post-Operative Complications

September 26, 2008

• At risk procedures include gastric bypass, sleeve gastrectomy, duodenal switch

• Cardinal Signs & Symptoms

Staple Line / Anastomotic Leak

Shoulder pain (leak until proven otherwise)

Tachycardia: pulse rate > 120 Abdominal pain Respiratory rate > 22

Extravasation of contrast on UGI Shortness of breath Abdominal / rebound tenderness Pleural effusion Fever

September 26, 2008

• Nausea, vomiting, and dehydration• Medication adjustment• Nutritional supplements• Laboratory testing• Psychological adaptations• Relapse prevention for a chronic disease

Medical Management Post Bariatric Surgery

Reference 36

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September 26, 2008

• Causes of nausea and vomiting Dehydration Diarrhea Pain medications Vitamin supplementation Eating too much or too quickly Not chewing food adequately

• Patients unable to keep down fluids for 24 hoursshould be evaluated for obstruction or dehydration

• Recurrent nausea Re-hydration and antiemetic medications

Nausea, Vomiting, and Dehydration

September 26, 2008

• Can occur in restrictive as well as malabsorptive procedures • Causes

New onset (often temporary) lactose intolerance Clostridium difficile colitis (“C diff”) Gluten intolerance Excess fat ingestion

Diarrhea

Reference 36

September 26, 2008

Essential medications should be administered in “regular-release” rather than sustained release/matrix formulations to offset the altered GI absorption/anatomy

Tolerance may be improved for certain bariatric procedures by crushing the tablets or liquid formulations during the early postoperative days

Medication Adjustments

September 26, 2008

• Diabetic Medications Insulin requirements fall immediately after surgery Oral agents usually held and replaced with sliding scale insulin

(SSI) if needed

• Antihypertensive Medications Usually reduced in dosage or discontinued Diuretic held

• Lipid Lowering Agents Usually held during the early postoperative period Tendency to produce nausea Not required after malabsorptive procedure

“Metabolic” Management

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September 26, 2008

• Dx: POST-SURGICAL MALABSORPTION, 579.3a @ 6 mos, 1 yr, 18 mos, annually thereafter (increased monitoring as laboratory results indicate) CBC COMPREHENSIVE METABOLIC PANEL COPPER CERULOPLASMIN FASTING LIPID PANEL FERRITIN FOLATE IRON MAGNESIUM PHOSPHORUS PTH, intact with Calcium THIAMINE (Vitamin B1) TSH VITAMIN A VITAMIN B6 VITAMIN B12 VITAMIN D, 25 HYDROXY ZINC, PLASMA

Screening & Laboratories for DS patients

September 26, 2008

• Multiple vitamin (Prenatal)Fat soluble vitamins ADEK in non-lipid (“dry”) formulation

• Ca citrate 1800-2400 mg daily in divided doses (adjusted)• Vitamin D3 (5,000-50,000 IU daily)• Iron

OTC ferrous sulfate / ferrous fumerate Multigen Rx

• Probiotic (daily)• PRN (based on serum levels)

Zinc Vit A Copper

• Pancreatic enzymes (if excessive weight loss)

Supplements

September 26, 2008