6/23/2011. Bariatric Surgery: What the Primary Care Provider Should Know. Case Presentation: Rachelle

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1 Bariatric Surgery: What the Primary Care Provider Should Know 2,000 B.C. 2,000 A.D. Case Presentation: Rachelle 35 year-old woman with morbid obesity lbs BMI 44.5 PMHx: mild depression obstructive sleep apnea (AHI 42, on CPAP) asthma polycystic ovarian syndrome gastroesophageal reflux disease Diet attempts: Weight Watchers Atkins HerbaLife South Beach Jonathan Carter, MD May 2011 No disclosures Case Presentation: Rachelle Case Presentation: Rachelle Intervention:??????? Weight versus time weight (pounds) time (months) PMHx: mild depression RESOLVED obstructive sleep apnea (AHI 42, on CPAP) RESOLVED asthma RESOLVED polycystic ovarian syndrome NO MEDS gastroesophageal reflux disease RESOLVED 1

2 Case Presentation: Rachelle BRFSS, 1990 No Data <10% 10% 14% BRFSS, 1991 BRFSS, 1992 No Data <10% 10% 14% 15% 19% No Data <10% 10% 14% 15% 19% 2

3 BRFSS, 1993 BRFSS, 1994 No Data <10% 10% 14% 15% 19% No Data <10% 10% 14% 15% 19% BRFSS, 1995 BRFSS, 1996 No Data <10% 10% 14% 15% 19% No Data <10% 10% 14% 15% 19% 3

4 BRFSS, 1997 BRFSS, 1998 No Data <10% 10% 14% 15% 19% 20% No Data <10% 10% 14% 15% 19% 20% BRFSS, 1999 BRFSS, 2000 No Data <10% 10% 14% 15% 19% 20% No Data <10% 10% 14% 15% 19% 20% 4

5 BRFSS, 2001 BRFSS, 2002 No Data <10% 10% 14% 15% 19% 20% 24% 25% No Data <10% 10% 14% 15% 19% 20% 24% 25% BRFSS, 2003 BRFSS, 2004 No Data <10% 10% 14% 15% 19% 20% 24% 25% No Data <10% 10% 14% 15% 19% 20% 24% 25% 5

6 BRFSS, 2005 BRFSS, 2006 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% BRFSS, 2007 BRFSS, 2008 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% 6

7 Why is obesity bad? Obesity reduces life expectancy For young men, BMI >45 took off 13 years of life expectancy For young women, BMI >45 took off 8 years of life expectancy Mechanick et al. SOARD 2008 Randomly assigned 811 patients to 4 groups: low fat, low protein high fat, high protein low fat, high protein high fat, low protein Intensive group/individual instructional sessions Intensive follow-up to 2 years Katan, NEJM

8 Medicines for the treatment of obesity Robert H. Eckel, MD INDICATIONS FOR BARIATRIC SURGERY Gastric bypass anatomy Definition BMI Normal < 25 Overweight Obese, class Obese, class Obese, class Superobese 60+ with co-morbidity SURGERY 8

9 What happens in the hospital? Annals of Surgery, 2000 BYPASS OPERATION remove bladder catheter start clear liquids transition to oral pain meds meet nutritionist meet pharmacist remove abdominal drain home 7am noon 7pm 7am noon 7pm 7am noon Day 0 Day 1 Day 2 remove bladder catheter start clear liquids BAND OPERATION transition to oral pain meds meet nutritionist meet pharmacist home 7am noon 7pm 7am noon 7pm 7am noon Day 0 Day 1 Day 2 9

10 Annals of Surgery, 2000 Results of gastric bypass Metabolic benefits of bariatric surgery courtesy of ASMBS 10

11 After gastric bypass, DM2 commonly resolves within days or weeks, before any significant weight loss has occurred. After gastric bypass, 83% of diabetics and 97% of patients with impaired glucose tolerance will normalize their fasting blood glucose, HbA1c, and insulin levels. The effect is durable, at least for 15 years. Metabolic benefits of bariatric surgery blood glucose insulin courtesy of ASMBS fasting blood glucose diabetic <5 years diabetic 6-10 years diabetic >10 years impaired fasting glucose diet controlled diabetics oral agent diabetics insulin dependent diabetics HbA1C (%) diabetic <5 years diabetic 6-10 years diabetic >10 years impaired fasting glucose diet controlled diabetics oral agent diabetics insulin dependent diabetics 11

12 WHY DOES DIABETES RESOLVE? By direct calorie restriction / weight-loss: % using medication for diabetes control oral agent diabetics insulin dependent diabetics fat mass adiponectin insulin sensitivity caloric intake insulin requirement = beta cell rest Specific to gastric bypass (and not LapBand or other restrictive procedures) ghrelin adiponectin, blocks hepatic insulin signaling, glucagon nutrients to ileum GLP-1 insulin, glucagon, insulin sensitivity beta-cell mass, beta-cell apoptosis nutrients to ileum peptide YY caloric intake nutrients to duodenum??? insulin sensitivity GHRELIN Bariatric surgery and comorbidity resolution Cummings, NEJM 2002 courtesy of ASMBS 12

13 systolic BP 50% of the morbidly obese have HTN About 40% of those on antihypertensives will be able to wean off medications completely. About 50% of undiagnosed hypertensives will resolve completely. diastolic BP Bariatric surgery and comorbidity resolution BMI courtesy of ASMBS About 70% of morbidly obese patients have sleep apnea. About 90% will come off CPAP completely Bariatric surgery Apnea-hypopnea index oxygen saturation sleepiness and comorbidity resolution courtesy of ASMBS 13

14 CANCER INCIDENCE Lancet July, year after RYGB 2 years after RYGB RYGB dropped percentage of dyslipidemic patients from 95% to 28% Number taking medication dropped to 15% Bariatric surgery reduces risk of: colon cancer endometrial cancer breast cancer prostate cancer ovarian cancer obese controls surgery Retrospective cohort study 7,925 gastric bypasses in Utah 7,925 age, sex, BMI matched compared rates of death and cause using National Death Index 40% reduction in mortality: 56% reduction from CAD 92% reduction from DM 60% reduction from cancer 58% increase in non-disease deaths after gastric bypass native obese population Prospective, controlled trial 2010 patients underwent bariatric surgery 2037 matched patients underwent conventional Rx Mean 11 years of follow-up 99% of patients were followed Decrease mortality was from decrease in incidence of myocardial infarction and cancer 14

15 Safety Safety: Early Complications Bypass Band Safety: Late Complications 15

16 Bypass stricture of gastrojejunostomy (2-3%) treatment: dilation during endoscopy Band acute pouch outlet obstruction (0-10%) treatment: nasogastric tube marginal ulceration (3-5%) treatment: antacids gallstone disease (2% with prevention) prevention: ursodiol for 6 months treatment: remove gallbladder internal hernias with obstruction (0-5%) treatment: surgery dumping syndrome (0-10%) treatment: limit simple sugars, high protein diet, complex carbs, high fiber, smaller more frequent meals band erosion (0-7%) treatment: surgery to remove band gallstone disease (2% with prevention) prevention: ursodiol for 6 months treatment: remove gallbladder port infection (0.3-9%) treatment: surgery to remove port band slippage (2-14%) treatment: surgery to remove/reposition band port or tubing malfunction (0.4-7%) treatment: surgery to fix malfunction acid reflux or esophageal dilation (0-10%) treatment: antacids or band removal psychological intolerance (0-5%) treatment: removal of band The Future. LATE REOPERATION (5-10%) LATE REOPERATION (12-20%) Surgery for the primary treatment of diabetes?!? Sleeve gastrectomy 16

17 Nutrition after bariatric surgery Nutritional monitoring after bariatric surgery Gastric bypass multivitamin daily omeprazole 20mg daily calcium + D 500mg 3x daily Iron sulfate 325mg daily (women) vitamin B12 500mcg daily LapBand multivitamin daily omeprazole 20mg daily calcium + D 500mg 3x daily GET THESE LABS YEARLY CBC Serum Iron Serum Folate LFTs Albumin Vitamin B12 Serum calcium / vitamin D Electrolytes Cholesterol panel Fasting blood sugar 17

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