10/29/2011. Metabolic, Obstetric, and Gynecological Consequences of Bariatric Surgery. Case Presentation: Rachelle. Jonathan Carter, MD

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1 Metabolic, Obstetric, and Gynecological Consequences of Bariatric Surgery 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 No disclosures Case Presentation: Rachelle Case Presentation: Rachelle Intervention: LRYGB 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 LapBand anatomy (a.k.a. gastric banding) Sleeve gastrectomy Annals of Surgery,

10 Metabolic benefits of bariatric surgery courtesy of ASMBS 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 10

11 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 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 11

12 systolic BP 50% of the morbidly obese have HTN Bariatric surgery and comorbidity resolution About 40% of those on antihypertensives will be able to wean off medications completely. About 50% of undiagnosed hypertensives will resolve completely. diastolic BP BMI courtesy of ASMBS About 70% of morbidly obese patients have sleep apnea. Bariatric surgery About 90% will come off CPAP completely and comorbidity resolution Apnea-hypopnea index oxygen saturation sleepiness courtesy of ASMBS 12

13 Bariatric surgery and comorbidity resolution 1 year after RYGB 2 years after RYGB RYGB dropped percentage of dyslipidemic patients from 95% to 28% Number taking medication dropped to 15% courtesy of ASMBS CANCER INCIDENCE Lancet July, 2009 Retrospective cohort study after gastric bypass Bariatric surgery reduces risk of: colon cancer endometrial cancer breast cancer prostate cancer ovarian cancer obese controls surgery 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 native obese population 58% increase in non-disease deaths 13

14 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 Safety: Early Complications Bypass Band Safety: Late Complications 14

15 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 LATE REOPERATION (5-10%) LATE REOPERATION (12-20%) Outcome Effect Sources Fertility anovulatory infertility (odds ratio 2-3) Miscarriage success with in-vitro fertilization no clear effect Thrombosis rate of PE, DVT (odds ratio 2) Gestational Diabetes Pregnancyinduced hypertension with odds ratio 2-5 with odds ratio 2 (CI ) Preeclampsia with odds ratio 2.7 (CI ) Green 1988, Grodstein 1994, Metwally 2007 Linstein 2005, Fedorcsak Wan 2002, Lashen 2004, Weiss 2004 Abdollahi 2003 Sebire 2001, Kumari 2001 Sattar 2001 Sattar 2001 Outcome Effect Sources Postpartum risk of hemorrhage risk of genital tract infection risk of wound complications Stillborns risk by factor of Preterm delivery Neural tube defects Obesity and Pregnancy no clear effect with odds ratio 1.8 (CI ) Omphalocele with odds ratio 3.3 (CI ) Sebire 2001 Nohr 2005 Spinillo 1998 Waller 1994 Watkins 2003 Labor 50% increase in fetal distress, C-section rate is 2x Bianco 1998 Weiss 2004 Macrosomia with odds ratio 2.1 (CI ) (independent effect of diabetes) Battacharya

16 Outcome Effect Sources Fertility menstrual regularity in 3 of 4 women with restoration of ovulation PCOS symptoms (less hirsuitism, blood testosterone, DHEA) overall fertility Pregnancy preeclampsia, eclampsia (OR 0.2) Perinatal outcomes Effects of bariatric surgery hypertension (OR 0.39) gestational diabetes (OR 0.6) no good data Birth Weight macrosomia 7.6% to 3.2% Nelson 2007 Escobar 2005 Maggard 2008 Bilenka 1995 Bennett 2010 Wittgrove 1998 Weintraub 2008 Premature birth or miscarriage increased, RR 1.30 McDonald 2010 Neonatal Outcomes after Bariatric Surgery Nutritional Outcomes for Pregnancy after Bariatric Surgery 16

17 Nutrition for pregnancy after bariatric surgery Before pregnancy While pregnant 2 prenatal MVIs daily 2 prenatal MVIs daily omeprazole 20mg daily calcium + D 500mg 3x daily Iron sulfate 325mg + vitamin C 500mg daily vitamin B12 500mcg daily omeprazole 20mg daily calcium + D 500mg 3x daily Iron sulfate 325mg + vitamin C 500mg daily vitamin B12 500mcg daily Weight gain goal: lbs, mostly in 3 rd trimester. Protein shakes if needed. No specific imaging needed Labs: yearly folate, iron, B12, LFTs, albumin, Ca, glu Labs: monthly folate, iron, B12, Ca, albumin, prealbumin (may be overkill) 17

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