Metabolic Surgery Update

Transcription

1 Metabolic Surgery Update SURGICAL TREATMENTS FOR OBESITY I Dr. Tim Christopher

2 CVSG Cahaba Valley Surgical Group

3 SURGICAL TREATMENTS FOR OBESITY I Dr. Tim Christopher

4 SURGICAL TREATMENTS FOR OBESITY I Dr. Tim Christopher

5 SURGICAL TREATMENTS FOR OBESITY I Dr. Tim Christopher

6 SURGICAL TREATMENTS FOR OBESITY I Dr. Tim Christopher

7 SURGICAL TREATMENTS FOR OBESITY I Dr. Tim Christopher

8 SURGICAL TREATMENTS FOR OBESITY I Dr. Tim Christopher

9 What is obesity? Why does it matter?

10 Obesity is a disease in which fat has accumulated to the extent that health is impaired. It is also multi-factorial (many different factors can cause obesity) life-long progressive potentially life-threatening costly American Obesity Association. Fact Sheet: Obesity in the U.S. May 2, SURGICAL TREATMENTS FOR OBESITY I

11 Obesity is a complex, multi-factorial, chronic metabolic disease Obesity involves the following factors: Genetic Metabolic Environmental Physiological Behavioral Psychological American Obesity Association. Fact Sheet: Obesity in the U.S. May 2,

12 Obesity : Feeding the epidemic SURGICAL TREATMENTS FOR OBESITY I Dr. Tim Christopher

13 A contributing factor to obesity is the body s metabolic set point Sumithran P, Prendergast, LA, Delbridge E, et al. Long-term persistence of hormonal adaptations to weight loss. N Engl J Med. 2011; 365:

14 Laurel (Leptin) and Hardy (Grehlin) SURGICAL TREATMENTS FOR OBESITY I Dr. Tim Christopher

15 SURGICAL TREATMENTS FOR OBESITY I Dr. Tim Christopher

16 SURGICAL TREATMENTS FOR OBESITY I Dr. John Doe, M.D. I November 24, 2008

17 SURGICAL TREATMENTS FOR OBESITY I Dr. Tim Christopher

18 SURGICAL TREATMENTS FOR OBESITY I Dr. Tim Christopher

19 SURGICAL TREATMENTS FOR OBESITY I Dr. Tim Christopher

20 How do we measure obesity? According to the National Institute of Health Body Mass Index (BMI) is a measure of body fat based on height and weight that applies to both adult men and women Classification BMI Health Risk BMI Indicators Normal Overweight Mild Obesity (class I) Moderate Obesity (class II) Severe Extreme Obesity (class III) 40+ Very Severe NHLBI. Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults. October

21 If your overweight, your not alone Approximately 70% of adults are overweight or obese million Americans - 75% male, 60% female Non Hispanic Black 48.1% Hispanic 42.5 % Non Hispanic White 34.5% Asian 11.7 % 17% of children (2-19 years old) are obese % of adults are extremely obese (BMI 40) % increase since National Center for Health Statistics. Health, United States, 2011: With special feature on socioeconomic status and health Ogden C, Carroll MD. Prevalence of high body mass index in US children and adolescents, JAMA 2010; 303(3): Finkelstein, EA, Trogdon, JG, Cohen, JW, and Dietz W. Annual medical September spending 26, attributable 2008 to obesity: Payer- and service-specific estimates. Health Affairs 2009; 28(5): w822-w Allison DB, Fontaine KR, Manson JE, Stevens J, VanItallie TB. Annual deaths attributable to obesity in the United States. JAMA. 1999;282: [PubMed]

22 Obesity Epidemic Percent Obese (BMI 30) Centers for Disease Control. Adult Obesity Prevalence Maps. Downloaded Nov 20, 2012 from

23 Obesity Epidemic Percent Obese (BMI 30) Centers for Disease Control. Adult Obesity Prevalence Maps. Downloaded Nov 20, 2012 from

24 Obesity Epidemic Percent Obese (BMI 30) Centers for Disease Control. Adult Obesity Prevalence Maps. Downloaded Nov 20, 2012 from

25 Obesity Epidemic Percent Obese (BMI 30) Centers for Disease Control. Adult Obesity Prevalence Maps. Downloaded Nov 20, 2012 from

26 Obesity Epidemic SURGICAL TREATMENTS FOR OBESITY I Dr. Tim Christopher

27 What s the cost? Total medical costs for obesity in 2008 was $147 billion. 1 Obese spend 42% more on direct healthcare cost compared to healthy weight individuals Obesity-related absenteeism cost US companies $73 billion Each BMI point > normal = ~ $200 / year/ employee normal-weight employees cost on average $3,838/year in health care costs overweight to morbidly obese employees cost between $4,252 and $8, Finkelstein, EA, Trogdon, JG, Cohen, JW, and Dietz W. Annual medical spending attributable to obesity: Payer- and service-specific estimates. Health Affairs 2009; 28(5): w822-w Allison DB, Fontaine KR, Manson JE, Stevens J, VanItallie TB. Annual September deaths attributable 26, 2008to obesity in the United States. JAMA. 1999;282: [PubMed] SURGICAL TREATMENTS FOR OBESITY I Dr. John Doe, M.D. I November 24, 2008

28 Medical visits and costs go up as BMI goes up % Increase in Utilization 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% BMI (Class I Obesity) BMI > 35 (Class II & III Obesity) Utilization rates as a proportion compared to normal or underweight persons (BMI<25). Quesenberry CP, Caan B, Jacobson A. Obesity, health services use, and health care costs among members of a health maintenance organization. Arch Intern Med 1998;158(5):

29 What s the cost? 300,000 obesity-related deaths occur annually. Second leading cause of preventable deaths in the US Elevated Cardiac Risk Elevated Risk of Cancer Endometrial Colon/rectal Esophageal Kidney Pancreas Post menopausal Breast 1. Finkelstein, EA, Trogdon, JG, Cohen, JW, and Dietz W. Annual medical spending attributable to obesity: Payer- and service-specific estimates. Health Affairs 2009; 28(5): w822-w Allison DB, Fontaine KR, Manson JE, Stevens J, VanItallie TB. Annual September deaths attributable 26, 2008to obesity in the United States. JAMA. 1999;282: [PubMed] SURGICAL TREATMENTS FOR OBESITY I Dr. Tim Christopher

30 High BMI can decrease life expectancy Relative risk of mortality reduced by 89% in a five year period Years of Life Lost Age 20 Age 30 Age 40 Age Body Mass Index 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): Fontaine KR, Redden DT, Wang C et al. Years of life lost due to obesity. JAMA 2003; 289:187. Graph represents years of life lost for white women.

31 Health conditions related to obesity Pulmonary disease abnormal PFTs obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Gallbladder disease Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome stress incontinence References at end of presentation Osteoarthritis Skin Gout Depression Stroke GERD Cardio/Metabolic Syndrome diabetes dyslipidemia hypertension metabolic syndrome Severe pancreatitis Cancer breast, uterus, cervix, colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis Premature Death

32 Physical and Psychological Obstacles

33 Options and expectations Treatment Excess Weight Loss 3 Years Excess Weight Loss 5 Years Diet / Behavior %* + 1.6%** Drug therapy 2 11%* No data Gastric bypass surgery 3,4 71% 93% Adjustable gastric banding 5,6 41% 59% Sleeve gastrectomy 7,8 66% 60% * Average weight loss, 2 years ** Average weight loss, 10 years Values in parentheses indicate weight gain. Full list of references at end of presentation.

34 What are the surgical options?

35 Obesity and Bariatric Surgery

36 What s in a Name? Surgical evolution incisional, extirpative, and reparative organ specific infection/cancer/trauma/malfunction Metabolic Surgery Richard Varco/Buchwald operative manipulation of normal organ or system to achieve a biologic result for potential health gain

37 Algorithm for the treatment of T2D, as recommended by DSS-II voting delegates 2016 by American Diabetes Association Francesco Rubino September et al. Dia Care 26, 2016;39:

38 Who is a candidate for bariatric surgery? BMI >35 with co-morbidities (obesity related diseases) or >40 without* Healthy enough to undergo a major operation Failed attempts at medical weight loss Absence of drug and alcohol problems No uncontrolled psychological conditions Consensus by multi-disciplinary team Understands surgery and risks Must be dedicated to a lifestyle change and lifetime follow-ups National Institutes of Health. The practical guide: Identification, evaluation, and treatment of overweight and obesity in adults. NIH Publication Number ; Only a patient and their physician can determine if surgery is right for them. All treatment options should be discussed with health care professionals.

39 History and Options for Bariatric Surgery

40 Orbera - Intragastric Balloon

41 Roux en Y Gastric Bypass

42 Risk and Benefits Associated with Gastric Bypass Procedure: Combined Restrictive/Malabsorptive Benefits: 71% excess weight loss after 3 years years maintain 60% EWL 96% resolution of associated comorbid diseases Risks: Anastomotic leak, stricture of anastomosis, ulcer formation Bowel obstruction internal hernia, afferent loop obstruction Dumping Syndrome Bypass portion of stomach and duodenum not accessible Malabsorptive/Nutritional deficiency Fe, B12, Ca

43 Sleeve Gastrectomy

44 Vertical sleeve gastrectomy Laparoscopic Mean excess weight loss at 3 years of 66% 1 No implanted medical device Weight loss and improvement in metabolic parameters are connected with the resection of the stomach and subsequent neurohormonal changes. 1. Fischer L, Hildebrandt C, Bruckner T, et al. Excessive weight loss after sleeve gastrectomy: a systematic review. Obes Surg May; 22(5):

45 What are the risks and complications of a vertical sleeve gastrectomy? Gastric leak Intra-abdominal abscess Splenic injury Stricture Late cholelithiasis General Operative risk Note: Your weight, age and medical history play a significant role in determining your specific risks. Your surgeon can inform you about your specific risks for bariatric surgery.

46 What can you expect after sleeve gastrectomy or gastric bypass? Recovery Most procedures will require overnight stay, but some may be able to performed in outpatient setting Liquid diet initially with slow advance to a soft diet in 1-2 weeks Sleeve or pouch size approximately 3 oz. Estimate off work 2-3 weeks but may be able to return to low impact setting in 1 week Wound care: laparoscopic incisions; shower post op day one Walking daily; avoid heavy lifting or straining for 2 weeks Follow up 1-2 weeks for post op check Every 3 months for first year Annual visit for 5 years with lab evaluation Weight loss Averages pounds at 3 months pounds at a year

47 Resolving your obesity related health conditions Obstructive sleep apnea 45% to 76% resolved Asthma 39% improved Depression* 47% reduced Migraines* 46% improved Type 2 diabetes 45% to 68% resolved High blood pressure 42% to 66% resolved Urinary stress incontinence* 50% resolved Nonalcoholic fatty liver disease 37% resolution of steatosis Osteoarthritis*/ Degenerative joint disease 41% resolved References at end of presentation. * Study population predominantly female. SURGICAL TREATMENTS FOR OBESITY I Cahaba Valley Group, PC

48 Patients Results

49 Our Patients Results

50 Our Patients Results

51 Our Patients Results * * 1/287/16 weight

52 Surgery can change lives Improves or resolves obesity related diseases Decreases mortality risk Reduces healthcare utilization and direct healthcare costs BUT surgery is a tool that requires commitment to a lifestyle change to meet long term goals 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):

53 What are the next steps?

54 What are the next steps? Contact Coordinator and/or Attend a seminar Schedule initial consultation with surgeon Verify benefits and obtain insurance authorization Psychological evaluation Nutritional evaluation & counseling with one of our dieticians Pre-operative testing Surgery Lifelong follow-up appointments and support groups

55 Insurance Requirements for approval depend on your policy Most Require: BMI >40 or >35 with significant co-morbidities Documented history of medical weight loss attempts (3-6 months) 5 year weight history Psychological evaluation Nutrition counseling We are here to help you! We will Verify your benefits to ensure coverage Review your specific plan requirements with you at your 1 st visit Submit your documentation for insurance approval for surgery Provide examples of documentation required by insurance However patients active involvement is very helpful in moving the process along

56 Contact Shelby Coordinator: Kaye O neil: CVSG Office : Cahabavalleysurgical.com to access patient information and forms.

57 Questions????

58 References for Many serious health conditions are related to obesity 1. Calle EE, Rodriguez C, Walker-Thurmond K. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of adults. NEJM 2003; 348(17): Koenig SM. Pulmonary complications of obesity. Am J Med Sci2001; 321(4): Mattar SG, Velcu LM, Rabinovitz M, et al. Surgically-induced weight loss significantly improves nonalcoholic fatty liver disease and the metabolic syndrome. Annals of Surgery 2005; 242(4): National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. 1998; NIH Publication No The Obesity Society. What is Obesity. Accessed May 19, 2010 from 6. Sugerman HJ, Sugerman EL, Wolfe L, et al. Risks and benefits of gastric bypass in morbidly obese patients with severe venous stasis disease. Annals of Surgery 2001; 234(1): Yosipovitch G, DeVore A, Dawn A. Obesity and the skin: Skin physiology and skin manifestations of obesity. J Am Acad Dermatol 2007; 56:

59 References for Setting your expectations 1. Sjostrom L, Lindroos A, Peltonen M et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. NEJM 2004; 351: Garvey WT, Ryan DH, Look M et al. Two-year sustained weight loss and metabolic benefits with controlled-release phentermine/topiramate in obese and overweight adults (SEQUEL): a randomized, placebo-controlled, phase 3 extension study. Am J Clin Nutr, 2012; 95(2): O Brien PE, McPhail T, Chaston TB, et al. Systematic review of medium-term weight loss after bariatric operations. Obes Surg. 2006; 16(8): Boza C, Gamboa C, Awruch D et al. Laparoscopic Roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding: five years of follow-up. Surg Obes Relat Dis 2010; 6(5): Phillips E, Ponce J, Cunneen SA, et al. Safety and effectiveness of REALIZE adjustable gastric band: 3-year prospective study in the United States. Surg Obes Rel Dis. 2009; 5: Boza C, Gamboa C, Perez G et al. Laparoscopic adjustable gastric banding (LAGB): surgical results and 5-year follow-up. Surg Endosc 2011; 25(1): Fischer L, Hildebrandt C, Bruckner T, Kenngott H, Linke GR, Gehrig T, Büchler MW, Müller-Stich BP. Excessive weight loss after sleeve gastrectomy: a systematic review. Obes Surg May;22(5): Deitel M, Gagner M, Erickson AL, Crosby RD, Third International Summit: Current status of sleeve gastrectomy. Surg Obes Relat Dis 2011; 7(6): Tice JA, Karliner L, Walsh J, et al. Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. Am J Med Oct;121(10): Cottam D, Qureshi FG, Mattar SG et al. Laparoscopic sleeve gastrectomy as an initial weight loss procedure for high-risk patients with morbid obesity. Surg Endosc 2006; 20:

60 References for Resolving your obesity related health conditions OSA: Tice JA, Karliner L, Walsh J, et al. Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. Am J Med Oct;121(10): Asthma: Reddy RC, Baptist AP, Fan Z, et al. The effects of bariatric surgery on asthma severity. Obes Surg Feb;21(2): Urinary stress incontinence: Kuruba R, Almahmeed T, Martinez F, et al. Bariatric surgery improves urinary incontinence in morbidly obese individuals. Surg Obes Relat Dis Nov-Dec;3(6): Osteoarthritis & Depression: Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg Oct;232(4): Migraines: Bond DS, Vithiananthan S, Nash JM, et al. Improvement of migraine headaches in severely obese patients after bariatric surgery. Neurology Mar 29;76(13): Type 2 Diabetes: Schauer PR, Sangeeta KR, Wolski K et al. Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes. The New England Journal of Medicine 2012; 366(17): ; Adams TD, Davidson LE, Litwen SE et al.health Benefits of Gastric Bypass Surgery After 6 Years. JAMA 2012; 308(11): ; Mingrone G, Panunzi S, De Gaetano A et al. Bariatric Surgery versus Conventional Medical Therapy for Type 2 Diabetes. The New England Journal of Medicine 2012; 366(17): ; Dorman RB, Serrot FJ, Miller CJ et al. Case Matched Outcomes in Bariatric Surgery Treatment of Type 2 Diabetes in Morbidly Obese Patient. Ann Surg 2012; 255: ; Tice JA, Karliner L, Walsh J et al. Gastric Banding or Bypass? A Systematic Review Comparing the Two Most Popular Bariatric Procedures. The American Journal of Medicine 2008: 121(10): ; Buchwald H, Avidor Y, Braunwald E et al. Bariatric Surgery: A Systematic Review and Meta Analysis. JAMA 2004; 292: Wong SKH, Kong APS, So WY et al. Use of laparoscopic sleeve gastrectomy and adjustable gastric banding for suboptimally controlled diabetes in Hong Kong. Diabetes, Obesity and Metabolism 2011; 14(4): ; Brethauer SA, Hammel JP Schauer PR et al. Review of sleeve gastrectomy as staging and primary bariatric procedure. Surgery for Obesity and Related Disease 2009; 5: Hypertension: Tice JA, Karliner L, Walsh J, et al. Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. Am J Med Oct;121(10): and EES analysis of data from US Clinical Trial PMA NAFLD: Mattar SG, Velcu LM, Rabinovitz M, et al. Surgically-induced weight loss significantly improves nonalcoholic fatty liver disease and the metabolic syndrome. Ann September Surg , Oct;242(4):