Surgical Therapy for Morbid Obesity. Janeen Jordan, PGY 5 Surgical Grand Rounds April 7, 2008

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1 Surgical Therapy for Morbid Obesity Janeen Jordan, PGY 5 Surgical Grand Rounds April 7, 28

2 Obesity BMI > 3 kg/m 2 Moderate 35-4 kg/m 2 Morbid >4 kg/m BILLION Overweight Adults in the world 63 MILLION in the US 5% Morbidly obese 15, operations yearly

3

4 Leading cause of preventable death Accounts for 112, deaths/year Associated Co-morbidities Hypertension Dyslipidemia Type 2 diabetes CAD CVA Cholelithiasis GERD Steatohepatitis Sleep apnea Hypoventilation Infertility Hernias Venous insufficiency DJD Urinary incontinence Pseudotumor cerebri Depression Increased Cancer Risk Prostate Endometrial Colon Ovarian Postmenopausal breast cancer

5

6 Indications and Contraindications for Bariatric Surgery Indications BMI >4, or BMI >35 with comorbidities Acceptable levels of surgical risk A clear understanding of the surgery and its impact on patient's life Realistic expectations Agreement to long-term follow-up Age years Contraindications Prohibitive surgical risk Indications of lack of compliance with perioperative regimen Uncontrolled alcohol or drug abuse Uncontrolled depression or other mental disorder A lack of family support or significant discord within the family about the planned surgeon BMI, body mass index

7 Treatment Options Non-operative therapy Jejunoileal Bypass Biliopancreatic Diversion and Duodenal Switch Gastric Bypass Vertical Banded Gastroplasty Laprascopic Adjustable Band Others: Balloon, gastric pacing

8 Bariatric Procedures Performed Worldwide Procedure Laparoscopic gastric bypass* Rate Performed 35% Open gastric bypass* 31% Laparoscopic adjustable gastric banding 24% Vertical banded gastroplasty 5% Biliopancreatic diversion/duodenal switch 5% *Includes long-limb gastric bypass. (From Buchwald H, Williams SE. Bariatric surgery worldwide 23. Obes Surg 24;14:1157.)

9 RYGBP as the Gold Standard 1987 Sugerman, et al Ann Surg PRCT RYGBP vs VBG Terminated 9months 2 patients per group

10 Age Male/Female AA/Caucasian % IBW Before Surgery 1yr 2yr 3yr Weight Loss (lbs) 1yr 2yr 3yr % Decrease in wt 1yr 2yr 3yr RYGBP 38 +/- 11 2/18 5/ / / / / / / / / / /- 18 VBGP 38 +/- 9 2/18 1/ / / / / / / / / / /- 1

11 Laparoscopic Roux-En-Y Gastric Bypass: Perioperative Outcomes First Author N BMI (kg/m 2 ) Operative Time Conversion (%) LOS (Day) Follow-up (mo) (mo) (%) de la Torre (3) DeMaria (12) Higa (12) Luján (18) Matthews (12) Nguyen (12) Papsavas (18) Schauer (3) Wittgrove >75 (6) Westling (12)

12 Laparoscopic Gastric Bypass: Complications First Author Leak Rate (%) DVT/PE (%) Bleed Stenosis (%) (%) Bowel Obstruction (%) Wound Infection (%) Pulmonary Complication (%) Internal Marginal Gastric Hernia (%) Ulcer (%) Perf (%) Mortality (%) DeMaria / Higa 2 2.2/ Luján Nguyen / Papsavas / Schauer / Wittgrove Westling 21 / % <1% 2.4% 4.7% 6.4% 3.2% 1.8% 2.% 3.5%.4% 1.4%

13 Outcomes after Laparoscopic Roux-en-Y Gastric Bypass Excess weight loss 65 8% Resolution of comorbidities Diabetes 82 98% Hypertension 52 92% Hypercholesterolemia 63% Metabolic syndrome 9% NAFLD inflammation/fibrosis* 37%/2% Gastroesophageal reflux 72 98% Sleep apnea 74 98% Degenerative joint disease 41 76% Migraines 57% Pseudotumor cerebri 96% Depression 55% Venous stasis disease 95% Polycystic ovarian syndrome 79 1% Urinary incontinence 44 88% NAFLD, nonalcoholic fatty liver disease; *9% improvement in steatosis.

14 Bariatric Procedures and Comorbidity Outcome 24 JAMA Buchwald, et al Meta-analysis 199 to studies 22,94 patients Impact of bariatric surgery on Diabetes Hyperlipidemia OSA Hypertension

15 Outcomes Following Bariatric Surgery Gastric Banding Gastrop lasty Gastric Bypass Duodenal Switch Excess weight loss 47.5% 68.2% 61.6% 7.1% Full resolution of diabetes 47.8% 68.2% 83.8% 97.9% Operative mortality 3 days.1%.1%.5% 1.1% Buchwald, et al. JAMA 24(292):1724

16 JAMA 24

17 Lap-Band Spivak, et al 25 Am J Surg Retrospective 5 patients Mean weight 123kg Mean BMI 45.2 kg/m 2 39., 36.9, , 45, 47% EBW

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19 Complications related to Laparoscopic Gastric Band First Author Nausea, Vomit (%) Prolapse Obstruction Esophageal (%) (%) Dilation (%) Erosion (%) Conversion to Open (%) Infection (%) Revision of Band (%) Removal (%) Death (%) Fielding Weiner FDA A Trial DeMaria O'Brien Cadiere Favretti Rubenstein Angrisani % 29.3% 5.4% 3% 1.1% 2.2% 4.6% 4.9% 11%.15%

20 LapBand 28 Surgery Dallal 186 patients 3% patients lost <25% EBW, 69% lost <5% 33% reoperation rate NO protocol for adjustments 27 Am J Surg Martin 485 devices 33% had devices removed 27 J Ped Gastenterol and Nutrit Dillard 24 adolescents Op time & complication rate same Only 2 patients followed at 4yrs 3 4 % EBW lost (BMI 38) 27 J Ped Surg Nadler 73 adolescents (13-17yrs) 15% overall complication rate 12% reoperation rate

21 Summary Obesity is an epidemic Surgical therapy is required for morbid obesity Surgical therapy should be tailored to patient RYGBP is the gold standard More weight lost Increased resolution of associated comorbidities Improving technology, technique and complication Laparoscopic bands are less effective

22 I saw an angel in the marble and carved until I set him free. I saw an angel in the marble and carved until I set him free. --Michaelangelo

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