2/10/2014 CARDIOVASCULAR BENEFITS OF BARIATRIC SURGERY. Disclosures. My Background

Transcription

1 CARDIOVASCULAR BENEFITS OF BARIATRIC SURGERY Anthony M Gonzalez, MD, FACS, FASMBS Associate Professor of Surgery, FIU College of Medicine Chief of Surgery, Baptist Hospital of Miami Medical Director Bariatric Surgery, South Miami Hospital Disclosures Intuitive Surgical- Epicenter, Speaker, Proctor Cadence Pharm- Speaker Bureau Ethicon Endo Surg- Speaker, Instructor My Background General, Laparoscopic and Robotic Surgeon University of Miami School of Medicine University of Miami/ Jackson Memorial Hospital Residency Private Practice since 1999 Chief of Surgery of Baptist Hospital of Miami (500 beds) Medical Director of Bariatric Surgery Program at SMH (300 beds) Program Director for MIS/ Bariatric Fellowship 1

2 Obesity Body Mass Index (BMI) Kg/m² is the most widely used measure of obesity due to its low cost and simplicity. Gastroenterol Clin North Am 201 March:30(1):1-7 BMI Chart Obesity Class BMI (Kg/m²) Underweight < 18.5 Normal Overweight Obesity I II Morbid Obesity III 40.0 Bariatric surgery for these groups National Institutes of Health, US Department of Health and Human Services. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda,Md: National Heart, Lung, and Blood Institute; NIH Publication

3 The Epidemic of Obesity and Diabetes OBESITY EPIDEMIC in Men OBESITY EPIDEMIC in Women 3

4 Obesity and related diseases Cardiovascular Endocrine Gastrointestinal and hepatobiliary Genitourinary Vascular system Muskuloskeletal Neurologic and Psychiatric Obstetric and gynecologic Pulmonary Obesity and Cardiovascular adverse outcomes Insulin resistance has been proposed as the potential link between obesity, diabetes, hypertension and cardiovascular risk. metabolic syndrome Obesity cardiomyopathy is the most lethal complication of Obesity. CVD Risk 4

5 Risk of Death & BMI Why does Obesity increase coronary artery disease risk factors? Mechanism involve: Hormonal Prothrombotic Proinflammatory factors Adipocytes are metabolically active cells. Adipocyte hormones and peptides Hormone Action site Effect Leptin RAAS components Adiponectin, prostanglandin and resistin Hypothalamus, to downregulate Neuropeptide Y Decreased hunger Increased physical activity Enhanced thermogenesis Sympathic nervous system Stimulates sympathetic activity resulting in volume retention Increased resting heart rate, cardiac output and blood pressure. Vascular system Vascular system Suggesting a mechanism of obesity-hypertension Role in modulating cardiovascular end organ damage 5

6 Intraabdominal adipocyte Hormones C-reactive protein Tumor necrosis factor α Interleukin 6 Plasminogen activator inhibitor 1 Factor VII, von Willebrand Fibrinogen Action site Vascular system Effect Modify atherosclerotic plaquets Coagulation cascade Favor a prothrombotic state BARIATRIC SURGERY Restrictive Procedures: Adjustable Gastric Band Sleeve Gastrectomy Malabsortive procedure: Biliopancreatic Diversion with Duodenal Switch Malabsortive and Restrictive: Gastric Bypass NIH Consensus Conference 1991 Surgery is the only way to obtain consistent, permanent weight loss for morbidly obese patients Surgery indicated in patients with: BMI of 40 or over BMI of with significant co-morbidity documented dietary attempts ineffective 6

7 FDA approval 2012 Feb 2012 Adjustable Gastric Band Approved for patients with BMI Needs to have a obesity related condition No insurance coverage Bariatric Surgery Indications Restrictive Procedures 7

8 Malabsorbtive Procedures Published Bariatric surgery

9 % EXCESS WEIGHT LOSS PER PROCEDURE % REMISION/IMPROVEMENT OF COMORBIDITIES PER PROCEDURE Post op 34 mo 9

10 What about long term results? More Long Term Results 10

11 LONG TERM CARDIOVASCULAR EVENTS LONG TERM CARDIOVASCULAR EVENTS MI Stroke Long term mortality after gastric bypass surgery Adams Study 11

12 Long term mortality after gastric bypass surgery Adams Study Reduced 40% Reduced 56% Reduced 92% Reduced 60% When matched, surgery group showed a 46% reduction in death rate from any cause 12

13 Bariatric Surgery should be reserved for patients who have severe obesity in whom efforts at medical therapy have failed and an acceptable operative risk is present. Malabsortive procedure mortality is 1% Gastric Bypass and Sleeve Gastrectomy mortality is 0.5% Gastric Band mortality is 0.1% The most clinically relevant impact of surgically induced compared with medically induced weight loss on diabetes mellitus is the ability of the former to completely reverse established diabetes mellitus in a large percentage of subjects OUR PROGRAM 13

14 OUR PROGRAM 3 surgeons 1 clinical Bariatric Fellow (Fellowship Council) Began 1995 Laparoscopic 2000 Robotic 2009 Offer: Roux en-y-gastric Bypass, Sleeve Gastrectomy Adjustable Gastric Band Revisions >300 cases a year Lap vs BaptistHealth Robotic 14

15 Robotic Sleeve Weight Loss Published Robotic Sleeves Baptist Health Robotic Gastric Bypass vs Sleeve Gastrectomy Review in process/ Pending Publication 15

16 Baptist Health Robotic Gastric Bypass vs Sleeve Gastrectomy Review in process/ Pending Publication Baptist Health Robotic Gastric Bypass vs Sleeve Gastrectomy Review in process/ Pending Publication Baptist Health Robotic Gastric Bypass vs Sleeve Gastrectomy Review in process/ Pending Publication 16

17 Conclusions Obesity is on the rise CVD & Death is related to BMI Bariatric surgery has been approved since options exist: Band, Sleeve, & Bypass Short & Long term results show CVD benefits Our program is trying to improve on outcomes Thank You! AnthonyG@BaptistHealth.net 17