Morbid Obesity The Surgical Approach. Jonathan A. Schoen, M.D. Assistant Professor of Surgery University of Colorado Health Sciences Center

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1 Morbid Obesity The Surgical Approach Jonathan A. Schoen, M.D. Assistant Professor of Surgery University of Colorado Health Sciences Center

2 Today s s Lineup Definition Population Statistics Childhood Obesity Hormones Infectious etiologies of obesity Food Adolescent Bariatrics UCHSC SWLC Video Session

3 Definition of Morbid Obesity ŅA life-long, progressive, life-threatening, genetically-related, costly, multi-factorial disease of [excess fat storage] with multiple co-morbidities (obesity related health condition).ó ASMBS

4 BMI-Associated Disease Risk Classification Class BMI (kg/m 2 ) Risk Normal Waist Circumference Increased Waist Circumference Underweight < Normal Overweight Increased High Obesity I High Very High Severe Obesity II Very high Very high Extreme Obesity III >40 Extremely high Extremely high From: NHLBI 2000 (NIH), Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults. *Normal waist circumference is ² 40 inches for males, ² 35 inches for females.

5 Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14%

6 Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14% 15% 19%

7 Obesity Trends* Among U.S. Adults BRFSS, 2001 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25%

8 Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14 15% 19% 20% 24% 25% 29% 30%

9 Obesity Trends* Among U.S. Adults BRFSS, 2009 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

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12 Childhood Obesity

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24 The likelihood of obesity is 22% lower among children who were breastfed

25 Breast Milk Hormones - Nutritional Programming?? Leptin Adiponectin Ghrelin IGF-1 Resistin Obestatin

26 Leptin QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. Leptos = thin DNA sequence - Friedman 1994 Obese (ob) gene Produced by adipocytes, stomach, placenta, mammary epithelial cells BMI Leptin Anorexigenic

27 Leptin Function

28 Ghrelin Discovered in 1999 Initially as growth hormone secretagogue receptor ligand Produced primarily in stomach fundus Active form requires fatty acid acylation Only orexigenic hormone Preprandial hunger and meal initiation Cummings D. Physiol and Behav

29 Plasma Ghrelin Profile After RYGB NEJM 2002; 346

30 Leptin, Ghrelin and the Arcuate Nucleus

31 Adiponectin Discovered 1995 Secreted exclusively from white adipose Most abundant adipose-specific protein Abundant plasma protein Receptor: Adipo-R1 and Adipo-R2 Multiple circulating isomers BMI Adiponectin Galic, et al. Mol and Cell Endocr 2010

32 Adiponectin

33 Adiponectin Anti-inflammatory Anti-atherosclerotic Anti-cancer Anti-NASH Insulin-sensitizing Cardioprotective 5% weight 20% serum level Mol and Cell Endocr 2010

34 Adipogenesis Adenovirus-36 AD-36 specific antibodies 124 children (14 yo) 19 + (15%) 15/19 (78%) obese Gabbert, et al. Peds Adults AD % obese vs. 11% non-obese Atkinson, et al. Int J Obes 2005

35 Gut Microbiota Bacteroidetes vs. Firmicutes Metagenomics and biochemical analysis Obese = Bacteroidetes Firmicutes Weight Loss = Bacteroidetes level increase Transmissible Trait Nature 2006

36 Top Ten List of High Calorie Fast Foods acaloriecount.com

37 HARDEES

38 Liquid Calories

39 Liquid Calories

40 Liquid Calories

41 Liquid Calories

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43 Restrictive Procedures Sleeve Gastrectomy

44 Combined Restrictive/Malabsorptive Roux-en-Y Gastric Bypass lesser curve 15 cc pouch complete gastric division Antecolic or retrocolic Roux limb: cm 0.8 cm 2.0 cm gastrojejunostomy

45 Malabsorptive Procedures ml 150 ml 200 cm cm 50 cm cm

46 Other Procedures Intragastric Balloon - BIB Gastric Pacer

47 Other Procedures TOGA Endobarrier QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

48 Adolescents: Banding vs. Lifestyle Prospective Randomized Trial 50 pts y.o. BMI > 35 Assigned to supervised lifestyle intervention or gastric banding 24 months O brien, et al. JAMA 2010

49 Banding vs. Lifestyle Community Recruitment - newspaper ads 1st visit - patient info session 2 week food diary + pedometer assignment 2nd visit - 4 weeks later Completion of tasks + clinical assessment 3rd visit - after 2 month lead-in Consent to randomize 7 day cooling-off period Reconfirmation and then computer randomization JAMA 2010

50 Lifestyle Program Reduced energy intake ( kcal/d) >10,000 steps/day 30 minutes scheduled daily exercise Personal trainer x 6 weeks 2 hour computer or t.v. time limit Food diary + step counts monitored Q6 wks JAMA 2010

51 Results 24/25 completed band 18/25 completed lifestyle Initial BMI Kg Lost %EWL BMI units Lost Band Lifestyle JAMA 2010

52 Adverse Events 33% re-operation rate (8/7) Pouch dilation 6(24%) Needle stick tubing injury 2(8%) Cholecystectomy 1(4%) per study arm JAMA 2010

53 Systematic Review and Meta-Analysis of Bariatric Surgery for Pediatric Surgery 163 Citations identified by literature searches Abstracts screened 121 Citations excluded 42 Full articles retrieved Full articles reviewed 15 articles excluded 27 Articles on 18 Studies met inclusion criteria 18 Studies assessed 8 of laparoscopic gastric band 6 of Roux-en-Y Gastric Bypass 3 of VBG Treadwell, et al. Ann Surg 2008

54 Meta-analysis analysis Results Banding [1996] N = 352 Age = 9 -> 20 (16.7) BMI = 42 -> 50.5 (46) Follow-up: 1 -> 3 yrs Bypass [1970s] N = 131 Age = 11 -> 21 (16.8) BMI = 38 -> 95.5 (52) 1/3 laparoscopic Follow-up: 1 -> 6 yrs Ann Surg 2008

55 Meta-analysis analysis Results Ann Surg 2008

56 Complications Bands No mortality 8% Reoperation rate Band slippage most frequent (3%) No data on growth or development Bypass No in-hospital death 4 deaths: 9 mos -> 6 years PE, leak, bleed, obstruction, marginal ulcer, hernia 1 study - no evidence of growth retardation Ann Surg 2008

57 Pediatric LAGB - NYU Experience Time N Age: (15.8) Mean weight Mean BMI %EWL Preoperative / /- 7.0 NA 6 mo y mo y Nadler, et al. J ped surg 2008

58 Pediatric LAGB - NYU Comorbidities: Resolution 68.5% Improved 17.5 Unchanged 10% Worse 4% Complications: 15% Reoperation rate 1 gastric perforation, 6 slips, 3 hiatal hernia J ped surg 2008

59 5 Centers 11 adolescents with T2DM Age 14 -> 21 (17.8) BMI 43 -> 63 (50) 1 year f/u BMI - 34% Fasting Blood Glucose - 41% Fasting Insulin Conc - 81% Hemoglobin A1c 7.3% -> 5.6% Total Cholesterol - 29% Heart Rate - 19% Diastolic B.P % Inge, et al. Peds 2008

60 38 adolescents Age 13 -> 19 (16) LRYGB Echo pre and 10 months post-op Pre-op Post-op BMI LV Mass 54 g/m 42 g/m Concentric LVH 28% 3% Normal LV geometry 36% 79% Ippisch, et al. J Am Coll Cardiol 2008

61 University of Colorado Hospital Surgical Weight Loss Center 7/2004 N = 608 female (86%) Average age = 42 (18 -> 65) Average BMI = 48 (35 -> 83) 4 pts in program BMI 98 -> 113 Average Co-morbidities = 5 28% T2DM 1 pt with T1DM 1 pt with paraplegia

62 UCH - SWLC 486 laparoscopic RYGB 0.3% conversion rate 13 VBG -> RYGB revision 2 proximal -> distal RYGB revision 3 lap bands -> RYGB revision 20 sleeve gastrectomy (3%) 93 lap bands (15%)

63 Complications UCH/SWLC Mortality 0.2 Leak 0.2 Pulmonary Embolism 0.8 DVT 0.5 CVA 0.3 GI Bleed 3.0 Stomal Stenosis 0.8 SBO 1.9 Wound Infection 0.7 Incisional Hernia 0.4 Re-admission 7.9 Re-operation 1.9

64 Perioperative Safety in the Longitudinal Assessment of Bariatric Surgery (LABS) Prospective, multicenter observational study 30-day outcomes in consecutive patients N=4776 RYGB LAGB Mean age Median BMI NEJM 2009;361

65 LABS 30-day Outcomes Outcome Total LAGB LRYGB ORYGB Death 0.3% DVT 0.4% Reintubation 0.4% Endoscopy 1.1% Tracheostomy 0.2% Perc Drain 0.3% Reoperation 2.6% Failure to D/C 0.4% Composite 4.1%

66 LABS Risk Factors Lowest BMI risk = 53 BMI 75 = 61% higher risk OSA Prior DVT/PE Impaired functional status (< 200 ft. walk)

67 Band vs. Bypass Weight Loss 181 matched LAGB vs. LRYGB LAGB LRYGB Time in Months Obes Surg 2006; 16

68 Long-term Weight Loss 984 patients // 8 year follow-up 19% 19% % Obes Surg 2003; 13

69 QuickTime and a DV/DVCPRO - NTSC decompressor are needed to see this picture.

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72 Happy Thanksgiving

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