Long-Term Follow Up: The Burning Platform

Transcription

1 Long-Term Follow Up: The Burning Platform John Morton, MD, MPH, FACS, FASMBS Chief, Bariatric & Minimally Invasive Surgery Stanford School of Medicine Past-President, American Society of Metabolic and Bariatric Surgery, Chair, Committee on Metabolic and Bariatric Surgery, American College of Surgeons

2 Postsurgical Comorbidity Remission Hypercholesterolemia Hypertension 63% 70% Sleep Apnea 74% Diabetes 82% Schauer, Annals of Surgery, 2000

3 UHC data: In-Hospital Mortality 4.5 Bariatric Surgery In-hospital Mortality by Year (N = 105,287) Deaths per 1, Year Nguyen et al. SOARD 2012

4 The Challenge Long-Term Follow Up Churn Rate National Migration Payor Demands Increase Confidence for Patients Optimize Care for Providers

5 Long Term Weight Loss Trends Sjostrom NEJM, 2004

6 ASMBS Metabolic and Bariatric Surgery Numbers Estimation for Total 158, , , , , , ,000 Sleeve 17.80% 33.00% 42.10% 51.70% 53.61% 58.11% 59.39% RYGB 36.70% 37.50% 34.20% 26.80% 23.02% 18.69% 17.80% Band 35.40% 20.20% 14.00% 9.50% 5.68% 3.39% 2.77% BPD-DS 0.90% 1.00% 1.00% 0.40% 0.60% 0.57% 0.70% Revision 6.00% 6.00% 6.00% 11.50% 13.55% 13.95% 14.14% Other 3.20% 2.30% 2.70% 0.10% 3.19% 2.63% 2.46% Balloons 0.36% 2.66% 2.75%

7 Heterogenity of weight loss RYGB, AGB, and SG patients follow a similar single peak distribution up to 1-year postop. AGB and SG patients experience less predictable and more variable weight loss results at 2- and 3- years after surgery compared to RYGB. A deeper exploration into factors that influence the greater variability in AGB and SG can help improve the counseling given to bariatric patients choosing which procedure can provide the most enduring weight loss.

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9 Heterogenity of weight loss

10 Comorbidity Recurrence Recurrence of diabetes and hypertension ~5 years following weight gain after surgery Yan, Am J Surg, 2008

11 Rationale for Reoperative Bariatric Surgery for Inadequate Weight Loss Morbid obesity is a chronic disease that requires lifetime treatment. As with many other chronic diseases requiring medical or surgical therapy, there will be patients who respond well to an initial therapy and others with only a partial response. There will also be a subset of patients who are nonresponders or have recurrent or persistent disease; these patients may require escalation of therapy or a new treatment modality.

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13 GERD and the Sleeve Create GERD Worse symptoms after sleeve. Lack of gastric compliance. Increased intraluminal pressure. Impair GE junction anatomy. Shape of the superior pouch and the tubular configuration lead to reflux.

14 GERD and the Sleeve Himpens et al Long term results of sleeve showed biphasic pattern: Initially GERD went from 22% at one year, to 3%at 3 years and then back up to 23% at 6 years.

15 Sleeve Course: Revision for Obstruction and GERD GERD and the Sleeve Himpens et al in Long term results of sleeve showed biphasic pattern: Results seem to correlate with weight regain.

16 Long Term Weight Follow-up

17 Defining Weight Follow-up A case is classified as having weight follow-up for a given visit period (30 day, 6 month, 1 year, 2 year, 3 year, etc.) if a weight was recorded on a follow-up form for the given visit period

18 Weight Follow-up Rates: Denominators Number of Cases With Locked Follow-up Period Follow-up Period Procedure 30 Day 6 Month 1 Year 2 Year 3 Year 4 Year BPDDS Band Band Removal Band to Bypass Band to Sleeve Lap Bypass Lap Sleeve Other Revision Total Data Amount 3 years 6 months 3 years 6 months 3 years 6 months 2 years 2 months 1 year 2 months 7 months All listed procedures performed from Jan 1, 2013 June 30, 2016 (3 years, 6 months of data)

19 Weight Follow-up Rates by Procedure Total of 156,335 Sleeve Cases with 2 year form locked, 46,002 (29.4%) had a weight recorded on this form 15-30%

20 Weight Follow-up Rates by Procedure and Year Performed

21 Are patients with 1 year weight follow-up different than patients without? YES Patients who have weight follow-up at 1 year tend to. (1) be older (2) have higher rates of preop comorbidities (3) have higher rates of 30-day postop complications (4) have lower smoking rates Lap Bypass Lap Sleeve Weight Follow-up at 1 year P-Value Weight Follow-up at 1 year P-Value No Yes No Yes N Patient Characteristics (%) Gender <.0001 <.0001 Female Male Hispanic Ethnicity <.0001 <.0001 No Unknown Yes BMI <.0001 <.0001 Less than Age <.0001 <.0001 Less than ASA Class <.0001 < or or Functional Status Dependent Independent Diabetes <.0001 <.0001 Insulin No Non-Insulin Smoker < <.0001 COPD < <.0001 Dialysis PTC < <.0001 Previous Cardiac Surgery <.0001 Hypertension < <.0001 Oxygen Dependent < <.0001 History of PE < <.0001 Sleep Apnea < <.0001 Renal Insufficiency GERD < <.0001 History of MI <.0001 Hyperlipidemia < <.0001 History of DVT < <.0001 Venous Stasis < <.0001 Limited Ambulation <.0001 Therapeutic Anticoagulation < <.0001 Previous Obesity/Foregut Surgery < <.0001 Chronic Steriod Use <.0001 Low Albumin High Albumin Low HCT < <.0001 High HCT < Day Morbidity < <.0001 Note: Many of the associations may be statistically significant, but not necessarily clinically significant

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23 1-5 with 1 low confidence and 5 high confidence Meaningful Health Outcomes Weight, Complications, Diabetes

24 1-5 with 1 low confidence and 5 high confidence Short-term Outcomes 4.23 Mid-term 3.63

25 1-5 with 1 low confidence and 5 high confidence Benefit Outweighs Harm Short Term 3.69 Mid-Term 3.15

26 1-5 with 1 low confidence and 5 high confidence Predictors of Success 2.08

27 ADJUVANT CHEMOTHERAPY Tamoxifen

28 What s Next EMR Patient Reported Outcomes Biometric Scale Telemedicine

29 Thank you John Morton, MD