11/11/2011. Bariatric Surgery for Sleep Apnea. Case Presentation: Rachelle. Case Presentation: Rachelle. Case Presentation: Rachelle

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1 Bariatric Surgery for Sleep Apnea 2,000 B.C. 2,000 A.D. 35 year-old woman with morbid obesity lbs BMI 44.5 PMHx: mild depression obstructive sleep apnea (AHI 42, on CPAP) asthma polycystic ovarian syndrome gastroesophageal reflux disease Diet attempts: Weight Watchers Atkins HerbaLife South Beach Jonathan Carter, MD No disclosures Intervention: Laparoscopic gastric bypass Weight versus time weight (pounds) time (months) PMHx: mild depression RESOLVED obstructive sleep apnea (AHI 42, on CPAP) RESOLVED asthma RESOLVED polycystic ovarian syndrome NO MEDS gastroesophageal reflux disease RESOLVED 1

2 Why is obesity bad? Mechanick et al. SOARD 2008 Obesity reduces life expectancy INDICATIONS FOR BARIATRIC SURGERY For young men, BMI >45 took off 13 years of life expectancy Definition BMI Normal < 25 Overweight Obese, class For young women, BMI >45 took off 8 years of life expectancy Obese, class Obese, class Superobese 60+ with co-morbidity SURGERY 2

3 GHRELIN Gastric bypass anatomy Cummings, NEJM 2002 Annals of Surgery, 2000 Change in BMI after gastric bypass Change in weight (%) BMI Years time 3

4 diabetic <5 years diabetic 6-10 years diabetic >10 years diet controlled diabetics oral agent diabetics insulin dependent diabetics Bariatric surgery and comorbidity resolution HbA1C (%) impaired fasting glucose courtesy of ASMBS Prospective, controlled trial 2010 patients underwent bariatric surgery 2037 matched patients underwent conventional Rx Mean 11 years of follow-up 99% of patients were followed 1 year after RYGB 2 years after RYGB RYGB dropped percentage of dyslipidemic patients from 95% to 28% Decrease mortality was from decrease in incidence of myocardial infarction and cancer Number taking medication dropped to 15% 4

5 Bariatric surgery and comorbidity resolution courtesy of ASMBS Multiple pathways of relatedness: Intermittent hypoxia increases liver triglycerides in mice -> fatty liver Sleep deprivation inhibits leptin (satiety) by 18%, increases ghrelin (hunger) by 28% Chronic OSA raises overall leptin levels -> leptin desensitization in hypothalamus -> obesity How well do diets treat OSA? 5

6 Review of 56 OSA patients who underwent gastric bypass. 29 (52%) were on CPAP preop All were off CPAP by 9 months Mean excess weight loss wass 73% at 12 months Complications Early complications after bariatric surgery 6

7 Bypass stricture of gastrojejunostomy (2-3%) treatment: dilation during endoscopy marginal ulceration (3-5%) treatment: antacids gallstone disease (2% with prevention) prevention: ursodiol for 6 months treatment: remove gallbladder internal hernias with obstruction (0-5%) treatment: surgery dumping syndrome (0-10%) treatment: limit simple sugars, high protein diet, complex carbs, high fiber, smaller more frequent meals Band acute pouch outlet obstruction (0-10%) treatment: nasogastric tube band erosion (0-7%) treatment: surgery to remove band gallstone disease (2% with prevention) prevention: ursodiol for 6 months treatment: remove gallbladder port infection (0.3-9%) treatment: surgery to remove port band slippage (2-14%) treatment: surgery to remove/reposition band port or tubing malfunction (0.4-7%) treatment: surgery to fix malfunction acid reflux or esophageal dilation (0-10%) treatment: antacids or band removal Bariatric surgery is highly effective for weight loss. The effect is durable in the long run. The metabolic benefits of bariatric surgery are even greater than the weight loss benefits. OSA is dramatically improved in most, (but not all) patients after bariatric surgery. The operations are now highly refined and safe. There is survival benefit after just 2 years. CONCLUSIONS psychological intolerance (0-5%) treatment: removal of band LATE REOPERATION (5-10%) LATE REOPERATION (up to 50%) Consider referral for bariatric surgery in OSA patients when the BMI > 35. 7

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