Bariatric Surgery Update

Transcription

1 Bariatric Surgery Update Alexander Perez, MD, FACS Professor of Surgery Chief, Division Minimally Invasive and Foregut Surgery

2 Speaker Disclosure Dr. Perez has disclosed that the has no actual or potential conflict of interest in relation to this topic.

3 Learning Objectives By the end of this activity, the participant should be better able to: Discuss how obesity is a chronic disease much like diabetes and hypertension and can be poorly understood. Discuss the complex multifactorial etiology of obesity. Implement a lifelong multidisciplinary team management approach with evolving multimodality therapies including bariatric surgery.

4 Obesity Pandemic Chronic metabolic disease Lifelong multidisciplinary team

5 Pandemic 5 th leading cause of mortality globally 2.8 million deaths per year World Health Organization (WHO). Obesity and Overweight. 2016

6 Obesity in the U.S.

7 Mechanisms, pathophysiology, and management of obesity. N Engl J Med 2017

8 Indications for Surgery BMI 40 BMI 35 with comorbid conditions Gastrointestinal Surgery for Severe Obesity. NIH Consensus Statement 1991

9 BMI = Weight (kg) Height 2 (m 2 )

10 BMI = Weight (kg) Height 2 (m 2 ) Lambert Adolphe Jacques Quetelet

11 Bariatric: Barús, Heavy

12 Metabolic: Metabolikos, Changeable

13 Metabolic Score Individualized Metabolic Surgery Score: Procedure Selection Based on Diabetes Severity. Ann Surg 2017

14 TG LDL T2DM HTN PSYCH GERD Complications

15 Obesity Management Well informed and motivated patient Multidisciplinary team Dietary, exercise, and behavior support Specialized center Lifelong surveillance Gastrointestinal Surgery for Severe Obesity. NIH Consensus Statement 1991

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17 Medicine Surgery Patient Admin Dietician Psychology

18 Surg+Med vs. Med Alone

19 Data Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012 Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med 2012 Roux en Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA 2013 Bariatric Surgery versus Intensive Medical Therapy for Diabetes 5 Year Outcomes. N Engl J Med 2017 Weight and Metabolic Outcomes 12 Years after Gastric Bypass. N Engl J Med 2017

20 Weight Loss 50% 25% 29% 33% 23% 27% Surg + Med Med Alone 0% 5% 5% 5% 1YR 2YR 5YR 12 YR 2%

21 Weight and Metabolic Outcomes 12 Years after Gastric Bypass. N Engl J Med 2017 Weight

22 T2DM Remission 75% 50% 42% 45% 51% Surg + Med 25% Med Alone 0% 0% 2% 5% 1YR 5YR 12 YR

23 HbA1c Decrease Med Alone Surg+Med Bariatric Surgery versus Intensive Medical Therapy for Diabetes 5 Year Outcomes. N Engl J Med 2017

24 HTN Remission 50% 43% 35% 36% 25% Surg + Med Med Alone 11% 10% 0% 0% 1YR 5YR 12 YR

25 Dyslipidemia Remission (12yr) 125% 100% 99% 82% 75% 50% 55% 59% 55% Surg + Med Med Alone 25% 19% 0% HIGH LDL LOW HDL HIGH TG Weight and Metabolic Outcomes 12 Years after Gastric Bypass. N Engl J Med 2017

26 Mortality (12yr) Med Alone Surg + Med Association Between Bariatric Surgery and Long term Survival. JAMA 2015

27 Evolution of Surgery

28 Bariatric surgery for morbid obesity. N Engl J Med 2007 Bypass

29 Bariatric surgery for morbid obesity. N Engl J Med 2007 Band

30 Bariatric surgery for morbid obesity. N Engl J Med 2007 Sleeve

31 Bypass Band Sleeve 2003 American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in 2015 and surgeon workforce in the United States. Surg Obes Relat Dis 2016, Buchwald H, et al. Obesity Surg 2004, 2009, and 2013

32 Bypass Band Sleeve American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in 2015 and surgeon workforce in the United States. Surg Obes Relat Dis 2016, Buchwald H, et al. Obesity Surg 2004, 2009, and 2013

33 Bypass Band Sleeve American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in 2015 and surgeon workforce in the United States. Surg Obes Relat Dis 2016, Buchwald H, et al. Obesity Surg 2004, 2009, and 2013

34 Bypass Band Sleeve American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in 2015 and surgeon workforce in the United States. Surg Obes Relat Dis 2016, Buchwald H, et al. Obesity Surg 2004, 2009, and 2013

35 Bypass vs. Sleeve Laparoscopic Sleeve Gastrectomy Versus Roux Y Gastric Bypass for Morbid Obesity 3 Year Outcomes of the Prospective Randomized Swiss Multicenter Bypass Or Sleeve Study (SM BOSS). Ann Surg 2017

36 Bypass vs. Sleeve Laparoscopic Sleeve Gastrectomy Versus Roux Y Gastric Bypass for Morbid Obesity 3 Year Outcomes of the Prospective Randomized Swiss Multicenter Bypass Or Sleeve Study (SM BOSS). Ann Surg 2017

37 Bypass vs. Sleeve Bariatric Surgery versus Intensive Medical Therapy for Diabetes 5 Year Outcomes. N Engl J Med 2017

38 Complications 14% 12% 10% 8% 6% 4% Bypass Sleeve 2% 0% Any Surgical Complication Infection Hemorrhage Extended Length of Stay ED Visit Roux En Y Gastric Bypass Vs. Sleeve Gastrectomy: Balancing the Risks of Surgery with the Benefits of Weight Loss. Obes Surg 2017 (chart above) Obes Surg 2017

39 Diet After Surgery Liquid diet Dehydration = Readmission 8 glasses daily Lifelong supplements (Vitamin B12, Vitamin D, Calcium, Iron) Protein ( grams/day) Carbohydrate (<50 grams/day)

40 Metabolic > Bariatric Surg+Med > Med Alone Evolution of Surgery Conclusions

41 Thank You