SURGICAL TREATMENT FOR OBESITY: WHATS THE BEST OPTION? Natan Zundel, MD, FACS
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1 SURGICAL TREATMENT FOR OBESITY: WHATS THE BEST OPTION? Natan Zundel, MD, FACS Professor of Surgery Vice-Chairman Department of Surgery Florida International University Herbert Wertheim College of Medicine Consultant MIS and Bariatric Surgery FSFB,Colombia. Page 1 of 26
2 Page 2 of 26
3 WORLDWIDE OBESITY PROBLEM Worldwatch Institute, Paganelli 2000 China Switzerland Austria Italy Brazil Colombia Gernany UK Russia US 0% 10% 20% 30% 40% 50% 60% 70% % of Overweight Adults Page 3 of 26
4 Page 4 of 26
5 The Obesity Epidemic spreading worldwide Surgery: The Problem? The only treatment option with sustained weight loss in long term follow up studies The only treatment option that achieves long term remission of co morbidities Buchwald H. 2004, Obesity Surgery 14: Therapeutic Options for Metabolic Syndrome -Mediterranean-style diet -Cardiac-prudent diet with a fat intake of <30% of total calories -Rimonabant -Metformin -Rosiglitazone -Gastric bypass -Vertical banded gastroplasty Are there specific treatments for the metabolic syndrome? Giugliano, D. et al. Am J Clin Nutr 2008;87:8-11 Page 5 of 26
6 GROWTH OF BARIATRIC SURGERY NEJM ; Page 6 of 26
7 Why are we doing so many operations? 4 decades of obesity epidemic being ignored Failure of conventional treatments Improved outcomes of surgical procedures Introduction of laparoscopic surgery Buchwald H. 2004, Obesity Surgery 14: Types of Surgeries done in USA ( ) Gastric Bypass 70 % ( 50%) Adjustable Gastric Band 25 % (10%) Vertical Banded (VBG) 2 % (0%) BPD / DS 2.5 % (1.5%) Sleeve Gastrectomy (45-55%) Buchwald H. 2004, Obesity Surgery 4: Page 7 of 26
8 Banding Sleeve Gastrectomy Gastric bypass Your Decision Invasiveness Least Middle Most Excess Weight Loss 40-60% 50-60% 50-70% Rate of Weight Loss Slower Faster Faster Risk of Death Lowest (1/1000) Middle (1/500) Highest (1/100) Complications Occur later Occur early Occur early or late Adjustable Yes No No Reversible Yes No Very difficult Implanted Device Yes No No Hospital Stay <1 day 1 day 2 days Time off work 1 week 1-2 weeks 2 weeks US track record Since 1991 Since ~2000 Since 1960 s Anti Inflammatory OK OK NOT OK Follow up Most frequent Less frequent Less frequent Bariatric Surgery Complication & Mortality Rates Comparable to Common Surgical Procedures (CMS) Page 8 of 26
9 The New England Journal of Medicine 357;8, August 23, 2007, 753 Original Article Long-Term Mortality after Gastric Bypass Surgery Ted D. Adams, Ph.D.,et al Background Although gastric bypass surgery accounts for 80% of bariatric surgery in the United States, Long-Term only limited long-term data Mortality are available on mortality after among Gastric patients who have undergone this procedure compared with severely obese persons from a general population. Bypass Surgery Methods In this retrospective cohort study, we determined the long-term mortality (from 1984 to 2002) among Ted 9949 patients D. Adams, who had undergone Ph.D., gastric bypass surgery and 9628 severely obese persons who applied for driver s licenses. From these subjects, 7925 surgical patients and 7925 severely obese control subjects were matched for age, sex, and body-mass index. We determined the rates of death from any cause and from specific causes with the use of the National Death Index. Results During a mean follow-up of 7.1 years, adjusted long-term mortality from any cause in the surgery 357;8 group decreased, August by 40%, as compared 23, with 2007, that in the control 753group (37.6 vs deaths per 10,000 person-years, P<0.001); cause-specific mortality in the surgery group decreased by 56% for coronary artery disease (2.6 vs. 5.9 per 10,000 person-years, P = 0.006), by Original 92% for diabetes (0.4 Article vs. 3.4 per 10,000 person-years, P = 0.005), and by 60% for cancer (5.5 vs per 10,000 person-years, P<0.001). However, rates of death not caused by disease, such as accidents and suicide, were 58% higher in the surgery group than in the control group (11.1 vs. 6.4 per 10,000 person-years, P = 0.04). Conclusions Long-term total mortality after gastric bypass surgery was significantly reduced, particularly deaths from diabetes, group heart disease, by and cancer. 40 However, %!! the rate of death from causes other than disease was higher in the surgery group than in the control group. The New England Journal of Medicine Decreased mortality in the surgical Comparision of Bariatric Operations Meta-analysis of 136 studies, % Excess Weight Loss n = 22,094 patients Lap Band Gastric Bypass Duodenal Switch/BPD 47.5% 61.6% 70.1% Operative Mortality 0.1% 0.5% 1.1% Resolution of Diabetes 47.8% 83.6% 97.9% Bariatric Surgery. A Systematic Review and Meta-analysis. Buchwald et al. JAMA. 2004;292: Page 9 of 26
10 TWO QUESTIONS: 1. TO THE PATIENT 2. TO MYSELF TWO QUESTIONS: 1. TO THE PATIENT WHAT PROCEDURE DO YOU WANT AND WHY? Page 10 of 26
11 Recent Study of 468 patients demonstrated strong preference for LAGB vs. RYGB 2 RYGB LAGB 1.71M About 3 Million patients are likely to have surgery over the next 5 years. 1 (not reimbursed).75 M.88 M 1.36 Even though there are only half as many patients in the BMI 40 category (12 Million) as in the BMI category (21 Million), more BMI 40 are expected to be treated Jul '05 Jul '05 Jul '05 BMI BMI BMI July 05 study of 468 patients interviewed who were in each of three BMI categories. Data were weighted to assure that the total is representative of the market with respect to BMI, age by sex, presence of significant co-morbidities, household income, race/ethnicity and health insurance. Patients were presented with comprehensive description of each procedure. * p < 0.05 Adjustable Gastric Banding Page 11 of 26
12 Procedure Mortality* Morbidity LAGB 0.05% 11.3% RYGB 0.50% 23.6% VBG 0.31% 25.7% LAGB Safety Chapman, et al. A systematic literature review. Surgery March 2004; 135: World literature review-comparison study 121 studies *LAGB 10 times safer than RYGB, and 6 times safer than VBG Mean EWL% 61.2% for all patients; 47.5% (40.7%-54.2%) LAGB; 61.6% (56.7%-66.5%), RYGB; 70.1% (66.3%-73.9%), BPD. Bariatric Surgery. A Systematic Review and Metaanalysis. Henry Buchwald, MD, PhD. Jama JAMA, October 13, 2004 Vol 292, No Page 12 of 26
13 OUR OUTCOMES OR Early Female time Conversion N Complications Hosp. Reop Follow EWL Autor N (%) BMI (min) (%) (%) Stay (d) (%) Up (%) Zimmermann (0.11) 3 (0.33) y 40 Belachew * (1.1) 2 (0.4) NI 56 5 y 50 Dargent NI NI 4 (0.8) NI mo 65 (2 y) Fielding (0.9) 7 (2.1) y 62 O'Brian (1.8) 12 (4.3) * 4 y 70 Favretti (3.8) NI NI NI Greenstein 250 NI 48.0 NI NI 14 (5.6) NI 5.2 * 5 y 42 Surgical Clinics of North America Volume 81 Number 5 October 2001 OR Early Female time Conversion N Complications Hosp. Reop Follow EWL Autor N (%) BMI (min) (%) (%) Stay (d) (%) Up (%) Zundel First 100 (14%) y 42% Next (0.28%) LAGB Complications Chapman, et al. A systematic literature review. Surgery March 2004; 135: Complication Band displacement Pouch dilatation LAGB (n=8,504) n % Erosion Port dislocation Catheter rupture/ disconnection/leak Infection band/port Page 13 of 26
14 BAND EROSION/MIGRATION/PENETRATION Sleeve Gastrectomy Procedure Page 14 of 26
15 SLEEVE GASTRECTOMY RESULTS SLEEVE GASTRECTOMY RESULTS Page 15 of 26
16 Jossart et al Sleeve Gastrectomy Is considered more invasive than GB Does not have the possibility of restitutio ad integrum. But Cummings DE et al. Physiol Behav 2006, 89:71-84 Himpens J et al. Obes Surg 2006; 16: Page 16 of 26
17 Long Term Complications 1. GERD 2. Gastric atony 3. Weight loss failure 4. Vitamin Deficiency 5. Slippage of the reduced stomach 6. Sleeve dilation 7. Other Page 17 of 26
18 Sleeve vs Traditional Bariatric Procedures (* p vs GBP) VG n=68 Lap Band n=156 GBP n=245 DS n=66 Reoperations 1.5* Major complications Total complications 1.5* 2.6* Readmissions Lee C Presented at the 90 th Annual Clinical Congress Page 18 of 26
19 TWO QUESTIONS: 2. TO MYSELF: WHY I SHOULD NOT DO WHAT THE PATIENT WANTS? LAGB / LSG NO INDICATIONS. WHY IS SO IMPORTANT? Page 19 of 26
20 1. Diabetes??????? 2. Super Super Obese???? 3. Significant Hiatal Hernias??? 4. Sweet Eaters, Greasers?????? 5. GERD / BARRETT S IS THE LSG THE NEXT BAND?? BETTER PATIENT SELECTION LESS WEIGHT LOSS FAILURE LESS MORBIDITY BETTER RESULTS Page 20 of 26
21 ROUX-EN-Y GASTRIC BYPASS LONG TERM PERSISTENT RESULTS pts 93% follow-up %EWL Poiries et al, Ann Surg 1995;222: % DMT2 normal Glucose levels up to 14 years Page 21 of 26
22 Gastric bypass for DMT2 Author Procedure Pories et al 1995 Gastric Bypass 89% Torquati et al 2005 Gastric Bypass 74% Schauer et al 2003 Gastric Bypass 82% Sugerman et al 2003 Gastric Bypass 86% Cohen et al 2006 Gastric Bypass 100% LAGB Vs LSG Vs LRYGB in Special Situations Children and Adolescents Elderly (In the US age greater than 65) As a primary bariatric for a second non-bariatric In low BMI s Transplant Candidates Cirrhotic Patients Extensive gastrointestinal surgery Inflammatory bowel disease Page 22 of 26
23 Data suggest that the morbidity of bariatric operations performed in adolescents is significantly lower when compared to adults. However the Mortality is comparable. Varela JE et al, SOARD 2007 Elderly The clinical benefits of weight loss in elderly patients are often less dramatic than in younger patients AGB or LSG provides a safe alternative to surgical weight loss. LAGB combined with shorter operating times Absorption of vitamins, minerals and medications usually is not affected Page 23 of 26
24 As a primary bariatric for a second non-bariatric procedure Complex oncologic procedures (Szymanski et al. Obes Surg Feb 24) Preoperatively in transplant patients (Koshy et al. Am J Kidney Dis Oct;52(4):e15-7) But Postop Rejection after ( Unes K et al, J Cardivasc Med,Nov 2009) Transplantation Foreign Body Vs Absorption Vs Side effects of medications Vs Anatomic changes Page 24 of 26
25 Transplant Candidates Severe obesity is associated with increased incidence of graft failure Transplant patient frequently require multiple medications, procedures that include malabsorption, interfere with the bioavailability of these drugs Obesity worsens after transplantation Campsen etal. Obes Surg. Dec 2008 LAGB NO INDICATIONS. WHY IS SO IMPORTANT? THE BAND WAS NOT FOR EVERYBODY LIKE THE BYPASS, THE SLEEVE,ETC ARE NOT FOR EVERYBODY Page 25 of 26
26 Diet and exercise Minimally Intraluminal Invasive Devices procedures and procedures Gastric banding Gastric bypass Medications Effectiveness Invasiveness We really need options: 1. For Low BMIs 2. For the Obese population 3. For Revisions 4. More acceptable for patients Page 26 of 26
SURGICAL TREATMENT FOR OBESITY: WHAT S THE BEST OPTION? Natan Zundel, MD, FACS, FASMBS
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