Obesity and Bariatric Surgery

Transcription

1 Obesity and Bariatric Surgery Disclosure Nothing to disclose Subhashini Ayloo MD, MPH, FACS Associate Professor of Surgery Director of MIS HPB/LT Rutgers, New Jersey Medical School March 24 th, 2017 Overview Background Introduction to Obesity Burden of Obesity Weight loss options Medically Supervised Weight Loss (MSWL) Bariatric Surgery Liver Transplantation in Obese patients Conclusion Measure of obesity = Body Mass Index (BMI) BMI= wt in kg/ht in m 2 Initially used by third payor parties for life expectancy determination Incorporated into mainstream as indices of obesity Acceptable scale but is not a perfect modality BMI Categories BMI Weight Categories < 18.5 Underweight Normal weight Overweight Class I obesity Class II obesity 40 Class III obesity Obesity Trends Among U.S. Adults BRFSS 1990,, 2010, 2015 (BMI 30, or about 30 lbs. overweight for 5 4 person) No Data 10 % 10 14% 15 19% 20 24% 25 29% 30% CDC.gov 1

2 Age adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity & Diabetes trends Obesity (BMI 30 kg/m 2 ) Burden of Obesity No Data < 14.0% 14.0% 17.9% 18.0% 21.9% 22.0% 25.9% > 26.0% Diabetes No Data <4.5% 4.5% 5.9% 6.0% 7.4% 7.5% 8.9% >9.0% Technical Considerations Intraoperative Challenges Intubation Lines placement Positioning Technical Challenges Exposure to vascular and deep organs such as aorta or portal vein or smv Retraction/Bleeding Inadvertent complications Longer operative time Perioperative Considerations Abdominal wall complications Seroma/Hematoma Surgical site Infections Dehiscence Hernias Perioperative Complications Mobility Nursing & Ancillary care Modalities to evaluate for postop complications Psychological Issues Absorption of medications Longer hospitalization Allocation Objective: Quantify association between obesity and access to liver tx Methods: 29,136 pts wait list candidates; adjusted for allocation system/access to healthcare severely obese (BMI: 35 40); Morbidly obese (BMI: 40 60); Reference (BMI: ) Results: Severely Obese (%) Morbidly Obese (%) MELD Exception < 30 < 38 Declined for organs > 10 > 16 Rates of Tx < 11 < 29 Conclusion: Current practice reluctance to transplant obese patients Formal change to our allocation policy Possible strategies Life style changes MSWL Rx with FDA approved weight loss meds Bariatric surgery Prolonged waiting times for liver transplantation in obese patients, Segev DL et al. Annals of Surgery, Vol 248, No. 5, Nov

3 MSWL FDA Approved Medications 1 yr wt change Adverse effects Challenging to loose significant wt loss Unreasonable expectations Ineffective in long term maintenance Wt regain in 2 yrs In summary, MSWL alone is ineffective Other options??? Ave wt loss to % pt 5% loss to Drug Name Ave price/month ($) Common placebo (kg) baseline wt Lipase inhibitor Abdominal pain/discomfort Orlistat oily stool, flatulence, malabsorption of fat soluble vitamins (A,D,E,K) & meds Cyclosporine (CSA), Thyroid Hormone Replacement (THR), anticonvulsion), potentiation of warfarin SSRA Lorcaserin Hypoglycemia, HA, fatigue Sympathomimetic amine anoretic/antiepileptic Paresthesia, xerostomia, combination constipation, HA Phentermine/topiramate Opioid antagonist/aminoketone Nausea, constipation, HA, vomiting antidepressant comb Naltrexone/buproprion Acylated human glucagon like Hypoglycemia, nausea, vomiting, peptide 1 receptor agonist diarrhea, constipation, HA Obesity Liraglutide management for the treatment of type 2 Diabetes. Diabetes Care Volume 40, Supplement 1, Jan 2017 serious Liver failure, oxalate nephropathy Serotonin syndrome or NMS like reactions, suicidal ideation, heart valve disorder (<2.4%), bradycardia Topiramate is teratogenic cleft lip/palate Depression, precipitation of mania, CI in seizure disorder Pancreatitis, CI hx of MTC or MEN2, ARF Categories of Metabolic Surgeries Purely Restrictive Restricts amount of food consumed Adjustable gastric banding/sleeve gastrectomy/intragastric balloons Mostly Restrictive Major component of food restriction with small component of limiting absorption Roux en Y gastric bypass Mostly Malabsorptive Large component of limiting absorption and small component of food restriction Duodenal Switch Estimates of Bariatric Surgery Am J Clin Nutr 1992; 55: of bariatric surgery numbers Metabolic surgeries Standard Procedures Adjustable gastric banding Sleeve gastrectomy Roux en Y gastric bypass Duodenal Switch Revisional procedures Standard Approaches Shift from open to MIS Excellent long term outcomes Maintaining weight loss Improvement/resolution of comorbidities Cost effective Prolongs survival Adjustable Gastric Banding 3

4 Sleeve Gastrectomy Roux en Y gastric bypass Comorbities status after metabolic surgery Fouse & Brethauer. Resolution of comorbidities and impact on longevity following Bariatric and Metabolic surgery. Surg Clin N AM 96 (2016)

5 Conclusions Obesity is a disease Burden of obesity for individual and Health system is enormous Impacts physician in delivering medical and surgical care Healthy life style changes are paramount importance MSWL/wt loss medications fail in long term maintenance of weight Metabolic Surgeries Time tested Effective long term wt loss Cost effective Prolongs Survival Alternate strategy for addressing obesity in transplantation 5