Chairman s Rounds, 02/15/2011 Edward Lipkin, MD Associate Professor, Department of Medicine Division of Metabolism, Endocrinology and Nutrition University of Washington
Predictive factors in patient s outcome Positive factors Employed Insured Socially integrated (sings) Able to lose weight volitionally No substance abuse No psychiatric red flags Negative factors Eats in restaurants 3-4 times per week
The horse is already out of the barn. Bariatric Operations in USA have exponentially increased (with some plateauing).
The psychological impact of obesity. Among people who had lost 100 lbs with obesity surgery, rather than be obese again: 100% would prefer to be deaf, dyslexic, diabetic, or have heart disease 92% would prefer to have a leg amputated 89% would prefer to be blind Rand CS et al, Int J Obes 15:577 (1991)
Surgery: Indications (NIH Consensus BMI >40 guidelines) BMI >35 with co-morbid conditions Evaluation by multi-disciplinary team with medical, surgical, psychiatric and nutritional expertise Gastrointestinal surgery for severe obesity. Nutrition. 1996;12(6):397-404.
Surgery: Indications (DSHS, state of Washington) Age twenty-one to fifty-nine; Body mass index (BMI) of thirty-five or greater; Not pregnant. (Pregnancy within the first two years following bariatric surgery is not recommended. When applicable, a family planning consultation is highly recommended prior to bariatric surgery); Diagnosis of one of the following: Diabetes mellitus; Degenerative joint disease of a major weight bearing joint(s) (the client must be a candidate for joint replacement surgery if weight loss is achieved) or; Other rare comorbid conditions (such as pseudo tumor cerebri) in which there is medical evidence that bariatric surgery is medically necessary and that the benefits of bariatric surgery outweigh the risk of surgical mortality and; Absence of other medical conditions such as multiple sclerosis (MS) that would increase the client's risk of surgical mortality or morbidity from bariatric surgery.
The GI tract after Roux-en-Y Gastric Bypass (the most effective surgical option for sustained weight loss) but prone to deficiencies in iron, calcium, vitamin D and B12 L Kaplan
Roux-en-Y Gastric Bypass. The most effective surgical option for sustained weight loss. But prone to deficiencies in iron, calcium, vitamin D and B12. These can be predicted from the altered anatomy. Site of acid production critical for iron and calcium absorption and intrinsic factor. Important in B12 absorption Site of majority of iron and calcium absorption Bile acid influx from biliary system diverted and/or disrupted. Important for fat and fat soluble vitamin absorption L Kaplan
Adjustable Band Gastroplasty. Less successful at sustained longterm weight loss. Less morbidity and mortality and can be done on an outpatient basis. Dietary restrictions can still result in nutrient deficiencies.
Weight loss is required prior to surgery by many third part payers 5% pre-operative weight loss is required of DSHS funded bariatric surgery patient in Washington State Also required is documented involvement in a structured diet/lifestyle modification program
If a surgical option for weight loss is selected, this data on factors predicting positive outcomes directs preoperative management. Positive <40, married female Employed Realistic expectations Nutritional compliance Social supports Higher education Pre-op weight loss Patient knowledge Negative Psychiatric hx Prior bariatric sx Low SES EtOH/ drug use Secondary gain Childhood abuse Poor support Poor knowledge/understanding
Co-morbid conditions of obesity that are positively modified by weight loss Cardiovascular CAD, HTN, CHF, RHF, DVT, PE, CVA Respiratory OSA, asthma, hypoventilation syndrome Endocrine DM2, IR, IFG, IGT, dyslipidemia, PCOS, infertility, hypogonadism Malignancy Breast, colon, pancreas, prostate, uterine Gastrointestinal GERD, NASH, gallstones Musculoskeletal DJD, OA, LBP Genitourinary Incontinence, UTI Skin Venous stasis, cellulitis, panniculitis, skin infections Psychologic/Neurologic Depression, migraine, pseudotumor cerebri
Rapid Improvement of Diabetes After Gastric Bypass. Surgery can be curative. 500 90 units insulin 400 Blood 300 16 Glucose (mg/dl) 200 8 8 4 8 4 0 0 0 insulin 100 0 0 4 8 12 16 20 24 28 Days After Surgery Adapted from Pories W, 1980
Recent randomized trials. Adjustable gastric banding vs conventional therapy for type 2 diabetes- Effect on outcomes at 2 years Dixon JB et al. JAMA. 2008: 229, 316-323. Mean (SD) Between-Group Surgery Conventional Difference, Mean P (n= 30) Therapy (n=30) (95% CI) Value RR for surgical remission Remission of diabetes 22 (73) 4 (13) 5.5 (2.2 to 14.0) <.001 No. (%) Weight change, kg -21.1 (10.9) -1.5 (5.4) -19.6 (-23.8 to -15.2) <.001 Waist Circumference -17.9 (10.8) -4.0 (9.1) -13.9 (-19.0 to -8.7) <.001 change, cm HbA1c % change -1.81 (0.82) -0.38 (1.26) -1.43 (-2.1 to -0.8) <.001 HOMA IR change -45.5 (19.0) -3.3 (35.4) -42.2 (-57 to -26.8) <.001 Triglyceride mg change -71.1 (92.9) -2.1 (120.6) -69.5 (-125.3 to -13.6) 0.02 HDLc mg/dl change 12.6 (9.6) 2.6 (6.1) 10.0 (5.8 to 14.2) <.001
15 Year follow up data from the Swedish Obese Subjects Study Sjostrom L et al. NEJM, 2007: 357: 741-752.
Mortality data from 15 year follow up of the Swedish Obese Subjects Study Sjostrom L et al. NEJM, 2007: 357: 741-752.
Is bariatric surgery cost-effective? That depends.
Complication rates from bariatric surgery
Well defined deficiency syndromes described in post GI restriction and bypass procedures for obesity Common: Bone loss/ osteoporosis Calcium insufficiency Vitamin D deficiency, osteomalacia Gallstones Uncommon Protein deficiency, adult Kwashiorkor Severe wasting, adult Marasmus thiamin deficiency including Weirnicke s encephalopathy B12 deficiency including posterior column degeneration iron deficiency, anemia folate deficiency, anemia vitamin A deficiency, night blindness vitamin E deficiency, posterior column degeneration, neuropathy vitamin C deficiency, adult scurvy vitamin K deficiency, easy bruising
Other syndromes seen in the post GI restriction and bypass procedures for obesity Post ingestion hypoglycemia Neisideroblastosis, insulinomas
Wheresoever you go, go with all your heart. Confucious Chinese philosopher & reformer (551 BC - 479 BC)