Long-Term Follow Up: The Burning Platform John Morton, MD, MPH, FACS, FASMBS Chief, Bariatric & Minimally Invasive Surgery Stanford School of Medicine Past-President, American Society of Metabolic and Bariatric Surgery, 2014-2015 Chair, Committee on Metabolic and Bariatric Surgery, American College of Surgeons
Postsurgical Comorbidity Remission Hypercholesterolemia Hypertension 63% 70% Sleep Apnea 74% Diabetes 82% Schauer, Annals of Surgery, 2000
UHC data: In-Hospital Mortality 4.5 Bariatric Surgery In-hospital Mortality by Year 2002-2009 (N = 105,287) 4.0 4.0 3.5 Deaths per 1,000 3.0 2.5 2.0 1.5 2.6 2.3 1.6 1.5 1.0 1.0 0.8 0.6 0.5 0.0 2002 2003 2004 2005 2006 2007 2008 2009 Year Nguyen et al. SOARD 2012
The Challenge Long-Term Follow Up Churn Rate National Migration Payor Demands Increase Confidence for Patients Optimize Care for Providers
Long Term Weight Loss Trends Sjostrom NEJM, 2004
ASMBS Metabolic and Bariatric Surgery Numbers Estimation for 2017 2011 2012 2013 2014 2015 2016 2017 Total 158,000 173,000 179,000 193,000 196,000 216,000 228,000 Sleeve 17.80% 33.00% 42.10% 51.70% 53.61% 58.11% 59.39% RYGB 36.70% 37.50% 34.20% 26.80% 23.02% 18.69% 17.80% Band 35.40% 20.20% 14.00% 9.50% 5.68% 3.39% 2.77% BPD-DS 0.90% 1.00% 1.00% 0.40% 0.60% 0.57% 0.70% Revision 6.00% 6.00% 6.00% 11.50% 13.55% 13.95% 14.14% Other 3.20% 2.30% 2.70% 0.10% 3.19% 2.63% 2.46% Balloons 0.36% 2.66% 2.75%
Heterogenity of weight loss RYGB, AGB, and SG patients follow a similar single peak distribution up to 1-year postop. AGB and SG patients experience less predictable and more variable weight loss results at 2- and 3- years after surgery compared to RYGB. A deeper exploration into factors that influence the greater variability in AGB and SG can help improve the counseling given to bariatric patients choosing which procedure can provide the most enduring weight loss.
Heterogenity of weight loss
Comorbidity Recurrence Recurrence of diabetes and hypertension ~5 years following weight gain after surgery Yan, Am J Surg, 2008
Rationale for Reoperative Bariatric Surgery for Inadequate Weight Loss Morbid obesity is a chronic disease that requires lifetime treatment. As with many other chronic diseases requiring medical or surgical therapy, there will be patients who respond well to an initial therapy and others with only a partial response. There will also be a subset of patients who are nonresponders or have recurrent or persistent disease; these patients may require escalation of therapy or a new treatment modality.
GERD and the Sleeve Create GERD Worse symptoms after sleeve. Lack of gastric compliance. Increased intraluminal pressure. Impair GE junction anatomy. Shape of the superior pouch and the tubular configuration lead to reflux.
GERD and the Sleeve Himpens et al Long term results of sleeve showed biphasic pattern: Initially GERD went from 22% at one year, to 3%at 3 years and then back up to 23% at 6 years.
Sleeve Course: Revision for Obstruction and GERD GERD and the Sleeve Himpens et al in Long term results of sleeve showed biphasic pattern: Results seem to correlate with weight regain.
Long Term Weight Follow-up
Defining Weight Follow-up A case is classified as having weight follow-up for a given visit period (30 day, 6 month, 1 year, 2 year, 3 year, etc.) if a weight was recorded on a follow-up form for the given visit period
Weight Follow-up Rates: Denominators Number of Cases With Locked Follow-up Period Follow-up Period Procedure 30 Day 6 Month 1 Year 2 Year 3 Year 4 Year BPDDS 2870 2870 2870 1459 690 336 Band 24018 24018 24018 19131 12757 7021 Band Removal 20628 20628 20628 11188 5611 2757 Band to Bypass 4986 4986 4986 3115 1766 911 Band to Sleeve 10288 10288 10288 5949 3095 1458 Lap Bypass 144648 144648 144648 91636 51154 26897 Lap Sleeve 284636 284636 284636 156335 75639 35601 Other Revision 26578 26578 26578 15055 7273 3478 Total 518652 518652 518652 303868 157985 78459 Data Amount 3 years 6 months 3 years 6 months 3 years 6 months 2 years 2 months 1 year 2 months 7 months All listed procedures performed from Jan 1, 2013 June 30, 2016 (3 years, 6 months of data)
Weight Follow-up Rates by Procedure Total of 156,335 Sleeve Cases with 2 year form locked, 46,002 (29.4%) had a weight recorded on this form 15-30%
Weight Follow-up Rates by Procedure and Year Performed
Are patients with 1 year weight follow-up different than patients without? YES Patients who have weight follow-up at 1 year tend to. (1) be older (2) have higher rates of preop comorbidities (3) have higher rates of 30-day postop complications (4) have lower smoking rates Lap Bypass Lap Sleeve Weight Follow-up at 1 year P-Value Weight Follow-up at 1 year P-Value No Yes No Yes N 59291 85357 147207 137429 Patient Characteristics (%) Gender <.0001 <.0001 Female 77.6 79.6 77.2 79.2 Male 22.4 20.4 22.8 20.8 Hispanic Ethnicity <.0001 <.0001 No 75.1 81.6 74.8 81.1 Unknown 11.0 7.7 11.6 8.7 Yes 14.0 10.7 13.6 10.3 BMI <.0001 <.0001 Less than 35 2.6 2.7 3.7 3.5 35-39 17.9 19.1 22.7 22.5 40-49 51.5 51.0 51.7 51.2 50-59 21.4 20.8 16.6 17.3 60-69 5.0 4.9 3.9 4.0 70+ 1.6 1.5 1.5 1.5 Age <.0001 <.0001 Less than 18 0.1 0.1 0.2 0.1 18-29 12.6 8.2 12.8 9.1 30-39 25.4 21.9 26.6 23.5 40-49 28.8 28.5 29.5 28.9 50-59 22.3 25.7 21.0 24.4 60-69 10.0 14.3 8.9 12.4 70+ 0.9 1.4 1.0 1.6 ASA Class <.0001 <.0001 1 or 2 19.3 17.4 27.8 24.9 3 76.1 77.8 68.5 71.8 4 or 5 4.6 4.8 3.7 3.4 Functional Status 0.298 0.4942 Dependent 1.0 0.9 0.7 0.7 Independent 99.0 99.1 99.3 99.3 Diabetes <.0001 <.0001 Insulin 14.0 15.6 6.7 7.7 No 65.8 63.0 77.7 75.5 Non-Insulin 20.3 21.4 15.6 16.8 Smoker 9.5 8.3 <.0001 9.5 8.1 <.0001 COPD 1.8 2.2 <.0001 1.4 1.8 <.0001 Dialysis 0.2 0.2 0.0355 0.3 0.4 0.0417 PTC 2.1 2.8 <.0001 1.7 2.3 <.0001 Previous Cardiac Surgery 1.2 1.4 0.0003 1.1 1.3 <.0001 Hypertension 52.0 57.1 <.0001 45.8 50.8 <.0001 Oxygen Dependent 0.8 1.1 <.0001 0.6 0.8 <.0001 History of PE 1.0 1.2 <.0001 0.8 1.3 <.0001 Sleep Apnea 38.6 45.0 <.0001 31.7 39.0 <.0001 Renal Insufficiency 0.7 0.7 0.2131 0.6 0.7 0.0036 GERD 32.6 38.1 <.0001 26.3 30.7 <.0001 History of MI 1.5 1.7 0.0004 1.1 1.4 <.0001 Hyperlipidemia 27.6 33.3 <.0001 21.3 26.2 <.0001 History of DVT 1.4 2.0 <.0001 1.2 1.8 <.0001 Venous Stasis 1.3 1.9 <.0001 0.8 1.4 <.0001 Limited Ambulation 2.3 2.5 0.0249 1.8 2.0 <.0001 Therapeutic Anticoagulation 2.1 2.6 <.0001 2.0 2.6 <.0001 Previous Obesity/Foregut Surgery 2.1 1.8 <.0001 1.9 1.6 <.0001 Chronic Steriod Use 1.3 1.5 0.0021 1.5 1.8 <.0001 Low Albumin 4.7 5.0 0.0026 3.8 4.0 0.0057 High Albumin 0.1 0.0 0.0588 0.1 0.0 0.5556 Low HCT 7.6 6.9 <.0001 7.6 7.1 <.0001 High HCT 0.9 0.7 0.0002 1.0 0.8 <.0001 30-Day Morbidity 3.5 4.0 <.0001 1.6 2.0 <.0001 Note: Many of the associations may be statistically significant, but not necessarily clinically significant
1-5 with 1 low confidence and 5 high confidence Meaningful Health Outcomes- 4.77 Weight, Complications, Diabetes
1-5 with 1 low confidence and 5 high confidence Short-term Outcomes 4.23 Mid-term 3.63
1-5 with 1 low confidence and 5 high confidence Benefit Outweighs Harm Short Term 3.69 Mid-Term 3.15
1-5 with 1 low confidence and 5 high confidence Predictors of Success 2.08
ADJUVANT CHEMOTHERAPY Tamoxifen
What s Next EMR Patient Reported Outcomes Biometric Scale Telemedicine
Thank you John Morton, MD morton@stanford.edu