Size Does Matter Bariatric Surgery New Procedures. What are the results? What is the future? Ashley Vergis MMEd MD FRCSC FACS Clinical Lead WRHA Bariatric Surgery Initiative Assistant Professor, Department of Surgery University of Manitoba Objectives Definitions Obesity epidemic Bariatric surgery rationale Procedures Indications and preoperative preparation Postoperative care and complications The Manitoba situation Definitions Bariatrics The branch of medicine that deals with the causes, prevention, and treatment of obesity
Definitions BMI (kg/m 2 ) Status 19 24.9 Normal body weight 25 29.9 Overweight 30 34.9 Class I Obesity 35-40 Class II Obesity >40 Class III Obesity Why Are We Talking About this?
World Health Organization (2000): The spread of obesity in the world is one of the greatest neglected public health problems of our time. U.S.A.
BRFSS, 1985 No Data <10% 10% 14% BRFSS, 1986 No Data <10% 10% 14% BRFSS, 1987 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14%
BRFSS, 1988 No Data <10% 10% 14% BRFSS, 1989 No Data <10% 10% 14% BRFSS, 1990 No Data <10% 10% 14%
BRFSS, 1991 No Data <10% 10% 14% 15% 19% BRFSS, 1992 No Data <10% 10% 14% 15% 19% BRFSS, 1993 No Data <10% 10% 14% 15% 19%
BRFSS, 1994 No Data <10% 10% 14% 15% 19% BRFSS, 1995 No Data <10% 10% 14% 15% 19% BRFSS, 1996 No Data <10% 10% 14% 15% 19%
BRFSS, 1997 No Data <10% 10% 14% 15% 19% 20% BRFSS, 1998 No Data <10% 10% 14% 15% 19% 20% BRFSS, 1999 No Data <10% 10% 14% 15% 19% 20%
BRFSS, 2000 No Data <10% 10% 14% 15% 19% 20% BRFSS, 2001 No Data <10% 10% 14% 15% 19% 20% 24% 25% BRFSS, 2002 No Data <10% 10% 14% 15% 19% 20% 24% 25%
BRFSS, 2003 No Data <10% 10% 14% 15% 19% 20% 24% 25% BRFSS, 2004 No Data <10% 10% 14% 15% 19% 20% 24% 25% BRFSS, 2005 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%
BRFSS, 2006 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% BRFSS, 2007 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% BRFSS, 2008 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%
BRFSS, 2009 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% BRFSS: 1990 & 2009 (*BMI 30, or about 30 lbs. overweight for 5 4 person) 1990 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% BRFSS: 1990 & 2009 (*BMI 30, or about 30 lbs. overweight for 5 4 person) 1990 2009 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%
What about Canadians? Canadians are also Obese!* % of population > age 20 with BMI > 30 -Katzmarzyk, CMAJ, April 2002 Canadians are also Obese!* 1985 5.6% 1990 9.2% 1994 13.4% 1996 12.7% 1998 14.8% 2004-23% *Katsmarzyk, P. The Canadian obesity epidemic, 1985 1998. CMAJ 2002. Canadian Community Health Survey, 2004.
Katzmarzyk,, P. T. et al. CMAJ 2006;174:156-157 157 Why Is this Happening? Causes of Obesity Energy in = Energy out
Causes of Obesity Energy in Shifts in food practices Less family meals Refined foods Fast foods Colas 30,000 products 12,000 new/yr Psychological Coping mechanism (stress/abuse) Behavioral Family tradition Food to comfort child Addiction Socioeconomic High/low income classes Cultural views Energy out Genetic predisposition Twin Studies Adopted Children Obesity gene Physiologic Leptin Decreased stretch receptors Hypothalamic Evolutionary Gender (women) Higher fat component Societal Technology has decreased energy expenditure Elevators, power windows, food delivery, remote controls, computers, TV, cars. Causes of Obesity Energy in Shifts in food practices Less family meals Refined foods Fast foods Colas 30,000 products 12,000 new/yr Psychological Coping mechanism (stress/abuse) Behavioral Family tradition Food to comfort child Addiction Socioeconomic High/low income classes Cultural views Energy out Genetic predisposition Twin Studies Adopted Children Obesity gene Physiologic Leptin Decreased stretch receptors Hypothalamic Evolutionary Gender (women) Higher fat component Societal Technology has decreased energy expenditure Elevators, power windows, food delivery, remote controls, computers, TV, cars.
Causes of Obesity Energy in Shifts in food practices Less family meals Refined foods Fast foods Colas 30,000 products 12,000 new/yr Psychological Coping mechanism (stress/abuse) Behavioral Family tradition Food to comfort child Addiction Socioeconomic High/low income classes Cultural views Energy out Genetic predisposition Twin Studies Adopted Children Obesity gene Physiologic Leptin Decreased stretch receptors Hypothalamic Evolutionary Gender (women) Higher fat component Societal Technology has decreased energy expenditure Elevators, power windows, food delivery, remote controls, computers, TV, cars.
Causes of Obesity Energy in Shifts in food practices Less family meals Refined foods Fast foods Colas 30,000 products 12,000 new/yr Psychological Coping mechanism (stress/abuse) Behavioral Family tradition Food to comfort child Addiction Socioeconomic High/low income classes Cultural views Energy out Genetic predisposition Twin Studies Adopted Children Obesity gene Physiologic Leptin Decreased stretch receptors Hypothalamic Evolutionary Gender (women) Higher fat component Societal Technology has decreased energy expenditure Elevators, power windows, food delivery, remote controls, computers, TV, cars.
Why Should I care? Obesity-related Mortality 400,000 obesity-related deaths per year in USA ~850-1000 Manitobans/yr Mortality rate for morbidly obese individual up to 1% per year
Mortality Risk of Obesity Our Patients Why Should I care About them? In real terms 5 4 BMI 30 175 35 205 55 320 Weight (lbs) BMI Weight (lbs) 5 10 30 210 35 245 55 385
Why Should Society Care? Costs What Can we do about it?
Treatment Primary Prevention Education Healthy lifestyle promotion Dieting & Exercise Effective in <5% of patients* Weight fluctuation- negative Pharmacologic Treatment Orlistat Sibutramine Fluoxetine Bupropion Topiramate Surgery *North American Association for the Study of Obesity and the National Heart, Lung, and Blood Institute.The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Bethesda, Md: National Institutes of Health; 2000. NIH publication 00-4084. Li Z, Maglione M, Tu Wenli, et at. Meta-Analysis: Pharmacologic treatment of obesity. Ann Intern Med 2005;142:532-546. What Are the indications?
Indications for Bariatric Surgery* BMI > 40 or BMI > 35 with obesity-related comorbidity and Failure of diet and exercise Compliant patient * NIH guidelines (1991) Contraindications Noncompliance Severe CAD or Pulmonary Hypertension Immobility Untreated psychiatric/eating disorder Substance abuse Age > 65 (relative contraindication) What Are the current procedures?
Current Procedures Current Procedures Restrictive Adjustable gastric banding Sleeve gastrectomy Malabsorptive Biliary-pancreatic diversion with duodenal switch Combined Restrictive and Malabsorptive Roux-en en-y Y Gastric Bypass Roux-en en-y Y Gastric Bypass Restrictive and malabsorptive Most Common Longest track record Most effective Technically challenging
Sleeve Gastrectomy Restrictive, +/-hormonal Originally stage 1 of a 2 stage operation Technically straightforward Safety profile similar to bypass Gastric physiology preserved Gastric Banding Restrictive Newer (1990 s) Day surgery Better safety profile but more finicky Technically simple What Do the OR Nurses Need to know?
Patient Preparation Minimize interventions Think Lap Chole Unless specific indication, no: Foley Arterial line Central line Heparin, Abx,, SCD s Patient Preparation Patients walk to OR Difficult for larger patients to transfer from stretcher to table Bariatric bed lowers to floor Room Setup Arms out Supine vs. Split Leg Surgeon variable Monitors (x2) over shoulders Scrub nurse at feet or pts left
Instrumentation Think Lap colon + Fundoplication Veress needle (thick abdominal panus) Optical trochars (entry off of midline) Liver retractor Needle drivers (bypass and band) 5-10 precut sutures (20 cm) Laparoscopic staplers 5-77 loads (bypass and sleeve) Multiple cartridge lengths and thicknesses Positioning- Safety Significant risk of nerve and pressure injuries Difficult to asses degree of joint angulation Increased weight on boney prominances Significant risk of patient movement Extreme bed positions to move intra abdominal fat Trendelenberg & Reverse
Transfer Extreme BMI poses a injury risk for caregivers Safety is paramount Patient counseled pre-operativley Will move themselves from table to bed Requires coaching What Good does it do? Weight-loss 100 80 77.1 82.1 %EWL 60 40 54.5 31.5 20 15 0 preop 1mo 3mo 6mo 12mo 18mo Follow-up Surgical group: decreased- hospital adm,, MD visits, overall costs (8/11k)
Summary of results Band Bypass Sleeve % EBWL (5 yr) 30-50 60-80 ~55 Mortality reduction 62% 89% UNKNOWN DM II a 48% 84% Likely Hypertension a 38% 71% somewhere Dyslipidemia* 71% 95% between bypass OSA a 95% 87% and band Osteosrthritis* ~80% ~80 a Remmission * Improvement Who IS Involved?
What IS the process? Preoperative Preparation Consultation Surgeon Assess NIH Criteria Exercise counseling Dietician Bariatric diet General dietary counseling Psychologist Assess for untreated psychopathology Coping strategies Anesthesiologist Family physician H&P, blood work Preoperative support! +/- Internist/Sleep lab Preoperative Diet (Optifast( Optifast) High protein, low carb, low calorie
Postoperative Care 0 3 day hospital stay Follow-up Surgeon 1, 3, 6, 12 months and yearly Dietician 1,6,12 months Family MD - Ongoing! Ensure adequate protein and vitamin intake High protein diet Multivitamins, Calcium, Fe Monitor Diabetic and Anti-hypertensive Meds Monitor blood work CBC, Electrolytes, Albumin, Vitamins (B1, B12, D) Watch for complications What Are the down sides?
Where IS Bariatric surgery done? Where IS Bariatric surgery not done?
Manitoba Manitoba Bariatric Surgery Program Manitoba University of Manitoba Phase I (June Sept 2011) Chris Andrew and John Bracken Sleeve gastrectomy Victoria hospital Phase II (Sept to Present) Above, plus Krista Hardy and Ashley Vergis Above, plus gastric bypass Victoria Hospital Low volumes (~6-8/month) What Have we done so far?
Manitoba Manitoba University of Manitoba Complications Leak 3 (2.1%) Post op bleed 4 (2.8%) Stricture 1 (0.7%) Manitoba Band N=185 82% female Mean age 45 Mean BMI 46.7 Mean OR time 62 min % EBWL 55.8 at 18 months 62.3 at 24 months
Manitoba Band complications 6 bands removed (3.2%) Infected/slipped/eroded 6 ports revised (3.2%) Flipped/infected 1 overnight admission (0.54%) What Do we still have left to do (so far)? Manitoba Wait times (U of M) Referral to consultation: 14-16 16 months Consultation to surgery: 6-86 8 months Overall: 20 24 months Changes every day! ~5 new consults per day! Waiting to be seen Patients who meet criteria: 330 Patients who do not meet criteria 650
When Are we going to pick up the pace? Manitoba Phase III Increased volumes Larger Older Males Comorbidities TBA Obesity is a major health problem Surgery works Multidisciplinary team necessary Manitoba s s program is up and running (limited capacity) Additional resources are necessary to expand to meet our community s s needs.
How do we choose I don t t know But: Band BMI 35-45 Minimal Comorbidities Able to f/u for multiple adjustments Disciplined with diet and exercise Bypass BMI 35+ DM, HTN, Dyslipidemia etc. Sweet tooth Reflux Sleeve In evolution Must be comfortable with some unknowns