What s New in Bariatric Surgery?

Bariatric Surgery: Update for the General Surgeon What s New in Bariatric Surgery? 2,000 B.C. 2,000 A.D. 1. America keeps getting fatter without an end in sight. 2. Bariatric surgery is not just about weight loss; it s about treating metabolic disease and reducing mortality. 3. Band: out. Sleeve: in Jonathan Carter, MD UCSF Postgraduate Course in General Surgery March 2012 4. Expanding the indications for bariatric surgery BRFSS, 1990 BRFSS, 1991 No Data <10% 10% 14% 1

BRFSS, 1992 BRFSS, 1993 BRFSS, 1994 BRFSS, 1995 2

BRFSS, 1996 BRFSS, 1997 20% BRFSS, 1998 BRFSS, 1999 20% 20% 3

BRFSS, 2000 BRFSS, 2001 20% 20% 24% 25% BRFSS, 2002 BRFSS, 2003 20% 24% 25% 20% 24% 25% 4

BRFSS, 2004 BRFSS, 2005 20% 24% 25% BRFSS, 2006 BRFSS, 2007 5

BRFSS, 2008 BRFSS, 2009 BRFSS, 2010 Obesity reduces life expectancy For young men, BMI >45 took off 13 years of life expectancy For young women, BMI >45 took off 8 years of life expectancy 6

What s New in Bariatric Surgery? Bariatric surgery has a durable effect on weight obese controls 2. Bariatric surgery is not just about weight loss; it s about treating metabolic disease and reducing mortality. bands VBG bypasses number of patients diet controlled oral agent insulin dependent Metabolic benefits of bariatric surgery HbA1C (%) 8.2% before bypass 5.5% after bypass impaired fasting glucose 6.0 5.0 7.6 5.2 8.3 8.7 5.5 6.0 courtesy of ASMBS 7

March 26, 2012 % using medication all 65% 27% All oral agent 64% All insulin dependent 13% 23% 21% 13% 6% 50% of the morbidly obese have hypertension About 40% of those on antihypertensives will be able to wean off medications completely. About 50% of undiagnosed hypertensives will normalize their blood pressure systolic BP diastolic BP Percent change from baseline preoperative value Change in lipid profile 2 years after gastric bypass -7% Total cholesterol -22% LDL cholesterol 40% RYGB dropped percentage of dyslipidemic patients from 95% to 28% HDL cholesterol Number taking medication dropped to 15% -27% Triglycerides 8

CANCER INCIDENCE Lancet July, 2009 Prospective, controlled trial Bariatric surgery reduces risk of: colon cancer endometrial cancer breast cancer prostate cancer ovarian cancer obese controls surgery 2010 patients underwent surgery 2037 matched patients underwent conventional Rx Mean 11 years of follow-up 99% of patients were followed Decreased mortality was from decreased myocardial infarction and cancer What s New in Bariatric Surgery? 151 patients who underwent gastric banding from 1994-1997 were contacted for follow-up, and 84 patients completed follow-up. 39% experienced major complications (28% had erosions) 49% of the bands were removed 17% required conversion to a gastric bypass 3. Band: out. Sleeve: in 9

In France: 10,000 gastric bands are placed each year and 5,000 gastric bands are removed Sleeve gastrectomy band sleeve bypass Change in BMI after bariatric surgery 10

What s New in Bariatric Surgery? Surgery for the primary treatment of diabetes?!? 4. Expanding the indications for bariatric surgery FDA approved gastric banding for BMI 30-35 with co-morbidity in 2011 Bariatric surgery for adolescents? This operation cures diabetes in skinny (BMI <35) about 85% of the time according to DePaula. Questions? 11