Bariatric Surgery Update Alexander Perez, MD, FACS Professor of Surgery Chief, Division Minimally Invasive and Foregut Surgery
Speaker Disclosure Dr. Perez has disclosed that the has no actual or potential conflict of interest in relation to this topic.
Learning Objectives By the end of this activity, the participant should be better able to: Discuss how obesity is a chronic disease much like diabetes and hypertension and can be poorly understood. Discuss the complex multifactorial etiology of obesity. Implement a lifelong multidisciplinary team management approach with evolving multimodality therapies including bariatric surgery.
Obesity Pandemic Chronic metabolic disease Lifelong multidisciplinary team
Pandemic 5 th leading cause of mortality globally 2.8 million deaths per year World Health Organization (WHO). Obesity and Overweight. 2016
Obesity in the U.S.
Mechanisms, pathophysiology, and management of obesity. N Engl J Med 2017
Indications for Surgery BMI 40 BMI 35 with comorbid conditions Gastrointestinal Surgery for Severe Obesity. NIH Consensus Statement 1991
BMI = Weight (kg) Height 2 (m 2 )
BMI = Weight (kg) Height 2 (m 2 ) Lambert Adolphe Jacques Quetelet 1796 1874
Bariatric: Barús, Heavy
Metabolic: Metabolikos, Changeable
Metabolic Score Individualized Metabolic Surgery Score: Procedure Selection Based on Diabetes Severity. Ann Surg 2017
TG LDL T2DM HTN PSYCH GERD Complications
Obesity Management Well informed and motivated patient Multidisciplinary team Dietary, exercise, and behavior support Specialized center Lifelong surveillance Gastrointestinal Surgery for Severe Obesity. NIH Consensus Statement 1991
Medicine Surgery Patient Admin Dietician Psychology
Surg+Med vs. Med Alone
Data Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012 Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med 2012 Roux en Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA 2013 Bariatric Surgery versus Intensive Medical Therapy for Diabetes 5 Year Outcomes. N Engl J Med 2017 Weight and Metabolic Outcomes 12 Years after Gastric Bypass. N Engl J Med 2017
Weight Loss 50% 25% 29% 33% 23% 27% Surg + Med Med Alone 0% 5% 5% 5% 1YR 2YR 5YR 12 YR 2%
Weight and Metabolic Outcomes 12 Years after Gastric Bypass. N Engl J Med 2017 Weight
T2DM Remission 75% 50% 42% 45% 51% Surg + Med 25% Med Alone 0% 0% 2% 5% 1YR 5YR 12 YR
HbA1c Decrease Med Alone Surg+Med Bariatric Surgery versus Intensive Medical Therapy for Diabetes 5 Year Outcomes. N Engl J Med 2017
HTN Remission 50% 43% 35% 36% 25% Surg + Med Med Alone 11% 10% 0% 0% 1YR 5YR 12 YR
Dyslipidemia Remission (12yr) 125% 100% 99% 82% 75% 50% 55% 59% 55% Surg + Med Med Alone 25% 19% 0% HIGH LDL LOW HDL HIGH TG Weight and Metabolic Outcomes 12 Years after Gastric Bypass. N Engl J Med 2017
Mortality (12yr) Med Alone Surg + Med Association Between Bariatric Surgery and Long term Survival. JAMA 2015
Evolution of Surgery
Bariatric surgery for morbid obesity. N Engl J Med 2007 Bypass
Bariatric surgery for morbid obesity. N Engl J Med 2007 Band
Bariatric surgery for morbid obesity. N Engl J Med 2007 Sleeve
Bypass Band Sleeve 2003 American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in 2015 and surgeon workforce in the United States. Surg Obes Relat Dis 2016, Buchwald H, et al. Obesity Surg 2004, 2009, and 2013
Bypass Band Sleeve 2003 2008 American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in 2015 and surgeon workforce in the United States. Surg Obes Relat Dis 2016, Buchwald H, et al. Obesity Surg 2004, 2009, and 2013
Bypass Band Sleeve 2003 2008 2011 American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in 2015 and surgeon workforce in the United States. Surg Obes Relat Dis 2016, Buchwald H, et al. Obesity Surg 2004, 2009, and 2013
Bypass Band Sleeve 2003 2008 2011 2015 American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in 2015 and surgeon workforce in the United States. Surg Obes Relat Dis 2016, Buchwald H, et al. Obesity Surg 2004, 2009, and 2013
Bypass vs. Sleeve Laparoscopic Sleeve Gastrectomy Versus Roux Y Gastric Bypass for Morbid Obesity 3 Year Outcomes of the Prospective Randomized Swiss Multicenter Bypass Or Sleeve Study (SM BOSS). Ann Surg 2017
Bypass vs. Sleeve Laparoscopic Sleeve Gastrectomy Versus Roux Y Gastric Bypass for Morbid Obesity 3 Year Outcomes of the Prospective Randomized Swiss Multicenter Bypass Or Sleeve Study (SM BOSS). Ann Surg 2017
Bypass vs. Sleeve Bariatric Surgery versus Intensive Medical Therapy for Diabetes 5 Year Outcomes. N Engl J Med 2017
Complications 14% 12% 10% 8% 6% 4% Bypass Sleeve 2% 0% Any Surgical Complication Infection Hemorrhage Extended Length of Stay ED Visit Roux En Y Gastric Bypass Vs. Sleeve Gastrectomy: Balancing the Risks of Surgery with the Benefits of Weight Loss. Obes Surg 2017 (chart above) Obes Surg 2017
Diet After Surgery Liquid diet Dehydration = Readmission 8 glasses daily Lifelong supplements (Vitamin B12, Vitamin D, Calcium, Iron) Protein (60 100 grams/day) Carbohydrate (<50 grams/day)
Metabolic > Bariatric Surg+Med > Med Alone Evolution of Surgery Conclusions
Thank You