Friday General Session Bariatric Surgery Update Alex Perez, MD Chief, Division of Minimally Invasive and Foregut Surgery James E. Thompson, MD Family Distinguished Professor in Surgical Simulation Co Director, Surgical Simulation UTMB Health Galveston, Texas Educational Objectives By the end of this educational activity, participants should be better able to: 1. Discuss how obesity is a chronic disease much like diabetes and hypertension and can be poorly understood. 2. Discuss the complex multifactorial etiology of obesity. 3. Implement a lifelong multidisciplinary team management approach with evolving multimodality therapies including bariatric surgery. Speaker Disclosure Dr. Perez has disclosed that he has no actual or potential conflict of interest in relation to this topic. 9
Speaker Disclosure Bariatric Surgery Update Dr. Perez has disclosed that the has no actual or potential conflict of interest in relation to this topic. Alexander Perez, MD, FACS Professor of Surgery Chief, Division Minimally Invasive and Foregut Surgery 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 Obesity in the U.S. 5 th leading cause of mortality globally 2.8 million deaths per year World Health Organization (WHO). Obesity and Overweight. 2016 1
Indications for Surgery BMI 40 BMI 35 with comorbid conditions Mechanisms, pathophysiology, and management of obesity. N Engl J Med 2017 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 2
Metabolic Score TG LDL T2DM HTN PSYCH GERD Complications Individualized Metabolic Surgery Score: Procedure Selection Based on Diabetes Severity. Ann Surg 2017 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 Admin Patient Dietician Surg+Med vs. Psychology 3
Data Weight Loss 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 5 25% 33% 29% 27% 23% 5% 5% 5% 2% 1YR 2YR 5YR 12 YR Surg + Med Weight T2DM Remission 75% 5 25% 42% 45% 51% Surg + Med 2% 5% 1YR 5YR 12 YR Weight and Metabolic Outcomes 12 Years after Gastric Bypass. N Engl J Med 2017 HbA1c Decrease HTN Remission 5 43% 35% 36% Surg+Med 25% Surg + Med 11% 1 1YR 5YR 12 YR Bariatric Surgery versus Intensive Medical Therapy for Diabetes 5 Year Outcomes. N Engl J Med 2017 4
Dyslipidemia Remission (12yr) Mortality (12yr) 125% 10 82% 99% 75% 5 55% 59% 55% Surg + Med 25% 19% Surg + Med HIGH LDL LOW HDL HIGH TG Weight and Metabolic Outcomes 12 Years after Gastric Bypass. N Engl J Med 2017 Association Between Bariatric Surgery and Long term Survival. JAMA 2015 Bypass Evolution of Surgery Bariatric surgery for morbid obesity. N Engl J Med 2007 Band Bariatric surgery for morbid obesity. N Engl J Med 2007 Bariatric surgery for morbid obesity. N Engl J Med 2007 5
Bypass Band Bypass Band 2003 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 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 Bypass Band 2003 2008 2011 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 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. Bypass vs. Laparoscopic Gastrectomy Versus Roux Y Gastric Bypass for Morbid Obesity 3 Year Outcomes of the Prospective Randomized Swiss Multicenter Bypass Or Study (SM BOSS). Ann Surg 2017 Laparoscopic Gastrectomy Versus Roux Y Gastric Bypass for Morbid Obesity 3 Year Outcomes of the Prospective Randomized Swiss Multicenter Bypass Or Study (SM BOSS). Ann Surg 2017 6
Bypass vs. Complications 14% 12% 1 8% 6% 4% 2% Bypass Any Surgical Complication Infection Hemorrhage Extended Length of Stay ED Visit Bariatric Surgery versus Intensive Medical Therapy for Diabetes 5 Year Outcomes. N Engl J Med 2017 Roux En Y Gastric Bypass Vs. 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 > Evolution of Surgery Conclusions Thank You 7
Notes