Morbid Obesity The Surgical Approach Jonathan A. Schoen, M.D. Assistant Professor of Surgery University of Colorado Health Sciences Center
Today s s Lineup Definition Population Statistics Childhood Obesity Hormones Infectious etiologies of obesity Food Adolescent Bariatrics UCHSC SWLC Video Session
Definition of Morbid Obesity ŅA life-long, progressive, life-threatening, genetically-related, costly, multi-factorial disease of [excess fat storage] with multiple co-morbidities (obesity related health condition).ó ASMBS
BMI-Associated Disease Risk Classification Class BMI (kg/m 2 ) Risk Normal Waist Circumference Increased Waist Circumference Underweight <18.5 - - Normal 18.5-24.9 - - Overweight 25.0-29.9 Increased High Obesity I 30.0-34.9 High Very High Severe Obesity II 35.0-39.9 Very high Very high Extreme Obesity III >40 Extremely high Extremely high From: NHLBI 2000 (NIH), Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults. *Normal waist circumference is ² 40 inches for males, ² 35 inches for females.
Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14%
Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14% 15% 19%
Obesity Trends* Among U.S. Adults BRFSS, 2001 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25%
Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14 15% 19% 20% 24% 25% 29% 30%
Obesity Trends* Among U.S. Adults BRFSS, 2009 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%
Childhood Obesity
The likelihood of obesity is 22% lower among children who were breastfed
Breast Milk Hormones - Nutritional Programming?? Leptin Adiponectin Ghrelin IGF-1 Resistin Obestatin
Leptin QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. Leptos = thin DNA sequence - Friedman 1994 Obese (ob) gene Produced by adipocytes, stomach, placenta, mammary epithelial cells BMI Leptin Anorexigenic
Leptin Function
Ghrelin Discovered in 1999 Initially as growth hormone secretagogue receptor ligand Produced primarily in stomach fundus Active form requires fatty acid acylation Only orexigenic hormone Preprandial hunger and meal initiation Cummings D. Physiol and Behav
Plasma Ghrelin Profile After RYGB NEJM 2002; 346
Leptin, Ghrelin and the Arcuate Nucleus
Adiponectin Discovered 1995 Secreted exclusively from white adipose Most abundant adipose-specific protein Abundant plasma protein Receptor: Adipo-R1 and Adipo-R2 Multiple circulating isomers BMI Adiponectin Galic, et al. Mol and Cell Endocr 2010
Adiponectin
Adiponectin Anti-inflammatory Anti-atherosclerotic Anti-cancer Anti-NASH Insulin-sensitizing Cardioprotective 5% weight 20% serum level Mol and Cell Endocr 2010
Adipogenesis Adenovirus-36 AD-36 specific antibodies 124 children (14 yo) 19 + (15%) 15/19 (78%) obese Gabbert, et al. Peds 2010 502 Adults AD-36 + 30% obese vs. 11% non-obese Atkinson, et al. Int J Obes 2005
Gut Microbiota Bacteroidetes vs. Firmicutes Metagenomics and biochemical analysis Obese = Bacteroidetes Firmicutes Weight Loss = Bacteroidetes level increase Transmissible Trait Nature 2006
Top Ten List of High Calorie Fast Foods acaloriecount.com
HARDEES
Liquid Calories
Liquid Calories
Liquid Calories
Liquid Calories
Restrictive Procedures Sleeve Gastrectomy
Combined Restrictive/Malabsorptive Roux-en-Y Gastric Bypass lesser curve 15 cc pouch complete gastric division Antecolic or retrocolic Roux limb: 60-150 cm 0.8 cm 2.0 cm gastrojejunostomy
Malabsorptive Procedures 200-500 ml 150 ml 200 cm 225-350 cm 50 cm 50-100 cm
Other Procedures Intragastric Balloon - BIB Gastric Pacer
Other Procedures TOGA Endobarrier QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.
Adolescents: Banding vs. Lifestyle Prospective Randomized Trial 50 pts 14-18 y.o. BMI > 35 Assigned to supervised lifestyle intervention or gastric banding 24 months O brien, et al. JAMA 2010
Banding vs. Lifestyle Community Recruitment - newspaper ads 1st visit - patient info session 2 week food diary + pedometer assignment 2nd visit - 4 weeks later Completion of tasks + clinical assessment 3rd visit - after 2 month lead-in Consent to randomize 7 day cooling-off period Reconfirmation and then computer randomization JAMA 2010
Lifestyle Program Reduced energy intake (800-2000 kcal/d) >10,000 steps/day 30 minutes scheduled daily exercise Personal trainer x 6 weeks 2 hour computer or t.v. time limit Food diary + step counts monitored Q6 wks JAMA 2010
Results 24/25 completed band 18/25 completed lifestyle Initial BMI Kg Lost %EWL BMI units Lost Band 42 34.6 78.8 12.7 Lifestyle 40 3.0 13.2 1.3 JAMA 2010
Adverse Events 33% re-operation rate (8/7) Pouch dilation 6(24%) Needle stick tubing injury 2(8%) Cholecystectomy 1(4%) per study arm JAMA 2010
Systematic Review and Meta-Analysis of Bariatric Surgery for Pediatric Surgery 163 Citations identified by literature searches Abstracts screened 121 Citations excluded 42 Full articles retrieved Full articles reviewed 15 articles excluded 27 Articles on 18 Studies met inclusion criteria 18 Studies assessed 8 of laparoscopic gastric band 6 of Roux-en-Y Gastric Bypass 3 of VBG Treadwell, et al. Ann Surg 2008
Meta-analysis analysis Results Banding [1996] N = 352 Age = 9 -> 20 (16.7) BMI = 42 -> 50.5 (46) Follow-up: 1 -> 3 yrs Bypass [1970s] N = 131 Age = 11 -> 21 (16.8) BMI = 38 -> 95.5 (52) 1/3 laparoscopic Follow-up: 1 -> 6 yrs Ann Surg 2008
Meta-analysis analysis Results Ann Surg 2008
Complications Bands No mortality 8% Reoperation rate Band slippage most frequent (3%) No data on growth or development Bypass No in-hospital death 4 deaths: 9 mos -> 6 years PE, leak, bleed, obstruction, marginal ulcer, hernia 1 study - no evidence of growth retardation Ann Surg 2008
Pediatric LAGB - NYU Experience Time N Age: 13-17 (15.8) Mean weight Mean BMI %EWL Preoperative 73 298 +/- 55 47.6 +/- 7.0 NA 6 mo 53 247 39.8 35.1 1 y 47 214 34.3 56.7 18 mo 30 211 33.9 54.7 2 y 16 204 32.1 60.9 Nadler, et al. J ped surg 2008
Pediatric LAGB - NYU Comorbidities: Resolution 68.5% Improved 17.5 Unchanged 10% Worse 4% Complications: 15% Reoperation rate 1 gastric perforation, 6 slips, 3 hiatal hernia J ped surg 2008
5 Centers 11 adolescents with T2DM Age 14 -> 21 (17.8) BMI 43 -> 63 (50) 1 year f/u BMI - 34% Fasting Blood Glucose - 41% Fasting Insulin Conc - 81% Hemoglobin A1c 7.3% -> 5.6% Total Cholesterol - 29% Heart Rate - 19% Diastolic B.P. -19.5% Inge, et al. Peds 2008
38 adolescents Age 13 -> 19 (16) LRYGB Echo pre and 10 months post-op Pre-op Post-op BMI 60 40 LV Mass 54 g/m 42 g/m Concentric LVH 28% 3% Normal LV geometry 36% 79% Ippisch, et al. J Am Coll Cardiol 2008
University of Colorado Hospital Surgical Weight Loss Center 7/2004 N = 608 female (86%) Average age = 42 (18 -> 65) Average BMI = 48 (35 -> 83) 4 pts in program BMI 98 -> 113 Average Co-morbidities = 5 28% T2DM 1 pt with T1DM 1 pt with paraplegia
UCH - SWLC 486 laparoscopic RYGB 0.3% conversion rate 13 VBG -> RYGB revision 2 proximal -> distal RYGB revision 3 lap bands -> RYGB revision 20 sleeve gastrectomy (3%) 93 lap bands (15%)
Complications UCH/SWLC Mortality 0.2 Leak 0.2 Pulmonary Embolism 0.8 DVT 0.5 CVA 0.3 GI Bleed 3.0 Stomal Stenosis 0.8 SBO 1.9 Wound Infection 0.7 Incisional Hernia 0.4 Re-admission 7.9 Re-operation 1.9
Perioperative Safety in the Longitudinal Assessment of Bariatric Surgery (LABS) Prospective, multicenter observational study 30-day outcomes in consecutive patients N=4776 RYGB - 3412 LAGB - 1198 Mean age - 44.5 Median BMI - 46.5 NEJM 2009;361
LABS 30-day Outcomes Outcome Total LAGB LRYGB ORYGB Death 0.3% 0 0.2 2.1 DVT 0.4% 0.3 0.4 1.1 Reintubation 0.4% 0.2 0.4 1.4 Endoscopy 1.1% 0.1 1.5 1.1 Tracheostomy 0.2% 0 0.2 1.1 Perc Drain 0.3% 0 0.4 0.7 Reoperation 2.6% 0.8 3.2 3.4 Failure to D/C 0.4% 0 0.4 0.9 Composite 4.1% 1.0 4.8 7.8
LABS Risk Factors Lowest BMI risk = 53 BMI 75 = 61% higher risk OSA Prior DVT/PE Impaired functional status (< 200 ft. walk)
Band vs. Bypass Weight Loss 181 matched LAGB vs. LRYGB 90 80 76 83 80 74 70 60 56.9 50 40 48 51 55 51 LAGB LRYGB 30 20 10 17.7 16.6 36.8 0 1 3 6 9 12 18 24 36 Time in Months Obes Surg 2006; 16
Long-term Weight Loss 984 patients // 8 year follow-up 19% 19% 0-30 31-60 61-100 62% Obes Surg 2003; 13
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Happy Thanksgiving