Obesity and Bariatric Surgery Michel M. Murr, MD, FACS Director of Bariatric Center Chief of Surgery, TGH Professor of Surgery, USF
Disclosure Covidien: educational grants
Obesity and Bariatric Surgery Outline Describe classes obesity, treatment, benefits, risk and success Discuss surgical options: risk, benefits, monitoring, success, persistence of benefit, and long-term complications. Delineate issues with modification or reversal of procedures Review the role of bariatric surgery and remission of comorbidities, diabetes, hypertension, etc Discuss the value of the timing of the procedure Comment the epidemic of childhood obesity
Obesity
Definition of Obesity Obesity is a chronic, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat results in adverse metabolic, biomechanical, and psychosocial health consequences ASBP 2015
Obesity Obesity Class BMI (Kg/m 2 ) Normal 18.5-24.9 Overweight 25.0-29.9 Mild Obesity I 30.0-34.9 Moderate Obesity II 35.0-39.9 Severe Obesity III 40.0
Obesity and Diabetes Trends Ford et al. Obes Res 2003;11:1223 31
Obesity and Diabetes 240 million diabetics worldwide 30% of US population will be diabetic by 2020 50% do not achieve adequate glycemic control 85% are overweight 55% are obese
Obesity and Sleep Apnea Murr et al, Surgery 2006
Obesity and GERD UGI contrast study: 40% hiatal hernia Symptoms: >30% of patients EGD: >20% abnormalities Gonzalvo, Murr et al 2016
Liver Biopsy in 660 Bariatric Surgery Pts Fibrosis 8% Steatohepatitis 9% Obesity and NAFLD Cirrohsis 1% Normal 4% Portal Inf 13% Steatosis 65% Murr et al, Obes Surg 2004
NAFLD Related Admissions in Children Koebnick et al JPGN 2009
Burden of Obesity Individual Multiple comorbidities Shorter longevity Poor quality of life Out of pocket care costs Absenteeism Stigmatization Fitch et al., 2013
Burden of Obesity Societal 30% of Americans are overweight or obese 80% of overweight youth become obese adults Impacts every resident, employer & government agency Incremental annual heath care cost of $1,429 (2009 dollars) per person
Goals of Treatment of Obesity Adult patient with overweight or obesity Improve patient health Improve quality of life Improve body weight and composition ASBP 2015
Individual Treatment of Obesity BMI for initial screening Waist circumference: low BMI obesity % body fat: extremes in muscle mass
Contemporary Treatment of Obesity Mainstay of Treatment Caloric Restriction Physical Activity Pharmacotherapy Surgical Procedures
Interventions for Obesity
Interventions Balanced meals for Obesity 300-500 calorie deficit Adherence >3 month is king 5-10% weight loss Manage recidivism
Interventions Don t change for Obesity behavior Best with diet and exercise Plan long term use 5-10% weight loss Monitor for side effects
TGH Employee Weight Management Pilot Study % BWL High Responders No Patients
Interventions for Obesity Balloons are back Mixed results
Most effective Bariatric Surgery Interventions for Obesity Rapid weight loss Inter-disciplinary approach Requires life long follow up Manage weight regain Set realistic expectations
Swedish Obesity Subjects (SOS) Study Sjostrom: NEJM; 2004
Swedish Obesity Subjects (SOS) Study Sjostrom: NEJM; 2004
Weight Loss After Gastric Bypass Percent Change in Excess Body Weight 0-20 -40-60 -80-100 0 5 10 15 Time After Surgery (years) Pories et al., 1995
Bariatric Surgery Resolution of Comorbidities after RYGB (90% F/U) 100 80 60 40 20 Preop Postop Percentage 0 OSA HTN Arth GERD Diabetes UI Dysfertility Fibrosis
Bariatric Surgery Swedish Obesity Subjects (SOS) Study Sjöström L, NEJM 2007
Bariatric Surgery Long Term Survival in 7,925 Pts after RYGB Disease Mortality Cardiac 56% Diabetes 92% Cancer 69% Adams T, NEJM 2007
Bariatric Surgery Cost Analysis of RYGB in 25 veterans Pre-op Op Post-op Expenses ($1K) 11.1±2.5 9.0±0.5 2.5±0.7* Clinic visits 57±6 14±3** *p=0.003 post-op vs. pre-op **p<0.001 post-op vs. pre-op Gallagher, Murr: Obes Surg 2003
The Rise and Fall of Glucose Glucose (mg/dl) 600 500 400 300 200 100 50 54 53 52 50 44 41 39 20 18 16 14 12 10 8 6 4 2 HgbA1c (%) 0 0-30 -24-4 0 1 2 5 11 Time from Surgery (months) Glucose (mg/dl) BMI (kg/m2) HgbA1c (%)
STAMPEDE Trial: RYGB vs SG vs Med 3 yr; n=150 RYGB SG Med HbA1C <6.0 38% 24% 9%* Wt loss (%) 25±9 21±9 4±8* * p<0.01; Schauer NEJM 2014
Improvement in Steatosis Pre-Bariatric Post-Bariatric
Improvement in Steatohepatitis Pre-Bariatric Post-Bariatric
Improvement in Fibrosis Pre-Bariatric Post-Bariatric
Bariatric Surgery Improves NAFLD Steatosis Steatohepatitis Fibrosis Resolved 63% Persisted 27% Resolved 90% Same 5% Improved 56% Same 25% Murr et al J GI Surg 2015
Types of Bariatric Procedures
Types of Bariatric Procedures Lap-Band: 10 year data Converted to bypass 25% Band in/no wt loss 25% Undetermined 40% Weight loss 10%
Types of Bariatric Procedures
Bariatric Procedures are Effective But Not Equal 100% DS 50% 10% Sleeve Banding RYGB Excess Weight Loss Diabetes Resolution Rate 0.01 0.1 1 10 30 Day Mortality
The Anti-Diabetic Effects of Diversionary Procedures Hepatic Insulin Sensitivity Food diverted from excluded stomach Decrease inflammatory cytokine form omentum Early delivery of undigested nutrients GLP-1
Types of Bariatric Procedures Our Recommendations for Adults Gastric Banding: not recommending Gastric Sleeve: non-diabetic or BMI<50 Gastric Bypass: all BMI or diabetic
Types of Bariatric Procedures Our Recommendations for Adolescents Gastric Banding: not recommending Gastric Sleeve: girls, non-diabetic, BMI<50 Gastric Bypass: boys, all BMI or diabetic
Bariatric Surgery Post-op: Mortality 0.3% Major complications: 2-4% leaks bleeding DVT/PE SBO
Bariatric Surgery Long Term Complications: Anastomotic ulcer 2% Small bowel obstruction 4% Protein calorie malnutrition 4% Anemia 5% Weight relapse 5-10%
Nutrition in Bariatric Patients Post-op Deficiencies: B12 Thiamine Folate Iron Vit D Vit A
Revisional Surgery Vs Reversal Revisional Surgery: Mostly to correct anatomical problems anastomotic stricture strictured sleeve hiatal hernia
Revisional Surgery Vs Reversal Revisional Surgery For poor weight loss band to bypass sleeve to bypass
Revisional Surgery Vs Reversal Removal of band for pseudoachalasia Reversal of gastric bypass or other diversionary procedures for intractable metabolic problems There is no reversal of gastric sleeve
Who should I refer for bariatric surgery? BMI: >35, no upper BMI limit Age: >16 years, no upper age limit Stable mental health Willingness to participate No substance abuse
Referral Information Session TGH+USF Bariatric Center Attend Support Group Patient Flow Diet Classes Chronic Disease Model Accreditation QIP Continue Life-Long F/U -6 mo Bariatric Surgery 2 yr 10+ yr Bariatrician Pulmonary Cardiac ENDO Surgery Surgery Follow up Surgery Maintenance Bariatrician Dietitian Psychologist Ex Phys Additional Psych/Diet Diagnostics Retail Plastic Surgery Orthopedics
Early Referral vs Last Resort?
Natural History of Type 2 Diabetes Glucose Postprandial glucose Fasting glucose -10-5 0 5 10 15 20 25 30 Relative Activity Insulin level Beta-cell function Insulin resistance hepatic and peripheral 10 5 0 5 10 15 20 25 30 Yrs from Diabetes Diagnosis Ramlo-Halsted et al. Prim Care. 1999;26:771 789.
Results Weight Loss Expectations %EWL 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Dream Happy Accept Disappoint
Interdisciplinary Clinically Integrated Team Three bariatric surgeons Two bariatric surgery fellows Adult and pediatric obesity medicine specialist Pulmonologist and cardiologist Two dietitians Two psychologists Three ARNP Exercise physiologist