Options for Obesity and Long-Term Results Bariatric Surgery Mark Kligman, M.D. Assistant Professor, Surgery Director, Center for Weight Management & Wellness University of Maryland, School of Medicine

The Problem

The BIG Secret !

Current Surgical Management

High risk health problems Indications Standard Criteria Age 18 – 65 years + BMI ≥ 40 kg/m2 Special Criteria Age 18 - 65 + BMI 35 - 40 kg/m2 High risk health problems

The Surgery Timeline OR 1 2 3 4 5 6 7 8 9 10 Initial Contact Educational Seminar Preoperative Office Visit Consent Written examination Submit Request for Preauthorization Initial Office Visit Bariatric surgery booklet Preoperative Workshop Dietician Evaluation 6 month supervised diet Nutrition education 1 2 3 4 5 6 7 8 9 10 Laboratory evaluation CBC, Chem, LFT, cholesterol, triglycerides Vit D, Vit B12, TFT, adrenal function tests Pulmonary evaluation: CXR, sleep study, PFT, ABG EKG, Stress test, echocardiogram UGI, GB U/S, EGD, Colonoscopy Pap, Mammogram Consultation: psychologist / psychiatrist Cardiology Anesthesia Pulmonary Gastroenterology Endocrine

Current Operative Approaches Adjustable Gastric Banding Sleeve Gastrectomy Biliopancreatic Diversion with Duodenal Switch Roux-en-Y Gastric Bypass Malabsorption Restriction More Weight Loss Less More Risks Less

Biliopancreatic Diversion with Duodenal Switch (BPD-DS) General Features Gastric pouch size: Standard: 300 mL Three segments Alimentary tract: 200-250cm Biliary tract: 250 cm Common channel: 50-150 cm Average Weight Loss 70 - 90 % of excess weight

Risks Associated with Duodenal Switch Protein malnutrition 15% Anemia < 5 % Marginal ulcer < 3 % Peripheral neuropathy 1.3 % Night Blindness 3 % Osteoporosis 14 % Renal stones Nausea 65 % Diarrhea 62 % Vitamin deficiencies: A, D, E, K, B12 Bowel obstruction Incisional hernia 10 % Death 1.1%

Adjustable Gastric Banding (AGB) Fill Port Portion of Band which wraps around stomach Realize™ LapBand™

Adjustable Gastric Banding GENERAL FEATURES Inflatable balloon can be adjusted using a port under the skin Average Weight loss 30 - 50% of excess weight

Band Adjustment Deflated Post-Adjustment

Risks Associated with Gastric Banding Injury to esophagus, stomach, spleen Migration of implant (band erosion, band slippage, port displacement)* Tubing-related complications (port disconnection, tubing kinking) * Band leak Esophageal spasm Gastroesophageal reflux disease (GERD) Port-site infection Death 0.1 % * Re-operation 5 -20 %

Vertical sleeve gastrectomy May be an option for carefully selected patients, including high-risk or super-super-obese patients1. Use: Primary operation Staged operation Mean %EWL at 1 yr: 59%2 No implanted medical device ASMBS, Position Statement on Sleeve Gastrectomy as a Bariatric Procedure. June 17, 2007. Lee CM, et al. Surg Endosc (2007) 21: 1810–1816

Risks Associated with Sleeve Gastrectomy Leak * 2.2 % Stricture * 0.6 % Gastroesophageal reflux disease (GERD) Delayed gastric emptying 0.2 % Wound infection Re-operation 6 % Death 0.19 % Obesity Surgery 2007, 17:962-969 Obesity Surgery 2009, 19:1672–1677 Surg Obes Relat Dis 2010; 6: 1–5

Sleeve Gastrectomy: Unresolved Issues Standardization of operation Optimal sleeve diameter Location of the sleeve termination Durability as a primary operation

Roux-en-Y Gastric Bypass (RYGBP) General Features Pouch size: 15 – 30 ml Pouch opening: 10 mm Roux-en-Y limb 70-150 cm Average EWL: 60 – 80%

Risks Associated with Gastric Bypass Early: Staple line leak <1 % Acute gastric distention Roux-Y obstruction Late: Stomal Stenosis <5 % Marginal ulcer ~5 % Anemia Folate deficiency Vitamin B12 deficiency Iron deficiency Calcium deficiency / osteoporosis Gallstones 10 % Death : ~ 0.1 %

Which Operation? Roux-en-Y Gastric Bypass Sleeve Gastrectomy Adjustable Gastric Banding Weight Loss (% EWL) 80 50 40 Time to achieve maximal weight loss (years) ~1 2-3 Number of Office visits (1st year) 4 6-8 Improvement of obesity-associated health problems Excellent Very Good Reversibility + / ─ ─ + Safety Risk of nutritional complications Moderate (easily correctable) Minimal

Measuring Success

Measuring Success — Part 1 Impact of surgery on: Weight Co-morbidities Mortality

Weight Maintenance 10 Years after Bariatric Surgery The SOS Study Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26

Effect of Gastric Bypass on Cardiac Risk Factors Preoperative Postoperative BMI (kg/m2) 46.9 ± 5.8 28.7 ± 4* Cholesterol (mg/dl) 202 ± 37 165 ± 29* LDL-Cholesterol (mg/dl) 118 ± 33 97 ± 26* HDL –Cholesterol (mg/dl) 45 ± 11 51 ± 11* Systolic BP (mmHg) 143 ± 20 123 ± 18* Diastolic BP (mmHg) 81 ± 10 71 ± 11* * p <0.0001 Kligman MD et al. Surgery 2008;143:533

Impact of Gastric Bypass on Cardiac Risk 10-year Risk of Cardiac Event (%) Pre-operative Post-operative Vogel 2007 6 3 Torquati 2007 5.4 2.7 Kligman 2008 6.7 3.2 Vogel et al. Am J Cardiol 2007;99:222-26. Torquati et al. J Am Coll Surg 2007;204:776-82. Kligman et al. Surgery 2008;143:533

Impact of Bariatric Surgery on Mortality Death Rates Adams et al. N Engl J Med 2007 357 753

Impact of Bariatric Surgery on Mortality The SOS Study Sjöström et al. N Engl J Med 2007;357:41

Measuring Success — Part 2 Comparison to Medical Therapy

Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes Schauer et al. N Engl J Med 2012;366:1567-76.

Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes Schauer et al. N Engl J Med 2012;366:1567-76.

Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes Schauer et al. N Engl J Med 2012;366:1567-76.

Measuring Success—Part 3 Weight Loss Traditional approach Final BMI: <35 for morbid obesity (starting BMI < 49) <40 for superobesity (Starting BMI > 50) Percent EWL: Excellent ≥75% Good 50-74% Fair 25-49% Poor <25% Co-morbidity Resolution Current approach The “real” goal of bariatric surgery is the reduction of life-threatening co-morbidity Biron S et al. Obes Surg 2004; 14: 160-164 Reinholt RB Surg Gynecol Obstet 1982; 155: 385-394

Remission Rate of Type 2 Diabetes is Associated with Greater Weight Loss Following Gastric Bypass gbp Kadera BE et al. Surg Obes Relat Dis 2009; 5:305–309

Remission Rate of Type 2 Diabetes is Associated with Greater Weight Loss Following Sleeve Gastrectomy EWL (%) Surg Obes Relat Dis 2009; 5: 429-434.

Does the Type of Procedure Influence the Improvement in Co-morbidities? Gastric Banding Gastric Bypass BPD±DS EWL (%) 47.5 61.6 70.1 Remission DM (%) 47.9 83.7 98.9 Buchwald et al. JAMA 2004;292:1724-1737

“[Weight loss] isn't everything, it's the only thing” --Vince Lombardi