Metabolic and Bariatric Surgery: Expected Outcomes, Merits Philip Omotosho, MD Assistant Professor of Surgery Rush Medical College

Review bariatric surgery as a treatment for morbid obesity Objectives Review bariatric surgery as a treatment for morbid obesity Review the indications for bariatric surgery Review the impact of bariatric surgery on co-morbidity resolution

Body Mass Index (BMI) = Weight (Kg) / Height (m2) Definition of Obesity Body Mass Index (BMI) = Weight (Kg) / Height (m2) Underweight < 18.5 Normal 18.5 – 24.9 Overweight 25 – 29.9 Class I Obesity 30 – 34.9 Class II Obesity 35 – 39.9 Morbid Obesity ≥ 40 Super Obesity ≥ 50

Prevalence. of Self-Reported Obesity Among U. S Prevalence* of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2013 *Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011. CA MT ID NV UT AZ NM WY WA OR CO NE ND SD TX OK KS IA MN AR MO LA MI IN KY IL OH TN MS AL WI PA WV SC VA NC GA FL NY VT ME HI AK NH MA RI CT NJ DE MD DC PR GUAM 15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%

World Health Organization Fact Sheet Key Facts Worldwide obesity has more than doubled since 1980 In 2008, 1.5 billion adults, 20 and older were overweight. Of these over 200 million men and nearly 300 million women were obese 65% of the world’s population live in countries where overweight and obesity kills more people than underweight Nearly 43 million children under the age of five were overweight in 2010 Obesity is preventable

Gray DS., Med Clin North Am. 1989; 73(1):1–13 Mortality risk associated with morbid obesity   2.5 2.0 1.5 1.0 20 25 30 35 40 BMI Mortality Ratio Moderate Very Low Low High Very High Men Women X Untreated Gray DS., Med Clin North Am. 1989; 73(1):1–13

Indications for bariatric surgery: 1991 NIH Consensus Development Conference on Gastrointestinal Surgery for Severe Obesity Although weight may be reduced acceptably with non-surgical means, most patients fail to maintain a reduced weight Indications for bariatric surgery: BMI ≥ 40 BMI ≥ 35 plus associated significant obesity-related comorbidity Failure of non-surgical weight loss attempts

Adjustable Gastric Banding Sleeve Gastrectomy Combined Modality Classification Restrictive Adjustable Gastric Banding Sleeve Gastrectomy Combined Modality (Both restrictive and malabsorptive mechanisms) Roux-en-Y Gastric Bypass Biliopancreatic Diversion with Duodenal Switch

Beyond Weight Loss Appetite Control Glucose and Lipid Metabolism Insulin Homeostasis Regulatory Peptides Surgically-induced changes in the entero–encephalic endocrine axis (Metabolic Surgery)

Adjustable Gastric Banding

FDA approved in 2001 for implantation in the United States Adjustable Gastric Banding FDA approved in 2001 for implantation in the United States Non-resectional Placed just below the esophagogastric junction, creating a “virtual pouch” Adjusted via subcutaneous access port

Subcutaneous Port / Huber needle

Sleeve Gastrectomy

Risk management strategy for severely obese or high risk patients Sleeve Gastrectomy Originally performed as the restrictive component of the duodenal switch procedure Risk management strategy for severely obese or high risk patients Substantial improvement in comorbidities in 1-2 yrs followed by a second-stage operation – RYGB or BPD/DS Early reports emerged of substantial weight loss with sleeve gastrectomy alone

Reduced stomach capacity (small pouch) Malabsorptive limb No resection Roux-en-Y Gastric Bypass Reduced stomach capacity (small pouch) Malabsorptive limb No resection Weight loss from both restriction and malabsorption Considered the gold standard for bariatric surgery

Biliopancreatic Diversion with Duodenal Switch

Buchwald Meta-analysis 22,094 patients Operative mortality Surgical Risk – Perioperative Mortality Buchwald Meta-analysis 22,094 patients Operative mortality Restrictive procedures 0.1% RYGB 0.5% BPD/DS 1.1% Buchwald H, et al: Bariatric Surgery: A systematic review and meta-analysis. JAMA 292:1724-1737, 2004

Surgical outcomes – Risk N Engl J Med 2009;361:445-54.

Christou et al. Ann Surgery 2004 Surgical outcomes Surgery decreases long-term mortality, morbidity, and healthcare use in morbidly obese patients Total direct healthcare cost for control patients was 45% HIGHER than for bariatric surgery patients 5-year mortality rates 0.68% bariatric surgery patients 6.17% control patients Lower number of hospitalizations, hospital LOS, physician visits 89% risk reduction in 5-yr mortality Christou et al. Ann Surgery 2004

Sjöström et al. N Engl J Med. 2007; 357 (8): 741-52 Outcomes of bariatric procedures Sjöström et al. N Engl J Med. 2007; 357 (8): 741-52

Sjöström et al. 357 (8): 741, NEJM ; August 23, 2007 Long-term Weight Loss Outcomes: SOS Study With long-term follow-up out to 15 years, the Swedish Obesity Study confirmed sustained weight loss (CLICK) in gastric bypass patients compared to the minimal effects of medical therapy. Sjöström et al. 357 (8): 741, NEJM ; August 23, 2007

Bariatric Surgery Efficacy – Weight Reduction Emphasize BMI decrease

Sleeve Gastrectomy 50-60% EWL at 1 year Some studies report EWL ~ 80% at 1 year (Schauer) Long term results? 84% EWL | 3yrs | Boza et al. Mean preop BMI 37 55% EWL | 5 years | Bohdjalian et al. Mean preop BMI 48.2 48% EWL | 8 years | Eid et al. Mean preop BMI 66

Hutter MM et al. Ann Surg 2011; 254:410-20 Reduction in BMI This slide is mainly here to show how LSG compares. 12 month. Hutter MM et al. Ann Surg 2011; 254:410-20

Obesity and Diabetes Risk 100 Overweight 19 Obese 30 Morbidly Obese 45-65 Incidence of New Cases per 1000 Persons/Year 80 - 60 40 20 <20 20-25 25-30 30-35 35-40 >40 BMI Levels Knowler WC et al. Am J Epidemiol 1981 25

Classic Pathogenesis of Type II Diabetes 1 Excess Energy Intake Diminished Energy Expenditure 2 Increase Body Weight Increase Insulin Resistance 3 Type II Diabetes

Evidence Based Pathogenesis of Type II Diabetes Environment Genetic Behavior Perturbation of energy/glucose homeostasis Evidence Based Pathogenesis of Type II Diabetes Look up data here. Obesity Diabetes

Surgical Treatment of Diabetes Cohort of 42 pts with Type 2 DM Post-operative normalization of fasting blood glucose, fasting insulin, and HbA1c Improvement in insulin release, insulin resistance and utilization of glucose Ann Surg 1987; 206(3):316-23

(95% Confidence Interval) Type 2 DM Remission % Resolution (95% Confidence Interval) 989 83.8 (77.3, 90.1) Gastric Bypass 205 Gastric Banding 47.9 (29.1, 66.7) HbA1c; fasting glucose; fasting insulin 288 Duodenal Switch 98.9 (96.8, 100.0) 20 40 60 80 100 Buchwald, H. et al. 2004 Bariatric surgery: a systematic review and meta-analysis

Surgery (N=30) Control (N=30) LAGB: Weight Loss and Diabetes Remission Surgery (N=30) Control (N=30) Remission in % (N) 73% (22/30) 13% (4/30) Achieving A1C < 6.2% in % 80% (N=24) 20% (N=6) Medication use (N) 4 28 Weight loss (mean±SD) in % 20±9.4 1.4±4.9 Excess wt loss (mean±SD) % 62.5 4.3 Change in BMI (kg/m2) - 7.4 - 1.5 Main problem with this study: Relatively mild diabetes, short, < 2 year duration. Dixon, JB et al. JAMA 2008;299:316-323

Copyright © 2012 Massachusetts Medical Society. N Engl J Med 2012. Copyright © 2012 Massachusetts Medical Society.

Schauer P. et al.

Schauer P. et al.

Schauer P. et al.

Copyright © 2012 Massachusetts Medical Society. N Engl J Med 2012. Copyright © 2012 Massachusetts Medical Society.

Mingrone G. et al

Bariatric Surgery Efficacy – Hyperlipidemia

Bariatric Surgery Efficacy – Obstructive Sleep Apnea

Efficacy – Pseudotumor Cerebri Sugerman, H. et al. Ann Surg 1999; Vol. 229(5): 634–642

Malik SM et al. World J Diabetes 2012; 3(4): 71-79 Bariatric Surgery Efficacy – PCOS “Bariatric surgery should be considered along with other medical and life-style alterations as first line therapy in PCOS women with obesity and MS.” Malik SM et al. World J Diabetes 2012; 3(4): 71-79

Efficacy – Cardiovascular Morbidity Torquati et al. J Am Coll Surg 2007;204:776–783

Efficacy – Cardiovascular Morbidity Framingham risk score Torquati et al. J Am Coll Surg 2007;204:776–783

Anatomic Modifications Result in Alteration of GI Hormone Activity ,

The Entero-Insular Axis The Foregut Theory Exclusion of the duodenum results in inhibition of a putative signal that is responsible for insulin resistance and/or abnormal glycemic control (T2DM) Rubino et.al, Ann Surg, 2006

The Entero-Insular Axis The Hindgut Theory The more rapid delivery of undigested nutrients to the distal bowel upregulates the production of L-cell derivatives such as GLP-1 Free fatty acids? Unlikely. Adipokines? Maybe. Our study - correlation between Si and decreased total body fat but not Changes in free fatty acids Mason E. Obes Surg 2005 15, 459-461

Conclusion ‘…Reflects the enormous positive effects of bariatric surgery on the metabolic complications of severe obesity, including type 2 diabetes mellitus, sexual hormone dysfunction in both men and women (polycystic ovarian syndrome), non-alcoholic liver disease, and lipid metabolism (both cholesterol and triglycerides), but maintains in its name the positive effect of weight loss on pressure-related phenomenon (baros or bariatric) such as joint disease, GERD, urinary incontinence, obesity hypoventilation, venous stasis disease, and pseudotumor cerebri.’ Harvey Sugerman, MD