Bariatric Surgery Anwar Ali Jammah PGY5

Case BR a 32y old women with BMI of 39.2 kg/m2. Obese science childhood and get very little exercise. She has been unable to lose weight despite multiple diets, and regains weight rapidly after each diet. Her medical history includes Type 2 Dm on OHA.

World Health Organ Tech Rep Ser 2000

Diet, and lifestyle Who should receive counseling on diet, lifestyle, and goals for weight loss. –All patients who are overweight (BMI ≥ 27 kg/m2) or obese (BMI ≥30 kg/m2). –Patients with a BMI of > 25 kg/m2 who have an increased waist circumference (>40 inches/102 cm in men or >35 inches/88 cm in women) or with comorbidities.

Life style modification Body composition changes in obese adults following diet, exercise or diet plus exercise intervention Diet and exerciseExerciseDietVariable 11.0 ± ± ± 0.5Weight lost, kg 7.3 ± ± ± 1.0% of body fat decrease 8.6 ± ± ± 0.5 Weight loss maintained at one year Tremblay, A, Despres, J, Maheux, J, et al, Med Sci Sports Exerc 1991;

Well designed, intensive lifestyle intervention typically achieve a weight loss of 8% to 10% and patient usually regain weight when the intervention ands.

Case BR Wt. decreased by 6% and then eventually stabilized. Her internist added pharmacotherapy to her weight loss regimen.

Net effect of drug trials for anti-obesity drugs FDA approval Weight loss kg (mean and 95% CI) Duration of studiesDrug Yes-2.75 (-3.32 to -2.20)52 wkOrlistat Yes-4.45 (-5.29 to -3.62)52 wkSibutramine Yes-3.6 (-6.0 to -0.6)2 to 24Phentermine Yes-3.0 (-11.5 to 1.6)6 to 52Diethylpropion Li Z, Maglione M, Tu W, et al. Ann Intern Med 2005

BR’ weight decreased and her comorbidities improved and she reduced her OHA dosage over 6 months of therapy. Her weight maintained for 2 months i.e. no further reduction.

case After 8 months she discontinued the drug therapy and did not follow the life style recommendation as before. Her weight went up again and started on insulin to control the blood sugar. BMI now is 41.3 kg/m2. She states that her obesity hurts he quality of life both socially and at work.

Bariatric Surgery Indications: –Have a BMI >40. –Adults with a BMI >35 who have serious comorbidities: Diabetes. Sleep apnea. Obesity-related cardiomyopathy. Severe joint disease. –Be well-informed and motivated. –Have acceptable risk for surgery. –Have failed previous non-surgical weight loss. National Institutes of Health (NIH) Consensus

Bariatric Surgery Contraindications: –Untreated major depression or psychosis. –Binge eating disorders. –Current drug and alcohol abuse. –Severe cardiac disease with prohibitive anesthetic risks. –Severe coagulopathy. –Inability to comply with nutritional requirements including life-long vitamin replacement. Bariatric surgery in advanced (above 65) or very young age (under 18) is controversial. National Institutes of Health (NIH) Consensus

AACE/TOS/ASMBS Bariatric Surgery Guidelines, Endocr Pract. 2008;14(No. 3)

Comorbidities –Hypertension. –Impaired glucose tolerance. –Diabetes mellitus. –Dyslipidemia. –Sleep apnea. AACE/TOS/ASMBS Bariatric Surgery Guidelines, Endocr Pract. 2008;14(No. 3)

Types of bariatric procedures Restrictive Vertical banded gastroplasty Laparoscopic adjustable gastric band Sleeve gastrectomy Malabsorptive Jejunoileal bypass Biliopancreatic diversion Biliopancreatic diversion with duodenal switch Combination of restrictive and malabsorptive Roux-en-Y gastric bypass

Vertical banded gastroplasty R Laparoscopic adjustable gastric band LAGB. R Jejunoileal bypass M Biliopancreatic diversion with duodenal switch M

Roux-en-Y gastric bypass (RYGB) R & M Biliopancreatic diversion M

Atul K Madan 2007

Technology Assessment Unit of McGill University Health Centre, 2004 enough evidence to indicate that LAGB is effective procedure with adequate safety record of up to 5 years while there is insufficient evidence to determine whether LAGB is a superior procedure to LRYGB, there are incidences where it is safer Australian Safety and Efficacy Register of New Interventional Procedures- Surgical (ASERNIP- S), 2002 comparative studies suggest that RYGB produces more weight loss than LAGB and VBG at least up to 2 years; after 2 years, advantage only seen between RYGB and VBG all 3 procedures resulted in considerable weight-loss up to 4 years post- surgery LAGB found to be safer in terms of short-term mortality rates

Alberta Heritage Foundation for Medical Research (AHFMR), 2000 concluded that RYGB was gold standard to treat morbid obesity early attempts at LAGB show high rate of complications and re- operations well-designed studies with at least 5-years follow-up will determine if LAGB will become more mainstream LAGB should become accepted option

Procedure-related Complications –Bleeding –Infection –Incisional hernia –Anastomotic, gastric pouch or duodenal leaks –Anastomotic or stomal stenosis –Perforation of a major blood vessel or organ

AACE/TOS/ASMBS Bariatric Surgery Guidelines, Endocr Pract. 2008;14(No. 3)

complications Dumping syndrome : –Cramping –Nausea –Diarrhea –Lightheadedness –Palpitations –Sweating Gallstones which can occur in anyone who loses weight rapidly. Ulcers at the margin of the anastomosis between the stomach and the pouch, may cause IDA. Drug absorption rates may change: –reduction in intestinal surface area. –changes in gastric pH.

G. Darby Pope Surg Innov 2006; 13; 265

Weight lost: –60%(95% CI 58-64%) of excess Wt. loss, varying according to the specific the procedure. Gastric banding < Gastricbypass < Gastroplasty < Biliopancreatic diversion or duodenal switch. 30-day mortality was: –0.1 % for purely restrictive procedures. –0.5 % for gastric bypass. –1.1 % for biliopancreatic diversion or duodenal switch. Diabetes: –completely resolved in 77 % and resolved or improved in 86 %. Hyperlipidemia: –improved in 70 % or more of patients. Hypertension: –resolved in 62 % and resolved or improved in 79 %. Obstructive sleep apnea: –resolved in 86 % and resolved or improved in 84 %.

Ghrelin Stimulates appetite and induces a positive energy balance that can lead to weight gain. Induces adiposity that is sustained as long as the levels is elevated. Activates neuropeptide Y (NPY) and agouti-related protein- producing neurons in the arcuate nucleus of the hypothalamus. Stimulates gastric contraction and enhances stomach emptying. Affect bone metabolism. osteoblasts have been shown to express the ghrelin. Ghrelin stimulates both osteoblast cell proliferation and differentiation.

Peptide YY Peptide YY(3–36) a gut-derived hormone. Reduces food intake over the short term. Obese persons have been found to have lower baseline PYY levels than lean persons. PYY deficiency may has a role in the pathogenesis of obesity.

OBESITY February 2006 Chan JL; Obesity (Silver Spring) Korner J. JClin Endocrinol Metab Alvarez Bartolome Obes Surg This post-prandial increase in PYY is not reported after an adjustable gastric band. series of 12 patients undergoing the vertical banded gastroplasty reported an increase in fasting and postprandial PYY after surgery.

Copyright ©2005 The Endocrine Society Korner, J. et al. J Clin Endocrinol Metab 2005;90: FIG. 2. Circulating concentrations of PYY in response to a liquid test meal (A); peak levels of PYY (B); AUC of PYY at 90, 120, and 180 min post meal (C), determined in lean, RYGBP, and BMI-matched groups

J Clin Endocrinol Metab, May 2006, 91(5):1735–

Effect of weight loss by gastric bypass surgery versus hypocaloric diet on glucose and incretin levels in patients with type 2 diabetes J Clin Endocrin Metab

DIABETES CARE, VOLUME 30, NUMBER 7, JULY 2007

Dixon JAMA Adjustable Gastric Banding and Conventional Therapy for Type 2 Diabetes. A Randomized Controlled Trial Published in JAMA Jan 23, 2008 Unblinded randomized controlled trial conducted from December 2002 through December 2006 in Australia. 60 patients (BMI >30 and <40) recently diagnosed (<2 years) type 2 DM. 2-years follow-up. Remission of type 2 diabetes was achieved by 22 (73%) in the surgical group and 4 (13%) in the conventional-therapy group. Surgical and conventional-therapy groups lost a mean (SD) of 20.7% (8.6%) and 1.7% (5.2%) of weight, respectively, at 2 years (P <.001). Remission of type 2 diabetes was higher in patient with: More weight loss Lower baseline HbA1c levels

conclusion Bariatric surgery frequently result in resolution of obesity-related comorbidities (40 to 90% of patients). This is significantly more effective than other interventions Possible mechanisms of this resolution includes: –Weight Loss –Decrease food intake. –Changes in gut hormones secreation

Bariatric surgery is powerful tool for management of obesity and its related comorbidities if all of the following factors assured: –Proper patient selection. –Good surgeon and right type of procedure. –Life long follow up including: »Monitoring of complications. »Nutritional monitoring. »Adjustment of medications. »Counseling. Required multidispinary approach. Several studies suggest that patient with poor follow-up have worse outcomes.

Weight loss with recombinant methionyl human leptin Heymsfield, SB, JAMA 1999