1. BED Eating Disorder: 5: Bariatric surgery
James E Mitchell, M.D.
Feel free to re-title and remove Penn specific stuff

2. Gastric Band

3. Roux-en-Y Gastric Bypass

4. Sleeve Gastrectomy

5. (Dietrich MO & Horvath TL © 2010 Nature Publishing Group)

6. + - ↑ Mechanism Band RYGBP Sleeve Δ Restriction Malabsorption GLP-1
PYY3-36
Bile Acids/
FXR; TGR 5/
Gut Microbiota Δ

10. Weight Change by Time Point
LAGB
14.5%
( )
Abbreviations: RYGB, Roux-en-Y gastric bypass; LAGB, laparoscopic adjustable gastric band.
Lines indicate modeled weight change based on mixed models, adjusted for baseline factors independently related to missing
follow-up data (i.e., site, age and smoking). Data markers, median values; bars, interquartile range of observed data.
Negative value indicates weight loss from baseline.
a Data collection ended before the 7 year assessment of 498 RYGB and 202 LAGB participants
Observed and modeled data are also reported in eTable 2 (Supplement).
RYGB
27.7%
( )

11. Prevalence of Comorbid Conditions - RYGB
Abbreviations: HDL, high-density lipoprotein cholesterol; RYGB, Roux-en-Y gastric bypass; LAGB, laparoscopic adjustable gastric band.
Lines indicate modeled prevalence, bars, 95% CI, based on mixed models, adjusted for baseline factors independently related to missing follow-up data (i.e., site, age and smoking).
aComorbidities were not assessed at 6 months or year-6.
bData collection ended before the 7 year assessment of 498 RYGB and 202 LAGB participants.
Observed and modeled data are reported in eTable 4 and eTable 5, respectively (Supplemental Material).

12. LABS I
Characteristic %
Medications in last 90 days:
Beta-blocker
17.9
Statin/lipid lowering agent
26.6
Oral/IV immunosuppressant
3.1
Therapeutic anticoagulation
4.4
Narcotic
16.1
Antidepressant
39.9

13. Sertraline/Duloxetine Protocols
Overview
Pharmacokinetic profile - single dose
Sertraline (100mg)
Duloxetine (60mg)
Groups of subjects
Post-RYGBP months
Nonsurgical matched subjects (BMI, Gender, Age)
Genetically typed Cytochrome P450 enzymes
Excluded ultra rapid and poor metabolizers

14. Sertraline Mean AUC
(Roerig et al. SOARD 8:62-66, 2012)

15. Duloxetine Mean AUC
ng/ml
(Roerig et al. J Clin Psychopharm 2014)

16. Alcohol Pharmacokinetic Changes
RYGB
RYGB
RYGB
(Klockoff et al. Br J Clin Pharm, 2002)
(Hagedorn et al. SOARD, 2007)
RYGB
Added title
Hagedorn graph not level but I can’t straighten.
(Woodard et al., J Am Coll Surg 2011)

17. Alcohol Pharmacokinetic Changes
RYGB
(Steffen et al., SOARD 9: , 2013)

18. Post-RYGB Cumulative Incidence
The 5-year cumulative incidence of AUD, illicit drug use and SUD treatment were 20.8% (95%CI, ), 7.5% (95%CI, ) and 3.5% (95%CI, ), respectively, following RYGB (Figure 2A) and 11.3% (95%CI, ), 4.9% (95%CI, ), and 0.9% (95%CI, ), respectively, following LAGB (Figure 2B).

19. Why Increase in Misuse of ETOH ???
Pharmacokinetic Change?
Central Nervous System Change? (Alteration in DA Reward Pathway; Ghrelin Modulation?)
Alcohol Dehydrogenase Reduction?
Other? Multifactorial?

20. in Bariatric Surgery Patients
Chronic Opioid Use
in Bariatric Surgery Patients
N = 11,719 Adults S/P Bariatric Surgery
N = 933 Chronic Opioid Users Pre-surgery
N = 723 Chronic Opioid Users Post-surgery
(Raebel et al., JAMA, 2013; 310: )

21. (Raebel et al., JAMA 310: , 2013)

22. Pre-surgery
15 Days Post
6 Month Post
(Lloret-Linares et al., Clin Pharmacokinet 53: , 2014)

23. Body Contouring Surgery

27. Desire for Contouring
Ross: Does this include participants who had contouring in other regions? Or were all participants who underwent any contouring surgery thrown out?
Add exact percentages to one decimal point.

28. Primary Reasons for Not Undergoing Contouring
ROSS: TWO DIFFERENT OUTPUTS FOR THIS SLIDE. ONE WITH ALL PARTICIPANTS, AND ONE WITH PARTICIPANTS DESIROUS OF CONTOURING? This appears to be all participants (n=949) whereas the other output has n=664.
Add percentages.

29. Compensatory Behaviors
N=12 Post-bariatric Surgery Inpatients on an ED Unit
Age
Adm
BMI
(pre-surg)
BMI (Adm)
Binge Eating
Compensatory Behaviors
DSM-V 1 65
58.6
23.8 X
Vomiting
AN-P 2 52
79.4
33.9
Over-exercise
EDNEC (Atypical AN-R) 3 31
48.7
29.6 4
42.4
17.4 O ?? 5 64
47.4
21.2
EDNEC (Atypical AN-R) 6 23
66.2
39.6 BN 7 69
43.1
28.8 8 29
43.6
27.9
Vomiting, Lax/ Diuretics 9 61
40.6
21.1
Diuretics 10
13.1
AN-B/P 11 26
44.8
17.3
Diet Pills
AN-R 12 38
45.2
19.8
(Conceicao et al, Int J Eat Disord 2014)

30. Long-term Mortality after Gastric Bypass Surgery at 7.1 Years
Reduced overall mortality 40% (sig)
Reduced CAD mortality 56% (sig)
Reduced DM mortality 92% (sig)
Reduced CA mortality 60% (sig)
Suicide risk/accidents increased 3x (n.s.)
(Adams et al., NEJM 357: , 2007)

31. Suicide After Bariatric Surgery
Pennsylvania State Dept. of Health Statistics
Residents
(Tindle et al Am J Med 123: , 2010)

32. Suicide After Bariatric Surgery
Males per 10, (US norms 2.4)
Females per 10,000
(US norms 0.7)
(Tindle et al Am J Med 123: , 2010)

33. Distribution of Time Between Bariatric Surgery and Suicide in Years
Cumulative %
<1 3 10
1-<2 6 29
2-<3 12 68
3-<4 77
4-<5 87
>5 4
100
Total 31
(Tindle et al Am J Med 123: , 2010)

34. Suicide after Bariatric Surgery
- Persistence/recurrence medical comorbidities - Disinhibition 2nd EToH - Antidepressant medication malabsorption - Peptidergic CNS effects (e.g. GLP-1) - Microbiome changes affect CNS - Disappointment with weight/other outcomes - Worsening depression - Were high risk group pre-operatively
(Mitchell, et al., Obesity, 2014)

35. Comment/Questions?