1. Bariatric Surgery Christopher Joyce, MD, FACS President
Illinois Association of Bariatric Surgeons
9/22/2018

2. Overview Obesity problem in America Bariatric Surgery overview
9/22/2018
Obesity problem in America
Bariatric Surgery overview
Surgical treatments
Direct Cardiac Effects
Impact on Metabolic syndrome
Impact on Mortality

3. What Is Morbid Obesity?
9/22/2018
Clinically severe obesity at which point serious medical conditions occur as a direct result of the obesity
Defined as >200% of ideal weight, >100 lb overweight, or a body mass index of ≥40

4. Body Mass Index (BMI) W.H.O. Classification BMI Ideal Weight 18-24.9
9/22/2018
W.H.O. Classification
BMI
Ideal Weight
Overweight
Moderate Obesity (Class I)
Severe Obesity (Class II)
Morbid Obesity (Class III)
(Super Obesity)
50+

5. Do You Know Your Own BMI? Weight (lbs) Height 9/22/2018 5'4" 5'2" 5'0"
5'10"
5'8"
5'6"
6'0"
6'2"
120
130
150
160
170
180
190
200
210
220
230
240
250
140
260
270
280
290
300
6'4"

6. NIH Criteria for Bariatric Surgery
9/22/2018
BMI > 40
BMI > 35 with comorbidities*
*Includes sleep apnea, cardiomyopathy, diabetes mellitus, hypertension, dyslipidemia, DJD
*BCBS of IL and Anthem (IN) require 2, all other insurers require 1

7. Obesity Trends* Among U.S. Adults BRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14%

8. Obesity Trends* Among U.S. Adults BRFSS, 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14% %–19%

9. Obesity Trends* Among U.S. Adults BRFSS, 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14% %–19%

10. Obesity Trends* Among U.S. Adults BRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14% %–19%

11. Obesity Trends* Among U.S. Adults BRFSS, 1994
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14% %–19%

12. Obesity Trends* Among U.S. Adults BRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14% %–19%

13. Obesity Trends* Among U.S. Adults BRFSS, 1996
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14% %–19%

14. Obesity Trends* Among U.S. Adults BRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14% %–19% ≥20%

15. Obesity Trends* Among U.S. Adults BRFSS, 1998
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14% %–19% ≥20%

16. Obesity Trends* Among U.S. Adults BRFSS, 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14% %–19% ≥20%

17. Obesity Trends* Among U.S. Adults BRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14% %–19% ≥20%

18. Obesity Trends* Among U.S. Adults BRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14% %–19% %–24% ≥25%

19. Multi-disciplinary Team
9/22/2018

21. Figure 1. Obesity, cardiac failure, and the beneficial role of bariatric surgery.
Figure 1. Obesity, cardiac failure, and the beneficial role of bariatric surgery. RV indicates right ventricular; LV, left ventricular.
Ashrafian H et al. Circulation 2008;118:
Copyright © American Heart Association

22. Figure 2. Mechanisms of atherosclerosis and the beneficial role of bariatric surgery.
Figure 2. Mechanisms of atherosclerosis and the beneficial role of bariatric surgery. ICAM-1 indicates intercellular adhesion molecule-1; PAI-1, plasminogen activator inhibitor-1.
Ashrafian H et al. Circulation 2008;118:
Copyright © American Heart Association

23. Severe Cardiomyopathy
9/22/2018
EF<35%(n=14)
EF improved from 23% to 6 mos. (p=0.4)
NYHA dropped by 1 Class
50% EBWL
Decrease in BMI from 51 to 37
McCloskey, SOARD 2007 Pitt.

24. Improved Cardiac Function: Utah Obesity Study
9/22/2018
Owan, JACC Salt Lake

25. Obesity, T2DM, and Other Comorbidities
9/22/2018
Prospective Cohort Study: Sleeve vs Medical Rx
80% vs 0% Resolution of Diabetes
80% vs 0% Resolution of OSA
Hypertension and dyslipidemia medications cut in half
Leonnetti ARCH SURG, 8/12

26. 9/22/2018

27. Leonnetti ARCH
SURG, 8/12
9/22/2018

28. Natural history and metabolic consequences of morbid obesity for patients denied coverage for bariatric surgery
189 patients denied, 587 LRYGB
3-year follow-up
BMI increased from 47.3 to 46.8 in denied pts.
BMI decreased from 48.5 to 30.5 in bypass pts.
New-onset DM, HTN, OSA, GERD, and dyslipidemias higher in denied group(p<.001)
Harakeh AB. SOARD 2010,591-6

29. Fear of Bariatric Surgery
9/22/2018
Bariatric Surgery (1035 Patients)
Controls (5746 patients) n %
P Value
CV Event 49
4.7
1530
26.7
0.001
Cancer 21
2.0
487
8.5 DM 98
9.47
1566
27.3
Inf. Disease 90
8.7
2140
37.3
Death 7
0.68
354
6.2
Christou et al. McGill Univ Annals of Surgery, Sept. 2004

30. Surgery Decreases Mortality
9/22/2018
Author
Decreased Mortality
Mean f/u (yrs)
Christou
Ann Surg 2004
89% 5
Flum
JACS 2004
40%
4.4
Bussetto
SOARD 2008
60%
Sjostrom
NEJM 2007
30%
10.9
Adams
7.1

31. 40% reduction in death from any cause Disease Specific Mortality
9/22/2018
Long Term Mortality (retrospective study )
9949 surgical patients matched to 9628 non-surgical patients
40% reduction in death from any cause
Disease Specific Mortality
56% reduction from CAD
92% reduction from DM
60% reduction from cancer
Long Term Mortality (retrospective study ) 9949 patients in surgery arm matched to 9628 non-surgical

32. Walk in the shoes of the morbidly obese person for one day and you will understand their suffering.

33. Questions???