1. 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

2. The Problem

3. The BIG Secret !

4. Current Surgical Management

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

7. 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

8. 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

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

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

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

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

14. Band Adjustment
Deflated
Post-Adjustment

15. 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 %

16. 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

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

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

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

20. 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 %
Death : ~ 0.1 %

21. 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

22. Measuring Success

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

24. 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

25. 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

26. 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:
Torquati et al. J Am Coll Surg 2007;204:
Kligman et al. Surgery 2008;143:533

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

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

29. Measuring Success — Part 2
Comparison to Medical Therapy

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

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

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

33. 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 %
Fair %
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:
Reinholt RB Surg Gynecol Obstet 1982; 155:

34. 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

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

36. 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:

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