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

2. 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

3. 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

4. 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 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% %–<25% %–<30% %–<35% ≥35%

5. 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

6. 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

7. 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

8. 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

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

10. Adjustable Gastric Banding

11. 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

12. Subcutaneous Port / Huber needle

13. Sleeve Gastrectomy

14. 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

15. 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

16. Biliopancreatic Diversion with Duodenal Switch

17. 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: , 2004

18. Surgical outcomes – Risk
N Engl J Med 2009;361:

19. 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

20. 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):

21. 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

22. Bariatric Surgery Efficacy – Weight Reduction
Emphasize BMI decrease

23. 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

24. 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

25. 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

26. Classic Pathogenesis of Type II Diabetes1
Excess Energy Intake
Diminished Energy Expenditure 2
Increase Body Weight
Increase Insulin Resistance 3
Type II Diabetes

27. 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

28. 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

29. (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

30. 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:

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

32. Schauer P. et al.

33. Schauer P. et al.

34. Schauer P. et al.

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

36. Mingrone G. et al

37. Bariatric Surgery Efficacy – Hyperlipidemia

38. Bariatric Surgery Efficacy – Obstructive Sleep Apnea

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

40. 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

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

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

44. Anatomic Modifications Result in Alteration of
GI Hormone Activity ,

45. 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

46. 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 ,

47. 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