Treatment of Obesity and Metabolic Disease Thomas Magnuson MD Associate Professor of Surgery Johns Hopkins University School of Medicine tmagnusjhmiedu JHI Partners Forum 1022012 ID: 999583
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1. Bariatric Surgery for the Treatment of Obesity and Metabolic DiseaseThomas Magnuson MD Associate Professor of SurgeryJohns Hopkins UniversitySchool of Medicine (tmagnus@jhmi.edu)JHI Partners Forum 10/2/2012
2. DisclosureNothing to disclose
3. OBESITY SURGERYOVERVIEW Indications for surgery and patient selection Current surgical procedures to treat obesity Outcomes of surgery: Benefits and risks “Metabolic surgery” and impact on diabetes and cardiometabolic risk
4. Why are we talking about Obesity Surgery today?1) Rapid rise in prevalence of obesity2) Recognition of Obesity as a Disease3) Better operations for Obesity and public/physician awareness4) Increased focus on improvement/ resolution of metabolic disease
5. Treatment of ObesityDiet & ExerciseMedications Behavioral modificationSurgical management
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7. Explosion in Bariatric SurgeryOver 200,000 procedures in the U.S. in 2010
8. Purpose of Bariatric SurgeryTo alleviate or eliminate obesity related medical diseasesIt is not cosmetic surgery and patients may still be overweight after plateau in weight loss postop
9. Bariatric Surgery Patient Selection (Based On The 1991 NIH Guidelines)BMI > 40; or > 35 with obesity related morbidityPrevious failed attempts at supervised weight reductionRealistic expectations; no recent substance abuseAge limits (18 to 70 yrs old in most programs) Supportive family/friendsLifelong commitment to dietary change and follow-upPre-op evaluation by dietician and psychologist
10. 10Obesity Surgery Patient SelectionAdditional ConsiderationsAdolescents (? informed consent, compliance)Age > 70yo (higher risk, less medical benefit, ? Improved quality of life)“End stage obesity” (severe CHF, home oxygen, non-ambulatory, BMI>100)Bridge to other procedures (transplantation; joint replacement)Patients post-transplant (liver; kidney)Lower BMI patients (30-35) with diabetes/htn
11. 11Obesity Surgery Pre-Operative EvaluationInsurance approval (most require 6 month dietary program/counseling within previous 2 years)Mandatory Dietary and Psych evaluation/counselingCardiac/pulmonary “clearance” if significant historySleep apnea testing/treatment if high riskIn select patients- EGD, UGI, IVC filterStop smoking and estrogen products (BCP’s) prior to surgery (high risk for VTE)Most Bariatric Surgery is performed at “Centers of Excellence” certified by the ACS and ASMBS
12. OBESITY SURGERYOPERATIONS FOR MORBID OBESITYRESTRICTIVE OPERATIONSAdjustable Gastric Banding (ABG)Vertical Sleeve Gastrectomy (VSG)Gastric Bypass (GBP) (also malabsorptive)MALABSORPTIVE OPERATIONSGastric Bypass (GBP)Duodenal Switch-biliopancreatic diversion (DS-BPD)
13. Roux-en-Y Gastric BypassSmall gastric pouch (20-30 ml) (remainder of stomach left in)~100 cm of small bowel bypassed creating nutrient malabsorption
14. Laparoscopic Gastric Bypass
15. Gastric BypassDurable weight loss: 60 to 70% excess wt loss at 2 yrsProven reduction of obesity related medical problemsRisk of death low if done by experienced team (<0.5%)Most common operation in US with the most follow-up dataMarginal UlcerStomal stenosisAnemiaCalcium deficiencyNutrition/vitamin defic.Difficult to reversePROSCONS
16. Laparoscopic Gastric BandLaparoscopic procedure that is less invasive than gastric bypassAdjustable, depending on desired wt. lossWeight loss less than gastric bypass (40% excess wt. loss at 1yr post-op)
17. Adjustable Gastric BandReversible Least invasiveLowest risk of DeathNo malabsorptionAdjustable40 to 50 % excess weight loss at 2 yearsForeign body / erosionEsophageal dilationGERDBreakage/slippageFailure to lose weightSlower weight loss30-50% reoperation rate/removal long termPROSCONS
18. Laparoscopic Vertical Sleeve Gastrectomy
19. Vertical Sleeve Gastrectomy
20. Laparoscopic Vertical Sleeve GastrectomyDoes not involve intestinal rearrangementRestrictive only; 50-60% excess weight lossMay be used as a first step operation in high risk patients to induce weight loss before performing duodenal switch or gastric bypassCurrently considered for weight loss in lower BMI morbidly obese patients who do not want an adjustable band or a malabsorptive operation
21. Duodenal SwitchPartial stomach resectionAll of the bowel bypassed except 150-200 cm of distal small bowelPrimarily malabsorptive: risk of malnutrition, vitamin deficiency, diarrhea
22. Duodenal Switch w/ BPDBest wt loss (80% excess weight)Best resolution of metabolic diseasePylorus preservedLess restriction than GBPMalabsorption AnemiaCalcium deficieincy10 % may need revisionDiarrhea/malodorous stoolsProtein malnutrition? Liver diseasePROSCONS
23. Summary of Obesity SurgeryGastric bypass (60-70% of all procedures)Laparoscopic adjustable gastric band (LAGB) (20-30%) Lap Sleeve Gastrectomy (15-25%)Duodenal Switch w/ biliopancreatic diversion (5%)
24. The Johns Hopkins Center for Bariatric Surgery Over 3,000 bariatric procedures since 1997Age = 41 yo (18 - 74 yrs)Female = 77 %Pre-Op weight = 349 lbs (210 - 740 lbs)Pre-Op Body Mass Index (BMI) = 55.3 (39 - 101)Hospital stay (median) = 2 days (lap=2; open=3)Pre-Op obesity related disease:Osteoarthritis = 83 %Hypertension = 47 %GERD = 40 %Diabetes = 27 %Sleep Apnea (requiring CPAP) = 22 %Analysis of 1000 gastric bypass procedures:
25. Obesity Surgery At Johns Hopkins Weight Loss Excess body wt. loss 12 months = 120 lbs 61% 24 months = 134 lbs 67% 36 months = 133 lbs 66% 48 months = 133 lbs. 62% 60 months = 128 lbs. 64%Impact on Medical Disease (by 1 year post-op) Hypertension 73% resolution Diabetes 75% resolution GERD 91% resolution Sleep Apnea 93 % resolution
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27. OBESITY SURGERY AT JHBMCPOST-OP COMPLICATIONS(1000 gastric bypass pts.)Mortality = 0.2 % Morbidity = 13 % Wound infection = 6.5 % Pulmonary embolus = 0.9 % Reoperation (< 30 days) = 1.2 % Decubitus ulcers = 0.6 % Anastamotic leak = 0.2 % Bowel obstruction = 0.6 % Readmission = 8 %
28. 28OBESITY SURGERY Evidence based analysisIs bariatric surgery effective? Buchwald 2004 (meta-analysis): Resolution of % excess wt loss DM HTN Gastric Band 49% 48% 43% Gastric Bypass 61% 83% 67% DS/BPD 70% 98% 83%
29. 29OBESITY SURGERY Evidence based analysisIs bariatric surgery effective? Buchwald 2004 (meta-analysis): Resolution of % excess wt loss DM HTN Gastric Band 49% 48% 43% Gastric Bypass 61% 83% 67% DS/BPD 70% 98% 83% Swedish Obese Subjects Study (SOS) 2007 Longitudinal matched-control cohort study; over 10 yr f/u of 2,010 pts. - Sustained weight loss in the surgical cohort with reductions in diabetes, dyslipidemia, and HTN compared to matched controls
30. Mean % Weight Change over 15 Years Swedish Obesity StudySjostrom: NEJM 2007;357:741-52ControlBandsVBG’sRYGB30%
31. Ann Intern Med. 2009;150(2):94-103. Diabetes Remission after Bariatric surgery
32. N Engl J Med. 2012. Compared the efficacy of three treatments for patients with T2DM and BMI between 27-42 kg/m2:Intensive Medical Therapy* Intensive Medical Therapy* + Laparoscopic Sleeve GastrectomyIntensive Medical Therapy* + Gastric BypassPrimary Endpoint: Proportion of patients with a glycated hemoglobin level of 6.0% or less at 12 months after treatment.
33. Med therapy GBP SleeveN Engl J Med. 2012
34. Medication Utilization and Annual Health Care Costs in Patients With Type 2 Diabetes Mellitus Before and After Bariatric Surgery Makary, et alArchives of Surgery, 2010 Large multistate insurance claims dataset Jan 2002 – Dec 2005 2235 patients with diabetes undergoing bariatric surgery at least 1 year pre-op and post-op follow up
35. Results
36. Diabetes resolution: 1669 (74.7%) of 2235 pts at 6 months 1489 (80.6%) of 1847 pts at 12 months 906 (84.5%) of 1072 pts at 2 years
37. Prompt Reduction in Use of Medications for Comorbid Conditions After Bariatric Surgery Segal et al, Obesity Surgery, 2009-6025 pts. undergoing bariatric surgery-Early post-op reductionin HTN, DM, and lipid-lowering medications
38. Effect of Surgery on Long-term Mortality Compared to Non-Operated ControlsStudyProcedureF/UMortality ReductionMacDonald,1997RYGB9 yrs88%Flum, 2004RYGB4.4yrs33%Christou, 2004RYGB5 yrs89%Sowemimo, 2007RYGB4.4 yrs50%O’brien, 2006LAGB12 yrs73%Adams, 2007RYGB8.4 yrs40%Sjostrom (SOS), 2007VBG/RYGB14 yrs31%
39. “Metabolic Surgery” Future directions: Patient selection based more on metabolic disease as opposed to weight (? BMI of 30-35 or lower)Better understanding of metabolic and hormonal effects of surgeryDevelopment of less invasive procedures or drugs which achieve the desired physiologic/metabolic effects
40. Weight Loss Procedures in DevelopmentGastric balloonGastric/vagus n. pacingEndoluminal Surgery
41. -Endoscopically placed plastic “sleeve” allowing nutrients to avoid contact with duodenal mucosa -Designed to achieve diabetes resolution by altering GI hormone production and islet cell stimulationEndoBarrier
42. OBESITY SURGERY Summary-Bariatric surgery is relatively safe with an expected mortality of <0.5% and morbidity of 10-15%-Surgery results in sustained weight loss and favorably impacts obesity related medical disease and reduces long term mortality-Further clinical trials are needed to help determine which operation is best for which patient
43. The End