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Bariatric Surgery in Obesity and Metabolic Disease

Bariatric Surgery in Obesity and Metabolic Disease. Olivier Court MD FRCSC Director, section of Bariatric Surgery McGill University Health Center. Disclosure of Conflict of Interest.

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Bariatric Surgery in Obesity and Metabolic Disease

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  1. Bariatric Surgery in Obesity and Metabolic Disease Olivier Court MD FRCSC Director, section of Bariatric Surgery McGill University Health Center

  2. Disclosure of Conflict of Interest • no affiliation with the manufacturer of any commercial product or provider of any commercial service discussed in this CME activity.

  3. Outline • Prevalence of Obesity • Consequences of Obesity • Treatments for obesity • Non-operative • Surgical options • Benefits of Bariatric Surgery • Mechanisms for metabolic benefits

  4. Weight classification according to BMI

  5. Prevalence of obesity

  6. Prevalence of obesity

  7. Prevalence of obesity

  8. Co-mobidities of obesity JAMA. 2004 Oct 13;292(14):1724-37

  9. Cost of obesity in Canada 1997 2006 The total direct cost of obesity in Canada was $1.8 billion 2.4% of the total health care expenditures The total direct costs of obesity in Canada was $4.0 billion 4.1% of the total health care expenditures CMAJ 1999 Feb 23;160(4):483-8 Obes Rev. 2010 Jan;11(1):31-40

  10. Obesity and mortality Lancet. 2009 Mar 28;373(9669):1083-96.

  11. Treatments for obesity

  12. Obesity: non-operative management • Diets • Few patients ever achieve more than 10% weight loss • Over 95% regain all weight lost by 5 years • Pharmacotherapy • Orlistat (Xenical) • Inhibits intestinal lipase • Not absorbed – Safe • Expected weight loss: 10% • Sibutramine (Meridia) • Monoamine reuptake inhibitor – acts centrally to diminish appetite • Average weight loss at 1 year: 10 lbs • Can induce significant hypertension • Taken off market in Canada, still available in US

  13. Obesity: Surgical management NIH Concensus recommendations • Patients whose BMI exceeds 40 • Patients with a BMI between 35 and 40 if they also have some severe comorbidities related to obesity: • NIDDM • Obstructive Sleep Apnea • Severe Osteoarthritis

  14. Surgical options • Restrictive procedures • Laparoscopic Adjustable Gastric Band • Laparoscopic Sleeve Gastrectomy • Malabsorptive procedures • Laparoscopic Roux-en-Y Gastric Bypass • Laparoscopic Biliopancreatic Diversion with Duodenal Switch

  15. Laparoscopic Adjustable Gastric Band • Creation of 30-60cc pouch • Adjustable pouch outlet • Easy insertion • Results • 2 years – 30-40% EBW • 5 years – 50% EBW

  16. Laparoscopic Adjustable Gastric Band • Disadvantages • Expensive • Band slipping/erosion • Band/port malfunction • Unknown durability

  17. Laparoscopic Sleeve Gastrectomy • Resection of about 75% of stomach • Few complications • Results • No long term data • 1 year - 50% EBW • 3 years - 60% EBW

  18. Laparoscopic Roux-en-Y Gastric Bypass • Creation of 30-60cc pouch • Roux limb 100 cm • Bypass stomach, duodenum and proximal jejunum • Results • 1 year – 65-70% EBW • 5 years – 60-70% EBW • 10 years – 60% EBW

  19. Laparoscopic Roux-en-Y Gastric Bypass • Complications • Mortality about 0.1% • Anastomotic leak 2-3% • Dumping syndrome • Iron/Calcium/vit B12 deficiency • Drinking • Marginal ulceration

  20. Laparoscopic Biliopancreatic Diversion with Duodenal Switch • Sleeve gastrectomy • Duodeno-jejunal anastomosis • Roux limb 150cm • Common channel 100cm • Results • 1year – 70% EBW • 5 years – 75-80% EBW • 10 years – 80% EBW

  21. Laparoscopic Biliopancreatic Diversion with Duodenal Switch • Complications • Mortality about 0.5% • Anastomotic leak 2-3% • Steatorrhea • Ca, Iron, vit A,D,E,K deficiency • Protein malnutrition 2-3%

  22. Benefits of Bariatric Surgery

  23. Resolution of Comorbidities(136 studies, 22,904 patients) JAMA. 2004 Oct 13;292(14):1724-37

  24. Metabolic benefits beyond weight loss

  25. Metabolic benefits beyond weight loss • 150 patients with BMI 27 – 43 followed for 12 months • 3 groups: • Intensive medical therapy (n=50): lifestyle counseling, weight mgt, home glucose monitoring, medications including incretin analogues to reach HbA1c < 6% • Gastric bypass (n=50) • Sleeve gastrectomy (n=50) • Primary endpoint: % of pts with HbA1c<6% • Secondary endpoints: Fasting glucose, fasting insulin, lipids, CRP, HOMA-IR, weight loss

  26. Metabolic benefits beyond weight loss

  27. Metabolic benefits beyond weight loss

  28. Diabetes

  29. Diabetes

  30. Metabolic benefits beyond weight loss

  31. Metabolic benefits beyond weight loss • 72 patients with BMI>35 with followed for 2 years • 3 groups: • Medical therapy (n=24) • Gastric bypass (n=24) • Biliopancreatic diversion (n=24) • Primary endpoint: rate of DM remission (fasting glucose<5.6 and HbA1c<6.5% without medication) • Secondary endpoints: Average HbA1c, body weight, triglycerides, total and HDL cholesterol

  32. Metabolic benefits beyond weight loss

  33. Resolution of comorbidities

  34. Bariatric Surgery: Impact on Mortality

  35. Cost effectiveness of Bariatric Surgery

  36. Conclusion • Impact of obesity on health care is growing • Bariatric Surgery results in weight loss, but also in resolution of comorbidities and improvement in mortality • Mechanisms are still unclear • Bariatric vs Metabolic Surgery

  37. Mechanisms for metabolic benefits of Bariatric Surgery

  38. Role of Gut hormones

  39. Mechanisms of action RNYGB AGB VSG

  40. Mechanisms of action RNYGB AGB VSG

  41. Mechanisms of action • Hind Gut vs Fore Gut theories for RNYGB • However, VSG and RNYGB are similar in their metabolic and hormonal effects • Both differ from AGB • Alternate explanation is required

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