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Bariatric Surgery

Bariatric Surgery . Roberto C. Mirasol, MD, FPCP, FPSEM Obesity and Weight Management Center St. Luke’s Medical Center. Bariatric Surgery. Indications BMI >40 kg/m 2 or BMI 35–39.9 kg/m 2 and life-threatening cardiopulmonary disease, severe diabetes, or lifestyle impairment

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Bariatric Surgery

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  1. Bariatric Surgery Roberto C. Mirasol, MD, FPCP, FPSEM Obesity and Weight Management Center St. Luke’s Medical Center

  2. Bariatric Surgery Indications BMI >40 kg/m2 or BMI 35–39.9 kg/m2 and life-threatening cardiopulmonary disease, severe diabetes, or lifestyle impairment Failure to achieve adequate weight loss with nonsurgical treatment Contraindications History of noncompliance with medical care Certain psychiatric illnesses: personality disorder, uncontrolled depression, suicidal ideation, substance abuse Unlikely to survive surgery NIH Consensus Development Panel. Ann Intern Med 1991;115:956.

  3. CLINICAL PRACTICE RECOMMENDATIONS, 2009ADA Bariatric surgery should be considered foradults with BMI 35kg/m2 and type 2 diabetes, especially ifthe diabetes is difficultto control with lifestyle and pharmacologictherapy. (B) Patientswith type 2 diabetes who have undergonebariatric surgeryneedlife-long lifestyle support and medicalmonitoring. (E)

  4. Bariatric Surgery Stats 1995 the number of bariatric surgeries performed was well over 20000 2003 - 103,000 2004 - 144,000 Average age of patient – 30 years old Length of Hospital Stay – 3.9 days Bariatric surgeons – increased by 500% Complication rate – 10% Deaths <1% CDC, 2006

  5. Current Bariatric Surgical Procedures Classification Gastric restriction Primarily restrictive and partially malabsorptive Primarily malabsorptive and partially restrictive Procedure Adjustable Gastric Banding Roux-en-Y Gastric Bypass • Biliopancreatic diversion with duodenal switch • Biliopancreatic diversion • Distal gastric bypass

  6. Gastric Bypass Procedure • A small (10–30 mL) gastric pouch is anastomosed to a Roux limb of jejunum. Increasing the length • of the Roux limb increases malabsorption and • weight loss.

  7. Long-term Effect of Gastric Bypass Surgery on Body Weight 0 20 40 Weight Loss (% of Excess Weight) 60 80 100 0 2 4 6 8 10 12 14 Years After Surgery BMI (kg/m2): 50 34 35 35 Poiries et al. Ann Surg 1995;222:339.

  8. Randomized, Controlled Trial Comparing Open With Laparoscopic Gastric Bypass Both procedures had Similar weight loss Similar incidence of anastomotic leaks Equivalent costs Laparoscopic procedure had Less wound complications (infection and hernia) Increased late anastomotic strictures Less blood loss Shorter hospital stay Faster recovery Faster improvement in quality-of-life Nguyen et al. Ann Surg 2001;234:279.

  9. Weight Loss With Gastric Bypass Procedure vs. Vertical Banded Gastroplasty 90 70 Gastric bypass 50 Vertical banded gastroplasty Decrease in Excess Weight (%) 30 10 0 12 18 24 30 36 6 Time (months) Sugerman et al. Ann Surg 1987;205:613.

  10. Laparoscopic Adjustable Gastric Banding LapBandTM Access port (reservoir) Connection tubing Gastric Band Silicone band placed around upper stomach to create a small pouch. Outlet diameter can be changed by infusing or withdrawing saline from port. American Society for Metabolic and Bariatric Surgery, www.asbs.org

  11. LAP BAND

  12. Laparoscopic Adjustable Gastric Banding Produces Greater Weight Loss than Comprehensive Medical Therapy* in Patients with Class I Obesity (BMI 30-35 kg/m2) Weight Loss, % Surgical Nonsurgical Baseline 6 mo 12 mo 18 mo 24 mo *(VLCD, behavioral modification, and pharmacotherapy) Obrien et al. Ann Intern Med. 2006;144:625-33

  13. Biliopancreatic Diversion With Duodenal Switch • Sleeve gastrectomy with rerouting of small intestine through “nutrient limb” and “biliopancreatic limb.” • Digestion and absorption are limited to 100 cm “common channel” of terminal ileum. • Causes marked weight loss, but can lead to significant nutritional deficiencies. Marceau P. et al. World J Surg 1998;22:947-54.

  14. Effect of Different Bariatric Surgical Procedures on Weight Loss Approximate Loss of Excess Procedure Weight (%) Laparoscopic gastric banding 45–65 Gastric bypass procedure 55–65 Biliopancreatic diversion 60–75 with duodenal switch Klein et al. Gastroenterology. 2002;123:882-932

  15. Relationship Between Rate of Weight Loss and Gallstone Formation 3 2 Incidence of Gallstone Formation (% subjects/wk) Data reported from individual studies 1 0 2.5 0 1 0.5 1.5 2 Rate of Weight Loss (kg/wk) Weinsier et al. Am J Med 1995;98:115.

  16. Complications of Bariatric Surgery All procedures: Atelectasis and pneumonia Deep vein thrombosis Pulmonary embolism Wound infection Gastrointestinal bleeding Gallstones Failure to lose weight Intractable vomiting/kwashiorkor (B1) Mortality (0.1%–2%) Gastric bypass: Anastomotic leak with peritonitis Stomal stenosis Marginal ulcers Staple line disruption Nutrient deficiencies (iron, calcium, folic acid, vitamin B12) Dumping syndrome Small bowel obstruction Internal hernia Adhesions Gastric banding procedure: Band slippage Band erosion Esophageal dilatation Band or port infections Port disconnection Port displacement Biliopancreatic diversion: Anastomotic leak with peritonitis Protein-calorie malnutrition Calcium, iron, folic acid, fat soluble vitamin (A,D,E,K) deficiencies Dehydration Steatorrhea Small bowel obstruction Internal hernia Adhesions

  17. 0 50 100 150 200 250 300 350 400 450 500 550 600 650 Relationship Between Surgical Experience and Perioperative Mortality in Gastric Bypass Surgery 7% 6% 5% 4% 3% 2% 1% 0% 125 case lifetime bariatric surgery experience Thirty Day Mortality Chronological case order per surgeon D Flum et al. J Am Coll Surg 199:543, 2004

  18. Gastric Bypass Surgery Improves Glycemic Control in Impaired Glucose Tolerance or Type 2 Diabetes 100 75 Patients with Normal Fasting Blood Glucose and HbA1c After Surgery (%) 50 25 0 Patents with Type 2 Diabetes Patients with IGT Pories et al. Ann Surg 1995;222:339.

  19. Prevention of Type 2 Diabetes at 8 Years After Bariatric Surgery (94% Restrictive) Control Surgery Initial BMI (kg/m2) 41  5 41  4 Weight change at year 8: 1  11% -16  12% 20.0 18.5 Control Bariatric surgery 16.0 12.0 Incidence of Type 2 Diabetes(% Patients) 8.0 4.7 3.6 4.0 0.0 0.0 2 8 Follow-up After Surgery (y) Sjostrom et al. Hypertension 2000;36:20.

  20. Effect of Bariatric Surgery on Obesity-related Metabolic Complications Control Surgery 72 62 46 36 Ratio of Recovery (% of subjects) 34 24 21 21 22 19 13 11 Diabetes Hypertension Hypertriglyceridemia Sjöström: N Engl J Med 2004;351:2683.

  21. 3 Before GBS 1 Yr after GBS 2 Histology score (Brunt et al. system) 1 0 Steatosis Inflammation Fibrosis Effect of Gastric Bypass Surgery-induced Weight Loss on Liver Histology Klein S. et al. Gastroenterology 130:1564, 2006

  22. Long-term Survival: Canada Rel. Risk = 0.11 (.04-.27) 89% reduction in risk ofdeath over 5 years % Mortality Christou et al. Ann Surg 2004;240:416-424

  23. Major Obesity-related Comorbidities That Have Been Improved by Bariatric Surgery Type 2 diabetes Hypertension Obstructive sleep apnea Obesity hypoventilation GERD NALD, NASH Pseudotumor cerebri Depression Dyslipidemias Coronary artery disease Cardiac dysfunction Venous stasis disease Polycystic ovary syndrome Infertility Cancers Degenerative joint disease Quality of life

  24. GLP-1 and GIP Are the Two Major Incretins GLP-1=glucagon-like peptide-1; GIP=glucose-dependent insulinotropic polypeptide. Drucker DJ. DiabetesCare. 2003;26:2929–2940; Ahrén B. Curr Diab Rep. 2003;3:365–372; Drucker DJ. Gastroenterology. 2002;122:531–544; Farilla L et al. Endocrinology. 2003;144:5149–5158; Trümper A et al. Mol Endocrinol. 2001;15:1559–1570; Trümper A et al. J Endocrinol. 2002;174:233–246; Wideman RD et al. Horm Metab Res. 2004;36:782–786.

  25. Nonincretin Gut Peptides • Peptide YY (PYY) • Secreted by the L cells of the distal intestine • Present in 2 molecular forms: PYY(1-36) and PYY (3-36), a cleavage product • PYY increases satiety and delays gastric emptying through neuropeptide Y-receptor subtypes in the central and peripheral nervous system • IV PYY(3-36) increases satiety and decreases food intake in humans

  26. Nonincretin Gut Peptides • GHRELIN • Secreted by gastric fundus and proximal small intestine and acts on the hypothalamus to regulate appetite • Inhibits insulin secretion by a paracrine mechanism • Systemic ghrelin levels increase before a meal and decrease afterward • Ghrelin stimulates appetite and food intake and suppresses energy expenditure and fat catabolism • Inversely proportional to body weight • Weight loss increases ghrelin levels suggests that ghrelin affects long term regulation of body weight

  27. PROPOSED MECHANISMS FOR IMPROVED GLYCEMIC CONTROL AFTER BARIATRIC SURGERY

  28. Effects of Decreased Caloric Intake on Fasting Glycemia • Decreased caloric intake affects glucose metabolism • Rate of diabetes remission are not the same • Complete remission within days of intestinal bypass procedures (Porries, 1995) • Takes months to occur in LAGB (Dixon, 2008)

  29. RUBINO EXPERIMENTS • Goto- Kakizaki Rats- non obese animal model for diabetes DJB (duodenal-jejunal bypass) – less fasting and postprandial hyperglycemia than control Weight loss by caloric restriction – glycemic control did not improve

  30. HINDGUT HYPOTHESIS (LOWER INTESTINAL HYPOTHESIS) • Intestinal rearrangement speeds the delivery of nutrients to the distal intestines • Causes exaggerated GLP-1 and PYY levels and improves glucose tolerance and insulin secretion Cummings, et al, 2007

  31. FOREGUT EXCLUSION THEORY (UPPER INTESTINAL HYPOTHESIS) Bypassing gut prevents the secretion of a “putative signal” that promotes insulin resistance and Type 2 DM. • Stomach sparing DJB vs Gastrojejunostomy (leaves nutrient flow in the proximal intestine intact) • Bypass of proximal gut prevents secretion “Anti-incretin factor” or “decretin” • May be implicated in the pathogenesis of diabetes

  32. Gut Peptide Response to Different Bariatric Surgical Procedures* *Folli, 2007

  33. BARIATRIC SURGERY IN ST LUKE’s

  34. PATIENT PROFILE* *Dineros, Obesity Surgery, 2007

  35. Weight Reduction in ALL Patients* Dineros, Obesity Surgery, 2007

  36. COMPLICATIONS • Early Complications • Wound infection 2/50 • Pneumonia 1/50 • Dehydration 1/50 • Gastritis 1/50 • Leakage 1/50

  37. COMPLICATIONS • Late Complications • Band Slippage 2/20 (10%) • Stomal Stenosis 1/20 (5%) • Ventral Hernia 1/5 (20%)

  38. STARTING WEIGHT: 307 lbs; BMI 49.44 END WEIGHT: 156 lbs; BMI 25.16

  39. STARTING WEIGHT: 516 lbs; BMI 83.10 END WEIGHT: 258 lbs; BMI 37.01

  40. 100 kg (220 lb) 76 kg (168 lb)

  41. BYPASS on Non- obese • 2 mildly overweight • Duodenal bypass lowered fasting insulin, fasting glucose, and HgbA1c within 1 month after surgery Diabetes Surgery Summit, Rome, 2007

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