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An Overview of Bariatric Surgery

An Overview of Bariatric Surgery. Kristin Dermody Angela Illing May 23, 2005. THE OBESITY EPIDEMIC. A Quick Background of Obesity. Derived from the Latin word obesus – “to devour” Definition: having a very high amount of body fat in relation to lean body mass

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An Overview of Bariatric Surgery

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  1. An Overview of Bariatric Surgery Kristin Dermody Angela Illing May 23, 2005

  2. THE OBESITY EPIDEMIC

  3. A Quick Background of Obesity • Derived from the Latin word obesus – “to devour” • Definition: having a very high amount of body fat in relation to lean body mass • Classifications using Body Mass Index (BMI)

  4. BMI Categories • A BMI of: Classifies one as: • <18.5 Underweight • 18.5-24.9 Normal weight • 25-29.9 Overweight • 30-34.9 Obesity Class I • 35-39.9 Obesity Class II • 40-49.9 Obesity Class III • 50 and above Super Obesity

  5. Obesity is a BIG problem… • 1.7 billion worldwide are overweight or obese • The US has a higher percentage of overweight and obese people than any country in the world • And the numbers are growing…

  6. US Incidence of Obesity • Approximately 2/3 of the United States population is overweight. • Of those, almost 50% are obese. • In total, approximately 5% of the US population is morbidly obese • Alarmingly, the BMI subgroups growing the most quickly are 35 or higher and 40 or higher.

  7. Massachusetts: Not-so-’Phat’ Facts • 55% of Mass adults  overweight or obese* • Of these obese adults** • 18% non-Hispanic white • 30% non-Hispanic black • 22% Hispanic • 24% of Mass high school students  overweight or at risk of becoming overweight • Obesity rate among Mass adults by 81% from 1990 to 2000* *CDC BRFSS, 2002; **CDC YRBSS, 2003

  8. History of Obesity 1985

  9. Potential Consequences of Obesity • Obesity is associated with a rise in many comorbid conditions, including: • Type 2 Diabetes • Hyperlipidemia • Hypertension • Obstructive Sleep Apnea • Heart Disease • Stroke • Asthma • Back and lower extremity weight- bearing degenerative problems • Cancer • Depression • AND MORE!

  10. CVD & Obesity • Fact: Obesity contributes to these co-morbid conditions, however… • Recent JAMA article by Gregg et al* suggests CVD risk factors across all BMI groups over past 40 years • Suggest: Overweight not quite as bad as it once was, considering other factors: • Risk r/t awareness, aggressive identification, pharmacological tx of high chol, HTN. • Note: Obese persons still have risk factor levels vs..lean persons. Gregg EW, et al. Secular Trends in Cardiovascular Disease Risk Factors According to Body Mass Index in US Adults. JAMA, 2005:293:1863-1874

  11. Impact of Obesity • These comorbid conditions are together responsible for more than 2.5 million deaths per year worldwide*. • This is in addition to billions of dollars in healthcare costs and lost productivity. *World Health Organization, World Health Report 2002

  12. Obesity and Life Expectancy • Recent NEJM article* – If current rates of obesity are left unchecked, the current generation of American children will be the first in two centuries to have a shorter life expectancy than their parents. • The life-shortening impact of obesity (currently estimated at 1/3 to ¾ year) could rise to 2 to 5 years, or more, as obese children spend more years at risk for comorbid conditions. Olshansky SJ, et al. A Potential Decline in Life Expectancy in the United States in the 21st Century. NEJM, 352(11):1138-1145, 2005

  13. Obesity and Life Expectancy • The morbidly obese are perhaps the worst off… • Compared to a normal-weight person, a 25-year-old morbidly obese man has a 22% reduction in expected remaining lifespan. • This is an approximate loss of 12 YEARS! • This number will also likely grow if the ever-expanding numbers of currently obese children continue as obese adults…

  14. TREATING OBESITY

  15. Weight Loss Strategies • Diet therapy • Increased Physical Activity • Pharmacotherapy (e.g., Orlistat, Meridia) • Behavioral Therapy • Hypnosis • Any combination of the above

  16. Bariatric Surgery An effective treatment for combating obesity

  17. Bariatric Surgery • 1991: NIH establishes guidelines for the surgical therapy of morbid obesity • Recommends BMI criteria • BMI > 40 • BMI > 35 + significant comorbidities • This therapy now referred to as Bariatric Surgery

  18. Types of Bariatric Surgery • Purely Restrictive • Gastric Balloons (not approved for use in USA) • Vertical-banded gastroplasty • Gastric adjustable banding (BWH) • Restrictive > Malabsorptive • Short-limb/Roux-en-Y gastric bypass (BWH) • Long-limb/distal Roux-en-Y gastric bypass • Malabsorptive > Restrictive • Biliopancreatic diversion (BPD) • BPD with duodenal switch • Very long limb Roux-en-Y gastric bypass • Purely Malabsorptive • Jejunoilieal bypass • Jejunocolonic bypass

  19. A Brief History of Bariatric Surgery • First developed: • Pts with short bowel syndrome  weight loss • First weight loss surgeries (ca. 1950s) • Intestinal bypass • Low-risk surgically BUT many patients developed serious and often fatal complications • Biliopancreatic diversion • Effective BUT with high risk and many complications

  20. Evolution of the Roux-en-Y • Gastric partitioning (Roux-en-Y GBP) • Based on observations of weight loss in pts receiving subtotal gastric resections for other conditions • 1967 – First performed • Continues to be studied and refined

  21. Roux-en-Y • Open* • 2 hour procedure • 3 days in-house • 4 weeks – Return to work • 60-70% EBW loss @ 2 yrs • 0.5-1.0% Risk of Death • Dumping Syndrome • Laparoscopic* • 2-4 hour procedure • 3 days in-house • 2-3 weeks – Return to work • 60-70% EBW loss @ 2yrs • 0.5-1.0% Risk of Death • Dumping Syndrome * Data based on averages.

  22. Evolution of Gastric Banding • 1970s • Alternative to Roux-en-Y in Europe & Scandinavia • 1980s • Adjustable silicone band developed • 1990s • Laproscopic techniques for placement developed

  23. Gastric Banding • Adjustable Lap Band • 1 hr procedure • 1 day in-house • 1 wk – Return to work • 40-45% EBW loss @ 2 yrs • <0.1% Risk of Death • Self-sabotage easier

  24. Who Gets Bariatric Surgery? • Gender • 19% Males • 72.6% Females • (8% gender not reported) • Age • Mean age 39 years • Range 16-64 years • BMI • Mean BMI 46.9 • Range 32.3-68.8 Buchwald H, et al. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA, 14:1724-37, 2004

  25. Medical Nutrition Therapy and The Post-op Bariatric Patient

  26. Post-Surgical Nutrition • Balanced/healthy diet • Liquids to pureed to soft to solid* • High nutrient density, quality • Modified in lactose, fat, sugar • Adequate fluid • Portion Control • Meal Periods/Eating time • MVI/MIN • Ca (>1200mg/d) + D (10-20mg) • Folate (800-1000mcg) +B12 • Iron (45-100mg elemental – pre-menstrual) • Vitamin C (75-100mg) • Thiamin • Self-monitoring • Eating triggers/behaviors • Exercise * Time line may vary among institutions

  27. Stage One (1 day) Water and clear liquids Non-caloric, non-carbonated, non-caffeinated liquids Fluid goal: 28-32oz/d Stage Two (14 days) High protein, low sugar beverages Fluid goal: 56oz Protein goal: 60-70g/d Chewable MVI + Ca Post-Op Roux-En-Y Diet

  28. Stage Three (4 weeks) 5 – 2oz servings diced protein Fluid goal: 56oz Protein goal: 60-70g Chewable MVI + Ca Stage Four (4 months) 3 meals, 2 snacks 850kcal/d Fluid goal: 56oz Protein goal: 60-70g Chewable MVI + Ca Post-Op Roux-En-Y Diet • Stage Five (ongoing) • Regular Meals • 1200-1500kcal • Fluid & Protein goals: same as above

  29. Stage One (1 day) Water & Clear Liquids Non-carbonated, non-caffeinated, non-caloric liquids Fluid goal: 28-32oz/d Stage Two (14 days) 5-8oz servings of High Protein, low sugar Beverage Fluid goal: 56oz Protein goal: 50-60g Chewable MVI + Ca Post-op Lap Band Diet

  30. Stage Three (14 days) Pureed Foods, Semi solids 2 small meals, 3 snacks Fluid goal: 56oz Protein goal: 50-60g Chewable MVI + Ca Stage Four (ongoing) Regular meals: 3 meals,2 snacks (1000-1200) Fluid goal: 56oz Protein goal: 50-60g Chewable MVI + Ca Post-op Lap Band Diet

  31. Post-Surgical Nutrition & Exercise • RD seen frequently • 1m 3m 6m 1yr • Exercise • No heavy lifting or exercise 6-8wks post-op • Walking daily OK, encouraged • After cleared, strength training important to help skin stretch back • Helps with weight loss in the long run

  32. When Surgery and Follow-Up Go Well…

  33. Efficacy of Bariatric Surgery for Weight Loss • Mean percentage excess weight loss: • 61.2% - All Patients • 47.5% - Gastric Banding • 61.6% - Gastric Bypass • 68.2% - Gastroplasty • 70.1% - BPD or duodenal switch *Buchwald H, et al. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA, 14:1724-37, 2004

  34. Roux-en-Y: Metabolic Sequelae • Human body regulates nutrient intake over time by secreting hormones • Over 40 hormones play a role in regulation of feeding.

  35. Roux-en-Y: Metabolic Sequelae • Two types: • Satiety hormones • Short-term • Help regulate meal size; daily intake • Secretion decreases meal size; reduces time to stop • Includes (among others) cholecystokinin, amylin, glucagon-like-peptide 1 (GLP-1), enterostatin, and bombesin • Adiposity hormones • Long-term • Related to energy stores • Secretion delays onset of beginning of meal • Includes insulin, leptin

  36. Roux-en-Y: Metabolic Sequelae • Also of note is ghrelin, the endogenous ligand for the growth hormone secretagogue receptor • Mostly secreted in the fundus of the stomach (part bypassed in RYGB) • Contrary to satiety hormones, ghrelin is orexigenic – i.e., increases appetite (fasting increases levels)

  37. Roux-en-Y: Metabolic Sequelae • Plasma ghrelin normally increases after non-surgical weight loss • This supports long-term weight homeostasis • Proportional to lean body mass • Initial report showed circulating plasma ghrelin greatly decreased in pts s/p RYGB • Past theory: exclusion of the fundus of the stomach responsible for lower ghrelin levels (and therefore greater weight loss)

  38. Roux-en-Y: Metabolic Sequelae • Studies since then have shown no change or increase in ghrelin after bypass • Additionally, found that post-pyloric nutrient stimulation vs.. stomach distention responsible for changes in ghrelin levels • Does not support idea that bypassing stomach fundus responsible for changes, if any, in ghrelin levels • Overall, still not well understood Strader AD, et al. Gastrointestinal Hormones and Food Intake. Gastroenterology, 128:175-91, 2005

  39. Roux-en-Y: Metabolic Sequelae • Further investigation is needed, but thought that one reason certain types (i.e., RYGB) of bariatric surgery are successful at reducing food intake and causing weight loss may be related to enhanced secretion of satiety signals (ghrelin or others).

  40. Effect on Comorbid Conditions • Diabetes • 76.8% - Completely resolved • 86.0% - Resolved or improved • Hyperlipidemia • 70% - Improved • HTN • 61.7% - Resolved • 85.7% - Resolved or improved • Obstructive Sleep Apnea • 83.6% - Resolved • 85.7% - Resolved or improved Buchwald H, et al. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA, 14:1724-37, 2004

  41. Metabolic Changes and Diabetes • Many metabolic changes contribute to improvement and/or resolution of DM s/p bariatric surgery: • Recovery of acute insulin response • Decreases of inflammatory indicators (C-reactive protein and interleukin 6) • Improvement in insulin sensitivity correlated w/increases in plasma adiponectin • Changes in the enteroglucagon response to glucose • Reduction in ghrelin levels (s/p RYGB, but not banding) • Improvement in beta cell function (s/p banding, but not RYGP)

  42. Effect on Quality of Life • Studies show overall QOL greatly improved • Relief from comorbidities • Improved appearance • Perception of improved: • Well-being • Social function • Body self-image • Self confidence • Ability to interact with others • Increased time spent in recreational and physical activities • Enhanced productivity • Increased economic opportunities • Often new employment • More lucrative employment

  43. PROBLEMS AND COMPLICATIONSof Bariatric Surgery

  44. Possible Complications of Bariatric Surgery • General Complications • Pulmonary embolism • Incisional hernia • Gallstone formation • Major wound infection and seroma • Abdominal fluid collection • Subphrenic abscess • Peritonitis

  45. Procedure-Specific Complications (RYGB) • Anastomotic or staple-line leak • Acute gastric distention • Staple-line disruption • Stomal stenosis • Stomal ulceration • Small-bowel obstruction • Occlusion of Roux limb

  46. Intermediate Complications • Wound Infection • Intra-abdominal bleed • Gastric remnant necrosis • Ischemic Roux-limb • Internal hernia

  47. Long-Term GI Complications • Nausea • Constipation • Abdominal pain • Marginal ulcers • Incisional hernias • Vomiting • Diarrhea • Gallstones • Gastritis • Intestinal Obstructions

  48. Incidence of Complications • Operative mortality (< 30 days): • 0.1% for Purely Restrictive Procedures • 0.5% for Gastric Bypass • 1.1% for BPD or Duodenal Switch

  49. Long-Term Nutrition Complications • Malnutrition • Vitamin and mineral deficiencies • Weight loss failure • Dehydration • Anemia • Dumping Syndrome • Hair loss • Dry skin

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