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Options for Obesity and Long-Term Results Bariatric Surgery Mark Kligman, M.D. Assistant Professor, Surgery Director, Center for Weight Management & Wellness.

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Presentation on theme: "Options for Obesity and Long-Term Results Bariatric Surgery Mark Kligman, M.D. Assistant Professor, Surgery Director, Center for Weight Management & Wellness."— Presentation transcript:

1 Options for Obesity and Long-Term Results Bariatric Surgery Mark Kligman, M.D. Assistant Professor, Surgery Director, Center for Weight Management & Wellness University of Maryland, School of Medicine

2 The Problem

3 The BIG Secret !

4 Current Surgical Management

5 Indications Standard Criteria Age 18 – 65 years + BMI ≥ 40 kg/m 2 Standard Criteria Age 18 – 65 years + BMI ≥ 40 kg/m 2 Special Criteria Age BMI kg/m 2 + High risk health problems Special Criteria Age BMI kg/m 2 + High risk health problems

6

7 The Surgery Timeline Educational Seminar Initial Office Visit Bariatric surgery booklet Dietician Evaluation 6 month supervised diet Nutrition education Submit Request for Preauthorization Preoperative Office Visit Consent Written examination Preoperative Workshop Initial Contact OR Laboratory evaluation CBC, Chem, LFT, cholesterol, triglycerides Vit D, Vit B 12, TFT, adrenal function tests Pulmonary evaluation: CXR, sleep study, PFT, ABG EKG, Stress test, echocardiogram UGI, GB U/S, EGD, Colonoscopy Pap, Mammogram Consultation: psychologist / psychiatrist Cardiology Anesthesia Pulmonary Gastroenterology Endocrine

8 Current Operative Approaches MoreWeight LossLess More RisksLess Malabsorption Restriction Biliopancreatic Diversion with Duodenal Switch Roux-en-Y Gastric Bypass Adjustable Gastric Banding Sleeve Gastrectomy

9 Biliopancreatic Diversion with Duodenal Switch (BPD-DS) General Features Gastric pouch size: Standard: 300 mL Three segments Alimentary tract: cm Biliary tract: 250 cm Common channel: cm Average Weight Loss % of excess weight

10 Risks Associated with Duodenal Switch Protein malnutrition 15% Anemia< 5 % Marginal ulcer< 3 % Peripheral neuropathy1.3 % Night Blindness 3 % Osteoporosis 14 % Renal stones Nausea 65 % Diarrhea62 % Vitamin deficiencies: A, D, E, K, B 12 Bowel obstruction Incisional hernia10 % Death1.1%

11 Adjustable Gastric Banding (AGB) Fill Port Portion of Band which wraps around stomach Realize ™ LapBand ™

12 Adjustable Gastric Banding GENERAL FEATURES Inflatable balloon can be adjusted using a port under the skin Average Weight loss % of excess weight

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14 Band Adjustment DeflatedPost-Adjustment

15 Risks Associated with Gastric Banding Injury to esophagus, stomach, spleen Migration of implant (band erosion, band slippage, port displacement)* Tubing-related complications (port disconnection, tubing kinking) * Band leak Esophageal spasm Gastroesophageal reflux disease (GERD) Port-site infection Death0.1 % * Re-operation %

16 Vertical sleeve gastrectomy May be an option for carefully selected patients, including high-risk or super-super-obese patients 1. Use: Primary operation Staged operation Mean %EWL at 1 yr: 59% 2 No implanted medical device 1.ASMBS, Position Statement on Sleeve Gastrectomy as a Bariatric Procedure. June 17, Lee CM, et al. Surg Endosc (2007) 21: 1810–1816

17 Risks Associated with Sleeve Gastrectomy Leak *2.2 % Stricture *0.6 % Gastroesophageal reflux disease (GERD) Delayed gastric emptying0.2 % Wound infection Re-operation 6 % Death0.19 % Obesity Surgery 2007, 17: Obesity Surgery 2009, 19:1672–1677 Surg Obes Relat Dis 2010; 6: 1–5

18 Sleeve Gastrectomy: Unresolved Issues Standardization of operation Optimal sleeve diameter Location of the sleeve termination Durability as a primary operation

19 Roux-en-Y Gastric Bypass (RYGBP) General Features Pouch size: 15 – 30 ml Pouch opening: 10 mm Roux-en-Y limb cm Average EWL: 60 – 80%

20 Risks Associated with Gastric Bypass Early: Staple line leak <1 % Acute gastric distention Roux-Y obstruction Late: Stomal Stenosis <5 % Marginal ulcer ~5 % Anemia Folate deficiency Vitamin B12 deficiency Iron deficiency Calcium deficiency / osteoporosis Gallstones 10 % Death :~ 0.1 %

21 Which Operation? Roux-en-Y Gastric Bypass Sleeve Gastrectomy Adjustable Gastric Banding Weight Loss (% EWL) Time to achieve maximal weight loss (years) ~1 2-3 Number of Office visits (1 st year) Improvement of obesity-associated health problems ExcellentVery Good Reversibility + / ──+ Safety Excellent Risk of nutritional complications Moderate (easily correctable) Minimal

22 Measuring Success

23 Measuring Success — Part 1 Impact of surgery on: Weight Co-morbidities Mortality

24 Weight Maintenance 10 Years after Bariatric Surgery The SOS Study Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26

25 Effect of Gastric Bypass on Cardiac Risk Factors PreoperativePostoperative BMI (kg/m 2 )46.9 ± ± 4 * Cholesterol (mg/dl)202 ± ± 29 * LDL-Cholesterol (mg/dl)118 ± 3397 ± 26 * HDL –Cholesterol (mg/dl)45 ± 1151 ± 11 * Systolic BP (mmHg)143 ± ± 18 * Diastolic BP (mmHg)81 ± 1071 ± 11 * * p < Kligman MD et al. Surgery 2008;143:533

26 Impact of Gastric Bypass on Cardiac Risk 10-year Risk of Cardiac Event (%) Pre-operativePost-operative Vogel Torquati Kligman Vogel et al. Am J Cardiol 2007;99: Torquati et al. J Am Coll Surg 2007;204: Kligman et al. Surgery 2008;143:533

27 Impact of Bariatric Surgery on Mortality Death Rates Adams et al. N Engl J Med

28 Impact of Bariatric Surgery on Mortality The SOS Study Sjöström et al. N Engl J Med 2007;357:41

29 Measuring Success — Part 2 Comparison to Medical Therapy

30 Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes Schauer et al. N Engl J Med 2012;366:

31 Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes Schauer et al. N Engl J Med 2012;366:

32 Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes Schauer et al. N Engl J Med 2012;366:

33 Measuring Success—Part 3 Weight Loss Traditional approach Final BMI: <35 for morbid obesity (starting BMI < 49) 50) Percent EWL: Excellent ≥75% Good50-74% Fair25-49% Poor<25% Co-morbidity Resolution Current approach The “real” goal of bariatric surgery is the reduction of life- threatening co-morbidity Biron S et al. Obes Surg 2004; 14: Reinholt RB Surg Gynecol Obstet 1982; 155:

34 Remission Rate of Type 2 Diabetes is Associated with Greater Weight Loss Following Gastric Bypass Kadera BE et al. Surg Obes Relat Dis 2009; 5:305–309

35 Remission Rate of Type 2 Diabetes is Associated with Greater Weight Loss Following Sleeve Gastrectomy Surg Obes Relat Dis 2009; 5: EWL (%)

36 Does the Type of Procedure Influence the Improvement in Co-morbidities? Gastric Banding Gastric Bypass BPD±DS EWL (%) Remission DM (%) Buchwald et al. JAMA 2004;292:

37 “[Weight loss] isn't everything, it's the only thing” “[Weight loss] isn't everything, it's the only thing” --Vince Lombardi

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