Bariatric Surgery for the Treatment of Obesity and Metabolic Disease JHI Partners Forum 10/2/2012 Thomas Magnuson MD Associate Professor of Surgery Johns Hopkins University School of Medicine (tmagnus@jhmi.edu)

Disclosure Nothing to disclose

OBESITY SURGERY OVERVIEW 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

Why are we talking about Obesity Surgery today? 1) Rapid rise in prevalence of obesity 2) Recognition of Obesity as a Disease 3) Better operations for Obesity and public/physician awareness 4) Increased focus on improvement/ resolution of metabolic disease

Treatment of Obesity Diet & Exercise Medications Behavioral modification Surgical management

Explosion in Bariatric Surgery Over 200,000 procedures in the U.S. in 2010

Purpose of Bariatric Surgery To alleviate or eliminate obesity related medical diseases It is not cosmetic surgery and patients may still be overweight after plateau in weight loss postop

Bariatric Surgery Patient Selection (Based On The 1991 NIH Guidelines) BMI > 40; or > 35 with obesity related morbidity Previous failed attempts at supervised weight reduction Realistic expectations; no recent substance abuse Age limits (18 to 70 yrs old in most programs) Supportive family/friends Lifelong commitment to dietary change and follow-up Pre-op evaluation by dietician and psychologist

Obesity Surgery Patient Selection Additional Considerations Adolescents (? 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

Obesity Surgery Pre-Operative Evaluation Insurance approval (most require 6 month dietary program/counseling within previous 2 years) Mandatory Dietary and Psych evaluation/counseling Cardiac/pulmonary “clearance” if significant history Sleep apnea testing/treatment if high risk In select patients- EGD, UGI, IVC filter Stop 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

OPERATIONS FOR MORBID OBESITY OBESITY SURGERY OPERATIONS FOR MORBID OBESITY RESTRICTIVE OPERATIONS Adjustable Gastric Banding (ABG) Vertical Sleeve Gastrectomy (VSG) Gastric Bypass (GBP) (also malabsorptive) MALABSORPTIVE OPERATIONS Gastric Bypass (GBP) Duodenal Switch-biliopancreatic diversion (DS-BPD)

Roux-en-Y Gastric Bypass Small gastric pouch (20-30 ml) (remainder of stomach left in) ~100 cm of small bowel bypassed creating nutrient malabsorption

Laparoscopic Gastric Bypass

Gastric Bypass PROS CONS Durable weight loss: 60 to 70% excess wt loss at 2 yrs Proven reduction of obesity related medical problems Risk of death low if done by experienced team (<0.5%) Most common operation in US with the most follow-up data Marginal Ulcer Stomal stenosis Anemia Calcium deficiency Nutrition/vitamin defic. Difficult to reverse

Laparoscopic Gastric Band Laparoscopic procedure that is less invasive than gastric bypass Adjustable, depending on desired wt. loss Weight loss less than gastric bypass (40% excess wt. loss at 1yr post-op)

Adjustable Gastric Band PROS CONS Reversible Least invasive Lowest risk of Death No malabsorption Adjustable 40 to 50 % excess weight loss at 2 years Foreign body / erosion Esophageal dilation GERD Breakage/slippage Failure to lose weight Slower weight loss 30-50% reoperation rate/removal long term

Laparoscopic Vertical Sleeve Gastrectomy

Vertical Sleeve Gastrectomy

Laparoscopic Vertical Sleeve Gastrectomy Does not involve intestinal rearrangement Restrictive only; 50-60% excess weight loss May be used as a first step operation in high risk patients to induce weight loss before performing duodenal switch or gastric bypass Currently considered for weight loss in lower BMI morbidly obese patients who do not want an adjustable band or a malabsorptive operation

Duodenal Switch Partial stomach resection All of the bowel bypassed except 150-200 cm of distal small bowel Primarily malabsorptive: risk of malnutrition, vitamin deficiency, diarrhea

Duodenal Switch w/ BPD Best wt loss (80% excess weight) PROS CONS Best wt loss (80% excess weight) Best resolution of metabolic disease Pylorus preserved Less restriction than GBP Malabsorption Anemia Calcium deficieincy 10 % may need revision Diarrhea/malodorous stools Protein malnutrition ? Liver disease

Summary of Obesity Surgery Gastric bypass (60-70% of all procedures) Laparoscopic adjustable gastric band (LAGB) (20-30%) Lap Sleeve Gastrectomy (15-25%) Duodenal Switch w/ biliopancreatic diversion (5%)

The Johns Hopkins Center for Bariatric Surgery Over 3,000 bariatric procedures since 1997 Analysis of 1000 gastric bypass procedures: Age = 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 %

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

OBESITY SURGERY AT JHBMC POST-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 %

OBESITY SURGERY Evidence based analysis Is 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%

OBESITY SURGERY Evidence based analysis Is 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

Mean % Weight Change over 15 Years Swedish Obesity Study Walter J. Pories, MD, FACS; East Carolina University Mean % Weight Change over 15 Years Swedish Obesity Study Control Bands VBG’s 30% RYGB Sjostrom: NEJM 2007;357:741-52

Diabetes Remission after Bariatric surgery Ann Intern Med. 2009;150(2):94-103.

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 Gastrectomy Intensive Medical Therapy* + Gastric Bypass Primary Endpoint: Proportion of patients with a glycated hemoglobin level of 6.0% or less at 12 months after treatment.

N Engl J Med. 2012 Med therapy GBP Sleeve

Medication Utilization and Annual Health Care Costs in Patients With Type 2 Diabetes Mellitus Before and After Bariatric Surgery Makary, et al Archives 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

Results

Diabetes resolution: 1669 (74. 7%) of 2235 pts at 6 months 1489 (80 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

-Early post-op reduction in HTN, DM, and lipid- lowering medications 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 reduction in HTN, DM, and lipid- lowering medications

Effect of Surgery on Long-term Mortality Compared to Non-Operated Controls Study Procedure F/U Mortality Reduction MacDonald,1997 RYGB 9 yrs 88% Flum, 2004 4.4yrs 33% Christou, 2004 5 yrs 89% Sowemimo, 2007 4.4 yrs 50% O’brien, 2006 LAGB 12 yrs 73% Adams, 2007 8.4 yrs 40% Sjostrom (SOS), 2007 VBG/RYGB 14 yrs 31%

“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 surgery Development of less invasive procedures or drugs which achieve the desired physiologic/metabolic effects

Weight Loss Procedures in Development Endoluminal Surgery Gastric/vagus n. pacing Gastric balloon

EndoBarrier -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 stimulation

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

The End