1. Bariatric Surgery in the Transplant Population Guilherme M. Campos, MD, FACS, FASMBS Associate Professor of Surgery University of Wisconsin – Madison campos@surgery.wisc.edu 5th Annual Wisconsin Chapter Transplant Symposium Transplant: Sharing and Caring

2. 1. Overview of Bariatric Surgery 1. Indications 2. Type of procedures 3. Peri-operative and long term-outcomes 4. Beyond Caloric Restriction, why does it work 2. Bariatric Surgery & Organ Transplantation 1. UCSF Data 2. CRF (with or without dialysis / pre Kidney Tx) 3. Post Kidney Tx 4. Before, during and after Liver Tx Bariatric Surgery Before and After Organ Transplantation

3. Surgery for Severe Obesity No. of Bariatric Sx. in the US Recent trends in bariatric surgery case volume in the United States. Kohn GP, Galanko JA, Overby DW, Farrell TM. Surgery 2009 146: 375-80 1. Increasing prevalence and recognition Health Hazard 2. Poor outcomes with nonsurgical management 3. Good outcomes with Bariatric Surgery 4. Introduction of Laparoscopic Techniques Surgery for Severe Obesity Steinbrook R N Eng J Med 2004 350: 1075-79

4. Failure supervised weight loss program Well-informed and motivated patients Acceptable operative risks BMI > 40 or BMI 35-40 with high risk comorbidities Surgery for Severe Obesity PATIENT SELECTION NIH Consensus Statement – March 25-27, 1991 Nutrition 1996; 12: 397-402

5. Laparoscopic Gastric Bypass Laparoscopic Gastric Banding 60% 25% Laparoscopic Sleeve Gastrectomy 20%

6. 1. Low perioperative and long-term complication rate. 2. Significant and Long Term Weight Loss 3. Improvement/Cure Obesity Associated Comorbidities 4. Improvement Quality of Life 5. Reduces Mortality Bariatric Surgery Overview O U T C O M E S

7. A prospective, multicenter, observational study of 30-day outcomes in consecutive patients undergoing bariatric surgical procedures at 10 clinical sites in the US from 2005 - 2007. 4,340 patients who had a first-time bariatric procedure 1. Open RYGB - 899 patients (21%)- BMI 51 2. Laparoscopic RYGB - 2243 patients (51%) - BMI 47 3. Laparoscopic Band - 1198 patients (28%)- BMI 44 Significant Differences in between all groups/p<0.01/ for BMI and Co-existing Conditions (Other procedures - 166 patients, not included in the analysis)

9. 1. Low perioperative and long-term complication rate. 2. Significant and Long Term Weight Loss 3. Improvement/Cure Obesity Associated Comorbidities 4. Improvement Quality of Life 5. Reduces Mortality Bariatric Surgery Overview O U T C O M E S

10. Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects Sjöström et al. NEJM. 2007; 357 (8):741-52

11. 1. Low perioperative and long-term complication rate. 2. Significant and Long Term Weight Loss 3. Improvement/Cure Obesity Associated Comorbidities 4. Improvement Quality of Life 5. Reduces Mortality Bariatric Surgery Overview O U T C O M E S

12. % Resolution Comorbidity Resolution of Obesity Associated Diseases after Gastric Bypass Buchwald H. et al. JAMA. 2004; 292(14):1724-37

13. 48% 75% 80%

14. 12 Studies, 576 patients, RYGB, 2cd Biopsy ~ 17 mo STEATOSISINFLAMMATIONFIBROSIS Improvement100%80% No Change-10% Worse/New Onset-10% (Portal)10% OUTCOME HISTOLOGY 2cd BIOPSY

15. Ralph, 46 y/o, 224 lbs Truck Driver High Blood Pressure (1 medication) Type 2 Diabetes Sleep Apnea Venous Disease (Healing) Ralph, 45 y/o, 394 lbs On Disability for Back Pain High Blood Pressure (3 meds.) Diabetes Sleep Apnea Venous Disease

16. 1. Low perioperative and long-term complication rate. 2. Significant and Long Term Weight Loss 3. Improvement/Cure Obesity Associated Comorbidities 4. Improvement Quality of Life 5. Reduces Mortality Bariatric Surgery Overview O U T C O M E S

17. Original Article Long-Term Mortality after Gastric Bypass Surgery Ted D. Adams, Ph.D., M.P.H., et al University of Utah School of Medicine Salt Lake City, UT N Engl J Med Volume 357(8):753-761 August 23, 2007 Original Article Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects Lars Sjöström, M.D., Ph.D., et al. Swedish Obese Subjects (SOS) Study Sahlgrenska University Hospital, Gothenburg, Sweden, N Engl J Med Volume 357(8):741-752 August 23, 2007

18. Distribution of Deaths and Death Rates per 10,000 Person-Years, According to Study Group Adams TD et al. N Engl J Med 2007;357:753-761

19. Cause of Death Sjostrom L et al. N Engl J Med 2007;357:741-752 5% 6.3%

20. Failure supervised weight loss program Well-informed and motivated patients Acceptable operative risks BMI > 40 or BMI 35-40 with high risk comorbidities Surgery for Severe Obesity PATIENT SELECTION NIH Consensus Statement – March 25-27, 1991 Nutrition 1996; 12: 397-402

21. Beyond Caloric Restriction, why does it work? Surgery for Severe Obesity Well-informed and motivated patients NIH Consensus Statement – March 25-27, 1991 Nutrition 1996; 12: 397-402 Change in Hunger-Satiety Mechanisms Change in Endocrine and Gluco-regulatory Mechanisms

22. Cummings D.E. et al. Ghrelin Secretion before & after Weight Loss

23. Cummings D.E. et al. Ghrelin Secretion before & after GBP

24. BAGGIO LL & DRUCKER DJ Gastroenterology 2007;132:2131–2157

25. GLP-1 LEVELS AFTER A MEAL Campos GM, et al. Journal of Gastrointestinal Surgery, Jan; 14 (1):15-23, 2010

26. Campos GM, et al. Journal of Gastrointestinal Surgery, Jan; 14 (1):15-23, 2010. * P=0.01 GLP-1 LEVELS AFTER A MEAL

27. INSULIN LEVELS AFTER A MEAL Campos GM, et al. Journal of Gastrointestinal Surgery, Jan; 14 (1):15-23, 2010. * P=0.01 - Gastric Bypass Group

28. BAGGIO LL & DRUCKER DJ Gastroenterology 2007;132:2131–2157

29. 1. UCSF Data 2. CRF (with or without dialysis / pre Kidney Tx) 3. Post Kidney Tx 4. Before and after Heart Tx 5. Before and after Lung Tx 6. Before, during and after Liver Tx Bariatric Surgery Before and After Organ Transplantation

30. Prevalence of Obesity in Patients Awaiting Kidney or Liver Transplant at UCSF - 2006 32% (n = 248) > 30 6% (n = 33) > 40 30% (n = 1,076) > 30 4% (n = 222) > 40 Liver (n = 986) Kidney (n =4,144) Background % of patients

31. Gore JL, et al. Am J of Transplantation 2006 Pischon T, et al. Neph Dail Transplant 2001 More post-op wound, pulmonary and cardiovascular complications Higher rate of primary graft non-function Longer length of hospitalization 30% higher cost of hospitalization Higher mortality More post-op wound, pulmonary and cardiovascular complications Higher rate of primary graft non-function Longer length of hospitalization 30% higher cost of hospitalization Higher mortality KIDNEYLIVER Nair S, et al. AJG 2001, Hepatol 2002 Sawyer RG, et al. Clin Trans 1999 Background Morbidity after Transplant - UNOS Higher rate of delayed graft function Higher rate of early graft loss Higher rate of acute rejection Higher rate of overall graft failure Longer length of hospitalization Higher mortality Higher rate of delayed graft function Higher rate of early graft loss Higher rate of acute rejection Higher rate of overall graft failure Longer length of hospitalization Higher mortality

32. Background Most transplant centers have implemented BMI limits beyond which patients are considered unsuitable for transplantation. Bariatric surgery is the most effective treatment for morbid obesity, but is not offered routinely to this patient population.

33. Laparoscopic Bariatric Surgery Improves Transplant Candidacy In Morbidly Obese Patients Takata M, Campos G, Ciovica R, Rogers S, Cello J, Ascher N, Posselt A Bariatric Surgery Program University of California San Francisco, USA

34. Objectives Evaluate the safety and efficacy of: –Laparoscopic gastric bypass - ESRD. –Laparoscopic sleeve cirrhosis and ESLD.

35. Patients and Methods Selected patients ineligible for a kidney, liver, or lung transplant because of their BMI. UCSF BMI limits for transplantation –Kidney: 40kg/m 2 –Liver: 40kg/m 2 (relative contraindication) and 50kg/m 2 (absolute contraindication). –Lung: 40kg/m 2

36. Results Operative and Perioperative Outcomes ESRD (n=19)Cirrhosis (n=14)ESLD (n=4) OperationLGBPLSG Total O.R. time (min)189 (148 - 222)141 (120 - 176)147 (90 & 213) Mean EBL, ml645850 Complications442 LOS, days3.0 (3 - 3)4.2 (2 - 8)4.0 (3 & 5) Follow-up, months36 (6 - 36)21 (3 - 21)18 (9 - 18) Bariatric Surgery Program University of California San Francisco, USA

37. Results LGBP in Patients With ESRD BMI Cutoff for Transplant Transplant candidate at 12 months 11/12 Bariatric Surgery Program University of California San Francisco, USA

38. Results LSG in Patients With Cirrhosis / ESLiverD BMI Cutoff for Transplant Transplant candidate at 12 months 6/9 Bariatric Surgery Program University of California San Francisco, USA

39. 1. CRF (with or without dialysis / pre Kidney Tx) 2. Post Kidney Tx 32 patients CRF, RYGB, no Tx 9 patients CRF, RYGB, Kidney Tx 10 patients Post kidney, RYGB

40. 1. Before Heart Tx N=2 Lap Sleeve

41. 1. After Liver Tx N=1 2 months after Liver Tx Biliary reconstruction and Open Sleeve BMI 37 to 30, 6 months post-op

42. 1. After Liver Tx N=2 1.BMI 65 to 48, 3 years post-op 2.BMI 63 to 43, 18 mo post-op

43. 1. CRF (with or without dialysis / pre Kidney Tx) 2. Post Kidney Tx 3. Before and after Heart Tx 4. Before and after Lung Tx 5. Before, during and after Liver Tx Bariatric Surgery Before and After Organ Transplantation

44. Laparoscopic Gastric Bypass Laparoscopic Gastric Banding 60% 25% Laparoscopic Sleeve Gastrectomy 20%

45. Laparoscopic Gastric Bypass Laparoscopic Sleeve Gastrectomy

47. Patient Selection – Initial Procedure 1.for patients considered high-risk 2.for transplant candidates 3.for morbidly obese patients with Met Syndrome 4.for pts. BMI 30-35 and comorbidities 5.for pts. with Inflammatory Bowel Disease 6.adolescent morbidly obese patients 7.for elderly morbidly obese patients LSG is a valid option 96% 91% 95% 86% 77% 100%

48. Bariatric Surgery in the Transplant Population Guilherme M. Campos, MD, FACS, FASMBS Associate Professor of Surgery University of Wisconsin – Madison campos@surgery.wisc.edu 5th Annual Wisconsin Chapter Transplant Symposium Transplant: Sharing and Caring