1. 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

2. Disclosure
Nothing to disclose

3. 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

4. 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

5. Treatment of Obesity Diet & Exercise Medications
Behavioral modification
Surgical management

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

8. 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

9. 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

10. 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

11. 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

12. 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)

13. 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

14. Laparoscopic Gastric Bypass

15. 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

16. 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)

17. 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

18. Laparoscopic Vertical Sleeve Gastrectomy

19. Vertical Sleeve Gastrectomy

20. 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

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

22. 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

23. 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%)

24. The Johns Hopkins Center for Bariatric Surgery Over 3,000 bariatric procedures since 1997
Analysis of 1000 gastric bypass procedures:
Age = 41 yo ( yrs)
Female = 77 %
Pre-Op weight = 349 lbs ( lbs)
Pre-Op Body Mass Index (BMI) = 55.3 ( )
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 %

25. 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

27. OBESITY SURGERY AT JHBMC
POST-OP COMPLICATIONS
(1000 gastric bypass pts.)
Mortality = %
Morbidity = 13 %
Wound infection = %
Pulmonary embolus = %
Reoperation (< 30 days) = %
Decubitus ulcers = %
Anastamotic leak = %
Bowel obstruction = %
Readmission = %

28. OBESITY SURGERY Evidence based analysis
Is bariatric surgery effective?
Buchwald 2004 (meta-analysis): Resolution of
% excess wt loss DM HTN
Gastric Band % % 43%
Gastric Bypass 61% % 67%
DS/BPD % % 83%

29. OBESITY SURGERY Evidence based analysis
Is bariatric surgery effective?
Buchwald 2004 (meta-analysis): Resolution of
% excess wt loss DM HTN
Gastric Band % % 43%
Gastric Bypass 61% % 67%
DS/BPD % % 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

30. 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

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

32. N Engl J Med
Compared the efficacy of three treatments for patients with T2DM and BMI between 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.

33. N Engl J Med. 2012
Med therapy GBP Sleeve

34. 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

35. Results

36. Diabetes resolution: 1669 (74. 7%) of 2235 pts at 6 months 1489 (80
Diabetes resolution: 1669 (74.7%) of 2235 pts at 6 months (80.6%) of 1847 pts at 12 months (84.5%) of 1072 pts at 2 years

37. -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

38. 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%

39. “Metabolic Surgery” Future directions:
Patient selection based more on metabolic disease as opposed to weight (? BMI of 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

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

41. 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

42. 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

43. The End