1. Bariatric Surgery Nicole Mancinelli

2. Objectives  Be familiar with the most common types of bariatric surgery procedures performed today.  Learn the criteria that need to be met to be considered a candidate for surgery.  Be familiar with the advantages/disadvantages of the most common procedures.

3. Burden of Obesity  Approx.72.5 million adults considered obese in 2007-2008  Biggest contributor of healthcare spending over last 20 yrs  Oklahoma was ranked 7 th most obese state in 2011 CDC

4. History of Bariatric Surgery  1954: first introduced by Kremen  1976: safer approach developed by Scopinaro  1988: crossbreed of Biliopancreatic diversion developed by Hess  1994: laproscopy was introduced by Wittgrove Maggard et al. Scopinaro et al.

5. Qualification for Surgery  BMI ≥40 kg/m 2  BMI ≥35 kg/m 2 + co-morbidities of obesity  Failed conventional weight control Padwell et al.

6. Current Surgical Procedures  Adjustable gastric banding  Vertical banded gastroplasty  Roux-en-Y procedure  Laproscopic sleeve gastrectomy  Biliopancreatic Diversion with duodenal switch

7. Vertical Banded Gastroplasty  Created in 1982  Band/staples used to create a small stomach pouch  Limited weight loss results and high re-operation rates Up to 56% as compared to other procedures  Complications: Stromal erosion, weight regain, severe GER symptoms

8. Lap Sleeve Gastrectomy  Fairly new restrictive procedure  Originally created as a bridging procedure  Ranked between LAGB and Roux en Y  More data needed to determine relative benefits

9. Biliopancreatic Diversion with Duodenal Switch  Originally created in 1988 for treatment of bile gastritis  Decrease usage due to increased risk of micro/macro nutritional deficiencies  Increased risk for metabolic consequences Protein malnutrition Fe deficiency anemia Hypocalcemia  Develop bone demineralization that could double fracture risk

10. Adjustable Gastric Banding  Approved in 2001  Ability to fine tune desired effects of silicone band and decrease adverse effects  Lowest morbidity and mortality among bariatric procedures  Disadvantages Foreign object Stomach prolapse Inferior weight loss when compared to Roux en Y

11. Long term efficacy/Safety  Followed 82 pts Jan. 1994- Dec 1997 22% experienced minor complications  Incisional hernia, port tube disconnections, infection 39% (23)experienced major complications  Dilation of pouch, erosion Re-operations  49 (59.8%) due to lack weight loss Mean BMI ↓ from 41.57 to 33.79 Nearly 50% required removal band, 1out of 3 had band erosion Scozarri et al.

12. Roux-en Y Procedure  First appeared in 1967  Most widely performed  Combo of restrictive/ malabsorption  Roux limb varies and each has its own advantages  Best results for long term weight loss, decrease GERD symptoms 95% of pts

13. RYGB vs LAG  Prospective randomized study  196 pts 111 LRYGB  Mean BMI 47.5 kg/m2 86 LAG  Mean BMI 45.5kg/m2

14. Weight loss Results

15. Early/ Late Complications

16. Long term consequences  Improves associated co-morbities related to obesity Diabetes Sleep Apnea HTN  >75% had HTN prior to surgery  69% reported HTN resolved in 1 year and sustained over 7 years GERD  >50% obese have GERD, >95% had resolution after bariatric procedure

17. DM Prevalence of DM in 1990 Prevalence of DM 1997-1998 Mokdad et al.

18. Efficacy of surgery in the management of obesity related type 2 Diabetes Mellitus Gan et al

19. Nutritional Deficiencies  Fe Deficiency > 50% were below pre op levels despite adequate oral supplements Only 3.5% required transfusion  B 12 Most commonly after RYGB Below normal in 26% of 66 pts after RYGB

20. Calcium Deficiency 243 pts followed after RYGB Johnson et al.

21. Dumping Syndrome  Caused when ingested food bypasses the stomach too rapidly and enters the small intestine largely undigested Expansion of the duodenum occurs too quickly due to the presence of hyperosmolar food from the stomach  >70% of individuals experienced at least one symptom of this syndrome after RYGB

22. Future of Bariatric Surgery  Single incision Uses silicone band around upper portion of the stomach  Incision Free Transoral gastroplasty Endolumenal Both create stapled, restrictive pouch

23. Conclusion  Most common bariatric procedures are Roux en Y, and Adjustable Gastric Band  Certain procedures should be selected based on multiple factors

24. References  Scozzari, MD, Toppino M, Famiglietti F, et al. 10 year follow up of laparoscopic Vertical banded gastroplasty. Annals of Surgery. November 2010; 225 (5): 831-839.  CDC. State-specific prevalence of obesity among adults- United States, 2009. MMWR 2010:59;951-955.  Padwal R, Klarenbach S, Tonelli M, et al. Bariatric Surgery: A systematic Review of the Clinical and Economic Evidence. JGIM: Journal of General Internal Medicine. October 2011;26 (10):1183-1194.  Suter M, Donadini A, Romy S, Demartines N, Giusti V. Laproscopic Roux-en-Y Gastric Bypass: Significant Long term weight loss, Improvement of Obesity-related Comorbidities and Quality of Life. Annals of Surgery. 2011;254 (2): 267-273.  Gan S. Talbot M, Jorgensen J. Efficacy of Surgery in the management of obesity related type 2 diabetes mellitus. Surgery. October 2007; 77:958-962.

25. References  Johnson J, Maher J, DeMaria E, Downs R, Wolfe L, Kellum J. The Long term effects of Gastric Bypass on Vitamin D Metabolism. Annals of Surgery. Scientific Papers of the 117 th Annual Meeting of the Southern Surgical Association. 2006: 243 (5): 701-705.  Mokad A, Ford E, Bowman B, Nelson D, Engelgau M, Vinicor F, Marks J. Diabetes trends in the US: 1990-1998. Diabetes Care. September 2000; 23:1278-1283.  Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: Surgical treatment of obesity. Annals of Internal Medicine. 2005; 142:547-559.  Scopinaro N, Adami GF, Marinarir GM, et al. Biliopancreatic Diversion. World Journal of Surgery. 1998; 22:936-946.  Special Thanks to G. Michael Steelman M.D.