How Do We Treat Obesity?
Bariatric Surgery
Bariatric Surgery
Surgery Options
2
Surgical Options
Laparoscopic Adjustable Gastric Band (LABG)
Laparoscopic Sleeve Gastrectomy (LSG)
Roux-en-Y Gastric Bypass (RYGB)
Biliopancreatic Diversion with Duodenal Switch
Mechanick JI, et al. Endocr Pract. 2013;19:337-372.
3
Laparoscopic Adjustable Gastric Band (LAGB) Expected weight loss / mechanism
EWL: 14% - 60% after 7-10 y
Use adjustable band to create upper gastric pouch of 15-45 mL and restrict inlet to stomach • Produce early satiety and limit food intake
Safety
1-Year mortality: 0.08%; 30-day reoperation/intervention rate: 0.92%; overall complication rate: 3.2%; high reoperation rate due to complications or weight loss failure
Common complications
Band slippage and erosion Band and port infections Balloon failure
Postoperative metabolic management
Greater adherence to lifestyle change required to maintain weight loss Daily multivitamin plus calcium with vitamin D; additional nutrient supplementation as needed
Reversible?
Yes
Cost
$$*
Port malposition Esophageal dilatation
*Increased risk of procedure failure may increase overall costs. EWL = excess weight loss (ie, weight loss as percentage of excess body weight). Mechanick JI, et al. Endocr Pract. 2008;14(suppl 1):1-83. Mechanick JI, et al. Endocr Pract. 2013;19:337-372. Jackson TD, Hutter MM. Adv Surg. 2012;46:25-268.
4
Laparoscopic Sleeve Gastrectomy (LSG) Expected weight loss / mechanism
Safety Common complications
EWL: 50% - 55% after 5-9 y
Excision of lateral aspect of stomach to create smaller gastric tube • Limits food intake • Increases GLP-1 and PYY; decreases ghrelin
1-Year mortality: 0.21%; 30-day reoperation/intervention rate: 2.97%; major complication rate: 12.1% Long-term safety/effectiveness data lacking (>5-10 years) Staple line leak Staple line bleeding
Sleeve stenosis Sleeve kinking Sleeve dilation
Postoperative metabolic management
Daily multivitamin-mineral preparation plus iron, vitamin B12, and calcium with vitamin D; iron may be required in some patients
Reversible?
No
Cost
$$$
EWL = excess weight loss (ie, weight loss as percentage of excess body weight). Mechanick JI, et al. Endocr Pract. 2008;14(suppl 1):1-83. Mechanick JI, et al. Endocr Pract. 2013;19:337-372. Jackson TD, Hutter MM. Adv Surg. 2012;46:25-268.
5
Roux-en-Y Gastric Bypass (RYGB) Expected weight loss / mechanism
EWL: 60%-70% after 7-10 y
Stomach transected to create proximal gastric pouch of 10-30 mL, which is anastomosed to a Roux-en-Y proximal jejunal segment, bypassing remainder of stomach and duodenum • Limits food intake • Induces micronutrient malabsorption • Decreases ghrelin and increases PYY and GLP-1
Safety
1-Year mortality: 0.34%; 30-day reoperation/intervention rate: 5.02%; overall complication rate: 16%
Common complications
Anastomotic leak Pouch dilation Internal hernia
Postoperative metabolic management
Daily multivitamin-mineral preparation plus iron, vitamin B12, and calcium with vitamin D; additional nutrient supplementation as needed
Reversible?
Yes
Cost
$$$
Staple line disruption/failure Stomal ulceration Gastrogastric fistula
EWL = excess weight loss (ie, weight loss as percentage of excess body weight). Mechanick JI, et al. Endocr Pract. 2008;14(suppl 1):1-83. Mechanick JI, et al. Endocr Pract. 2013;19:337-372. Jackson TD, Hutter MM. Adv Surg. 2012;46:25-268.
6
Biliopancreatic Diversion with Duodenal Switch (BPD-DS) Sleeve gastrectomy with intestinal bypass of all but ~100-150 cm of distal ileum • Limits digestion and absorption to 50-100 cm of small intestine • Induces extensive nutrient and caloric malabsorption
Expected weight loss / mechanism
EWL: 60% - 80% after 7-10 y
Safety
1-Year mortality : 1.1%; overall complication rate: 16%
Common complications
Anastomotic leak Pouch dilation Incisional hernia
Staple line disruption/failure Stomal ulceration Gastrogastric fistula Malabsorption with nutritional deficiencies
Postoperative metabolic management
Daily multivitamin-mineral preparation plus iron, vitamin B12, calcium with vitamin D, and fat-soluble vitamins
Reversible?
Partially
Cost
$$$
EWL = excess weight loss (ie, weight loss as percentage of excess body weight). Mechanick JI, et al. Endocr Pract. 2008;14(suppl 1):1-83. Mechanick JI, et al. Endocr Pract. 2013;19:337-372.
7
Bariatric Surgery
Outcomes Data
8
Effects of Different Types of Bariatric Surgery on Weight Weight Loss as a Percentage of Excess Body Weight
Follow-up Period (years) Procedure
1-2
3-6
7-10
Vertical banded gastroplasty
50-72
25-65
—
Gastric banding
29-87
45-72
14-60
Laparoscopic sleeve gastrectomy
33-58
66
50-55
Roux-en-Y gastric bypass
48-85
53-77
25-68
Banded Roux-en-Y gastric bypass
73-80
66-78
60-70
Long-limb Roux-en-Y gastric bypass
53-74
55-74
—
Biliopancreatic diversion ± duodenal switch
65-83
62-81
60-80
Mechanick JI, et al. Endocr Pract. 2008;14(suppl 1):1-83. Mechanick JI, et al. Endocr Pract. 2013;19:337-372.
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Weight Loss with Different Bariatric Surgeries in Severely Obese Patients Swedish Obese Subjects Study (N=4047)
5 ∆ Mean Weight (%)
0
Control Banding Vertical banded gastroplasty Gastric bypass
-5 -10 -15 -20 -25 -30 -35
No. patients Control Banding Gastroplasty Bypass
0 1 2 3 4
6
8
10
15
20
556 150 489 37
176 50 82 13
Years 2037 376 1369 265
1490 333 1086 209
1242 284 987 184
BMI entry criteria: ≥34 kg/m2 men, ≥38 kg/m2 women. Sjostrom L, et al. JAMA. 2012;307:56-65.
1267 284 1007 180
10
Bariatric Surgery Reduces Mortality in Severely Obese Patients Swedish Obese Subjects Study (N=4047)
Control (49 events) Surgery (28 events) HR, 0.56; 95% CI, 0.35-0.88; Log-rank P = 0.01
Cumulative incidence
0.035 0.030 0.025 0.020 0.015 0.010 0.005 0 No. at risk Control Surgery
0
6
12
18
Total CV Events Control (49 events) Surgery (28 events) HR, 0.83; 95% CI, 0.69-1.00; Log-rank P = 0.05
0.16 Cumulative incidence
Fatal CV Events
0.14 0.12 0.10 0.08 0.06 0.04 0.02 0
0
6
Years 2037 2010
1993 1970
1423 1557
BMI entry criteria: ≥34 kg/m2 men, ≥38 kg/m2 women. Sjostrom L, et al. JAMA. 2012;307:56-65.
12
18
Years 405 412
2037 2010
1945 1921
1326 1468
361 375
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Long-Term Diabetes Remission After Bariatric Surgery Swedish Obese Subjects Study
(N=603 Patients with T2D at Baseline) Prevalence of Diabetes Remission
Patients Without T2D (%)
Surgery
Odds Ratio of Diabetes Remission
Control
Odds ratio (95% CI)
100 80
72.3
2 years
13.3 (8.5-20.7)
10 years
5.3 (2.9-9.8)
15 years
6.3 (2.1-18.9)
60 38.1
40 20
16.4
30.4 10
7
0 2 Years
10 Years 15 Years Follow-up Time
0
10
20
30
Favors Surgery T2D = type 2 diabetes. Sjostrom L, et al. JAMA. 2014;311:2297-2304.
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Weight Loss with Different Bariatric Surgeries in Obese Patients
ACS Bariatric Surgery Center Network Prospective Observational Study (N=28,616)
∆ BMI (kg/m2)
30 days 0 -2 -4 -6 -8 -10 -12 -14 -16 -18
-2.45
-3.36 -3.76
6 months
1 year
-5.02
*
-7.05 -8.75
*
-10.82
* LAGB
LSG
RYGB
* -11.87
*
-15.34
*
*P