How Do We Treat Obesity? Bariatric Surgery

How Do We Treat Obesity? Bariatric Surgery Bariatric Surgery Surgery Options 2 Surgical Options Laparoscopic Adjustable Gastric Band (LABG) L...
Author: Bernice Spencer
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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.

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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.

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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.

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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.

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Bariatric Surgery

Outcomes Data

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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

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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