Bariatric Surgery

The most effective treatment for combating obesity

Lt Col Alok Bhalla

Weight Control:
Fashion Statement or a Medical Necessity?

Historical Perspective
Paleolithic era >25,000 years ago

Obesity is a BIG problem now

1.7 billion worldwide are overweight or obese The US has the highest percentage of obese people And the numbers are growing

Epidemiology of Obesity
31.3% of U.S. males
34.7% of U.S. females 30% increase in the last 10 years Health care costs - >$100 billion/year Results in 300,000 preventable deaths each year in the U.S. 6-7% of total sick care costs in the Western world due to obesity

 Indian Scenario
20-30% of adults and 10-20% of children are obese. Its fast gaining unmanageable proportion.

 Obesity is not a condition. It's a disease needing medical intervention. Surgical treatment is a medical necessity as it is the only proven method to achieve sustained long term weight loss. Bariatric Surgery does not involve liposuction or abdominoplasty. Involves reducing the size of stomach with or without a malabsorptive procedure.

Obesity and Life Expectancy

If current rates of obesity are left unchecked, the current generation of American children will be the first in two centuries to have a shorter life expectancy than their parents.

Olshansky SJ, et al. A Potential Decline in Life Expectancy in the United States in the 21st Century. NEJM, 352(11):1138-1145, 2005

Classification of Overweight and Obesity

A BMI of:
<18.5 18.5-24.9 25-29.9 30-34.9 35-39.9 40-49.9 50 and above

Classifies one as:

Underweight Normal weight Overweight Obesity Class I Obesity Class II Obesity Class III Super Obesity

What Causes Obesity?

Nutrient and energy model of obesity Metabolism Appetite regulation Energy expenditure Genetics Behavior and cultural factors

Nutrient and Energy Model Of Obesity

Obesity results from increased intake of energy or decreased expenditure of energy, as required by the first law of thermodynamics.

Energy Intake Adipose tissue

Energy Expenditure

Medical Complications of Obesity

Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Gall bladder disease Gynecologic abnormalities abnormal menses infertility PCOS Osteoarthritis Skin Gout Idiopathic intracranial hypertension Stroke Cataracts CHD Diabetes Dyslipidemia Hypertension Severe pancreatitis Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis

Consequences of Obesity
Obesity is associated with a rise in many comorbid conditions, including:
Type 2 Diabetes Hyperlipidemia Hypertension Obstructive Sleep Apnea Heart Disease Stroke Asthma Osteoarthritis Cancer Depression

Obesity and Diabetes Risk

100 80 60 40 19 20 0 <20 20-25 25-30 30-35 35-40 >40 30
Incidence of New Cases Overweight per 1000 Persons/Year Obese Morbidly Obese

45-65

BMI Levels
1981 Knowler WC et al.Am J Epidemiology

Metabolic syndrome
MS is a clustering of risk factors : High levels of triglycerides and serum glucose. Low levels of high-density lipoprotein. High blood pressure. Abdominal obesity.

Effects of Obesity Surgery on the Metabolic Syndrome Wei-Jei Lee, MD, PhD; Ming-Te Huang, MD; Weu Wang, ARCH SURG/VOL 139, OCT 2004

Weight Loss Strategies

Diet therapy Increased Physical Activity Pharmacotherapy Behavioral Therapy Any combination of the above

Dieting
Dieting is highly ineffective - 95% long term failure rate Often results in higher weight than before the diet

Diet
Low calorie diets (LCD)
Consist of 800-1500 kcal/day

Very low calorie diets (VLCD)

Consist of <800 kcal/day

LCD recommended over VLCD because of equal efficacy at 1-year LCD has been shown to reduce body weight by 8% at 6 months but benefit does not persist at 12 month

Exercise and Behavior Modification

Physical Exercise (3-7 sessions per week, lasting 30-60 minutes) can achieve modest weight loss, of 2-3% of body weight. Behavior therapy in conjunction with diet and exercise can produce weight loss of 10% over 4 months-1 year. The fundamental problem is recidivism.

Non Operative Treatment

Not effective in achieving medically significant long term wt loss Almost all regain wt in 5 years Combination of anorectic drugs ,diet control, exercise and behavior modification led to initial optimistic results but could not be sustained with 1/3rd drop outs and only 3 lbs wt loss over 4 years Some of the drugs have dangerous side effects Still all patients should give at least one trial of non medical treatment before being subjected to surgery

Pharmacotherapy
Sibutramine
Appetite suppressant NE and Serotonin reuptake inhibitor Side effects: Increase HR, Blood Pressure, nervousness and insomnia Mean weight loss 4.45 kg at 12 months

Pharmacotherapy Orlistat
Lipase inhibitor: decreases absorption of fat. Side effects: diarrhea, flatulence, bloating, abdominal pain, dyspepsia

Mean weight loss: 2.89 kg at 12 months

Pharmacotherapy

Phenteramine and Diethylproprion

Appetite suppressant: sympathomimetic amine Side effects: cardiovascular and gastrointestinal Mean weight loss: 3.0-3.6 kg at 6 months

Weight Loss Definitions

Excess weight=actual weight - ideal body weight
Excess Weight Loss (EWL) is the standard in the bariatric surgery nomenclature %EWL=(weight loss/excess weight) x 100

Obesity warning on London buses

Indications for Surgery

BMI 40 or More BMI 35-39.9, if associated with co-morbidities ( Metabolic syndrome) Motivated Patient

Rationale for Surgery

Associated with increased Mortality

2-12 fold increase in mortality in both sexes. Mortality rate revert back to normal following Bariatric Surgery. Statistically significant improvement in associated co-morbidities with 10% wt loss. Cancer mortality rates higher in obese patients. Increased Fertility after Bariatric Surgery.

Goals of Surgery
* To achieve long term and medically significant wt loss (Surgery a medical necessity as its the only treatment option to achieve long term wt loss) * Prevention of secondary complications of morbid obesity * Adhere to the time tested principle of therapeutic intervention has to be less harmful than the disease being treated

Goals of Surgery
Obesity a psychological and Biological challenge for the patient Lack of respect for morbidly obese by the society 80% of them feel disrespect by the medical professionals Negative attitude of general public; weak willed, ugly, awkward and self indulgent Obesity a stigma leading to increased psychological distress and disorders. At high risk of developing affective, anxiety and substance abuse disorders.

Pre operative evaluation

Evaluation by an Endocrinologist All patients undergoing surgery should have adequate trial of medical therapy Patients should be advised and counseled regarding life long monitoring Surgery should be performed in a well established setup Patients should be treated with more compassion & concerned

Pre operative Psychological evaluation

To weed out patients with psychiatric disorders Select patients who will benefit from surgery However it has revealed : No single personality type No higher incidence of psychiatric disorders Binge eaters

Bariatric Surgery
1991: NIH establishes guidelines for the surgical therapy of morbid obesity Recommends BMI criteria BMI > 40 BMI > 35 + significant comorbidities
This therapy now referred to as Bariatric Surgery

Estimated Number of Bariatric Operations Performed in the United States, 1992-2003

Stein brook, R. N., 2004

Bariatric Surgery Procedures

Its neither lipo- suction nor abdominoplasty
Procedures Restrictive Adjustable Gastric Banding Vertical Banded Gastroplasty Sleeve Gastrectomy Malabsorptive Bilio Pancreatic Diversion (Scopinaros Procedure) Combined Roux-en-Y gastric Bypass Sleeve Resection with Duodenal Switch

A Brief History of Bariatric Surgery

Intestinal bypass ( 1950s) by Drs. Kremen and Linner

Biliopancreatic diversion (1976) by Dr. Scopinaro

The Advent of the Roux-en-Y GBP

Based on observations of weight loss in pts receiving subtotal gastric resections for other conditions Today's most common form of gastric bypass surgery is a derivative of a procedure pioneered in 1966 by Edward E. Mason, MD, PhD, at the University of Iowa

Evolution of Gastric Banding

1980s Alternative to Roux-en-Y in Europe & Scandinavia 1990s Adjustable silicone band developed by Dr Kuzmak who devised a band with an inflatable balloon as its lining. 2000s Laparoscopic techniques for placement developed

Types of Bariatric Surgery

Purely Restrictive Gastric Balloons (not FDA approved) Vertical-banded gastroplasty Gastric adjustable banding

Restrictive > Malabsorptive Short-limb/Roux-en-Y gastric bypass Long-limb/distal Roux-en-Y gastric bypass Malabsorptive > Restrictive Biliopancreatic diversion (BPD) BPD with duodenal switch

Adjustable Gastric Band

A low pressure high volume silicone elastomer adjustable band placed round the upper part of the stomach, creating a small gastric pouch to hold a very small quantity of food

Adjustable Gastric Band

Advantages Simple and relatively safe procedure No anastamosis Reversible Disadvantages 5% Failure Needs highly motivated patients

Vertical Banded Gastroplasty

Commonest restrictive procedure in USA Both band & staples are used to create a small gastric pouch Being replaced by LAGB allover the world

Vertical Banded Gastroplasty

Weight loss: 50-60% EWL Plateau in weight loss reached at 2 years Operative mortality: 0.1% Operative morbidity: 5% Long-term complications: vomiting, outlet obstruction, erosion, staple line dehiscence

Vertical Banded Gastroplasty

Advantages Easier to perform Shorter operative time Disadvantages Poor operation for sweet eaters Restrictive only Nonadjustable Staple line disruption and leaks

Sleeve Gastrectomy
Per se a restrictive procedure but mostly used as an adjunct to duodenal switch for a better outcome

Roux-en-Y GBP
Open
3 hour procedure 3-4 days in-house 4-6 weeks Return to work 60-70% EBW loss @ 2 yrs 0.5-1.0% Risk of Death

Laparoscopic 3 hour procedure 2 days in-house 2-3 weeks Return to work 60-70% EBW loss @ 2yrs 0.5-1.0% Risk of Death

* Data based on averages.

Roux-en-Y GBP
Weight loss: 65-70% EWL Weight loss plateaus at 1-2 years Operative mortality: 0.5% Operative morbidity: 5% (pulmonary emboli, anastamotic leak, bleeding, wound infection)

Buchwald J Am Coll Surg 2005

Roux-en-Y GBP
Advantages
Combines the advantages of both restrictive as well as malabsorptive procedures

Disadvantages
Staple line failure Marginal ulcers Narrowing of stoma Vomiting

Adjustable Lap Band

A silicone band is placed around the upper part of the stomach A small pouch is created Stomach holds less food Induces feeling of satiety Shorter OR time Same day surgery Return quickly to work Evaluated every 6-8 weeks for gradual tightening if necessary

Adjustable Lap Band

Adjustability is the most important attribute. Filled with a saline solution. By adding or removing the saline, can be made tighter or looser. Adjust as necessary to support gradual, steady weight loss. Often 5-6 times in the first year. - Place reservoir on anterior rectus sheath - Palpate, mark the site, no-touch technique - Office procedure, rarely needs radiology

Adjustable Lap Band

Weight loss: 50% EWL at 2 years Operative mortality: 0.1% Operative morbidity: 5% Long-term complications: gastric prolapse, stomal obstruction, esophageal and gastric pouch dilation, gastric erosion and necrosis, access port problems.

Adjustable Lap Band Results

OBrien: 57% EWL at 6 yrs Dargent: 64% EWL at 3 yrs Vertruyen: 52% EWL at 7 yrs Belachew: 50-60% EWL at 5 yrs Rubenstein: 54% EWL at 3 yrs Fox: 60% EWL at 4 yrs

LAGB Complications
Failure: 20-25% Slip: 5.6% Erosion: 0.6% Access Port or Tubing: 1.7% Death: 0.05% Pulmonary embolism: 0.1%

Adjustable Lap Band

Advantages

Disadvantages
Foreign body Slower weight loss Lower overall weight loss Higher failure rate Poor operation for sweet eaters

Simple to perform Adjustable Lowest mortality Minimally invasive Shortest operative time No need for vitamin and mineral supplementation

Biliopancreatic Diversion
A complicated malabsorptive procedure

Biliopancreatic Diversion

Advantages
Highest malabsorptive component
Best long term weight loss Allows larger quantity of food intake

Disadvantages
Greater chances of chronic diarrohea,,stomal
ulcers

Higher risk of nutritional deficiencies

Duodenal Switch
A combined procedure where a part of duodenum is kept in the digestive pathway, regulating release of gastric contents in to the small bowel

Duodenal Switch
Advantages Better absorption of Vit B12 Better eating quality Eliminates stomal ulcers Disadvantages Same as biliopancreatic bypass

BPD Duodenal Switch

3 hr procedure 2-3 day in-house 1 wk Return to work 70-75% EBW loss @ 2 yrs 2% Risk of Death Diarrhea, Calcium and fatsoluble vitamin malabsorption

Biliopancreatic Diversion Duodenal Switch

Weight loss: 70% EWL Operative mortality: 1% Operative morbidity: 5% Long-term complications: diarrhea, malodorous stools and flatus, vitamin, mineral and nutrient deficiencies, in particular, protein deficiency

Biliopancreatic Diversion Duodenal Switch

Advantages Superior weight loss Most durable weight loss Most difficult to beat

Disadvantages Protein and calcium malnutrition Most complicated Malodorous stool and flatulence

Comparing EWL: GBP vs. Banding

Prospective matched-pair design Bypass = 103 - Banding = 103

Weber M. et al 2004, Annals of Surgery

Type 2 DM Resolution
% Resolution (95% Confidence Interval) 989

Gastric Bypass
205

83.8 (77.3, 90.1)

Gastric Banding
288

47.9 (29.1, 66.7)

Duodenal Switch 0 20 40 60 80 100

98.9 (96.8, 100.0)

Buchwald, H. et al. 2004 Bariatric surgery: a systematic review and meta-analysis

Bariatric Surgery A Systematic

Review and Metaanalysis

Buchwald, H. JAMA 2004
22,094 patients: 19% men, 72.6% women Mean age 39 years Mean percentage excess weight loss 61.2% Gastric banding: 47.5% EWL Gastric bypass: 61.6% EWL

Bariatric Surgery A Systematic Review and Meta-analysis

Gastroplasty: 68.2% EWL Biliopancreatic diversion or duodenal switch: 70.1% EWL

Operative mortality:
0.1% purely restrictive surgeries 0.5% gastric bypass 1.1% biliopancreatic diversion or duodenal switch

Bariatric Surgery A Systematic Review and Meta-analysis: Overall

Diabetes completely resolved in 76.8% of patients and resolved or improved in 86% Hyperlipidemia improved in 70% Hypertension was resolved in 61.7% and resolved or improved in 78.5% Obstructive sleep apnea was resolved in 85.7% and resolved and improved in 83.6%

Swedish Obese Subjects Study

Sjostrom, L. N Engl J Med 2004
Prospective, nonrandomized, interventional trial involving 4047 subjects Largest trial comparing surgical versus medical treatment of morbid obesity 2010 patients underwent surgery (gastric banding, gastroplasty, or gastric bypass) 2037 chose medical treatment

Swedish Obese Subjects Study

At 2 years, weight had increased by 0.1 percent in the control group and decreased by 23.4 percent in the surgery group. At 10 years, weight had increased by 1.6 percent in the control group and decreased by 16.1 percent in the surgery group.

Swedish Obese Subjects Study

Energy intake was lower and the proportion of physically active subjects was higher in the surgery group Two and ten-year rates of recovery were better for diabetes, hypertriglyceridemia, low levels of high-density lipoprotein cholesterol, hypertension and hyperuricemia were more favorable in the surgery group

Swedish Obese Subjects Study

Surgery group had lower two and ten year incidence rates of diabetes, hypertriglyceridemia, and hyperuricemia Surgically treated patients were significantly less likely to require medications for cardiovascular disease or diabetes at two and six years

Swedish Obese Subjects Study

Costs of medications were reduced significantly in the surgically treated group. Surgically treated patients had dramatic improvement in scores on validated measures of quality of life

Life Expectancy
Christou found that the 5-year death rate in the Bariatric surgical group was 0.68% compared with 16.2% in the medically managed patients and 89% relative risk reduction.

Flum and Dellinger found a 27% lower 15-year death rate in those undergoing gastric bypass.
After the first postoperative year, the long-term survival advantage increased to 33%

Weight control is a journey, not a destination.