bariatric surgery in obesity and metabolic disease
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Bariatric Surgery in Obesity and Metabolic Disease. Olivier Court MD FRCSC Director, section of Bariatric Surgery McGill University Health Center. Disclosure of Conflict of Interest. - PowerPoint PPT PresentationTRANSCRIPT
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Bariatric Surgery in Obesity and
Metabolic DiseaseOlivier Court MD FRCSC
Director, section of Bariatric SurgeryMcGill University Health Center
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Disclosure of Conflict of Interest
• no affiliation with the manufacturer of any commercial product or provider of any commercial service discussed in this CME activity.
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Outline• Prevalence of Obesity
• Consequences of Obesity
• Treatments for obesityo Non-operativeo Surgical options
• Benefits of Bariatric Surgery
• Mechanisms for metabolic benefits
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Weight classification according to BMI
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Prevalence of obesity
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Prevalence of obesity
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Prevalence of obesity
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Co-mobidities of obesity
JAMA. 2004 Oct 13;292(14):1724-37
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Cost of obesity in Canada
1997 2006
• The total direct cost of obesity in Canada was $1.8 billion
• 2.4% of the total health care expenditures
• The total direct costs of obesity in Canada was $4.0 billion
• 4.1% of the total health care expenditures
CMAJ 1999 Feb 23;160(4):483-8 Obes Rev. 2010 Jan;11(1):31-40
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Obesity and mortality
Lancet. 2009 Mar 28;373(9669):1083-96.
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Treatments for obesity
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Obesity: non-operative management
• Diets• Few patients ever achieve more than 10% weight loss• Over 95% regain all weight lost by 5 years
• Pharmacotherapyo Orlistat (Xenical)
• Inhibits intestinal lipase• Not absorbed – Safe• Expected weight loss: 10%
o Sibutramine (Meridia)• Monoamine reuptake inhibitor – acts centrally to diminish appetite• Average weight loss at 1 year: 10 lbs• Can induce significant hypertension• Taken off market in Canada, still available in US
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Obesity: Surgical management
NIH Concensus recommendations
• Patients whose BMI exceeds 40
• Patients with a BMI between 35 and 40 if they also have some severe comorbidities related to obesity:
o NIDDMo Obstructive Sleep Apneao Severe Osteoarthritis
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Surgical options
• Restrictive procedures• Laparoscopic Adjustable Gastric Band• Laparoscopic Sleeve Gastrectomy
• Malabsorptive procedures• Laparoscopic Roux-en-Y Gastric Bypass• Laparoscopic Biliopancreatic Diversion with
Duodenal Switch
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Laparoscopic Adjustable Gastric
Band• Creation of 30-60cc
pouch• Adjustable pouch
outlet• Easy insertion
• Resultso 2 years – 30-40% EBWo 5 years – 50% EBW
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Laparoscopic Adjustable Gastric
Band
• Disadvantages
o Expensiveo Band slipping/erosiono Band/port malfunctiono Unknown durability
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Laparoscopic Sleeve Gastrectomy
• Resection of about 75% of stomach
• Few complications
• Resultso No long term datao 1 year - 50% EBWo 3 years - 60% EBW
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Laparoscopic Roux-en-Y Gastric Bypass
• Creation of 30-60cc pouch
• Roux limb 100 cm• Bypass stomach,
duodenum and proximal jejunum
• Resultso 1 year – 65-70% EBWo 5 years – 60-70% EBWo 10 years – 60% EBW
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Laparoscopic Roux-en-Y Gastric Bypass
• Complications
o Mortality about 0.1%o Anastomotic leak 2-3%o Dumping syndromeo Iron/Calcium/vit B12 deficiencyo Drinkingo Marginal ulceration
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Laparoscopic Biliopancreatic Diversion with Duodenal
Switch• Sleeve gastrectomy• Duodeno-jejunal
anastomosis• Roux limb 150cm• Common channel
100cm
• Resultso 1year – 70% EBWo 5 years – 75-80% EBWo 10 years – 80% EBW
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Laparoscopic Biliopancreatic Diversion with Duodenal
Switch
• Complications
o Mortality about 0.5%o Anastomotic leak 2-3%o Steatorrheao Ca, Iron, vit A,D,E,K deficiencyo Protein malnutrition 2-3%
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Benefits of Bariatric Surgery
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JAMA. 2004 Oct 13;292(14):1724-37
Resolution of Comorbidities
(136 studies, 22,904 patients)
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Metabolic benefits beyond weight loss
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Metabolic benefits beyond weight loss
• 150 patients with BMI 27 – 43 followed for 12 months
• 3 groups:o Intensive medical therapy (n=50): lifestyle counseling, weight mgt,
home glucose monitoring, medications including incretin analogues to reach HbA1c < 6%
o Gastric bypass (n=50)o Sleeve gastrectomy (n=50)
• Primary endpoint: % of pts with HbA1c<6%
• Secondary endpoints: Fasting glucose, fasting insulin, lipids, CRP, HOMA-IR, weight loss
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Metabolic benefits beyond weight loss
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Metabolic benefits beyond weight loss
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Diabetes
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Diabetes
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Metabolic benefits beyond weight loss
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Metabolic benefits beyond weight loss
• 72 patients with BMI>35 with followed for 2 years• 3 groups:
o Medical therapy (n=24)o Gastric bypass (n=24)o Biliopancreatic diversion (n=24)
• Primary endpoint: rate of DM remission (fasting glucose<5.6 and HbA1c<6.5% without medication)
• Secondary endpoints: Average HbA1c, body weight, triglycerides, total and HDL cholesterol
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Metabolic benefits beyond weight loss
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Resolution of comorbidities
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Bariatric Surgery: Impact on Mortality
Study Center Surgery Type Reduction in Risk of Death
McGill University(Canada)
Gastric Bypass 89%
University of Padoa(Italy)
Adjustable Gastric Band 60%
Monash University(Australia)
Adjustable Gastric Band 72%
Gothenberg University(Sweden)
Gastric Bypass, GastroplastyAdjustable Gastric Band
24%
University of Utah(USA)
Gastric Bypass 40%
Average 57%
Study Center Surgery Type Reduction in Risk of Death
McGill University(Canada)
Gastric Bypass 89%
University of Padoa(Italy)
Adjustable Gastric Band 60%
Monash University(Australia)
Adjustable Gastric Band 72%
Gothenberg University(Sweden)
Gastric Bypass, GastroplastyAdjustable Gastric Band
24%
University of Utah(USA)
Gastric Bypass 40%
Average 57%
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Cost effectiveness of Bariatric Surgery
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Conclusion• Impact of obesity on health care is growing
• Bariatric Surgery results in weight loss, but also in resolution of comorbidities and improvement in mortality
• Mechanisms are still unclear
• Bariatric vs Metabolic Surgery
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Mechanisms for metabolic benefits of
Bariatric Surgery
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Role of Gut hormones
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Mechanisms of action RNYGB AGB VSG
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Mechanisms of action RNYGB AGB VSG
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Mechanisms of action• Hind Gut vs Fore Gut theories for RNYGB
• However, VSG and RNYGB are similar in their metabolic and hormonal effects
• Both differ from AGB
• Alternate explanation is required