Bariatric Surgery Preserving the Choice by yaosaigeng


									      Bariatric Surgery
A Powerful Option in the Weight
    Loss Armamentarium

    Marina Kurian, MD, FACS
 Manhattan Minimally Invasive and
       Bariatric Surgery P.C.
 Lenox Hill Hospital, New York, NY
33% of adult women
27.5% of adult men
15.5% of adolescents
BMI > 45 adults 20-30 years old
     loss of between 8 to 20 years of life
117 Billion cost
Obesity Related Co-Morbidities
 Co-Morbidity               Occurrence in the Obese
 – Diabetes                          –   14–20%
 – Hypertension
                                     –   25–55%
 – Hyperlipidemia
 – Cardiac disease                   –   35–53%
 – Respiratory disease               –   10–15%
     • sleep apnea                   –   10–20%
 – Arthritis
 – Depression
                                     – 20–25%
 – Stress Incontinence
 – Menstrual irregularity            – 70–90%
                                    • 50%
  Increased Risk of Obesity Related
     Diseases With Higher BMI
                              BMI > 35
Arthritis                     2.39
Heart Disease                 1.67
Type II Diabetes              6.16
Hypertension                  3.77
Stroke                        1.75

Source Center for Disease Control
Non-Medical Co-Morbidities

    •   Physical
    •   Economic
    •   Psychological
    •   Social
      Physical Co-Morbidity

• Clothing choice
• Tying shoelaces
• Furniture incapacity
  – seats in theater, planes, buses
  – restaurant booths
  – toilet and shower cubicles
• Personal hygiene (limits of reach)
    Economic Co-Morbidity

• Employment discrimination
  – getting hired
  – promotions
  – special projects or accounts

• Education discrimination
  – select schools and universities
   Psychological Co-Morbidity
• Major psychiatric illness same as rest of
• Low self-esteem common
• Depression very common
  – normal weight 20–25%
  – moderately obese 60%
  – morbidly obese 90%
        Social Co-Morbidity

• Weight harassment and prejudice
• Studies show society has low respect for
  morbidly obese
  – same as for alcoholics and drug addicts
• Many have limited number of friends
• Dating and marriage is less common
• Energy balance
  – In = food intake
  – Out = RMR, Physical Activity, Energy
• Resting metabolic rate
  – 70% of caloric expenditure
  – Constant temperature
  – Goes down when you loss weight
• Decreases visceral fat
• Improves parameters of
  –   Glucose intolerance/ Insulin sensitivity
  –   Hypertension
  –   CAD
  –   hypercholesterolemia
• Alone does not result in significant weight
          A Guide to Selecting Treatment
                                                              BMI Category
  •Treatment                      < 24.9       25-26.9        27-29.9          30-35 35-39.9 >40

  •Diet, exercise,                             With co-       With co-            +           +            +
   behavior therapy                            morbidities morbidities

  •Pharmacotherapy                                            With co-           +           +             +

  •Surgery                                                                               With co-         +

Source: The Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults,
            Obesity Pharmacotherapy

                Approved for Long-Term Use
System        Mechanism                     Examples
Digestive     Inhibition of lipase          Orlistat(Xenical)

CNS           Inhibit norepinephrine,   Sibutramine(Meridia)
              serotonin and
              dopamine reuptake

                Approved for short-term use
 CNS         Norepinephrine release      Phentermine, others
                     Drugs in human testing
  • Phase III
  • Ciliary neurotrophic factor - Axokine
  • Cannabinoid CB1 receptor antagonist-Rimonabant

  •   Various Stages
  •   Topiramate
  •   Bupropion
  •   Leptin
  •   gAcrp30 - Adiponectin analog
  •   Beta 3 agonists
  •   Botanical - P57
  •   CCK-a promoter
  •   Glucagon-like peptide
  •   Human growth hormone fragment - AOD 9064
  •   Lipase inhibitor-ATL 962

Variety of sources
    Surgical Procedures Growing in
•   Estimated > 140,000 in 2004
•   1% are adolescents
•   Obesity is a disease
•   Minimally invasive options
•   Realization that little else works
Obesity Surgery Doubling Annually

• 1994      16,000 cases
• 2003      120,000 cases
• Public Demand based on understanding the
  reduced quality of life, lack of other
• Not ignorance to risk
• Celebrities and media
           ADVANTAGES OF
•   Appealing to patient
•   Reduced wound complications
•   Faster healing
•   Improved visualization in areas difficult to
• Operations to make you eat less

• Malabsorption
       •   Restrictive procedure
       •   Mayo clinic
       •   Losing popularity
       •   Maladaptive eating
       •   High recidivism
       •   Replaced by
           adjustable bands
  Pros               Cons
• Easy to insert        •   Foreign body
• No malabsorption      •   Higher failure rate
• Low mortality and     •   Slippage
                        •   Erosion
• Adjustable
• Preserves normal      •   Esophageal dilation
  anatomy               •   Maladaptive eating
• Short hospital stay
                 Lenox Hill Data
•   362 Lap bands
•   45% of excess weight at one year
•   0 mortality or serious complications
•   Results more variable
    – 12% revisions or removal
• Complications
    –   <4% slippage
    –   2.5% port revision
    –   0.5% port infection
    –   0.3% Erosion
         • Excellent weight loss
         • Technically demanding
         • Divalent cations
         • 90% curative for type II
         • Low failure rate
         • Short hospital stay and
•   1400 Lap RYGB
•   No mortality for two years
•   No gastric leaks for over 1000 cases
•   72% of excess weight in12 months
•   recidivism
Duodenal Switch
        • Preserves pylorus to
          reduce dumping
        • Malabsorptive
        • Prolongs weight loss
        • Calcium metabolism
        • Super obesity
       Duodenal Switch
  Pros           Cons
• 82% excess weight      • Protein malnutrition
  loss at twelve years   • Brittle bone disease
• Most sustainable       • Night blindness
  weight loss            • Fat soluble vitamin
• Low recidivism           deficiencies
                         • Liver failure
    Insurers trim bariatric surgery
   Pressured by employers, health
plans are looking at cutting coverage
 of gastric bypass surgery and other
procedures perceived as being high-
         cost and low-benefit.
By Robert Kazel, AMNews staff. April
                5, 2004
       The Approval Process
• Six months of physician supervised diet
  with weigh in – years of weight loss efforts
  mean little
• Need to show compliance
• Doctors offer prescription drugs and surgery
• Psychiatric clearance
• Exclusions to care
      Total Joint Replacement
• 440,000 procedures in US
• Reduce pain
• Improve mobility
• Reduced reliance on devices to assist with
• Not deadly disease
• Covered with little question
Coronary Artery Bypass Grafting
• 300,000 procedures annually
• 5 -10% redo procedures
• 4.3 month increase in survival as compared to
  medical therapy at 10 years
• At 5 years improved quality of life, which
  disappears at 10 years.
• No change in behavior, no limitation of services

ACC/AHA Guidelines for CABG
            Prostate Cancer
New England Journal of Medicine 9/12/02

A Randomized Trial Comparing Radical
 Prostatectomy With Watchful Waiting in
 Early Prostate Cancer

No difference in overall survival
         Breast Reconstruction
•   Medically necessary
•   No problem with approval
•   Reconstruction after weight loss is cosmetic
•   Reconstruction for children with
    deformities that others make fun of is
              Colon Surgery
•   Mortality between 1.2% to 9.8%
•   Morbidity up to 48%
•   Elective and emergent
•   Benign and malignant disease
Medicare Recognizes Obesity as
          a Disease
              THE FACTS
• Severe obesity is deadly disease
• Fitness is the central issue
• Hard to find fit, very heavy people
• Men 20 -30YRS, BMI>45 lose 13 years of life
• Woman 20 – 30YRS, BMI>45 lose 8 years of life
Source: Years of Life Lost Due to Obesity
  JAMA 1/8/03
                THE FACTS

• Poor understanding of why it is so difficult to
  lose weight
• Lack of objective analysis of data
• Strong prejudice against obesity
• Net result is bias against obesity treatments
 The Evidence is Overwhelming
• What is excess weight loss of surgery
  compared to nonsurgical treatment?
• Does the weight loss lead to benefits in
  health outcomes?
• Does surgery increase life expectancy?
• Pories 60% of weight loss maintained
• McClean 78% of weight loss maintained
• Obesity is a chronic disease, but surgery is a
  powerful tool
• Successful patients become active
      Swedish Obese Subjects
• SOS trial began in 1987
• Each Surgical is matched with nonsurgical
  based on 18 variables
• VBG 70%
• Gastric Bypass 6%
• Banding 23%
• 16% weight loss compared to increase
• Maintain 50% of weight loss with bulk
  having operations of lower efficacy than
• Diabetes 30 fold lower
• At 8 years 3.6% vs 18.5 % diabetic
• Improved sf 36
    Gastric Bypass Saves Lives
• Gastric Bypass Reduces the Mortality and
  Progression of Non-Insulin Diabetes
• 27% vs 9 % mortality over course of the
     MacDonald et al
     Journal of Gastrointestinal Surgery
 Economic Considerations
Treating Diabetes, Hypertension, and
Dyslipidemia by Weight Loss Saves Money
                                                               Percent Loss From
Obesity Comorbidity              Savings/Mo.                      Initial Weight

Diabetes (insulin Rx)                     $104                                 7%
Diabetes (sulfonylurea Rx)                 $55                                 7%
Hypertension                               $20                                10%
Dyslipidemia                               $61                                 5%
                         Greenway et al. Poster presentation. Obes Res. 1997;5 (suppl 1):56S.
Treatment of Obesity: Use of
 Evidence Based Medicine?

•   Cultural bias
•   Group afflicted
•   Powerful Lobby
•   How we view the disease
     How do we view obesity?
• Poor understanding of how difficult it is to
  sustain weight loss
• People do this to themselves and should be
  able to control caloric intake
• Lack of understanding of energy balance
Dr. Frumkin: Friend and Colleague
               Obesity Surgery
•   Provides lasting weight loss
•   Reduces medical problems
•   Improves quality of life
•   Eliminates disability
•   Prolongs survival
•   Compares favorably to other fields of surgery
•   Insurance companies want to limit
• Lenox Hill Hospital
  –   Lap RYGB >500 cases annually
  –   No mortality in two years
  –   One mortality in first 500 cases
  –   Lap Band >200 cases annually
  –   Experience matters
  –   <1% incidence of thrombotic events
• Blue Cross of Florida excludes all weight
  loss surgery as of January 1, 2004
• Anecdotal bad results
• Cannot condemn procedure and limit access
• Contradicts conclusion of Blue Cross
  Special Report on Weight Loss Surgery in
          Improving Results
• Center of Excellence Approach
• Increase reimbursement to contract with top
  physicians. Managed care rates are
  ridiculously low.
• Increase reimbursement for better hospitals
• Not limiting access
          VAGUS NERVE
• 6 Patient pilot
• 0-110 lb wt loss avg = 30 lbs
• No complications from stimulation
• Most successful patient had most c fiber
  symptoms and was most sensitive to rising
• Leptin level decrease exceeded weight loss
Tone and VNS
on Same Image
                   Visceral/Emotional Brain

                                                                            Auditory Brai

9 Subjects, p<0.01, extent p<0.05 for Display
                                                VNS - red, Tone-yellow
                            Visual Brain
                                                  MUSC Brain Stimulation Laboratory
                                                  And Center for Advanced Imaging Research
• New lead to allow higher current
• Add nutritional and psychological
• Laparoscopic placement below diaphragm
• Vagus nerve maybe afferent circuit but
  declining leptin counteracts effect
          The Teenage Debate
• Same problems as          • Too early for
  adults with weight loss     permanent solution
• Before permanent          • Do not understand
  medical problems            limitations
• Sociological and          • Same environment
  psychological issues        that created problem
• Results look beneficial   • Parent issues
                            • Tort concerns
   The Lap Band for Teenagers
• Low morbidity and mortality for surgery
• Long term sequelae of fixed obstruction at
  GE junction
• Variable results
• Case series in literature, no long term data
   Gastric Bypass for Teenagers
• Should wait until full grown, unless serious
  medical problems
• Long term issues
• Recidivism in adults
• Becoming thought of as quick fix
• Results excellent but short term follow-up
  and non randomized studies
     Ideal Process for Surgery
• Multi disciplinary approach, that educates
  entire nuclear family
• Surgery after lengthy evaluation process
• Establishment of preventive strategies
•   Real problem
•   20 -40% weight gain over 10 years
•   Behavioral, dietary or mechanical
•   Bard trial of endoscopic suturing
         Endoscopic Treatment for
•   Dilation of gastrojejunostomy
•   Loss of restriction
•   Endoscopic suturing
•   15 person clinical trial completed
•   Next step multi-center trial with nutritional
       Solutions not Problems

• Easy to fault bariatric surgery
• But what would we do with our colleague
  Bill and others just like him
• Need for better obesity treatments is finally
  being recognized
• Surgical procedures offer best hope for
  weight loss in the morbidly obese and are a
  tough standard to beat
• Drug cocktails
• Endoscopic options
• Synergistic treatment
• Bariatric Surgery saves lives
• By combining anecdotal reports of bad outcomes and
  the cultural bias and prejudice regarding obesity, a
  financially motivated argument is being made to limit
  access to bariatric surgery.
• Cannot be allowed until there is better alternative
• Exclusions for treatment of severe and morbid
  obesity are unethical
• Physicians must stay united to prevent access being
  limited because of torts and insurance companies
• What are implications of so many gastric
  bypass procedures
• What happens with obese but not morbidly
  obese population
• Can weight loss be maintained with
  modalities other than surgery
• Can less invasive devices be used to prevent
  obesity and limit side effects of long term

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