Bariatric Surgery Preserving the Choice

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Bariatric Surgery Preserving the Choice Powered By Docstoc
					      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
       OBESITY EPIDEMIC
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
  population
• 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
     WHY IS IT SO HARD TO
       LOSE WEIGHT?
• Energy balance
  – In = food intake
  – Out = RMR, Physical Activity, Energy
    transformation
• Resting metabolic rate
  – 70% of caloric expenditure
  – Constant temperature
  – Goes down when you loss weight
                     Exercise
• Decreases visceral fat
• Improves parameters of
  –   Glucose intolerance/ Insulin sensitivity
  –   Hypertension
  –   CAD
  –   hypercholesterolemia
• Alone does not result in significant weight
  loss
          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-           +           +             +
                                                              morbidities



  •Surgery                                                                               With co-         +
                                                                                         morbidities




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
               Popularity
•   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
  alternatives.
• Not ignorance to risk
• Celebrities and media
           ADVANTAGES OF
            LAPAROSCOPY
•   Appealing to patient
•   Reduced wound complications
•   Faster healing
•   Improved visualization in areas difficult to
    expose
       OBESITY SURGERY
• Operations to make you eat less
  (Restrictive)

• Malabsorption
VERTICAL BANDED
 GASTROPLASTY
       •   Restrictive procedure
       •   Mayo clinic
       •   Losing popularity
       •   Maladaptive eating
       •   High recidivism
       •   Replaced by
           adjustable bands
ADJUSTABLE LAP BAND
               LAP-BAND
  Pros               Cons
• Easy to insert        •   Foreign body
• No malabsorption      •   Higher failure rate
• Low mortality and     •   Slippage
  morbidity
                        •   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
LAPAROSCOPIC GASTRIC
      BYPASS
         • Excellent weight loss
         • Technically demanding
         • Divalent cations
         • 90% curative for type II
           diabetes
         • Low failure rate
         • Short hospital stay and
           recovery
         LENOX HILL DATA
•   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
          procedure
        • 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
              BUSINESS
    Insurers trim bariatric surgery
               coverage
   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
  ambulation
• 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
    cosmetic
              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?
                Outcomes
• 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%
                  Results
• 16% weight loss compared to increase
• Maintain 50% of weight loss with bulk
  having operations of lower efficacy than
  bypass
• 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
  study
     MacDonald et al
     Journal of Gastrointestinal Surgery
     1997
 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
                  Outcomes
• 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
               Outcomes
• 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
  2003
          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
          STIMULATION
• 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
  current
• 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
             CHANGES
• New lead to allow higher current
• Add nutritional and psychological
  counseling
• Laparoscopic placement below diaphragm
• Vagus nerve maybe afferent circuit but
  declining leptin counteracts effect
Transneuronix
ENDOSCOPIC
          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
                Recidivism
•   Real problem
•   20 -40% weight gain over 10 years
•   Behavioral, dietary or mechanical
•   Bard trial of endoscopic suturing
         Endoscopic Treatment for
               Recidivism
•   Dilation of gastrojejunostomy
•   Loss of restriction
•   Endoscopic suturing
•   15 person clinical trial completed
•   Next step multi-center trial with nutritional
    counseling
       Solutions not Problems

• Easy to fault bariatric surgery
• But what would we do with our colleague
  Bill and others just like him
           CONCLUSIONS
• 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
                  Conclusion
• 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
  QUESTIONS FOR FUTURE
• 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
  therapy
 LAPAROSCOPIC
ADJUSTABLE BAND



           QuickTime™ and a
         Cinepak decompressor
    are needed to see this picture.
LAPAROSCOPIC GASTRIC
      BYPASS



              QuickTime™ and a
            Cinepak decompressor
       are needed to see this picture.

				
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posted:10/28/2011
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