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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