Bariatric and Metabolic Institute · Bariatric and Metabolic Institute June 3, 2008 Philip Schauer...

Bariatric and Metabolic Institute

June 3, 2008Philip Schauer MDProfessor of SurgeryCleveland Clinic Lerner College of Medicine

Cleveland ClinicBariatric and Metabolic Institute (BMI)

www.ccf.org/bariatricsurgery

Comprehensive obesity treatment integrating sub-specialty medical care

Inter-nationally ranked Cleveland Clinic Specialties–Endocrinology–Cardiology–Gastroenterology–Nutrition–Sleep Medicine–Orthopedics–Plastic Surgery–Neurology

Cleveland Clinic Bariatric and Metabolic Institute

–Emphasizes minimally invasive surgical approach promoting speedy recovery while minimizing complications

–>97% of cases are performed laparoscopically

–Adolescent bariatric surgery–Specialize in higher risk patients–Expertise in re-operative surgery

BMI Surgeons

Philip Schauer, MD Bipan Chand, MD Stacy Brethauer, MD

BMI Team

State-of-the-art inpatient/outpatient unit

Obesity Research CollaboratorsLoutfi Aboussouan, M.D.

Matthew Barber, M.D.

Deepak Bhatt, M.D.

Gordon Blackburn, Ph.D.

Carol Blixen, Ph.D.

Charles Bae, M.D.

Tracey Bonfield, Ph.D.

Stacy Brethauer, M.D.

William Carey, M.D.

Bipan Chand, M.D.

Silas Chikunguwo, M.D.

Leslie Cho, M.D.

Karen Cooper, D.O.

Susan Curtas, R.N., M.S.

Gary Falk, M.D.

Nancy Foldvary-Schaefer, D.O.

Zhenghong Fu, Ph.D.

John Fung, M.D., Ph.D.

Joseph Golish, M.D.

Heather Gornik, M.D.

Eileen Groh, R.N., M.S.N.

Cindy Hamilton, M.S., R.D.

J. Michael Henderson, M.D.

Amir Jaffer, M.D.Ruth Jerkins, R.N., C

Sangeeta Kashyap, M.D.

Roop Kaw, M.D.

Dympna Kelly, M.D.

Allan Klein, M.D.

Matthew Metz, M.D.

Annitta Morehead

Marie Fidela Paraiso, M.D.Tracy Pitt, M.D..

Stanley Hazen, M.D., Ph.D.

Steven Nissen, M.D.

Carrie Geither, R.N. Ofer Reizes, Ph.D.Kitty Ribar, R.N., M.S.N.

Tomasz Rogula, M.D.

Ellen Rome, M.D., M.P.H.

Samuel Rossi, M.D.

Douglas Seidner, M.D.

Daniel Sessler, M.D.

Allan Siperstein, M.D.Glennys Smith

Laura Smolenak, R.N.

Ezra Steiger, M.D.

John Vargo, M.D., M.P.H.

Tammy Wade, L.P.N. Esteban Walker, Ph.D.

R. Matthew Walsh, M.D.

Amy Windover, Ph.D.

Massarat Zutshi, M.D.

James Young, M.D.

Keith Rosenbaum

Bariatric and Metabolic Institute l l 12

OBESITY ICEBERG: US Population = 300 Million

Morbidly Obese: 15 mil

Obese: 85 mil

Over Weight: 100 mil

Normal Weight: 100 mil

Bariatric and Metabolic Institute l l 13

Obesity is a Metabolic Disease

Liver disease

Gallbladder disease

OsteoarthritisGout

Asthma

Heart disease

Menstrual/

Infertility problems

Type 2 diabetes

High blood pressure

Sleep apnea

GERD

Bariatric and Metabolic Institute l l 14

Obesity Treatment Pyramid

Surgery

Pharmacotherapy

Lifestyle Modification

Diet Physical Activity

BMI

Operations for Severe Obesity

BPD10%

RY-Gastric Bypass75%

BPD2%

RY-Gastric Bypass73%

Gastric Banding15%

Gastric Banding25%

Laparoscopic Open

Heath Economics of Obesity l July 8, 2008 l 17

Bariatric SurgeryA Systematic Review and Meta-analysis: 136 studies, 22,094 patients

• Excess Weight Loss– All Patients: 61.2% (58.1%-64.4%) – Gastric Banding 47.5% (40.7%-54.2%) – Gastric bypass 61.6% (56.7%-66.5%)– Gastroplasty 68.2% (61.5%-74.8%)– BPD/DS 70.1% (66.3%-73.9%)

• Operative mortality ( 30 days)– Restrictive procedures 0.1%– Gastric bypass 0.5% – BPD/DS 1.1%

• Comorbidity Resolution– Diabetes 76.8% – Hyperlipidemia 70.0% (improved not resolved)– Hypertension 61.7% – Obstructive sleep apnea 85.7%

Buchwald et al. JAMA. 2004;292:1724-1737

Heath Economics of Obesity l July 8, 2008 l 18

Comparative Mortality

Craniotomy Esophagectomy Pancreatectomy

Peds

HeartAortic

Aneurysm CABG Hip Replacement

10.7% 9.1% 8.3% 5.4% 3.9% 3.5% 0.3%

BARTIATRIC SURGERY

0.28%

**Adopted from Dimiek et al. JAMA 2004;292:847Adopted from Dimiek et al. JAMA 2004;292:847--851.851.

Bariatric and Metabolic Institute 2007 Outcomes l July 8, 2008 l 20

Bariatric and Metabolic InstituteSurgical Cases

404133

0

25

50

75

100

High Risk Super Obesity Diabetes Cases

%

High Risk - Cases with BMI > or = to 55 and age > 60, N= 663Super Obesity > BMI 50Diabetes Cases - 2006

Source: ORIS/EPIC, 2004-2007

Bariatric and Metabolic Institute 2007 Outcomes l July 8, 2008 l 21

Bariatric and Metabolic Institute2007 Length of Stay

Source: 2007 TSI data

ICU Cases (%) Days Number of Cases

Lap Gastric Bypass 1.6% 3.3 252

Lap Adjustable Gastric Band 1.5% 1.8 66

Bariatric and Metabolic Institute 2007 Outcomes l July 8, 2008 l 22

Two years and greater post surgery (N=116)

70

0

25

50

75

100

Excess Weight LossLosing > 50% of excess body weight

%

Bariatric and Metabolic InstituteExcessive Weight Loss

Source: ORIS/EPIC, 2004-2005

Bariatric and Metabolic Institute 2007 Outcomes l July 8, 2008 l 23

Bariatric and Metabolic Institute

Source: 2004 -2007 ORIS/EPIC

Resolution of Diabetes (N=248)

53

0

25

50

75

100

% Resolved by Cessation of Diabetic Medications

%

Bariatric and Metabolic Institute 2007 Outcomes l July 8, 2008 l 24

Bariatric and Metabolic InstituteSurgical Cases

404133

0

25

50

75

100

High Risk Super Obesity Diabetes Cases

%

High Risk - Cases with BMI > or = to 55 and age > 60, N= 663Super Obesity > BMI 50Diabetes Cases - 2006

Source: ORIS/EPIC, 2004-2007

Bariatric and Metabolic Institute 2007 Outcomes l July 8, 2008 l 25

Bariatric and Metabolic Institute2007 Length of Stay

Source: 2007 TSI data

ICU Cases (%) Days Number of Cases

Lap Gastric Bypass 1.6% 3.3 252

Lap Adjustable Gastric Band 1.5% 1.8 66

Bariatric and Metabolic Institute 2007 Outcomes l July 8, 2008 l 26

Two years and greater post surgery (N=116)

70

0

25

50

75

100

Excess Weight LossLosing > 50% of excess body weight

%

Bariatric and Metabolic InstituteExcessive Weight Loss

Source: ORIS/EPIC, 2004-2005

Bariatric and Metabolic Institute 2007 Outcomes l July 8, 2008 l 27

Bariatric and Metabolic Institute

Source: 2004 -2007 ORIS/EPIC

Resolution of Diabetes (N=248)

53

0

25

50

75

100

% Resolved by Cessation of Diabetic Medications

%

BARIATRIC SURGERY

Overall Mortality

Effect on Long-term Mortality Compared to Non-Operated Controls

Study Procedure F/U Mortality

Reduction

MacDonald,1997 RYGB 9 yrs 88%

Flum, 2004 RYGB 4.4yrs 33%

Christou, 2004 RYGB 5 yrs 89%

Sowemimo, 2007 RYGB 4.4 yrs 50%

O’brien, 2006 LAGB 12 yrs 73%

Adams, 2007 RYGB 8.4 yrs 40%

Sjostrom, 2007 VBG/other 14 yrs 31%

How would You manage this Patient?

• Obesity• Hypertension• Dyslipidemia• Diabetes/impaired GT• Insulin resistance

• Central obesity• Visceral obesity• Nonalcoholic steatohepatitis

(NASH)• Obstructive sleep apnea • Left ventricular hypertrophy

Before and After Bariatric Surgery

Presentation Title l July 8, 2008 l 35

Before After

Presentation Title l July 8, 2008 l 36

Before After

Presentation Title l July 8, 2008 l 37

Before After

Presentation Title l July 8, 2008 l 38

Before After

Presentation Title l July 8, 2008 l 39

Before After

Presentation Title l July 8, 2008 l 40

Before After