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Bariatric Surgery
Roberto C. Mirasol, MD, FPCP, FPSEMObesity and Weight Management CenterSt. Luke’s Medical Center
Bariatric Surgery
• Indications1. BMI >40 kg/m2 or
BMI 35–39.9 kg/m2 and life-threatening cardiopulmonary disease, severe diabetes, orlifestyle impairment
2. Failure to achieve adequate weight loss with nonsurgical treatment • Contraindications
1. History of noncompliance with medical care2. Certain psychiatric illnesses: personality disorder, uncontrolled
depression, suicidal ideation, substance abuse3. Unlikely to survive surgery
NIH Consensus Development Panel. Ann Intern Med 1991;115:956.
CLINICAL PRACTICE RECOMMENDATIONS, 2009ADA
• Bariatric surgery should be considered for
adults with BMI 35 kg/m2 and type 2 diabetes, especially if the diabetes is difficult to control with lifestyle and pharmacologic therapy. (B)
• Patients with type 2 diabetes who have undergone bariatric surgery need life-long lifestyle support and medical monitoring. (E)
Bariatric Surgery Stats 1995 the number of bariatric surgeries performed
was well over 20000 2003 - 103,000 2004 - 144,000 Average age of patient – 30 years oldLength of Hospital Stay – 3.9 daysBariatric surgeons – increased by 500%Complication rate – 10%Deaths <1%
CDC, 2006
Current Bariatric Surgical ProceduresClassification
Gastric restriction
Primarily restrictive and partially malabsorptive
Primarily malabsorptive and partially restrictive
Procedure
• Adjustable Gastric Banding
• Roux-en-Y Gastric Bypass
Biliopancreatic diversion with duodenal switch
Biliopancreatic diversion
Distal gastric bypass
Gastric Bypass ProcedureA small (10–30 mL) gastric pouch is anastomosed to a Roux limb of jejunum. Increasing the length of the Roux limb increases malabsorption and weight loss.
Long-term Effect of Gastric Bypass Surgery on Body Weight
Poiries et al. Ann Surg 1995;222:339.
BMI (kg/m2): 50 34 35 35
We
igh
t Los
s(%
of E
xces
s W
eig
ht)
Years After Surgery
0
20
40
60
80
1000 2 4 6 8 10 12 14
Randomized, Controlled Trial Comparing Open With Laparoscopic
Gastric Bypass• Both procedures had
– Similar weight loss– Similar incidence of anastomotic leaks– Equivalent costs
• Laparoscopic procedure had– Less wound complications (infection and hernia)– Increased late anastomotic strictures – Less blood loss– Shorter hospital stay – Faster recovery– Faster improvement in quality-of-life
Nguyen et al. Ann Surg 2001;234:279.
Weight Loss With Gastric Bypass Procedure vs. Vertical Banded GastroplastyD
ecre
ase
in E
xces
s W
eigh
t (%
)
Gastric bypass
Vertical banded gastroplasty
6 3612 18 24 300
Time (months)
Sugerman et al. Ann Surg 1987;205:613.
10
90
70
50
30
Laparoscopic Adjustable Gastric Banding
Silicone band placed around upper stomach to create a small pouch. Outlet diameter can be changed by infusing or withdrawing saline from port.
Gastric BandConnection tubing
Access port (reservoir)
LapBandTM
American Society for Metabolic and Bariatric Surgery, www.asbs.org
LAP BAND
-30
-25
-20
-15
-10
-5
0
Obrien et al. Ann Intern Med. 2006;144:625-33
Wei
ght L
oss,
%
Baseline
Surgical
Nonsurgical
*(VLCD, behavioral modification, and pharmacotherapy)
6 mo 12 mo 18 mo 24 mo
LLaparoscopic aparoscopic AAdjustable djustable GGastric astric BBanding anding Produces Produces Greater Weight Loss than CGreater Weight Loss than Comprehensive omprehensive MMedical edical TTherapyherapy** in in PPatients with Class I Obesity (BMI 30-35 kg/matients with Class I Obesity (BMI 30-35 kg/m22))
Sleeve gastrectomy with rerouting of small intestine through “nutrient limb” and “biliopancreatic limb.”
Digestion and absorption are limited to 100 cm “common channel” of terminal ileum.
Causes marked weight loss, but can lead to significant nutritional deficiencies.
Biliopancreatic Diversion With Biliopancreatic Diversion With Duodenal SwitchDuodenal Switch
Marceau P. et al. World J Surg 1998;22:947-54.
ApproximateLoss of Excess
Procedure Weight (%)
Laparoscopic gastric banding 45–65
Gastric bypass procedure 55–65
Biliopancreatic diversion 60–75
with duodenal switch
Effect of Different Bariatric Surgical Procedures on Weight Loss
Klein et al. Gastroenterology. 2002;123:882-932
Relationship Between Rate of Weight Loss and Gallstone Formation
Weinsier et al. Am J Med 1995;98:115.
Inci
denc
e of
Gal
lsto
ne F
orm
atio
n(%
sub
ject
s/w
k)
1
3
2
00 0.5 1 1.5 2 2.5
Rate of Weight Loss (kg/wk)
Data reported from individual studies
Complications of Bariatric SurgeryAll procedures: • Atelectasis and pneumonia • Deep vein thrombosis• Pulmonary embolism• Wound infection• Gastrointestinal bleeding• Gallstones• Failure to lose weight• Intractable vomiting/kwashiorkor (B1)• Mortality (0.1%–2%)Gastric bypass:• Anastomotic leak with peritonitis• Stomal stenosis • Marginal ulcers • Staple line disruption• Nutrient deficiencies (iron, calcium, folic
acid, vitamin B12)• Dumping syndrome• Small bowel obstruction
– Internal hernia– Adhesions
Gastric banding procedure:• Band slippage • Band erosion • Esophageal dilatation• Band or port infections• Port disconnection• Port displacementBiliopancreatic diversion:• Anastomotic leak with peritonitis • Protein-calorie malnutrition• Calcium, iron, folic acid, fat soluble
vitamin (A,D,E,K) deficiencies• Dehydration• Steatorrhea• Small bowel obstruction
– Internal hernia– Adhesions
D Flum et al. J Am Coll Surg 199:543, 2004
Thi
rty
Day
Mor
talit
yRelationship Between Surgical Experience and Relationship Between Surgical Experience and Perioperative Mortality in Gastric Bypass Surgery Perioperative Mortality in Gastric Bypass Surgery
7%
6%
5%
4%
3%
2%
1%
0%0 50 100 150 200 250 300 350 400 450 500 550 600 650
Chronological case order per surgeon
125 case lifetime bariatric 125 case lifetime bariatric surgery experiencesurgery experience
0
25
50
75
100
Patents with Type 2 Diabetes
Patients with IGT
Pa
tie
nts
wit
h N
orm
al F
asti
ng
B
loo
d G
luc
os
e a
nd
Hb
A1
c A
fte
r S
urg
ery
(%)
Gastric Bypass Surgery Improves Glycemic Control in Impaired Glucose Tolerance or Type 2 Diabetes
Pories et al. Ann Surg 1995;222:339.
4.7
18.5
0.0
3.6
0.0
4.0
8.0
12.0
16.0
20.0
2 8Follow-up After Surgery (y)
Inci
denc
e of
Typ
e 2
Dia
bete
s(%
Pat
ient
s) Control Bariatric surgery
Prevention of Type 2 Diabetes at 8 Years After Bariatric Surgery (94% Restrictive)
Sjostrom et al. Hypertension 2000;36:20.
Control Surgery Initial BMI (kg/m2) 41 5 41 4Weight change at year 8: 1 11% -16 12%
0
20
40
60
80
100
2 yr 10 yr 2 yr 10 yr 2 yr 10 yr
Effect of Bariatric Surgery on Obesity-related Metabolic Complications
Sjöström: N Engl J Med 2004;351:2683.
Rat
io o
f Rec
over
y (%
of s
ubje
cts)
21
72
Diabetes Hypertension Hypertriglyceridemia
13
36
21
34
11
19 22
62
24
46
Control Surgery
0
1
2
3
Steatosis
His
tolo
gy
sco
re
(Bru
nt
et
al.
sy
ste
m) Before GBS
1 Yr after GBS
Inflammation Fibrosis
Effect of Gastric Bypass Surgery-induced Effect of Gastric Bypass Surgery-induced Weight Loss on Liver HistologyWeight Loss on Liver Histology
Klein S. et al. Gastroenterology 130:1564, 2006
0
1
2
3
4
5
6
7
Control Bariatric Surgery
Long-term Survival: Canada
Rel. Risk = 0.11 (.04-.27)
89% reduction in risk ofdeath over 5 years
Christou et al. Ann Surg 2004;240:416-424
% M
ort
alit
y
Major Obesity-related Comorbidities That Have Been Improved by Bariatric Surgery
• Type 2 diabetes• Hypertension• Obstructive sleep apnea• Obesity hypoventilation• GERD• NALD, NASH• Pseudotumor cerebri• Depression
• Dyslipidemias• Coronary artery disease• Cardiac dysfunction• Venous stasis disease• Polycystic ovary syndrome• Infertility• Cancers• Degenerative joint disease• Quality of life
GLP-1 and GIP Are the Two Major Incretins
GLP-1 GIP• Produced by L cells mainly located
in the distal gut (ileum and colon) • Stimulates glucose-dependent
insulin release
• Produced by K cells in the proximal gut (duodenum)
• Stimulates glucose-dependent insulin release
Other effects• Suppresses hepatic glucose output
by inhibiting glucagon secretion in a glucose-dependent manner
• Inhibition of gastric emptying; reduction of food intake and body weight
• Enhances beta-cell proliferation and survival in animal models and isolated human islets
• Minimal effects on gastric emptying; no significant effects on satiety or body weight
• Potentially enhances beta-cell proliferation and survival in islet cell lines
GLP-1=glucagon-like peptide-1; GIP=glucose-dependent insulinotropic polypeptide.
Drucker DJ. Diabetes Care. 2003;26:2929–2940; Ahrén B. Curr Diab Rep. 2003;3:365–372; Drucker DJ. Gastroenterology. 2002;122:531–544; Farilla L et al. Endocrinology. 2003;144:5149–5158; Trümper A et al. Mol Endocrinol. 2001;15:1559–1570; Trümper A et al. J Endocrinol. 2002;174:233–246; Wideman RD et al. Horm Metab Res. 2004;36:782–786.
Nonincretin Gut Peptides
• Peptide YY (PYY)– Secreted by the L cells of the distal intestine– Present in 2 molecular forms: PYY(1-36) and PYY
(3-36), a cleavage product– PYY increases satiety and delays gastric emptying
through neuropeptide Y-receptor subtypes in the central and peripheral nervous system
– IV PYY(3-36) increases satiety and decreases food intake in humans
Nonincretin Gut Peptides
• GHRELIN– Secreted by gastric fundus and proximal small intestine
and acts on the hypothalamus to regulate appetite– Inhibits insulin secretion by a paracrine mechanism– Systemic ghrelin levels increase before a meal and
decrease afterward– Ghrelin stimulates appetite and food intake and
suppresses energy expenditure and fat catabolism– Inversely proportional to body weight – Weight loss increases ghrelin levels suggests that ghrelin
affects long term regulation of body weight
PROPOSED MECHANISMS FOR IMPROVED GLYCEMIC CONTROL AFTER BARIATRIC SURGERY
Effects of Decreased Caloric Intake on Fasting Glycemia
• Decreased caloric intake affects glucose metabolism
• Rate of diabetes remission are not the same – Complete remission within days of intestinal
bypass procedures (Porries, 1995)– Takes months to occur in LAGB (Dixon, 2008)
RUBINO EXPERIMENTS
• Goto- Kakizaki Rats- non obese animal model for diabetes
DJB (duodenal-jejunal bypass) – less fasting and postprandial hyperglycemia than control
Weight loss by caloric restriction – glycemic control did not improve
HINDGUT HYPOTHESIS (LOWER INTESTINAL HYPOTHESIS)
• Intestinal rearrangement speeds the delivery of nutrients to the distal intestines
• Causes exaggerated GLP-1 and PYY levels and improves glucose tolerance and insulin secretion
Cummings, et al, 2007
FOREGUT EXCLUSION THEORY (UPPER INTESTINAL HYPOTHESIS)
Bypassing gut prevents the secretion of a “putative signal” that promotes insulin resistance and Type 2 DM.
• Stomach sparing DJB vs Gastrojejunostomy (leaves nutrient flow in the proximal intestine intact)
• Bypass of proximal gut prevents secretion “Anti-incretin factor” or “decretin”
• May be implicated in the pathogenesis of diabetes
Gut Peptide Response to Different Bariatric Surgical Procedures*
HORMONE Cell Type (Location)
Effect on Insulin Secretion
BPD RYGB LAGB
Ghrelin X/A cells Stomach
Decrease Increase Increase/Decrease
Increase/No Change
GIP K cells duodenum
Increase Decrease Decrease No change
GLP-1 L cellsDistal ileum
Increase Increase Increase No change
Peptide YY L cellsDistal ileum
Decrease Increase Increase No change
*Folli, 2007
BARIATRIC SURGERY IN ST LUKE’S
PATIENT PROFILE*MALE FEMALE TOTAL
Number (%) 18 (36%) 32 (64%) 50
Age group
14-18 1 (6%) 1(3%) 2 (4%)
19-59 15 (83%) 30 (94%) 45 (90%)
>60 2 (11%) 1 (3%) 3 (6%)
BMI (mean)
14-18 57 46.8 51.9
19-59 47.07 46.15 46.5
>60 39.45 39 39.3
Obesity Types
Obese (30-40) 7 (39%) 10 (31%) 17 (34%)
Morbidly obese (40-50)
4 (22%) 12 (38%) 16 (32%)
Super obese 7(39) 10(21%) 17 (34%)
*Dineros, Obesity Surgery, 2007
Weight Reduction in ALL Patients*Postoperative Period
Initial Weight(kg+ SD)
Weight Loss(kg + SD)
% Excess Weight Loss
BMI(kg / m2)
Start 126.7+ 25.4 0 0.00 48.0+ 11.7
1 month 115.9 + 19.4 10.7 + 6.4 8.50% 43.2 + 9.2
3 months 113.2 + 21.4 13.4 + 6.4* 10.60% 42.3 + 9.9
6 months 93.5 + 24.7 33.1+ 10.9* 26.10% 33.7 + 7.1
9 months 91.4 + 20.8 35.3 +10.4* 27.90% 32.4 + 8.7
12 months 68.6+ 10.8 38.3 +11.9* 31.00% 27.5 + 3.1
Dineros, Obesity Surgery, 2007
COMPLICATIONS
• Early Complications• Wound infection 2/50• Pneumonia 1/50• Dehydration 1/50• Gastritis 1/50• Leakage 1/50
COMPLICATIONS
• Late Complications• Band Slippage 2/20 (10%)• Stomal Stenosis 1/20 (5%)• Ventral Hernia 1/5 (20%)
STARTING WEIGHT: 307 lbs; BMI 49.44END WEIGHT: 156 lbs; BMI 25.16
STARTING WEIGHT:
516 lbs; BMI 83.10
END WEIGHT:
258 lbs; BMI 37.01
100 kg (220 lb)
76 kg (168 lb)
BYPASS on Non- obese
• 2 mildly overweight• Duodenal bypass lowered fasting insulin,
fasting glucose, and HgbA1c within 1 month after surgery
Diabetes Surgery Summit,
Rome, 2007