Transcript BARIATRIC SURGERY: WHY SOONER THAN LATER? Bruce Schirmer, M.D. DISCLOSURES • Consulting Board for Allurion Inc., which has no conflict regarding the content of this talk •

BARIATRIC SURGERY:
WHY SOONER THAN
LATER?
Bruce Schirmer, M.D.
DISCLOSURES
• Consulting Board for Allurion Inc.,
which has no conflict regarding
the content of this talk
• I have been doing bariatric and
metabolic surgery for 27 years
TALK OUTLINE
• Progress in bariatric surgery in
the U.S. in past two decades
• Available operations and
outcomes
• Ten reasons why sooner is better
than later (with apologies to
David Letterman)
NIH Consensus Conference 1991
• Diet/non-surg rx tried first
• Gastric restrictive or bypass
procedures for informed patients
with BMI >40 or >35 with comorbid
medical problem
• Multidiscipline evaluation
• Done by experienced surgeon
• Lifelong medical follow-up
BARIATRIC SURGERY ‘93
• National volume 15,000/yr
• Few academic centers
• History of multiple failed
operations (VBG data going sour)
• Laparoscopy will be hard to do
LAPAROSCOPIC REVOLUTION
• Lap cholecystectomy widespread by
1991, dramatic acceptance
• By 1994 most major types of
abdominal surgery being done with a
laparoscopic approach EXCEPT
bariatric surgery and liver/pancreas
surgery
GASTRIC BYPASS
140000
120000
100000
80000
60000
40000
20000
0
1994
1996
1998
2000
2002
2004
THE BARIATRIC REVOLUTION
• Began around 1998
• Combination of factors:
–Laparoscopic alternative
–Mass communication/internet
–Industry and mass media
–Public/medical opinion
UVA BARIATRIC SURGERY
# OPERATIONS BY YEAR
80
70
60
50
Total
40
Open GBP
30
Lap GBP
20
10
0
1996
1997
1998
1999
2000
UVA BARIATRIC SURGERY
# OPERATIONS BY YEAR
350
300
250
200
Total
Open GBP
150
Lap GBP
100
50
0
2000
2001
2002
2003
2004
Membership
• Growth 7% last year
EFFICACY OF BARIATRIC
SURGERY
• Large meta-analyses:
Maggard et al Ann Int Med
April 2005; 142:547-59
Buchwald et al JACS
April 2005; 200:593-604
LAP BARIATRIC SURGERY: IT IS
BETTER THAN OPEN ?
• Evidence-based medicine: PRCT by
Nguyen*, others
• Multiple reports of improvements
in wound and hernia complication
rates
* Nguyen NT, et al. Ann Surg 2000; 232:515-29
UVA GASTRIC BYPASS: PATIENT
CHARACTERISTICS
OPEN
LAP.
p value
Patients 363
41.8
Age
765
% male 19.6%
Wt lbs 357.4
57.5
BMI
17.8%
ns
ns
315.6
<0.001
50.9
<0.001
Comorb 3.6
2.7
<0.001
42.1
UVA GASTRIC BYPASS: PATIENT
CHARACTERISTICS
LOS days
Intraop c
Tot comp
Reoperat
30 d mort
Tot mort
OPEN
5.13
2.2%
57.3%
41.3%
1.7%
5.0%
LAP
3.18
0.7%
14.5%
8.8%
0.3%
0.7%
p value
<.001
<0.03
<.001
<.001
<0.02
<0.05
UVA GASTRIC BYPASS: PATIENT
CHARACTERISTICS
OPEN
LAP
p value
Wnd infx 7.4%
1.8%
<.001
In. hernia 33.9%
1.7%
<.001
Pulmon. 4.4%
2.1%
<0.03
DVT/PE
3.6%
0.6%
<0.01
%EWL 1yr 62.6%
65.2%
<0.03
%EWL 3yr 63.1%
61.4%
ns
UVA: LRYGB RESOLUTION OF
COMORBIDITIES
•
•
•
•
•
•
Diabetes in 80% of cases
Reflux in 90% of cases
Hypertension in over 50%
Sleep apnea in over 70%
Venous stasis: better in all
Asthma: over 90% improved
LAP BAND RESULTS
• Improve with increased
frequency of followup, coverage
• Best results from Australia
• EWL approaches bypass at 5 yrs
(45-50% EWL overall best series)
• Other countries much less good
LAP BAND RESULTS
• Up to 40% of lap bands
reoperated or removed in France
• UVA data: 35-40% EWL
• Tend to be dramatic positives and
negatives
• Effort dependent (exercise)
OPTIMAL LAP BAND CANDIDATE
•
•
•
•
•
•
BMI < 50 (certainly no 400 lbs)
Physically can and will exercise
Good support system
Very motivated
Have successfully dieted
Adjustments easy (distance, money)
BSCN: RISK ADJUSTED OUTCOMES
LAGB
LSG
LRYGB ORYGB
n
12,193
944
14,491
988
30d
mortal
0.05%
0.11%
0.14%
0.71%
1yr
mortal
0.08%
0.21%
0.34%
1.11%
30d
morbid
1.44%
5.61%
5.91%
14.98%
30d
1.71%
readmit
30d
0.92%
reop
5.40%
6.47%
9.41%
2.97%
5.02%
5.06%
BMI LOSS AT 1 YEAR
Hutter MM et al Ann Surg 2011; 254:410-22
OPERATION
BMI loss
LAGB
7.05
LSG
11.87
LRYGB
15.34
% IMPROVED OR RESOLVED
LAGB
LSG
LRYGB
DIABETES 44
55
83
HTN
44
68
79
OSA
38
62
66
HYPERLIP 33
35
66
GERD
50
70
64
BOLD DATABASE
(30 DAY)(11/11)
BYPASS
BAND
SLEEVE
n
149,847
120,269
16,885
% / %lap
50.7 91.5
40.7 99.4
5.7 97.9
mortality
0.15%
0.03%
0.08%
morbidity
11.79%
3.42%
8.52%
LOS
2.4
0.7
1.9
Readmit
4.8%
1.4%
3.7%
Reoperate
2.8%
0.65%
1.7%
Recent Improvements in Bariatric Surgery Outcomes
William E. Encinosa, PhD,* Didem M. Bernard, PhD,† Dongyi Du, MS,‡
and Claudia A. Steiner, MD, MPH*
N Engl J Med 2009;361:445-54.
11/7/2015
Ann of Surg, 248, 5, Nov 08
29
LABS RESULTS
• 4776 patients
• Age 44.5 yrs, 21% male, BMI 46.5
• RYGB in 3412 (87.2% lap.)
• LAGB in 1198
• Mortality: band=0
• 4.3% patients had one major
adverse outcome
RYGB: LABS OUTCOMES
OPEN
LAP RYGB
RYGB (#/%) (#/%)
# PATIENTS
437
2975
DEATHS
9 (2.1)
6 (0.2)
REINTUB.
6 (1.4)
12 (0.4)
ENDOSC.
5 (1.1)
45 (1.5)
ABD. OP.
15 (3.4)
94 (3.2)
LOS > 30 D.
4 (0.9)
13 (0.4)
CANDIDATE FOR SLEEVE VS
BYPASS
• Insurance now covering both
• Diabetes and GERD better with
bypass
• Very high risk: sleeve?
• Sleeve long-term data still not in
• Patient preference big factor
Recent Improvements in Bariatric Surgery
Outcomes
William E. Encinosa, PhD,* Didem M.
Bernard, PhD,† Dongyi Du, MS,‡
and Claudia A. Steiner, MD, MPH*
• Funded by the Agency for Healthcare Research and
Quality
Medical Care • Volume 47, Number 5, May 2009
MAJOR CHANGES OF
st
BARIATRIC SURGERY IN 21
CENTURY
• Conversion to laparoscopy
• U.S.: lap band in 2003
• Centers of Excellence (2004-5)
• ASBS to ASMBS (2009) and
emphasis on rx medical problems
Of Aesculapius and the Medicine Man: Some Comments on the College Seal
by George W. Stephenson, MD, FACS
Descriptions of the Seal of the College and explanations of its symbolism have appeared in the Bulletin several times since 1915,
lows may now be interested in such information.
TOP TEN REASONS
WHY BARIATRIC
SURGERY SHOULD BE
SOONER RATHER THAN
LATER
# 10
Improves
cardiovascular function
IMPROVED CARDIAC FUNCTION AFTER
BARIATRIC SURGERY
• Matched control study showing 1yr after
bariatric surgery LVEF 22% to 35% vs. no
change in controls Ramani GV et al Clin Cardiol
2008; 31:516-20.
• Improved LVEF from 25% to 45% in young
Class IV heart failure males after bariatric
surgery, taken off transplant list Ristow B et al. J
Cardiac Failure 2008; 14:198-202.
#9
Decreases the risk of
cancer
BARIATRIC SURGERY EFFECT ON
MORBIDITY AND MORTALITY
• Search of databases including Medline,
Cochran library, and Science Direct
• Six studies clearly showed that bariatric
surgery prolongs life, and the effect is
most marked in diabetics and
predominantly attributable to due to
reductions in death due to cardiovascular
causes and cancer.
Chang J, Wittert G Int J Evidence-Based Healthcare 2009;
7:43-8
#8
Improves or resolves components of
the metabolic syndrome
–Hypertension
–Hyperlipidemia
–Glucose intolerance (type 2 diabetes)
–Fatty liver
HEPATIC
•
•
•
•
NAFLD: present in over 90%
NASH: evolves or present in 30%
Only known treatment is weight loss
One study showed paired liver bx
pre- and postop with 70% resolution
of NASH
Mummadi RR et al Clin Gastroenterol Hepatol
2008; 6:1396-1402
RYGB VS. DIABETES AND HYPERTENSION
•
•
•
•
•
1025 pts at MCV treated with RYGB
Preop 15% with DM2, 51% with HTN
One year postop DM2 resolved 83%
One year postop HTN resolved 69%
Five years postop resolution of DM2 and
HTN were 86% and 66%
From: Sugerman HJ et al Ann Surg 2003; 237:751-6
RYGB REDUCES PROGRESSION AND
MORTALITY OF NON-INSULIN DEPENDENT
DIABETES
•
•
•
•
ECU patients 1979-94
154 RYGB vs. 78 who had no surgery
Mean follow-up: 9 (S), 6.2 (NS) yrs
% oral hyoglycemics: Surg: 8.6%, nonSurg
87.5%
• Mortality rate: Surg 9%, nonSurg 28%
From MacDonald KG et al J Gast. Surg 1997; 1:213-30.
CHANGE IN COMORBIDITIES
AFTER GASTRIC BYPASS
% RESOLVED / %IMPROVED
DIABETES 76.8
/ 85.4
HTN
61.7
/ 78.5
OSA
85.7
/ 83.6
HYPERLIPID 70.0
/ 96.9
Buchwald H et al JACS 2005; 200:593-604
IMPROVEMENTS IN DIABETES
(% improved or resolved)
Brolin et al (1992) 100%
Hall et al (1990) 75%
Pories et al (1982) 100%
Karason et al (2000) 48%
Van Rij (1984) 83%
Brolin et al (1994)
90%
Kothari et al (2002) 75%
Mittermair et al (2003) 86%
O’Brien et al (2002) 96% (LAP BAND)
Scopinaro (1996) 100% (BPD)
LAP BAND AND DIABETES
• RCT from 2002-6, lap band vs.
conventional diet rx.
• Remission of diabetes 73% in surgical
group vs. 13% in medical group
Dixon JB, et al. JAMA 2008; 299:316-23
SURGERY VS. MEDICAL RX FOR DIABETES
• PRCT medical vs surgical rx for
uncontrolled diabetes (1 yr rx)
• Endpoint: HgbA1C < 6.0%
– 4/41 medical rx =12%
– 21/50 RYGB = 42% (p = .002)
– 18/49 Sleeve = 37% (p = .008)
• More DM, HTN, Statin drugs in medical
and less in surgical pts
Schauer PR, et al NEJM 2012; 366:1567-76
#7
Benefits last for decades
SWEDISH OBESITY STUDY
• 4047 patients: 2010 surgery vs. 2037
conventional rx.
• Mortality at 10.9 yr follow:
• 129 vs. 101 deaths, p=.04
• Wt loss 25, 16, and 14% based on
operation
Sjostrom L, et al NEJM 2007; 357; 741-52
#6
Disease regression is best
and more durable if it
occurs earlier in the
course of the disease
REMISSION AND RELAPSE OF TYPE 2
DIABETES AFTER GASTRIC BYPASS
• 4434 adults with type 2 diabetes and bypass
• 68% achieved remission within 5 yrs postop
• Of these, 35% re-developed diabetes within
five years
• Avg duration of remission 8.3 years
• Predictors of relapse were poor preop control,
insulin use, longer diabetes duration
Aterburn DE et al Obes Surg 2013; 23:93-102
#5
Surgical mortality is
higher in older patients
MORTALITY AFTER GASTRIC BYPASS
• Strong correlation with age in
patients over age 70, significant for
patients over age 60
• For patients over age 50, survival of
a complication is less than for a
younger patient
Flum DR, Dellinger EP JACS 2004; 199:543-51
#4
Bariatric surgery prolongs
life
BARIATRIC SURGERY PROLONGS
LIFE
• 1035 patients treated at McGill
from 1986-2002
• Control group from Quebec health
database
• Those with comorbids excluded
McGILL STUDY
• 67.1% excess weight loss
• Mortality: 0.68% vs. 6.17%
• Relative risk of death reduced by
89%
Christou et al Ann Surg 2004;240:416-24
U.S. POPULATION STUDY
• Compared 9949 patients undergoing
RYGB to 9628 obese applied drivers
license
• National Death Index; 7.1 yr.
• 36.7 vs. 57.1 deaths/10,000 person
yrs, p<.001
Adams et al. NEJM 2007; 357:753-61
#3
Less office visits
Less medications
Lower cost of health care
McGILL STUDY: COSTS
YEAR SURGERY MEDICAL
1 $12,461,938* $3,609,680
5 $19,516,667 $25,264,608*
Costs of surgery amortized over 3.5
years
Sampalis et al Obes Surg 2004;14:939
#2
Why wouldn’t you want
to give a patient an
effective treatment
against so many
diseases?
#1
Because they may not be
around long enough if
you don’t
(especially the men)
OBESITY BY AGE/SEX
% population BMI > 40
Age
Males
Females
>20
3.3
6.4
40-59 59>60
3.9
1.7
7.8
5.6
From: Hedley et al JAMA 06/16/04
THANK YOU