Bariatric Surgery

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Bariatric Surgery

• Roberto C. Mirasol, MD, FPCP, FPSEM
• Obesity and Weight Management Center
• St. Lukes Medical Center

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Bariatric Surgery

• Indications
• BMI gt40 kg/m2 or
• BMI 3539.9 kg/m2 and
• life-threatening cardiopulmonary
• disease, severe diabetes, or
• lifestyle impairment
• Failure to achieve adequate weight loss with
  nonsurgical treatment
• Contraindications
• History of noncompliance with medical care
• Certain psychiatric illnesses personality
  disorder, uncontrolled depression, suicidal
  ideation, substance abuse
• Unlikely to survive surgery

NIH Consensus Development Panel. Ann Intern Med
1991115956.
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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)

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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 old
• Length of Hospital Stay 3.9 days
• Bariatric surgeons increased by 500
• Complication rate 10
• Deaths lt1
• CDC, 2006

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Current Bariatric Surgical Procedures

• Classification
• 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

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Gastric Bypass Procedure
A small (1030 mL) gastric pouch is anastomosed
to a Roux limb of jejunum. Increasing the length
of the Roux limb increases malabsorption and
weight loss.

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Long-term Effect of Gastric Bypass Surgery on
Body Weight
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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 2001234279.
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Weight Loss With Gastric Bypass Procedure vs.
Vertical Banded Gastroplasty
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Laparoscopic Adjustable Gastric Banding
LapBandTM
Access port (reservoir)
Connection tubing
Gastric Band
Silicone band placed around upper stomach to
create a small pouch. Outlet diameter can be
changed by infusing or withdrawing saline from
port.
American Society for Metabolic and Bariatric
Surgery, www.asbs.org
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LAP BAND
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Laparoscopic Adjustable Gastric Banding Produces
Greater Weight Loss than Comprehensive Medical
Therapy in Patients with Class I Obesity (BMI
30-35 kg/m2)
Weight Loss,
Surgical
Nonsurgical
Baseline
6 mo
12 mo
18 mo
24 mo
(VLCD, behavioral modification, and
pharmacotherapy)
Obrien et al. Ann Intern Med. 2006144625-33
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Biliopancreatic Diversion With Duodenal Switch
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.
Marceau P. et al. World J Surg 199822947-54.
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Effect of Different Bariatric Surgical Procedures
on Weight Loss
Approximate Loss of Excess
Procedure Weight () Laparoscopic
gastric banding 4565 Gastric bypass
procedure 5565 Biliopancreatic
diversion 6075 with duodenal
switch
Klein et al. Gastroenterology. 2002123882-932
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Relationship Between Rate of Weight Loss and
Gallstone Formation
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Complications of Bariatric Surgery

• Gastric banding procedure
• Band slippage
• Band erosion
• Esophageal dilatation
• Band or port infections
• Port disconnection
• Port displacement
• Biliopancreatic 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

• All procedures
• Atelectasis and pneumonia
• Deep vein thrombosis
• Pulmonary embolism
• Wound infection
• Gastrointestinal bleeding
• Gallstones
• Failure to lose weight
• Intractable vomiting/kwashiorkor (B1)
• Mortality (0.12)
• 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

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Relationship Between Surgical Experience and
Perioperative Mortality in Gastric Bypass
Surgery
7 6 5 4 3 2 1 0
125 case lifetime bariatric surgery experience
Thirty Day Mortality
Chronological case order per surgeon
D Flum et al. J Am Coll Surg 199543, 2004
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Gastric Bypass Surgery Improves Glycemic Control
in Impaired Glucose Tolerance or Type 2 Diabetes
Pories et al. Ann Surg 1995222339.
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Prevention of Type 2 Diabetes at 8 Years After
Bariatric Surgery (94 Restrictive)
20.0
18.5
Control Bariatric surgery
16.0
12.0
Incidence of Type 2 Diabetes( Patients)
8.0
4.7
3.6
4.0
0.0
0.0
2
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Follow-up After Surgery (y)
Sjostrom et al. Hypertension 20003620.
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Effect of Bariatric Surgery on Obesity-related
Metabolic Complications
Control
Surgery
72
62
46
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Ratio of Recovery ( of subjects)
34
24
21
21
22
19
13
11
Diabetes
Hypertension
Hypertriglyceridemia
Sjöström N Engl J Med 20043512683.
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Effect of Gastric Bypass Surgery-induced Weight
Loss on Liver Histology
Klein S. et al. Gastroenterology 1301564, 2006
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Effects of GPS-induced Weight Loss on Hepatic
Inflammation and Fibrogenesis
?-SMA
MCP-1
0.06
0.0020
0.0015
0.04


0.0010
0.02
0.0005
plt0.05 vs before
0.00
0.0000
Data are expressed relative to 18s mRNA
Collagen-I?1
IL-8
0.0003
0.02
0.0002
0.01


0.0001
0.0000
0.00
Klein S. et al. Gastroenterology 1301564, 2006
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Long-term Survival Canada
Rel. Risk 0.11 (.04-.27)
89 reduction in risk ofdeath over 5 years
Mortality
Christou et al. Ann Surg 2004240416-424
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Major Obesity-related Comorbidities That Have
Been Improved by Bariatric Surgery

• Dyslipidemias
• Coronary artery disease
• Cardiac dysfunction
• Venous stasis disease
• Polycystic ovary syndrome
• Infertility
• Cancers
• Degenerative joint disease
• Quality of life

• Type 2 diabetes
• Hypertension
• Obstructive sleep apnea
• Obesity hypoventilation
• GERD
• NALD, NASH
• Pseudotumor cerebri
• Depression

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Prevalence Rates of Axis I Disorders

• Lifetime prevalence
• Treatment-seeking obese 48 - 57
• General population 26 - 35
• Rx-seeking gt non-Rx seeking obese
• Point Prevalence
• Bariatric surgery applicants 27 - 42

Berman WH et al., Behav Med, 1993 18167-162
Goldsmith SJ et al. Int J Eating Disord, 1992
1263-71 Halmi KA et al. Am J Psychiatry, 1980
137470-472 Robins LN et al. Arch Gen Psych,
1984 41949-958 Kessler RC et al, Arch Gen
Psych, 1994, 518-19 Herpertz et al, Int J
Obesity, 2003 27 1300-1314.
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Potential Use of Psychological Assessment and
Intervention in Bariatric Surgery

• Determine capacity to provide informed consent
• Evaluate psychosocial capacity for post-op
  compliance
• Specify targets of pre- and post-op education
• Detect disorders that are a contraindication for
  surgery (e.g. substance abuse)
• Assess pre-existing psychopathology for potential
  referral and management
• Identify psychosocial issues likely to be raised
  by weight loss and/or eating restriction

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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-1glucagon-like peptide-1 GIPglucose-depende
nt insulinotropic polypeptide. Drucker DJ.
Diabetes Care. 20032629292940 Ahrén B. Curr
Diab Rep. 20033365372 Drucker DJ.
Gastroenterology. 2002122531544 Farilla L et
al. Endocrinology. 200314451495158 Trümper A
et al. Mol Endocrinol. 20011515591570 Trümper
A et al. J Endocrinol. 2002174233246 Wideman
RD et al. Horm Metab Res. 200436782786.
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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

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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

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PROPOSED MECHANISMS FOR IMPROVED GLYCEMIC CONTROL
AFTER BARIATRIC SURGERY
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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)

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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

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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

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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

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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 cells Distal ileum Increase Increase Increase No change
Peptide YY L cells Distal ileum Decrease Increase Increase No change
Folli, 2007
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BARIATRIC SURGERY IN ST LUKEs
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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)
gt60 2 (11) 1 (3) 3 (6)
BMI (mean)
14-18 57 46.8 51.9
19-59 47.07 46.15 46.5
gt60 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
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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
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COMPLICATIONS

• Early Complications
• Wound infection 2/50
• Pneumonia 1/50
• Dehydration 1/50
• Gastritis 1/50
• Leakage 1/50

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COMPLICATIONS

• Late Complications
• Band Slippage 2/20 (10)
• Stomal Stenosis 1/20 (5)
• Ventral Hernia 1/5 (20)

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STARTING WEIGHT 307 lbs BMI
49.44 END WEIGHT 156 lbs BMI 25.16
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STARTING WEIGHT 516 lbs BMI
83.10 END WEIGHT 258 lbs BMI 37.01
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100 kg (220 lb)
76 kg (168 lb)
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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

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