Surgery for Morbid Obesity: A Retrospective Review of our Experience in a Community Hospital Setting
A. Ahmad, J. Carleton, A. Agarwala, Z. Ahmad John T. Mather Memorial Hospital, Port Jefferson, NY, USA St. Charles Hospital, Port Jefferson, NY, USA
Disclosure
Arif Ahmad MD I have NO actual or potential conflict of interest in relation to this activity. I do not have any relevant financial relationships with any commercial interests.
Disclosure Information In compliance with the guidelines established by ACCME, I have no actual or potential conflict of interest in relation. I have no relevant financial interest to this program or presentation.
Venus of Willendorf
Evolution
The Obesity Epidemic A Rapidly Expanding Problem
One in five people in the United States is obese
Three in five Americans are either overweight or obese
In the past 20 years, obesity among adults has doubled
Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity.
Risks to Psychological & Social WellBeing
Obesity Affects All Areas of Life
Who is a Candidate for Surgery?
Normal Weight
BMI*:
18.5 to 24.9
Overweight
25 to 29.9
Obese
30 to 34.9 With co-morbidity Lap-Band only*
Severely Obese
Morbidly Obese
35 to 39.9
40 or more
With comorbidity
*Lower BMI (30-34.9) may not be covered by insurance at this time.
Physiological Impact of Obesity Pulmonary disease
abnormal function obstructive sleep apnea hypoventilation syndrome
Nonalcoholic fatty liver disease
Idiopathic intracranial hypertension Stroke Cataracts Coronary heart disease Diabetes
steatosis steatohepatitis cirrhosis
Dyslipidemia Hypertension
Gall bladder disease Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome
Osteoarthritis Skin Gout
Severe pancreatitis Cancer
breast, uterus, cervix colon, esophagus, pancreas kidney, prostate
Phlebitis
venous stasis NAASO Obesity Online
Major Obesity Related Diseases
NIDDM ( Type 2 DM)
Hypertension
GERD
Cardiovascular Disease and Hypercholesterolemia
Pulmonary (Sleep Apnea)
Degenerative Joint Disease
Urinary Stress Incontinence
Weight Loss Strategies •
Physical Activity Alone
Weight Watchers, Jenny Craig, NutriSystem etc, does not work for 99% of Obese individuals long term • Does not always lead to weight loss
Behavior Modification
• Requires ongoing professional contact, and failure rate can be high
Drug Treatments
• Weight is typically regained when treatment ends
Weight Loss Surgery and lifestyle changes
• The most effective approach for long-term weight loss
Dietary Intervention
Without weight loss surgery 99.5% of Obese patients will regain their weight within 2 years
Most Common Procedures
Adjustable Gastric Band
Sleeve Gastrectomy
Roux-En-Y Gastric Bypass
Our Patient Selection Criteria
Body Mass Index (BMI) ≥ 40.0
or BMI of 35.0 – 39.9 with co-morbidities such as Type 2 diabetes, hypertension, sleep apnea, etc. –
Failure of non-surgical control (diet, exercise, behavior modification)
Psychological stability
Patient –Physician relationship
Weight loss prior to surgery
Free from alcohol, drugs, or smoking
Preoperative Work-Up
Standard pre-op labs and work-up
Nutrition assessment and education
Upper Endoscopy/UGI series
Ultrasound exam of the Gall Bladder
Psychological Evaluation
Pulmonary & Cardiac consults and clearance
Medical clearance from PCP
Major Co-morbidities That Have Been Improved or Resolved by Bariatric Surgery
Type 2 Diabetes Hypertension Obstructive sleep Apnea Obesity Hypoventilation GERD NALD, NASH Pseudotumor cerebri Depression Dyslipidemia
Coronary Artery Disease Cardiac Dysfunction Venous Stasis Disease Polycystic Ovarian Syndrome Infertility Cancers Degenerative Joint Disease Quality of Life
Weight-Loss Surgery is Now Recommended by the Top Medical Societies • Nonsurgical treatments are found ineffective for most morbidly obese patients • The American Academy for Clinical Endocrinologists, The Obesity Society, and the American Society for Metabolic & Bariatric Surgery have recommended that morbidly obese patients (BMI >40 or BMI >35 with a obesity related co morbidity) should be offered weight-loss surgery • American Diabetes Association: Weight-loss surgery should be considered for adults with BMI of 35 and type 2 diabetes, especially if the diabetes is difficult to control with lifestyle and pharmacologic therapy
Bariatric Surgery versus Intensive Medical Therapy for Diabetes: 3-Year Outcomes OBJECTIVE:
In short-term randomized trials (duration, 1 to 2 years), bariatric surgery has been associated with improvement in type 2 diabetes mellitus. In the Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial, we found that 1 year after randomization, gastric bypass and sleeve gastrectomy were superior to intensive medical therapy alone in achieving glycemic control and reducing cardiovascular risk factors while decreasing dependency on pharmacotherapy for diabetes management. Although bariatric surgery yields short-term improvements in glycemic control, questions remain regarding the durability of the metabolic benefits of surgery, long-term safety, quality of life, and effects on diabetes-related end-organ disease. The current report provides results of the 3-year follow-up analyses from the STAMPEDE trial and addresses other unanswered questions about the durability of the benefits of bariatric surgery as compared with intensive medical therapy for treating diabetes mellitus. METHODS: We assessed outcomes 3 years after the randomization of 150 obese patients with uncontrolled type 2 diabetes to receive either intensive medical therapy alone or intensive medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy. The primary end point was a glycated hemoglobin level of 6.0% or less. RESULTS: The mean (±SD) age of the patients at baseline was 48±8 years, 68% were women, the mean baseline glycated hemoglobin level was 9.3±1.5%, and the mean baseline body-mass index (the weight in kilograms divided by the square of the height in meters) was 36.0±3.5. A total of 91% of the patients completed 36 months of follow-up. At 3 years, the criterion for the primary end point was met by 5% of the patients in the medical-therapy group, as compared with 38% of those in the gastric-bypass group (P<0.001) and 24% of those in the sleevegastrectomy group (P=0.01). The use of glucose-lowering medications, including insulin, was lower in the surgical groups than in the medical-therapy group. Patients in the surgical groups had greater mean percentage reductions in weight from baseline, with reductions of 24.5±9.1% in the gastric-bypass group and 21.1±8.9% in the sleeve-gastrectomy group, as compared with a reduction of 4.2±8.3% in the medical-therapy group (P<0.001 for both comparisons). Quality-of-life measures were significantly better in the two surgical groups than in the medical-therapy group. There were no major late surgical complications.
CONCLUSION: Among obese patients with uncontrolled type 2 diabetes, 3 years of intensive medical therapy plus bariatric surgery resulted in glycemic control in significantly more patients than did medical therapy alone. Analyses of secondary end points, including body weight, use of glucose-lowering medications, and quality of life, also showed favorable results at 3 years in the surgical groups, as compared with the group receiving medical therapy alone. N Engl J Med 2014; 370:2002-2013May 22, 2014DOI: 10.1056/NEJMoa1401329 Philip R. Schauer, M.D., Deepak L. Bhatt, M.D., M.P.H., et al. for the STAMPEDE Investigators Massachusetts Medical Society, May 22, 2014
Lifestyle, Diabetes, and Cardiovascular Risk Factors 10 Years after Bariatric Surgery
OBJECTIVE: Obesity is associated with increased morbidity and mortality. The increased morbidity is assumed to be mediated mainly by insulin resistance, diabetes, hypertension, and lipid disturbances — conditions that affect one quarter of the North American population. Over the short term (1-3 years), lifestyle changes resulting in weight loss result in improvements in insulin resistance,4 diabetes, hypertension, and lipid disturbances or in the prevention of these conditions. In contrast, several (but not all) observational epidemiologic studies have suggested that weight loss is associated with increased overall mortality and mortality from cardiovascular causes, not only among thin and normal-weight subjects, but also among obese subjects. One overall aim of the Swedish Obese Subjects (SOS) Study was to address this apparent discrepancy between the effects of weight loss on risk factors and hard end points. In the current study, we assessed changes in cardiovascular risk factors over follow-up periods of 2 and 10 years in surgically treated subjects and contemporaneously matched, conventionally treated control subjects. Changes in energy intake and physical activity over the 10-year period were also evaluated. METHODS: The prospective, controlled Swedish Obese Subjects Study involved obese subjects who underwent gastric surgery and contemporaneously matched, conventionally treated obese control subjects. We now report follow-up data for subjects (mean age, 48 years; mean body-mass index, 41) who had been enrolled for at least 2 years (4047 subjects) or 10 years (1703 subjects) before the analysis (January 1, 2004). The follow-up rate for laboratory examinations was 86.6 percent at 2 years and 74.5 percent at 10 years. RESULTS: After two years, the weight had increased by 0.1 percent in the control group and had decreased by 23.4 percent in the surgery group (P<0.001). After 10 years, the weight had increased by 1.6 percent and decreased by 16.1 percent, respectively (P<0.001). Energy intake was lower and the proportion of physically active subjects higher in the surgery group than in the control group throughout the observation period. Two- and 10-year rates of recovery from diabetes, hypertriglyceridemia, low levels of high-density lipoprotein cholesterol, hypertension, and hyperuricemia were more favorable in the surgery group than in the control group, whereas recovery from hypercholesterolemia did not differ between the groups. The surgery group had lower 2- and 10-year incidence rates of diabetes, hypertriglyceridemia, and hyperuricemia than the control group; differences between the groups in the incidence of hypercholesterolemia and hypertension were undetectable..
CONCLUSION: As compared with conventional therapy, bariatric surgery appears to be a viable option for the treatment of severe obesity, resulting in long-term weight loss, improved lifestyle, and, except for hypercholesterolemia, amelioration in risk factors that were elevated at baseline. N Engl J Med 2004; 351:2683-2693December 23, 2004DOI: 10.1056/NEJMoa035622 Lars Sjöström, M.D., Ph.D., Anna-Karin Lindroos, Ph.D.,et al. for the Swedish Obese Subjects Study Scientific Group Massachusetts Medical Society, Dec 23, 2004
Lap Band Surgery
Atypical Presentations of Band Problems
Pneumonia
Asthma
Fever of Unknown Origin
GERD
Chest Pain
Port-site Infection
Long-term Outcomes after Bariatric Surgery: Fifteen-year Followup of Adjustable Gastric Banding and a Systematic Review of the Bariatric Surgical Literature RESULTS: A total of 3227 patients, with a mean age of 47 years and a mean body mass index of 43.8 kg/m, were treated by laparoscopic adjustable gastric band placement between September 1994 and December 2011. Seven hundred fourteen patients had completed at least 10 years of follow-up. Follow-up was intact in 81% of patients overall and 78% of those beyond 10 years. There was no Perioperative mortality for the primary placement or for any revision procedures. CONCLUSION: The LAGB study from 1 center demonstrates a durable weight loss with 47% EWL maintained to 15 years. This weight loss occurred regardless of whether any revisional procedures were needed. A systematic review shows substantial and similar long-term weight losses for LAGB and other bariatric procedures. Ann Surg. 2013 Jan;257(1):87-94. doi: 10.1097/SLA.0b013e31827b6c02. O'Brien PE, MacDonald L, Anderson M, Brennan L, Brown WA. Source Centre for Obesity Research and Education (CORE), Monash University, Melbourne, Victoria, Australia. paul.obrien@monash.edu
Sleeve Gastrectomy Surgery
removed
Sleeve Gastrectomy Surgery Disadvantages
Advantages
Restrictive procedure
No foreign body
Low malnutrition risk
Eliminates the portion of the stomach
that produces the hormone Ghrelin, which stimulates hunger
Avoids dumping syndrome because the pylorus is preserved
Decreased risk of intestinal obstruction, and marginal ulcers than RNY bypass
Not reversible Potential for Leaks or Bleeding related to stapling Slower weight loss than gastric bypass Heart burn is common
Potential Complications of the Gastric Sleeve
Bleeding , Infection, Damage to adjacent organs
Leaks from Stapling of the stomach
Clots in legs and lungs
Mortality is < 0.2 %
Hiatal Hernia
Roux-en-Y Gastric Bypass
Gastric pouch: 15-20 ml 1.2 cm stoma 2 Anastomoses Inaccessible gastric remnant Theoretically reversible, but very difficult
Food Flow Before & After Gastric Bypass
Gastric Banding or Bypass? A Systematic Review Comparing the Two Most Popular Bariatric Procedures OBJECTIVE: Bariatric surgical procedures have increased exponentially in the United States. Laparoscopic adjustable gastric banding is now promoted as a safer, potentially reversible and effective alternative to Roux-en-Y gastric bypass, the current standard of care. This study evaluated the balance of patient-oriented clinical outcomes for laparoscopic adjustable gastric banding and Roux-en-Y gastric bypass. METHODS: The MEDLINE database (1966 to January 2007), Cochrane clinical trials database, Cochrane reviews database, and Database of Abstracts of Reviews of Effects were searched using the key terms gastroplasty, gastric bypass, laparoscopy, Swedish band, and gastric banding. Studies with at least 1 year of followup that directly compared laparoscopic adjustable gastric banding with Roux-en-Y gastric bypass were included. Resolution of obesity-related comorbidities, percentage of excess body weight loss, quality of life, perioperative complications, and long-term adverse events were the abstracted outcomes. RESULTS: The search identified 14 comparative studies (1 randomized trial). Few studies reported outcomes beyond 1 year. Excess body weight loss at 1 year was consistently greater for Roux-en-Y gastric bypass than laparoscopic adjustable gastric banding (median difference, 26%; range, 19%-34%; P < .001). Resolution of co morbidities was greater after Roux-en-Y gastric bypass. In the highest-quality study, excess body weight loss was 76% with Roux-en-Y gastric bypass versus 48% with laparoscopic adjustable gastric banding, and diabetes resolved in 78% versus 50% of cases, respectively. Both operating room time and length of hospitalization were shorter for those undergoing laparoscopic adjustable gastric banding. Adverse events were inconsistently reported. Operative mortality was less than 0.5% for both procedures. Perioperative complications were more common with Roux-en-Y gastric bypass (9% vs. 5%), whereas long-term reoperation rates were lower after Roux-en-Y gastric bypass (16% vs. 24%). Patient satisfaction favored Roux-en-Y gastric bypass (P=.006).
CONCLUSION: Weight loss outcomes strongly favored Roux-en-Y gastric bypass over laparoscopic adjustable gastric banding. Patients treated with laparoscopic adjustable gastric banding had lower short-term morbidity than those treated with Roux-en-Y gastric bypass, but reoperation rates were higher among patients who received laparoscopic adjustable gastric banding. Gastric bypass should remain the primary bariatric procedure used to treat obesity in the United States. Am J Med. 2008 Oct;121(10):885-93. doi: 10.1016/j.amjmed.2008.05.036. Tice JA, Karliner L, Walsh J, Petersen AJ, Feldman MD. Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94143-1732, USA. jtice@medicine.ucsf.edu
Potential Complications of the Gastric Bypass
Bleeding, Infection, Damage to adjacent organs
Leaks from site of joining stomach and intestine
Obstruction, Ulcers, Narrowing of gastric outlet
Malnutrition
Clots in legs and lungs
Mortality is 0.2%
The da Vinci® Surgical System
Clearer 3-D Visualization
More Precise Suturing
Reduced Surgeon Fatigue (leads to more focus on the specific procedure)
No Difference in Leak Rate When Compared to Traditional Laparoscopic Method
The da Vinci® Surgical System
Using the da Vinci® Surgical System, the surgeon operates seated comfortably at a console while viewing a high definition, 3D image inside the patient’s body. The surgeon's fingers grasp the master controls below the display with hands and wrists naturally positioned relative to his or her eyes. The system seamlessly translates the surgeon’s hand, wrist and finger movements into precise, real-time movements of surgical instruments.
Roux-En-Y Gastric Bypass Dr. Ahmad controls the robotic arms for precise suturing
Robotic vs. Laparoscopic Roux-en-Y Gastric Bypass in Morbidly Obese Patients: Systematic Review and Pooled Analysis BACKGROUND:
The aim of this study was to provide pooled analysis of individually small trials comparing robotic Roux-en-Y gastric bypass (RRYGB) with standard laparoscopic RYGB (LRYGB). METHOD: A systematic literature search of Medline, Embase and Cochrane Library databases was performed. Primary outcome measures were the incidence of anastomotic leak and stricture. Secondary outcome measures were post-operative complications, operative time and length of hospital stay. RESULTS: Seven relevant studies of 1686 patients were included in this analysis. There was a significantly reduced incidence of anastomotic stricture in the robotic group (POR = 0.43; 95% CI = 0.19 to 0.98; p = 0.04). There was no significant difference between robotic and laparoscopic groups for anastomotic leak, post-operative complications, operative time and length of hospital stay.
CONCLUSION: The incidence of anastomotic stricture was reduced with RRYGB compared with LRYGB over a minimum follow-up period of 6 months, thus demonstrating the potential benefit of RRYGB Int J Med Robot. 2011 Dec;7(4):393-400. doi: 10.1002/rcs.414. Epub 2011 Oct 7. Markar SR, Karthikesalingam AP, Venkat-Ramen V, Kinross J, Ziprin P. Source Academic Surgical Unit, St Mary's Hospital, Imperial College, London, UK. sheraz_markar@hotmail.com RRYGB.
Surgery for Morbid Obesity: A Retrospective Review of our Experience in a Community Hospital Setting OBJECTIVE: To analyze and evaluate the safety and efficacy with which bariatric surgeries can be performed in the community hospital setting DESIGN: Study is a chart review and analysis of the outcomes and complications of over 2900 bariatric surgical cases performed in the community hospital setting
Disclosure Information In compliance with the guidelines established by ACCME, I have no actual or potential conflict of interest in relation. I have no relevant financial interest to this program or presentation.
Materials & Methods of Our Study
Total of 2916 bariatric surgical cases performed by a single surgeon at two different community hospitals were reviewed from June, 2001 until October, 2014
Surgical cases included were adjustable gastric band placements, Roux-en-Y gastric bypasses, sleeve gastrectomies, and banded gastric plications
All of these procedures were performed laparoscopically
Patient demographics, adverse events, return to the operating room within 30 days, and average length of stay were retrospectively analyzed from a prospective database
RESULTS LAP BAND: • 35.46% of the total procedures performed were adjustable gastric band placements • The average length of stay (number of days) was 2.0 • Of the total 1034 patients who underwent adjustable gastric banding, there were nine (0.87%) who had band erosion and forty-six (4.45%) who had a slipped band/pouch dilation • There were zero (0%) mortalities
RESULTS SLEEVE GASTRECTOMY: • 22.56% of the total procedures performed were sleeve gastrectomies • The average length of stay (number of days) was 2.5 • There was one case (0.16%) of possible staple line leak vs. fluid collection and one (0.16%) case of SMV thrombosis in the 658 total sleeve gastrectomies performed • There were zero (0%) mortalities
RESULTS LAPAROSCOPIC ROUX-en-Y GASTRIC BYPASS: • 38.31% of procedures were Roux-en-Y gastric bypasses, the single most common bariatric procedure performed • The average length of stay (number of days) was 3.0 • There were zero (0%) leaks from anastomotic sites in primary Roux-en-Y gastric bypass cases and one (0.09%) leak from the anastomotic site in a revisional case. There was one (0.09%) case of anastomotic bleeding that did not require any additional interventional surgery. • There were zero (0%) mortalities
RESULTS ROBOTIC-ASSISTED ROUX-en-Y GASTRIC BYPASS : • 231 Roux-en-Y gastric bypasses were performed (20.68% of total Roux-en-Y) with robotic assistance utilizing the daVinci® surgical platform and recorded from the period of February, 2011 until October, 2014 • There were zero (0%) leaks, zero (0%) bleeds, zero (0%) infections, and zero (0%) patients that needed to return to the OR within 30 days • There were zero (0%) mortalities
Primary Care Follow-Up: A Lifetime Commitment
Bariatric surgery is a long-term commitment for the patient, surgeon, and PCP
Follow-up with bariatric surgeon or PCP every 3 months is essential for sustaining weight loss
Lifelong attendance at monthly support groups and regular consults with nutritionists are encouraged
Primary Care Follow-Up: A Lifetime Commitment Vitamins
If
on multivitamins regularly, most bariatric patients do not develop deficiencies
Very
rarely, patients may develop thiamine deficiency with neurological symptoms
Intravenous
thiamine supplementation is required as a precaution in some RNY Gastric Bypass patients Menstruating women may develop iron-deficiency anemia 5%
of bariatric patients require intravenous iron Sites of calcium absorption are bypassed with the RNY Gastric Bypass Supplemental Abdominal
calcium is required for some patients
Pain
All
pain must be assessed by a bariatric surgeon. However, common causes after bariatric surgery may include:
Gallstones Internal
hernia
Marginal
ulcers
Primary Care Follow-Up: Bariatric Surgery and GERD
Gastroesophageal Reflux Disease (GERD) is completely resolved after Roux-en-Y Gastric Bypass
Esophagus is no longer connected to tissues secreting gastric acid
GERD is more likely to develop in Sleeve Gastrectomy patients
Gastric banding patients who develop GERD should be assessed for a “slipped” band
Lap Band Suzanne
243 lbs
July 2007
123 lbs
July 2013
Sleeve Gastrectomy Tara
Gastric Bypass Kim
316 lbs
135 lbs
Disclosure
Arif Ahmad MD I have NO actual or potential conflict of interest in relation to this activity. I do not have any relevant financial relationships with any commercial interests.
Conclusion Our data shows that bariatric surgery can be performed safely and effectively in the community hospital setting
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