Lunch CME Lecture Bariatric Surgical Patient Care

Robert F. Kushner, MD

8/6/2014

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Bariatric Surgery Robert Kushner, MD

Professor of Medicine

Northwestern University Feinberg School of Medicine

rkushner@northwestern.edu

Outline

• Prevalence, health implications and cost of severe obesity

• Clinical decision making in obesity care

• Bariatric surgery procedures

• Effectiveness and risks

• Nutritional complications and management

Classification BMI (kg/m2) Risk

Underweight <18.5 Increased Normal 18.5–24.9 Normal Overweight 25.0–29.9 Increased Obese I 30.0–34.9 High II 35.0–39.9 Very high III 40 Extremely high Additional risks:

• Large waist circumference (men >40 in; women >35 in)

• Poor aerobic fitness

• Specific races and ethnic groups

BMI-Associated Disease Risk

Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight

and Obesity in Adults—The Evidence Report. Obes Res 1998;6(suppl 2).

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Trends in

Obesity and Overweight

among US Adults, 1960-2010

Obesity and Overweight Prevalence

Fryar C, et al. http://www.cdc.gov/nchs/data/hestat/obesity_adult_09_10/obesity_adult_09_10.pdf. Accessed February 19, 2014. Flegal KM, et al. JAMA. 2012;307(5):491-497.

Prevalence of

Obesity and Overweight

in US Adults, 2009-2010

20.4%

33.3%

30.8%

6.3%

9.2%

Overweight (BMI ≥25.0-29.9)

Normal / Underweight (BMI <25.0)

Obese Class 1 (BMI ≥30.0-34.9)

Obese Class 2 (BMI <≥35.0-39.9)

Obese Class 3 (BMI ≥40.0)

40

20

0

1960- 1962

Pre

vale

nce

(%)

30

10

Obese (BMI ≥30.0 kg/m2)

Obese Class 3 (BMI ≥40.0 kg/m2)

Overweight (BMI ≥25.0-29.9 kg/m2)

25

5

35

15

1971- 1974

1976- 1980

1988- 1994

2001- 2002

2005- 2006

2009- 2010

7.3

18

6.1

0

2

4

6

8

10

12

14

16

18

20

Whitewomen

Black women Hispanicwomen

5.8 7.6

4.1

02468

101214161820

White men Black men Hispanicmen

Prevalence of Extreme Obesity

(BMI ≥ 40) by Gender and Ethnicity

Men Women

Flegal K, et al. JAMA 2012;307:491-7.

The Impact of Obesity on Health

Obesity burden largely driven by

increased risk of • Cardiovascular

diseases • Type 2 diabetes

• Certain cancers • Musculoskeletal

pain

Centers for Disease Control and Prevention. http://www.cdc.gov/VitalSigns/AdultObesity/Risk-large. html#Complications. Accessed February 19, 2014. Singh-Manoux A, et al. Neurology. 2012;79(8):755-762. Guh DP, et al. BMC Public Health. 2009;9:88. Wang YC, et al. Lancet. 2011;378(9783):815-825.

Sleep apnea

Lung disease

Asthma Pulmonary blood clots

Liver disease

Fatty liver Cirrhosis

Gallstones

Urinary

incontinence

Venous insufficiency

Inflamed veins, often with blood clots

Peripheral edema

Stroke Cognitive decline

Chronic back pain

Infertility

Arthritis

Gout

Cancer Musculoskeletal pain

Diabetes

Heart disease

Abnormal lipid profiles

High blood pressure

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Additional Yearly per Capita Healthcare and Productivity Costs Due to Obesity among

Full-Time US Employees ($2006)

All values significant (P<.05) compared to normal-weight workers. Finkelstein EA. J Occup Environ Med. 2010;52(10):971-976.

0

$2524

$4112

$7092

Ad

dit

ion

al Y

earl

y p

er C

apit

a C

ost

s

abo

ve N

orm

al-W

eigh

t Wo

rker

s ($

)

Obese Class 2 (BMI ≥35-39.9)

Obese Class 3 (BMI ≥40)

Obese Class 1 (BMI ≥30-34.9)

Women

0

$1143

$2491

8,000

6,000

4,000

3,000

2,000

1,000

7,000

5,000

Obese Class 2 (BMI ≥35-39.9)

Obese Class 3 (BMI ≥40)

Obese Class 1 (BMI ≥30-34.9)

Men

$6087

8,000

6,000

4,000

3,000

2,000

1,000

7,000

5,000

Absenteeism

Healthcare

Presenteeism

Obesity Treatment Pyramid

Surgery

Pharmacotherapy

Lifestyle Modification

Diet Physical Activity

BM

I

Co

-mo

rbid

itie

s

A Guide to Selecting Treatment

Treatment

BMI category

25-26.9 27-29.9 30-34.9 35-39.9 ≥40

Diet, physical activity,

and behavior therapy

Pharmacotherapy

Surgery

With

co-morbidity

With

co-morbidity

With

co-morbidity

+ + + +

+

+

+ +

The Practical Guide. 2000

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Factor Criteria

Weight (adults) BMI ≥ 40 kg/m2 with no comorbidities BMI ≥ 35 kg/m2 with obesity-associated comorbidity

Weight loss history Failure of previous nonsurgical attempts at weight reduction, including nonprofessional programs (e.g., Weight Watchers, Jenny Craig)

Commitment Expectation that patient will adhere to postoperative care; follow-up visits with physician(s) and team members; recommended medical management, including the use of dietary supplements; instructions regarding any recommended procedures or tests

Exclusion Reversible endocrine or other disorders that can cause obesity; current drug or alcohol abuse Uncontrolled, severe psychiatric illness Lack of comprehension of risks, benefits, expected outcomes, alternatives, and lifestyle changes required with bariatric surgery

Selection Criteria for Bariatric Surgery AACE/TOS/ASMBS Guidelines

Mechanick JI, et al. Endocr Pract. 2008;14 Suppl 1:1-83.

Efficacy and safety of currently available treatments

Lifestyle1 Gastric Band3

Gastric Bypass3

0% 5% 10% 15% 20% 25% 30% 35% Weight Loss

1. Jensen et al., Circulation. Published Online Nov 12, 2013. 2. Courcoulas AP et al. JAMA, November 2013 3. LABS consortium. N Engl J Med 2009;361:445-54. 4. Colman et al. N Engl J Med 2012; 367:1577-1579.

Meds + Lifestyle4

Weight loss at 3 years2 16% for gastric band

33% for bypass2

Medical Care Reducing perioperative risk

• Screen for Obstructive sleep apnea (OSA) • Polysomnogram and CPAP/BiPAP if indicated

• Deep vein thrombosis/pulmonary embolism • Preoperative DVT/PE prophylaxis

• Blood glucose control in diabetes

• Smoking cessation

• Screen for Coronary artery disease • Cardiac stress testing

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Bariatric Surgery Procedures

Laparoscopic Adjustable Gastric Band (LAGB)

Band placed at fundus is adjustable by way of its connection to a reservoir that is implanted under the skin. Injection or removal of saline into the reservoir tightens or loosens the band’s internal diameter

Roux-en-Y Gastric Bypass (RYGB) A small proximal gastric pouch is created and connected to the jejunum through a narrow (10 mm) gastrojejunostomy. “Bypass” refers to the exclusion or bypassing of the distal stomach, duodenum, and proximal jejunum.

Laparoscopic Gastric Sleeve (LGS) the stomach is restricted by stapling and dividing it vertically and removing approximately 80% of the greater curvature, leaving a slim ‘banana shaped’ remnant stomach along the lesser curvature.

How does Bariatric Surgery Work? Gut Peptides that Regulate Appetite

Murphy KG, Bloom SR. Nature 2006;444:854-859

Effect of Bariatric “Metabolic” Surgery

LAGB RYGB LGS

Mechanisms

Food intake

Ghrelin

GLP-1

Bile acids

Gut microbiota Unaltered Altered Altered

Gastric emptying

Madsbad S, et al. Lancet Diabetes Endocrinol 2014;2:152-164

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Rates of Comorbidity Reduction after Bariatric Surgery

Disease or Symptom % improvement or remission at ≤ 2y

% improvement or remission at 5-7 y

% improvement or remission at 10 y

Diabetes 72% 54% 30%

Hypertension 24% 66% 41%

Hypertriglyceridemia 62% 82% 40%

Hypercholesterolemia 22% 53% 21%

Sleep apnea 94% 66%

Fatty liver disease 84%

Stress urinary incontinence

64% resolved, 92% improved

Depression 50%

Vest AR, et al. Circ 2013;127:945-959

The Swedish Obese Subjects (SOS) study

Sjostrom L, et al. JAMA 2012;307:56-65

Recovery (Remission) From HTN and DM: SOS Study (Swedish Obese Subjects Study)

13% 21%

36% 34%

11% 19%

72%

0%

20%

40%

60%

80%

100%

2 years P < 0.001

10 years P = 0.001

2 years P < 0.001

10 years P = 0.02

Diabetes Hypertension

Adapted from Sjostrom L, et al. N Engl J Med. 2004;351(26):2683-2693.

21%

Control Surgery

Re

co

ve

ry

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Incidence of HTN and DM: SOS Study (Swedish Obese Subjects Study)

24% 29%

7%

24%

49% 41%

1% 0%

10%

20%

30%

40%

50%

2 years P < 0.001

10 years P = 0.0001

2 years P = 0.06

10 years P = 0.13

Diabetes Hypertension

Adapted from Sjostrom L, et al. N Engl J Med. 2004;351(26):2683-2693.

8%

60%

Control Surgery

Inc

ide

nc

e

The Swedish Obese Subjects (SOS) study Reduction in CV Mortality

Sjostrom L, et al. JAMA 2012;307:56-65

Effect of Bariatric Surgery on Type 2 Diabetes

• Increased insulin secretion

• Reduced peripheral insulin resistance

• Increased hepatic insulin sensitivity

• Increased muscle insulin sensitivity

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Meta-analysis of Randomized Controlled Trials of Bariatric Surgery Vs. Non-surgical Treatment for

Remission of T2DM

Gloy VL et al. BMJ 2013;347:f5934

Bariatric Surgery versus Intensive Medical Therapy for Diabetes

Schauer et al. NEJM 2014;370:2002-2013

Bariatric Surgery versus Intensive Medical Therapy for Diabetes

Schauer et al. NEJM 2014;370:2002-2013

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RYGB Results in Durable Remission of T2DM in Most (but not all) Patients

Retrospective cohort study of 4,434 adults who with T2DM who underwent RYGB Complete remission rates: 37% (yr 1), 63% (yr 3), 68% (yr 5) Lower remission rates predicted by poor preoperative glycemic control (HbA1c ≥6.5%), longer duration of diabetes, and receiving insulin Relapse of diabetes rates: 8% (yr 1), 22% (yr 3), 35% (yr 5). Median time to relapse was 8.3 yrs

Aterburn DE, et al. Obes Surg 2013;23:93-102

Take Home Messages: Bariatric Surgery and T2DM

• Bariatric surgery is more effective in inducing weight loss and remission of T2DM

• Remission of T2DM occurs by two main mechanisms • Increase in hepatic insulin sensitivity due to caloric restriction

(depletion of liver fat) and improved beta-cell function associated with exaggerated postprandial GLP-1 secretion, caused by altered exposure of the distal small intestine to nutrients

• A weight loss induced improvement in peripheral skeletal muscle insulin sensitivity

• 77% of patients achieve a partial or complete remission of T2DM by year 5. Of those who experience a complete remission, 35% have a relapse after a median of 8.3 years

Madsbad S, et al. Lancet Diabetes Endocrinol 2014;2:152-164; Gloy VL, et al. BMJ 2013;347:f5934; Arterburn DE, et al. Obes Surg 2013;23:93-102

The Longitudinal Assessment of Bariatric Surgery (LABS) Study

Lap Band Lap Roux-en-Y Open Roux-en-Y

Number 1198 2975 437

Age (mean) 46 ± 12.5 43.6 ± 11 45.9 ± 10.7

BMI (median) 44.1 46.9 50.9

Death in 30 days 0 6 (0.2) 9 (2.1)

DVT 3 (0.3) 12 (0.4) 5 (1.1)

Failure to be

discharged in 30 days 0 13 (0.4) 4 (0.9)

Composite endpoint*

in 30 days 12 (1.0) 143 (4.8) 34 (7.9)

*Composite endpoint: death, DVT or venous thromboembolism,

intervention or failure to be discharged within 30 days

4776 patients in 10 United States Centers 2005-2007

Flum DR, et al. N Engl J Med. 2009;361(5):445-454. Copyright © 2009 Massachusetts Medical Society.

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Perioperative Complication Rates for Roux-en-Y Gastric Bypass

Immediate Complications (Post op d 0-<3)

Early Complications (Post op d 3-30)

Late Complications (Usually beyond Post op d 30)

Mild Nausea and vomiting consequences, up to 100%; self resolving impairment in renal function, 2%

Moderate Arrhythmia without hemodynamic instability, 2%; abdominal hemorrhage or anemia without a clear source, requiring blood transfusion, 5%

Wound infection, 3%; pneumonia, 4%; nausea and vomiting requiring inpatient admission for IV repletion, 8%

Malnutrition of vitamins or minerals, up to 50%; dumping syndrome, up to 75% but clinically significant in <5%; gallstones, 2%; anastomotic ulcer, 8%; anastomotic stricture, 7%; stomal stenosis, 5%

Severe Reoperation or abdominal hemorrhage, 2%; reoperation for any reason, 6%; MI, 0.5%; unstable arrhythmia or cardiac arrest<1%

Pulmonary embolus, respiratory failure, or other potentially fatal medical complications, 0.5%

Herniation or small bowel obstruction, 4%

General overall risk of mortality to postoperative day 30, =0.3%

Vest AR, et al. Circ 2013;127:945-957

Anastomotic Ulcer

Anastomotic ulcers occur in 3-

20% of patients after RYGB

Usual presentation is epigastric

pain, but nausea and/or vomiting

may accompany pain or be the

sole presenting symptom(s)

Diagnosed via EGD

Ulcers on jejunal side (marginal

ulcers) require careful endoscopic

examination to detect

Anastomotic Stricture

Anastomotic strictures occur in 10% of

patients after RYGB

Usual presentation is vomiting or early

satiety with or without vomiting, but

abdominal pain may also present

Diagnosed via EGD

Stoma diameter usually greater than 1cm

when created

Stricture arbitrarily defined as inability to

pass standard 9mm diagnostic

gastroscope across pouch-enteric

anastomosis without resistance

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Meal Progression after Bariatric Surgery

Diet Stage Begin Fluids/food

Stage I Post op days 1 and 2 Clear liquids

Stage II Post op day 3 (discharge) Clear + protein-rich full liquids

Stage III Post op days 1-14 Soft, moist foods

Stage III, week 2 4 – 5 weeks post op Add well-cooked, soft vegetables + peeled fruit

Stage IV As hunger increases and more food is tolerated

Healthy solid food diet

AACE/TOS/ASMBS Guidelines. Obesity, 2009

Dumping Syndrome • Cause

• Carbohydrate load or liquids w/meals causing rapid dumping from pouch into jejunum

• enteroglucagon release

• Symptoms

• 10 to 15 minutes after eating: flushing, nausea, cramping,

• May have diarrhea, warm, dizzy, weak, faint, pulse, and cold sweat

Jejunum -

Duodenum

bypassed;

absorptive

area for sugar

Dumping Syndrome

>25 grams or more per serving may cause dumping in some people

• Teach slow, mindful eating

• Recommend not drinking with meals

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Clinical Presentation of Nutritional Deficiencies

Presentation Nutrient Deficiency

Anemia Iron, folate, vitamin B12, copper,

Neurological abnormality Thiamine, vitamin B12, copper, vitamin E, vitamin B6

Metabolic bone disease Vitamin D, calcium

Protein-calorie malnutrition Protein, calories

Risk of Selected Nutritional Deficiencies Resulting from Bariatric Surgery

Nutrient LAGB LGS RYGB BPD/DS

Macronutrients √√√

Thiaminea √ √ √ √

Ironb √√ √√ √

Vitamin B12 √√√ √√√ √

Vitamin D √√ √√√ √√√

Vitamin A √ √√

LAGB = Laparoscopic adjustable gastric banding; LGS = laparoscopic gastric sleeve RYGB = Roux-en-Y gastric bypass; BPD/DS = biliopancreatic bypass/duodenal switch awith persistent vomiting; bincreased with menstruation

Bariatric Surgery and Micronutrient Deficiencies

• Micronutrient deficiencies are predictable based on the surgically altered anatomy and the patient’s medical history.

• Micronutrient deficiencies are preventable by routine monitoring and prophylactic supplementation.

• All patients who undergo a malabsorptive bariatric weight loss surgery need to take vitamin and mineral supplements for their entire life.

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• Routine • CBC

• Chemistry profile

• Liver function tests

• Lipid panel

• HbA1c

• Micronutrients • Iron, TIBC, Saturation

• Ferritin

• Folate

• Vitamin B12

• 25 (OH) vitamin D

• iPTH

• DEXA scan

• *Cu, Zn, vitamin A

Nutritional Monitoring for the Bariatric Surgical Patient

*if suspect deficiency

Mechanick JI, et al. Clinical Guidelines for Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient – 2013 Update. Obesity 2013;21(S1):S1-S27

Routine Vitamin & Mineral Supplementation for RYGB Patients

a Depending on dietary calcium intake b For most menstruating women

Supplement Dosage

Multivitamin-mineral or prenatal

Calcium citrate with vitamin Da

Elemental ironb

Vitamin B12

1-2 daily

1,200-2,000 mg/day + 3000 U/day

40-65 mg/day

≥500 µg/day orally

or 1,000 µg/mo intramuscularly

Or 3,000 µg every 6 mo intramuscularly

or 500 µg every week intranasally

Mechanick JI, et al. Clinical Guidelines for Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Baiatric Surgery Patient – 2013 Update. Obesity 2013;21(S1):S1-S27

Take home Messages

• The prevalence of severe class III obesity (BMI ≥ 40) is increasing and is costly

• Bariatric surgery is indicated for a BMI ≥ 35 with co-morbidities or BMI ≥ 40, along with other weight and history criteria

• The 3 most commonly performed procedures are: LAGB, RYGB and SG

• The mechanism of action of bariatric surgery procedures are thought to be primarily metabolic

• Remission or improvement rates are seen for diabetes, hypertension, dyslipidemia, OSA and depression; and reduced mortality

• Most common long-term complications are nutritional – iron, calcium, vitamin B12, vitamin D