Bariatric Surgery
in Obesity and
Metabolic Disease
Olivier Court MD FRCSC
Director, section of Bariatric Surgery
McGill University Health Center
Disclosure of Conflict of
Interest
• no affiliation with the manufacturer of any
commercial product or provider of any commercial
service discussed in this CME activity.
Outline
• Prevalence of Obesity
• Consequences of Obesity
• Treatments for obesity
o Non-operative
o Surgical options
• Benefits of Bariatric Surgery
• Mechanisms for metabolic benefits
Weight classification
according to BMI
Prevalence of obesity
Prevalence of obesity
Prevalence of obesity
Co-mobidities of obesity
JAMA. 2004 Oct 13;292(14):1724-37
Cost of obesity in Canada
1997
2006
• The total direct cost of
obesity in Canada was
$1.8 billion
• The total direct costs of
obesity in Canada was
$4.0 billion
• 2.4% of the total health
care expenditures
• 4.1% of the total health
care expenditures
CMAJ 1999 Feb 23;160(4):483-8
Obes Rev. 2010 Jan;11(1):31-40
Obesity and mortality
Lancet. 2009 Mar 28;373(9669):1083-96.
Treatments for obesity
Obesity: non-operative
management
• Diets
• Few patients ever achieve more than 10% weight loss
• Over 95% regain all weight lost by 5 years
• Pharmacotherapy
o Orlistat (Xenical)
• Inhibits intestinal lipase
• Not absorbed – Safe
• Expected weight loss: 10%
o Sibutramine (Meridia)
• Monoamine reuptake inhibitor – acts centrally to diminish appetite
• Average weight loss at 1 year: 10 lbs
• Can induce significant hypertension
• Taken off market in Canada, still available in US
Obesity: Surgical
management
NIH Concensus recommendations
• Patients whose BMI exceeds 40
• Patients with a BMI between 35 and 40 if they also
have some severe comorbidities related to obesity:
o NIDDM
o Obstructive Sleep Apnea
o Severe Osteoarthritis
Surgical options
• Restrictive procedures
• Laparoscopic Adjustable Gastric Band
• Laparoscopic Sleeve Gastrectomy
• Malabsorptive procedures
• Laparoscopic Roux-en-Y Gastric Bypass
• Laparoscopic Biliopancreatic Diversion with
Duodenal Switch
Laparoscopic Adjustable
Gastric Band
• Creation of 30-60cc
pouch
• Adjustable pouch
outlet
• Easy insertion
• Results
o 2 years – 30-40% EBW
o 5 years – 50% EBW
Laparoscopic Adjustable
Gastric Band
• Disadvantages
o
o
o
o
Expensive
Band slipping/erosion
Band/port malfunction
Unknown durability
Laparoscopic Sleeve
Gastrectomy
• Resection of about 75%
of stomach
• Few complications
• Results
o No long term data
o 1 year - 50% EBW
o 3 years - 60% EBW
Laparoscopic Roux-en-Y
Gastric Bypass
• Creation of 30-60cc
pouch
• Roux limb 100 cm
• Bypass stomach,
duodenum and
proximal jejunum
• Results
o 1 year – 65-70% EBW
o 5 years – 60-70% EBW
o 10 years – 60% EBW
Laparoscopic Roux-en-Y
Gastric Bypass
• Complications
o
o
o
o
o
o
Mortality about 0.1%
Anastomotic leak 2-3%
Dumping syndrome
Iron/Calcium/vit B12 deficiency
Drinking
Marginal ulceration
Laparoscopic Biliopancreatic
Diversion with Duodenal Switch
• Sleeve gastrectomy
• Duodeno-jejunal
anastomosis
• Roux limb 150cm
• Common channel
100cm
• Results
o 1year – 70% EBW
o 5 years – 75-80% EBW
o 10 years – 80% EBW
Laparoscopic Biliopancreatic
Diversion with Duodenal Switch
• Complications
o
o
o
o
o
Mortality about 0.5%
Anastomotic leak 2-3%
Steatorrhea
Ca, Iron, vit A,D,E,K deficiency
Protein malnutrition 2-3%
Benefits of Bariatric Surgery
Resolution of Comorbidities
(136 studies, 22,904 patients)
JAMA. 2004 Oct 13;292(14):1724-37
Metabolic benefits beyond
weight loss
Metabolic benefits beyond
weight loss
• 150 patients with BMI 27 – 43 followed for 12 months
• 3 groups:
o Intensive medical therapy (n=50): lifestyle counseling, weight mgt, home
glucose monitoring, medications including incretin analogues to reach
HbA1c < 6%
o Gastric bypass (n=50)
o Sleeve gastrectomy (n=50)
• Primary endpoint: % of pts with HbA1c<6%
• Secondary endpoints: Fasting glucose, fasting
insulin, lipids, CRP, HOMA-IR, weight loss
Metabolic benefits beyond
weight loss
Metabolic benefits beyond
weight loss
Diabetes
Diabetes
Metabolic benefits beyond
weight loss
Metabolic benefits beyond
weight loss
• 72 patients with BMI>35 with followed for 2 years
• 3 groups:
o Medical therapy (n=24)
o Gastric bypass (n=24)
o Biliopancreatic diversion (n=24)
• Primary endpoint: rate of DM remission (fasting
glucose<5.6 and HbA1c<6.5% without medication)
• Secondary endpoints: Average HbA1c, body
weight, triglycerides, total and HDL cholesterol
Metabolic benefits beyond
weight loss
Resolution of
comorbidities
Bariatric Surgery: Impact
on Mortality
Study Center
Surgery Type
Reduction in Risk of
Death
McGill University
(Canada)
Gastric Bypass
89%
University of Padoa
(Italy)
Adjustable Gastric Band
60%
Monash University
(Australia)
Adjustable Gastric Band
72%
Gothenberg University
(Sweden)
Gastric Bypass, Gastroplasty
Adjustable Gastric Band
24%
University of Utah
(USA)
Gastric Bypass
40%
Average
57%
Cost effectiveness of
Bariatric Surgery
Conclusion
• Impact of obesity on health care is growing
• Bariatric Surgery results in weight loss, but also in
resolution of comorbidities and improvement in
mortality
• Mechanisms are still unclear
• Bariatric vs Metabolic Surgery
Mechanisms for metabolic
benefits of Bariatric Surgery
Role of Gut hormones
Mechanisms of action
RNYGB
AGB
VSG
Mechanisms of action
RNYGB
AGB
VSG
Mechanisms of action
• Hind Gut vs Fore Gut theories for RNYGB
• However, VSG and RNYGB are similar in their
metabolic and hormonal effects
• Both differ from AGB
• Alternate explanation is required