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Metabolic and WeightManagement ProceduresJeffrey Rosen, MD, FACS
Obesity is aMetabolic DiseaseLiverdiseaseAsthmaHeart diseaseGallbladderdiseaseObesityincreases thechances ofdeveloping oneor more ofthese diseases.Sleep apneaType 2diabetesHigh oarthritisGout
Types of Procedures Restrictive– Food intake is limited by decreasing the effective stomachsize or decreasing the amount of food going entering thesmall bowel Malabsorptive– A procedure that creates a physiological condition ofdecrease absorption of nutrients Mixed– Combination of the above Metabolic– Treats metabolic diseases ( Insulin resistance, DM,Dyslipidemia)
Who can POTENTIALLY QUALIFY forMetabolic Weight Loss Surgery AgePrevious Weight HistoryHistory and PhysicalPsychological AssessmentGoal/AchievementsTeam Evaluation and ApprovalPatient Approval
Post-Operative Immediate RisksGeneral Procedures Bleeding Infection/MSOD/MSOF DVT/PE MI ARI SBO DeathStapling Procedures Leaks Edema
Nutritional Deficiencies Albumin B12 –Cyanocobalamine– Anemia– Neurological late with earlyemesis B9 –Folate– Anemia, Apathy, Fatigue, HA,diarrhea B1 – Thiamine– Neuro, ataxia, lethargy A,D,E,K- fat soluble– Vit A night blindness Calcium Iron and anemia
Long Term Post-Operative RisksGeneral MalnutritionVitamin DeficienciesAnemiaUlcersBand ComplicationsSBOStricturesFailure to lose WeightWeight Regain– Mechanic– Psychological Hernias Hair LossStapled Fistula Internal Hernias Stomal Stenosis Marginal Ulcers Dumping Syndrome Cholelithiasis
RESTRICTIVE PROCEDURES
Surgical Treatment ForMorbid Obesity Lap-BAND One weight losscomponent:–Reduces thesize of thestomach*Picture provided byAllReferHealth.com
Gastric Banding Slippage
Gastric Banding Slippage
BAND EROSION
Band late complications Tube issues: Breakage, Disconnection Port site infection, Port rotation, Port skinerosion Tube kinking SBO due to tubing Prolapse or pouch dilation
Surgical TreatmentMorbid ObesitySLEEVE GASTRECTOMY Procedure that removes2/3’s of the stomach Two weight losscomponents:– Restrictive – reduces sizeof the stomach– Hormonal changes
Sleeve Complitations NauseaGERDHiatal herniaStrictureLeak
Sleeve Leak
Stent Placement after leak
Evolution of Minimally Invasive SurgeryEndoscopicOpenLaparoscopic
Endoluminal & Transgastric Benefitsfor Obesity Treatment Fewer complications and side effects Less invasive treatments delivered in anoutpatient setting Lower cost procedures Improved access to treatment Procedures to prevent progression tomorbid obesity
Endoscopic Sleeve Gastroplasty
Endoluminal Suturing Gastroplasty 64 patients were treated withEndoCinch at single center Pre-procedure BMI 28-44 No intra-operativecomplications Outpatient procedureFogel et al. Gastrointestinal Endoscopy 61: AB106Bariatric and Metabolic Institute l l 24
Endoluminal StaplingGastroplasty 21 patients were treated with TOGa system at2 centers BMI 35-53 Complications 1 Temporo-mandibular dysfunction Discharge at 48 hours Median Weight Loss– 1 month : 16%– 3 months : 21%Deviere J. et al. Presented at (UEGW), 2006
Treatment ContinuumDIET & EXERCISEPHARMACEUTICALDiets can be successful in the shortterm, but have a failure rate ofapprox 87-95% at 10 yearsGrowing number ofpharmaceuticaloptions with modestweight loss approx10%1. American Gastroenterological Association medical position statementon obesity. Gastroenterology. 2002;123:879-881.SURGERYMost effectiveapproach for long-termweight loss1Perceived to be “tooinvasive” for manypatients
ORBERA Intragastric balloon fills the gapDIET & EXERCISEPHARMACEUTICALSURGERYORBERA is a medical incision-less, non-surgical option that can beused in treatment of fertility, joint pain and high risk cardiacpatients in need of weight loss.
Placement of ORBERA Simple non surgical procedure under mild sedativeProcedure takes 20–30 minutes—home same dayHelp you eat smaller meals and proper portion controlTwo-part program, starting with balloon placed temporarily in stomach for sixmonths and continuing with diet and exercise support.Learn long term eating habits that help sustain weight loss
Removal After six monthsNon-surgical procedure under mild sedative
ORBERA INTRAGASTRIC BALLOON—INDICATION Indicated for use as an adjunct to weight reduction for patients obesityand a body mass index (BMI) of 30 or 40 kg/m2 To be used in conjunction with a long-term supervised diet andbehavior modification program designed to increase the possibility ofsignificant weight loss and the maintenance of that weight loss Intended for adults who have attempted more conservative weightreduction alternatives, such as supervised diet, exercise, andbehavior modification programs Note: Indication does not require an obesity related co-morbidityand the presence of co-morbidities is not a contraindication.
Apollo Oberra Intragastric Balloon Essentially non surgical weight loss Temporary placement of intragastric balloon withapprox 500cc of saline Placed for a period of 6 months Patient works intensely with diet and exerciseprogram for 12 months Followed long term Currently not approved by insurance is done as aself pay procedure.
US Pivotal Study 255 total US patients (125 treatment/130 control) Balloon group achieved a mean 38.4% excessweight loss statistically significant to control at 6months and 1 year. The Orbera Balloon group lost 3.1X as much weightas the control group over the course of the studyand was able to maintain significant weight lossthrough month 12
TERIS
AspireAssist
Attiva
Surgical TreatmentMorbid ObesityGASTRIC BYPASSThree weight losscomponents: Reduces the sizeof the stomach Reduces calorieabsorption Hormonalchanges*Picture provided byAllReferHealth.com
Roux-en-Y Gastric Bypass Advantages– Excellent excess weight loss (60-75%)– Very good long-term results– Solid food well tolerated Disadvantages– Perioperative complications– Potential nutrient deficiencies
Anastomotic Leak
Anastomotic Stricture
Marginal Ulcer
Internal Hernia
Internal Hernia
Procedures
Sleeve with ileal interposition
EfficacyTreatments for myRisk
Exclusion of the proximal small bowel from the flow ofnutrients is the primary mediator of diabetes resolutionafter DJBAnnals of Surgery Nov 2006Bariatric and Metabolic Institute l l 53
Controls: Fenestrated Duodenal Sleeve
EndoluminalRestriction/Conduit/AbsorptionFood limitationDecreases absorptionBariatric and Metabolic Institute l l 56
Apollo Overstitch Endoscopic reduction of stomach pouch Endoscopic reduction of gastrojejunal anastomosis Non surgical revision of previous roux en Y gastricbypass patient Outpatient procedure
Gastrojejunostomy Reduction
Electro-stimulation
Vagal Stimulator
Transgastric ProceduresTransendoluminal Gastric BypassBariatric and Metabolic Institute l l 62
Recent Transgastric ToolsBariatric and Metabolic Institute l l 63
NOTES ApplicationsTransgastric GastrojejunostomyKantsevoy SV et al, Gastrointestinal Endoscopy, 2005
Comparative 5.4%3.9%3.5%0.3%BARIATRICSURGERY0.28%*Adopted from Dimiek et al. JAMA 2004;292:847-851.
Obesity Treatment PyramidSurgeryBMIPharmacotherapyLifestyle ModificationDietPhysical ActivityBariatric and Metabolic Institute l l 66
Resolution orimprovement ofcomorbidities Only surgery hasresulted inweightmaintenance forthe long-term forsevere obesityThe Current State of Bariatric Surgery l Feb 18, 2010
Algorithm for management of obesity
Summary:Endoscopic Bariatric Surgery Concepts mimic conventional bariatric surgery Nerve stimulation/ablation new strategy Instrumentation - limited Minimal outcome data available Promising field of development
The LifeWeigh Bariatrics Team PatientTherapistExercise InstructionRegistered DietitiansNurse Practitioner andSurgeonsSome parts of the team may be offsite and you will be referred to them
References tp://jama.jamanetwork.com/article.aspx?articleid le/S00165107(13)01865-8/abstract Endoscopic sleevegastroplasty MayoGut 2014 Apr;63(4);687-695 http://laparoscopy.blogs.com/prevention management youtube.com/watch?v Ho43hPwecnEAspireassistObesity and bariatrics for the endoscopist: ion/51760537 Obesity and bariatrics for the endoscopist New tric-bypasspill-passes-human-trial/ MAGIC PILL Attiva
Metabolic Weight Loss Surgery Age Previous Weight History History and Physical Psychological Assessment Goal/Achievements Team Evaluation and Approval . EndoCinch at single center Pre-procedure BMI 28-44 No intra-operative complications Outpatient procedure Fogel et al. Gastrointestinal Endoscopy 61: AB106.
