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Restrictive Procedures in BMI > 50
 

Restrictive Procedures in BMI > 50

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  • Brolin, et al. The dilemma of outcome assessment after operations for morbid obesity. Surgery 1989; 105: 337 (Long-limb study- Kral)

Restrictive Procedures in BMI > 50 Restrictive Procedures in BMI > 50 Presentation Transcript

  • Restrictive Procedures in BMI > 50 Craig B. Morgenthal, MD George S. Ferzli, MD SUNY Health Science Center at Brooklyn
  • Definitions
    • Overweight: BMI > 25 kg/m 2
    • Obesity: BMI > 30 kg/m 2
    • Severe obesity: BMI >35 kg/m 2
    • Morbid obesity: BMI > 40 kg/m 2 or BMI > 35 kg/m 2 with concomitant obesity related morbidity
    • Superobesity: BMI > 50 kg/m 2 , >225% IBW
  • Options in Bariatric Surgery
    • Restrictive procedures
    • Vertical-banded gastroplasty
    • Laparoscopic gastric band placement
    • Combined restrictive/malabsorptive
    • Roux-en-Y bypass
    • Malabsorptive procedures
    • Biliopancreatic bypass +/- duodenal switch
    • Jejunoileal bypass
  • Trends in Bariatric Surgery
    • The U.S. rate of bariatric surgery increased from 2.7 to 6.3 per 100,000 adults from 1990 to 1997
    • VBG was formerly the most commonly performed bariatric procedure in the U.S in the 1980s, only 14% of bariatric procedures in 1997
    • Lap band is now the most commonly performed bariatric operation outside the U.S., especially in Europe and Australia
    • RYGB-the percent of bariatric procedures done by gastric bypass increased from 52% to 84% between 1990 to 1997, making it the most popular procedure in the U.S.
    • Pope G, et al. J Gastroint Surg 2002;6:855.
    • Comparative overview of weight loss in 54
    • studies, performed in 14,964 patients
    • according to bariatric operation performed.
    • Operation Total %EWL %BMI
    • (# studies) patients (n) loss
    • Gastric banding (16) 4429 48.6 22.2
    • BPD (9) 3903 68.8 35.5
    • VBG (15) 3382 58.3 29.0
    • Roux-en-Y GB (11) 2949 68.6 34.7
    • Long-limb RYGB (3) 301 71.6 33.9
    • Buchwald H. Obesity Surg 2002; 12: 733
    • Selected Laparoscopic VBG Series
    • Source N BMI FU (mo.) Weight
    • loss
    • Goergen et al 1999 203 43.0 Not stated Not stated
    • Naslund et al 1999 60 44.4 23 (mean) BMI ↓ 10.9
    • Salval et al 1999 87 43.4 6-18 (range) 76%EWL
    • Toppino et al 1999 170 43.9 1-36 (range) 61% EWL
    • Morino et al 2002 250 45.0 48 62% EWL
    • Selected Lap Adjustable
    • Silastic Banding Series
    • Source N BMI FU (mo.) Weight
    • loss
    • Fielding et al 1999 335 47 18 62% EWL
    • Zimmerman et al 1998 894 42 12 40% EWL
    • Dargent 1999 500 43 28 65% EWL
    • Blanco et al 2001 407 49 24 58 kg loss
    • Angrisani 2001 1265 44 48 BMI 32
    • Szold, Abu-Abeid 2001 715 43 17 BMI 32
    • Nehoda et al 2001 320 47 24 71% EWL
    • Chevallier et al 2002 400 44 24 53% EWL
    • Belachew et al 2002 763 42 48 BMI 30
    • Favretti et al 2002 830 46 72 BMI 29
    • O’Brien et al 2002 655 45 72 57% EWL
  • Is superobesity a distinct entity?
    • Term superobesity first used when it became apparent
    • that morbid obesity operations were less effective in
    • bringing the extremely obese to normal weight.
    • Incidence of coexisting medical problems and overall
    • health risk greater in superobese
    • Heaviest patients must lose more weight to achieve a
    • level that represents a valid reduction in their
    • actuarial risk
    • Mason E, Doherty C, et al. Gastro Clin NA 1987; 16: 495.
    • Brolin, et al. Surgery 1989; 105: 337
    • Buchwald H. A bariatric surgery algorithm.
    • Obesity Surg 2002; 12: 733.
    • OC = 1.0 + BMI # ± 0.5(age) ± 0.5 (GRH) ± 1(CoM)
    • OC = Operative category decided based on score
    • GB = 0-3, VBG= 2-5, RYGBP=3-6, BPD/DS=4-7,
    • Long-limb RYGBP= 6-9
    • Overlap of numbers allows for surgeon and patient preference
    • Age = <40yrs add 0.5, >40yrs subtract 0.5
    • GRH = body habitus; favorable +0.5, unfavorable -0.5
    • CoM = CoMorbidities; high + 1, low – 1
    • BMI# = 1 to 6 points given depending on BMI
    • BMI strongly influences decision:
    • • 35 – 40 (LASGB)
    • • 40 – 50 (BPD or RYGBP )
    • • > 50 (long-limb RYGBP)
    • Selected Malabsorptive
    • Series for Superobesity
    • Source N BMI Procedure EWL
    • Hess & Hess 1998 987 51 BPD-DS >50% in 99%
    • Marceau et al 1998 181 >50 BPD-DS >60% in 97%
    • Kalfarentzos 132 57 BPD-RYGB >50% in 81% 1yr
    • et al 2004 >50% in 40% 5yr
    • DeMaria 2004 27 >60 RYGB 58% EWL
    • Capella J, Capella R. The weight reduction operation of
    • choice: VBG or gastric bypass? Amer J Surg 1996; 171: 74.
    • 329 patients had open VBG and 560 had open VBG combined with Roux-en-Y GB (VBG-RGB), mean preop BMI 52 in both groups
    • Complications- early 1VBG (0.3%), 6 VBG-RGB (1%); late 29 VBG (9%), 73 VBG-RGB (12%)
    • Conclusions:
    • VBG-RGB superior to VBG as weight loss operation BMI 52 to 34 at 5 years vs. 52 to 40.
    • For superobese, % EWL at 5 years in VBG-RGB was 60% vs. 45% in VBG.
    • Biertho L, Gagner M, et al. Lap gastric bypass vs.
    • LAGB: a comparative study. JACS 2003; 197: 536.
    • Series of 805 lap Swedish adjustable gastric bands at the OBEX Institute (Zurich and Bern, Switzerland) compared with 456 lap gastric bypass at Mt. Sinai Hospital, NY
  • Biertho L, Gagner M, et al. Lap gastric bypass vs. LAGB: a comparative study. JACS 2003; 197:536
  • Biertho L, Gagner M, et al. Lap gastric bypass vs. LAGB: a comparative study. JACS 2003; 197:536
    • Biertho L, Gagner M, et al. Lap gastric bypass vs.
    • LAGB: a comparative study. JACS 2003; 197: 536
    • Conclusions:
    • LGB gives higher EWL at 18 months for all ranges of
    • preoperative BMI. LGB associated with greater
    • intraoperative complication rates (2% vs. 1.3%), early major
    • complication rates (4.2% vs. 1.7%), and postoperative death
    • rates (0.44% vs. 0%).
    • Best indication for the two procedures still unclear.
    • LGB could be preferred for heavier patients and those with
    • associated morbidities.
    • Dolan K, Fielding G, et al. Comparison of LAGB
    • and biliopancreatic diversion in superobesity.
    • Obesity Surg 2004; 13: 165.
    • 134 morbidly obese patients had bilio-pancreatic diversion over 7 year period, 23 were superobese
    • 1319 patients had LAGB, 23 sex- matched and BMI-matched controls compared to BPD
    • BPD done on patients if LAGB failure, prior gastric surgery, or at patient request
    • -1 st 11 BPD done via laparotomy, last 12 lap BPD (all completed)
  • Dolan K, Fielding G, et al. Comparison of LAGB and biliopancreatic diversion in superobesity. Obesity Surg 2004; 13: 165.
    • BPD LAGB
    • # patients 23 23
    • Females 16 16
    • Age 41 39
    • Complications 13 2
    • Reoperations 7 2
    • Hospital stay 8 1
    • Follow up (mo) 57 56
    • BPD LAGB
    • Preop BMI 56.9 55.9
    • BMI 6 mo 42.7 46.8
    • BMI 12 mo 39.1 43.6
    • BMI 24 mo 34.6 38.9
    • %EWL 6 mo 39.8 29.5
    • %EWL12 mo 57.5 37.0
    • %EWL24 mo 64.4 48.4
    • Resolved HTN 4/6 4/6
    • Resolved DM 2/2 2/3
  • Dolan K, Fielding G, et al. Comparison of LAGB and biliopancreatic diversion in superobesity. Obesity Surg 2004; 13: 165.
    • lapBPD LAGB
    • # patients 12 12
    • Females 9 9
    • Age 35 35
    • Complications 4 1
    • Reoperations 2 1
    • Hospital stay 8 1
    • Follow up (mo) 58 58
    • lapBPD LAGB
    • Preop BMI 58.4 57.5
    • BMI 6 mo 42.7 48.3
    • BMI 12 mo 38.6 45.1
    • BMI 24 mo 34.0 39.2
    • %EWL 6 mo 39.8 27.6
    • %EWL12 mo 59.1 37.0
    • %EWL24 mo 68.1 46.7
    • Resolved HTN 1/2 2/3
    • Resolved DM 1/2 1/1
    • Dolan K, Fielding G, et al. Comparison of LAGB and
    • biliopancreatic diversion in superobesity. Obesity Surg
    • 2004; 13: 165.
    • Complications:
    • LAGB 1 band slippage, 1 port-site leak
    • open/lap BPD 9/4: wound infection 3/2, wound
    • dehiscence 3/0, anastomotic leak 1/1, postop bleed 0/1,
    • incisional hernia 2/0
    • Conclusions:
    • No obvious difference in resolution of obesity related co-morbidities, but small population size
    • Extra weight loss with BPD, but longer hospital stay and more complications
  • Results of Vertical Banded Gastroplasty
    • Mason E, Doherty C, et al. Super obesity and
    • gastric reduction procedures. Gastroent Clin NA
    • 1987; 16: 495.
    • Retrospective study of 1000 patients undergoing open VBG between 11/80 and 5/87
    • 711 morbidly obese, 289 super obese (29%)
    • M:F ratio: MO 1: 5.3, SO 1: 2.2
    • Operation length: MO 103 min, SO 117 min
    • Mason E, Doherty C, et al. Gastroent Clin NA 1987;
    • 16: 495.
    • Marlex Collar Size
    • 5.5 5.0 4.5
    • Super 2 yrs Pts (n) 48 79 17
    • EWL (%) 41 54 58
    • Super 5 yrs Pts (n) 17 22
    • EWL (%) 38 49 ִ
    • Morbid 2 yrs Pts (n) 90 220 69
    • EWL (%) 52 62 60
    • Morbid 5 yrs Pts (n) 18 58
    • EWL (%) 45 61
    • Mason E, Doherty C, et al. Gastroent Clin NA 1987;
    • 16: 495.
    • Conclusions:
    • Marlex collar size 5 cm is optimum
    • Greater percentage of superobese are men, as opposed to morbidly obese (women may be motivated earlier by appearance, while men wait until can not function)
    • Restrictive procedures in superobese produce more absolute weight loss than morbidly obese, but does not return patients to “normal” weight (50% EWL in superobese with VBG in this study)
    • To achieve close to ideal body weight in super obese, something additional needs to be done
    • MacLean L, et al. Late results of vertical banded
    • gastroplasty for morbid and super obesity. Surgery
    • 1990; 107: 20.
    • 201 pts underwent VBG at McGill U. and were followed from 2 to 5 years
    • reoperation offered if weight loss stabilized without good result; 201 pts, 283 operations
    • 48% pts had staple line disruption during 5 years
    • 54/80 pts with staple line disruption had reoperation
    • 21 pts reoperation for gastroplasty outlet stenosis
    • Final results in all patients: at 2 yrs 65% EWL, at 5 yrs 60% EWL
    • subgroup analysis of 59 super obese patients
  • MacLean L, et al. Late results of vertical banded gastroplasty for morbid and super obesity. Surgery 1990; 107: 20
    • Subgroup analysis
    • of morbid obese
    • vs. super obese.
    • Conclusion:
    • Large weight
    • losses occurred in
    • super obese but
    • remained
    • significantly obese.
    • Bloomston M, Rosemurgy A, et al. Outcome following
    • bariatric surgery in super vs. morbidly obese patients.
    • Obesity Surg 1997; 7: 414.
    • Between 11/84-3/94 157 nonrandomized pts had gastric bypass or VBG at Univ. of South Florida
    • 78 pts super obese, BMI 60.9 vs. 79 MO, BMI 43.6
    • #VBG/#RYGB: SO 69/9, MO 64/15
    • Complications not significantly different b/w groups
    • BMI and % EWL values displayed graphically only
  • Bloomston M, Rosemurgy A, et al. Outcome following bariatric surgery in super vs. morbidly obese patients. Obesity Surg 1997; 7: 414.
    • Bloomston M, Rosemurgy A, et al. Outcome following
    • Bariatric surgery in super vs. morbidly obese patients. Obesity
    • Surg 1997; 7: 414.
    • Conclusions:
    • males responsible for greater percentage of super obese than MO
    • MO lost excess body weight at faster rate
    • MO weight loss plateaus at 1yr, SO continue to lose weight until 3 years postop
    • both groups regain weight after reaching plateaus
    • at 6 yrs MO 48% EWL, SO 39% EWL
    • SO lose > weight, but not to lower BMI or greater %EWL
    • Mason E, et al. Vertical Gastroplasty: Evolution of Vertical
    • Banded Gastroplasty. World J Surg 1998; 22: 919.
    • 30 years of experience in gastroplasty at U of Iowa
    • multiple refinements in technique over that time with 10 year results available using current VBG technique
    • 42 morbidly obese had 5.0 cm collar (VBG5) placed
    • 26 superobese patients had 4.5 cm collar (VBG4.5)
  • Mason E, et al. Vertical Gastroplasty: Evolution of Vertical Banded Gastroplasty. World J Surg 1998; 22: 919.
    • VBG 5 = MO
    • VBG 4.5= SO
    • Conclusion:
    • VBG is an
    • effective
    • operation
    • that provides
    • weight control
    • extending at
    • least 10 years.
  • Results of Laparoscopic Adjustable Gastric Band
    • Silva AS, et al. Treatment of morbid obesity with adjustable
    • gastric band: preliminary report. Obesity Surgery 1999; 9: 194.
    • 18 patients had lap Swedish adjustable gastric band between 11/95 – 4/98 at Hospital Geral Santo Antonio, Portugal
    • 17 women, 1 man, mean age 35, preop BMI 50.4
    • Mean OR time 160 min
    • 2 conversions- 1 gastric perforation, 1 exposure
    • Mean hospital stay 5 days
    • Complications- early: 1 pneumonia late: 1 intragastric band migration, 1 pouch dilation
    • Silva AS, et al. Treatment of morbid obesity with adjustable
    • gastric band: preliminary report . Obesity Surgery 1999; 9: 194.
    • Weight loss (BMI)
    • Preop 6 mo 12 mo 18 mo
    • 50.4 39 32 30.4
    • Comorbidity resolution (# off medications/# preop):
    • Hypertension 2/3 (66%), Arthropathy 3/4 (75%)
    • Sleep apnea 3/3 (100%), Dyslipidemia 2/3 (66%)
    • Taskin M, et al. Laparoscopy in Turkish bariatric surgery:
    • initial experience. Obesity Surgery 2000; 10: 263.
    • 50 patients had Swedish adjustable gastric band placed from 4/98-4/99 at Istanbul Univ, Turkey
    • Mean preop age 35, mean preop BMI 50.4
    • 2 Conversions: 1 bleeding, 1 respiratory difficulty
    • Postop stay average 4 days
    • Weight loss:
    • BMI 50.4 to 29.0 at 12 months, EWL 48%
    • Favretti F, et al. Laparoscopic banding: selection and technique in 830 patients. Obesity Surg 2002; 12: 385.
    • LAGB placed in 830 patients between 9/93- 11/00 at 2 institutions in Belgium and Italy
    • 565 patients morbidly obese with mean BMI 42.7, 235 patients superobese, mean BMI 55.7
    • Years 0 1 2 3 4 5 6 7
    • BMI (series) 46 37 36 37 37 36 40 29
    • BMI (MO) 43 35 34 34 35 35 38 30
    • BMI (SO) 56 44 43 43 43 42 56 –
    • Chevallier JM, et al. Adjustable gastric banding in a public university hospital. Obesity Surg 2002; 12: 93.
    • 400 patients underwent LAGB from 4/97 to 1/01 at Hopital Europeen, Paris, France
    • 352 women, 48 men, mean age 40, mean BMI 43.8
    • 55 superobese patients
    • Weight loss:
    • ALL PATIENTS SUPEROBESE
    • Mo postop n BMI %EWL Mo postop n BMI %EWL
    • 0 400 43.8 0 0 55 none stated 0
    • 6 257 36.2 31.8 6 34 45.8 38
    • 12 168 34.3 42.1 12 23 42.3 54
    • 24 33 32.7 52.7 24 6 37.2 73
    • Fielding G. Laparoscopic adjustable gastric banding for
    • massive superobesity (BMI> 60). Surg Endosc 2003; 17: 1541.
    • Lap adjustable bands placed in 76 pts with BMI >60, median BMI 69, 5 patients BMI > 100
    • Done between 2/96 to 1/02 in Brisbane, Australia
    • 49 females, 27 males; median age 39 years
    • Average hospital stay 3 days; no mortality
    • Complications: no PE, 5 wound infections, 6 bands removed for dysphagia (5/6 of these were in pts with previous open VBG; all 6 removed after 2yrs)
    • Fielding G. Surg Endosc 2003; 17: 1541.
    • Weight loss
    • Time (mos) No. pts BMI (kg/m 2 ) % EWL
    • 0 76 69 -
    • 12 58 49 47
    • 24 49 39 57
    • 36 33 37 59
    • 48 17 37 60
    • 60 13 35 61
    • Conclusions : this series demonstrated excellent weight loss
    • that matches more complex surgeries, with low morbidity
    • and no mortality, supporting lap band in superobese
  • Conclusion
    • Best to design each operation individually based on BMI, associated morbidities, eating habits, and esophageal motility
    • Successful loss of body weight may be best with malabsorptive procedures, but these have higher operative risks and complications
  • Conclusion
    • Restrictive procedures are not as reliable for weight loss but have lower associated risks
    • Superobesity may be a relative contra-indication to undergoing restrictive procedures and risk-benefit ratio may be shifted toward gastric bypass or malabsorptive operations