Download Health Improvement Following Bariatric Surgery

Bariatric/Metabolic Surgery and
Type 2 Diabetes
September 2015
Deron Ludwig MD/Erik Simchuk MD
North Valley Surgical Associates
Chico, CA.
Disclosures
• None
Scope of the Problem
• 50% of Americans Diabetic (12-14%) or PreDiabetic (38%)
• Most T2, Most common cause Obesity
JAMA Sept 2015
Obesity Epidemic
Obesity Epidemic
What We Eat
How Much We Eat
How Much We Eat
Hidden Danger in Our Food
Hidden Danger in our Food
WLS Procedure Type
WLS Procedure Type
Health Outcome: WLS
Long-Term effects Of RYGB
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Ave f/u 6.9 years
EWL 60%
Insulin use 40% to 6%
HTN 73% to 54%
DL 71% to 54%
Obesity Surg. 2014
LRYGB 10 YEARS
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EWL 57%
T2DM 83%
HTN 87%
DL 67%
OSA 76%
Soard June 2009
LSG 5 year Results
• 30 Patients
• EWL Year 1: 65%
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Year 3: 62%
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Year 5: 56%
• No Deaths or Major Morbidity
Am J Surg 2014
Long-Term outcome after LSG
• 161 PT
– EWL at 5 years: 63%
– DL 81%
– T2DM 85%
– New GERD 27%
Soard Apr 2014
LRYGB vs LSG prospective 5 yr results
• EWL LRYGB: 69%
• EWL LSG: 67%
• WL failures no different/Comparable
effectiveness
Obesity Surg July 2014
LRYGB vs LSG
• Retrospective: 200 Pt. each
• EWL same at 12 and 18 months
• Similar resolution comorbidities except slightly
higher DM resolution of LRYGB
Soard July 2011
LRYGB and LSG
• Both very effective and comparable for both
weight-loss and improvement in health in
short and long-term
DIABESITY
• A direct relationship exist between the obesity
epidemic and an emerging epidemic of diabetes in
America.
• In the past two decades the rate of obesity has
doubled in America.
• In the past two decades the rate of diabetes has
doubled in America.
Source: Diabesity, Dr. Katherine Kaufman, former ADA president, Bantam
Books, 2005
DIABESITY
• Diabetes is the sixth leading cause of death in the USA.
• 2002: 71,000 Americans died from diabetes, but another
186,000 died from diabetes related conditions.
• Diabetes increases the risk for heart disease sixfold and
multiplies the risk of stroke by four.
Source: Diabesity, Dr. Katherine Kaufman, former ADA president, Bantam
Books, 2005
DIABETES
DIABESITY
• Diabetes is the most costly disease in America,
consuming one out of every 7 dollars.
– Today 1 in 5 dollars
• $137.7 billion per year with $92 billion spent on
medical care and the remainder on lost wages, lost
productivity.
Source: Diabesity, Dr. Katherine Kaufman, former ADA president, Bantam
Books, 2005
T2 Diabetes
DIABESITY
• Cost of Diabetes 2012: 245 billion
Am Diabetes
Assoc
DIABESITY
• The annual cost of diabetes medical care was
$10,683 in 2002 and $13,700 in 2012
• http://www.diabetes.org/diabetes-statistics/cost
Cost of Diabetes 2012
Could an Operation Cure Type II
Diabetes?
Who Would Have Thought It? An Operation Proves to Be
the Most Effective Therapy for Adult-Onset Diabetes
Mellitus, Pories WJ, Swanson MS, MacDonald KG et al. Annals of
Surgery, 222:3, 1995
Paradigm Shift
Traditional: Maximize diabetic control through strict diet, oral
medications, insulin, or even insulin pump to slow the
progression of diabetes and its sequela
Bariatric Surgery today: If a patient has T2 Diabetes and
Morbid Obesity (BMI ≥35)
Bariatric Surgery in ideal world: WLS for T2 diabetics
with BMI ≥30
T2 Diabetes
International Diabetes Federation
Position Statement 2010/2011
• Bariatric surgery appropriate if T2DM and BMI
>35
• Surgery should be prioritized if BMI >35 and
T2DM
– Previous wording surgery an “option”
– That group often refractory to medical mgt
• Surgery considered for BMI >30 if not meeting
medical treatment targets
T2 Diabetes
Case Study
• 62 y/o M: 404 lb. (BMI 63.3): MI/CAGB, CHF,
Severe T2DM on 3 pills and >150 u insulin-10
YR duration, Diabetic ulcer, DL, OSA on BIPAP
and O2, edema, CKD, narcotics for LBP/JT pain
• LRYGB 2006: Today: Wt. 200 lb.(BMI 27): OSA,
DL, Renal, edema-resolved
• T2DM: improved with 35 u insulin/d
– WLS effects: DURATION/INSULIN
Results of Bariatric Surgery
Diabetes
• 240 patients with T2DM
• F/U mean 20 months, 80%
• Clinical resolution: 83% (NL FBG and
HGBa1C and no meds)
• Marked improvement 17%
– 100% response rate!
• Predictors of remission: duration less than
5 years, no insulin
Schauer PR,Burguera B. Effect of Lap r-y gastric bypass on Type II
diabetes. Annals of Surgery Oct 2003.
Results of Bariatric Surgery
Diabetes
• 117 patients with T2DM
• Remission: 72 (74%)
• Improvement: 25 (26%)
• Predictors of remission: Waist
circumference (odds ration 2.4), absence
of insulin treatment
Torquati. Is Roux-enY gastric bypass surgery the most effective treatment
for Type 2 diabetes in morbidly obese patients? Journal of gastrointestinal
surgery 2005.
Results of Bariatric Surgery
Diabetes
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608 Patients (open RYGB)
14 year follow-up
50% EBW loss
83% clinical resolution diabetes
Ave 108 lb weight loss
Pories WJ. Ann Surg 1995.
Results of Bariatric Surgery
Diabetes
• 154 patients with T2DM
• 1 year postop: 83% resolution
• 5 years postop: 86% resolution
Sugerman HJ, Wolfe LG. Ann Surg, Jun 2003
Long-Term T2 DM remission LSG
• 88% off meds at 3 months
• 85% at 3 years
• 77% at 5 years
Soard July 2013/Dr
Abbatini
Bariatric Surgery vs Intensive Medical
NEJM 2012
• Randomized controlled, 1 center (STAMPEDE),
1 year, 150 pt: Medical/LSG/RYGB
• Target A1c(6.0%) Medical 12%, Surgical 40%
• Insulin use 38% in Med grp at 12 mo. /
4%RYGB-8%LSG surgery grp
• EWL 88% RYGB/81% LSG/13% Med
• AVE PRE A1C 9%/Duration 9 yr.
NEJM 2012/Dr
Schauer
Bariatric Surgery vs Medical treatment
3 year Outcomes NEJM 2014
• Primary End point A1C <6.0% 150 pt RCT
– WLS: bypass 38%, Sleeve: 24%
– Medical Group: 5%
• Secondary End points: QOL, WT, glucose
lowering meds all significantly greater in
surgical group
NEJM 2014/Dr Schauer
Metabolic surgery vs. Conventional
Medical
• 5yr RCT medical vs. Surgery (RYGB/BPD)
– 40% CR at 5 yr (A1C <6.5%)-surgical grp (RYGB)
– 27% of medical had DM complic vs. none
– Wt loss, Lower lipids, CV risk, Med use in surg
The LANCET, Dr Mingrone, Sept 2015
LSG vs Medical mgt
• At 2 years 76% surgical able to stop or reduce
meds vs 26%
– VA group with intense medical “MOVE” pgm
• 52% in medical group needed more meds
Dr Malbotra
T2DM Class 1 Obesity
• BMI≥ 30
• 4 RCT and 16 observational studies showing
benefit
– Not usually covered by insurance or MEDICARE
• Same benefit as higher BMI for T2DM
• Lap Band
Class 1 Obesity
• Dr Abbatini/SOARD: T2DM BMI 30-34: 18
patients
– 9 LSG: 88.8% resolution@1year
– 9 Medical: no change
• D Lakdawala/SOARD: 52 Patients: LRYGB
– EWL 72%@1yr, 68%@5yr
– DM2: CR 73%@1yr/58%@ 5yr
Class 1 Obesity
• RCT: 61 pt, BMI 30-35: Surgery vs. Lifestyle
intervention. Endpoints: DM remission full/
partial, medication reduction
• 3 yr: 40% RYGB full or partial remission
– 65% off insulin or oral DM meds
– None in medical control grp
T2DM: Paradigm Shift?
• Tremendous rapid/durable response with
bypass and sleeve (100% improvement,
majority CR)
• WLS should be prioritized for all T2DM with
morbid obesity who are Surgical Candidates
• The earlier the intervention the better the CR
rates (drop at 5 yr with large drop at 7)
What about Morbidly Obese
Type 1 DM?
• WLS: Sleeve or bypass improves insulin
sensitivity/control, Improves other comorbid
conditions like HTN/DL/OSA the same as Pt’s
withT2DM
• Consider WLS referral for selected T1DM with
morbid obesity
Type 1 Diabetes Case Report
• 41F T1 DM x10 years, insulin pump 6 yr, BMI
38
– 4.8 units insulin/hr, A1c Pre: 9.8%
– Severe hypertriglyceridemia: 950-3000
– GERD/SUI
• 10 months post LSG : 80lb wt loss, BMI 25
• Insulin .3u/hr night, .6u/hr day, A1C 6.8%
• Trig: 106, SUI/GERD resolved
What About Surgical Risk?
• Intl Journal of Cardiology Mar 2014
– 29000 pt’s, 14 studies
– After surgery 50% less risk of CVA or MI
– 40% lower death rate
Amer J Cardiol 2011: 52 studies/ 16,867 pt
• 40% reduction in 10-yr Coronary dz risk
What About Surgical Risk?
• SOS study surgery vs medical group
– CV dz decreased by 72% at 5 years
– Mortality from cardiac dz 59% lower
– Mortality all causes 29% lower, 10.9 yr f/u
(used mostly VBG/band, 2010 surgery pt vs 2037
med)
National Health and Nutrition Survey 99-2006
Coronary heart risk increases with BMI >30
What About Surgical Risk?
• Univ Utah 7,925 RYGB , 1984-02 compared to
random controls with BMI>35
• 7 yr f/u: 40% lower death rate in surgical
group
– 92%less for T2DM
– 59% less cardiac
– 60% less for CA
What About Surgical Risk?
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1035 bariatric pt (1986-02)
5746 matched medical controls
5 yr F/U
EWL 67%
Mortality 0.68% vs 6.17%
Relative RR: 89%
Dr Christou, Ann of Surg Sept
2004
FIVE-YEAR MORTALITY REDUCTION
•89 Percent Reduction in Risk of Death
Over Five Years
7.0%
6.17%
MORTALITY
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.68%
0.0%
BARIATRIC*
CONTROLS
* Includes perioperative (30-day) mortality of 0.4%.
p-value 0.001
Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality, Morbidity, and
Health Care Use in Morbidly Obese Patients. Annals of Surgery 2004;240(3):416-424.
What About Surgical Risk?
• People with BMI >30 have 50%-100%
increased risk of premature death compared
to healthy weight
• Risk of WLS today is 0.1%, less than
gallbladder (0.7%) or hip replacement (0.93%)
– Caveats: COE, Laparoscopic
• Overall risk of major complications 4.3%
Why Surgery?
• WLS alleviates associated comorbid disease
and prolongs length of life
• Risk of WLS today is far less than the natural
history of severe obesity and associated
health risks
Medical Co-Morbidities Resolved
Type 2 Diabetes
95%
Cholesterol
97%
Hypertension
92%
GERD
98%
Cardiac Function
Improvement
95%
Stress Incontinence
87%
Osteoarthritis
82%
Sleep Apnea
75%
Wittgrove AC,Clark GW. Laparoscopic Gastric bypass roux-en-y-500 patients. Obes Surg 2000. And others.