bariatric surgery in the transplant population
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Bariatric Surgery in the Transplant Population. Guilherme M. Campos, MD, FACS, FASMBS Associate Professor of Surgery University of Wisconsin – Madison [email protected]. 5th Annual Wisconsin Chapter Transplant Symposium Transplant: Sharing and Caring. - PowerPoint PPT PresentationTRANSCRIPT
Bariatric Surgery in the Transplant Population
Guilherme M. Campos, MD, FACS, FASMBSAssociate Professor of Surgery
University of Wisconsin – [email protected]
5th Annual Wisconsin Chapter Transplant Symposium
Transplant: Sharing and Caring
1. Overview of Bariatric Surgery1. Indications2. Type of procedures3. Peri-operative and long term-outcomes4. Beyond Caloric Restriction, why does it work
2. Bariatric Surgery & Organ Transplantation1. UCSF Data2. CRF (with or without dialysis / pre Kidney Tx)3. Post Kidney Tx4.Before, during and after Liver Tx
Bariatric Surgery Before and After Organ Transplantation
Surgery for Severe ObesityN
o. o
f Ba
ria
tric
Sx.
in th
e U
S
Recent trends in bariatric surgery case volume in the United States.Kohn GP, Galanko JA, Overby DW, Farrell TM.Surgery 2009 146: 375-80
1. Increasing prevalence and recognition Health Hazard
2. Poor outcomes with nonsurgical management
3. Good outcomes with Bariatric Surgery
4. Introduction of Laparoscopic Techniques
Surgery for Severe ObesitySteinbrook RN Eng J Med 2004 350: 1075-79
• Failure supervised weight loss program
• Well-informed and motivated patients
• Acceptable operative risks
• BMI > 40 or BMI 35-40 with high risk comorbidities
Surgery for Severe Obesity
PATIENT SELECTION
NIH Consensus Statement – March 25-27, 1991 Nutrition 1996; 12: 397-402
LaparoscopicGastric Bypass
LaparoscopicGastric Banding
60% 25%
LaparoscopicSleeve Gastrectomy
20%
1. Low perioperative and long-term complication rate.
2. Significant and Long Term Weight Loss
3. Improvement/Cure Obesity Associated Comorbidities
4. Improvement Quality of Life
5. Reduces Mortality
Bariatric Surgery Overview O U T C O M E S
• A prospective, multicenter, observational study of 30-day outcomes in consecutive patients
undergoing bariatric surgical procedures at 10 clinical sites in the US from 2005 - 2007.
• 4,340 patients who had a first-time bariatric procedure
1. Open RYGB - 899 patients (21%) - BMI 51
2. Laparoscopic RYGB - 2243 patients (51%) - BMI 47
3. Laparoscopic Band - 1198 patients (28%) - BMI 44
Significant Differences in between all groups/p<0.01/ for BMI and Co-existing Conditions
(Other procedures - 166 patients, not included in the analysis)
1. Low perioperative and long-term complication rate.
2. Significant and Long Term Weight Loss
3. Improvement/Cure Obesity Associated Comorbidities
4. Improvement Quality of Life
5. Reduces Mortality
Bariatric Surgery Overview O U T C O M E S
Effects of Bariatric Surgery on Mortality in Swedish Obese SubjectsSjöström et al. NEJM. 2007; 357 (8):741-52
1. Low perioperative and long-term complication rate.
2. Significant and Long Term Weight Loss
3. Improvement/Cure Obesity Associated Comorbidities
4. Improvement Quality of Life
5. Reduces Mortality
Bariatric Surgery Overview O U T C O M E S
% R
eso
lutio
n C
omor
bid
ityResolution of Obesity Associated Diseases after
Gastric Bypass
Buchwald H. et al. JAMA. 2004; 292(14):1724-37
48%
75%80%
12 Studies, 576 patients, RYGB, 2cd Biopsy ~ 17 mo
STEATOSIS INFLAMMATION FIBROSIS
Improvement 100% 80% 80%
No Change - 10% 10%
Worse/New Onset - 10% (Portal) 10%
OUTCOME HISTOLOGY 2cd BIOPSY
• Ralph, 45 y/o, 394 lbs• On Disability for Back Pain• High Blood Pressure (3 meds.)• Diabetes• Sleep Apnea• Venous Disease
1. Low perioperative and long-term complication rate.
2. Significant and Long Term Weight Loss
3. Improvement/Cure Obesity Associated Comorbidities
4. Improvement Quality of Life
5. Reduces Mortality
Bariatric Surgery Overview O U T C O M E S
Original Article Long-Term Mortality after Gastric Bypass Surgery
Ted D. Adams, Ph.D., M.P.H., et alUniversity of Utah School of Medicine
Salt Lake City, UT
N Engl J MedVolume 357(8):753-761
August 23, 2007
Original Article Effects of Bariatric Surgery on Mortality in Swedish
Obese SubjectsLars Sjöström, M.D., Ph.D., et al.
Swedish Obese Subjects (SOS) StudySahlgrenska University Hospital, Gothenburg, Sweden,
N Engl J MedVolume 357(8):741-752
August 23, 2007
Distribution of Deaths and Death Rates per 10,000 Person-Years, According to Study Group
Adams TD et al. N Engl J Med 2007;357:753-761
Cause of Death
Sjostrom L et al. N Engl J Med 2007;357:741-752
5% 6.3%
• Failure supervised weight loss program
• Well-informed and motivated patients
• Acceptable operative risks
• BMI > 40 or BMI 35-40 with high risk comorbidities
Surgery for Severe Obesity
PATIENT SELECTION
NIH Consensus Statement – March 25-27, 1991 Nutrition 1996; 12: 397-402
Beyond Caloric Restriction, why does it work?
Surgery for Severe Obesity
• Well-informed and motivated patients
NIH Consensus Statement – March 25-27, 1991 Nutrition 1996; 12: 397-402
• Change in Hunger-Satiety Mechanisms
• Change in Endocrine and Gluco-regulatory
Mechanisms
Cummings D.E. et al.
Ghrelin Secretion before & after Weight Loss
Cummings D.E. et al.
Ghrelin Secretion before & after GBP
BAGGIO LL & DRUCKER DJ Gastroenterology 2007;132:2131–2157
GLP-1 LEVELS AFTER A MEAL
Campos GM, et al.Journal of Gastrointestinal Surgery, Jan; 14 (1):15-23, 2010
Campos GM, et al.Journal of Gastrointestinal Surgery, Jan; 14 (1):15-23, 2010.
* P=0.01
GLP-1 LEVELS AFTER A MEAL
INSULIN LEVELS AFTER A MEAL
Campos GM, et al.Journal of Gastrointestinal Surgery, Jan; 14 (1):15-23, 2010.
* P=0.01
- Gastric Bypass Group
BAGGIO LL & DRUCKER DJ Gastroenterology 2007;132:2131–2157
1. UCSF Data2. CRF (with or without dialysis / pre Kidney Tx)3. Post Kidney Tx4. Before and after Heart Tx5. Before and after Lung Tx6. Before, during and after Liver Tx
Bariatric Surgery Before and After Organ Transplantation
4%
35%
4%
33%
18%
8%
0
5
10
15
20
25
30
35
40
< 18.5 18.5 - 24.9 25 - 29.9 30 - 34.9 35 - 39.9 > 40
BMI
Prevalence of Obesity in Patients Awaiting Kidney or Liver Transplant at UCSF - 2006
6%
18%
34%
8%
3%
32%
0
5
10
15
20
25
30
35
40
< 18.5 18.5 - 24.9 25 - 29.9 30 - 34.9 35 - 39.9 > 40
BMI
32% (n = 248) > 306% (n = 33) > 40
30% (n = 1,076) > 304% (n = 222) > 40
Liver (n = 986)Liver (n = 986)Kidney (n =4,144)Kidney (n =4,144)
Background%
of
patie
nts
% o
f pa
tient
s
Gore JL, et al. Am J of Transplantation 2006Pischon T, et al. Neph Dail Transplant 2001
• More post-op wound, pulmonary and cardiovascular complications
• Higher rate of primary graft non-function
• Longer length of hospitalization
• 30% higher cost of hospitalization
• Higher mortality
• More post-op wound, pulmonary and cardiovascular complications
• Higher rate of primary graft non-function
• Longer length of hospitalization
• 30% higher cost of hospitalization
• Higher mortality
KIDNEYKIDNEY LIVERLIVER
Nair S, et al. AJG 2001, Hepatol 2002Sawyer RG, et al. Clin Trans 1999
BackgroundMorbidity after Transplant - UNOS
• Higher rate of delayed graft function
• Higher rate of early graft loss
• Higher rate of acute rejection
• Higher rate of overall graft failure
• Longer length of hospitalization
• Higher mortality
• Higher rate of delayed graft function
• Higher rate of early graft loss
• Higher rate of acute rejection
• Higher rate of overall graft failure
• Longer length of hospitalization
• Higher mortality
Background
• Most transplant centers have implemented BMI limits beyond which patients are considered unsuitable for
transplantation.
• Bariatric surgery is the most effective treatment for morbid obesity, but is not offered routinely to this patient
population.
Laparoscopic Bariatric Surgery Improves Transplant Candidacy In Morbidly Obese
Patients
Takata M, Campos G, Ciovica R, Rogers S, Cello J, Ascher N, Posselt A
Bariatric Surgery Program
University of California San Francisco, USA
Objectives
• Evaluate the safety and efficacy of:– Laparoscopic gastric bypass - ESRD.– Laparoscopic sleeve cirrhosis and ESLD.
Patients and Methods
• Selected patients ineligible for a kidney, liver, or lung transplant because of their BMI.
• UCSF BMI limits for transplantation– Kidney: 40kg/m2
– Liver: 40kg/m2 (relative contraindication) and 50kg/m2 (absolute contraindication).
– Lung: 40kg/m2
ResultsOperative and Perioperative Outcomes
ESRD (n=19) Cirrhosis (n=14) ESLD (n=4)
Operation LGBP LSG LSG
Total O.R. time (min) 189 (148 - 222) 141 (120 - 176) 147 (90 & 213)
Mean EBL, ml 64 58 50
Complications 4 4 2
LOS, days 3.0 (3 - 3) 4.2 (2 - 8) 4.0 (3 & 5)
Follow-up, months 36 (6 - 36) 21 (3 - 21) 18 (9 - 18)
Bariatric Surgery Program
University of California San Francisco, USA
ResultsLGBP in Patients With ESRD
25
30
35
40
45
50
55
60
65
Preop 1 3 6 9 12
Time since Surgery (months)
BMI
25
30
35
40
45
50
55
60
65
Preop 1 3 6 9 12
Time since Surgery (months)
BMI
BMI Cutoff for Transplant
Transplant candidate at 12 months11/12
Bariatric Surgery Program
University of California San Francisco, USA
ResultsLSG in Patients With Cirrhosis / ESLiverD
25
30
35
40
45
50
55
60
Preop 1 3 6 9 12
Time since surgery (months)
BMI
25
30
35
40
45
50
55
60
Preop 1 3 6 9 12
Time since surgery (months)
BMI
BMI Cutoff for Transplant
Transplant candidate at 12 months6/9
Bariatric Surgery Program
University of California San Francisco, USA
1. CRF (with or without dialysis / pre Kidney Tx)2. Post Kidney Tx
32 patients CRF, RYGB, no Tx9 patients CRF, RYGB, Kidney Tx10 patients Post kidney, RYGB
1. Before Heart Tx
N=2Lap Sleeve
1. After Liver Tx
N=12 months after Liver TxBiliary reconstruction and Open SleeveBMI 37 to 30, 6 months post-op
1. After Liver Tx
N=21. BMI 65 to 48, 3 years post-op2. BMI 63 to 43, 18 mo post-op
1. CRF (with or without dialysis / pre Kidney Tx)2. Post Kidney Tx3. Before and after Heart Tx4. Before and after Lung Tx5. Before, during and after Liver Tx
Bariatric Surgery Before and After Organ Transplantation
LaparoscopicGastric Bypass
LaparoscopicGastric Banding
60% 25%
LaparoscopicSleeve Gastrectomy
20%
LaparoscopicGastric Bypass
LaparoscopicSleeve Gastrectomy
Patient Selection – Initial Procedure
1. for patients considered high-risk
2. for transplant candidates
3. for morbidly obese patients with Met Syndrome
4. for pts. BMI 30-35 and comorbidities
5. for pts. with Inflammatory Bowel Disease
6. adolescent morbidly obese patients
7. for elderly morbidly obese patients
LSG is a valid option
96%
96%
91%
95%
86%
77%
100%
Bariatric Surgery in the Transplant Population
Guilherme M. Campos, MD, FACS, FASMBSAssociate Professor of Surgery
University of Wisconsin – [email protected]
5th Annual Wisconsin Chapter Transplant Symposium
Transplant: Sharing and Caring