Restrictive Restrictive Procedures in Procedures in BMI > 50BMI > 50

Craig B. Morgenthal, MDCraig B. Morgenthal, MD

George S. Ferzli, MDGeorge S. Ferzli, MD

SUNY Health Science Center SUNY Health Science Center

at Brooklynat Brooklyn

DefinitionsDefinitions

1. Overweight: BMI > 25 kg/m2

2. Obesity: BMI > 30 kg/m2

3. Severe obesity: BMI >35 kg/m2

4. Morbid obesity: BMI > 40 kg/m2 or BMI > 35 kg/m2 with concomitant obesity related morbidity

5. Superobesity: BMI > 50 kg/m2, >225% IBW

Options in Bariatric SurgeryOptions in Bariatric Surgery

• Restrictive proceduresVertical-banded gastroplastyLaparoscopic gastric band placement

• Combined restrictive/malabsorptiveRoux-en-Y bypass

• Malabsorptive procedures Biliopancreatic bypass +/- duodenal switch

Jejunoileal bypass

Trends in Bariatric SurgeryTrends 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 54studies, performed in 14,964 patientsaccording to bariatric operation performed.

Operation Total %EWL %BMI(# studies) patients (n) lossGastric banding (16) 4429 48.6 22.2BPD (9) 3903 68.8 35.5VBG (15) 3382 58.3 29.0Roux-en-Y GB (11) 2949 68.6 34.7Long-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% EWLZimmerman et al 1998 894 42 12 40% EWLDargent 1999 500 43 28 65% EWLBlanco et al 2001 407 49 24 58 kg lossAngrisani 2001 1265 44 48 BMI 32Szold, Abu-Abeid 2001 715 43 17 BMI 32Nehoda et al 2001 320 47 24 71% EWL Chevallier et al 2002 400 44 24 53% EWLBelachew et al 2002 763 42 48 BMI 30Favretti et al 2002 830 46 72 BMI 29O’Brien et al 2002 655 45 72 57% EWL

Is superobesity a distinct entity?Is superobesity a distinct entity? Term superobesity first used when it became apparentthat morbid obesity operations were less effective inbringing the extremely obese to normal weight.

Incidence of coexisting medical problems and overallhealth risk greater in superobese

Heaviest patients must lose more weight to achieve alevel that represents a valid reduction in theiractuarial 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 scoreGB = 0-3, VBG= 2-5, RYGBP=3-6, BPD/DS=4-7, Long-limb RYGBP= 6-9Overlap of numbers allows for surgeon and patient preferenceAge = <40yrs add 0.5, >40yrs subtract 0.5GRH = body habitus; favorable +0.5, unfavorable -0.5CoM = CoMorbidities; high + 1, low – 1BMI# = 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 ofpreoperative BMI. LGB associated with greaterintraoperative complication rates (2% vs. 1.3%), early majorcomplication rates (4.2% vs. 1.7%), and postoperative deathrates (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 LAGBand 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

• -1st 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.

BPDLAGB

# patients 23 23

Females 16 16

Age 41 39

Complications 13 2

Reoperations 7 2

Hospital stay 8 1

Follow up (mo) 57 56

BPDLAGB

Preop BMI 56.9 55.9BMI 6 mo 42.7 46.8BMI 12 mo 39.1 43.6BMI 24 mo 34.6 38.9%EWL 6 mo 39.8 29.5%EWL12 mo 57.5 37.0%EWL24 mo 64.4 48.4Resolved HTN 4/6 4/6Resolved DM 2/2 2/3

Dolan K, Fielding G, et al. Comparison of LAGB and biliopancreatic diversion in superobesity. Obesity Surg 2004; 13: 165.

lapBPDLAGB

# patients 12 12

Females 9 9

Age 35 35

Complications 4 1

Reoperations 2 1

Hospital stay 8 1

Follow up (mo) 58 58

lapBPDLAGB

Preop BMI 58.4 57.5BMI 6 mo 42.7 48.3BMI 12 mo 38.6 45.1BMI 24 mo 34.0 39.2%EWL 6 mo 39.8 27.6%EWL12 mo 59.1 37.0%EWL24 mo 68.1 46.7Resolved HTN 1/2 2/3Resolved DM 1/2 1/1

Dolan K, Fielding G, et al. Comparison of LAGB andbiliopancreatic diversion in superobesity.Obesity Surg2004; 13: 165.

Complications: LAGB 1 band slippage, 1 port-site leak open/lap BPD 9/4: wound infection 3/2, wounddehiscence 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 GastroplastyResults of Vertical Banded Gastroplasty

Mason E, Doherty C, et al. Super obesity andgastric reduction procedures. Gastroent Clin NA1987; 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 Size5.5 5.0 4.5

Super 2 yrs Pts (n) 48 79 17EWL (%) 41 54 58

Super 5 yrs Pts (n) 17 22

EWL (%) 38 49 ִ

Morbid 2 yrs Pts (n) 90 220 69EWL (%) 52 62 60

Morbid 5 yrs Pts (n) 18 58EWL (%) 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 bandedgastroplasty for morbid and super obesity. Surgery1990; 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 followingbariatric 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 followingBariatric surgery in super vs. morbidly obese patients. ObesitySurg 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 VerticalBanded 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 Results of Laparoscopic Adjustable Gastric BandAdjustable Gastric Band

Silva AS, et al. Treatment of morbid obesity with adjustablegastric 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)Preop6 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 formassive 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/m2) % 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 lossthat matches more complex surgeries, with low morbidityand 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