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Metabolic SurgeryMetabolic SurgeryChandra Hassan MD
Director of Bariatric SurgerySt. Vincent’s Charity Medical Center
Cleveland, OH
Chandra Hassan MDDirector of Bariatric Surgery
St. Vincent’s Charity Medical CenterCleveland, OH
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ObjectivesObjectives
brief overview of Bariatric surgery
management of bariatric surgery patients and complications
effects of bariatric surgery on diabetes
revision procedures
brief overview of Bariatric surgery
management of bariatric surgery patients and complications
effects of bariatric surgery on diabetes
revision procedures
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Metabolic SyndromeMetabolic Syndrome
Central obesity. (defined as waist circumference ≥ 40 inches for men and ≥ 35cm for women)
raised TG level: ≥ 150 mg/dL
reduced HDL cholesterol: < 40 mg/dL
raised blood pressure: systolic BP ≥ 130 or diastolic BP ≥ 85 mm Hg, or treatment of previously diagnosed hypertension
raised fasting plasma glucose (FPG) ≥ 100 mg/dL or previously diagnosed type 2 diabetes
Central obesity. (defined as waist circumference ≥ 40 inches for men and ≥ 35cm for women)
raised TG level: ≥ 150 mg/dL
reduced HDL cholesterol: < 40 mg/dL
raised blood pressure: systolic BP ≥ 130 or diastolic BP ≥ 85 mm Hg, or treatment of previously diagnosed hypertension
raised fasting plasma glucose (FPG) ≥ 100 mg/dL or previously diagnosed type 2 diabetes
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Metabolic SyndromeMetabolic Syndrome54 Million Americans!A quarter of the world’s adults have metabolic syndrometwice as likely to die from, and three times as likely to have a MI or CVAa five-fold greater risk of developing type 2 diabetesway ahead of HIV/AIDS in morbidity and mortality
54 Million Americans!A quarter of the world’s adults have metabolic syndrometwice as likely to die from, and three times as likely to have a MI or CVAa five-fold greater risk of developing type 2 diabetesway ahead of HIV/AIDS in morbidity and mortality
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Body Mass IndexBody Mass Index
BMI > 25: Over weight, 2/3rd US
BMI > 30: Obese, 1/3rd US
BMI > 40: Morbid Obese, 6% US (18 million Americans)
BMI > 25: Over weight, 2/3rd US
BMI > 30: Obese, 1/3rd US
BMI > 40: Morbid Obese, 6% US (18 million Americans)
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CriteriaCriteria
BMI > 40
BMI > 35 plus 1 or 2 co-morbidities
T2D , Hypertension
OSA, NASH
Hyperlipidemia, Pseudo tumor cerebri
Considerably impaired quality of life
BMI > 40
BMI > 35 plus 1 or 2 co-morbidities
T2D , Hypertension
OSA, NASH
Hyperlipidemia, Pseudo tumor cerebri
Considerably impaired quality of life
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Historical PerspectiveHistorical Perspective
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Band vs SleeveBand vs Sleeve
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Pre-op work upPre-op work up
Cardiology, Pulmonary, Psychiatry
Home sleep study
Blood test
Clinical nutrition evaluation
smoking cessation
Pregnancy counseling
Cardiology, Pulmonary, Psychiatry
Home sleep study
Blood test
Clinical nutrition evaluation
smoking cessation
Pregnancy counseling
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QuickTime™ and a decompressor
are needed to see this picture.
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QuickTime™ and a decompressor
are needed to see this picture.
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QuickTime™ and a decompressor
are needed to see this picture.QuickTime™ and a
decompressorare needed to see this picture.
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post-op carepost-op care
Monitored telemetry at least 24 hrs
Protocol-derived staged meal progression
Monitor blood glucose
Adequate hydration
Ambulation
Incentive spirometry
GI, DVT prophylaxis
Specialists Consult
Monitored telemetry at least 24 hrs
Protocol-derived staged meal progression
Monitor blood glucose
Adequate hydration
Ambulation
Incentive spirometry
GI, DVT prophylaxis
Specialists Consult
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continued care continued care
Initial 2 weeks, then 3,6,12 months
Monitor weight loss and complications
Adjust medications
Physical activity recommendations
Blood work up per protocol
Bone density (DXA) at 2 years
Need for support groups
Consider body contouring surgery
Initial 2 weeks, then 3,6,12 months
Monitor weight loss and complications
Adjust medications
Physical activity recommendations
Blood work up per protocol
Bone density (DXA) at 2 years
Need for support groups
Consider body contouring surgery
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Early risksEarly risks
Anastomotic leak 1-4%
Bleeding 0-5%
Wound infection 0-5%
Conversion <5%
DVT 0-1.5%
PE 0-1.3%
Anastomotic leak 1-4%
Bleeding 0-5%
Wound infection 0-5%
Conversion <5%
DVT 0-1.5%
PE 0-1.3%
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risksrisks
30-day mortality for procedures 0.3%
Increased risk if BMI > 50, h/o DVT, PE, OSA, Poor functional status
30-day mortality for procedures 0.3%
Increased risk if BMI > 50, h/o DVT, PE, OSA, Poor functional status
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complications and managementcomplications and management
leak - return to OR
bleed - may return to OR
anastomotic stricture - EGD/dilatation
internal hernia - laparoscopic repair
pouch dilatation - diet/behavior mod.
leak - return to OR
bleed - may return to OR
anastomotic stricture - EGD/dilatation
internal hernia - laparoscopic repair
pouch dilatation - diet/behavior mod.
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OutcomesOutcomes
Non-Surgical management: only 5-10% success
T2D remission: up to 72% at 2 years
RYGB sustained remission of 62% at 6 years
All-cause mortality reduced by 40% 7 years after RYGB
Cause specific mortality reduction:
T2D 92%, Cancer 60%, CAD 56%
Non-Surgical management: only 5-10% success
T2D remission: up to 72% at 2 years
RYGB sustained remission of 62% at 6 years
All-cause mortality reduced by 40% 7 years after RYGB
Cause specific mortality reduction:
T2D 92%, Cancer 60%, CAD 56%
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Five-Year Results of Laparoscopic Sleeve Gastrectomy
Patricia Sieber, M.D., Markus Gass, M.D., Beatrice Kern, M.D., Thomas Peters, M.D., Marc Slawik, M.D. and Ralph Peterli, Ph.D.
Surgery for Obesity and Related DiseasesDOI: 10.1016/j.soard.2013.06.024
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Five-Year Results of Laparoscopic Sleeve Gastrectomy
Patricia Sieber, M.D., Markus Gass, M.D., Beatrice Kern, M.D., Thomas Peters, M.D., Marc Slawik, M.D. and Ralph Peterli, Ph.D.
Surgery for Obesity and Related DiseasesDOI: 10.1016/j.soard.2013.06.024
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Restoration of glycemic control in patients Restoration of glycemic control in patients with type 2 DM after bariatric surgery is with type 2 DM after bariatric surgery is
associated with reduction in microparticles.associated with reduction in microparticles.
CD14 MonocyteCD14 MonocyteCD144 EndothelialCD144 Endothelial
CD41 PlateletsCD41 Platelets
Vicky Cheng, M.D., Sangeeta R. Kashyap, M.D., Philip R. Schauer, M.D., John P. Kirwan, M.D. and Keith R. McCrae, M.D.
Surgery for Obesity and Related Diseases
Volume 9, Issue 2, Pages 207-212 (March 2013)DOI: 10.1016/j.soard.2011.09.026
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revision proceduresrevision procedures
Lap band removal and conversion to sleeve or RNY (1 or 2 stage)
Vertical banded gastroplasty to RNY
Reversal of Nissens and RNY
Sleeve to RNY
Lap band removal and conversion to sleeve or RNY (1 or 2 stage)
Vertical banded gastroplasty to RNY
Reversal of Nissens and RNY
Sleeve to RNY