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Bariatric Surgery in the Transplant Population

Bariatric Surgery in the Transplant Population. Guilherme M. Campos, MD, FACS, FASMBS Associate Professor of Surgery University of Wisconsin – Madison campos@surgery.wisc.edu. 5th Annual Wisconsin Chapter Transplant Symposium Transplant: Sharing and Caring.

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Bariatric Surgery in the Transplant Population

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  1. Bariatric Surgery in the Transplant Population Guilherme M. Campos, MD, FACS, FASMBS Associate Professor of Surgery University of Wisconsin – Madison campos@surgery.wisc.edu 5th Annual Wisconsin Chapter Transplant Symposium Transplant: Sharing and Caring

  2. Bariatric Surgery Before and After Organ Transplantation • Overview of Bariatric Surgery • Indications • Type of procedures • Peri-operative and long term-outcomes • Beyond Caloric Restriction, why does it work • Bariatric Surgery & Organ Transplantation • UCSF Data • CRF (with or without dialysis / pre Kidney Tx) • Post Kidney Tx • Before, during and after Liver Tx

  3. Surgery for Severe Obesity 1. Increasing prevalence and recognition Health Hazard 2. Poor outcomes with nonsurgical management 3. Good outcomes with Bariatric Surgery 4. Introduction of Laparoscopic Techniques No. of Bariatric Sx. in the US Recent trends in bariatric surgery case volume in the United States. Kohn GP, Galanko JA, Overby DW, Farrell TM. Surgery 2009 146: 375-80 Surgery for Severe Obesity Steinbrook R N Eng J Med 2004 350: 1075-79

  4. Surgery for Severe Obesity PATIENT SELECTION • Failure supervised weight loss program • Well-informed and motivated patients • Acceptable operative risks • BMI > 40 or BMI 35-40 with high risk comorbidities NIH Consensus Statement – March 25-27, 1991 Nutrition 1996; 12: 397-402

  5. Laparoscopic Gastric Bypass Laparoscopic Gastric Banding Laparoscopic Sleeve Gastrectomy 60% 25% 20%

  6. Bariatric Surgery Overview O U T C O M E S • Low perioperative and long-term complication rate. • Significant and Long Term Weight Loss • Improvement/Cure Obesity Associated Comorbidities • Improvement Quality of Life • Reduces Mortality

  7. 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)

  8. Bariatric Surgery Overview O U T C O M E S • Low perioperative and long-term complication rate. • Significant and Long Term Weight Loss • Improvement/Cure Obesity Associated Comorbidities • Improvement Quality of Life • Reduces Mortality

  9. Effects of Bariatric Surgery on Mortality in Swedish Obese SubjectsSjöström et al. NEJM. 2007; 357 (8):741-52

  10. Bariatric Surgery Overview O U T C O M E S • Low perioperative and long-term complication rate. • Significant and Long Term Weight Loss • Improvement/Cure Obesity Associated Comorbidities • Improvement Quality of Life • Reduces Mortality

  11. Resolution of Obesity Associated Diseases after Gastric Bypass % Resolution Comorbidity Buchwald H. et al. JAMA. 2004; 292(14):1724-37

  12. 48% 75% 80%

  13. 12 Studies, 576 patients, RYGB, 2cd Biopsy ~ 17 mo OUTCOME HISTOLOGY 2cd BIOPSY

  14. Ralph, 46 y/o, 224 lbs • Truck Driver • High Blood Pressure (1 medication) • Type 2 Diabetes • Sleep Apnea • Venous Disease (Healing) • Ralph, 45 y/o, 394 lbs • On Disability for Back Pain • High Blood Pressure (3 meds.) • Diabetes • Sleep Apnea • Venous Disease

  15. Bariatric Surgery Overview O U T C O M E S • Low perioperative and long-term complication rate. • Significant and Long Term Weight Loss • Improvement/Cure Obesity Associated Comorbidities • Improvement Quality of Life • Reduces Mortality

  16. Original ArticleLong-Term Mortality after Gastric Bypass Surgery Ted D. Adams, Ph.D., M.P.H., et al University of Utah School of Medicine Salt Lake City, UT N Engl J Med Volume 357(8):753-761 August 23, 2007 Original ArticleEffects of Bariatric Surgery on Mortality in Swedish Obese Subjects Lars Sjöström, M.D., Ph.D., et al. Swedish Obese Subjects (SOS) Study Sahlgrenska University Hospital, Gothenburg, Sweden, N Engl J Med Volume 357(8):741-752 August 23, 2007

  17. 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

  18. Cause of Death 5% 6.3% Sjostrom L et al. N Engl J Med 2007;357:741-752

  19. Surgery for Severe Obesity PATIENT SELECTION • Failure supervised weight loss program • Well-informed and motivated patients • Acceptable operative risks • BMI > 40 or BMI 35-40 with high risk comorbidities NIH Consensus Statement – March 25-27, 1991 Nutrition 1996; 12: 397-402

  20. Surgery for Severe Obesity • Beyond Caloric Restriction, why does it work? • Well-informed and motivated patients • Change in Hunger-Satiety Mechanisms • Change in Endocrine and Gluco-regulatory Mechanisms NIH Consensus Statement – March 25-27, 1991 Nutrition 1996; 12: 397-402

  21. Ghrelin Secretion before & after Weight Loss Cummings D.E. et al.

  22. Ghrelin Secretion before & after GBP Cummings D.E. et al.

  23. BAGGIO LL & DRUCKER DJ Gastroenterology 2007;132:2131–2157

  24. GLP-1 LEVELS AFTER A MEAL Campos GM, et al. Journal of Gastrointestinal Surgery, Jan; 14 (1):15-23, 2010

  25. GLP-1 LEVELS AFTER A MEAL * P=0.01 Campos GM, et al. Journal of Gastrointestinal Surgery, Jan; 14 (1):15-23, 2010.

  26. * P=0.01 INSULIN LEVELS AFTER A MEAL - Gastric Bypass Group Campos GM, et al. Journal of Gastrointestinal Surgery, Jan; 14 (1):15-23, 2010.

  27. BAGGIO LL & DRUCKER DJ Gastroenterology 2007;132:2131–2157

  28. Bariatric Surgery Before and After Organ Transplantation • UCSF Data • CRF (with or without dialysis / pre Kidney Tx) • Post Kidney Tx • Before and after Heart Tx • Before and after Lung Tx • Before, during and after Liver Tx

  29. Background Kidney (n =4,144) Liver (n = 986) Prevalence of Obesity in Patients Awaiting Kidney or Liver Transplant at UCSF - 2006 % of patients % of patients 32% (n = 248) > 30 6% (n = 33) > 40 30% (n = 1,076) > 30 4% (n = 222) > 40

  30. Background Morbidity after Transplant - UNOS KIDNEY LIVER • 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 • 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 Gore JL, et al. Am J of Transplantation 2006 Pischon T, et al. Neph Dail Transplant 2001 Nair S, et al. AJG 2001, Hepatol 2002 Sawyer RG, et al. Clin Trans 1999

  31. 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.

  32. 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

  33. Objectives • Evaluate the safety and efficacy of: • Laparoscopic gastric bypass - ESRD. • Laparoscopic sleeve cirrhosis and ESLD.

  34. 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

  35. Results Operative and Perioperative Outcomes Bariatric Surgery Program University of California San Francisco, USA

  36. Results LGBP in Patients With ESRD BMI Cutoff for Transplant Transplant candidate at 12 months 11/12 Bariatric Surgery Program University of California San Francisco, USA

  37. Results LSG in Patients With Cirrhosis / ESLiverD BMI Cutoff for Transplant Transplant candidate at 12 months 6/9 Bariatric Surgery Program University of California San Francisco, USA

  38. CRF (with or without dialysis / pre Kidney Tx) • Post Kidney Tx 32 patients CRF, RYGB, no Tx 9 patients CRF, RYGB, Kidney Tx 10 patients Post kidney, RYGB

  39. Before Heart Tx N=2 Lap Sleeve

  40. After Liver Tx N=1 2 months after Liver Tx Biliary reconstruction and Open Sleeve BMI 37 to 30, 6 months post-op

  41. After Liver Tx • N=2 • BMI 65 to 48, 3 years post-op • BMI 63 to 43, 18 mo post-op

  42. Bariatric Surgery Before and After Organ Transplantation • CRF (with or without dialysis / pre Kidney Tx) • Post Kidney Tx • Before and after Heart Tx • Before and after Lung Tx • Before, during and after Liver Tx

  43. Laparoscopic Gastric Bypass Laparoscopic Gastric Banding Laparoscopic Sleeve Gastrectomy 60% 25% 20%

  44. Laparoscopic Gastric Bypass Laparoscopic Sleeve Gastrectomy

  45. Patient Selection – Initial Procedure LSG is a valid option • for patients considered high-risk • for transplant candidates • for morbidly obese patients with Met Syndrome • for pts. BMI 30-35 and comorbidities • for pts. with Inflammatory Bowel Disease • adolescent morbidly obese patients • for elderly morbidly obese patients 96% 96% 91% 95% 86% 77% 100%

  46. Bariatric Surgery in the Transplant Population Guilherme M. Campos, MD, FACS, FASMBS Associate Professor of Surgery University of Wisconsin – Madison campos@surgery.wisc.edu 5th Annual Wisconsin Chapter Transplant Symposium Transplant: Sharing and Caring

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