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Obesity – Obstructive sleep apnea Bariatric surgery

Obesity – Obstructive sleep apnea Bariatric surgery. Dr John B Dixon, MBBS PhD Associate Professor Head of Obesity Research School of Primary Health Care Monash University, Melbourne, Australia NHMRC Senior research fellow Hypertension and Vascular – Obesity Research

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Obesity – Obstructive sleep apnea Bariatric surgery

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  1. Obesity – Obstructive sleep apneaBariatric surgery Dr John B Dixon, MBBS PhD Associate Professor Head of Obesity Research School of Primary Health Care Monash University, Melbourne, Australia NHMRC Senior research fellow Hypertension and Vascular – Obesity Research Baker Heart Research Institute Melbourne, Australia

  2. Disclosures: Associate Professor John B Dixon Abbott Speakers Bureau & Educational Material Allergan Inc Consultant, Research Support Bariatric Advantage Consultant, Speakers Bureau Eli Lilly Speakers Bureau Merck Sharp and Dohme Speakers Bureau Nestle Australia Medical Advisory Board, Speakers Bureau, Research Support Novartis Australia Educational material ResMed Research Support Scientific Intake Consultant & Research Support SP Health Co Consultant Weight Watchers Speaker and Educational Material Valeant Pharmaceuticals Speaker and Educational Material

  3. Positive outcomes overwhelm! • Obstructive sleep apnea was resolved in 85.7% of patients Buchwald, H., Y. Avidor, et al. (2004). "Bariatric surgery: a systematic review and meta-analysis." Jama292(14): 1724-173 • In the SOS study the surgery group, there was a marked improvement in all obstructive sleep apnea symptoms • Persistence of snoring OR 0.14, 95% CI 0.10-0.19 • Apnea OR 0.16, 95% I 0.10-0.23 Grunstein, R. R., K. Stenlof, et al. (2007). Sleep 30(6): 703-710.

  4. From one of our studies • Improvement in the responses to all questions at follow-up • Habitual snoring reduced to 14% (82%) • Observed sleep apnea to 2% (33%) • Abnormal daytime sleepiness to 4% (39%) • Poor sleep quality to 2% (39%) Obesity-related sleep disorders improve markedly with weight loss Dixon, J. B., L. M. Schachter, et al. (2001). Arch Intern Med 161(1): 102-106.

  5. OSA was one of the comorbidities at the top of the list as cured by bariatric surgery Should this have been sleep symptoms or OSA?

  6. 25 patients with severe OSA polysomnography at 1-2 years • Age 44.7 y, weight 154 kg and body mass index 52.7 kg/m(2) • Weight loss 50.1+/-15% and 44.9+/-22 kg, respectively. • AHI from 61.6+/-34 to 13.4+/-13 • Improved sleep architecture with increased REM and stage III and IV sleep • Epworth Sleepiness Scale - 13+/-7.0 to 3.8+/-3.0, • Fewer patients requiring nasal continuous positive airways pressure (CPAP) Dixon, J. B., L. M. Schachter, et al. (2005). IJO 29(9): 1048-1054.

  7. Greenburg, D. L., C. J. Lettieri, et al. (2009). "Effects of Surgical Weight Loss on Measures of Obstructive Sleep Apnea: A Meta-Analysis." American Journal of Medicine 122(6): 535-542.

  8. Repeat polysomnographyWhat can the literature tell us?

  9. Repeat polysomnographyWhat can the literature tell us?

  10. Summary • AHI reduction in 38 events / hr • The mean final AHI was > 15 events / hr and this is moderate OSA • Very few patients were cured (younger and lighter did better) • Many studies were retrospective and subject to selection bias • It’s difficult to get repeat testing

  11. Summary • Patients feel well sleep improved, daytime sleepiness gone, but significant OSA with its risks remain Our data suggest that patients undergoing bariatric surgery should not expect a cure of OSA after surgical weight loss. These patients will likely need continued treatment for OSA to minimize its complications. Greenburg, D. L., C. J. Lettieri, et al. (2009). American Journal of Medicine 122(6): 535-542.

  12. Systematic review of weight loss on AHI

  13. % Weight loss and % change in AHI

  14. Randomized controlled trial on the effects of significant weight loss in severely obese patients with newly diagnosed moderate to severe OSA

  15. Obesity and severe OSA • Obstructive sleep apnoea (OSA) is strongly related to obesity • Observational data regarding the effectiveness of weight loss is impressive • Conventional therapy, such as nasal CPAP, for obstructive sleep apnoea is unlikely to have a major impact on other obesity related comorbidities that accompany OSA • Significant weight loss may provide an additional solution for the severely obese patient with severe OSA

  16. Aim • To look at changes in sleep quality, sleep apnoea, obesityrelated comorbidities and quality of life over 2 years • Subjects were randomized to conventional best care (nasal CPAP) or conventional best care (nasal CPAP) and obesity surgery

  17. Outcome measuresSleep and functional status • AHI (primary endpoint on inpatient diagnostic PSG) after a 2 day washout • CPAP pressure requirements and usage Other Sleep information • Arousal index, % REM sleep, % stage III, IV sleep, SaO2 nadir, longest apnoea • Functional status • Sleep symptoms • Quality of life • Exercise status • 6 minute walk test

  18. Inclusion criteria • 60 subjects – 30 to each program • Aged between 18 - 60 years • BMI 35-55 kg/m2 • Failed attempts to lose weight • Recently diagnosed (< 6months) moderate to severe OSA (AHI > 20) and have been advised to use nasal CPAP. • Satisfactory implementation or compliance with nasal CPAP would not be required as an entry criterion • Willing to be randomised to either of the treatment programs

  19. Exclusion criteria • Not made at least 3 significant attempts to lose weight • History of previous obesity or abdominal surgery which may preclude LAGB surgery (not cholecystectomy) • Obesity hypoventilation syndrome requiring BiPAP • History of surgery to the upper airway for snoring or OSA • Upper airway deformity or obstruction which is not related to obesity • Other medical problems which contra-indicate either arm of the study • Eg MI in last 6/12, dementia, active psychosis, alcohol or drug abuse

  20. Program 1 – medical treatment • Conventional treatment of OSA, obesity and associated conditions • Continued management of OSA • Weight loss advice • Dietitian • Exercise • Behaviouralchange • VLCD and Medications could be used • Regular review – attendance 6/52 during 2 year study period

  21. Program 2 – Surgical treatment • Continued conventional management of OSA • LAGB surgery performed by a standard technique within 1 month of randomization • Followed in the usual way at the bariatric surgical centre • Which includes lifestyle advice • Diet • Exercise • Behavioural change • Regular review – attendance 6/52 during 2 year study period

  22. Baseline characteristics of groups

  23. Absolute change in RDI • Surgical • 23.2 +/- 23 / hr (P<0.001) • Medical • 11.9 +/- 28 / hr (P=0.023) Between group difference: p = 0.2 Not significant

  24. Percentage change in RDI • Surgical • 34.8% +/- 46.9 % • Medical • 11.2 +/- 55.6 %

  25. Is there a relationship between weight loss and % change in RDI? • R=0.49 (p<0.001) • Surgical • R=0.33 (p=0.18) • Medical • R=0.69 (p<0.07)

  26. Quintiles of weight loss • range +12.3 to +2.0 kg • range +1.8 to -7.7 kg • range -8.4 to -14.2 kg • range -14.9 to -32kg • range -34.1 to -68kg

  27. Change in AHI with change in weight

  28. % change in AHI with % change in weight

  29. SF-36 domain scores baseline & 2 years

  30. Beck Depression Inventory • Medical Pre • 16.22 • Medical Post • 13.5 • Surgical Pre • 16.0 • Surgical Post • 8.28 The difference in change mean BDI scores was significantly greater in the Surgical group

  31. Epworth sleepiness scale ESS Baseline 12.6 and 24 months 7.5 p<0.001 • Medical Pre • 12.4 • Medical Post • 8.7 P=0.002 • Surgical Pre • 12.7 • Surgical Post • 6.5 P<0.001 The between change in ESS was not significant

  32. % Weight loss and % change in AHI

  33. Conclusion • This trial confirms weight loss is associated with improvement in AHI • The effects are very variable and major weight loss can have little effect • The effect appears attenuated with increasing weight loss • Few are cured and most will still need CPAP therapy.

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