Published on August 11, 2007
Morbid Obesity:No longer just a hopeless disease: Morbid Obesity: No longer just a hopeless disease Walter J. Pories, MD, FACS Departments of Surgery and Biochemistry The Brody School of Medicine East Carolina University You’ve heard it all…..: You’ve heard it all….. 'I hate fat people, they’re just gluttons' You can get some weight loss but it won’t last'. 'Surgery? You’ve got to be kidding. Those fat ladies are just awful risks.' 'Diabetes? Now there is a disease! Nothing works and folks just keep getting worse.' But the pessimism is not warrented. The truth is that: But the pessimism is not warrented. The truth is that Morbid obesity is a disease, not a moral failing Morbid obesity can be treated successfully and safely with surgery Diabetes can be placed into long-term remission with a reduction in morbidity and mortality What is Morbid Obesity?: What is Morbid Obesity? 100 lbs. over normal weight BMI (Kg/M2) 35 % body fat 25% Our average patient weighed 317 lbs: Equal to carrying three 60 lb. bags of feed 24 hrs/day “Obesity is a chronic, lifelong, genetically-related, life-threatening disease with highly significant medical, psychological, social, physical, and economic co-morbidities”: 'Obesity is a chronic, lifelong, genetically-related, life-threatening disease with highly significant medical, psychological, social, physical, and economic co-morbidities' Statement on morbid obesity and its treatment. Obesity Surgery 1997 7:40-41 Health Problems Associated with Morbid Obesity: Health Problems Associated with Morbid Obesity Diabetes Sleep Apnea Pulmonary Failure Hypertension Cardiovascular Disease Hernias Pseudotumor cerebri Slide7: Health Problems Associated with Morbid Obesity Musculoskeletal Problems Psychological Problems Gastroesophageal Reflux Infertility Cancers of colon, stomach, breast The Emotional Side of Morbid Obesity: The Emotional Side of Morbid Obesity In the 16 year cohort Of the 17 deaths 5 were alcohol related 2 were suicides And others required treatment 1 (1%) was hospitalized for depression 2 (2%) had suicide attempts 1 (1%) became addicted to alcohol “In 1991, the National Institutes of Health concluded in its Consensus Conference that diets, exercise programs, appetite suppressants and behavior modifications are not effective therapies”: 'In 1991, the National Institutes of Health concluded in its Consensus Conference that diets, exercise programs, appetite suppressants and behavior modifications are not effective therapies' Report of the Consensus Conference on Surgery of Morbid Obesity, National Institutes of Health, Washington, DC 1991 The Greenville Gastric Bypass: The Greenville Gastric Bypass 10 - 20 ml gastric pouch 8 - 10 mm. anastomosis 40 - 60 cm alimentary loop Total group 1980-1998 = 831 16 year cohort =147 Bariatric Surgery at East Carolina University 1980 -1997: Bariatric Surgery at East Carolina University 1980 -1997 Primary Gastric Bypass 831 Revisions 180 Other Vertical Banded Gastroplasty 19 Adjustable Gastric Banding 35 Total 1,065 Follow-up Was Rigorous: Follow-up Was Rigorous 147 patients underwent the gastric bypass between Jan. 1980 - 1982 8 were lost ( 95% 16 year follow-up) 17 (12%) patients died 122 (83%) had a 16 year followup 16 Yr. Gastric Bypass Follow-up Study Population: 16 Yr. Gastric Bypass Follow-up Study Population 93 (76%) White Females 14 (12%) Black Females 15 (12%) White Males Ages: 31-72 years Average age at follow-up = 52 years Weight Loss After Bariatric Surgery @ 16 Years: Weight Loss After Bariatric Surgery @ 16 Years Slide15: 0 1 2 5 10 16 150 200 250 300 LB Years The weight loss is sustained The improvement was sustained: The improvement was sustained Slide17: Initial Conclusions The Greenville gastric bypass provides better control of weight than any other therapy even after 16 years The gastric bypass is safe with a 1% mortality And a 10% perioperative complication rate. The operation also controls diabetes, hypertension, arthritis, sleep apnea, and infertility in many of the patients Hey?Did you say thatthe operation controls diabetes?: Hey? Did you say that the operation controls diabetes? Yes, the gastric bypass:: Yes, the gastric bypass: Restores euglycemia in 83% of diabetics Restores euglycemia in 99% of IGT Prevents progression of occult diabetes Improves the mortality rate from 4.5% to 1% per year In fact, the diabetes is usually gonebefore the patient leaves the hospital : In fact, the diabetes is usually gone before the patient leaves the hospital Why does it work?: Why does it work? Patients eat less after the operation In most patients, the diet changes The operation excludes much of the foregut from food The hyperglycemia and excessive insulin disappear within days Some clues: It doesn’t make senseAre we wrong about diabetes?: It doesn’t make sense Are we wrong about diabetes? The current textbook explanation? Type 2 diabetes is an intracellular disease due to increased insulin resistance. Yes, the return to euglycemia is very rapid,a matter of days!: Yes, the return to euglycemia is very rapid, a matter of days! Before there is significant loss of weight or fat! Slide24: Is Weight Loss the Critical Factor? Two groups of 6 weight stable women Surgical Group: Had the gastric bypass and were now weight stable Control Group: Also weight stable; No surgery but matched to the other group in adiposity: %fat, age, waist size, weight, aerobic capacity The groups were well matched: The groups were well matched Control Bypass Age (yrs) 40.4 41.2 % fat 40.7 40.2 BMI 39.6 43.7 Waist (cm) 122.3 114.7 VO2max 20.5 20.1 VO2max=ml*kg-1*min-1 The gastric bypass produced remarkable changes:: The gastric bypass produced remarkable changes: control bypass fasting glucose (mM) 5.70 4.82 fasting insulin (pM) 95.3 23.0 leptin (ng/ml) 35.8 22.3 insulin sensitivity 1.75 3.90 ? intake (Kcal/day) 2252 1156 all significant at pandlt;0.05 level Exclusion of food from the foregutproduces profoundalterations of glucose metabolismindependent of weight: Exclusion of food from the foregut produces profound alterations of glucose metabolism independent of weight Nor is the change in glucose metabolism just of academic interest: Nor is the change in glucose metabolism just of academic interest NIDDM with gastric bypass 1%/yr NIDDM controls; no surgery 4.5%/yr The operation reduces mortality And morbidity from diabetes If changingthe plumbing of the gutprovides full remissionof diabetescould it be that diabetesis a disease of the gut?: If changing the plumbing of the gut provides full remission of diabetes could it be that diabetes is a disease of the gut? And other clues to the role of the gut in the etiology of diabetes: And other clues to the role of the gut in the etiology of diabetes Surgical observations: The obese gut is different: thicker walls, more vascular, ? longer Tumors: Patients with insulinomas have a high insulin resistance Incretins: insulin-stimulating intestinal hormones have been identified Slide31: CHO incretins Slide32: CHO Insulin Resistance Slide33: CHO Insulin Resistance Slide34: Diabetes may be an Endocrine disease of the gut Diabetes may be due to hyperincretinism and Insulin resistance may be a Protective mechanism of the gut Conclusions: Conclusions The gastric bypass provides safe and effective control of morbid obesity and many of complications of that disease. The gastric bypass provides long-term control of diabetes; a phenomenon that is Still poorly understood.