7jahre freiburg

Successful multi-intervention treatment of
severe obesity: a 7 year prospective study with
96% follow up
F. Horber
N. Bieri, N. Potoczna, Rudolf Steffen
Adipositas Zentrum, Klinik Lindberg, Winterthur, Schweiz
Hintergrund
The SOS-Studie hat gezeigt
Dass 10 Jahre nach Bariatrisch-Chirurgischem
Eingriff
- die Hypertonie nicht ohne Medikamente
kontrolliert bleibt
-häufig eine sekundäre Gewichtszunahme
beobachtet wird (mehrere Bodymasseinheiten)
Hintergrund (2)
Ob eine multimodale Adipositas-Therapie
(Chirurgie kombiniert mit konservativen
Massnahmen)
- das Gewicht langfristig reduziert halten kann
- ein Rezidiv des Metabolen Syndroms
verhindert
Ist unbekannt.
Patient`s characteristics
(318 / 86 )
N ( f/m )
404
Age [y]
42.5
+/- 0.5
Weight [kg]
118.5
+/- 0.8
BMI [kg/m2]
42.6
+/- 0.2
EBW [%]
55.8
+/- 0.7
Values are given as mean ± SEM
Methodik
Primäroperation: Magenband
Chirurgischer Reoperationsalgorhythmus:
Surgery 2005;137:33-41
-68 Roux-en-Y gastric bypass
-23 Biliopankreatische Diversion
-Slippage und Band Leck: Bandersatz
Methodik (2)
Primäroperation: Magenband
- Lebensstilmodifikation
-- Ernährung
-- Individuelle Bandanpassung
-- Bewegungsmotivation mit Pedometer
-- Stopp Rauchen
-  Regelmässige Befragung bez.
Esstörungen
-  Psychosoziale Beratung
-  Rollende Behandlung der Komorbiditäten
Follow up
Completed seven-year follow up
388 ( 96%)
Lost of follow up
11 (2.7%)
Nonprocedural mortality
5 (1.3%)
Mortalität
Patients treated with
bariatric surgery (N=404)
Nonprocedural mortality
Cancer (pulmonary, pancreas)
Myocardial infarction
N=5
N=2
N=2
Liver transplantation due to
Autoimmune hepatitis
N=1
(men)
(women)
(women)
Mortalitätsreduktion durch
Gewichtsreduktion
Adams et al. NEJM 2007
57.1 Todesfälle per 100’000
37.6 Todesfälle per 100’000
aktuelle Rate
18.1 Todesfalle per 100’000
Komplikationen
Number of patients [in %] with complications
related to the gastric band each followup year
Complications
Follow up
Band intolerance
Band slippage
Insufficient weight loss
Band leak
Band removal
Band migration
Total
1
0.5
0.3
0.8
2
1.5
0.5
1.8
3.9
3
3.9
1.8
1.5
7.2
All [N=388]
4
5
3.6 3.4
1.5 1.0
0.8 1.3
0.8 1.8
0.3
0.5
6.7 8.2
6
3.1
1.0
1.5
0.5
0.3
6.4
7
1.8
0.8
0.3
0.5
0.3
0.3
3.9
mean
2.5
1.0
0.8
0.7
0.2
0.1
5.3
Number of patients [in %] with complications
related to the gastric band each followup year
[%] of all patients
100
Mean of total per year 5.3%
10
0
1
2
3
4
Year of followup
5
6
7
Complications of laparoscopic bypass
necessitating invasive treatment
Complications
Change to another bariatric Procedure
Year of followup
1
2
3
4
n*
83
71
53
36
Anastomotic ulcer without stenosis
2.4
2.8
-
-
Anastomosis stenosis with
endoscopic dilatation
19.3
1.4
3.8
2.8
1.2 (2.4)
1.4 (9.9)
0 (3.8)
0 (13.9)
Internal hernia
2.4
4.2
1.9
2.8
Total
22.9
9.9
5.7
5.6
Incisional hernia°
n*: Follow up of patient after conversion to bypass. 100% patient included.
°: Incisional hernias after laparoscopic bariatric therapies. In Parenthesis are given all incisional hernia.
Gewichtsverlauf
Time course of Excessive Weight Loss
[%]
-10
Change to Bypass
mean 3.6± 0.17 years after SAGB.
-30
-50
SAGB [N=292]
Change to Bypass
[N=91]
-70
0
1
2
3
4
5
6
7
EWL at 7 years (Reinhold Criteria)
Metaboles
Syndrom
Metabolic syndrome according ATP III
Hypertension
> 130 / 85 mmHg
or taking antihypertensive drugs
Type 2 Diabetes
Hb-A1c > 7%
or taking antidiabetic drugs
Low HDL-Cholesterol
women
< 1.28 mmol/l
men
< 1.04 mmol/l
Hyper-Triglyceridemia
< 1.7 mmol/l
Metabolic syndrome
Metabolic syndrome
Hypertension
Hypertension
Type 2 Diabetes
Type 2 Diabetes
Lebensqualität
Lebensqualität
Gemessen mittels Fragen
des BAROS-Fragebogen
(identische Resultate wie SF36)
0: gleiche Lebensqualität
3: MAXIMALE VEBESSEUNG
-3: MAXIMALE VERSCHLECHTERUNG
Quality of life as estimated by BAROS
BAROS
=bariatric reporting and
outcome system
Overall outcome after 7 years according to
Baros Score
SAGB
Excellent
5.8%
Very Good
30.5%
Good
34.6%
Fair
21.9%
Failure
7.2%
}
70.9%
}
Change to another
bariatric procedure
1.1%
§
2.2%
24.2%
54.9%
29.1%
17.6%
}
}
27.5%
§
72.5%
§: Chi2-test: p<0.001
BAROS: reoperation corrected
SAGB
Excellent
12.7%
Very Good
33.2%
Good
33.2%
Fair
16.1%
Failure
4.8%
}
79.1%
}
Change to another
bariatric procedure
8.8%
§
25.3%
44.0%
17.6%
20.9%
4.4%
}
}
78.0%
§
22.0%
§: Chi2-test: p=not significant
Schlussfolgerung
Schlussfolgerung
1.  Gewichtsreduktion kann nach 7
Jahren erhalten weren
MINUS 12 BMI Einheiten
2.  Mortalität sinkt um über 60% in 7 Jahren
3.  Das Metabole Syndrom kann gewichtsabhängig
reduziert werden
MINUS 16 BMI EINHEITEN: 0
4.  Die Lebensqualität abh. vom abgenommenen
Gewicht, „the more, the better“
Schlussfolgerung(2)
Je mehr Gewicht verloren wird, desto
- Besser Lebensqualität
- Tiefer die Rate des metabolen
Syndroms
ABER:
- Reoperationsrate von 5.3%/Jahr
- Outcome Revisions Magenbypass und
Primäres Magenband identisch
Anhang
Odds for resolved disease metabolic
syndrome and its components
Patients [in%]
25%
30%
30%
15%
Referenz: SPSS Vers. 11.0, logistic regression and linearize the resulted odds-function for a interval of interest
Rebanding for band leak
18.9 +/- 2.0
Rebanding for pouch-dilatation /
slippage
30.9 +/- 2.0
Rebanding for band migration
25.5 +/- 8.5
Revisonal Roux-Y for band intolerance
11.5 +/- 1.3
Revisional BPD for insufficient
weight loss
11.6 +/- 1.7
Weight lost intervention band removed
12.1 +/- 8.0
Odds for resolved metabolic syndrome
and its components
Parameter
Odds for resolved (Factor
1000) (b=BMI lost[%])
Interval BMI
lost [%]
- 132 + 56b - 0.7b2
[10%, 40%]
280 + 30b - 0.3b2
[10%, 40%]
Diabetes T2D
- 5.8 + 24b
[10%, 40%]
Hypertension
2.5 + 14b
[10%, 50%]
- 39 + 6.3b
[10%, 40%]
Odds > 0.9
> 15%
Metabolic syndrome
LDL-cholesterol (bypass)
SAGB group is independent
Cholesterol (SAGB)
Bypass group is independent
Hypertriglycerid
HDL-cholesterol is independent
Referenz: SPSS Vers. 11.0, logistic regression and linearized the resulted odds-function for a interval of interest