- Email: [email protected]
The role of bariatric surgery in morbidly obese patients with inflammatory bowel disease
Surgery for Obesity and Related Diseases ] (2014) 00–00
Original article
The role of bariatric surgery in morbidly obese patients with inflammatory bowel disease Andrei Keidar, M.D.a,*, David Hazan, M.D.b, Eran Sadot, M.D.a, Hanoch Kashtan, M.D.a, Nir Wasserberg, M.D.a a
Department of Surgery, Beilinson Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel b Carmel Medical Center, Bruce Rappaport Faculty of Medicine, The Technion, Haifa, Israel Received April 29, 2014; accepted June 30, 2014
Abstract
Background: Bariatric surgery is considered as being contraindicated for morbidly obese patients who also have inflammatory bowel disease (IBD). The aim of our study was to report the outcomes of bariatric surgery in morbidly obese IBD patients. Methods: The prospectively collected data of all the patients diagnosed as having IBD who underwent bariatric operations in 2 medical centers between October 2006 and January 2014 were retrieved and analyzed. Results: One male and 9 female morbidly obese IBD patients (8 with Crohn’s disease and 2 with ulcerative colitis) underwent bariatric surgery. Their mean age was 40 years, and their mean body mass index was 42.6 kg/m2. Nine of them underwent a laparoscopic sleeve gastrectomy and 1 underwent a laparoscopic adjustable gastric band. Eight patients had obesity-related co-morbidities, including type 2 diabetes, hypertension, sleep apnea, osteoarthropathy, etc. After a median follow-up of 46 months (range 9–67), all of the patients lost weight, with an excess weight loss of 71%, and 10 out of 16 obesity-related co-morbidities were resolved. There was 1 complication not related to IBD, and no IBD exacerbation. Conclusion: Bariatric surgery was safe and effective in our morbidly obese IBD patients. The surgical outcome in this selected patient group was similar to that of comparable non-IBD patients. (Surg Obes Relat Dis 2014;]:00–00.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Morbidly obese; Inflammatory bowel disease; Laparoscopic sleeve gastrectomy; Laparoscopic adjustable gastric banding; Co-morbidities
The prevalence of obesity has increased over the last few decades and is now considered a global epidemic [1]. Although obesity is traditionally considered unusual in patients with inflammatory bowel disease (IBD), it has been reported to be on the increase in this patient population as well [2,3], with significantly higher rates for Crohn’s disease (CD) than for, ulcerative colitis (UC) patients. A *
Correspondence: Andrei Keidar, M.D., Department of Surgery, Beilinson Medical Center, Jabotinsky 39, Petach Tikva, Israel. E-mail: [email protected]
recent observational Scottish study found that 18% of the IBD population was obese (body mass index [BMI] 430 kg/m2) in comparison to 23% of the Scottish population as a whole [2]. Another report revealed that weight has been increasing over time from 1991–2008 in CD patients, as evidenced by baseline data from randomized clinical trials [4]. Although IBD is not considered a “classical” obesityrelated co-morbidity, both entities share a cause-and-effect relationship and are associated with increased inflammatory reaction [5]. There is some evidence that overexpressed obesity-related inflammatory cytokines may actually induce
http://dx.doi.org/10.1016/j.soard.2014.06.022 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
2
A. Keidar et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
IBD [4]. Moreover, several studies showed increased morbidity among obese IBD patients, including a higher hospital admission rate, more frequent anoperineal complications and increased disease activity [6,7]. Other published data indicated that obese IBD patients are subject to higher rates of complications after IBD-related surgical interventions, and that those complications were because of obesity co-morbidities as well as anatomic considerations [8,9]. Bariatric surgery is reported to be the most effective option for weight loss in the severely obese, and the number of patients undergoing surgery for weight loss is dramatically increasing [1,10]. When it comes to severely obese IBD patients, however, surgeons are reluctant to carry out any non-IBD related intestinal operation because of the probable higher rates of short- and long-term complications [11]. This is especially applicable to bariatric procedures [12], and therefore evidence in the literature on the outcome of obesity surgery in patients with IBD is sparse and mostly derived from small numbers of case reports [13]. We report the outcomes of surgically induced weight loss in a series of 10 morbidly obese IBD patients.
Methods Patients and study design The data collection was approved by the Research Ethics Committee of both participating medical centers, and patient consent was waived. The records of all the patients diagnosed as having IBD who underwent bariatric operations in 2 hospitals were retrieved from the prospectively collected data throughout the study period (from October 2006 to January 2014). All of the morbidly obese patients referred to our obesity clinics for potential surgical treatment undergo a multidisciplinary evaluation by a dietician, psychologist, and a bariatric surgeon. In addition, they all attend a lecture that includes a comprehensive description of the indications, risks, and benefits of the different types of bariatric procedures. The indications for surgery included a BMI 440 kg/m2 or 435 kg/m2 together with at least 1 severe obesity-related co-morbidity (type 2 diabetes, hypertension, sleep apnea, osteoarthropathy, etc.) and the failure of previous conservative attempts to lose weight. The choice of the procedure was made according to the individual characteristics of the patient, such as age, BMI, health-related conditions, previous operations, medications, degree of self-discipline, eating habits (“addiction” to sweets, binge eating), anatomic conditions (e.g., large hiatal hernia), and individual preferences of the candidate when there was more than one option. The diagnosis of IBD was established by an appropriate clinical picture, endoscopic findings and occasionally by pathologic examination. A prerequisite before proceeding with the decision for performing bariatric surgery was a
letter of referral from the treating gastroenterologist, which included a detailed explanation of the clinical manifestations, extent of the disease, complications, and treatment. Special emphasis was placed on an endoscopic report describing the extent of bowel involvement. Each patient underwent preoperative blood tests consisting of complete blood count, routine blood chemistry, liver and kidney function tests, lipid profile, albumin, transferrin, iron, ferritin, folic acid, vitamin B12, parathyroid hormone, calcium and phosphorus, preoperatively. The same tests were performed postoperatively. Anthropometric measurements included weight, height, BMI, and percent excess weight loss (%EWL). Operative technique Only 2 types of bariatric operations were performed in the current series, laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (SG). The pneumoperitoneum was created by insertion of the optic trocar to the left of the midline above the umbilicus. After insufflation, additional 12-mm working trocars were introduced under direct vision. Dissection was performed with 5-mm ultrasonic shears (Ethicon Endosurgery, Cincinnati, OH). LAGB was performed by a pars flaccida technique, using a Swedish band (Obtech, Johnson & Johnson, Cincinnati, OH) without suture band fixation. The SG was performed using 5 ports. The omentum adjacent to the whole length of the greater curvature and splenic short gastric vessels were divided by a harmonic scalpel (Ethicon Endosurgery). Different sizes of gastric bougies were inserted into the pylorus. The longitudinal stomach division started at 2 cm proximally to the pylorus by consecutive application of an endoscopic stapler (blue and green load, EndoGIA 45 mm, or Echelon golden load, Ethicon Endosurgery) parallel to the bougie, up to the gastroesophageal junction. A gastric tube (sleeve) o100 cc in volume was placed, and the remaining 80% of the stomach was excised. The staple line was inverted by placing a sero-serosal continuous polydioxanone suture in patients operated by author DH but not by author AK. Diluted half-strength methylene blue dye (50 cc) was used to test for leaks. The duodenum was clamped, and irrigating the sleeve usually caused the dye to overflow back to the patient’s mouth. The excised stomach was removed by enlarging the peritoneal and fascial opening of the 12-mm trocar and by pulling the entire bulk from the antrum without the need for a protecting bag. The enlarged fascial opening was closed with a single figure-of-8 Maxon No. 1 suture, and a drain was left along the suture line through one 5-mm port for 2 days. On postoperative day (POD) 1, the patients underwent a Gastrografins X-ray study to rule out leaks, after which they were started on sips of clear liquids. None of these tests showed an obstruction on the POD 1 contrast swallow studies
Bariatric Surgery for Morbidly Obese IBD Patients / Surgery for Obesity and Related Diseases ] (2014) 00–00
Results A total of 1,900 patients underwent bariatric surgery in the 2 medical centers during the study period, and the ten among them who had been diagnosed as having IBD comprised the present study group. There were 9 females and one male whose median age was 40 years (range 25–58). The bariatric procedures included SG in 9 patients and LAGB in one patient. The median follow-up was 46 months (range 9–67). Bariatric-related data The mean preoperative weight, BMI, and excess weight of the study group were 114 kg, 42.6 kg/m2, and 59.5 kg, respectively, (Table 1). The mean weight, BMI, and %EWL at the longest follow-up were 78.6 kg, 29 kg/m2, and 71, respectively. All of the patients were followed-up at the medical center’s bariatric clinic. Four of the patients developed serious vitamin B12 and vitamin D deficiencies and iron deficiency anemia, and they responded well to appropriate treatment. Eight patients had 16 obesity-related co-morbidities, and 10 of those co-morbidities resolved after the bariatric procedure. The single postoperative complication consisted of staple line leakage which was discovered on POD 14 in a UC patient who underwent an SG. After multiple failures of conservative treatment by percutaneous drainage and an attempted Over-the-scope clip deployment, that patient underwent a completion total gastrectomy with esophagojejunostomy 4 months after the original surgery and experienced no further complications. IBD-related data Eight patients were diagnosed as having CD and 2 as having UC. The average IBD duration before bariatric surgery was 6.8 years (range 1–15) (Table 2). Seven of the patients were under maintenance treatment during
3
bariatric surgery, 6 with 5-ASA derivatives and one with 5-ASA and adalimumab (Humira). None of the patients had undergone any surgical procedures related to their IBD before the index bariatric operation. One CD patient underwent percutaneous drainage of an interloop abscess 10 years before the bariatric intervention. All of the study patients continued their medical IBD treatment without any change or interruption. Three patients were able to stop their 5-ASA treatment, while 2 others continued taking the medication with good therapeutic effect. Another patient that had not received any prior IBD treatment was started on 5-ASA for mild exacerbation of the disease. All stomach specimens from the SG were sent for pathologic evaluation and none showed any evidence of IBD. Discussion This report presents the outcomes of a small series of morbidly obese IBD patients who underwent a weight reduction surgical procedure. Our data suggest that SG and LAGB appear to be safe for morbidly obese IBD patients and yield satisfying weight loss-related results without a higher risk of postoperative complications or an increased risk of postintervention IBD exacerbation. Bariatric surgery is considered as being contraindicated for IBD patients because of the risk of postoperative complications, such as anastomotic leaks, fistulas, abscesses, bowel stricture and bowel obstruction, and the risk for neoplasm in a bypassed bowel loop [14]. Moreover, CD and UC patients are reportedly at increased risk of requiring future surgical interventions, including repeated bowel resection in CD patients [15] and the altered small bowel anatomy after gastric bypass may affect technical issues of construction, accessibility and function of an ileoanal pouch reservoir in UC patients [13]. Previous case reports have provided contradictory information about the effect of weight reduction surgery on IBD patients [13]. Some of them reported exacerbation of IBD symptoms after surgery [16], while others have suggested
Table 1 Bariatric data PT
Age
Sex
Bariatric procedure
Weight (kg)
Height (cm)
EW (kg)
BMI (kg/m2)
1 2 3 4 5 6 7 8 9 10
25 44 30 32 42 58 26 44 38 58
F F F F F M F F F F
SG SG SG LAGB SG SGþHH SG SG SG SG
112 93.5 153 126 127 124 115 99 106 90
168 159 163 176 171 173 160 154 158 156
41.4 34.4 86.6 48.6 53.9 49 51 39.7 43.6 28.8
40 39 57.6 41 43 41 44 42 42 37
Co-morbidity Hyperchol, hyperTG, HTN FL DM,TG, cholesterol HTN-GERD None FL IFG, FL DM, HTN, Triglyc, proteinuria
FU (mo)
%EWL
46 66 65 56 48 45 24 2 12 7
79 73 63 61 79 69 73 75 71 71
BMI ¼ body mass index; DM ¼ diabetes mellitus; EW ¼ excess weight; %EWL ¼ percent excess weight loss; F ¼ female; FL ¼ fatty liver; FU ¼ follow up; GERD ¼ gastroesophageal reflux disorder; HH ¼ hiatal hernia; HTN ¼ hypertension; Hyperchol ¼ hypercholesterol; HyperTG ¼ hypertriglycerides; IFG ¼ impaired fasting glucose; LAGB ¼ laparoscopic adjustable gastric band; M ¼ Male; PT ¼ patient; SG ¼ sleeve gastrectomy.
A. Keidar et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
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Table 2 Inflammatory bowel disease (IBD)-related data IBD type
Bowel involved
Past treatment
Treatment at time of operation
Current treatment
IBD exacerbation
CD CD CD CD CD CD CD CD UC UC
Ti Sb Sb TI, cecum Ti Ti TI-left colon Sigmoiditis,ileitis Pancolitis Left colon
Pentasa Pentasa Pentasa None Pentasa Humira-salazopirin Steroids-pentasa Asacol Rafasal
Pentasa Pentasa Pentasa None Pentasa Humira-slazopirin Pentasa Pentasa None None
Azulfidin Pentasa None None None Humira None
None Yes, mild Yes, mild Yes, mild None None None None None
Rafasal
CD ¼ Crohn’s disease; IBD ¼ inflammatory bowel disease; SB ¼ small bowel; TI ¼ terminal ileum; UC ¼ ulcerative colitis.
that bariatric surgery may actually reduce systemic inflammation, leading to better symptom control and reduced medication use [17]. Ahn et al. [16] reported 3 morbidly obese patients without any prior personal or family history of gastrointestinal disease symptoms who underwent a Roux-en-Y gastric bypass and developed endoscopically proven newly diagnosed CD within 11–60 months of surgery. Similarly Janczewska et al. [18], reported 2 patients who were diagnosed as having CD after undergoing GB for morbid obesity. Moun et al. [19] described a 40-year-old morbidly obese female with type 2 diabetes and hypertension who also had medically controlled ileocolic CD. She underwent a Roux-en-Y gastric bypass with successful weight reduction and resolution of her hypertension and diabetes but developed active CD after surgery. Tenorio Jiménez et al. [20] reported a 39-year-old morbidly obese male (BMI 52 kg/m2) with a history of type 2 diabetes mellitus, thrombophilia, and UC who developed severe protein malnutrition after biliary-pancreatic diversion requiring readmission and rigorous medical therapy 10 months after surgery. Most of the reported indications for bariatric surgery are related to obesity and its related co-morbidities. However, both patients with active IBD and patients with morbid obesity are reported to have elevated serum levels of interleukin-6 and tumor necrosis factor alpha, as well as other inflammatory mediators, which correlate to adipocyte mass [21] and are overexpressed in the mesenteric fat of patients with active IBD [5,22]. Owing to the common inflammatory pathways shared by obesity and IBD, obesity surgery may be hypothetically indicated for refractory IBD symptoms or for loss of medical response [23] in obese IBD patients. Weight loss surgery could also be considered for planned restorative proctocolectomy and ileal pouch reservoir in morbidly obese UC patients for whom obesity poses a significant technical challenge to the surgeon and is even considered a relative contraindication for this procedure. Lascano et al. [17] reported a 39-year-old morbidly obese male (BMI 57 kg/m2) with steroid-treated UC and
hypertension, who demonstrated significant clinical improvement after gastric bypass surgery and 80% excess weight loss. In their poster presented at the American Society for Metabolic and Bariatric Surgery, Gagne et al. [24] retrospectively reviewed the outcomes of 8 UC and 9 CD morbidly obese patients (a median BMI of 46.7 kg/m2). Eleven patients underwent laparoscopic Roux-en-Y gastric bypass, 4 had LAGB, and 1 had SG. Five of them had undergone previous IBD-related surgical interventions, including total colectomy with ileostomy (n ¼ 3), abdominal perineal resection (n¼1), and total colectomy and smallbowel resection (n ¼ 1). Surgery was aborted in 1 CD patient who was found to have small-bowel anastomoses and small-bowel bypass. Three other CD patients had postoperative complications, including lower gastrointestinal bleeding, abdominal phlegmon, and abscess with stomal hernia necessitating port removal. All of the patients in their cohort had successful weight loss after a median follow-up of 34 months (range 9–110), together with resolution of their obesity-related co-morbidities. Those authors concluded that IBD can complicate bariatric surgery, but should not be a contraindication to performing it. The art of tailoring the appropriate bariatric procedure for a morbidly obese patient involves many considerations [25]. Our data, supported by those of others, indicate that weight reduction surgery should not be denied to morbidly obese IBD patients provided that there is careful patient selection through a multidisciplinary team approach and a proper preoperative evaluation. IBD patients are at risk of requiring future small bowel surgery or, alternatively, already had one or more in the past that may make malabsorptive procedures more challenging. There are few descriptions of the performance of SG on morbidly obese IBD patients, while SG was our primary surgical procedure in the current report. Gastroduodenal CD is rare, occurring in fewer than 2% of CD patients [26], and we consider that SG and LAGB seem to be good surgical options for the morbidly obese patients, although additional supportive evidence is required.
Bariatric Surgery for Morbidly Obese IBD Patients / Surgery for Obesity and Related Diseases ] (2014) 00–00
Conclusion Our study showed that bariatric surgery appears to be effective and safe for morbidly obese IBD patients. The risk of surgical complications is no greater for them than it is for other bariatric surgical candidates. The choice of a specific surgical procedure must be made judiciously and in consensus by a multidisciplinary team and the patient. Finally, small bowel sparing procedures may be preferable. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Obesity and overweight Fact Sheet No. 311. Geneva (Switzerland): World Health Organization; Mar, 2011. [accessed 2012 Oct. 3]. Available: www.who.int/mediacentre/factsheets/fs311/en/print.html. [2] Steed H, Walsh S, Reynolds N. A brief report of the epidemiology of obesity in the inflammatory bowel disease population of Tayside, Scotland. Obes Facts 2009;2:370–2. [3] Long MD, Crandall WV, Leibowitz IH, et al. Prevalence and epidemiology of overweight and obesity in children with inflammatory bowel disease. Inflamm Bowel Dis 2011;17:2162–8. [4] Moran GW, Dubeau MF, Kaplan GG, Panaccione R, Ghosh S. The increasing weight of Crohn’s disease subjects in clinical trials: a hypothesis-generating time-trend analysis. Inflamm Bowel Dis 2013;19: 2949–56. [5] Bertin B, Desreumaux P, Dubuquoy L. Obesity, visceral fat and Crohn’s disease. Curr Opin Clin Nutr Metab Care 2010;13:574–80. [6] Blain A, Cattan S, Beaugerie L, Carbonnel F, Gendre JP, Cosnes J. Crohn’s disease clinical course and severity in obese patients. Clin Nutr 2002;21:51–7. [7] Nic Suibhne T, Raftery TC, McMahon O, et al. High prevalence of overweight and obesity in adults with Crohn’s disease: Associations with disease and lifestyle factors. J Crohns Colitis 2013;7:e241–8. [8] Efron JE, Uriburu JP, Wexner SD, et al. Restorative proctocolectomy with ileal pouch anal anastomosis in obese patients. Obes Surg 2001;11:246–51. [9] Benoist S, Panis Y, Alves A, Valleur P. Impact of obesity on surgical outcomes after colorectal resection. Am J Surg 2000;179:275–81. [10] Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA 2005;294:1909–17.
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[11] Navaneethan U, Parasa S, Venkatesh PG, Ganapathi TT, Kiran RP, Shen B. Impact of inflammatory bowel disease on postcholecystectomy complications and hospitalization costs: a Nationwide Inpatient Sample study. J Crohns Colitis 2013;7:e164–70. [12] Krane MK, Allaix ME, Zoccali M, et al. Does morbid obesity change outcomes after laparoscopic surgery for inflammatory bowel disease? Review of 626 consecutive cases. J Am Coll Surg 2013;216:986–96. [13] Boutros M, Maron D. Inflammatory bowel disease in the obese patient. Clin Colon Rectal Surg 2011;24:244–52. [14] Hass DJ, Brensinger CM, Lewis JD, Lichtenstein GR. The impact of increased body mass index on the clinical course of Crohn’s disease. Clin Gastroenterol Hepatol 2006;4:482–8. [15] Riss S, Schuster I, Papay P, Mittlböck M, Stift A. Repeat intestina resections increase the risk of recurrence of Crohn’s disease. Dis Colon Rectum. 2013;56:881–7. [16] Ahn LB, Huang CS, Forse RA, Hess DT, Andrews C, Farraye FA. Crohn’s disease after gastric bypass surgery for morbid obesity: is there an association? Inflamm Bowel Dis 2005;11:622–4. [17] Lascano CA, Soto F, Carrodeguas L, Szomstein S, Rosenthal RJ, Wexner SD. Management of ulcerative colitis in the morbidly obese patient: is bariatric surgery indicated? Obes Surg 2006;16:783–6. [18] Janczewska I, Nekzada Q, Kapraali M. Crohn’s disease after gastric bypass surgery. BMJ Case Rep 2011 Jun 3;2011. [19] Moum B, Jahnsen J. Obesity surgery in inflammatory bowel disease [in Norwegian]. Tidsskr Nor Laegeforen 2010;130:638–9. [20] Tenorio Jiménez C, Manzano García G, Prior Sánchez I, et al. Bariatric surgery in inflammatory bowel disease; case report and review of the literature [in Spanish]. Nutr Hosp 2013;28:958–60. [21] Das UN. Is obesity an inflammatory condition? Nutrition 2001;17: 953–66. [22] Fink C, Karagiannides I, Bakirtzi K, Pothoulakis C. Adipose tissue and inflammatory bowel disease pathogenesis. Inflamm Bowel Dis 2012;18:1550–7. [23] Harper JW, Sinanan MN, Zisman TL. Increased body mass index is associated with earlier time to loss of response to infliximab in patients with inflammatory bowel disease. Inflamm Bowel Dis 2013;19:2118–24. [24] Gagné D, Palmer J, Urbandt J. Inflammatory bowel disease and bariatric surgery: our experience after 3,000 cases. ASMBS 2012; Abstract P-95.Poster Annual Meeting 2012 American Society for Metabolic and Bariatric Surgery (ASMBS) West Penn Allegheny Health System, Pittsburgh, PA, US. http://2012.asmbs.org/files/2012/ 06/Abstracts-Posters.pdf. [25] Gould J, Ellsmere J, Fanelli R, et al. Panel report: best practices for the surgical treatment of obesity. Surg Endosc 2011;25:1730–40. [26] Nugent FW, Roy MA. Duodenal Crohn’s disease: an analysis of 89 cases. Am J Gastroenterol 1989;84:249–54.
Original article
The role of bariatric surgery in morbidly obese patients with inflammatory bowel disease Andrei Keidar, M.D.a,*, David Hazan, M.D.b, Eran Sadot, M.D.a, Hanoch Kashtan, M.D.a, Nir Wasserberg, M.D.a a
Department of Surgery, Beilinson Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel b Carmel Medical Center, Bruce Rappaport Faculty of Medicine, The Technion, Haifa, Israel Received April 29, 2014; accepted June 30, 2014
Abstract
Background: Bariatric surgery is considered as being contraindicated for morbidly obese patients who also have inflammatory bowel disease (IBD). The aim of our study was to report the outcomes of bariatric surgery in morbidly obese IBD patients. Methods: The prospectively collected data of all the patients diagnosed as having IBD who underwent bariatric operations in 2 medical centers between October 2006 and January 2014 were retrieved and analyzed. Results: One male and 9 female morbidly obese IBD patients (8 with Crohn’s disease and 2 with ulcerative colitis) underwent bariatric surgery. Their mean age was 40 years, and their mean body mass index was 42.6 kg/m2. Nine of them underwent a laparoscopic sleeve gastrectomy and 1 underwent a laparoscopic adjustable gastric band. Eight patients had obesity-related co-morbidities, including type 2 diabetes, hypertension, sleep apnea, osteoarthropathy, etc. After a median follow-up of 46 months (range 9–67), all of the patients lost weight, with an excess weight loss of 71%, and 10 out of 16 obesity-related co-morbidities were resolved. There was 1 complication not related to IBD, and no IBD exacerbation. Conclusion: Bariatric surgery was safe and effective in our morbidly obese IBD patients. The surgical outcome in this selected patient group was similar to that of comparable non-IBD patients. (Surg Obes Relat Dis 2014;]:00–00.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Morbidly obese; Inflammatory bowel disease; Laparoscopic sleeve gastrectomy; Laparoscopic adjustable gastric banding; Co-morbidities
The prevalence of obesity has increased over the last few decades and is now considered a global epidemic [1]. Although obesity is traditionally considered unusual in patients with inflammatory bowel disease (IBD), it has been reported to be on the increase in this patient population as well [2,3], with significantly higher rates for Crohn’s disease (CD) than for, ulcerative colitis (UC) patients. A *
Correspondence: Andrei Keidar, M.D., Department of Surgery, Beilinson Medical Center, Jabotinsky 39, Petach Tikva, Israel. E-mail: [email protected]
recent observational Scottish study found that 18% of the IBD population was obese (body mass index [BMI] 430 kg/m2) in comparison to 23% of the Scottish population as a whole [2]. Another report revealed that weight has been increasing over time from 1991–2008 in CD patients, as evidenced by baseline data from randomized clinical trials [4]. Although IBD is not considered a “classical” obesityrelated co-morbidity, both entities share a cause-and-effect relationship and are associated with increased inflammatory reaction [5]. There is some evidence that overexpressed obesity-related inflammatory cytokines may actually induce
http://dx.doi.org/10.1016/j.soard.2014.06.022 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
2
A. Keidar et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
IBD [4]. Moreover, several studies showed increased morbidity among obese IBD patients, including a higher hospital admission rate, more frequent anoperineal complications and increased disease activity [6,7]. Other published data indicated that obese IBD patients are subject to higher rates of complications after IBD-related surgical interventions, and that those complications were because of obesity co-morbidities as well as anatomic considerations [8,9]. Bariatric surgery is reported to be the most effective option for weight loss in the severely obese, and the number of patients undergoing surgery for weight loss is dramatically increasing [1,10]. When it comes to severely obese IBD patients, however, surgeons are reluctant to carry out any non-IBD related intestinal operation because of the probable higher rates of short- and long-term complications [11]. This is especially applicable to bariatric procedures [12], and therefore evidence in the literature on the outcome of obesity surgery in patients with IBD is sparse and mostly derived from small numbers of case reports [13]. We report the outcomes of surgically induced weight loss in a series of 10 morbidly obese IBD patients.
Methods Patients and study design The data collection was approved by the Research Ethics Committee of both participating medical centers, and patient consent was waived. The records of all the patients diagnosed as having IBD who underwent bariatric operations in 2 hospitals were retrieved from the prospectively collected data throughout the study period (from October 2006 to January 2014). All of the morbidly obese patients referred to our obesity clinics for potential surgical treatment undergo a multidisciplinary evaluation by a dietician, psychologist, and a bariatric surgeon. In addition, they all attend a lecture that includes a comprehensive description of the indications, risks, and benefits of the different types of bariatric procedures. The indications for surgery included a BMI 440 kg/m2 or 435 kg/m2 together with at least 1 severe obesity-related co-morbidity (type 2 diabetes, hypertension, sleep apnea, osteoarthropathy, etc.) and the failure of previous conservative attempts to lose weight. The choice of the procedure was made according to the individual characteristics of the patient, such as age, BMI, health-related conditions, previous operations, medications, degree of self-discipline, eating habits (“addiction” to sweets, binge eating), anatomic conditions (e.g., large hiatal hernia), and individual preferences of the candidate when there was more than one option. The diagnosis of IBD was established by an appropriate clinical picture, endoscopic findings and occasionally by pathologic examination. A prerequisite before proceeding with the decision for performing bariatric surgery was a
letter of referral from the treating gastroenterologist, which included a detailed explanation of the clinical manifestations, extent of the disease, complications, and treatment. Special emphasis was placed on an endoscopic report describing the extent of bowel involvement. Each patient underwent preoperative blood tests consisting of complete blood count, routine blood chemistry, liver and kidney function tests, lipid profile, albumin, transferrin, iron, ferritin, folic acid, vitamin B12, parathyroid hormone, calcium and phosphorus, preoperatively. The same tests were performed postoperatively. Anthropometric measurements included weight, height, BMI, and percent excess weight loss (%EWL). Operative technique Only 2 types of bariatric operations were performed in the current series, laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (SG). The pneumoperitoneum was created by insertion of the optic trocar to the left of the midline above the umbilicus. After insufflation, additional 12-mm working trocars were introduced under direct vision. Dissection was performed with 5-mm ultrasonic shears (Ethicon Endosurgery, Cincinnati, OH). LAGB was performed by a pars flaccida technique, using a Swedish band (Obtech, Johnson & Johnson, Cincinnati, OH) without suture band fixation. The SG was performed using 5 ports. The omentum adjacent to the whole length of the greater curvature and splenic short gastric vessels were divided by a harmonic scalpel (Ethicon Endosurgery). Different sizes of gastric bougies were inserted into the pylorus. The longitudinal stomach division started at 2 cm proximally to the pylorus by consecutive application of an endoscopic stapler (blue and green load, EndoGIA 45 mm, or Echelon golden load, Ethicon Endosurgery) parallel to the bougie, up to the gastroesophageal junction. A gastric tube (sleeve) o100 cc in volume was placed, and the remaining 80% of the stomach was excised. The staple line was inverted by placing a sero-serosal continuous polydioxanone suture in patients operated by author DH but not by author AK. Diluted half-strength methylene blue dye (50 cc) was used to test for leaks. The duodenum was clamped, and irrigating the sleeve usually caused the dye to overflow back to the patient’s mouth. The excised stomach was removed by enlarging the peritoneal and fascial opening of the 12-mm trocar and by pulling the entire bulk from the antrum without the need for a protecting bag. The enlarged fascial opening was closed with a single figure-of-8 Maxon No. 1 suture, and a drain was left along the suture line through one 5-mm port for 2 days. On postoperative day (POD) 1, the patients underwent a Gastrografins X-ray study to rule out leaks, after which they were started on sips of clear liquids. None of these tests showed an obstruction on the POD 1 contrast swallow studies
Bariatric Surgery for Morbidly Obese IBD Patients / Surgery for Obesity and Related Diseases ] (2014) 00–00
Results A total of 1,900 patients underwent bariatric surgery in the 2 medical centers during the study period, and the ten among them who had been diagnosed as having IBD comprised the present study group. There were 9 females and one male whose median age was 40 years (range 25–58). The bariatric procedures included SG in 9 patients and LAGB in one patient. The median follow-up was 46 months (range 9–67). Bariatric-related data The mean preoperative weight, BMI, and excess weight of the study group were 114 kg, 42.6 kg/m2, and 59.5 kg, respectively, (Table 1). The mean weight, BMI, and %EWL at the longest follow-up were 78.6 kg, 29 kg/m2, and 71, respectively. All of the patients were followed-up at the medical center’s bariatric clinic. Four of the patients developed serious vitamin B12 and vitamin D deficiencies and iron deficiency anemia, and they responded well to appropriate treatment. Eight patients had 16 obesity-related co-morbidities, and 10 of those co-morbidities resolved after the bariatric procedure. The single postoperative complication consisted of staple line leakage which was discovered on POD 14 in a UC patient who underwent an SG. After multiple failures of conservative treatment by percutaneous drainage and an attempted Over-the-scope clip deployment, that patient underwent a completion total gastrectomy with esophagojejunostomy 4 months after the original surgery and experienced no further complications. IBD-related data Eight patients were diagnosed as having CD and 2 as having UC. The average IBD duration before bariatric surgery was 6.8 years (range 1–15) (Table 2). Seven of the patients were under maintenance treatment during
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bariatric surgery, 6 with 5-ASA derivatives and one with 5-ASA and adalimumab (Humira). None of the patients had undergone any surgical procedures related to their IBD before the index bariatric operation. One CD patient underwent percutaneous drainage of an interloop abscess 10 years before the bariatric intervention. All of the study patients continued their medical IBD treatment without any change or interruption. Three patients were able to stop their 5-ASA treatment, while 2 others continued taking the medication with good therapeutic effect. Another patient that had not received any prior IBD treatment was started on 5-ASA for mild exacerbation of the disease. All stomach specimens from the SG were sent for pathologic evaluation and none showed any evidence of IBD. Discussion This report presents the outcomes of a small series of morbidly obese IBD patients who underwent a weight reduction surgical procedure. Our data suggest that SG and LAGB appear to be safe for morbidly obese IBD patients and yield satisfying weight loss-related results without a higher risk of postoperative complications or an increased risk of postintervention IBD exacerbation. Bariatric surgery is considered as being contraindicated for IBD patients because of the risk of postoperative complications, such as anastomotic leaks, fistulas, abscesses, bowel stricture and bowel obstruction, and the risk for neoplasm in a bypassed bowel loop [14]. Moreover, CD and UC patients are reportedly at increased risk of requiring future surgical interventions, including repeated bowel resection in CD patients [15] and the altered small bowel anatomy after gastric bypass may affect technical issues of construction, accessibility and function of an ileoanal pouch reservoir in UC patients [13]. Previous case reports have provided contradictory information about the effect of weight reduction surgery on IBD patients [13]. Some of them reported exacerbation of IBD symptoms after surgery [16], while others have suggested
Table 1 Bariatric data PT
Age
Sex
Bariatric procedure
Weight (kg)
Height (cm)
EW (kg)
BMI (kg/m2)
1 2 3 4 5 6 7 8 9 10
25 44 30 32 42 58 26 44 38 58
F F F F F M F F F F
SG SG SG LAGB SG SGþHH SG SG SG SG
112 93.5 153 126 127 124 115 99 106 90
168 159 163 176 171 173 160 154 158 156
41.4 34.4 86.6 48.6 53.9 49 51 39.7 43.6 28.8
40 39 57.6 41 43 41 44 42 42 37
Co-morbidity Hyperchol, hyperTG, HTN FL DM,TG, cholesterol HTN-GERD None FL IFG, FL DM, HTN, Triglyc, proteinuria
FU (mo)
%EWL
46 66 65 56 48 45 24 2 12 7
79 73 63 61 79 69 73 75 71 71
BMI ¼ body mass index; DM ¼ diabetes mellitus; EW ¼ excess weight; %EWL ¼ percent excess weight loss; F ¼ female; FL ¼ fatty liver; FU ¼ follow up; GERD ¼ gastroesophageal reflux disorder; HH ¼ hiatal hernia; HTN ¼ hypertension; Hyperchol ¼ hypercholesterol; HyperTG ¼ hypertriglycerides; IFG ¼ impaired fasting glucose; LAGB ¼ laparoscopic adjustable gastric band; M ¼ Male; PT ¼ patient; SG ¼ sleeve gastrectomy.
A. Keidar et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
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Table 2 Inflammatory bowel disease (IBD)-related data IBD type
Bowel involved
Past treatment
Treatment at time of operation
Current treatment
IBD exacerbation
CD CD CD CD CD CD CD CD UC UC
Ti Sb Sb TI, cecum Ti Ti TI-left colon Sigmoiditis,ileitis Pancolitis Left colon
Pentasa Pentasa Pentasa None Pentasa Humira-salazopirin Steroids-pentasa Asacol Rafasal
Pentasa Pentasa Pentasa None Pentasa Humira-slazopirin Pentasa Pentasa None None
Azulfidin Pentasa None None None Humira None
None Yes, mild Yes, mild Yes, mild None None None None None
Rafasal
CD ¼ Crohn’s disease; IBD ¼ inflammatory bowel disease; SB ¼ small bowel; TI ¼ terminal ileum; UC ¼ ulcerative colitis.
that bariatric surgery may actually reduce systemic inflammation, leading to better symptom control and reduced medication use [17]. Ahn et al. [16] reported 3 morbidly obese patients without any prior personal or family history of gastrointestinal disease symptoms who underwent a Roux-en-Y gastric bypass and developed endoscopically proven newly diagnosed CD within 11–60 months of surgery. Similarly Janczewska et al. [18], reported 2 patients who were diagnosed as having CD after undergoing GB for morbid obesity. Moun et al. [19] described a 40-year-old morbidly obese female with type 2 diabetes and hypertension who also had medically controlled ileocolic CD. She underwent a Roux-en-Y gastric bypass with successful weight reduction and resolution of her hypertension and diabetes but developed active CD after surgery. Tenorio Jiménez et al. [20] reported a 39-year-old morbidly obese male (BMI 52 kg/m2) with a history of type 2 diabetes mellitus, thrombophilia, and UC who developed severe protein malnutrition after biliary-pancreatic diversion requiring readmission and rigorous medical therapy 10 months after surgery. Most of the reported indications for bariatric surgery are related to obesity and its related co-morbidities. However, both patients with active IBD and patients with morbid obesity are reported to have elevated serum levels of interleukin-6 and tumor necrosis factor alpha, as well as other inflammatory mediators, which correlate to adipocyte mass [21] and are overexpressed in the mesenteric fat of patients with active IBD [5,22]. Owing to the common inflammatory pathways shared by obesity and IBD, obesity surgery may be hypothetically indicated for refractory IBD symptoms or for loss of medical response [23] in obese IBD patients. Weight loss surgery could also be considered for planned restorative proctocolectomy and ileal pouch reservoir in morbidly obese UC patients for whom obesity poses a significant technical challenge to the surgeon and is even considered a relative contraindication for this procedure. Lascano et al. [17] reported a 39-year-old morbidly obese male (BMI 57 kg/m2) with steroid-treated UC and
hypertension, who demonstrated significant clinical improvement after gastric bypass surgery and 80% excess weight loss. In their poster presented at the American Society for Metabolic and Bariatric Surgery, Gagne et al. [24] retrospectively reviewed the outcomes of 8 UC and 9 CD morbidly obese patients (a median BMI of 46.7 kg/m2). Eleven patients underwent laparoscopic Roux-en-Y gastric bypass, 4 had LAGB, and 1 had SG. Five of them had undergone previous IBD-related surgical interventions, including total colectomy with ileostomy (n ¼ 3), abdominal perineal resection (n¼1), and total colectomy and smallbowel resection (n ¼ 1). Surgery was aborted in 1 CD patient who was found to have small-bowel anastomoses and small-bowel bypass. Three other CD patients had postoperative complications, including lower gastrointestinal bleeding, abdominal phlegmon, and abscess with stomal hernia necessitating port removal. All of the patients in their cohort had successful weight loss after a median follow-up of 34 months (range 9–110), together with resolution of their obesity-related co-morbidities. Those authors concluded that IBD can complicate bariatric surgery, but should not be a contraindication to performing it. The art of tailoring the appropriate bariatric procedure for a morbidly obese patient involves many considerations [25]. Our data, supported by those of others, indicate that weight reduction surgery should not be denied to morbidly obese IBD patients provided that there is careful patient selection through a multidisciplinary team approach and a proper preoperative evaluation. IBD patients are at risk of requiring future small bowel surgery or, alternatively, already had one or more in the past that may make malabsorptive procedures more challenging. There are few descriptions of the performance of SG on morbidly obese IBD patients, while SG was our primary surgical procedure in the current report. Gastroduodenal CD is rare, occurring in fewer than 2% of CD patients [26], and we consider that SG and LAGB seem to be good surgical options for the morbidly obese patients, although additional supportive evidence is required.
Bariatric Surgery for Morbidly Obese IBD Patients / Surgery for Obesity and Related Diseases ] (2014) 00–00
Conclusion Our study showed that bariatric surgery appears to be effective and safe for morbidly obese IBD patients. The risk of surgical complications is no greater for them than it is for other bariatric surgical candidates. The choice of a specific surgical procedure must be made judiciously and in consensus by a multidisciplinary team and the patient. Finally, small bowel sparing procedures may be preferable. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Obesity and overweight Fact Sheet No. 311. Geneva (Switzerland): World Health Organization; Mar, 2011. [accessed 2012 Oct. 3]. Available: www.who.int/mediacentre/factsheets/fs311/en/print.html. [2] Steed H, Walsh S, Reynolds N. A brief report of the epidemiology of obesity in the inflammatory bowel disease population of Tayside, Scotland. Obes Facts 2009;2:370–2. [3] Long MD, Crandall WV, Leibowitz IH, et al. Prevalence and epidemiology of overweight and obesity in children with inflammatory bowel disease. Inflamm Bowel Dis 2011;17:2162–8. [4] Moran GW, Dubeau MF, Kaplan GG, Panaccione R, Ghosh S. The increasing weight of Crohn’s disease subjects in clinical trials: a hypothesis-generating time-trend analysis. Inflamm Bowel Dis 2013;19: 2949–56. [5] Bertin B, Desreumaux P, Dubuquoy L. Obesity, visceral fat and Crohn’s disease. Curr Opin Clin Nutr Metab Care 2010;13:574–80. [6] Blain A, Cattan S, Beaugerie L, Carbonnel F, Gendre JP, Cosnes J. Crohn’s disease clinical course and severity in obese patients. Clin Nutr 2002;21:51–7. [7] Nic Suibhne T, Raftery TC, McMahon O, et al. High prevalence of overweight and obesity in adults with Crohn’s disease: Associations with disease and lifestyle factors. J Crohns Colitis 2013;7:e241–8. [8] Efron JE, Uriburu JP, Wexner SD, et al. Restorative proctocolectomy with ileal pouch anal anastomosis in obese patients. Obes Surg 2001;11:246–51. [9] Benoist S, Panis Y, Alves A, Valleur P. Impact of obesity on surgical outcomes after colorectal resection. Am J Surg 2000;179:275–81. [10] Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA 2005;294:1909–17.
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