Dr. Sunil Bhoyrul discusses obesity and heart disease while outlining the role of bariatric surgery in improving health outcomes.
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I think it's a perfect segue to our next speaker. Dr Boy Roll. I think we have the seed team here that we need for a cardio metabolic clinic right here in this session. So Dr borough is the director of the Old Delmar surgical center and the medical director of our bariatric surgery program here at Scripts Hospital. He was trained initially the University of Aberdeen, continued his training at brooks General Hospital in London, followed by residencies at UCSF and Stanford before coming down here to Scripts clinic. And we're very fortunate to have him as a colleague here too in our heart failure program because of the fact that we know so much that obesity and heart failure are so interconnected and we've had the ability to send patients to him um and see, you know, just incredible changes in the trajectory of their, not only their heart failure but their lives really, patients have gone from being not candidates for any sort of advanced therapies to becoming heart transplant candidates after their treatment with dr barrel. And we've also seen patients who had heart failure and essentially their heart failure was cured after their treatment with Dr Barroso. Um With that, once his slides are up and running, we'll have dr Borrell take it away um and give us an update on his approach. I think, you know, following Dr Einhorn is absolutely perfect. I just want to echo what he said about scripts being so far ahead, not only in cardio, metabolic, but certainly the collaboration we've had with the heart failure team, just the numbers we've been able to put up on the board with just the number of patients that we've had, The outcomes were literally years ahead of of many of our colleagues. And and it's entirely because of the forward thinking nature of of you folks in heart failure, so, thank you very much. Alright, so anyway, so I just want to echo what Dr Einhorn said. We really, really are far, far ahead um scripts and tremendous tribute to you folks in the heart failure um world because you've been so forward thinking and the numbers we've been able to put up, not just in terms of numbers of patients that we've been able to help, but just the shared outcomes have just been staggering. Um And so once again, thank you very much. So, I'm here today to spend about half an hour talking about the impact of bariatric surgery on heart failure and not only to review the literature, but to talk about the experience we've had here at scripts, I want to talk about obesity, heart disease and the role of surgery. So, I'll start off by defining obesity and bariatric surgery. I'll review some of the current literature on bariatric surgery as it pertains to heart failure patients. And then I want to focus on the weight loss independent effects of bariatric surgery in the same way that I want to persuade you that obesity is not about calories in and calories out and Israeli a metabolic illness. We really want to talk about how bariatric surgery works independent of just losing weight. And I think that's really what makes it so unique. Um And then I'll share the scripts experience. I'll share our data. We were going to share a video but unfortunately the file was too big to upload. So we'll save that for next year. So and then we'll have a call to action and conclusion. So first of all, one of the reasons I think that the scripts is so far ahead is because none of this makes any sense. Why would you offer such a high risk procedure to an even higher risk population? And so that's where we lean on my my favorite surgeons, Chevy Chase and dan Ackroyd from spies like us before they completely botched an appendectomy. And right before he's about to make an incision in the chest, turns around to the camera and says, we mark what we do not understand. And I think as funny as that is, we really do. We really do mock the idea of operating on patients with heart failure because it makes no sense. And yet it does. We'll come back to that. The classic definition of obesity is your BMR, your body mass index, which is your relationship of your weight to your height. And I think that's archaic. And I think even though we use it right now, we've got to get beyond BME and we've got to start looking at body composition where we all want to be is out here. We want to be not only have a normal BMI, but we want to be metabolically healthy. Now you can have an obese BMI and still be metabolically healthy, the classic example of your football players. But our patients here, they're metabolically unhealthy whether or not they have an obese BME. Uh and you know, the american diabetic association recognizes that intervention is warranted earlier in asians and Southeast asians because they have more visceral obesity. So a lot of people are beginning to recognize that B. M. I is really it's a it's a very 20th century way of thinking of things. So we have to get beyond weighing patients. We have to use very simple and inexpensive tools to measure patient's body fat, metabolic rates and muscle mass in order to get a much better understanding of the body composition and target therapy based more on body composition than B. M. I. So having said that, that's important because obesity itself is a metabolic illness. We spend way way too much time figuring out why people got obese and and and the blame and shame game and and talking about, you know, politics and Mcdonald's and all the rest of it. But that's quite irrelevant because once you become obese you stay obese. In other words, obesity is really a state of hypothalamic dysfunction. Obese patients who suffer from obesity have reset their homeless stasis. We know time and time again that not only is calorie restriction ineffective, but when you really interview patients who suffer from obesity, they have such a low basal metabolic rate that, you know, they're not eating that much to start off with once they've become obese and so going and restricting their calories even more makes makes very little sense once you reset your hypothalamus and once you suffer from this metabolic illness known as as obesity, we know about the manifestation of the metabolic illness and um you know, dr Einhorn has talked all about type two diabetes, but what about reflux? What about fatty liver? What about gall stones? These are all classic manifestations of the metabolic illness that obesity is. And of course the reason we're here today is to talk about the cardiovascular manifestations of this metabolic illness, not just coronary artery disease, hypertension and high pol epidemiologic. Also focusing especially on on heart failure. Let's not forget Pcos the number used to joke for the longest time before I got in trouble with my family that I created more pregnancies in this town than anyone I know because pcos polycystic ovarian syndrome is a manifestation of of obesity and the soon as we we do bariatric surgery patients on our young women who suffer from pCOS the first thing they experiences resolution of their infertility. So much so the contraception is a big, big part of the pre op preparation degenerative joint disease obviously. And then depression, sleep apnea and depression of the classic manifestations of the metabolic illness that obesity is. So you know, when I was a medical student, we talked about surgery being a failure of medical treatment, we've got to get beyond that. You know, surgery and medical treatment are not mutually exclusive treatments. We have to look at the the hand and hand approach between medical and surgical treatment and certainly for for the multiple manifestations of of obesity and metabolic illness that it is individual medical therapy exists and and it's and it's well proven and again, doesn't go away once once you have metabolic surgery. So, we know about the lifetime treatment of dystopia, leukemias, hypertension, diabetes and of course medical treatment of obesity itself and the overall success certainly nationally has been poor or moderate. So it is time to think of surgery. The bariatric surgical options that we'll talk about today will include the lap band, which is pretty much disappeared now, sleeve gastrectomy, which is probably one of the most popular operations in the United States today, and gastric bypass, which is probably the gold standard metabolic operation for obesity. Suffice to say that Not the overall successes has been excellent. I'm not going to spend too much time rehashing what Dr Einhorn said about obesity and type two diabetes except to make the point that um this was really our segue into looking at the treatment surgical treatment from this metabolic illness for the other metabolic illnesses that that we have given the overwhelming success that we have with Type two diabetes. We know the medical treatment of Type two diabetes is very, very well established. But we also know that there's a dramatic difference in outcomes to patients who have Metabolic surgery. This statement, gastric bypass cures diabetes in 48 hours. It's actually technically wrong. We have a cure diabetes. We pushed diabetes into remission. But the mere fact that patients who suffer from type two diabetes go into remission within 48 hours of surgery. Way, way before they've had any they've lost a single pound. And wait tells you that there's something else going on that that the success of metabolic and obesity surgery has less to do with losing weight and more to do with something else. And it's really that something else that we're here to talk about this morning. So, the experience with type two diabetes and the experience with metabolic surgery for type two diabetes, it was really the first thing that opened our eyes into the weight loss, independent effects of bariatric surgery and extrapolating those effects to other metabolic illnesses, specifically sleep apnea and heart failure. Where we've had the two biggest weight loss independent effects of bariatric surgery. Um just briefly about some of the clinical trials with Type two diabetes. This is really an excellent randomized prospective controlled trial from the Cleveland clinic A 12 that they had follow up studies at 18 and 24 months looking at patients who had best medical therapy or randomized to bariatric surgery, in which the primary indication of surgery wasn't weight but was Type two diabetes. And you can see that the number of medications that they on after 369 and 12 months goes from 3 to 1 to zero medications. So we know that patients who have bariatric surgery can get off their medications and stay off their medications after bariatric surgery. Dr. Einhorn is exactly right A one CS and arcade way of looking at things. But nevertheless, it's from from a literature standpoint, it is still the most prevalent way of looking at things and looking at a one c reduction in A one C after patients who were randomized. The best medical therapy at the Cleveland clinic or bariatric surgery at the Cleveland clinic. There was a dramatic and significantly different difference in the decrease in A one C in patients treated surgically as opposed to patients treated medically. So, we know that the The benefits of bariatric surgery and type two diabetes. Oh, well, well established. And that was the initial segue that led us to think about, well, what can obesity do for heart failure? And so what I want to do then is review some of the published outcomes um for heart failure patients, some of the national outcomes. Um and then really focus on the weight loss, independent effects of bariatric surgery and talk about what seems to be a molecule of the year GLP one because that's really where a lot of attention is for Type two diabetes for heart failure and for metabolic surgery. And I think that that seems to be um certainly have an important role. I'll talk about our scripts experience and we'll take it from there. So in reviewing the literature, we know that bariatric surgery reduces inpatient mortality for patients who suffer from heart failure. And there was again for the Cleveland clinic that uh collated all the data from from Medicare data that's nationally reported looked at seven year nationwide data retrospectively in patients who suffered from heart failure and had obesity surgery. They compared inpatient mortality and the length of stay in patients whose primary diagnosis with heart failure. And they compared the patients who had bariatric surgery with controls who were matched for BMI. So it's a retrospective study, it's not not as that's powerful. But again, some insights we gained. The first thing they found was that there was a 50 reduction in mortality and a decreased length of stay in patients who had bariatric surgery when they compared those patients with patients who had heart failure who didn't have bariatric surgery and we'll match for BME. So, you know, again, just some insights into the fact that this may actually make sense. And dan Ackroyd and Chevy Chase's comments about mocking what we don't understand, may actually have some points here. Um And again, another study from N. Y. U. This time they looked at the percentage Um of uh bariatric surgery patients who had admissions for heart failure before and after surgery. So the first bar down here is um 11 of patients with heart failure and morbid obesity who are going to have bariatric surgery had an admission in the year before surgery, a heart failure admission and the number. And that went down from 11 to just over 3% and just under 3% in the 1st and 2nd year after bariatric surgery. And that's what we're seeing at scripts as well. We're seeing a dramatic reduction in E. D. Visits and we're seeing a dramatic reductions in inpatient hospitalizations in which the primary diagnosis as heart failure, the patients who've had bariatric surgeries. That that that also parallels our experience. Um The outcomes of heart failure patients who undergo bariatric surgery similar to the Cleveland clinic study the folks at Mount Sinai in new york did a really, really good retrospective study and concluded the bariatric surgery in heart failure patients reduces mortality, reduces hospital stay reduced duties. I have no idea why that is and lowered the medium cost of care, which obviously makes sense. Um So then how does obesity caused heart failure? Because if we're going to talk about the role of metabolic surgery for heart failure, then why not just get patients to lose weight? Why not get patients to why put them through this difficult and expensive and challenging surgery? And so the cause of heart failure gets important, Right? And and dr Einhorn a lot of this very well, we know that obviously patients who are overweight do have a weight dependent cause of heart failure. Obviously, the increase in systemic mass and blood volume associated with obesity cannot be ignored. But what's more important when it comes to therapeutic options I think is looking at the weight independent causes of heart failure. Clearly the comorbidities associated with obesity, obesity hyperventilation and paul Marie hypertension in particular reduced left ventricular filling pressure and have some very direct effects on heart failure. And clearly, patients with heart failure very often suffer from concomitant ischemic heart disease. So there are comorbidities that are important, but there are also a path of physiological and biochemical changes which get more interesting. We know that when you, when you biopsy the heart muscle, the changes that you see very similar to what we see in the liver. We're getting staccato sis of the heart muscle and we're getting fibrosis very similar to fatty liver and cirrhosis that we see. And then the most exciting thing in terms of the cause and subsequent treatment of heart failure at the biochemical changes. We know that insulin resistant leads to impaired glucose uptake by my sites and least mitochondrial dysfunction. And I think that's the that's the best segue that we have for everything that Dr Einhorn mentioned and everything that we can possibly do with with bariatric surgery. So, if that's the case, well, how does bariatric surgery improve heart failure is the next question, and obviously it does so because patients lose weight, but more importantly and far more aggressively, there are weight loss. Independent effects on heart failure on patients who undergo bariatric surgery. And that's the that's the area that we're very, very excited about. So, what are these weight loss independent effects of bariatric surgery? Well, there's change in the bile acid pool. When you do gastric bypass surgery, you're basically diverting gastric secretions away from the four got into the mid gut. And we know that we know that they are changed in the bile acid pool. And some very good basic science research that I think will become more and more relevant in the years to come for how this might be relevant in uh in in weight loss. We know that there's a change in the gut microbiome and there's tons and tons of completely meaningless over the counter um supplements that are supposed to somehow emulate these changes. The truth is we just don't have the fidelity to understand this yet. But we know there's something there and then the number of people feel that obesity is is a bacterial illness but it probably isn't. But the change in the gut microbiome is certainly very very important but where we are today and and it's such a pleasure to follow. Dr Einhorn is GLP one. We know that there's an increase in GLP one production and GLP one receptor signaling after bariatric surgery. And we strongly believe that these weight loss independent effects of bariatric surgery, a singularly responsible for the dramatic improvement, not just in time to diabetes, but in sleep apnea and in congestive heart failure way before there's been any significant weight loss uh to our patients. So I'm almost embarrassed to present the slide after DR Einhorn. Um but let's talk about GLP one because we were totally getting a we're totally getting very excited about this GLP one is secreted from the interior endocrine cells in the distal small intestine and colon. We know the GLP one and improves glucose dependent insulin secretion by beta cells. And a lot of attention was there and we know that GLP one delays gastric emptying. So it makes you full earlier. We know the GLP one suppresses appetite. All those things are well established and for the longest time we've been talking about the effects of GLP one in the pancreas and the stomach, but more pertinent to this talk, GLP one receptors, as was mentioned, one of DR Einhorn slides everywhere, not just in the pancreas, there, in the lung, there in the cns and there in the heart muscle. And that's probably why we're seeing a lot of effects, not just these medications, but of improving GLP one production after bariatric surgery. So, specific to this talk, we're seeing dramatic effects of bariatric surgery in obesity cardiomyopathy that have been described to GLP one, we know that not only is there increased GLP one production um and signaling after bariatric surgery which we think is responsible. We know that not just in the heart, but we know that there's a dramatic improvement in primary hypertension. There's a dramatic improvement in left ventricular filling pressures. Obviously, the the weight loss associated with bariatric surgery causes a reduction in left ventricular mass and left ventricular hypertrophy. And we we know clearly that is a dramatic improvement, not just in diastolic but in systolic function that is only partly dependent on weight loss after bariatric surgery. So most importantly, we know that weight loss through calorie restriction alone. Medical weight loss doesn't really have any of the same effects as bariatric surgery. There's something else going on. It's not just the reduction in mass, it's not just the reduction in blood volume, it's not just the reduction in after load that's going on from weight loss. Let's talk a little about weight loss surgery. The two most common surgical options that we offer scripts and the offered nationally in the United States are the sleeve gastrectomy and the gastric bypass. The sleeve is the safest option. We jokingly call it the sleeve them and leave them. It has the same mobility as an appendectomy or a gastric bypass. And essentially, we're excising the the funders in the body of the stomach. And why do we do that? Because we think that that's where, that's where a lot of Ghrelin is produced. We think that the control of hunger and satiety is mediated by Ghrelin. Um and so just just doing the simple operation seems to help not just with loss of weight, but it has tremendous metabolic effects because we're seeing a dramatic reduction in visceral fat, especially in the first 1 to 2 years after sleeve gastrectomy, sleeve gastrectomy definitely depends on a more motivated patient and so younger, more active patients. A great candidates to sleeve gastrectomy. But given that safety profile, we do tend to favor it. But the majority of our heart failure patients because by and large it's a safe operation. It's again, if you think about it is the same side of the same risk profile as an appendectomy or call the suspect to me, um you'll understand why this is this is a great operation. Having said that there's no malabsorption and the effects on GLP one may be less pronounced than after gastric bypass surgery. The mortality scripts is is, you know, less than 1000 and the serious morbidity is less than 2%. So we've done very, very well with this with this operation, but it does require a patient who is going to be far more engaged in their care. I tell our patients look a sleeve is a 5050 deal. We do have to work. You do have to work. The gastric bypass is 6040, we'll do 60 of the work. You're a little bit less involved, you can do 40 of the work. So that's the gastric bypass. Gastric bypass to this day is thought to be the gold standard and bariatric surgery with this operation where we're dividing the stomach and creating a stomach pouch the size of a deck of playing cards and then we're bypassing the four gut. And and really this is where we think a lot of the beneficial effects of metabolic. So this is the true gold standard metabolic operation. And we're taking a loop of intestine, just distal to the ligaments outright. We're measuring it for about 100 centimeter. Live and connecting it to this new stomach pouch. This is an operation that we do laparoscopically. And um my colleague Dr Wingrove was one of the pioneers of this operation. He's done a great job and we've added another 5000 cases here um at scripts we've we've been very very proud to be to be leaders in the surgery. We do them all laparoscopically. It's certainly the best operation for anyone who has a body mass index who suffers from super obesity and has a body mass index greater than 50. And it's clearly the best metabolic surgery that we have because of the long term effects of gastric bypass have been very, very well studied. The data are really excellent. The mortality is less than 0.2 and the serious morbidity has always been less than 4%. Um And so that that's gastric bypass. So let's talk now about the collaboration that we've had without colleagues here in cardiology at scripts. Um We've to date, it's been honestly just a proud, proud collaboration. We've now operated on 11 patients who have had N. Y. H. A. Class for heart failure. Five of them have already had elbow pads in place. We've done the majority of had sleeve gastrectomy, eight had a sleeve gastrectomy. Three have had a gastric bypass, thankfully we haven't killed anyone yet. Um and two of them off the transplant list, three of them have had successful heart transplant. These results they sound like small numbers, but when you, when you do apartment search of the national data were either at or above. Um any of the major academic senses in the United States who are trying the same thing. Um just briefly profiled. Some of them are first patient, was was a while ago. Um I think about four or five years ago NBC was being worked up for an L. VAD and uh um and uh in the sentence while he was being worked up he was found to have a stage one gastric cancer. So we went off and just did a total gastrectomy on this guy. And sure enough his chf improved so much that he no longer needed an L. VAD. So so that was that was our first introduction that um M. S. Was turned down by the university because he was too high risk. You know the list the list of these patients goes on. The certainly our most, I'm cognizant of the time, most dramatic patient was was MJ MJ was in the I. C. U. With a. B. M. I. 50. He had an ejection fraction of 18%. He was on the w. I mean pump. Um He was getting ready to be worked out for an L. VAD. He had bilateral pulmonary emboli. So he was ruled out for an L. VAD and placed on palliative care. And um we dr Heywood asked us to operate on him. The anesthesiologist refused to anesthetized them. We have to get the ethics committee involved before they would actually let us operate on this guy. This guy now has an ejection fraction of 45%. No longer needs an elevated Um and is walking you know walking five miles a day. This surgery saves lives and and this patient more dramatically demonstrated that than anyone else. Quick. I'll go quickly through the remaining slides because of time. Um our approach to bariatric surgery is we have to measure the right parameters. We have to measure body composition. We have to have a patient's work without clinical psychologist and dietitians and we have to work as a team. Once again what dr Einhorn and dr Mohamed survived. The Fed the cardio metabolic center makes total sense. We have to use everything that we can to not just reduce visceral fat but improve vo two max. The two vis visceral fat and vo two max where it's at not just for our specialty but all the specialties who are talking today. Um I think that the tremendous access to wireless follow up is phenomenal but obesity is a lifelong chronic illness. You have to do lifelong care. And so you know the methodologies um here very briefly this is looking at data from our patients who are doing well. This is a typical patient on a withing scale just sending her data to us showing that she's losing fat in parallel with losing weight. This is a patient who is losing weight but not losing fat. We know she's starving herself and she's losing the wrong type of weight. We can make a tremendous changes so quickly call to action. Three things. First of all, any patient who has a BMI greater than 35. We need to begin that discussion about metabolic surgery and how do you do that? Well, just educate them. Just send them to your local website, get them educational materials which are available in english, spanish and Arabic because the time it takes from the initial thought of bariatric surgery to ending up having surgery for the average patient is about two years. So you're not going to talk to a patient that surgery today and they'll say sure I'll have gastric bypass next week. There's a tremendous personal journey. So it just begins consider it and educate them and then finally refer them all the dietary counseling. You don't have to refer them to us, get them going with the dietician because it doesn't hurt and it's also a prerequisite by every insurance company before they'll even consider bariatric surgery. So in conclusion, I would like to remind all of us that obesity is not calories in calories out obesity is a true metabolic illness, but it is a lifelong chronic illness. And the only way we're gonna make significant inroads by measuring the right parameters and offering lifelong, multidisciplinary follow up surgery has weight loss independent effects and has dramatic and organ effects, especially as it pertains to the cardiovascular system and heart failure. And then finally, obesity surgery on heart failure patients dramatically improves not just the quantity, but the quality of their life. And we've demonstrated clearly and unequivocally without collaboration with our heart failure colleagues, that scripts that we can certainly do this safely thank you very much. Mhm.
