Chichester 21 09 2009 J P Mulier 1

Risks Costs Benefits When to say Risks Costs Benefits When to say No No

J P Mulier MD PhDJ P Mulier MD PhDSint Jan Brugge-OostendeSint Jan Brugge-Oostende

www.publicationslist.org/jan.mulier www.publicationslist.org/jan.mulier

1150 1850 1947 1977 2010

Chichester 21 09 2009 J P Mulier 2

No, never operateNo, never operate

When morbidity and mortality of When morbidity and mortality of surgery is higher than the non surgical surgery is higher than the non surgical treatmenttreatment

To discuss with the patient: To discuss with the patient: when the when the improvement in quality of life is a lot better improvement in quality of life is a lot better it might outweighing the higher risk.it might outweighing the higher risk.

Do you know? General results?Do you know? General results? your surgical mortality / morbidityyour surgical mortality / morbidity your surgical results in weight lossyour surgical results in weight loss your outcome in higher risk patientsyour outcome in higher risk patients

Chichester 21 09 2009 J P Mulier 3

Surgical versus non surgical Surgical versus non surgical treatmenttreatment

For all patients and all centers:For all patients and all centers: every surgical procedure is more every surgical procedure is more

efficient and mortality is lower efficient and mortality is lower Sjostrom Sjostrom N Engl J Med 2007 ( study not powered to detect mortality difference for type of surgery)

We are required to treat people There are many other surgical procedures that do not have

such a clear benefit.

Chichester 21 09 2009 J P Mulier 4

Mortality by procedureMortality by procedure

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

open lap

gastricbandinggastroplasty

gastric bypass

BPD

revision

30 day mortality Buchwald Surgery 200730 day mortality Buchwald Surgery 2007 Not powered for > 30 dayNot powered for > 30 day Not powered for lap revisions (221/85000) sleeve Not powered for lap revisions (221/85000) sleeve

gastrectomygastrectomy

Chichester 21 09 2009 J P Mulier 5

Frequency of Frequency of reinterventionsreinterventions

Sjostrom 2007Sjostrom 2007 1338 pt followed for at least 10 years:1338 pt followed for at least 10 years:

Exclusion early reinterventions ( 1 month) for Exclusion early reinterventions ( 1 month) for complicationscomplications

0

5

10

15

20

25

30

35

% Reintervention

gastricbandinggastroplasty

gastric bypass

Chichester 21 09 2009 J P Mulier 6

Mortality of higher risk Mortality of higher risk patients?patients?

co morbidities Buchwald study 2007co morbidities Buchwald study 2007

0

1

2

3

4

5

6

mortality %

malesSuper obesediabeteshypertensionelderly

Prevalence Mortality

Chichester 21 09 2009 J P Mulier 7

Patient type with a Patient type with a high mortality riskhigh mortality risk

Elderly male diabetes Elderly male diabetes patient with hypertension patient with hypertension and being super obeseand being super obese Buchwald 2007Buchwald 2007

Central abdominal fat, not Central abdominal fat, not stopped smoking, alcoholicstopped smoking, alcoholic General risk General risk

Asthma and coronary artery Asthma and coronary artery diseasedisease xxxxxx

Chichester 21 09 2009 J P Mulier 8

30 day mortality by study year is 30 day mortality by study year is decreasingdecreasing

0

0,1

0,2

0,3

0,4

0,5

0,6

mortality

90-9495-9900-012002-20032004-20052006

Chichester 21 09 2009 J P Mulier 9

No, post poneNo, post pone

When you can improve the outcome When you can improve the outcome by waiting, or adapt type of surgeryby waiting, or adapt type of surgery Lower body weight with minimum 10kgLower body weight with minimum 10kg

by diet, gastric balloonby diet, gastric balloon Improve liver functionImprove liver function

Fatty liverFatty liver Improve lung functionImprove lung function

Stop smokingStop smoking Evaluate and improve cardiac functionEvaluate and improve cardiac function

Hypertension, CAD, edema, Hypertension, CAD, edema,

Chichester 21 09 2009 J P Mulier 10

Abdominal complianceAbdominal compliance

0

5

10

15

20

25

0 1 2 3 4 5

Effect of 10 kg weight loss

0

5

10

15

20

25

0 0,5 1 1,5 2 2,5 3 3,5

IAV: liter

IAP

: m

mH

g

> 10 kg weight loss no effect muscle > 10 kg weight loss no effect muscle relaxrelax

Mulier Dillemans preliminary dataMulier Dillemans preliminary data

Chichester 21 09 2009 J P Mulier 11

How changing abd E : flexion How changing abd E : flexion hiphip

Mulier JP, Dillemans B Surg endos Mulier JP, Dillemans B Surg endos 20092009

Chichester 21 09 2009 J P Mulier 12

No, send to other centers No, send to other centers with more surgical with more surgical

expertiseexpertise If your center startsIf your center starts If your surgical time is more than 60 minutesIf your surgical time is more than 60 minutes If your surgeon can’t do every patient If your surgeon can’t do every patient

laparoscopic yet ( unless post laparatomy)laparoscopic yet ( unless post laparatomy) Exclude patients with one or more risk factorsExclude patients with one or more risk factors

Super super obeseSuper super obese Man with central obesity and no weight lossMan with central obesity and no weight loss Re intervention after failed bariatric surgeryRe intervention after failed bariatric surgery Cardiac failure NYH class VCardiac failure NYH class V Pulmonary hypertensionPulmonary hypertension Respiratory asthma, low vital capacityRespiratory asthma, low vital capacity Other less frequent high risk co morbidity for non obese Other less frequent high risk co morbidity for non obese

patientspatients Get surgical and anesthesilogic expertise by Get surgical and anesthesilogic expertise by

doing many cases before doing difficult and risk doing many cases before doing difficult and risk cases.cases.

Chichester 21 09 2009 J P Mulier 13

Impact of centre Impact of centre expertiseexpertiseyear no cases Mortality %

Carucci 2006 904 5.3

Marshall 2003 400 5.25

DeMaria 2002 281 5.1

Ballesta 2008 1200 4.9

Hamilton 2003 210 4.3

Lee 2007 3828 3.9

Madan 2006 300 3.0

Gonzalez 2007 3018 2.1

Durak 2008 1133 1.5

agaba 2008 1364 0.15

carraquiulla 2004 1000 0.1

Dillemans 2009 2606 0.04

Chichester 21 09 2009 J P Mulier 14

Our Results in lap Our Results in lap RNYRNY

Chichester 21 09 2009 J P Mulier 15

No, postpone tillNo, postpone till

Your experienced surgeon and Your experienced surgeon and experienced anaesthetist are experienced anaesthetist are available available To shorten the surgery and the To shorten the surgery and the

anaesthesiaanaesthesia To take the best preventive To take the best preventive

measuresmeasures To have intensive care follow up To have intensive care follow up

Chichester 21 09 2009 J P Mulier 16

A patient with increased A patient with increased risk in our centerrisk in our center

is done only by one surgeon and one is done only by one surgeon and one anaesthetist with sufficient expertise, anaesthetist with sufficient expertise, otherwise postponed.otherwise postponed.

We have one surgeon and one anaesthetist We have one surgeon and one anaesthetist with long expertise and many cases > 500with long expertise and many cases > 500

We have two surgeons with less than 200 We have two surgeons with less than 200 cases a yearcases a year

We have one qualified abdominal surgeon in We have one qualified abdominal surgeon in training for bariatric surgerytraining for bariatric surgery

We have many anaesthetist doing less than We have many anaesthetist doing less than 200 cases a year.200 cases a year.

They will never do the risk patients alone They will never do the risk patients alone and loose timeand loose time

Chichester 21 09 2009 J P Mulier 17

ConclusionConclusion

No, neverNo, never When morbidity and mortality of surgery is When morbidity and mortality of surgery is

higher than the non surgical treatment higher than the non surgical treatment except…except…

No, post poneNo, post pone When you can improve the outcome by waitingWhen you can improve the outcome by waiting

No, not now, not hereNo, not now, not here When the waiting list is too long, no resourcesWhen the waiting list is too long, no resources

you prefer to postponeyou prefer to postpone The highest risk?The highest risk? The estimated longest hospital stay?The estimated longest hospital stay? The lowest or the highest BMI?The lowest or the highest BMI?

Chichester 21 09 2009 J P Mulier 18

Attend first ESPCOP Attend first ESPCOP meetingmeeting

14 nov 2009 Ostend 14 nov 2009 Ostend BelgiumBelgium

““The sea” from Georges GrardThe sea” from Georges Grard

Better known as Better known as

““fat Mathilde of Ostend”fat Mathilde of Ostend”

www.ESPCOP.org

Chichester 21 09 2009 J P Mulier 19

Scientific meetingScientific meeting

Chichester 21 09 2009 J P Mulier 20