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05/04/2013
1
Surgical management of Morbid Obesity
- the pros and cons
Dr. Sumer Aditya
Consultant Physician / CD
Diabetes & Endocrine Dept
Why talk about Obesity & Bariatric surgery?
Epidemic
Millennium disease
Associated with numerous co-morbidities and complications
Healthcare costs
Affects all aspects of care
Management of Morbid Obesity
• Lifestyle
–Diet
– Exercise
–Behaviour
• Drugs (Orlistat)
• Bariatric Surgery
Overview
• Types of Bariatric surgery
• Benefits of surgery
• Risks / Problems
• Current situation and possible future
• Patient selection
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Weight loss surgery types
Mechanism Common procedure/s
Purely Restriction
LAGB (Band)
Gastric Balloon
Gastroplasty (VBG, Stapling)
Restriction with some
malabsorption
Roux-en-Y Gastric Bypass
(RYGB)
Predominantly
Malabsorption
BPD, Duodenal Switch (BPD-
DS)
Predominantly Restriction Sleeve Gastrectomy (SG)
Restrictive procedures
Mixed – RYGB
Predominantly restriction
with some malabsorption
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Malabsorptive procedures
BPD – Scopinaro procedure
BPD-DS – Duodenal switch
Sleeve Gastrectomy
Predominantly restriction
Sleeve gastrectomy
Evidence
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Procedure Excess Weight
loss % Diabetes
remission % Mortality %
LAGB 46.2 56.7 0.06 (1 in 2000)
Gastroplasty 55.5 79.7 0.21 (1 in 500)
RYGB 59.7 80.3 0.16 (1 in 750)
BPD & DS 63.6 95.1 1.01 (1 in 100)
All procedures 55.9 78.1 0.28 (1 in 300)
Meta-analysis – 621 studies, 135,246 procedures
Buchwald H et al. Am J Med 2009; 122(3):248-256. Buchwald H et al. Surgery 2007; 142(4):621-632.
Evidence of other benefits of surgery
HTN (2 yrs but not 8 yrs)
Dyslipidaemia
Heart – LV mass, EF, Atherosclerosis, ↓MI
Fertility - ↓SHBG, ↑Testo, ↑Oest (no change in hirsutism)
↓GDM, Preeclampsia, LSCS rates, Birth weight
GORD
Asthma
Cancers
Backache, Arthritis
NASH
Incontinence
Pseudotumour cerebri
Venous stasis & ulcers
Pickwickian syndrome, hypoventilation, OSAS
QOL (SF36), Employment
Depression
SOS data – NEJM August 2007
SOS data – NEJM August 2007
What to tell your patient?
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Procedure
Excess
Weight loss
(total percent)
Diabetes
remission
Mortality %
Band 46.2 (15-25%) 56.7 0.06 (1 in 2000)
Bypass 59.7 (25-40%) 80.3 0.16 (1 in 750)
Switch 63.6 (30-50%) 95.1 1.01 (1 in 100)
Meta-analysis – 621 studies, 135,246 procedures Summary
• Only about 3% of morbidly obese patients will get weight loss surgery
• BMI alone is a poor indicator
• Selection should be based of presence/ severity of co-morbidities and those who are likely to benefit the most
• I have had my bariatric surgery ......
• What next?
Post surgical care – Roles need defining?
Surgical team
GP
Patient
Other clinicians
(Diabetes)
• Lifestyle change ...
– Dietary
– Exercise
– Behaviour
• Most important prognostic indicator
Nutritional deficiencies
Band,
Sleeve Gastrectomy
RYGB BPD-DS
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Nutritional deficiencies
• Protein malnutrition
• Iron
• B12, folic acid
• Calcium, Vitamin D
• Vitamin A, E, K, B1
• Zinc, Magnesium, Selenium & Copper
Some common problems ...
• Hair loss
• Vomiting
• Altered bowel habits
– Steatorrhoea
• Rapid weight loss
• Dumping syndrome
• Hypoglycaemia
• Failure & weight regain
Also remember
• Postural hypotension
• Autonomic dysfunction
• Peripheral neuropathy
– with or without diabetes
• Worsening of retinopathy
Diabetes remission
• Eye & Feet screening essential
• Diabetes remission not cure
– Can recur with or without weight regain
Diabetes Remission
Terminology
• Cure
• Resolution
Definition
OGTT – inappropriate
HbA1c
Fasting plasma glucose
Timing
LAGB – gradual
Months to years
RYGB – immediate
Days to months
DS – very immediate
Days to weeks
Diabetes remission definition
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ADA – Diabetes remission
Remission Fasting glucose mmol/l
HbA1c Duration
Partial 5.6 – 6.9 <6.5% 12 months
Complete <5.6 <6.0% 12 months
Prolonged 5 years
Sleep apnoea
• Most will be able to return machine in 18-24 months
• Keep contact with sleep clinic – will need re-test
Psychological considerations
• Body image / abnormal perception
• Depression / anxiety
• Disordered eating
• Altered relationships
• This is not me ...
• I have to succeed .... failure scares me
• Loose skin – I was better off ...FAT
Surgery for diabetes even if BMI low?
Several papers with BMI 30 – 40
Diabetes remission /improvements
Risk – Benefit ratio?
Who should have surgery?
Bariatric Surgery – NICE Guidelines
Bariatric surgery is recommended as a treatment option for adults with obesity if all of the following criteria are fulfilled:
– they have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight
– all appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months
– the person has been receiving or will receive intensive management in a specialist obesity service
– the person is generally fit for anaesthesia and surgery
– the person commits to the need for long-term follow-up.
Bariatric surgery is also recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m2 in whom surgical intervention is considered appropriate.
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Current NWSC criteria (2012-2013)
• A BMI of 40kg/m2 or more
• Between 35 kg/m2 and 40kg/m2 or greater in the presence of other significant disease
– Significant disease must include one major or two or more minor co-morbidities which may be amenable to treatment if obesity is modified by surgery.
Major criteria • Type 2 diabetes, requiring insulin or another high cost drug or use
of 2 or more HA agents, diabetic complications • Established coronary heart disease, transient ischaemic attack (TIA)
or stroke ( if good functional recovery), heart failure, peripheral vascular disease
• Severe obstructive sleep apnoea (sleep apnoea requiring treatment) or obesity hypoventilation syndrome
• Hypertension requiring the use of 3 or more drugs • Benign intracranial hypertension • Obesity related cardiomyopathy or pulmonary hypertension • Any orthopaedic intervention which has potential to improve
mobility but is precluded on safety grounds due to patient’s BMI • Severe dysmobility due to obesity sufficient to affect essential
activities of daily life e.g. bathing, toileting, dressing, cooking, shopping, that is likely to be improved with weight loss.
• Other co-morbid conditions which have been agreed as exceptional, on an individual patient basis
Minor criteria
• Infertility/polycystic ovary syndrome, male hypogonadism where weight loss is required prior to In vitro fertilisation (IVF), where a couple meet all the other criteria other than BMI of the woman, and the woman is less than 38 years old
• Diabetes requiring only one Oral Hypoglycaemic Agents (OHA) or diet controlled
• Hyperlipidaemia not controlled by statin alone • Liver biopsy proven NASH (Non Alcoholic Steatohepatitis) • Back pain lasting more than six months and causing
interference with daily life • Severe depression where confirmed by psychiatrist or
psychologist that obesity is major causal factor, and there is no other major life event .e.g. relationship breakdown or bereavement in the last 12 months that might be impacting on the depressive illness
Current Welsh bariatric pathway
• Engagement with weight management services
• Referral to WIMOS, Swansea
• Once funding approved patients referred to locally agreed surgical providers
Current WHSSC / WIMOS criteria
• BMI > 50
– Uncontrolled diabetes (HbA1c > 8.1%) despite
being on 3 oral agents or Insulin + one agent
– Uncontrolled hypertension despite 3 or more agents at optimised dosing
– Uncontrolled sleep apnoea despite being on CPAP therapy
• Is there a better way?
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Edmonton Obesity Staging System (EOSS)
Stage 0
Sharma AM & Kushner RF, Int J Obes 2009
Stage 1
Stage 2
Stage 3
Stage 4
co-morbidity
moderate
moderate
Obesity
EOSS vs. BMI in predicting Mortality
Padwal R, Sharma AM et al. CMAJ 2011
The proposed future ...
Questions ...