Obesity and Bariatric Surgery Paul Burton FRACS, PhD
Obesity and Bariatric Surgery
Paul Burton FRACS, PhD
Current Standard of Care for Obesity
• = 0• For success ………………..this needs to change
• Ignoring obesity and its treatment needs to become no more acceptable than ignoring other disorders
Lee Kaplan: Director of the Weight Center at the Massachusetts General Hospital and associate professor of medicine at Harvard Medical School.
NHMRC Guidelines
Franz et al. J Am Diet Assoc. 2007 Oct;107(10):1755-67.
Ten year follow: A randomised control trial surgical versus medical treatment of mild to moderate obesity
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Two years Ten years
WEI
GH
T LO
SS (
KG
)
Chart Title
Surgical Medical
Outcome data are available on 37 (92.5 %) of the surgical patients and 27 (62.5 %) of
the non-surgical patients at 10 years.
12% removal of gastric band
Key benefits of surgically induced weight loss
Physical quality of lifeTie shoelacesWalk up a flight of stairsGet on an airplane and do up the seatbelt
Decreased mortality Co-morbidity improvement• Type II diabetes• Metabolic syndrome• NASH• Obstructive sleep apnoea• Asthma• Hypertension
Reduced health care costsCost efficacyCost effectiveness
Proportion of potentially eligible patients undergoing bariatric surgery annually
Australia 0.3%
Surgery No Surgery
United States 0.7%
Surgery No Surgery
Male Female ratio of patients having bariatric surgery
(2014 calendar year)
58
155
Chart Title
Male Female
“If you have not had a friend, family member or colleague who has struggled with their weight and particularly if you haven't tried to lose weight yourself, then it’s easy for you to ascribe negative stereotypical traits to overweight and obese people. It's a lot like alcohol and drug addiction. Our society is more accepting of these conditions as a disease and less so for obesity”*
*American Obesity association
Surgical procedures
Eligibility for bariatric surgery
• Age 18-65 years
• Ability and willingness to engage in follow up
• Body Mass index 30-35 kg/m2 with obesity related co-morbidity (band)
• Body Mass index >35 kg/m2 with obesity related co-morbidity (sleeve or bypass)
• Body Mass index >40 kg/m2
13
Bariatric (obesity) Surgery
• Goal of every bariatric procedure is to assist in reducing daily calorie intake
• Surgery levels the playing field, making it possible for the patient to control their weight.
Calories In = Calories Out Weight Stable
Calories In > Calories Out Weight Gain
Calories In < Calories Out Weight Loss
Laparoscopic Adjustable Gastric Band
Key Strengths:SafeEffectiveGentle, adjustable, reversibleGood evidence base
Key Weaknesses:Requires good follow upRequires a “partnership”Requires revisional surgery –
20-30% in 15 years
Adjustments and Follow up
Patient Education
-10
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70
0y 0.5y 1y 1.5y 2y 3y 4y 5y 6y 7y 8y 9y 10y 11y 12y 13y 14y 15y
%EWL
Years of follow-up
Weight Loss up to 15 years after gastric bandingO’Brien/Brown Series; N = 3,227; 81% follow up
54234714
%EWL – Mean +/- 95% CIs
1,983
Annals of Surgery 2013; Volume 257, Pages 87-94
Sleeve GastrectomyStrengths:Technically simpleExcellent early weight loss“No need for follow up”
(Sleeve and Leave)Few intermediate term problemsGood eating quality
Weaknesses:2-3% Leaks rate - major problemRefluxLimited long term dataRevision may be neededIrreversible
Roux-en-Y Gastric Bypass (RYGB)
Strengths:Good weight lossWell known - > 40 yearsReasonable evidence base?Adjuvant benefits - diabetes
Weaknesses:Risk of deathMajor GI tract change?Weight loss fades/Revisions Irreversible Nutritional deficienciesUlcers and internal hernias
Malabsorption - Biliopancreatic Diversion
Strengths:Very good weight lossProbably durable
Weaknesses:Highest surgical riskMetabolically toxic – risks with non-complianceIndefinite follow upMajor long term problemsOffensive diarrhea
NEW PROCEDURES
Weight Loss at 2 years
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Band Sleeve Bypass Bilio-pancreaticdiversion
% Excess weight loss
Weight loss at 10 years
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Band Bypass Bilio-pancreatic diversion
%Ex
cess
We
igh
t Lo
ss
% Excess weight loss
Re-operations over 10 years
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60
70
Band Bypass
Pe
rce
nta
ge
Peri-operative mortality risk
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Band Sleeve Bypass Bilio-pancreaticdiversion
Per
cen
tage
Nutritional follow up
• Baseline, then annual or six monthly measurements of metabolic and nutritional health.
• Vitamin D, iron, thiamine, B12, folate, protein (albumin).
• Malabsorptive procedures – fat soluble vitamins: Vitamin A, and Vitamin D, parathyroid hormone, Vitamin K.
• More major procedures require more intense follow up and nutritional supplementation.
Key messages
1) Surgery involves simple, anatomical modifications to the gastrointestinal tract
2) Bariatric surgery is not about surgery, it is about the post-operative follow up – “weight loss is a journey not a destination”
3) Any gastro-intestinal or nutritional issue is highly likely to be related to the bariatric surgery
4) More variability in the surgical outcomes based on the quality of bariatric surgical care, than there is between different operations - Always, Always get the patients to follow up