Dr Stephanie Ulmer - GP CME North/Sat_Room8_1100_Ulmer... · returned to original weight quickly....
56
Dr Stephanie Ulmer General Surgeon Middlemore Hospital Auckland 11:00 - 11:55 WS #114: Bariatric Surgery - What GPs Need to Know 12:05 - 13:00 WS #126: Bariatric Surgery - What GPs Need to Know (Repeated)
Transcript of Dr Stephanie Ulmer - GP CME North/Sat_Room8_1100_Ulmer... · returned to original weight quickly....
Dr Stephanie UlmerGeneral Surgeon
Middlemore Hospital
Auckland
1100 - 1155 WS 114 Bariatric Surgery - What GPs Need to Know
1205 - 1300 WS 126 Bariatric Surgery - What GPs Need to Know (Repeated)
BARIATRIC SURGERY
THE EVOLUTION
Obesity ndash rare before the 20th century
Carnival ldquofreaksrdquo
Medical opinion ndash self-inflicted defect of the will
Little to offer ndash ldquoeat less exercise morerdquo
Hospital based starvation programmes
Altered metabolism ndash relatively new concept
THE EVOLUTION
New concept ndash Obesity is a multifactorial disease Genetic component to adult obesity
Children born of obese biologic parents but lean adoptive parents mirrored their biological parents body habitus
Vermont Prison - deliberately overfed inmates
- natural ectomorphs ndash gained weight with difficulty
returned to original weight quickly
THE SURGERY
1960s - Surgical mavericks attracted
Initially Malabsorptive techniques common
Jejuno-ileal bypass JIB (1960s)
Biliopancreatic Diversion(1970s ndash Scopinaro)
Duodenal Switch
Open surgery ndash limited technology
High complication rates long ICU stays
Long term complications - Metabolic deficiencies weight regain
1980s - Decreased Malabsorptive effect and introduced Restrictive
Roux-en-Y Gastric Bypass
THE EVOLUTION
Laparoscopic techniques perfected (Hess 1990s)
Swing to Restrictive surgical procedures
Gastric Band Gastric Sleeve
Modified Roux-en-Y Gastric Bypass
Future ndash Neurohormonal manipulation (surgical and non-surgical)
Robotic surgery
Purely Endoscopic techniques ndash Plication sutures Endobarrier
THE EVOLUTION
Changed from least attractive surgical subspecialty to Golden Boy
- lsquofreaksrsquo to lsquofriends and familyrsquo
Significant investments in research and technology
Many major international conferences
Number one public interest story in surgery
lsquoobesity epidemicrsquo
Awakening the Giant
YOUR PATIENTS
Why do they want Bariatric surgery
Many reasonshellip
Different for males and females
2 categories Medical reasons
ldquoMy GP just told me I am diabeticrdquo
ldquoMy Orthopedic surgeon asked me to lose weight before my hip joint replacementrdquo
ldquoI donrsquot qualify for IVF at my BMIrdquo
Non-medical reasons ie quality of life or cosmesis
ldquoI want to be able to keep up with my kidsrdquo
ldquoI want to travelrdquo
ldquoI donrsquot like the lsquomersquo I see in the mirrorrdquo
YOUR PATIENTS
Who qualifies
YOUR PATIENTS
Middlemore Hospital
BMI gt 40 or BMI gt 35 plus comorbidities
Obesity gt 5 years
Weight lt 200 kgs or BMI lt55
Failed non-surgical attempts at weight loss for more than 2 years
Understanding of and motivated for surgery
Accepts long term follow up
Non-smoker
YOUR PATIENTS
Self-funded ndash Who Qualifies
BMI gt 30
Costs - $19 750 - $23 500
Insurance companies ndash Southern Cross BMI gt 35 with comorbidities ndash IHD T2DM OSA Osteoarthritis
BMI gt40 without comorbidities
$5 500 or $7 000
Unimed ndash fully covered
Sovereign NIB ndash not covered
NZ STATISTICS
NZ STATISTICS
NZ STATISTICS
NZ
NZ
CASE 1
50yo male Accountant BMI 50 T2DM diagnosed 12 months ago no previous abdominal surgery I would A advise him to undergo Bariatric surgery
B advise him to see a dietitian and set up a Green prescription
C measure his HbA1C and thyroid function and give him a repeat prescription
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with
Type 2 Diabetes Mellitus
Ischaemis Heart Disease
Hypertension
Obstructive Sleep Apnoea
Osteoarthritis requiring joint replacement surgery
PCOS or Primary Infertility
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
BARIATRIC SURGERY
THE EVOLUTION
Obesity ndash rare before the 20th century
Carnival ldquofreaksrdquo
Medical opinion ndash self-inflicted defect of the will
Little to offer ndash ldquoeat less exercise morerdquo
Hospital based starvation programmes
Altered metabolism ndash relatively new concept
THE EVOLUTION
New concept ndash Obesity is a multifactorial disease Genetic component to adult obesity
Children born of obese biologic parents but lean adoptive parents mirrored their biological parents body habitus
Vermont Prison - deliberately overfed inmates
- natural ectomorphs ndash gained weight with difficulty
returned to original weight quickly
THE SURGERY
1960s - Surgical mavericks attracted
Initially Malabsorptive techniques common
Jejuno-ileal bypass JIB (1960s)
Biliopancreatic Diversion(1970s ndash Scopinaro)
Duodenal Switch
Open surgery ndash limited technology
High complication rates long ICU stays
Long term complications - Metabolic deficiencies weight regain
1980s - Decreased Malabsorptive effect and introduced Restrictive
Roux-en-Y Gastric Bypass
THE EVOLUTION
Laparoscopic techniques perfected (Hess 1990s)
Swing to Restrictive surgical procedures
Gastric Band Gastric Sleeve
Modified Roux-en-Y Gastric Bypass
Future ndash Neurohormonal manipulation (surgical and non-surgical)
Robotic surgery
Purely Endoscopic techniques ndash Plication sutures Endobarrier
THE EVOLUTION
Changed from least attractive surgical subspecialty to Golden Boy
- lsquofreaksrsquo to lsquofriends and familyrsquo
Significant investments in research and technology
Many major international conferences
Number one public interest story in surgery
lsquoobesity epidemicrsquo
Awakening the Giant
YOUR PATIENTS
Why do they want Bariatric surgery
Many reasonshellip
Different for males and females
2 categories Medical reasons
ldquoMy GP just told me I am diabeticrdquo
ldquoMy Orthopedic surgeon asked me to lose weight before my hip joint replacementrdquo
ldquoI donrsquot qualify for IVF at my BMIrdquo
Non-medical reasons ie quality of life or cosmesis
ldquoI want to be able to keep up with my kidsrdquo
ldquoI want to travelrdquo
ldquoI donrsquot like the lsquomersquo I see in the mirrorrdquo
YOUR PATIENTS
Who qualifies
YOUR PATIENTS
Middlemore Hospital
BMI gt 40 or BMI gt 35 plus comorbidities
Obesity gt 5 years
Weight lt 200 kgs or BMI lt55
Failed non-surgical attempts at weight loss for more than 2 years
Understanding of and motivated for surgery
Accepts long term follow up
Non-smoker
YOUR PATIENTS
Self-funded ndash Who Qualifies
BMI gt 30
Costs - $19 750 - $23 500
Insurance companies ndash Southern Cross BMI gt 35 with comorbidities ndash IHD T2DM OSA Osteoarthritis
BMI gt40 without comorbidities
$5 500 or $7 000
Unimed ndash fully covered
Sovereign NIB ndash not covered
NZ STATISTICS
NZ STATISTICS
NZ STATISTICS
NZ
NZ
CASE 1
50yo male Accountant BMI 50 T2DM diagnosed 12 months ago no previous abdominal surgery I would A advise him to undergo Bariatric surgery
B advise him to see a dietitian and set up a Green prescription
C measure his HbA1C and thyroid function and give him a repeat prescription
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with
Type 2 Diabetes Mellitus
Ischaemis Heart Disease
Hypertension
Obstructive Sleep Apnoea
Osteoarthritis requiring joint replacement surgery
PCOS or Primary Infertility
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
THE EVOLUTION
Obesity ndash rare before the 20th century
Carnival ldquofreaksrdquo
Medical opinion ndash self-inflicted defect of the will
Little to offer ndash ldquoeat less exercise morerdquo
Hospital based starvation programmes
Altered metabolism ndash relatively new concept
THE EVOLUTION
New concept ndash Obesity is a multifactorial disease Genetic component to adult obesity
Children born of obese biologic parents but lean adoptive parents mirrored their biological parents body habitus
Vermont Prison - deliberately overfed inmates
- natural ectomorphs ndash gained weight with difficulty
returned to original weight quickly
THE SURGERY
1960s - Surgical mavericks attracted
Initially Malabsorptive techniques common
Jejuno-ileal bypass JIB (1960s)
Biliopancreatic Diversion(1970s ndash Scopinaro)
Duodenal Switch
Open surgery ndash limited technology
High complication rates long ICU stays
Long term complications - Metabolic deficiencies weight regain
1980s - Decreased Malabsorptive effect and introduced Restrictive
Roux-en-Y Gastric Bypass
THE EVOLUTION
Laparoscopic techniques perfected (Hess 1990s)
Swing to Restrictive surgical procedures
Gastric Band Gastric Sleeve
Modified Roux-en-Y Gastric Bypass
Future ndash Neurohormonal manipulation (surgical and non-surgical)
Robotic surgery
Purely Endoscopic techniques ndash Plication sutures Endobarrier
THE EVOLUTION
Changed from least attractive surgical subspecialty to Golden Boy
- lsquofreaksrsquo to lsquofriends and familyrsquo
Significant investments in research and technology
Many major international conferences
Number one public interest story in surgery
lsquoobesity epidemicrsquo
Awakening the Giant
YOUR PATIENTS
Why do they want Bariatric surgery
Many reasonshellip
Different for males and females
2 categories Medical reasons
ldquoMy GP just told me I am diabeticrdquo
ldquoMy Orthopedic surgeon asked me to lose weight before my hip joint replacementrdquo
ldquoI donrsquot qualify for IVF at my BMIrdquo
Non-medical reasons ie quality of life or cosmesis
ldquoI want to be able to keep up with my kidsrdquo
ldquoI want to travelrdquo
ldquoI donrsquot like the lsquomersquo I see in the mirrorrdquo
YOUR PATIENTS
Who qualifies
YOUR PATIENTS
Middlemore Hospital
BMI gt 40 or BMI gt 35 plus comorbidities
Obesity gt 5 years
Weight lt 200 kgs or BMI lt55
Failed non-surgical attempts at weight loss for more than 2 years
Understanding of and motivated for surgery
Accepts long term follow up
Non-smoker
YOUR PATIENTS
Self-funded ndash Who Qualifies
BMI gt 30
Costs - $19 750 - $23 500
Insurance companies ndash Southern Cross BMI gt 35 with comorbidities ndash IHD T2DM OSA Osteoarthritis
BMI gt40 without comorbidities
$5 500 or $7 000
Unimed ndash fully covered
Sovereign NIB ndash not covered
NZ STATISTICS
NZ STATISTICS
NZ STATISTICS
NZ
NZ
CASE 1
50yo male Accountant BMI 50 T2DM diagnosed 12 months ago no previous abdominal surgery I would A advise him to undergo Bariatric surgery
B advise him to see a dietitian and set up a Green prescription
C measure his HbA1C and thyroid function and give him a repeat prescription
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with
Type 2 Diabetes Mellitus
Ischaemis Heart Disease
Hypertension
Obstructive Sleep Apnoea
Osteoarthritis requiring joint replacement surgery
PCOS or Primary Infertility
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
THE EVOLUTION
New concept ndash Obesity is a multifactorial disease Genetic component to adult obesity
Children born of obese biologic parents but lean adoptive parents mirrored their biological parents body habitus
Vermont Prison - deliberately overfed inmates
- natural ectomorphs ndash gained weight with difficulty
returned to original weight quickly
THE SURGERY
1960s - Surgical mavericks attracted
Initially Malabsorptive techniques common
Jejuno-ileal bypass JIB (1960s)
Biliopancreatic Diversion(1970s ndash Scopinaro)
Duodenal Switch
Open surgery ndash limited technology
High complication rates long ICU stays
Long term complications - Metabolic deficiencies weight regain
1980s - Decreased Malabsorptive effect and introduced Restrictive
Roux-en-Y Gastric Bypass
THE EVOLUTION
Laparoscopic techniques perfected (Hess 1990s)
Swing to Restrictive surgical procedures
Gastric Band Gastric Sleeve
Modified Roux-en-Y Gastric Bypass
Future ndash Neurohormonal manipulation (surgical and non-surgical)
Robotic surgery
Purely Endoscopic techniques ndash Plication sutures Endobarrier
THE EVOLUTION
Changed from least attractive surgical subspecialty to Golden Boy
- lsquofreaksrsquo to lsquofriends and familyrsquo
Significant investments in research and technology
Many major international conferences
Number one public interest story in surgery
lsquoobesity epidemicrsquo
Awakening the Giant
YOUR PATIENTS
Why do they want Bariatric surgery
Many reasonshellip
Different for males and females
2 categories Medical reasons
ldquoMy GP just told me I am diabeticrdquo
ldquoMy Orthopedic surgeon asked me to lose weight before my hip joint replacementrdquo
ldquoI donrsquot qualify for IVF at my BMIrdquo
Non-medical reasons ie quality of life or cosmesis
ldquoI want to be able to keep up with my kidsrdquo
ldquoI want to travelrdquo
ldquoI donrsquot like the lsquomersquo I see in the mirrorrdquo
YOUR PATIENTS
Who qualifies
YOUR PATIENTS
Middlemore Hospital
BMI gt 40 or BMI gt 35 plus comorbidities
Obesity gt 5 years
Weight lt 200 kgs or BMI lt55
Failed non-surgical attempts at weight loss for more than 2 years
Understanding of and motivated for surgery
Accepts long term follow up
Non-smoker
YOUR PATIENTS
Self-funded ndash Who Qualifies
BMI gt 30
Costs - $19 750 - $23 500
Insurance companies ndash Southern Cross BMI gt 35 with comorbidities ndash IHD T2DM OSA Osteoarthritis
BMI gt40 without comorbidities
$5 500 or $7 000
Unimed ndash fully covered
Sovereign NIB ndash not covered
NZ STATISTICS
NZ STATISTICS
NZ STATISTICS
NZ
NZ
CASE 1
50yo male Accountant BMI 50 T2DM diagnosed 12 months ago no previous abdominal surgery I would A advise him to undergo Bariatric surgery
B advise him to see a dietitian and set up a Green prescription
C measure his HbA1C and thyroid function and give him a repeat prescription
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with
Type 2 Diabetes Mellitus
Ischaemis Heart Disease
Hypertension
Obstructive Sleep Apnoea
Osteoarthritis requiring joint replacement surgery
PCOS or Primary Infertility
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
THE SURGERY
1960s - Surgical mavericks attracted
Initially Malabsorptive techniques common
Jejuno-ileal bypass JIB (1960s)
Biliopancreatic Diversion(1970s ndash Scopinaro)
Duodenal Switch
Open surgery ndash limited technology
High complication rates long ICU stays
Long term complications - Metabolic deficiencies weight regain
1980s - Decreased Malabsorptive effect and introduced Restrictive
Roux-en-Y Gastric Bypass
THE EVOLUTION
Laparoscopic techniques perfected (Hess 1990s)
Swing to Restrictive surgical procedures
Gastric Band Gastric Sleeve
Modified Roux-en-Y Gastric Bypass
Future ndash Neurohormonal manipulation (surgical and non-surgical)
Robotic surgery
Purely Endoscopic techniques ndash Plication sutures Endobarrier
THE EVOLUTION
Changed from least attractive surgical subspecialty to Golden Boy
- lsquofreaksrsquo to lsquofriends and familyrsquo
Significant investments in research and technology
Many major international conferences
Number one public interest story in surgery
lsquoobesity epidemicrsquo
Awakening the Giant
YOUR PATIENTS
Why do they want Bariatric surgery
Many reasonshellip
Different for males and females
2 categories Medical reasons
ldquoMy GP just told me I am diabeticrdquo
ldquoMy Orthopedic surgeon asked me to lose weight before my hip joint replacementrdquo
ldquoI donrsquot qualify for IVF at my BMIrdquo
Non-medical reasons ie quality of life or cosmesis
ldquoI want to be able to keep up with my kidsrdquo
ldquoI want to travelrdquo
ldquoI donrsquot like the lsquomersquo I see in the mirrorrdquo
YOUR PATIENTS
Who qualifies
YOUR PATIENTS
Middlemore Hospital
BMI gt 40 or BMI gt 35 plus comorbidities
Obesity gt 5 years
Weight lt 200 kgs or BMI lt55
Failed non-surgical attempts at weight loss for more than 2 years
Understanding of and motivated for surgery
Accepts long term follow up
Non-smoker
YOUR PATIENTS
Self-funded ndash Who Qualifies
BMI gt 30
Costs - $19 750 - $23 500
Insurance companies ndash Southern Cross BMI gt 35 with comorbidities ndash IHD T2DM OSA Osteoarthritis
BMI gt40 without comorbidities
$5 500 or $7 000
Unimed ndash fully covered
Sovereign NIB ndash not covered
NZ STATISTICS
NZ STATISTICS
NZ STATISTICS
NZ
NZ
CASE 1
50yo male Accountant BMI 50 T2DM diagnosed 12 months ago no previous abdominal surgery I would A advise him to undergo Bariatric surgery
B advise him to see a dietitian and set up a Green prescription
C measure his HbA1C and thyroid function and give him a repeat prescription
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with
Type 2 Diabetes Mellitus
Ischaemis Heart Disease
Hypertension
Obstructive Sleep Apnoea
Osteoarthritis requiring joint replacement surgery
PCOS or Primary Infertility
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
THE EVOLUTION
Laparoscopic techniques perfected (Hess 1990s)
Swing to Restrictive surgical procedures
Gastric Band Gastric Sleeve
Modified Roux-en-Y Gastric Bypass
Future ndash Neurohormonal manipulation (surgical and non-surgical)
Robotic surgery
Purely Endoscopic techniques ndash Plication sutures Endobarrier
THE EVOLUTION
Changed from least attractive surgical subspecialty to Golden Boy
- lsquofreaksrsquo to lsquofriends and familyrsquo
Significant investments in research and technology
Many major international conferences
Number one public interest story in surgery
lsquoobesity epidemicrsquo
Awakening the Giant
YOUR PATIENTS
Why do they want Bariatric surgery
Many reasonshellip
Different for males and females
2 categories Medical reasons
ldquoMy GP just told me I am diabeticrdquo
ldquoMy Orthopedic surgeon asked me to lose weight before my hip joint replacementrdquo
ldquoI donrsquot qualify for IVF at my BMIrdquo
Non-medical reasons ie quality of life or cosmesis
ldquoI want to be able to keep up with my kidsrdquo
ldquoI want to travelrdquo
ldquoI donrsquot like the lsquomersquo I see in the mirrorrdquo
YOUR PATIENTS
Who qualifies
YOUR PATIENTS
Middlemore Hospital
BMI gt 40 or BMI gt 35 plus comorbidities
Obesity gt 5 years
Weight lt 200 kgs or BMI lt55
Failed non-surgical attempts at weight loss for more than 2 years
Understanding of and motivated for surgery
Accepts long term follow up
Non-smoker
YOUR PATIENTS
Self-funded ndash Who Qualifies
BMI gt 30
Costs - $19 750 - $23 500
Insurance companies ndash Southern Cross BMI gt 35 with comorbidities ndash IHD T2DM OSA Osteoarthritis
BMI gt40 without comorbidities
$5 500 or $7 000
Unimed ndash fully covered
Sovereign NIB ndash not covered
NZ STATISTICS
NZ STATISTICS
NZ STATISTICS
NZ
NZ
CASE 1
50yo male Accountant BMI 50 T2DM diagnosed 12 months ago no previous abdominal surgery I would A advise him to undergo Bariatric surgery
B advise him to see a dietitian and set up a Green prescription
C measure his HbA1C and thyroid function and give him a repeat prescription
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with
Type 2 Diabetes Mellitus
Ischaemis Heart Disease
Hypertension
Obstructive Sleep Apnoea
Osteoarthritis requiring joint replacement surgery
PCOS or Primary Infertility
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
THE EVOLUTION
Changed from least attractive surgical subspecialty to Golden Boy
- lsquofreaksrsquo to lsquofriends and familyrsquo
Significant investments in research and technology
Many major international conferences
Number one public interest story in surgery
lsquoobesity epidemicrsquo
Awakening the Giant
YOUR PATIENTS
Why do they want Bariatric surgery
Many reasonshellip
Different for males and females
2 categories Medical reasons
ldquoMy GP just told me I am diabeticrdquo
ldquoMy Orthopedic surgeon asked me to lose weight before my hip joint replacementrdquo
ldquoI donrsquot qualify for IVF at my BMIrdquo
Non-medical reasons ie quality of life or cosmesis
ldquoI want to be able to keep up with my kidsrdquo
ldquoI want to travelrdquo
ldquoI donrsquot like the lsquomersquo I see in the mirrorrdquo
YOUR PATIENTS
Who qualifies
YOUR PATIENTS
Middlemore Hospital
BMI gt 40 or BMI gt 35 plus comorbidities
Obesity gt 5 years
Weight lt 200 kgs or BMI lt55
Failed non-surgical attempts at weight loss for more than 2 years
Understanding of and motivated for surgery
Accepts long term follow up
Non-smoker
YOUR PATIENTS
Self-funded ndash Who Qualifies
BMI gt 30
Costs - $19 750 - $23 500
Insurance companies ndash Southern Cross BMI gt 35 with comorbidities ndash IHD T2DM OSA Osteoarthritis
BMI gt40 without comorbidities
$5 500 or $7 000
Unimed ndash fully covered
Sovereign NIB ndash not covered
NZ STATISTICS
NZ STATISTICS
NZ STATISTICS
NZ
NZ
CASE 1
50yo male Accountant BMI 50 T2DM diagnosed 12 months ago no previous abdominal surgery I would A advise him to undergo Bariatric surgery
B advise him to see a dietitian and set up a Green prescription
C measure his HbA1C and thyroid function and give him a repeat prescription
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with
Type 2 Diabetes Mellitus
Ischaemis Heart Disease
Hypertension
Obstructive Sleep Apnoea
Osteoarthritis requiring joint replacement surgery
PCOS or Primary Infertility
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
YOUR PATIENTS
Why do they want Bariatric surgery
Many reasonshellip
Different for males and females
2 categories Medical reasons
ldquoMy GP just told me I am diabeticrdquo
ldquoMy Orthopedic surgeon asked me to lose weight before my hip joint replacementrdquo
ldquoI donrsquot qualify for IVF at my BMIrdquo
Non-medical reasons ie quality of life or cosmesis
ldquoI want to be able to keep up with my kidsrdquo
ldquoI want to travelrdquo
ldquoI donrsquot like the lsquomersquo I see in the mirrorrdquo
YOUR PATIENTS
Who qualifies
YOUR PATIENTS
Middlemore Hospital
BMI gt 40 or BMI gt 35 plus comorbidities
Obesity gt 5 years
Weight lt 200 kgs or BMI lt55
Failed non-surgical attempts at weight loss for more than 2 years
Understanding of and motivated for surgery
Accepts long term follow up
Non-smoker
YOUR PATIENTS
Self-funded ndash Who Qualifies
BMI gt 30
Costs - $19 750 - $23 500
Insurance companies ndash Southern Cross BMI gt 35 with comorbidities ndash IHD T2DM OSA Osteoarthritis
BMI gt40 without comorbidities
$5 500 or $7 000
Unimed ndash fully covered
Sovereign NIB ndash not covered
NZ STATISTICS
NZ STATISTICS
NZ STATISTICS
NZ
NZ
CASE 1
50yo male Accountant BMI 50 T2DM diagnosed 12 months ago no previous abdominal surgery I would A advise him to undergo Bariatric surgery
B advise him to see a dietitian and set up a Green prescription
C measure his HbA1C and thyroid function and give him a repeat prescription
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with
Type 2 Diabetes Mellitus
Ischaemis Heart Disease
Hypertension
Obstructive Sleep Apnoea
Osteoarthritis requiring joint replacement surgery
PCOS or Primary Infertility
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
YOUR PATIENTS
Who qualifies
YOUR PATIENTS
Middlemore Hospital
BMI gt 40 or BMI gt 35 plus comorbidities
Obesity gt 5 years
Weight lt 200 kgs or BMI lt55
Failed non-surgical attempts at weight loss for more than 2 years
Understanding of and motivated for surgery
Accepts long term follow up
Non-smoker
YOUR PATIENTS
Self-funded ndash Who Qualifies
BMI gt 30
Costs - $19 750 - $23 500
Insurance companies ndash Southern Cross BMI gt 35 with comorbidities ndash IHD T2DM OSA Osteoarthritis
BMI gt40 without comorbidities
$5 500 or $7 000
Unimed ndash fully covered
Sovereign NIB ndash not covered
NZ STATISTICS
NZ STATISTICS
NZ STATISTICS
NZ
NZ
CASE 1
50yo male Accountant BMI 50 T2DM diagnosed 12 months ago no previous abdominal surgery I would A advise him to undergo Bariatric surgery
B advise him to see a dietitian and set up a Green prescription
C measure his HbA1C and thyroid function and give him a repeat prescription
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with
Type 2 Diabetes Mellitus
Ischaemis Heart Disease
Hypertension
Obstructive Sleep Apnoea
Osteoarthritis requiring joint replacement surgery
PCOS or Primary Infertility
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
YOUR PATIENTS
Middlemore Hospital
BMI gt 40 or BMI gt 35 plus comorbidities
Obesity gt 5 years
Weight lt 200 kgs or BMI lt55
Failed non-surgical attempts at weight loss for more than 2 years
Understanding of and motivated for surgery
Accepts long term follow up
Non-smoker
YOUR PATIENTS
Self-funded ndash Who Qualifies
BMI gt 30
Costs - $19 750 - $23 500
Insurance companies ndash Southern Cross BMI gt 35 with comorbidities ndash IHD T2DM OSA Osteoarthritis
BMI gt40 without comorbidities
$5 500 or $7 000
Unimed ndash fully covered
Sovereign NIB ndash not covered
NZ STATISTICS
NZ STATISTICS
NZ STATISTICS
NZ
NZ
CASE 1
50yo male Accountant BMI 50 T2DM diagnosed 12 months ago no previous abdominal surgery I would A advise him to undergo Bariatric surgery
B advise him to see a dietitian and set up a Green prescription
C measure his HbA1C and thyroid function and give him a repeat prescription
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with
Type 2 Diabetes Mellitus
Ischaemis Heart Disease
Hypertension
Obstructive Sleep Apnoea
Osteoarthritis requiring joint replacement surgery
PCOS or Primary Infertility
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
YOUR PATIENTS
Self-funded ndash Who Qualifies
BMI gt 30
Costs - $19 750 - $23 500
Insurance companies ndash Southern Cross BMI gt 35 with comorbidities ndash IHD T2DM OSA Osteoarthritis
BMI gt40 without comorbidities
$5 500 or $7 000
Unimed ndash fully covered
Sovereign NIB ndash not covered
NZ STATISTICS
NZ STATISTICS
NZ STATISTICS
NZ
NZ
CASE 1
50yo male Accountant BMI 50 T2DM diagnosed 12 months ago no previous abdominal surgery I would A advise him to undergo Bariatric surgery
B advise him to see a dietitian and set up a Green prescription
C measure his HbA1C and thyroid function and give him a repeat prescription
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with
Type 2 Diabetes Mellitus
Ischaemis Heart Disease
Hypertension
Obstructive Sleep Apnoea
Osteoarthritis requiring joint replacement surgery
PCOS or Primary Infertility
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
NZ STATISTICS
NZ STATISTICS
NZ STATISTICS
NZ
NZ
CASE 1
50yo male Accountant BMI 50 T2DM diagnosed 12 months ago no previous abdominal surgery I would A advise him to undergo Bariatric surgery
B advise him to see a dietitian and set up a Green prescription
C measure his HbA1C and thyroid function and give him a repeat prescription
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with
Type 2 Diabetes Mellitus
Ischaemis Heart Disease
Hypertension
Obstructive Sleep Apnoea
Osteoarthritis requiring joint replacement surgery
PCOS or Primary Infertility
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
NZ STATISTICS
NZ STATISTICS
NZ
NZ
CASE 1
50yo male Accountant BMI 50 T2DM diagnosed 12 months ago no previous abdominal surgery I would A advise him to undergo Bariatric surgery
B advise him to see a dietitian and set up a Green prescription
C measure his HbA1C and thyroid function and give him a repeat prescription
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with
Type 2 Diabetes Mellitus
Ischaemis Heart Disease
Hypertension
Obstructive Sleep Apnoea
Osteoarthritis requiring joint replacement surgery
PCOS or Primary Infertility
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
NZ STATISTICS
NZ
NZ
CASE 1
50yo male Accountant BMI 50 T2DM diagnosed 12 months ago no previous abdominal surgery I would A advise him to undergo Bariatric surgery
B advise him to see a dietitian and set up a Green prescription
C measure his HbA1C and thyroid function and give him a repeat prescription
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with
Type 2 Diabetes Mellitus
Ischaemis Heart Disease
Hypertension
Obstructive Sleep Apnoea
Osteoarthritis requiring joint replacement surgery
PCOS or Primary Infertility
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
CASE 1
50yo male Accountant BMI 50 T2DM diagnosed 12 months ago no previous abdominal surgery I would A advise him to undergo Bariatric surgery
B advise him to see a dietitian and set up a Green prescription
C measure his HbA1C and thyroid function and give him a repeat prescription
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with
Type 2 Diabetes Mellitus
Ischaemis Heart Disease
Hypertension
Obstructive Sleep Apnoea
Osteoarthritis requiring joint replacement surgery
PCOS or Primary Infertility
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with
Type 2 Diabetes Mellitus
Ischaemis Heart Disease
Hypertension
Obstructive Sleep Apnoea
Osteoarthritis requiring joint replacement surgery
PCOS or Primary Infertility
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Type 2 Diabetes Mellitus257 000 diabetics 500 000 pre-diabetics
Pacific Islanders and Indians ndash highest rates
Incidence parallels obesity epidemicBMI 25 ndash 5x risk compared BMI 21
BMI 30 ndash 35x risk compared BMI 21
BMI 35 ndash 93x risk compared BMI 21
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
SURGERY FOR T2DM
Not a new concept ndash
- 1955 - amelioration of diabetes was noted in hemi-gastrectomy pts for peptic ulcer disease
- 1995 ndash Pories 608 patients having RNY Gastric Bypass
at 14 yr follow up ndash 83 normalised glycosylated Hb
- 2015 ndash Systematic review of RCTs comparing Bariatric Surgery to Medical management T2DM
Remission rates in Surgery arm 14x Medical arm (OR14)
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
SURGERY FOR T2DM
Long term results Annals of Surgery 2013
24 of patients who have bariatric surgery experience complete long-term ndash five years or more ndash remission of their type 2 diabetes
26 experience partial remission and 34 improve from baseline
JAMA 2012
Six years after surgery 62 of gastric bypass patients experienced type 2 diabetes remission compared to 6-8 in control groups
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Morbidly obese patients without T2DM N Eng J Med (2007) ndash Swedish Obese Subjects (SOS) trial12
Effects of Bariatric Surgery on Mortality
Case Control Trial
N=4047 (2010 surgery 2037 conventional treatment)
Average FU 11 years
Rate of FU 999
initial wt loss at 10 years
23 Surgery
0 Conventional treatment
Patients in Surgery arm were 3x less likely to go on to develop T2DM
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Cardiovascular Disease
O2 Consumption
CO
SV
Blood volume
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
EFFECT OF BARIATRIC SURGERY ON CARDIOVASCULAR DISEASE
Hypertension Resolves in 60-90
Review article 2011
Differing between studies and types of surgery
Congestive Heart Failure American Journal of Cardiology Nov 2011
52 studies 1950-2010
16 867 patients
Average EWL 52 at 3 years FU
40 Relative Risk Reduction for CHF risk (Framingham Risk score)
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
Cause soft tissue enlargement
muscle tone
pharyngeal obstruction
RR10 if BMI 40
Symptoms daytime somnolence
psychosocial and cognitive dysfunction
Sequelae Hypoxia Hypercapnia
Pulmonary Hypertension RV Failure
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
bull Obese patients with Obstructive Sleep Apnoea
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with Obstructive Sleep Apnoea
Systematic review - Obesity Surgery 2013
13 900 patients 69 articles
Over 75 saw at least an improvement in their OSA
53 stopped using CPAP 1 year after Sleeve Gastrectomy
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
CASE 2
65yo female BMI 38 first THJR 1995 complaining of increasing pain in both hips and canrsquot play bowls anymore Would youhellip A Advise her to consider Bariatric surgery
B Refer her to an Orthopedic surgeon
C Give her a prescription for Voltaren and Losec
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obes Rev 2015 Feb16(2)161-70 doi 101111obr12236 Epub 2014 Dec 8
Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients a systematic review
Groen VA1 van de Graaf VA Scholtes VA Sprague S van Wagensveld BA Poolman RW
Abstract
Obesity is a major risk factor for the development of knee osteoarthritis and over the past 30 years the prevalence of obesity has more than doubled In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty and the demand for primary total knee arthroplasties is expected to grow exponentially However total knee arthroplasty in obese patients is associated with more complications longer hospital stay and higher costs We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index gt30 kg m(-2) ) adult patients The Cochrane Central Register of Controlled Trials MEDLINE EMBASE TRIP BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English German French and Dutch studies There was no restriction on study design We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients with a minimal follow-up of 3 months Studies on the effects oflipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded Thirteen studies were included in this systematic review with a total of 3837 patients Although different assessment tools were used an overall significant improvement in knee pain was seen in 73 out of the used assessments All studies measuring intensity of knee pain knee physical function and knee stiffness showed a significant improvement after bariatric surgery The quality ofevidence was very low or too low for most of the included studies and moderate for one study Bariatric surgery with subsequent marked weight loss is likely to improve knee pain physical function and stiffness in (morbidly) obese adult patients However with the current available evidence there is need for high-quality studies
bull Obese patients with Knee or Hip Pain
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Obese patients with knee pain Systematic review 2015
3837 patients
Significant improvement in knee pain 73
Assumption that this translates to fewer Joint replacements
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
CASE 3
39yo female primary infertility and on 2 meds for HT BMI 39 previously prescribed Duromine Would youhellip
A advise her to consider bariatric surgery
B refer her to Fertility specialists
C give her another prescription for Duromine and BP meds
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
WHICH OF MY PATIENTS SHOULD I ADVISE TO HAVE BARIATRIC SURGERY
Cause Obesity ndash high circulating insulin causes
an increase in androgen levels in females
Exact mechanism unknown
High correlation between PCOS and Metabolic Syndrome India ndash increased thickness of the carotid
intima
- prevalence diabetes (lt50yo) 3-4x general population
Obese patients with Polycystic Ovary SyndromePrimary infertility
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
EFFECTIVENESS OF BARIATRIC SURGERY ON PCOS
Retrospective review between 1997-2001 24 women with PCOS underwent RNYGB
After 2 years follow up
All women had resumed normal menstrual cycles
Most had spontaneous ovulation
Half had resolution of hirsutism
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
WHAT ABOUT DIET AND EXERCISEhellip
Ann Intern Med 2006 (OrsquoBrien)11
Randomised Controlled Trial Gastric Banding vs Intensive Medical Programme
Non-surgical Gp VLCD Pharmacotherapy Behavioural Therapy
Surgical Gp Lap Gastric Banding
At 2 yrs FU Non-surg ndash 5 of initial wt lost
22 excess wt lost
Surg ndash 22 of initial wt lost
87 excess wt lost
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
WHAT ABOUT DIET AND EXERCISEhellip
Obesity Rev 2008 (Sweden)9
Long term weight loss maintenance strategies
Day Care Treatment physician nurse dietician physiotherapist health educators psychologist
1daywk for 12 wks
1daymth for 3 months
booster sessions for 18 months
Programme breakfast lectures (nutrition exercise motivational psychosocial) homework
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
DIET AND EXERCISEhellip
N=385
60 completion 2 year course
Weight loss 12 mth 51 initial weight
47 initial weight
24 mth 38 initial weight
38 initial weight
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
LONG-TERM EFFECTIVENESS OF DIETS
Long-term effectiveness of diet-plus-exercise interventions vs diet-only interventions for weight loss a meta-analysis
T Wu13 X Gao1 M Chen1 and R M Van
Obesity Reviews May 2009 18 studies included
At least 6 mos followup
Results Pooled weight loss ndash 114kg in diet+exercise vs 05kg in diet alone
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
WEIGHT LOSS MEDICATIONS
Duromine - Sympathomimetic SEs ndash insomnia tachycardia anxiety dependence
Not tolerated long term
Reductil ndash Serotonin agonist SEs ndash insomnia xerostomia tachycardia HT
Xenical ndash Lipase inhibitor SEs ndash freq BMs foul flatus abdo discomfort
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
TYPES OF SURGERY
bull1 Malabsorptive proceduresbull bypass the digestive tract
bull eg Gastric Bypass Biliopancreatic Diversion Duodenal Switch
bull2 Restrictive proceduresbull decrease stomach capacity
bull eg Gastric Band Sleeve Gastrectomy Gastric Bypass
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
ROUX-EN-Y GASTRIC BYPASS
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
ROUX-EN-Y GASTRIC BYPASS
Advantages
bull Excellent weight loss and longest track
record
bull Keyhole surgery
bull Rapid improvement in Type II Diabetes
Disadvantages
Irreversible
Malabsorption
Nonadjustable
Cutting and stapling of stomach
Increased risk major long term
complications ndash Vit def 30 Dumping
Syndrome 70
Highest post-op morbidity and mortality
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
DUODENAL SWITCH
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
Advantages Best weight loss
Best resolution of Diabetes
Disadvantages Malabsorptive+++
Fat soluble vitamins (ADE and K)
Vitamin B12 and Folate
Iron
Calcium
Often performed Open
Highest morbidity and mortality rate
High longterm complication rate
DUODENAL SWITCH
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
SLEEVE GASTRECTOMY
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
STEPHANIE ULMER
wwwbetterlifesurgeryconz
Advantages Excellent weight loss
bull Keyhole surgery
bull No malabsorption
Disadvantages
Cutting and stapling of stomach
Irreversible
Durability unproven
Sleeve Gastrectomy
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
GASTRIC BAND
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
Advantages Safest bariatric procedure
Adjustable
Fully reversible
Keyhole surgery
No malabsorption
Disadvantages Poor Long term complication
rate
Intensive Follow up requirements
Use of Foreign Body
Gastric Band
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
LONG TERM PERFORMANCE
Gastric Bypass ndash longest track record ndash 30+years 50EWL maintained at 10 years
Complications ndash Vitaminmineral deficiency
- Stenosis stretching Gastrojejunal anastomosis
- Gastric pouch ulceration
- Dumping syndrome
Gastric Banding ndash approx 10-15 year 20EWL maintained
10-15 will require re-do surgery in longterm (slippage erosion port complications etc)
Foreign body
Gastric Sleeve ndash newest procedure ndash results to 7 years only 50EWL maintained
Potential for stretching of sleeve ndash weight regain
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
NEW TECHNOLOGIES
Gastric Balloon Endoscopic procedure
Must be removed after 6 months
Poor tolerance
Cost ++
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
NEW TECHNOLOGIES
V Block (Vagal N blockade)
Preliminary study V Block vs sham operation
96 initial weight loss vs 6
Long term effect unknown
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
NEW TECHNOLOGIES
Gastric Artery Embolisation Image guided injection of microscopic
beads into Left Gastric A
Beads decrease blood flow to the Fundus
Decreased production Ghrelin
Decreased hunger
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
NEW TECHNOLOGIES
Aspire Assist
Gastrostomy ndash aspirate the stomach 20mins after a meal
Reduces the calories absorbed by the body
The AspireAssist allows patients to remove about 30 of the food from the stomach before the calories are absorbed into the body causing weight loss
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
AFTER GASTRIC SLEEVE SURGERYhellip
How much will I be able to eat
Start on a pureed diet following the operation
By about 6 weeks should be on a lsquonormalrsquo diet
2 dsp quarter cup food
Minimal food avoidance
Will I be able to eat out
Yes but you will either eat an entreacutee sized meal
or have soup as your Main
Doggy bag
Cheap
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
AFTER GASTRIC SLEEVE SURGERYhellip
What about alcohol
Yes you can drink alcohol but less is more
How long will I need off work
Keyhole surgery so pain is less of an issue
2 nights in hospital
2 weeks off work is the norm
Self employed
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
AFTER GASTRIC SLEEVE SURGERYhellip
Follow up
3 weeks and 6 months
then yearly
3 months with Nutritionist
Yearly Nutrition blood tests CBC U and Ersquos LFTs
Fe studies
Vitamins B12folate A and E and D
Zinc
Magnesium
Thiamine
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
WEIGHT LOSS ndash WHAT TO EXPECThellip
Very rapid ndash first 6 months
Slows ndash 2nd 6 months
Continues to 18months thenhellip
Plateaux
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
WEIGHT LOSS ndash WHAT TO EXPECThellip
Weight Regain More than maintenance calories in 24 hour period regularly
