NHS Specialist Obesity Services

Transcription

1 NHS Specialist Obesity Services

2 Teaching session for Trainee Doctors 5 th December 2017 Yvonne O Donnell, Obesity Specialist Nurse Andrea Maestre Guillen, Obesity Specialist Dietitian

3 Outline Introduction to NHS Specialist Obesity Services Who and how to refer Referral letters and what happens next Patient pathway through the service Bariatric surgery Guidelines What can GP s do to help? Questions

4 Service Structure Specialist Obesity Services OBESITY CLINIC TIER 3 SERVICES Weigh Management Clinic BARIATRIC CLINIC TIER 4 SERVICES Bariatric surgery And follow up CENTRE OF OBESITY RESEARCH In house research, clinical trials & collaborations

5 Bariatric Surgeons Specialist Dietitians Anaesthetics Specialist Nurses Multidisciplinary Team Service Manager & admin Specialist Physicians Clinical Psychology

6 Evolution of Obesity Services at LDUH 1992: Medical obesity service & research unit 2001: Bariatric surgical service - gastric banding 2004: Gastric bypass and sleeve resection & 2 nd bariatric surgeon : increasing volume of referrals 2007: ESCG designation process initiated 2008: Ratification by EoE as centre of excellence 2008/09: 200 cases/year additional Surgeon (3 rd ) 2009/10: 300 cases/year with improved patient pathways 2011/12: capped at 400 cases

7 WHO AND HOW TO REFER

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9 Referral criteria for Tier 3 Patients 18 years old BMI 40 or 35 with a significant co-morbidity Obese for at least the last 5 years Prior attendance to a Tier 2 or similar intervention at a local level Undergone all relevant weight loss interventions in primary care Insight, motivation & readiness to change

10 Example Referral Letter Tier 3

11 What can be expected on Tier 3 Up to 12 months intervention in our Weigh Forward programme Counselling, including diet and behavioural modification with holistic support Regular appointments Individualised advice

12 What can be expected on Tier 3 Dietary plans MDT approach from individually skilled and registered professionals Dietitians Nurses Psychologist Physician Possible referral to Tier 4

13 After Tier 3 Progression to Tier 4 for assessment for surgery Regular attendance with engagement 5 % weight loss and maintainance LCLD for 4 weeks Evidence of positive change Ask GP to refer for ongoing support Back to local community weight management programme or Tier 2 Local community dietitian Commercial weight loss support group

14 Referral criteria for Tier 4 Patients 18 years old BMI 40 or 35 with a co-morbidity Have completed a Tier 3 service Internal or external referral Patients from Hertfordshire will need to seek for prior funding approval CCGs are now responsible for setting their own criteria

15 LDUH Criteria for Surgery Aged 18 Exclusion of active psychological contra-indications influencing outcomes Excess alcohol intake or drug / substance misuse Evidence of ability to comply with pre-op regimen Insight, motivation & readiness to change Understanding of long-term responsibilities Recognition of need for long-term follow-up Realistic expectations and goals Support of family / partner / friends

16 Example Referral Letter Tier 4

17 What can be expected on Tier 4 MDT approach from individually skilled and registered professionals Dietitians Nurses Psychologist Surgeons Anaestethist Surgical procedure of their choice

18 Outcome of MDT Assessment Patient choice Inappropriate to progress Need further intervention prior to surgery Surgical / anaesthetic risk too high MDT decision in conjunction with patient Opportunity to reassess in future

19 What can be expected on Tier 4 Regular appointments in the Bariatric clinic 6 weeks post surgery 3 months post surgery 6 months post surgery 12 months post surgery 2 years post surgery Followed by yearly appointments in the Obesity clinic Ongoing support to encourage weight loss maintainance and prevent nutrition deficiencies

20 Tier 4 pathway Tertiary referral Lead Physician Intra clinic referral Specialist Nurse Assessment Bariatric clinic Bariatric Team Evaluation Dietitian Nurse Clinical Psychologist Surgical and Anaesthetic Assessment Pre-operative evaluation Pre- Operative Assessment Surgery Long term follow-up and audit: 6 weeks, 3 months, 6 months 1 year and annually for 5 years minimum

21 Overview of Surgery options Adjustable Gastric Banding Sleeve Gastrectomy Roux-en-Y Gastric Bypass

22 Adjustable Gastric Banding

23 Sleeve Gastrectomy

24 Roux-en-Y Gastric Bypass

25 Why Bariatric Surgery? Intensive lifestyle intervention 10% at 1 year 5.3% over 8 years Improvement in co-morbidity control Bariatric Surgery RYGB 30-35% TBW maintain over years SG Similar or slightly less than RYGB LAGB 15.9% TBW at 3 years Treatment of Obesity: Weight Loss and Bariatric Surgery Bruce M. Wolfe, Elizaveta Kvach and Roberts H. Eckel

26 Stampede Trial

27 Stampede Trial

28 Benefits of Bariatric Surgery Type 2 Diabetes Obstructive Sleep Apnoea Dyslipidemia Hypertension GORD Funtional

29 Type 2 Diabetes Miellitus In million people suffer with Diabetes (Diabetes UK) One of the leading causes of Morbidity and Mortality worldwide. (Kesavadev et.al 2017) Primary purpose of surgery was for weight loss, but in recent years it has been found beneficial for T2DM. (Kashyap et al 2010)

30 T2DM & Bariatric surgery Duration and severity of the disease has a significant impact on the likelihood of remission. (Li et al 2011) 78 % of morbidly obese patients who have undergone bariatric surgery achieve complete resolution of T2DM (Amouyal and Andreeli, 2017) Klein et al (2011) have reported that 26 months following bariatric surgery are fully recovered.

31 Obstructive Sleep Apnoea (OSA) More than 70% of patients undergoing Bariatric Surgery have OSA. Pre operative assessment of OSA is important because of its perioperative implications. Pathophysiological consequences can be reversed or mitigated with the use of CPAP. CPAP compliance reports are part of the pre op assessment

32 CPAP Continuous Positive Airways Pressure is the treatment for OSA 2 weeks of effective CPAP can correct their abnormal ventilatory drive (Cartagena, 2005) 3 weeks improves left-ventricular ejection fraction (EF) in patients with heart failure. (Tkacova et al 1998) 4 weeks reduces blood pressure and heart rate and results in a 35% improvement to the EF (Golbin,2008) 4-6 weeks reduces tongue volume and increases pharyngeal space. (Ryan et al 1991) 8 weeks can improve cardiovascular risk and morning hypertension Evidence suggests that those who have been treated with CPAP pre operatively, have less peri-operative complications. (Bryson et al, 2004)

33 Obstructive Sleep Apnoea (OSA) Bariatric surgery is associated with impressive remission rates for OSA (Greenburg DL, Lettieri CK, Eliasson AH) Less likely full remision (Greenburg DL, Lettieri CK, Eliasson AH) >75% resolution or improvement (Bruce M. Wolfe1, Elizaveta Kvach1, and Robert H. Eckel) The benefit typically relates to the amount of weight reduction and the severity of the OSA

34 Dyslipidemia Dyslipidemia improved at 3 years post RYGB in 62% (Courcoulas AP, Christian NJ, Belle SH, Berk PD, Flum DR, Garcia L, Patterson EJ) Fasting hypertriglyceridemia (>200mg/dl) remitted in 86 % of patients (Gletsu-Miller N, Wright BN) RYGB a reduction of more tan 50% of CVD compared to BMI and age matched controls (KJ Neff, T Olbers and CV le Roux)

35 Hypertension Effects are variable, procedure-related and time-dependent. During the active weight loss phase blood pressure decreases (Hinojosa MW, Varela JE, Smith BR, Che F, Nguyen NT) After weight stabilization the results are less clear (KJ Neff, T Olbers and CV le Roux)

36 Others Functional (Peltonen M, Lindroos AK, Torgerson JS) Improved function status Reduced levels of pain Greater levels of Independence GORD RYGB can reduce the symptoms when surgical treatment can be ineffective (Prachand VN, Alverdy JC) SG and AGB may worsen symptoms in patients (Gutschow CA, Collet P, Prenzel K, Holscher AH, Schneider PM)

37 Bariatric Surgery The Obesity surgery Mortality Risk Score is a validated scoring systems specific to obese patients undergoing Bariatric surgery. (DeMaria et al, 2007) It allocates 1 point to each of 5 pre operative variables BMI> 50kg/m2 Male gender Systemic Hypertension Risk factors for a pulmonary Embolism Age > Low risk % mortality 2-3 Medium 1.9% mortality 4-5 High 7.56% mortality (these account for a disproportionate 9% of all mortalities)

38 Short Term Risk Very rare Blood cloths Infection Bleeding Leakage Blockage Death (<0.2%)

39 Long Term Risk Gastric band slipping out of place Poor weight loss/weight regain Malnutrition Excess skin Dumping syndrome Post-pandrial hypoglycaemia (late dumping syndrome) Reflux/nausea Gallstones Constipation

40 Dietary management post-surgery Four phases to post-operative dietary regimen: Phase 1 Phase 2 Phase 3 Phase 4 Timescale 1-2 days postsurgery Day 3 end of week 2-3 postsurgery Week 3 end of week 8-10 postsurgery Week 10 + Dietary regimen Clear Fluids Liquids only Puree-Soft diet Healthy-eating and portion control

41 Post-surgery care A-Z Multivitamin and mineral supplement Iron supplement Calcium supplement Vit B12 injection Protein intake

42 Yearly post-operation blood test FBC Renal LFT Ferritin Calcium Zn Cu Se Vit D B12 Folate PTH Mg (only if loose stools) HbA1c or glucose Cholesterol

43 BOMSS Guidelines

44 BOMSS Guidelines

45 NICE criteria Morbid obesity BMI >40kg/m 2 +/- co-morbidities BMI >35kg/m 2 with significant co-morbidities Aged 18 years+ All interventions + pharmacotherapy tried No specific clinical or psychological contra-indications Fit for anaesthesia and surgery Understanding of need for long-term dietary & behavioural change Commitment to long-term follow-up Specialist multi-disciplinary pre-operative evaluation First line treatment in BMI >50kg/m 2

46 What can GP s do to help? Optimise glycaemic Control Facilitate any required investigations Provide a complete past medical history Encourage patients to comply with CPAP therapy Be realistic

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