Obesity Management Workshop for Health Professionals

Transcription

1 Obesity Management Workshop for Health Professionals 17 th November 2017 Dr Graeme Rich Gastroenterologist Director of Bariatrics Australia

2 Is a procedure the magic bullet?

3 Energy in >> Energy out

4

5 Accepted Contributors to developing obesity Hormonal disturbance Increased use of medications that can cause weight gain Physical impairment Anxiety/ depression Pregnancy at a later age Decreased rates of smoking Insufficient/ poor sleep Increased financial pressure Culture of food/ westernisation Natural selection for higher BMI

6 Accepted Contributors to developing obesity Hormonal disturbance Increased use of medications that can cause weight gain Physical impairment Anxiety/ depression Pregnancy at a later age Decreased rates of smoking Insufficient/ poor sleep Increased financial pressure Culture of food/ westernisation Natural selection for higher BMI Energy Homeostasis

7 Biology Changing Procedures Anatomy or physiology of the GI tract Correct or enhance physiologic pathways that regulate appetite and energy metabolism Energy Homeostasis

8 Classically Restrictive Biology Changing Procedures

9 Biology Changing Procedures Classically Restrictive Sleeve Gastrectomy Adjustable Gastric Band

10 Biology Changing Procedures Classically Malabsorptive Roux en Y Gastric Bypass

11 Surgical Procedures Sjöström L. NEJM 2007

12 The role of minimally invasive therapies Conservative therapy Lower Risk Stigma of failing Availability Financial impact Contraindications Perceived risk Less effective More effective Higher Risk VBG Lap Band LSG Gastric Bypass BPD/ DS 1%

13 The role of minimally invasive therapies Lower Risk Conservative therapy Less effective Bariatric Endoscopy Higher Risk VBG Lap Band LSG More effective Gastric Bypass BPD/ DS

14 Bariatric Endoscopy Classically Restrictive Intragastric Balloon

15 Bariatric Endoscopy Classically Restrictive Intragastric Balloon

16 Intragastric Balloons Abu Dayyeh BK. Gastrointest Endosc 2015

17 Intragastric Balloons Abu Dayyeh BK. Gastrointest Endosc 2015

18 Intragastric Balloons Abu Dayyeh BK. Gastrointest Endosc 2015

19 Intragastric Balloons > px Mean TBWL 18.4+/-2.9% Failure rate (<10%TBWL)- 8.3% Migration requiring surgical removal- 24 cases Ulcer- 1% - 28 removed due to ulcer. 6 Perforations during removals 12 deaths with balloons in situonly 3 were balloon-related (1x gastric rupture, 1x PE, 1x aspiration) Galvao Neto M. Surgery for Obesity and Related Diseases 2017

20 Bariatric Endoscopy Classically Restrictive Endoscopic sleeve Gastroplasty

21 Bariatric Endoscopy Classically Restrictive Endoscopic sleeve Gastroplasty 248 consecutive patients across 3 centres. 62% of patients were followed up to completion of the trial per protocol. At 6 months 15.2%TBWL At 12 months -18.6% TBWL 24 months after ESG, 84% of reviewed patients achieved >10% sustained TBWL 56% achieved >15% sustained TBWL.

22 Bariatric Endoscopy Classically Restrictive Endoscopic sleeve Gastroplasty 248 consecutive patients across 3 centres. 62% of patients were followed up to completion of the trial per protocol. 38% were lost to follow up by 2 years post-procedure and were considered failures in the Intention-to-treat analysis. Allowing for this, 53% and 35% achieved sustained weight loss of >10% and >15%TBWL. Lopez-Nava G. Obesity Surgery. 2017

23 Bariatric Endoscopy Classically Restrictive Endoscopic sleeve Gastroplasty 91 consecutive patients, 66% follow up rate. At 6 months 14.4%TBWL At 12 months -17.6% TBWL 24 months after ESG 20.9% 70% of patients achieved >15%TBWL Sharaiha RZ, Clinical Gastroenterology and Hepatology. 2017

24 Endoscopic Sleeve Gastroplasty Contraindications Cirrhosis- particularly if associated with portal hypertension Anticoagulation Unacceptable Anaesthetic risk Current pregnancy or early future pregnancy Psychiatric conditions* Large hiatus hernia Ulceration or bleeding lesions Complications Self limiting hours Abdominal pain Nausea Serious Adverse Events Perigastric collections 1% Bleeding 1% PE 1 case Pneumothorax 1 case Dayyeh B. Clinical Gastroenterology and Hepatology. 2017

25 Classically Malabsorptive Bariatric Endoscopy

26 Hindgut hypothesis Increased delivery of nutrient to the distal gut leads to increased secretions of enteroendocrine hormones such as the incretins. Decreases appetite and improves glycaemic control.

27 Mechanism GLP-1 increased GLP-1 antagonist removed this effect

28 Classically Malabsorptive Bariatric Endoscopy

29 Duodenal-Jejunal Bypass Liner Endobarrier

30 GI Windows Partial bypass

31 GI Windows Partial bypass

32 Bariatric Endoscopy Is a procedure the magic bullet?