Outline. Types of Bariatric Surgery. Adjustable Gastric Band (LAP-BAND) Bariatric surgery

Transcription

1 Bariatric surgery Rona Osborne, Specialist Obesity Dietitian Glasgow and Clyde Weight Management Service November Weight Management Training Outline Types of Bariatric surgery Evidence Clinical Guidelines Current and Future NHS GGC Surgery criteria and selection of candidates Gastric banding- how does it work? Keys to success for gastric banding Band Adjustments Case studies Conclusions Types of Bariatric Surgery Adjustable Gastric Band (LAP-BAND) Sleeve Gastrectomy Gastric Bypass Endobarrier 1

2 Evidence Swedish Obese Subjects - Mortality: up to 40% lower risk over 10years (Sjöström et al.,2007) Diabetes: >70% remission after 2 years (in recently diagnosed) (Sjöström et al.,2004) (Dixon et al., 2008) Improvement in HR-QoL Other benefits but harder to measure e.g. mobility, blood pressure, lipids NICE Obesity Guidelines 2006 BMI >40kg/m 2 or BMI >35kg/m 2 with co-morbidities that could be improved with weight loss All appropriate non surgical measures have failed to achieve clinically significant weight loss Intensive management in specialist obesity service Commit to the need for long term follow up Consider first line for BMI >50kg/m 2 SIGN Obesity Guidelines 2010 BMI 35kg/m 2, bariatric surgery should be considered on a individual case basis following assessment of risk/benefit and the patient fulfilling the following criteria: presence of one or more severe co-morbidities which are expected to improve significantly with weight reduction (e.g severe mobility problems, arthritis, type 2 diabetes) evidence of completion of a structured weight management program involving diet, lifestyle, psychological and drug interventions, not resulting in significant and sustained improvement in the comorbidities 2

3 SIGN Obesity Guidelines 2010 should be included as part of an overall clinical pathway for adult weight management Part of a programme of care delivered by multidisciplinary team including Surgeons, Dietitians, Psychologists, Nurses, Physicians Specialist psychological/ psychiatric opinion should be sought as to which patients require assessment/treatment prior to and following surgery Bariatric Surgery Criteria Present - Developed in conjunction with NHSGGC surgeons Completion of GCWMS structured program years of age BMI<60 and without any condition deemed as a clinical risk by surgeon who fail to lose 5kg. Must not gain weight (>5kg) 40 procedures a year Only Gastric bands New - National Planning Forum Guidance Developed in conjunction with Health Boards across Scotland (Accepted 2nd June 2012 NHSGGC, implementation April 2013) <45 years of age BMI of35-45 Diagnosed Diabetic < 5 Years HbA1c < 9% >5kg weight loss 108 procedures by types -Gastric band and Sleeve in NHSGGC Criteria for Bariatric Surgery? Criteria varies throughout the UK Variation through NHS boards in Scotland SCOTS- Severe & Complex Obesity Treatment Service, multidisciplinary group of clinicians. Ensure the equitable access to high quality, multidisciplinary treatment for people with severe or complex obesity National Planning Forum- NHS boards and Scottish Government aim for consistent approach and criteria 3

4 GCWMS Pathway to Bariatric Surgery BMI >40kg/m 2 or BMI >35kg/m 2 with co-morbidities 16 week Lifestyle programme <5kg weight loss Anti obesity medication 12 weeks <5kg weight loss Low calorie diet programme 12 weeks Referral to GCWMS Surgical Team Gastric band An adjustable prosthesis is placed at the upper part of the stomach. The stoma of the prosthesis is calibrated with saline introduced via a subcutaneous access port. (Diagram courtesy of Johnson and Johnson Medical.) Mode of action of gastric band Each bite should pass across the band before another bite is swallowed Signal message to brain that no more food is neededsatiation Waves through the food pipe generate feeling of not being hungry- satiety 4

5 Mode of action of Gastric banding Band is placed at top of stomach which creates a small pouch Reduction in intake, quicker and longer satiety Intraluminal pressure and semi solid swallows- transit across resistance of LAGB- peristaltic contractions. - Proposed that compression of vagal afferent nerves in band area mediates satiety effect (O Brien, 2010) Activation of peripheral satiety mechanism without physically restricting meal size (Burton& Brown, 2011) Pre Surgery- Psychology assessment Clinical interview & standardised measures: Psychological functioning (current & past) Eating behaviour Level of social support Coping skills Motivation /expectations Appraisal of the surgical process Social and cognitive functioning Pre Surgery- Dietetic Dietetic assessment Dietary changes to date Dietary patterns, portion sizes Eating habits which may improve with gastric banding surgery Triggers for eating- energy dense food choices Hunger v s non hunger Expectations from surgery 2 week Assessment diet Refer onto surgeons if patient successful and still wishes to proceed 5

6 Weight Loss Expectations Majority of weight loss within the first 2 years post op LAGB- ~50-60% EWL ( Weiner et al., 2003) RYGB- greatest weight loss 2years post op 60-70% EWL Overall, LAGB and RYGB not different 3-8years post op-both ~50-60% EWL (O Brien, 2010) Weight Loss Expectations Case Study Patient weighs 170kg (26 stone 10lbs), BMI 54kg/m 2 Height- 1.78m Ideal body weight, BMI of 25kg/m 2-80kg Excess body weight of 90kg Weight loss approx 50% of his excess body weight following surgery Could expect to lose in the region of 45kg (7stone) Target weight for surgery to be deemed a success - 125kg (19st 9lbs) over 2 year period- BMI 39kg/m 2 GCWMS Group Support Programmes Support & skill-based: monthly rolling programmes Pre-Surgery group Preparation for surgery- Identify eating, activity and behavioural changes and emotional factors to be addressed in order to achieve success with weight loss surgery Post-Surgery Group Encouragement of adherence, support new coping techniques in high risk situations, relapse prevention, interpersonal learning & support 6

7 Pre Operative- Liver Reduction Diet Diet before and after surgery 2 weeks pre op diet to shrink the liver~800kcal low CHO, low fat Post operative progression Fluids only for 2 weeks post surgery Soft diet gradually progressing to solid textures- week 2-6 post surgery Weeks 6 onwards- Solid food Importance of progressing to solid diet to achieve satiety and satiation from band Aiming for approx kcal/day when in Green Zone Adjustment of band Acrobat Document 7

8 Adjustment of patientthe 10 Keys to Success 1. Eat three small main meals per day 2. Focus on balance of nutritious solid food 3. Limit serving size 4. Do not graze between meals 5. All drinks should be zero calories 6. Eat slowly and stop when no longer hungry 7. Chew foods thoroughly 8. Avoid drinking with meals, sips only- do not gulp 9. Be active for 30 minutes every day 10. Always attend follow up Chew thoroughly 20/20/20 rule 20p coin bite size Chew 20 times Wait 20 seconds Adjustment of band Consultation to determine if adjustment needed. General progress, weight loss Eating, appetite, hunger, satiety Activity Range of food intake and nutrition Any symptoms e.g. reflux, heartburn, vomiting Requirement for further advice on eating and activity Decision made on need for adjustment 8

9 Adjustment of band First adjustment dependent on centre - ~ 6weeks post surgery, every 6 weeks thereafter Target - find the Green Zone Incremental increase in saline to right volume, right pressure Linear relationship between follow up and weight loss outcomes. ( Dixon et al., 2009) Adjustment of band Not a case of the more the better Dangers of Red Zone - maladaptive eating Narrow range of foods Soft foods slide through- energy dense- high sugar, high fat soft/ liquid foods Preserve the precious pouch Eating too quickly? Eating too much? Not chewing food well Leads to stretching of area above band -Enlargement of new stomach -Risk of band slippage 9

10 Case study- Patient 1 39 year old female Surgery -May 2008 Adherence with necessary changes Recent referral to plastic surgery Patient 1 -Success (91% Excess Weight Loss) Weight (kgs) Pre-op 2wk 4wk 6m 1yr 2yrs 64.3 BMI 46.5kg/m 2 to 25kg/m 2 91% EWL Case study- Patient 2 52 year old female Awareness of eating behaviour Well established regular eating plan Significantly reduced portion sizes Decrease in Diabetes medication 10

11 Pt 2 success (92%) Weight (kgs) Pre-op 2wk 4wk 6m 1yr 2yrs 75.3 BMI 38kg/m 2 to 24kg/m 2 92% EWL Case study- Patient 3 48 year old female Surgery -May 2008 Major stressors in life since surgery- difficult family circumstances Comfort eating- chocolate, ice cream Weight gain despite functioning band Psychology input comfort eating, low mood Patient 3 - Non success (11%Excess Weight Loss) Weight (kgs) Pre-op 2wk 4wk 6m 1yr 2yrs 11

12 Case study- Patient 4 53 year old female Surgery January 2008 Avoidance eating behaviour Difficulty with normal texture- related to pace of eating Continuing to revert to liquid/ soft textures Patient 4- Non success (17%EWL) Weight (kgs) Pre-op 2wk 4wk 6m 1yr 2yrs Conclusion Remember the band should be a good friend, not something to conquer Needs to be and adjustment of the patient combined with adjustment of band Multid disciplinary Surgery team support is a key determinant in surgery outcomes 12

13 Further considerations Implementation of new surgery criteria from 1 st of April 2013 Disseminate and increase awareness of new criteria to referrers With increased number of surgeries allocated to NHSGGC what other groups of patients should be considered for bariatric surgery 13