Bariatric Surgery Options & Outcomes
Obesity Obesity now leading cause of premature death & illness in Australia 67% of Australians are overweight or obese Australia 4 th fattest nation in OECD Obesity cost Australian society $21 billion in 2005 Life expectancy 13 years shorter for 30 year old male with BMI >45
Obesity-Related Comorbidities Diabetes mellitus Arterial hypertension Ischaemic heart disease Heart failure Cardiomyopathy Obstructive sleep apnoea Gallstones Steatohepatitis Cirrhosis Hypercholesterolaemia Hypertriglyceridaemia Menstrual disorders Polycystic ovary syndrome Infertility Obstetric complications Stress incontinence Gastro-oesophageal reflux Stroke Cancer Arthritis Psychological disorders
Medical Therapy vs Surgery Medical therapy can achieve 10% excess weight loss in short-term <5% of medical patients maintain weight loss beyond 5 years Bariatric surgery results in average excess weight loss of 61% 89% reduction in 5-year mortality with surgery* 76% relative risk reduction in cancer observed after surgery* *Christou NV, Sampalis JS, Liberman M, et. al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg. 2004;240(3):416-423.
BMI 35 Criteria for Bariatric Surgery BMI 30-35 with obesity-related comorbidity Obesity for more than 5 years Failed non-surgical attempts at weight loss Fit enough for surgery No clinical or psychological contraindications Understand risks of surgery Be committed to long-term follow-up
Bariatric Procedures Laparoscopic Adjustable Gastric Band Roux-En-Y Gastric Bypass
Bariatric Procedures Biliopancreatic Diversion BPD - Duodenal Switch
Bariatric Procedures Sleeve Gastrectomy Gastric Plication
Laparoscopic Adjustable Gastric Band Band + Fluid Gastric Pouch
Laparoscopic Adjustable Gastric Band
What are you eating? Should be solid food Follow-Up Liquid diet suggests band too tight When are you eating? Two (or three) meals per day is normal Most will not eat in morning How are you eating? Should be slowly Should take 20 min to eat small meal
Follow-Up Are you eating because you are hungry? Hunger = adjustment Loss of satiety consider erosion or leakage How often are you vomiting or having blockages? Can occur after eating too fast or certain foods (e.g. bread) Persistent vomiting if band too tight or slippage Do you regurgitate or reflux at night? Danger symptom Suggests band too tight or pouch dilatation
The Eight Golden Rules 1. Eat three or less small meals per day 2. Do not eat anything between meals 3. Eat slowly and stop when no longer hungry 4. Focus on nutritious foods 5. Avoid calorie-containing liquids 6. Exercise for at least 30 minutes every day 7. Be active throughout the day 8. Always keep in contact
Anterior Slip / Prolapse
Posterior Slip / Prolapse
Symmetrical Pouch Dilatation
Oesophageal Dilatation
Comorbidities
Percentage Resolution of Comorbidities (1 year) 90 80 70 60 50 40 Pre-op 12 months 30 20 10 0 Hypertension Diabetes Obstructive Sleep Apnoea Comorbidities Lipids
Resolution of Comorbidities (1 year) Comorbidities (n=41) Pre-op 12 months % Resolution Hypertension 63.4% 41.5% 34.5% Diabetes 46.3% 26.8% 42.1% Obstructive sleep apnoea 85.4% 48.8% 42.9% Lipids 51.2% 41.5% 18.9% GORD 31.7% 29.3% 7.6% Congestive heart failure 4.9% 2.4% 51.0% Ischaemic heart disease 22.0% 14.6% 33.6% Angina 2.4% 2.4% 0% Peripheral vascular disease 2.4% 2.4% 0% Lower extremity oedema 2.4% 0% 100% Gout hyperuricaemia 4.9% 2.4% 51.0%
Weight Loss
Sleeve Gastrectomy Initially performed as part of duodenal switch (BPD-DS) Substantial weight loss often occurred with SG alone Used as part of staged approach in high risk patients
Sleeve Gastrectomy
Change in Comorbidites
Sleeve Gastrectomy
Which Procedure? Attribute LAGB RYGB Sleeve Gastrectomy BPD +/- DS Weight loss - Short term - Medium term - Long term ++ ++ ++ +++ ++ ++ ++ ++ ++ +++ +++ +++ Safe +++ ++ ++ + Durable ++ ++ ++ +++ Side effects ++ ++ + ++ Reversible easily Yes No No No Minimally invasive +++ ++ ++ + Acid reflux control ++ +++ Variable + Controllable/adjustable Yes No No No Long-term revision rate High Low Low Low Requires follow-up +++ ++ ++ ++
Orbera
Orbera Endoscopically inserted soft silicone intragastric balloon Filled with 700mL of saline Remains in situ for maximum of 6 months Part of long-term supervised lifestyle management program Adults with BMI 27 Average weight loss at removal 14.7kg (12.2% of initial weight)* Weight loss 12 months later maintained at 9.6kg *Imaz I, Martinez-Cervell C, Garcia-Alvarez EE, Sendra-Gutierrez JM, Gonzalez-Enriquez J. Safety and effectiveness of the intragastric balloon for obesity. A meta-analysis. Obes Surg. 2008;18(7):841 846.