Obesity Who is suitable for surgery? Professor Rob Andrews University of Exeter / Taunton NHS trust

Obesity Who is suitable for surgery? Professor Rob Andrews University of Exeter / Taunton NHS trust

Investigator on BYBAND study Conflict of interest 3 Diet and Exercise studies (ACTID, EXTOD, STAMP2) Talked for Allergan

Defining Obesity - BMI

Risk of obesity Health risks associated with overweight and obesity. Kopelman P. Obes Rev. 2007 Mar;8 Suppl 1:13-7.

Bariatric operations Roux-en-y-By pass Gastric band

Bariatric operations Gastric sleeve Duodenal switch

Sleep apnoea Diabetes Insulin Resistance High lipids High BP Bariatric surgery Bariatric surgery: metabolic consequences Healthy BMI 48 BMI 26

Overview The benefits The risks Risk/ benefit for a patient

Long-term mortality after gastric bypass Deaths reduced by surgery Overall 40% Coronary artery disease 56% Diabetes 92% 7,925 RYGB 7,925 controls 1984-2002 Utah Matched Age, sex, BMI Cancer 60% Adams TD et al NEJM 2007; 357: 753-61

What happens if you don t operate Operation No operation Risk of dying 1% 6% New cancer diagnosis 2% 8% Heart problems 5% 27% New onset diabetes 9% 27% Significant infections 9% 37% Arthritis 5% 12% Respiratory problems 3% 11% Time in hospital 21 days 36 days 5-year follow up 6,000 patients average BMI 50 Christou 2004

Diabetes and bariatric surgery My daddy is a doctor and he treats diabetes My daddy is a surgeon and he cures it!

Remission of diabetes % True diabetes remission rates HbA1c 6.2 + 1.2 HbA1c 6.3 + 0.7 Gastric bypass Sleeve Gastric band Pournaras DJ et al Br J Surg. 2012 Jan;99(1):100-3

Bariatric surgery and macrovascular disease CVE Incidence MI Incidence Romeo S et al Diabetes Care 2012

Bariatric surgery and microvascular disease Johnson et al, Journal of the American College of Surgeons, 2013, 545-556

Intense medical therapy vs bypass and sleeve HbA1c Tablet usage 150 patients type 2 diabetes N Engl J Med 2012; 366:1567-1576

Bariatric surgery and Type 1 DM 10 patients (7 bypass, 2 bands and 1 sleeve) mean follow up 3 yrs Brathaeur SR et al Diabetes Care 2014

5 year incidence of retinopathy (%) How diabetes was defined Fastiing cut off 5.7 mmol 2 hr cut off 11.2 mmol BMJ 1994;308:1232

Summary 1 Bariatric surgery does improve T2DM control and outcomes Remission rates are less than first reported and outcomes may only be improved if caught early In true terms diabetes is not cured

Blood pressure

BP and Bariatric surgery 2 years 10 years

Lipids

Lipids Bypass Band 9 studies RR 0.28 p<0.0001 4 studies RR 0.57 p=0.037 Ricci C, Obesity Surgery 2013

Lipid change Intense medical vs Bypass JAMA. 2013;309(21):2240-2249.

Summary 2 Bariatric surgery improves BP & lipids But All patients will need to stay on lipid lowering and BP agents No evidence bariatric surgery better than intense medical therapy

Sleep apnoea Ever since the doctor gave him that machine to help with his sleep apnoea we never cuddle any more!

Sleep apnoea and obesity

Bariatric surgery and Sleep apnoea = pre op = post op Ravesloot MJL et al Obesity surgery 2012

Summary 3 Obesity improves Sleep apnoea But Only 1/3 cured Those with Mild OSA are the most likely to be cured

Morbidity and weight loss sensitivity or resistance Metabolic Ventilatory Reproductive CV risk Perceived health status Eating behaviour -5-10 -15-20 -25-30 % weight loss to improve morbidity ADL / QoL Depression Body Image dysphoria Economic cost Aylwin 2005

Nice criteria BMI>40 BMI>35 with co-morbidity known to improve with surgery BMI>30 with Type 2 diabetes diagnosed past 10 years and poorly controlled

Vitamin deficiency Off hand, Id say you re suffering from an arrow Through your head, but just to play it safe. I will Order a bunch of tests.

Common vitamin deficiencies Bypass Band 21,345 patients Gudzune KA, Obesity Surgery 2013

Hypoglycaemia Blood sugar a little low honey?

Post meal hypoglycaemia Meal Meal Meal

Oxalate Well done Mr Jones, it looks like you have Passed that kidney stone at last

Normal Oxalate metabolism

Oxalate metabolism post bypass

Distal and normal bypass

Mayo series Nephrolithiasis rate Standard Bypass = 2% Nephrolithiasis rate Distal Bypass = 14% Sinha MK et al Kidney international 2007

Summary 4 Vitamin deficiency is common thus long term monitoring is needed Hypoglycaemia is rare but can be troublesome Renal stones and damage can occur due to oxalate problems

Sleep apnoea Diabetes Insulin Resistance High lipids High BP Bariatric surgery Bariatric surgery: metabolic consequences Sleep apnoea Diabetes High Healthy lipids High BP Vitamin Deficiency Hypoglycaemia Oxalate Problems BMI 48 BMI 26 32

Choosing the right patient So if I need to stop smoking and lose weight, What are you going to do about it?

What patients want Understanding of why overweight Information pre-op To lose large amount of weight Support post-op Help with preventing weight gain Removal of excess skin

What doctors want To identify patients who will be successful Explain why they are overweight? Patients health to improve Minimise risk pre-op Limit problems post-op Continued contact

Sharma AM.Obes Rev. 2010 Nov;11(11):808-9

Patients sometimes say what you want

More than one view is needed We all interpret things differently

Dietitian Dietary intake Dietary Behaviour 80% patient deficient In at least on vitamin 60% miss at least one Meal per day Binge eating (27%) Night time eating (30%) Sabotage behaviour Feeding up

Psychologist sees All Bed patients - 74% have one additional psychiatric disorder Patients unable to loss 10% weight Patients with serious life event Patients with body image or serious self esteem problems Patients with Untangable hunger

Physician - High Risk patients BMI>60 Age Sleep apnoea CAD Male Fitness BP Diabetes Revision surgery Large liver

High risk patients BMI>60 weight loss, intragastric balloon Sleep apnoea Screen and treat 3/12 CAD Assess Fitness try and improve BP target 130/80 Diabetes target 7% Revision surgery Experienced surgeon

Surgery should be delayed if patients Have untreated mental health condition Have unstable psychotic presentation Have a substance misuse problem Are using high levels of alcohol and/or who use alcohol as a way of managing mood Have unrealistic expectations of surgical outcome would not be able to tolerate the risks of surgery or comply with post-surgical regimen and lifestyle changes have recently had or due to have a major life change/event/stressor

Predictors for success Family member has done well with surgery. Not Predictive Motivation Previous weight loss Age

Complex patients Evidence suggest poor results Prader willi Craniopharyngioma (3 people done well) Evidence results as good as general pop MC4 No evidence either way Noonan s Syndrome - 2 Cornelia de Lange syndrome Pituitary tumours

Summary 5 No real predictors as to who will do well But are certain people who might do badly (in terms of risk) Delaying surgery sometimes might be the best option

Choosing the right operation We ran out of Gastric bands so I ve Put in a brass band

One op better than another? our data 60 50 40 30 20 10 All L AG B L R Y G B SG 0 P re-op 6 month 12 months 24 months 36 months 48 months

Surgical favorites Bypass /Band Bypass BAND

Weight loss bands, bypass and BPD

Studies of Band Vs By passes Lancet 2012:379:2300-11

Summary 6 No good studies to say which operation is best Ideally enter study if not patient should be able to make choose

Limited funds Sure we re underfunded but we manage

Who target?

Save lives Morbid obesity vs Obese morbidity Padwal RS et al. CMAJ. 2011 Oct 4;183(14):E1059-66 Sharma et al CMAJ 2011

Summary 7 To prevent disease operate on young patients without co-morbidities To save lives operate on patients with more than 2 comorbidities

Summary Obesity Diabetes Co-Morbidities Operative Risks Obesity Surgery Benefits: - Weight loss - Co-morbidities improvements - Mortality benefit Complications: - Nutrient deficiency - Dumping syndrome - Hypoglycemia -Band complications

Contact details R.C.Andrews@Exeter.ac.uk