Family Doctors Association July 2015 Weight Loss Surgery Consultant Surgeon Salford Royal Hospital
Introduction
Definition BMI = weight (kg) height (m) 2 Classification: BMI (kg/m2) Description <18.5 Underweight 18.5-24.9 Desirable 25-27 Mildly overweight 27-30 Moderately overweight 30-40 Obese 40-50 Morbidly obese 50 Superobese
Prevalence of obesity among UK adults 1993 to 2007
Obesity-related morbidity Disease RR-women RR-men Type-II Diabetes 12.7 5.2 Hypertension 4.2 2.6 Myocardial infarction 3.2 1.5 Colon cancer 2.7 3.0 Angina 1.8 1.8 Gallbladder disease 1.8 1.8 Ovarian cancer 1.7 - Osteoarthritis 1.4 1.9 Stroke 1.3 1.3 Tackling Obesity in England, NAO, February 2001
Severe and complex obesity: Impact on morbidity Per cent afflicted 60% 50% 40% 30% 20% 10% 0% Prevalence of significant morbidities per weight 7% 4% 15% 26% 14% 10% 23% 18% 24% 32% 44% 16% 28% 41% Diabetes Asthma Arthritis High Blood Pressure BMI <25 25-30 30-40 BMI >40 51% 3% 0% 15% Cancer* 52% Mokdad et al. JAMA 2002 *Call et al. New Engl J Med 2003
Waist circumference and risk of long-term health problems NICE risk criteria
Obesity-related mortality Those naturally fat are more liable to sudden death than the thin. Hippocrates Aphorisms A BMI of 30-35 cuts life expectancy by up to 4 years A BMI of 40 or more cuts life expectancy by up to 10 years
Who should be referred or not referred?
NICE guidance BMI of 40 kg/m2, or 35-40 kg/m2 + other significant disease that could be improved if they lost weight (e.g. type 2 diabetes or hypertension) Dec 2006
GP referral process
Update on surgical techniques
2 state-of-the-art Endosuites Range of procedures
Laparoscopic surgical options Gastric restriction: Gastric banding Sleeve gastrectomy Vertical banded gastroplasty Gastric restriction + malabsorption: Gastric bypass Severe malabsorption: Biliopancreatic diversion (BPD) Duodenal switch (DS)
Bariatric Procedures
Laparoscopic gastric banding
Lap sleeve gastrectomy
Laparoscopic gastric bypass Roux-en-Y gastric bypass Omega loop (mini) gastric bypass
Biliopancreatic Diversion + Duodenal Switch
Bilio-pancreatic diversion (BPD)
Vertical banded gastroplasty
Laparoscopic Gastric Imbrication
Gastric Balloon
GP support after surgery
GP support Prescription: vitamin and minerals, PPI Annual blood tests: FBC (e.g. anaemia) U&E LFTs (e.g. hypoalbuminaemia) Fe, Ferritin (e.g. consider referral for iron infusion) B12, Folic acid Vitamin D, PTH (e.g. secondary hyperparathyroidism)
GP support Consider referral to: Psychologist Bariatric surgeon (e.g. suspected complications) Gastroenterologist: Chronic diarrhoea (dietary, bacterial overgrowth, bile salt malabsorption, pancreatic exocrine insufficiency) Reactive hypoglycaemia Malnutrition Plastic surgeon Maintain diabetic on the register for annual HbA1c and retinal checks
What s gone right? Is bariatric surgery beneficial?
Obesity surgery & co-morbidities 295 patients (mean BMI 45 kg/m 2 ) laparoscopic gastric banding 4-year FU Co-morbidity Frequency Cure Improvement Hypertension 52% 58% 42% Diabetes 20% 75% 08% Dyspnoea 85% 85% 12% Arthralgia 89% 52% 24% Reflux 57% 79% 11% Self-esteem 95% 45% 39% Physical perform 96% 58% 33% Frigg et al. Obesity Surgery 2004
Resolution of sleep apnoea 56 patients with OSA on polysomnography mean preop duration of OSA 44 ± 55 months severity: severe 50%, moderate 30%, mild 20% Mean BMI 49 kg/m 2 LRYGBP Results: Epworth Sleepiness Scale (ESS) score decreased: 13.7 5.3 @1 month (p<0.05) and maintained below the threshold level (<7) for the entire 12 months of follow-up CPAP: 29 (52%) patients preop 4 (14%) @ 3 months and 0 @ 9 months %EWL: 73 ± 3% @ 12 months Varela et al. Obes Surg 2007
Co-morbidities: meta-analysis 136 studies, 22094 patients 72.6% women. Age 39 (16-64) yr. BMI 46.9 (32.3-68.8) %EWL: mean (95% CI): 61.2% (58.1-64.4%) for all patients Co-morbidities: Co-morbidity Resolved Diabetes 76.8% 86% Hyperlipidaemia 70% Resolved or improved Hypertension 61.7% 78.5% OSA 85.7% 83.6% Buchwald et al. JAMA 2004
Bariatric surgery reduces cancer incidence Swedish Obesity Subjects (SOS) study 2010 bariatric surgery patients 2037 matched obese controls treated conventionally Started 1987, cancer incidence reported until Dec 2005 Cancer follow-up: rate 99.9%, median 10.9 (range, 0-18.1) years Weight changes over 10 years: 19.9 kg (SD 15.6 kg) vs. +1.3 kg (SD +13.7 kg) First-time cancers: 117 vs. 169 patients (HR 0.67, 95% CI 0.53-0.85, p=0.0009). In women: 79 vs. 130 patients (HR 0.58, 0.44-0.77; p=0.0001) In men: 38 vs. 39 patients (HR 0.97, 0.62-1.52; p=0.90) Sjöström et al. Lancet Oncol 2009
Gastric bypass in chronic renal failure and renal transplant 41 morbidly obese patients (25 on dialysis) with CRF: 68% mean EWL at 12m 5 stabilised or resolved their kidney disease 9 underwent successful TL 10 patients who became morbidly obese after TL: 70% mean EWL No operative mortality Co-morbid conditions associated with morbid obesity improved in all patients and permitted eligibility for TL Alexander & Goodman. Nutr Clin Pract 2007
Recovery of sexual dysfunction in men Significant (p<0.05) sexual dysfunction compared with published normative controls approached normal postop. The amount of weight loss independently predicted the degree of improvement in all BSFI domains BMI correlated positively with oestradiol and negatively with total and free testosterone After 2 yr. the lap bypass group had significant in BMI and oestradiol and in total and free testosterone Dallal et al. J Am Coll Surg 2008
Weight loss cures infertility Effective treatment of polycystic ovarian syndrome with Roux-en-Y gastric bypass Eid et al. Surg Obes Relat Dis 2005 24 women with PCOS: 100% Normal menstrual cycle at mean FU of 3.4m Resolution of hirsutism: complete 52% at mean FU of 8m moderate 25% at mean FU of 21m 5 women conceived without clomiphene
Bariatric surgery & QoL Comparative study: 50 operated (at 5 years post-surgery) vs. 78 non-operated morbidly obese patients Results: significant improvement in health-related QoL and co-morbidities Sanchez-Santos et al. Obes Surg 2006
Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients Surgery (n=1035) vs. Control (n=5746) morbidly obese subjects: Age & sex matched Subjects with other medical conditions excluded 5 year FU Results: Significant risk reductions for developing cardiovascular, cancer, endocrine, infectious, psychiatric and mental disorders Mortality rate 0.68% vs. 6.17% ( RR of death by 89%) Absolute mortality reduction of 5.5% Christou et al. Ann Surg 2004
Mortality and risk reduction Adjusted hazard ratio 0.71 Sjostrom et al. Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. New Eng J Med 2007
Weight loss & prescriptions 1. 78 patients, 6 months post lap gastric bypass Average preop prescription cost $369 6 and 24 month cost: $119 ( 68%) and $105 ( 72%) Snow et al. Obes Surg 2004 2. 50 patients, 6 months post lap gastric bypass 52% EWL at 6 months Average prescriptions (not over-the-counter) per patient: 3.7 1.7 (p<0.05) Gould et al. J Gastrointest Surg 2004
Obesity surgery: is it cost-effective? Clinical and cost effectiveness of surgery for morbid obesity: a systematic review and economic evaluation. HTA cost-effectiveness study Systematic review of clinical trials of surgery vs. medical therapy Surgery greater wt loss (+ 23-37 kg), maintained at 8 yr Surgery improved quality of life and co-morbidities Surgery more cost-effective at 11,000 per qualityadjusted life year Clegg et al. Int J Obes Relat Metab Disord 2003
Bariatric surgery and prevention of T2D in Swedish Obese Subjects 1658 patients had bariatric surgery (band 19%, VBG 69%, bypass 12%) vs. 1771 obese matched controls 15 year follow up (36.2% dropped out, 30.9% not reached 15 years) T2D incidence rates: 6.8 vs. 28.4 cases/1000 personyears (adjusted HR with bariatric surgery, 0.17; 95% CI, 0.13 to 0.21; p<0.001) Carlsson et al. New Engl J Med 2012
Bariatric surgery reduces MI in Swedish patients with T2D 345 diabetics underwent bariatric surgery vs. 262 diabetic obese controls Mean (IQR) follow-up: 13.3 (10.2-16.4) years Bariatric surgery reduced the incidence of myocardial infarction (MI): adjusted HR 0.56, 95% CI 0.34-0.93; p=0.025 The effect of surgery in reducing MI incidence was stronger in individuals with higher serum total cholesterol and triglycerides at baseline (interaction p=0.02 for both traits). Romeo et al. Diabetes Care 2012
Salford Royal Hospital: results October 2008 March 2016 1234 procedures: Gastric bypass 773 (62.6%) Sleeve gastrectomy 256 (20.7%) Gastric band (new/repositioned) 73 ( 5.9%) Band removal 73 ( 5.9%) Revision procedures 39 ( 3.1%) Intragstric balloon 10 ( 0.8%) Reversal procedures 8 ( 0.6%) Duodenal switch 2 ( 0.2%)
Morbidity & Mortality All Wales Morbidity @ 2 years 65 (5.3%) 6 (6.6%) Mortality 2 (0.16%) 0 Bleeding/haematoma 11/2 Anastomotic leak/perforation: GJA/JJA 3/3 Anastomotic stricture: GJA/JJA 8/2 Venous thromboembolism 3 Pneumonia 5 Acute renal failure 3 Bacterial overgrowth 2 Organ injury (colon, spleen) 2 Wound infection (SSI) 5 Others 16
Excess weight loss (%EWL) 80% 70% 60% 50% 40% 30% 20% 10% 0% 6 weeks 6 months 12 months 24 months Bypass Sleeve % FU 91% 87% 75% 51% 94% 88% 60% 25%
Resolution of comorbidities 80% 70% 60% 50% 40% 30% 20% 10% 0% 70% 60% 50% 40% 30% 20% 10% 0% 6 months 12 months 24 months 6 months 12 months 24 months Diabetes Hypertension OSA BYPASS Diabetes Hypertension OSA SLEEVE
What s gone wrong? Complications of bariatric surgery
Band complications Dysphagia & vomiting: Band too tight Food bolus Band slippage, pouch dilatation GORD, oesophageal dysmotility Acute abdominal pain: Peritonitis (band erosion) Biliary colic Tube detachment Port infection or erosion GORD Long-term band management Weight regain Refer to bariatric surgeon Refer to bariatric surgeon Refer to bariatric surgeon Refer to bariatric surgeon No NHS funding
Normal Bolus obstruction Pouch dilatation Band slippage
Oesophageal dysmotility Oesophageal dilatation Band erosion Port Leak, Infection, Erosion
Gastric bypass complications Acute abdominal pain: Anastomotic leak (within 2 weeks) Gallstones: colic, cholecystitis, pancreatitis Ulcer perforation Intestinal obstruction Chronic abdominal pain: Biliary colic Marginal ulceration Internal small bowel hernia (Petersen s) Chronic diarrhoea: Dietary: fat or CHO indulgence Bacterial overgrowth Bile salt malabsorption Pancreatic exocrine insufficiency Refer to A&E USS:?gallstones Urgent referral to bariatric surgeon Dietary advice Empirical 1-2 weeks Ciproxin + Metronidazole Faecal elastase-1, Creon Refer to Gastrenterologist
Gastric bypass complications Chronic marginal ulcer: Smoking NSAID H. pylori Anaemia: Fe deficiency Folate deficiency B12 deficiency GI blood loss Excessive hair loss (alopecia): Zinc and Selenium deficiency Fe deficiency No smoking Avoid NSAID + PPI prophylaxis Stool for H. pylori antigen; eradication therapy Refer to Gastroenterologist or Bariatric Surgeon Check Fe, Folate, B12 Stool for occult blood Correct deficiencies Refer to a Gastroenterologist Check Zn, Se & Fe Correct deficiencies
Gastric bypass complications Malnutrition: Dietary Bacterial overgrowth Malabsorption Neurological complications: Thiamine (B1), B12, Folate, Cupper deficiencies Alcoholism (Wernicke s encephalopathy) Nutritional supplements Dietary advice Referral to bariatric service:?reversal Check B1, B12, Folate & Cu Correct deficiencies Refer to a Neurologist Muscle and bone pain, muscle weakness: Vitamin D deficiency Check PTH and vitamin D High dose vitamin D Refer to Rheumatologist
Sleeve complications Acute abdominal pain: Gastric leak (within 2 weeks) Gallstones: colic, cholecystitis, pancreatitis Vomiting and reflux: Dietary Hiatus hernia, GORD Stricture within the sleeve Anaemia: Fe, Folate, B12 deficiencies GI blood loss Excessive hair loss (alopecia): Zinc and Selenium deficiency Fe deficiency Refer to A&E USS of abdomen:?gallstones PPI therapy. Anti-emetics Dietary advice. Refer to a Gastroenterologist or Bariatric Surgeon Check Fe, Folate, B12 Stool for occult blood Correct deficiencies Refer to a Gastroenterologist Check Zn, Se & Fe Correct deficiencies
Future service aspirations 1. Single site for Greater Manchester 2. 24/7 on-call service for bariatric surgery 3. Long term follow up @ MWM service