Bariatric surgery: a treatment for

our times Trisha O’Moore-Sullivan MBBS FRACP

Director, Medical and Chronic Disease Services Mater Health

Safe harbour discussion

• Context and definitions

• Myth busting and facts

• Current recommendations from professional societies

• Other speakers – Cost effectiveness in various clinical settings

within Qld context

– Surgical framework

– Delivering a service within a fixed funding envelope

– Panel – Prof John Dixon

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Obesity Prevention vs Treatment

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Prevention Treatment

Lifestyle

Diet inc VLCD

Drugs

Surgery

Definition of obesity

• Obesity is defined as abnormal

or excessive fat accumulation that

may impair health1

• BMI provides the most convenient

population-level measure of

overweight and obesity currently

available1

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=𝑤𝑒𝑖𝑔ℎ𝑡 (𝑘𝑔)

ℎ𝑒𝑖𝑔ℎ𝑡 𝑚 2

Classification BMI (kg/m2)

Underweight <18.5

Normal range ≥18.5 and <25

Overweight ≥25 and <30

Obese ≥30

Obese class I ≥30 and <35

Obese class II ≥35 and <40

Obese class III ≥40

BMI, body mass index; WHO, World Health Organization

References: 1. WHO. Fact sheet number 311. 2015. Available at: www.who.int/mediacentre/factsheets/fs311/en/; 2. WHO. Global database on BMI. 2015 Available at:

http://apps.who.int/bmi/index.jsp?introPage=intro_3.html.

WHO classification of BMI2

What is bariatric surgery?

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Adjustable Gastric

Banding (AGB)

Sleeve

Gastrectomy (SG) Roux-en-Y Gastric

Bypass (RYGB))

Bariatric procedures MBS

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1354 1769 2150 2800

3949

5495 6730

9577

13787 13403

11304

9755 8981

11300

14850

16650

18,980

What problem are we trying to

address?

• Obesity and type 2 diabetes are serious chronic diseases

– Complex metabolic dysfunction

– Increased risk for morbidity and mortality

– Limited effective treatments

• Significant social and financial burden

– Individuals

– Health system

• Finite healthcare resources

• Provide a value based outcome

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Case discussion: Gloria

• BMI 40 – class 3

• Age 43

• Biliary colic - repeated

• Waiting list for lap cholecystectomy

• Is this reasonable?

• What is the cost?

• 2015-16 average cost $7,897 (median $7,305)

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Case discussion: Gloria

• BMI 40

• Age 43

• Diabetes, ↑BP, sleep apnoea, ↑cholesterol, albuminuria

• Surgical treatment available that could fix her metabolic dysfunction

• Is this reasonable?

• What is the cost?

• 2015-16 average cost $9048 (median $8,168)

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Case discussion: Gloria

• BMI 40

• Age 65

– Goes on to develop OA in

her left knee

– Pain, debilitated

– Needs a knee replacement

• Is this reasonable?

• What is the cost?

• 2015-16 average cos

$17,719 (median $17,075)

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Weight regain is the natural history1

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Very-low-calorie diet

Modified diet plus behaviour therapy

Very-low-calorie diet plus

behaviour therapy

Years after intervention

0

–5

–10

–15

–20

5

1 Intervention 2 3 4 5

We

igh

t ch

an

ge

(kg

)

References: 1. Wadden TA et al. Ann Intern Med 1993; 119:688–93.

-30

-25

-20

-15

-10

-5

0

5

Maintenance of weight loss achieved by diet

and exercise is challenging1

Weig

ht

change (

kg)

Mean change from baseline to end of diet (kg)

Mean change from baseline to follow-up (kg)

Anderson et al.

Foster et al.

Graham et al.

Hensrud et al.

Jordan et al.

Kramer et al.

Lantz et al.

Murphy et al.

Stalonas et al.

Wadden et al.

Walsh & Flynn

Wadden & Frey

Pekkarinen & Mustajoki

Stunkard & Penik

Follow-up range from 4 to 7 years

References: 1. Mann T et al. Am Psychol 2007; 62:220–33; 2. MacLean PS et al. Obesity 2015; 23:7–15.

Weight regain after weight

loss remains the most

substantial problem in

obesity management2

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Physiological mechanisms defend

weight during diet induced weight loss

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Hunger signals Satiety signals

Bariatric surgery modulates physiological

responses to help maintain lost weight

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Hunger signals Satiety signals

Some facts re surgery and diabetes

• Bariatric surgery is superior to medical/lifestyle interventions for glucose control and cardiovascular risk factor reduction in people with obesity and T2DM – 30-65% sustained remission

• Relapse does occur over time – 30-50%

– Median disease free period RYGB 8.3 years

– Remainder there are substantial improvements sustained

• Predictors of remission – Duration < 8 yrs

– RYGB>SG>AGB

– Baseline BMI does not predict

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Some facts in general

• Cost per QALY $3200-$6300

– SOS – economic benefits were seen in

medications savings for surgery group in

people with diabetes

• Safe

– Mortality rates similar to lap chole or

hysterectomy (0.1-0.5%)

– Major complications 2-6%

– Minor complications up to 15%

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Who should be treated?

• NHMRC – Clinical practice guidelines for management of

overweight and obesity

• Consider bariatric surgery depending on individual situation – BMI >40

– BMI >35 plus reversible co-morbidities

– BMI >30 plus T2DM poorly controlled

• Part of an overall clinical pathway for weight management and should be delivered by MDT

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12%

Qld

2nd Diabetes Surgery Summit 2016

• DSS-II – 48 international clinicians/scholars

– All leading international diabetes/obesity organisations – including Australian

• Surgery recommended to Rx T2DM – Class 3 obesity

– Class 2 + suboptimal control

• Surgery considered to Rx T2DM – Class 1 + suboptimal control despite oral plus injectables

• High volume centres with MDTs

19 Diabetes Care 2016;39:861-877

Challenges

• Bias

• Equity of access

• Transparency

• Case selection Right outcomes

• Place in the treatment algorithm

• Ensuring high quality low variability care

– Data and benchmarking

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Chawla et al PharmacoEconomics 2015;33:629-641

Bariatric surgery: a cost effective

treatment option

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