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Surgical management of Morbid Obesity

- the pros and cons

Dr. Sumer Aditya

Consultant Physician / CD

Diabetes & Endocrine Dept

Why talk about Obesity & Bariatric surgery?

Epidemic

Millennium disease

Associated with numerous co-morbidities and complications

Healthcare costs

Affects all aspects of care

Management of Morbid Obesity

• Lifestyle

–Diet

– Exercise

–Behaviour

• Drugs (Orlistat)

• Bariatric Surgery

Overview

• Types of Bariatric surgery

• Benefits of surgery

• Risks / Problems

• Current situation and possible future

• Patient selection

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Weight loss surgery types

Mechanism Common procedure/s

Purely Restriction

LAGB (Band)

Gastric Balloon

Gastroplasty (VBG, Stapling)

Restriction with some

malabsorption

Roux-en-Y Gastric Bypass

(RYGB)

Predominantly

Malabsorption

BPD, Duodenal Switch (BPD-

DS)

Predominantly Restriction Sleeve Gastrectomy (SG)

Restrictive procedures

Mixed – RYGB

Predominantly restriction

with some malabsorption

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Malabsorptive procedures

BPD – Scopinaro procedure

BPD-DS – Duodenal switch

Sleeve Gastrectomy

Predominantly restriction

Sleeve gastrectomy

Evidence

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Procedure Excess Weight

loss % Diabetes

remission % Mortality %

LAGB 46.2 56.7 0.06 (1 in 2000)

Gastroplasty 55.5 79.7 0.21 (1 in 500)

RYGB 59.7 80.3 0.16 (1 in 750)

BPD & DS 63.6 95.1 1.01 (1 in 100)

All procedures 55.9 78.1 0.28 (1 in 300)

Meta-analysis – 621 studies, 135,246 procedures

Buchwald H et al. Am J Med 2009; 122(3):248-256. Buchwald H et al. Surgery 2007; 142(4):621-632.

Evidence of other benefits of surgery

HTN (2 yrs but not 8 yrs)

Dyslipidaemia

Heart – LV mass, EF, Atherosclerosis, ↓MI

Fertility - ↓SHBG, ↑Testo, ↑Oest (no change in hirsutism)

↓GDM, Preeclampsia, LSCS rates, Birth weight

GORD

Asthma

Cancers

Backache, Arthritis

NASH

Incontinence

Pseudotumour cerebri

Venous stasis & ulcers

Pickwickian syndrome, hypoventilation, OSAS

QOL (SF36), Employment

Depression

SOS data – NEJM August 2007

SOS data – NEJM August 2007

What to tell your patient?

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Procedure

Excess

Weight loss

(total percent)

Diabetes

remission

Mortality %

Band 46.2 (15-25%) 56.7 0.06 (1 in 2000)

Bypass 59.7 (25-40%) 80.3 0.16 (1 in 750)

Switch 63.6 (30-50%) 95.1 1.01 (1 in 100)

Meta-analysis – 621 studies, 135,246 procedures Summary

• Only about 3% of morbidly obese patients will get weight loss surgery

• BMI alone is a poor indicator

• Selection should be based of presence/ severity of co-morbidities and those who are likely to benefit the most

• I have had my bariatric surgery ......

• What next?

Post surgical care – Roles need defining?

Surgical team

GP

Patient

Other clinicians

(Diabetes)

• Lifestyle change ...

– Dietary

– Exercise

– Behaviour

• Most important prognostic indicator

Nutritional deficiencies

Band,

Sleeve Gastrectomy

RYGB BPD-DS

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Nutritional deficiencies

• Protein malnutrition

• Iron

• B12, folic acid

• Calcium, Vitamin D

• Vitamin A, E, K, B1

• Zinc, Magnesium, Selenium & Copper

Some common problems ...

• Hair loss

• Vomiting

• Altered bowel habits

– Steatorrhoea

• Rapid weight loss

• Dumping syndrome

• Hypoglycaemia

• Failure & weight regain

Also remember

• Postural hypotension

• Autonomic dysfunction

• Peripheral neuropathy

– with or without diabetes

• Worsening of retinopathy

Diabetes remission

• Eye & Feet screening essential

• Diabetes remission not cure

– Can recur with or without weight regain

Diabetes Remission

Terminology

• Cure

• Resolution

Definition

OGTT – inappropriate

HbA1c

Fasting plasma glucose

Timing

LAGB – gradual

Months to years

RYGB – immediate

Days to months

DS – very immediate

Days to weeks

Diabetes remission definition

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ADA – Diabetes remission

Remission Fasting glucose mmol/l

HbA1c Duration

Partial 5.6 – 6.9 <6.5% 12 months

Complete <5.6 <6.0% 12 months

Prolonged 5 years

Sleep apnoea

• Most will be able to return machine in 18-24 months

• Keep contact with sleep clinic – will need re-test

Psychological considerations

• Body image / abnormal perception

• Depression / anxiety

• Disordered eating

• Altered relationships

• This is not me ...

• I have to succeed .... failure scares me

• Loose skin – I was better off ...FAT

Surgery for diabetes even if BMI low?

Several papers with BMI 30 – 40

Diabetes remission /improvements

Risk – Benefit ratio?

Who should have surgery?

Bariatric Surgery – NICE Guidelines

Bariatric surgery is recommended as a treatment option for adults with obesity if all of the following criteria are fulfilled:

– they have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight

– all appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months

– the person has been receiving or will receive intensive management in a specialist obesity service

– the person is generally fit for anaesthesia and surgery

– the person commits to the need for long-term follow-up.

Bariatric surgery is also recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m2 in whom surgical intervention is considered appropriate.

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Current NWSC criteria (2012-2013)

• A BMI of 40kg/m2 or more

• Between 35 kg/m2 and 40kg/m2 or greater in the presence of other significant disease

– Significant disease must include one major or two or more minor co-morbidities which may be amenable to treatment if obesity is modified by surgery.

Major criteria • Type 2 diabetes, requiring insulin or another high cost drug or use

of 2 or more HA agents, diabetic complications • Established coronary heart disease, transient ischaemic attack (TIA)

or stroke ( if good functional recovery), heart failure, peripheral vascular disease

• Severe obstructive sleep apnoea (sleep apnoea requiring treatment) or obesity hypoventilation syndrome

• Hypertension requiring the use of 3 or more drugs • Benign intracranial hypertension • Obesity related cardiomyopathy or pulmonary hypertension • Any orthopaedic intervention which has potential to improve

mobility but is precluded on safety grounds due to patient’s BMI • Severe dysmobility due to obesity sufficient to affect essential

activities of daily life e.g. bathing, toileting, dressing, cooking, shopping, that is likely to be improved with weight loss.

• Other co-morbid conditions which have been agreed as exceptional, on an individual patient basis

Minor criteria

• Infertility/polycystic ovary syndrome, male hypogonadism where weight loss is required prior to In vitro fertilisation (IVF), where a couple meet all the other criteria other than BMI of the woman, and the woman is less than 38 years old

• Diabetes requiring only one Oral Hypoglycaemic Agents (OHA) or diet controlled

• Hyperlipidaemia not controlled by statin alone • Liver biopsy proven NASH (Non Alcoholic Steatohepatitis) • Back pain lasting more than six months and causing

interference with daily life • Severe depression where confirmed by psychiatrist or

psychologist that obesity is major causal factor, and there is no other major life event .e.g. relationship breakdown or bereavement in the last 12 months that might be impacting on the depressive illness

Current Welsh bariatric pathway

• Engagement with weight management services

• Referral to WIMOS, Swansea

• Once funding approved patients referred to locally agreed surgical providers

Current WHSSC / WIMOS criteria

• BMI > 50

– Uncontrolled diabetes (HbA1c > 8.1%) despite

being on 3 oral agents or Insulin + one agent

– Uncontrolled hypertension despite 3 or more agents at optimised dosing

– Uncontrolled sleep apnoea despite being on CPAP therapy

• Is there a better way?

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Edmonton Obesity Staging System (EOSS)

Stage 0

Sharma AM & Kushner RF, Int J Obes 2009

Stage 1

Stage 2

Stage 3

Stage 4

co-morbidity

moderate

moderate

Obesity

EOSS vs. BMI in predicting Mortality

Padwal R, Sharma AM et al. CMAJ 2011

The proposed future ...

Questions ...