Obesity Surgery : Is it only for losing weight ?
Joint Hospital Surgical Grand RoundSimon Chu
Prince of Wales Hospital
Obesity Classification
WHO
Class Asian
Underweight < 18.5
Normal 18.8 – 22.9
Overweight >23
Obese I >25
Obese II >30
Obese III N/a
WHO guidelines 2005
Figures in Hong Kong
Burden of Obesity – lessons learnt from Hong Kong Chinese Obesity Reviews (2008) 9 (Suppl. 1,) 35-40
Gastric Banding• Reversibility• Ability to calibrate • Less destructive to
stomach
Sleeve Gastrectomy
• Preserve normal food passage
• Second stage procedure is possible
• Serious complications
Gastric Bypass
• Most common procedures performed in U.S.
• Better long term outcome than pure gastric restrictive technique
• Persistent nutritional problems
Biliopancreatic diversion with duodenal switch
• Achieved best weight loss
• Possible for 2-stage procedure
• High operative complications
Intragastric balloon
• Artificial bezoar• Increase in satiety
reduction of food intake• Part of a diet programme• Temporary procedure to
aid further conventional intervention
• 1st element of assessing the efficacy of an bariatric surgery• Where is the evidence of GOOD WEIGHT REDUCTION = IMPROVEMENT OF CO-
MORBIDITIES
Meta-analysis : Surgical treatment of Obesity Ann Intern Med 2005; 142 : 547-559
• Swedish Obese Subjects (SOS)
• Prospective non-randomized, interventional trial
• Patients undergo bariatric surgery vs conventionally treated patients
• Effects of weight loss on risk factors and hard end points
• Changes in cardiovascular risk factors over follow-up periods
• Bariatric Surgery is a viable option for treatment of severe obesity as
1. Result in long term weight loss
2. Amelioration in risk factors
• Another prospective study using the same group of patients published in 2007
• To determine association between weight loss and mortality rate
• Study period : 10.9 years
• Weight loss from baseline : at least more than 15%
• Adjusted hazard ratio 0.76 surgery group
New England Journal Of Medicine Vol 347, No 8 Aug 23, 2007
Apart from weight reduction…..
Apart from weight reduction
Circulation 2004; 110 : 1245-1250
• Asia patients :
Abdominal obesity Men : 90cm Women : 80cm
Any help?• Significant improvement in all parameters after gastric
bypass surgery at post-operative 6 months Remission of Metabolic Syndrome : A study of 140 patients Six Months after Roux-en-Y Gastric Bypass
Obesity Surgery ( 2008 ) 18: 601-606
• Gastric Bypass Surgery induces persistent and considerable improvement in MetS prevalence compared with patients treated conventionally
Effect of Bariatric Surgery on the Metabolic Syndrome : A population based, Long-term Controlled Study
Mayo Clinic Proceedings : Aug 2008 : 83, 8
JAMA 2008; 299 (3) : 316-323
• Unblinded randomized controlled trial• 60 patients with BMI between 30 and 40 and recently diagnosed type 2 DM• Conventional diabetes therapy vs laparoscopic adjustable gastric banding• Outcomes : Remission of type 2 diabetes ( Fasting glucose < 7 mmol/L and HbA1c < 6.2% while not on glycemic
therapy )
Diabetic Remission : 22/30 (73%) in surgical group 4/30 (13%) in conventional group at 2 years
The Future..
Metabolic Surgery
• Return to euglycaemia and normal insulin levels are observed within days after bypass surgery
• Weight loss alone cannot explain the association
• “ Rearrangement of gastrointestinal anatomy as a primary mediator of surgical control of diabetes ?“
Open questions for clinical Research
• Surgical treatment for Diabetes in patients
1. BMI < 30 ?
2. Or with normal BMI ?
Conclusion• Bariatric Surgery is effective in promoting weight loss in
morbid obesity which has a long lasting effect
• Effect of weight loss can be transferred to reduction in mortality rate
• Apart from weight loss, remission of metabolic syndrome and type 2 diabetes are the other clinical outcomes associated with bariatric surgery