Obesity and Bariatric Surgery

Paul Burton FRACS, PhD

Current Standard of Care for Obesity

• = 0• For success ………………..this needs to change

• Ignoring obesity and its treatment needs to become no more acceptable than ignoring other disorders

Lee Kaplan: Director of the Weight Center at the Massachusetts General Hospital and associate professor of medicine at Harvard Medical School.

NHMRC Guidelines

Franz et al. J Am Diet Assoc. 2007 Oct;107(10):1755-67.

Ten year follow: A randomised control trial surgical versus medical treatment of mild to moderate obesity

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Surgical Medical

Outcome data are available on 37 (92.5 %) of the surgical patients and 27 (62.5 %) of

the non-surgical patients at 10 years.

12% removal of gastric band

Key benefits of surgically induced weight loss

Physical quality of lifeTie shoelacesWalk up a flight of stairsGet on an airplane and do up the seatbelt

Decreased mortality Co-morbidity improvement• Type II diabetes• Metabolic syndrome• NASH• Obstructive sleep apnoea• Asthma• Hypertension

Reduced health care costsCost efficacyCost effectiveness

Proportion of potentially eligible patients undergoing bariatric surgery annually

Australia 0.3%

Surgery No Surgery

United States 0.7%

Surgery No Surgery

Male Female ratio of patients having bariatric surgery

(2014 calendar year)

58

155

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Male Female

“If you have not had a friend, family member or colleague who has struggled with their weight and particularly if you haven't tried to lose weight yourself, then it’s easy for you to ascribe negative stereotypical traits to overweight and obese people. It's a lot like alcohol and drug addiction. Our society is more accepting of these conditions as a disease and less so for obesity”*

*American Obesity association

Surgical procedures

Eligibility for bariatric surgery

• Age 18-65 years

• Ability and willingness to engage in follow up

• Body Mass index 30-35 kg/m2 with obesity related co-morbidity (band)

• Body Mass index >35 kg/m2 with obesity related co-morbidity (sleeve or bypass)

• Body Mass index >40 kg/m2

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Bariatric (obesity) Surgery

• Goal of every bariatric procedure is to assist in reducing daily calorie intake

• Surgery levels the playing field, making it possible for the patient to control their weight.

Calories In = Calories Out Weight Stable

Calories In > Calories Out Weight Gain

Calories In < Calories Out Weight Loss

Laparoscopic Adjustable Gastric Band

Key Strengths:SafeEffectiveGentle, adjustable, reversibleGood evidence base

Key Weaknesses:Requires good follow upRequires a “partnership”Requires revisional surgery –

20-30% in 15 years

Adjustments and Follow up

Patient Education

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%EWL

Years of follow-up

Weight Loss up to 15 years after gastric bandingO’Brien/Brown Series; N = 3,227; 81% follow up

54234714

%EWL – Mean +/- 95% CIs

1,983

Annals of Surgery 2013; Volume 257, Pages 87-94

Sleeve GastrectomyStrengths:Technically simpleExcellent early weight loss“No need for follow up”

(Sleeve and Leave)Few intermediate term problemsGood eating quality

Weaknesses:2-3% Leaks rate - major problemRefluxLimited long term dataRevision may be neededIrreversible

Roux-en-Y Gastric Bypass (RYGB)

Strengths:Good weight lossWell known - > 40 yearsReasonable evidence base?Adjuvant benefits - diabetes

Weaknesses:Risk of deathMajor GI tract change?Weight loss fades/Revisions Irreversible Nutritional deficienciesUlcers and internal hernias

Malabsorption - Biliopancreatic Diversion

Strengths:Very good weight lossProbably durable

Weaknesses:Highest surgical riskMetabolically toxic – risks with non-complianceIndefinite follow upMajor long term problemsOffensive diarrhea

NEW PROCEDURES

Weight Loss at 2 years

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Weight loss at 10 years

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Re-operations over 10 years

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Peri-operative mortality risk

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Nutritional follow up

• Baseline, then annual or six monthly measurements of metabolic and nutritional health.

• Vitamin D, iron, thiamine, B12, folate, protein (albumin).

• Malabsorptive procedures – fat soluble vitamins: Vitamin A, and Vitamin D, parathyroid hormone, Vitamin K.

• More major procedures require more intense follow up and nutritional supplementation.

Key messages

1) Surgery involves simple, anatomical modifications to the gastrointestinal tract

2) Bariatric surgery is not about surgery, it is about the post-operative follow up – “weight loss is a journey not a destination”

3) Any gastro-intestinal or nutritional issue is highly likely to be related to the bariatric surgery

4) More variability in the surgical outcomes based on the quality of bariatric surgical care, than there is between different operations - Always, Always get the patients to follow up