Abeezar I. Sarela MSc MS MD FRCSConsultant in Upper GI & Bariatric SurgerySt James’s University Hospital, Leeds, UK

PN Hinduja National Hospital, Mumbai, India

Bariatric Surgery:What Does The Future Hold?

Surgery for Obesity

• Global epidemic of obesity• Bariatric surgery is the only effective and

sustained treatment for morbid obesity• Bariatric surgery resolves diabetes and

other co-morbidity and saves lives• Laparoscopic surgery has significant

advantages over open procedures• Surgical morbidity and mortality are very

low in experienced units

The Future

Revisional Surgery

Endoscopic Procedures

Gastric Neuromodulation

Sleeve Gastrectomy: The Rise…

Sleeve GastrectomyCurrent Status

Updated Position Statement on Sleeve Gastrectomy as a Bariatric Procedure

– Clinical Issues Committee of the ASMBS.

SOARD 2010.

•Systematic review of sleeve gastrectomy as staging and primary bariatric procedure.

– Brethauer, Hammel, Shauer. SOARD 2009;5:469-475

Sleeve GastrectomyAvailable Long-Term Follow-Up Data

• 36 studies-2570 patients

• BMI 37-69 (51.2)

• % EWL 33-85 (55)

• 12 studies >100 patients

• FU>36 months –3 studies

• FU>60 months –1 studySOARD 2009;5:469-475

Follow-up Intervals

•3 y 123 patients

•4 y 26 patients

•5 y 8 patients

SOARD 2010

What is Success in

Bariatric Surgery?

Durable

Excess Weight Loss > 50%

Success & Failure

Sleeve Gastrectomy

FailureSuccess:

Sleeve with >50% EWL

Revisional Surgery Lost to Follow-UpSleeve with <50% EWL

Sleeve Gastrectomy: Long-Term Follow-Up (…and ? Fall)

Author Follow-Up No. of patients

Failure

Himpens et al

Brussels, 2010

6+ years 53 64%

Sarela et al

Leeds, 2010

8+ years 20 45%

Evolution of Surgery

Open Surgery (big cuts)

Laparoscopic Surgery (key-hole sized cuts)

Natural Orifice Surgery (no cuts)

Technique Product

Sclerotherapy

Suturing EndoCinch (Bard)

Spiderman (J&J)

Anchors ROSE, POSE (USGI)

T-Fasteners StomaphyX (Endogastric Solutions)

Staplers TOGa (Satiety Inc.)

Sleeves EndoBarrier (GI Dynamics)

ValenTx

Endoscopic Bariatric Procedures

TOGA

TOGA: ex-vivo Anatomy

TOGATransOral Gastroplasty

• ~ 500 patients in Europe & USA

• Full data-set on 171 patients

• Follow-up– 6 months: 111 patients

– 12 months: 76 patients

– 24 months: 20 months

• Median 39% EWL at 12 months

• Safety: Adverse events – 3%

The Search Continues……

• Behaviour modification

• Monitor activity and eating pattern

• Adjustable parameters

Implantable Gastric Electrical Stimulators

Transcend IGS™ SystemTransneuronix - Medtronics

•800 patients world-wide•10 years follow-up•35% excess weight loss

Consumption - Expenditure Wt Change=

Gastric Stimulation• Creates early sensation of satiety• Reduces desire to eat between meals• Reduced meal volume

Patient Support System• Tracks & reports eating events• Tracks & reports exercise trends• Useful diagnostic for sleep disorders • Supports behavior modification

Low Impact• Excellent safety profile • Minimal lifestyle changes

• No special diets• No vitamin supplements

IntraPace: Abiliti™

GSA102 Analyzer

P102 Programmer

W102 Programmer

Wand

LGS102 Stimulator

LGL102

Lead

IntraPace: abiliti™

Endoscopy 6 Months Post-Implant

Abiliti™: Weight Loss

Unpublished data

Emerging Paradigms in Obesity Therapy

• Super-Obesity: Conventional Bariatric

Surgery e.g. laparoscopic gastric bypass

• Less Severe Obesity

– Classes 1 and 2

– Class 3 with BMI<45 kg/m2

• Gastric Electrical Stimulation

• Endoscopic Bariatric Procedures