Weight loss surgery more than just a gastric band

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1 Weight loss surgery more than just a gastric band Presented by Ms Beth Murgatroyd Honorary Bariatric Nurse Practitioner Mr Ameet G Patel Consultant Surgeon Director of Bariatric Surgery at King s College Hospital Minimal Access, HPB and Bariatric Surgery

2 Obesity Associated increased morbidity & mortality Increased risk CVS disease, BP, diabetes, cancer, sleep apnoea, musculoskeletal disease Body image Quality of life

3 Does bariatric surgery decrease obesity related mortality and morbidity?

4 Mortality: Swedish obesity subjects matched control n = 2037 bariatric surgery n = 2010 (Av 10.9 FU years) deaths: control group n = 129 and surgery group n = 101 (p<0.04) (MI - control group = 25, surgery =13; cancer - control group = 47, surgery = 29) Sjostrom L et al NEJM 2007

5 Mortality Retrospective cohort study (applied for drivers license) RYGB n = 9949, severely obese n = 9628 matched n = 7925 surgical, n = 7925 controls FU = 7.1 years Mortality - control = 57/10,000 surgery = 38/ 10,000 (p<0.001) specific mortality in surgery group - 56% decrease coronary artery disease - 92% decrease diabeties - 60% decrease for cancer - 58% increase in accidents and suicide Adams TD et al NEJM 2007

6 Which patients should be considered for surgery?

7 NICE guidelines for Surgery BMI >40/35 (+2) Age >18 (55) ASA I-II Failure of non surgical methods No clinical or psychological exclusion Long term follow up

8 Which operation and why?

9 Bariatric Surgery Restrictive - laparoscopic gastric banding - vertical banded gastroplasty - laparoscopic sleeve gastrectomy Malabsorptive - jejunoileal bypass - biliopancreatic diversion - duodenal switch (laparoscopic) Combination - roux en Y gastric bypass (laparoscopic)

10 Laparoscopic Gastric Banding

11

12 Advantages of LAGB Simple, relatively safe op No anastomosis No resection Potentially reversible Average EWL 50% Low mortality <1/500 Resolution of type 2 diabetes -50% over 2 years

13 Complications Non responders (5-20%, mean 10%) Gastric perforation (1/1000) Port/band (0-10%) Reflux oseophagitis (4%) Slippage 5% Erosion 5% Re-operation (20%) Chelala et al, 1997; Belachew et al, 1999; Dargent et al, 1999; Fielding et al, 1999; Forsell et al, 1999; O Brien et al, 1999, Miller et al, 1999

14 Pouch dilation/ slippage (5%)

15 Gastric erosion (0-5%) Chelala et al, 1997; Belachew et al, 1999; Dargent et al, 1999; Fielding et al, 1999; Forsell et al, 1999; O Brien et al, 1999, Miller et al, 1999

16 Laparoscopic sleeve gastrectomy Average EWL 50% Mortality <1/100 80% remission of type 2 diabetes after 1 year If not enough weight loss => option of additional malabsorptive operation

17 Pros and Cons Pros No foreign body No risks of slippage or erosion Lower re-operation rates No need for gastric band fills Low maintenance for patient?more guaranteed and faster weight loss than the band Cons Unknown long term weight loss Higher short term complication rate Risks of leakage from staple line Cannot be reversed Risk of stricture Prolonged liquid only diet

18 Laparoscopic biliopancreatic diversion & sleeve gastrectomy (duodenal switch)

19 Pros and Cons Pros No foreign body Best guaranteed weight loss 80%EWL at least 100% cure for diabetes Good for those who like to eat! Cons Higher short term and long complication rate Risk of leaks from staple line Risk of leaks from anastomosis Cannot be reversed Strict protein intake per day Significant risk of protein malnutrition MUST take supplementation Life long blood tests Bone scans

20 Laparoscopic Roux en Y gastric bypass

21 Laparoscopic Roux en Y gastric bypass

22 Advantages of laparoscopic gastric bypass Safe operation - mortality 0.3%, 1% Average EWL >60% Resolution of type 2 diabetes 84% (immediate effect 1/52) Potentially reversible

23 Long term problems Dumping 1/3 Hair loss Nausea Upper GI symptoms Malabsorption and consequences Hypoglycaemia (rare) gallstones

24 After Surgery Post-operative course Food and diet changes Post-operative follow-up Band adjustments (for banding) Blood tests Supplementation Bone scans

25 Complications After Lap RNY A Review of 3464 Cases Podnos Y et al. 2003

26 Bariatric Surgery NICE - laparoscopic surgery is as effective as open surgery, but results in fewer complications and a reduced length of hospital stay.

27 Laparoscopic Roux en Y Gastric Bypass: laparoscopic versus open Same weight loss?longer operation time <ICU,<stay,<pain, <time to daily activity and work Nguyen NT, 2001; Westling A 2001; Lujan JA 2004

28 Which Bariatric Operation? factors to consider Criteria Weight loss Metabolic / endocrinological Mobility Co-morbidities eg sleep apnoea diabetes Psychological and social? Operative morbidity and mortality Patient pre-conceived ideas

29 Weight Changes among Subjects in the SOS Study over a 10-Year Period Sjostrom L et al. 2004

30 Bariatric Surgery: Which Operation? BMI LRNY Lap gastric banding/sleeve gastrectomy? BMI >50 LRNY DS BMI >60 DS (2 steps)

31 Any other options? Endoscopic Gastric Balloon Banded gastric bypass Bandinaro Duodenal Sleeve Distal v Proximal Roux-en-Y Gastric Bypass Paediatric Bariatrics contentious or reality

32 Outcomes of Surgical Weight Loss on Type 2 Diabetes Mellitus Author Procedure N BMI % T2DM FU (years) %EWL T2DM pts/ All pts Resolved (R) Improved (I) SOS study (2000) 70% VBG 24% GB 6% RYGB % 2 RYGB = 33% EWL VBG = 23% EWL GB = 21% EWL R = 47% I = N/A Dixon (2002) LAGB % 1 T2DM = 38% All = 47% R = 64% I = 26% Poiries (1995) RYGB 608 (134 Kg) 27% 10 All = 54% R= 89% I = 7% Schauer (2003) LRYGB % 4 T2DM = 60% All = N/A R = 83% I = 17% Sugerman LRYGB % 1-10 T2DM = N/A R = 86% (2003) RYGB All = 66% Scopinaro (1996) BPD % IBW 8% 1-21 T2DM = N/A All = 75% R = 100% Schauer P et al. 2003

33 Centres of Excellence

34 The USA experience Mortality in gastric bypass surgery is estimated at 1 in 200 With the establishments of centres of excellence, this mortality figure reduced to 1 in 500 for RNY and 1 in 1000 for Lap bands

35 King s College Hospital Accreditation 1) Designated preferred provider of bariatric surgery within South East of England 2) European Accreditation for Bariatric Surgery (IFSO European Chapter), granted provision status

36

37

38 Mortality 2/518 patients (0.38%) Small bowel obstruction and anastomotic leak Sudden death 10 days post surgery?arrhythmia (diabetic autonomic neuropathy)

39 Re-operations why? 6/518 (1.6%) Laparoscopic gastric banding Dysphagia lap bands x 2 Rectus sheath haematoma on band removal Laparoscopic gastric bypass Small bowel obstruction (5mm port) Proximal leak NG stapled revised laparoscopically Laparoscopic sleeve gastrectomy Staple line leak

40 Laparoscopic bariatric surgery conversion to open 5/518 = 1% Last 4 years, 0% conversion

41 Bariatric Service Experienced Nurses and support staff to care for bariatric patients Bariatric Surgeons Mr Ameet Patel 1999 to date Ms Avril Chang 2006 to date Mr Ali Halal 2010 to date

42 Endocrinologist Diabetes Dietician Service Respiratory Cardiology Anaesthetics Bariatric Service Dr S Aylwin / Dr Carel le Roux Dr R Malik Mr Rick Wilson Prof Moxham/Dr Rebecca Lyle Dr Phil McCarthy Dr Fraser Dunsire/Dr Jay Dasan Psychologist/Counselling service Support Group BOSPA / WLSinfo

43 Bariatric Surgery The future

44 Bariatric Surgery The future is laparoscopic NOT Open! scarless

45 The Obese patient What does it mean for you, the GP? Identifying patients who may benefit BMI >50 (& relatively fit) straight to surgery BMI <50 to try all other methods to lose weight

46 Long term care RNY & DS Vitamin & mineral deficiency Compliance Prescribing Blood tests Routine checks via GP Annual check-up at King s

47 Thank you Any questions?

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