Treatment for Severely Obese Patients

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1 Treatment for Severely Obese Patients Associate Professor Jimmy So Senior Consultant Surgeon Director, Centre for Obesity Management and Surgery (COMS) National University Hospital

2 Obesity Shortens Lives Bray, Am J Clin Nutr, 1992

3 Real Life Example BMI = 40 Diabetes on medications High blood pressure Knee pain Lifespan shortened by 12 years

4 What is Severe obesity

5 Treatment of Severe Obesity Possible! But need commitment Best with multi-modality treatment 1. Dietary 2. Exercise 3. Drugs 4. Weight loss Surgery (Bariatric Surgery)

6 How to deal with Severe Obesity (BMI > 32) With a committed program with drugs, exercise and diet, the average weight loss is about 10kg, and rarely sustainable The only methods to achieve major and sustainable weight loss are surgical Int J Obesity 1997, Arch Surg 2004

7 According to the US NIH... Surgery is the most effective option in achieving sustained weight loss in the morbidly obese patient population. Family Physicians Update 2010

8 Surgical Treatment Surgery can not only reduce the body weight but also reverse the medical complications of obesity However, Surgery is viewed as drastic & a last resort by most. Family Physicians Update 2010

9 Benefits of Weight Loss or Bariatric Surgery Surgery can not only reduce the body weight but also reverse the medical complications of obesity

10 Bariatric (Weight Loss) Surgery First described in 1960 s Become very popular in last 10 years because more people are obese and the technology of laparoscopy (key-hole Surgery)

11 Key-hole Surgery

12 No. of Weight Loss Surgery /year (USA) 120,000/year New England Journal of Medicine 2004

13 Who is suitable for Surgery Morbidly obese (BMI>37) Severely obese (BMI>32) with comorbidities Previous attempt of dietary treatment No serious psychiatric problems

14 How Does it Works 1. Reduce the volume of Stomach 2. Reduce the volume of Stomach AND food absorption

15 How Does it Works 1. Reduce the volume of Stomach Lap gastric band Lap sleeve gastrectomy 2. Reduce the volume of Stomach AND food absorption Lap Gastric bypass

16 Gastric Band Sleeve Gastrectomy Gastric Bypass 16

17 Laparoscopic Gastric Banding Advantages Simple Adjustable reversible Disadvantages Frequent follow up Foreign body

18 Laparoscopic Sleeve Gastrectomy Fundus and greater curve removed- Enhance satiety Reduce appetite due to serum Ghrelin

19 Laparoscopic Sleeve Gastrectomy Advantages: Technically simple No foreign body Good weight loss Disadvantages: No long term data yet

20 Gastric Bypass Gold standard since 1960 s Small gastric pouch and bypass part of intestine Best weight loss Best results for medical complications Disadvantages Not a easy operation Nutrition supplements after surgery

21 Outcomes after Weight Loss Surgery

22 Excess Weight Loss (EWL) 62% Annual of Surgery 2003

23 Comorbidities after Surgery

24 Weight Loss and Diabetes Mellitis after Surgery Procedure % EWL T2DM (Resolved) Gastric Banding Gastroplasty (VBG) 47% (n=1848) 48% 68% (n=506) 68% Gastric Bypass Biliopancreatic Diversion 62% (n=4204) 84% 70% (n=2480) 98% Buchwald H. JAMA, 2004

25 *30% discontinued DM drugs before significant weight loss Schauer P et al., Ann Surg 2003

26 Randomized Study on Laparoscopic gastric banding for T2DM 60 patients: BMI 30-40: T2DM < 2yr Randomized into 2 arms LAGB Conventional diabetes care Best available practice Diabetes medications Lifestyle changes by dietitians and nurses Dixon et al., JAMA 2008

27 Results 92% completed a 2yr follow-up Remission of DM 73% (Surgery); 13% (conventional) p<0.001 Weight loss 21% (surgery); 1.7% (conventional) p<0.001 Dixon et al., JAMA 2008

28 Operative Risk Bariatric surgery is not a cosmetic surgery! Postoperative mortality 0.1-1% 2 kinds of risk surgery-related Medical problems associated with obesity

29 Surgery Saves Lives Swedish Obese Study NEJM obese subjects with 10 yr follow-up Patients with surgery reduce mortality by 26% USA study NEJM ,000 patients: Gastric Bypass vs controls Significant reduction (40%) of mortality, 92% reduction in death related to DM

30 NUH Centre for Obesity Management & Surgery (COMS)

31 Centre for Obesity Management & Surgery (COMS) Team: Specialist surgeons Dietitians Physiotherapists Behavioral Therapist Endocrinologists Psychiatrist

32 NUH Weight Management Program Four Months Program Week Doctor Consultation x x x x Nurse Educator x x x x Dietitian x x x x Behaviorial Therapist x x x Physiotherapist x x x

33 NUH Weight Management Program First Visit Detailed health history Physical exam Laboratory tests- fasting glucose, lipids & TFT Dietary and Exercise therapy start

34 NUH Weight Management Program Next visits Continue Diet & Exercise Therapy If weight loss not optimal BMI <32: starts anti-obesity drugs BMI >32: considers surgery

35 NUH Weight Management Program

36 Strait Times Aug 2009 Before WMP : 98kg (BMI 48) Now (6 months after surgery): 74kg (BMI 34) Diabetes, high blood pressure and knee pain healed

37 Summary Bariatric Surgery is the only proven treatment for morbid obesity It treats both obesity and its comorbidities with acceptable risks Best outcome requires a multi-disciplinary approach

38 Summary- Who needs Surgery Morbid Obesity: >37.5 Severe Obesity : BMI with obesity associated diseases Failed dietary attempts US National Institute of Health Guideline

39 Role of General Practitioners As Gatekeepers for surgery Recognize the co-morbidities of morbid obesity & their treatment Understand various treatment options and the follow up Family Physicians Update 2006

40 NUH Weight Management Clinic Every Wednesdays University Surgical Clinic Appointment: (65)

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