Choices Around Bariatric Surgery

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1 Choices Around Bariatric Surgery What should you know? Richard Stubbs MD FRCS FRACS Wakefield Obesity Clinic, Wellington

2 152 kg / BMI kg / BMI 29

3 Indications (NIH Consensus Statement 1991) BMI > 40 BMI > 35 with co-morbidities

4 Co-morbidities type 2 diabetes hypertension dyslipidaemia sleep apnoea asthma Pickwickian syndrome G-O reflux back/joint problems infertility depression self esteem self confidence

5 Gastric Band Gastric Sleeve Gastric Bypass

6 Evolution Today s procedures open Fobi Pouch gastric bypass laparoscopic gastric bypass laparoscopic adjustable gastric banding laparoscopic gastric sleeve

7 advantages ease for patient ease for surgeon simple procedure least expensive few micronutrient issues adjustable band

8 disadvantages unpredictable weight loss poor long-term results high reversal rate (>50%) high maintenance (10% pa) adjustable band

9 advantages ease for patient ease for surgeon few micronutrient issues no bowel obstructions cost a little risk similar to bypass sleeve gastrectomy

10 disadvantages less data available variable weight loss less reliable than bypass G-O reflux revision rate high (40-60%) sleeve gastrectomy

11 Not all gastric bypasses are the same (Roux-en-Y procedure = gastric bypass)

12 Gastric bypass pouch size and shape not all gastric bypasses are the same

13 advantages Shorter hospital stay Quicker recovery No large incision Metabolic benefits Similar cost Similar risk Laparoscopic GB

14 disadvantages More variable weight loss Not so durable weight loss Late bowel obstruction (5-10%) Major weight regain 20% Laparoscopic GB

15 advantages More predictable weight loss More durable weight loss Very few bowel obstructions No large incision Metabolic benefits Major weight regain <5% Fobi Pouch GB

16 disadvantages One week in hospital 4-6 weeks off work Large scar Incisional hernias Fobi Pouch GB

17 Assessing the procedures risk of the surgery recovery time from surgery surgical complications late complications weight loss short term (1-5 years) weight loss long term revision rates reversal rates ongoing issues

18 Assessing the procedures risk of the surgery lap band % others % recovery time from surgery laparoscopic weeks open surgery weeks surgical complications lap band - 5% others %

19 Assessing the procedures late complications lap band +++ lap gastric bypass + Fobi Pouch + sleeve gastrectomy ± revision rates lap band 40-50% at 5 years lap gastric bypass low Fobi Pouch low gastric sleeve 40-60% at 5 years

20 Assessing the procedures Reversal rates Lap band Lap gastric bypass Fobi Pouch sleeve gastrectomy Ongoing issues Lap band Lap gastric bypass Fobi Pouch sleeve gastrectomy 40-50% by 5 years nil nil not reversable lifelong low low low

21 So what about the weight loss?

22 Systematic review O Brien et al Obes Surg 2006

23 Systematic review O Brien et al Obes Surg 2006

24 Systematic review O Brien et al Obes Surg 2006

25 % EWL Obesity Surgery in a Nutshell 100 Sleeve Gastrectomy vs Gastric Bypass (n=64) LSG 40 LRYGB Time post surgery (yr) Zhang et al, Obes Surg, 2014: 24:

26 Obesity Surgery 2015; 25: Laparoscopic Sleeve Gastrectomy Versus Laparoscopic Roux-En-Y Gastric Bypass for Morbid Obesity and Related Comorbidities: A Meta-Analysis of 21 Studies. Total n = 18,766 Zhang Y, Ju W, Sun X, Cao Z, Xinsheng X, Daquan L, Xiangyang X, Qin M Weight loss after 18 months superior in LRYGB patients (p<0.05) Equivalent improvement in co-morbidities except Type 2 diabetes Superior resolution rates for Type 2 diabetes for LRYGB (p<0.001)

27 Am J Surg Dec;208(6): Is laparoscopic sleeve gastrectomy a lower risk bariatric procedure compared with laparoscopic Roux-en-Y gastric bypass? A meta-analysis. Total n = 15,722 Zellmer JD, Mathiason MA, Kallies KJ, Kothari SN. leak rate: 1.9% for LRYGB vs 2.3% for LSG (p=0.077) mortality: 0.4% for LRYGB vs 0.2% for LSG (p=0.11)

28 Systematic review n = 1627 n = 856 O Brien et al Obes Surg 2006

29 EWL % Obesity Surgery in a Nutshell band n=260 no band n=218 Awad et al Obes Surg 2012, 22: 271-8

30 Systematic Review - 5 studies (n=470 vs 426) 100 Mahawar et al, Obes Surg, 2014: 24: % EWL % Band No Band 62.3% Time after surgery (yr)

31 Metabolic benefits diabetes / hypertension / lipids heart disease / stroke Pories et al. Ann Surg 1995; 222:

32 HOMA Obesity Surgery in a Nutshell Diabetic Impaired glucose tolerance Normal glucose tolerance 5 0 Pre surgery 6 days 3 months 6 months 9 months 12 months

33 123 Type 2 diabetics n A B C D unrecognised diet controlled oral agents insulin depend Totals 100% 32% 70% 15% 15% A - resolved by 3 months C - indeterminate at 12 months B - resolved by 12 mo (FPG < 6 and HbA1c <6) D - not resolved at 12 mo (FPG 7 or HbA1c 7)

34 10,251 patients Median duration of diabetes 10 yrs

35 Summary gastric band is the easiest and least reliable gastric bypass gives superior metabolic benefits gastric bypass gives most reliable and durable weight loss gastric sleeve hold an intermediate position bowel obstruction a problem after lap gastric bypass Fobi pouch /open surgery most reliable gastric bypass micronutrients after gastric bypass multivit, B12, folic acid, Fe

36 Conclusions What should determine which operation is done? ease of operation for the surgeon? ease of operation for the patient? long-term results? need for revision or reversal?

37 105 kg / BMI kg / BMI 23

38 Canadian Study Aim: To evaluate healthcare costs following surgery 1035 patients have bariatric surgery matched patients not having surgery All direct healthcare costs Hospital GP / specialist visits investigations prescription costs auxillary medical services

39 Cost ($m) per 1000 patients Obesity Surgery in a Nutshell Cumulative costs Years

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