23% Trend-line Men Women / /08 Year

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1 How to Treat PULL-OUT SECTION Complete How to Treat quizzes online ( to earn CPD or PDP points. inside Treatment options Current methods Surgery outcomes Decision-making a personal view Selection criteria The author Emeritus Professor Paul O Brien head of the Centre for Bariatric Surgery, Glen Iris; and Emeritus Professor of Surgery, Monash University, Melbourne, Victoria. Background Figure 1: Prevalence of obesity, people ages 25-64, 1980 to 2007/08. % Obesity % OBESITY, the accumulation of fat to the point where health is impaired and defined in Western communities as a BMI exceeding 30kg/m 2, is one of our most significant pathogens. One in four Australian adults, more than three million people and about one in 10 adolescents, is obese. Figure 1 shows how the prevalence of obesity has increased markedly in the past 30 years. In 1980, just 9% of adults were obese; now the Australian Bureau of Statistics estimates that 24% of all adults are obese. It is similar around the world. A systematic review of 199 countries in 2008 estimated 502 million people worldwide were obese. The WHO projects this number to increase to 700 million by the middle of this decade. Obesity causes or exacerbates numerous common and potentially fatal diseases including type 2 diabetes, cardiovascular diseases such as ischaemic heart disease, hypertension, dyslipidaemia, stroke, depression, several common cancers, and degenerative conditions of the back, hips, knees and feet. It markedly reduces quality of life as a result of the severe physical limitations and social isolation it can generate. It competes with 23% Men Women Trend-line / /08 Year Adapted from Australian Institute of Health and Welfare. Australia s Health 2012, Australian Government, Canberra, smoking as the most common cause of premature death and it costs the healthcare system dearly. If you are one of those GPs who struggle to find a solution or maybe just avoid recognising obesity as a problem that you should confront, you will be pleased to know that, through bariatric surgery in particular, there are solutions available. Let us examine the options to see who we can help, how we can help and what difference we can make. First, you must accept that there is a role for bariatric surgery, as the non-surgical options are not yet capable of generating the substantial and durable weight loss required. While this acceptance has not yet occurred broadly, hopefully this review will encourage you to accept its role in treating obesity. Obesity is one of the most significant medical problems facing GPs, who may have up to 200 patients in the obese range, varying from mildly to morbidly obese. As patients struggle to lose sufficient weight with nonsurgical options, there is a significant and at present under-utilised role for bariatric surgery in achieving substantial and durable weight loss. cont d next page 5 October 2012 Australian Doctor 23

2 Treatment options Table 1: Types and frequency of bariatric procedures currently used in Australia Procedure Proportion of total Approach Length of stay Risk score Gastric banding 80% Laparoscopic 2-4 hours 2 Sleeve gastrectomy 17% Laparoscopic 2-4 days 5 Gastric bypass 2% Open or laparoscopic 2-4 days 6 Biliopancreatic diversion <1% Open or laparoscopic 3-7 days 8 Risk score: ranges from 1(lowest) to 10 (highest), based on mortality and perioperative morbidity Non-surgical options CURRENT weight-loss programs involve reducing energy intake, (for example, the numerous diet programs and the special variant of very-low-calorie diets such as Optifast), behavioural modification, and increased exercise and activity, all with or without drug supplementation. These programs can generally achieve a modest weight loss that is usually sustained for the duration of the program. However, a small proportion of obese patients do achieve a mediumto long-term benefit from such programs and therefore adequate trials of these is a crucial first step. A dietary program must restrict energy intake to less than 6000kJ (1500kcals) a day. Increased exercise and daily activity is essential. There are no current pharmacotherapies that will make a difference. Very-low-calorie meal-replacement diets can be very effective in achieving short-term weight loss if used strictly and should always be considered as a part of the weight-loss program. Various endoscopic procedures, such as the intragastric balloon and the duodenal sleeve, are available in Australia but have not yet established a clear benefit. They can be expensive and are not covered by Medicare or private health insurance. Arguably, the most significant contribution the GP can make is the recognition that the patient s obesity is a very real problem and that a solution must be sought. Although an adequate trial of non-surgical options is essential, for most there will not be sufficient weight loss and what is achieved will not be maintained for an extended period. After testing the non-surgical options, the next step to consider in those who remain obese is bariatric surgery. This article will review the bariatric surgical options, and their strengths and weaknesses, to provide a framework of evidence that enables a logical treatment approach to this major healthcare challenge. Surgical approaches have been known to achieve substantial and durable weight loss for more than half a century and yet they have not achieved a significant impact on community health. During their 60 years of evolution, the risk benefit ratio has vastly improved and the cost benefit ratio has also been shown to be favourable. It is time for a change in attitude about bariatric surgery and the data are there to justify a change. Currently, fewer than one in 200 Australians who would benefit from obesity treatment are accessing surgery each year. The benefit these people achieve through surgery is abundantly clear. We now need to consider the remaining 199 who are not currently accessing this solution whom should we help and how should we help them? Table 1 lists the surgical weight loss options in use around the world. In Australia, the gastric band is dominant, comprising about 80% of bariatric surgery, sleeve gastrectomy is increasing in popularity while the use of other procedures is negligible. Current methods in bariatric surgery Laparoscopic adjustable gastric banding banding is the first of the surgical options on table 1. The procedure is generally performed as an outpatient procedure with a 2-4-hour length of stay. It has very low level of risk and is effective and durable. It is adjustable and easily reversible. On the basis of doing what is simple and safe before doing what is more complex and risky, laparoscopic adjustable gastric banding becomes the primary bariatric procedure of choice. The other options can be considered if this procedure is contraindicated or if there is an inadequate outcome. The procedure was introduced into clinical practice in Initially there were significant gaps in the knowledge of the entire process that laparoscopic adjustable gastric banding required, including the skills in placement, optimal after-care and management of late adverse events. It was not known how the band worked or even if it would work. There were no data on optimal placement and fixation. Protocols for the after-care process, the adjustment of the band and the education of the patient about the specific requirements for eating and activity after the placement were not initially available. There has been important growth in knowledge since that time, with more than 1000 peer-reviewed papers defining the laparoscopic adjustable gastric banding process and outcomes. It is now more studied than any bariatric procedure, with better knowledge of its mechanisms and a higher-quality evidence regarding outcomes. There are several adjustable gastric bands available. The Lap-Band is the best known, most studied and most commonly used. It has about 80% of the gastric band market, followed by the Realize Band, which has about 15%. Others include the Mid-Band, the Heliogast band, the Minimizer band and the AMI Figure 2: The Lap-Band AP. The band consists of a ring of silicone with an inner balloon. The balloon is connected to an access port placed under the skin of the abdominal wall. Adding saline to or removing saline from the port changes the pressure the balloon exerts on the cardia of the stomach. Figure 3: The laparoscopic adjustable gastric band is placed over the cardia of the stomach within 1cm of the oesophago-gastric junction. Note there is no pouch of stomach above, just a small cuff of proximal cardia. band. These are in use principally in Europe. They lack adequate published data attesting to their effectiveness, are not approved for use in the US so their uptake in Australia has been modest. The discussion below will focus primarily on the data on the Lap-Band. The current version of the Lap- Band, known as the Lap-Band AP (Advanced Platform), is shown in figure 2. Laparoscopic placement of the band normally takes minutes to complete. The patient is able to go home at two or more hours after completion of the procedure. The band lies at the very top of the stomach, around the cardia and within 1cm of the oesophago-gastric junction (figure 3). The access port is placed in the subcutaneous layer of the anterior abdominal wall and is accessed by a percutaneous injection. The primary mechanism of action of the gastric band is appetite control. There are two components to this satiety and satiation. Satiety is the state of not being hungry. It is achieved in gastric banding patients by adding or removing of fluid from the system to change the degree of compression of the band on the gastric wall. When this compression is optimal, it induces a sense of satiety that remains throughout the day. Although some hunger may develop at times, there is a general reduction of appetite, interest in food and concern about not eating. Satiation is the resolution of hunger with eating. For gastric banding patients, it is induced by each bite of food as it passes across the band. When the band is optimally adjusted, each bite is squeezed across by oesophageal peristalsis, generating increased pressure on that segment of the gastric wall. This induces signalling to the satiety centres of the brain and reduces appetite. The combination of these effects cont d page Australian Doctor 5 October

3 from page 24 allows the person to eat up to three small meals per day. The mean energy intake of the banded patient is typically between 1000 and 1200kcals a day. Figure 4 shows two views of the Lap-Band AP. On the left, it contains only the base volume of 3mL of saline and on the right it is well inflated, containing 7mL of saline. The space within is occupied by the cardia of the stomach. These two spaces represent the limits within which the gastric banding is set for most patients. This ability to titrate the level of adjustment against the level of satiety is a key to the effectiveness of the band. The adjustments are performed by the doctor in follow-up consultations. Oesophageal peristalsis squeezes each bite of food through this narrowed area and thereby induces the sense of satiation (figure 5). Each squeeze generates signals to the satiety centre in the arcuate nucleus of the hypothalamus. The signalling of both satiety and satiation in the hypothalamus appears to be mediated by vagal afferent fibres in the gastric cardia. It may require several peristaltic contractions to get a single bite across the band. This could take up to one minute. Complete chewing of food and slow eating become essential parts of eating for banded patients. The gastric banding patient needs good after-care. Placement of the band is simply the first step of an ongoing process of care, including education and support, adjustments of the band and monitoring of health. It requires a partnership between the medical team and the patient to achieve an optimal outcome. If such a partnership is not possible, an alternative bariatric procedure should be considered. Figure 4: The Lap-Band AP showing the effect of addition of saline to the band. A: Without added saline beyond the base amount of 3mL. B: With added saline to a total volume of 7mL. A B Figure 5: A small bite of food being squeezed across the band, thereby compressing the vagal afferents and generating a feeling of satiety. Figure 6: Sleeve gastrectomy. Most of the stomach is discarded leaving a tube of stomach along the lesser curve. Sleeve gastrectomy The sleeve gastrectomy is shown in figure 6. It involves removal of 80-85% of the stomach by using multiple firings of a linear stapler/ cutter to create a narrow tube of the lesser curve of the stomach, with the remainder of the stomach discarded. The antrum is preserved to maintain controlled gastric emptying. A tube is placed in the lesser-curve segment during the resection to maintain an adequate lumen. The optimal size of this tube is not yet established. The procedure is nonadjustable and non-reversible. It is an inpatient procedure with a normal length of stay of 2-4 days. Sleeve gastrectomy has recently become popular because of the ease of surgery, early effectiveness and perceived lack of need for close follow-up ( sleeve and leave ). It is primarily a restrictive procedure resulting in a sense of fullness that discourages further eating. However, there are suggestions that the near-total gastrectomy modifies the hormonal response to hunger and food. It is associated with significant perioperative risks and, as the remaining gastric tube is not reinforced, it can be expected to expand, with weight gain following in due course. An additional procedure will then need to be considered. Roux en Y gastric bypass The Roux en Y gastric bypass combines a marked reduction in the size of the stomach with a narrow stoma passing directly from the gastric pouch to a Roux en Y loop of the jejunum, which diverts food from the duodenum and proximal jejunum. In a typical, current laparoscopic version (figure 7, see next page), the stomach is divided completely by multiple firings of a device that places two rows of staples and cuts the gastric wall in between. This creates a small, proximal gastric pouch with a volume of 50mL or less and a large residual stomach that is now segregated from food. A Roux loop of jejunum is formed by dividing the proximal jejunum completely at about 50cm from the duodeno jejunal flexure. The distal aspect of this point of division is taken up to form an anastomosis with the small gastric pouch. The proximal aspect is anastomosed to the more distal jejunum, 50cm or more below the gastro jejunal anastomosis. The procedure takes minutes and the patient usually stays in hospital for 2-4 days. Roux en Y gastric bypass is a complex procedure both anatomically and physiologically. There are several mechanisms of action involved in associated weight loss. First, there is early satiation after eating a small amount of food due to the small volume and slow cont d page Australian Doctor 5 October

4 from page 26 emptying of the gastric pouch. The small stoma provides a restrictive component through delayed gastric emptying. The diversion of food away from the distal stomach, duodenum and proximal jejunum reduces digestion and possibly absorption of food by this area of the gut. As most of the small bowel remains in the absorptive pathway, it is unlikely the absorption of macronutrients is affected. Therefore, the standard Roux en Y gastric bypass should not be regarded as having a malabsorptive component. Absorption of micronutrients, such as calcium, in the upper gut are unaffected. Finally, it can have an aversion effect with the symptoms of dumping syndrome (faintness, dizziness, sweating, need to lie down, cramping abdominal pains) occurring with ingestion of simple sugars, leading to reduced sweet-eating. This may be due to the diversion of food from the duodenum and proximal jejunum mediating gut hormonal effects, with increased release of glucagon-like peptide 1 (GLP-1) and gastric inhibitory polypeptide (GIP) from the distal gut. These hormones act as incretins, increasing release of insulin from pancreatic beta cells. The Roux en Y gastric bypass has been available for more than 40 years and is therefore well known. It leads to good weight loss and associated health benefits. However, the surgery is relatively complex and therefore carries significant risk. It is non-adjustable and non-reversible. Nutritional deficiencies, due to inadequacies of the postoperative diet, particularly deficiencies of iron, folate, vitamin B12 and calcium, need to be monitored and managed. Figure 7: Roux en Y gastric bypass showing a small gastric pouch, a narrow gastrojejunostomy and exclusion of foods from the duodenum and proximal jejunum. Biliopancreatic diversion/ duodenal switch The biliopancreatic diversion contains a restrictive component and a malabsorptive component. The restrictive component is a partial gastrectomy, leaving a large proximal gastric segment of between 200 and 500mL. The malabsorptive component consists of division of the small intestine, usually 250cm proximal to the ileocaecal valve. The distal side of this division is anastomosed to the gastric pouch. The proximal side of the division is anastomosed to the terminal ileum, usually at 50cm proximal to the junction with the caecum. In the duodenal switch variant of the biliopancreatic diversion (figure 8), a sleeve gastrectomy is performed, preserving the pylorus and proximal duodenum. The distal end of the transected small bowel is anastomosed to the duodenum. This Figure 8: The duodenal switch variant of biliopancreatic diversion with a sleeve gastrectomy, retention of the gastric antrum, diversion of food into the mid small gut and diversion of pancreatic and biliary secretions to the distal small gut. structure is designed to avoid dumping syndrome but any particular benefit of one variant over the other is unclear. The biliopancreatic diversion appears to achieve very good weight loss and health benefits but has failed to gain acceptance because of the severe metabolic risk, the offensive diarrhoea that accompanies fat malabsorption and the need for revision for poor outcomes. It is the most metabolically severe of the current options and therefore hasn t proven to be popular with patients or surgeons, despite favourable published outcomes. Malabsorption of amino acids can lead to hypoproteinaemia and malabsorption of micronutrients and minerals can lead to osteoporosis and anaemia. Biliopancreatic diversion has been available for 30 years and yet constitutes 1% of bariatric surgery. However, it could be considered as a second-line bariatric surgical option. outcomes What weight loss can we expect and will it last? ALL current procedures are able to generate substantial weight loss. Weight loss can be described in different ways, each of which has its advantages and drawbacks. In the bariatric surgical literature, the percentage of excess weight lost (%EWL) is the preferred method. The excess weight approximates the excess fat within the body. If we think about the person s excess weight as roughly equivalent to their excess fat, they should lose at least half of that excess fat. Some will lose all their excess weight and some will lose less than half, but overall, the typical outcome is about 50% of excess weight lost. As obesity is a chronic disease, treatments must be effective in the long term. Short-term weight-loss studies (1-3 years) are plentiful but simply suggest potential effectiveness. Medium-term studies (3-10 years) are far fewer but are more assuring of real effectiveness. Long-term studies (greater than 10 years) are very few and yet are the only ones that truly enable rational decision-making on effectiveness. Table 2 shows the weight loss, expressed as a percentage of excess weight lost, for the principal procedures. The revisional surgery Table 2: Pooled data from a systematic review with weighted mean % excess weight lost for the principal procedures with 10 or more years of follow-up Procedure No of studies Weighted mean %EWL rates are also included. Roux en Y achieves faster initial weight loss than laparoscopic adjustable gastric banding, as all the weight loss that is going to occur with Roux en Y will occur in the first year. There is weight stability for another year and then a gradual regaining of weight. However, even after 10 years a good level of weight loss is maintained and Roux en Y gastric bypass is considered to have a durable effect banding will generally reach its peak of weight loss at three years and then remains steady, as the adjustability of the band permits weight maintenance. It is notable that the weight loss following after 10 years Range of mean %EWL Roux en Y gastric bypass % Revisions range Laparoscopic adjustable % gastric banding Gastroplasty % Biliopancreatic diversion/ NR duodenal switch Note that sleeve gastrectomy is a specific form of gastroplasty for which no reports of long-term outcomes are yet published. NR = not reported; EWL = excess weight lost is identical for both procedures. I have now followed my own patients after laparoscopic adjustable gastric banding over a 15-year period. Figure 9 shows the weight loss in kilograms. Weight loss stabilised after three years, with an average weight loss of about 26kg maintained over that time. There are no long-term data on outcomes after sleeve gastrectomy and there are few medium-term (3-10 years) data. A literature review of the 36 published reports available in 2009 gave few outcomes beyond three years. There was a mean weight loss of 55% excess weight lost. This is good but no better than the laparoscopic adjustable banding or Roux en Y gastric bypass. As there is nothing to stop the tube of stomach from expanding over time, we expect there will be steady weight increase in subsequent years. Health benefits of weight loss Weight loss is among the most powerful treatments available in medicine today. It prevents, cures or alleviates several significant health problems, improves quality of life and increases life expectancy. Of particular importance are the effects on the metabolic diseases such as type 2 diabetes, metabolic syndrome, hypertension, cardiac and cerebrovascular diseases, dyslipidaemias, polycystic ovary syndrome, non-alcoholic steatohepatitis and obstructive sleep apnoea. It has a significant impact on conditions related to the mechanical effects of the excess weight, including lumbar spinal disorders, other vertebral disorders, and degenerative diseases of the hip, knee and ankle. Of all these diseases, type 2 diabetes deserves special mention. Type 2 diabetes is the paradigm of an obesity-related illness. It is increasingly common, with more than one million Australians currently receiving treatment and almost 300 more diagnosed each day. Although there are important 28 Australian Doctor 5 October

5 genetic components to type 2 diabetes, the recent escalation of the problem reflects the obesity epidemic, as 80% of all newly diagnosed patients with type 2 diabetes are overweight or obese. It is now a major cause of premature death; it costs the Australian healthcare system more than $50 billion annually and in many cases is preventable and reversible by weight loss. Obesity is the most important non-genetic determinant of diabetes and even modest weight loss can have a beneficial effect. However, non-surgical weight-loss options lack the durability for treating a chronic disease and therefore bariatric surgical options have now been comprehensively evaluated. There have been three major randomised controlled trials comparing the relative effects of surgery and optimal non-surgical care on type 2 diabetes in obese patients. We performed the first of these at the Centre for Obesity Research and Education (CORE) at Monash University. The study was published in We showed a remission rate for type 2 diabetes of 73% at two years after laparoscopic adjustable gastric banding. More recently, two studies of gastric bypass have been reported. They achieved remission rates for Roux en Y gastric bypass of 75% (Rome study)and 44% (Cleveland Clinic study) in patients who underwent Roux en Y. 2,3. The latter study also achieved a 37% remission rate after sleeve gastrectomy. These are all impressive findings, ranging from remission rates of one out of three for sleeve gastrectomy to three out of four for laparoscopic adjustable banding and Roux en Y gastric bypass. As shown by these studies, laparoscopic adjustable gastric banding was better than sleeve gastrectomy and at least equal to Roux en Y. It is the safest and most gentle option and therefore it remains our preferred primary approach to the obese patient with type 2 diabetes. GPs have the opportunity to identify obesity in their type 2 diabetes patients and to advise them Figure 9: Weight loss (in kg) for a series of the author s 2684 patients treated with the Lap-Band procedure and with followup for up to 15 years. There is an 81% follow-up rate and total of 82 patients have now reached the 15-year follow-up Weight loss (kg) regarding the importance of weight loss. If the non-surgical options fail, laparoscopic adjustable gastric banding should be discussed. Improvement in quality of life Improvement in quality of life is one of the most gratifying outcomes of bariatric surgery. To the patient, lowered self-esteem, self-confidence, employability and reduced physical capacity are among the most significant disabilities of obesity. At CORE we have used the Medical Outcomes Trust Short Form-36 (SF-36) to measure quality of life in our patients before and up to four years after laparoscopic adjustable gastric banding. The SF-36 is a reliable, broadly used instrument that has been validated in obese people. In one of our studies, 459 severely obese preoperative subjects had lower scores compared with community normal values for all eight aspects of quality of life measured, especially the physical health scores. Weight loss provided a dramatic and sustained improvement in all measures of the SF-36. Improvement was greater in those with more preoperative disability, and the extent of weight loss was not a good predictor of improved quality of life. Mean N = 2684 at zero time 0y Years of follow-up scores returned to those of community normal values within one year of banding, and remained in the normal range throughout the four years of the study. Improvement in survival after bariatric surgery The ultimate test of effectiveness of a treatment is the reduction of mortality. A comparison of the longterm mortality of bariatric surgical patients with obese controls shows improved survival. At CORE we compared the late mortality of the laparoscopic adjustable gastric banding patients with a group of obese people in Melbourne who did not have any weight loss. After adjusting for the important variables, there was a 72% survival advantage for the banded patients. Other researchers have found similar benefits after bariatric surgery. The fear of reduced life expectancy is one of the common reasons given to me by patients when asked why they seek gastric banding. These studies have confirmed that we are addressing that fear. Perioperative mortality and adverse events Perioperative mortality There is a mortality risk with any surgery and this risk was strongly N = 82 at 15 years evident for bariatric surgery before the general use of the laparoscopic approach. In the days of open gastric stapling surgery, mortality rates of 2% or more were observed. The overall mortality has decreased in recent years, particularly with the introduction of gastric banding and the widespread use of a laparoscopic surgical approach. Death from Roux en Y is now about 0.5% (one in 200). Mortality after laparoscopic adjustable gastric banding is rare and is at least times less likely than after Roux en Y gastric bypass. At the Centre for Bariatric Surgery in Melbourne, we have performed more than 7000 primary gastric banding procedures and have performed revisional banding surgery on more than 1000 of these or other patients without a single surgical mortality. The most definitive evaluation of mortality available is derived from the Longitudinal Assessment of Bariatric Surgery (LABS) study. 4 This study, sponsored by the US National Institutes of Health, involved 10 sites, carefully selected for their expertise and experience. The 30-day rate of death was monitored closely. There were 4610 patients who had Roux en Y or laparoscopic adjustable gastric banding. There were 15 deaths in the Roux en Y group, and no deaths in the laparoscopic adjustable gastric banding group. Early adverse events The LABS study served also to inform on early adverse events for the two major bariatric procedures. Not surprisingly, the incidence of adverse events mirrored the perioperative mortality rates. Significant adverse events occurred in 177 of the Roux en Y group (5.2%) and 12 in the laparoscopic adjustable gastric banding group (1.0%), a difference that was highly significant. The complication rate for sleeve gastrectomy is at least comparable with Roux en Y. Postoperative leaks from the staple line after sleeve gastrectomy are relatively frequent (2-3%) and appear to be independent of surgeon experience. In contrast to leaks after Roux en Y, they tend to be slow to close, thereby generating long stays in intensive care, and high anxiety and costs. Late adverse events There is, and always will be, a maintenance requirement with any bariatric procedure. The procedure needs to remain effective over decades rather than years. It is inevitable that there will be the need to correct or repair. While reversal of a bariatric procedure should be counted as failure, revision to correct or repair should not. It is a part of the process of care. All bariatric procedures have been shown to have a maintenance requirement. The revisional surgery rate of the studies shown in table 2 had a median of 24% and it was not different between procedures. Due to efforts to minimise the revisional surgery rates after any bariatric procedures and on our current figures, a patient today would have about a 10% chance of requiring corrective surgery in the subsequent 10 years. Careful attention to the central tenet of the gastric banding aftercare process, eat a small amount of good food slowly serves to minimise the risk of needing revision. Decision-making regarding surgical options a personal view HOW should obese patients be advised? The advice we give to our patients will reflect the resources available in the healthcare setting. The following is my personal view on the basis of extensive experience with Roux en Y gastric bypass and the gastroplasty stapling procedures, and with laparoscopic adjustable gastric banding, many years of research into obesity, weight loss and bariatric surgery, and current clinical activity within the Australian and US healthcare systems. banding is the first option We use this type of banding as our initial option in almost all patients. When applied properly, it has been proven to be effective, safe and comparatively gentle. Adjustability permits maintenance of effect as long as the band is in place. Reversibility permits access to other therapeutic options that may be developed in the future. There is a need for long-term skilled after-care and there is a maintenance requirement, with about 10% of patients needing some revisional procedure in the first 10 years. However, we know that removal and replacement of the band for proximal gastric enlargement is effective and the revised patients have a weight loss on a par with the total group. Roux en Y is not now favoured This procedure has been known to be the most effective of the stomach stapling procedures since the 1980s and was my personal preference before availability of laparoscopic adjustable gastric banding. It achieves good weight loss, particularly in the short term. However, it carries significant risk, is non-adjustable and essentially not reversible. Its effectiveness tends to fade with time. In the first 12 months after Roux en Y, an excellent weight loss of 60-70% excess weight lost can be expected. This effect is maintained for months and then begins to gently fade to an average of 55% excess weight lost for those still attending follow-up at five years. It is now commonly but not universally performed laparoscopically. The mortality of 0.44% seen in the LABS study involved expert bariatric surgeons. The community mortality rate is likely to be higher. I cannot justify the increased risk and the lack of adjustability or reversibility when I can achieve as good a weight loss and health effect with laparoscopic adjustable gastric banding. Biliopancreatic diversion has a small second line role This is the most metabolically severe of the current options and therefore hasn t proven to be popular with patients or surgeons in spite of favourable published outcomes. Biliopancreatic diversion has been available for 30 years and yet remains a very minor part of bariatric surgery, constituting less than 2% of bariatric surgery. However, it does generate good weight loss and should be considered as a secondline bariatric surgical option. Sleeve gastrectomy is not favoured The sleeve is the first element of the duodenal switch procedure, a variant of the biliopancreatic diversion. It has lately become popular as a single procedure because of the ease of surgery, early effectiveness and perceived lack of need for close follow-up. There is a general expectation that the sleeve will fail to maintain acceptable levels of weight loss in the medium term as the residual stomach inevitably expands. Continuation to completion of the duodenal switch or another bariatric procedure would then need to be considered. cont d next page References 1. Dixon JB, et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: A randomized controlled trial. Journal of the American Medical Association 2008; 299: Mingrone G, et al. versus conventional medical therapy for type 2 diabetes. New England Journal of Medicine 2012; 366: Schauer PR, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. New England Journal of Medicine 2012; 366: Flum DR, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. New England Journal of Medicine 2009; 361: O Brien PE, et al. Laparoscopic adjustable gastric banding in severely obese adolescents: A randomized trial. Journal of the American Medical Association 2010; 303: October 2012 Australian Doctor 29

6 Selection criteria for gastric banding BMI THERE is level 1 evidence supporting a better outcome for using laparoscopic adjustable gastric banding in the mild-to-moderately obese (BMI 30-35) when compared with lifestyle therapy. This approach is cost-effective. When the two treatment paths are modelled over time, the banding approach is dominant; that is, it provides increased qualityadjusted life years at a lower cost than non-surgical therapies. Any person who is obese (BMI >30), with the medical, physical or psychosocial consequences of obesity and who has diligently sought a solution through a range of lifestyle options over time could be considered for laparoscopic adjustable gastric banding. This recommendation is supported by the US Food and Drug Administration, which approves use of the Lap-Band for patients in the BMI range. Because the stapling group of surgical options lack level 1 evidence, carry greater risk, and are not controllable or reversible, the existing cut-off of BMI >40, or BMI >35 with major comorbidities, should remain for these procedures. Age In 2010, CORE published the results of a randomised control trial showing the clear benefit for laparoscopic adjustable gastric banding for the obese teenager and we offer this option to severely obese teens from age 14 years. 5 We could not countenance offering an irreversible procedure to teens when a safe, effective and reversible option is available. We are generally reluctant to offer bariatric surgery above the age of 65 but do at least consider people between age 65 and 70 who do not have chronic cardiovascular or pulmonary disease. Contraindications banding is unsuitable for those patients who are unable to engage in the partnership needed for an optimal outcome. Other contraindications include portal hypertension and remote living, which could preclude adequate followup. Another bariatric procedure not requiring patient co-operation or follow-up, such as sleeve gastrectomy, could be considered in this situation. Summary OBESITY is the accumulation of fat to the point where health is impaired. It is one of our worst pathogens, being common and generating numerous serious diseases. Substantial and durable weight loss is one of our powerful therapies. The GP should recognise the presence of obesity and advise of its potential pathogenicity. Initial therapy should involve lifestyle changes of eating less and being more active. Very-lowcalorie diets can help, and effective drug therapy may become available in the future. All current bariatric surgical procedures can achieve substantial and durable weight loss and should be discussed if lifestyle changes do not solve the problem. Gastric banding is a safe, gentle, adjustable and reversible day-surgery procedure. Gastric banding should be the first option to be considered. Gastric bypass and sleeve gastrectomy are additional options if banding is not available or contraindicated. Statement of competing interests The Centre for Obesity Research and Education (CORE) at Monash University receives a grant from Allergan Inc for research support, however Allergan has no control of the protocol, analysis and reporting of any studies. CORE also receives a grant from Applied Medical towards educational programs. Professor O Brien has written a patient information book,, The Lap-Band Solution: A Partnership for Weight Loss, which is given to patients without charge but some are sold to surgeons and others for which he receives a royalty. He is employed as the national medical director for the American Institute of Gastric Banding, a centre that treats obesity predominantly by gastric banding. How to Treat Quiz 5 October 2012 Instructions Complete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. We no longer accept quizzes by post or fax. The mark required to obtain points is 80%. Please note that some questions have more than one correct answer. Online ONLY for immediate feedback 1. Which THREE statements regarding obesity are correct? a) One in 20 Australian adolescents is obese b) The Australian Bureau of Statistics estimates that 25% of all Australian adults are obese c) Obesity competes with smoking as the most common cause of premature death d) is currently under-utilised in achieving substantial and durable weight loss in overweight and obese patients 2. Which TWO statements are correct? a) Current weight-loss programs involving reduced energy intake, behavioural modification, and increased exercise and activity achieve significant, long-lasting weight loss b) A dietary program must restrict energy intake to less than 6000kJ (1500kcals) a day and increased exercise and daily activity is essential to achieve weight loss c) There are currently several successful pharmacotherapies available for treating obesity d) Endoscopic procedures, such as the intragastric balloon and the duodenal sleeve, are available in Australia but have not yet established a clear benefit 3. Which TWO statements are correct? a) Fewer than one in 200 Australians who would benefit from treatment of their obesity are accessing the surgical approach each year b) Sleeve gastrectomy accounts for 80% of bariatric surgery in Australia c) There are a number of adjustable gastric bands available and the Lap-Band is the best known, most studied and most commonly used d) The laparoscopic adjustable gastric banding procedure always requires a hospital stay of several days duration 4. Which THREE statements regarding the gastric band and appetite are correct? a) The primary mechanism of action of the gastric band is appetite control b) Satiety is the state of not being hungry c) Satiation is the resolution of hunger with eating. d) The mean energy intake of the banded patient is about 2000kcals via three large meals a day 5. Which TWO statements regarding the gastric band are correct? a) The effectiveness of the gastric band is due to the ability to titrate the level of adjustment of the band against the level of satiety b) The gastric band can be adjusted by the patient at will c) The signalling of both satiety and satiation of the hypothalamus appears to be mediated by vagal afferent fibres in the gastric cardia d) One advantage of the gastric band is that patients require very little follow-up once the band is in place 6. Which THREE statements regarding sleeve gastrectomy are correct? a) Sleeve gastrectomy involves removal of 80-85% of the stomach to create a narrow tube of the lesser curve of the stomach, and the antrum is preserved to maintain controlled gastric emptying b) Similar to the gastric band, sleeve gastrectomy is adjustable and reversible c) Sleeve gastrectomy is primarily a restrictive procedure that results in a sense of fullness that discourages further eating d) The remaining gastric tube in sleeve gastrectomy is not reinforced and, despite early effectiveness, it can be expected to expand, with weight gain following in due course 7. Which THREE statements regarding Roux en Y gastric bypass are correct? a) The Roux en Y gastric bypass combines a marked reduction in the size of stomach available for food with a narrow stoma passing from the gastric pouch to a Roux en Y loop of the jejunum, diverting food from the duodenum and proximal jejunum b) Roux en Y gastric bypass results in early satiation after eating a small amount of food due to the small volume and slow emptying of the gastric pouch c) The standard Roux en Y gastric bypass should be regarded as having a significant malabsorptive component d) Nutritional deficiencies, particularly in iron, folate, vitamin B12 and calcium, need to be monitored and managed in patients with Roux en Y gastric bypass 8. Which TWO statements are correct? a) The percentage of excess weight lost is the preferred method of evaluating bariatric procedures b) Repair and repositioning of procedures and devices are never required after bariatric surgery c) banding will generally reach its peak of weight loss at three years and then remains steady as the adjustability of the band permits weight maintenance d) banding results in significantly greater weight loss at 10 years than Roux en Y gastric bypass 9. Which THREE statements are correct? a) Forty-five per cent of all newly diagnosed cases of type 2 diabetes are in patients who are overweight or obese b) Studies have shown that weight loss from bariatric surgery results in type 2 diabetes remission of one in three for sleeve gastrectomy and three in four for laparoscopic adjustable gastric banding and Roux en Y gastric bypass c) The overall perioperative mortality of bariatric surgery has decreased in recent years, particularly with the introduction of the laparoscopic adjustable gastric banding and the widespread use of a laparoscopic surgical approach d) Postoperative leaks from the staple line after sleeve gastrectomy are relatively frequent (2-3%) 10. Which TWO statements regarding selection criteria for bariatric surgery are correct? a) The stapling group of surgical options are recommended for patients with a BMI of b) There is no clear benefit for laparoscopic adjustable gastric banding for the obese teenager c) banding is unsuitable for those patients who are unable to engage in the partnership needed for an optimal outcome d) banding should be considered as the primary approach to obesity that is resistant to lifestyle changes CPD QUIZ UPDATE The RACGP requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the triennium. You can complete this online along with the quiz at Because this is a requirement, we are no longer able to accept the quiz by post or fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online. how to treat Editor: Dr Barbara Tink barbara.tink@reedbusiness.com.au Next week A patient presenting with a red eye is a common scenario for GPs. The next How to Treat gives an overview of the many conditions that can cause red eye, differentiating between benign conditions and the more serious conditions that require immediate referral. The authors are Dr Weng Sehu, clinical lecturer, department of ophthalmology, University of Sydney, ophthalmic surgeon, Sydney Eye Hospital and in private practice, Sydney CBD, Eastwood and Epping, NSW; and Dr Sophia Zagora, senior ophthalmology registrar, Sydney Eye Hospital, Sydney, NSW. 30 Australian Doctor 5 October