ESPEN Congress Geneva 2014 LLL LIVE COURSE: NUTRITION IN OBESITY

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1 ESPEN Congress Geneva 2014 LLL LIVE COURSE: NUTRITION IN OBESITY Pre-operative medical assessment, post-operative follow-up and clinical outcome in bariatric surgery patients A. Thorell (SE)

2 Nutrition in obesity Pre-operative medical assessment, postoperative follow-up and clinical outcome in bariatric surgical patients Anders Thorell MD, PhD Karolinska Institutet & Department of Surgery, Ersta Hospital Stockholm, Sweden

3 Ethical dilemmas Bioethical principles Application of bioethical principles to Nutrition at the end-of-life The decision-making process

4 Outline Treatment modalities Indications for bariatric surgery Bariatric surgical procedures Preoperative assessement Postop follow-up Clinical outcome

5 Obesity - Treatment modalities Diet regimens Behavioural therapy Physical activity Pharmacological Surgical (Bariatric surgery)

6 Bariatric surgery- indications BMI > 40 kg/m 2 or BMI > 35 kg/m 2 with comorbidity Earlier serious weight-reducing attempts No major eating disorders BED (Binge eating disorder) AN (Anorexia nervosa) Well informed Well motivated

7 Bariatric surgical procedures Restrictive Vertical banded gastroplasty Adjustable gastric banding Sleeve gastrectomy Gastroplication Malabsorptive Biliopancreatic diversion Biliopancreatic diversion with duodenal switch Combined Roux-en-Y gastric bypass

8 Vertical banded gastroplasty

9 Adjustable Gastric Banding

10 Sleeve resection

11 Gastroplication 11

12 Gastroplication 12

13 Biliopancreatic diversion

14 Biliopancreatic diversion with duodenal switch

15 Roux-en-Y Gastric bypass

16 Bariatric procedures trends Worldwide: Europe: % procedures Gastric Band Gastric Bypass Sleeve Gastrectomy BPD/DS Mini GB Buchwald & Oien, Obes Surg 2013

17 Preoperative assessment Aim to ensure that: Comorbidities are identified and optimized Patients are well informed regarding: Expected outcome/risks Importance of adherence to postop regimens Well motivated and willing

18 Preoperative assessment Multidisciplinary team: Bariatric surgeon Internist Anaesthesist Dietician Specialist nurse Psychologist/Psychiatrist

19 Preoperative assessment General Identify risk factors that increase risk: Cariovascular Iscaemic heart disease Thromboembolic events Unregulated hypertension Metabolic disease (diabetes) Previous surgery (adhesions)

20 Preoperative assessment Procedure specific: RYGB Inflammatory Bowel Disease Premalignant gastric conditions H.Pylori Sleeve gastrectomy Gastroesophageal reflux disease

21 Early Postoperative Follow-up - Complications Postoperative complications Late Anastomotic leak Bleeding Infections Thromboembolic events Complications Internal herniation Stomal ulcers Chronic pain Nutitional deficiencies

22 Early complications (< 1 week) Symptoms Abdominal pain Tachycardia Fever Nausea/vomiting Respiratory distress Actions Blood sampling Upper endoscopy Radiology Immediate surgical intervention

23 Long term follow up 6 weeks, 6 months, annually Athropometrics Blood sampling Prescription of supplementation: Multivitamin Cobolamine (Vitamin B12) Calcium Citrate Vitamin D Iron (Menstruating women) Councelling Dietary Lifestyle

24 Long term follow up Procedure specific Band Adjustment (AGB) VBG, Sleeve: only multivitamin supplementation Malabsorptive: More extensive laboratory checks Outcome dependent on adherence to follow-up!

25 Outcome after bariatric surgery Weight (SOS) Sjöström L et al. NEJM 2007

26 Outcome after bariatric surgery Diabetes incidence (SOS) Odds ratio: % CI: N control N surgery Sjöström L et al NEJM 2004;351:

27 Outcome after bariatric surgery Diabetes remission (SOS) Sjöström L et al NEJM 2004;351:

28 Outcome after bariatric surgery HbA1c (Randomized) Schauer et al NEJM 2014

29 Outcome after bariatric surgery Cardiovascular disease (MI) 8 Cumulative incidence, % Individuals with MI, n Control 87 Surgery % HR = % CI: to P= Years of follow up Sjöström et al NEJM 2006 Schauer et al NEJM 2014

30 Outcome after bariatric surgery - Mortality (SOS) % 6 4 HR = % CI: to P= Years of follow up Sjöström L et al NEJM 2004;351:

31 Outcome after bariatric surgery - Kidney function HR = % CI: to P= Years of follow up Iaconelli et al. Diabetes Care 2011

32 Summary Volumes of bariatric surgery increasing Effects on: Weight Co-morbidities Quality of life Mortality Invasive procedures (risks) Pre- and postop assessment crucial Life-long follow up mandatory

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