Michael Talbot. The St George Hospital, Sydney SLEEVE OR BYPASS FOR MEGA OBESE
Disclosures Educational grants by Coviden, Applied Medical, Endogastric Solutions and Allergan in the last 3 years
Social isolation, depression Sleep apnea AF, Pulmonary hypertension DVT BMI 70 Recurrent cellulitis & ulceration
Evidence is thin on the ground Patients with BMI > 70 are uncommon Patients with extreme obesity related disease are not, these are the patients cause concern Data are available for patients with BMI > 50 The data are very messy, failing to account for the population treated, medical system/insurance, and other factors
Why the Interest? More severe obesity is a marker for Increased co morbidies Increased operative risk, and technical challenges Physiological resistance to weight loss Psychological/behavioural resistance to weight loss
How to treat these patients Refuse surgery LAGB Bypass/Sleeve Malabsorptive procedures, D RYGBP, Scopinaro, BPD The published literature suggests equipoise, with a trade off of increased risk with increased weight loss with larger procedures
Conflicting goals Balancing the risk of treatment vs the risk of failure Perioperative risk Weight loss (Reinhold classification) Co mordidity resolution Late failure Outcomes worsened and risks increased in men and as co mordidities, age, and weight increase
No treatment/medical treatment The burden of responsibility can be passed onto the patient. Surgical delay is a useful therapeutic tool. VLCD or Balloon Feasibility of a Supervised Inpatient Low Calorie Diet Program for Massive Weight Loss Prior to RYGB in Superobese Patients. OBES SURG (2010) 20:173 180
LAGB Obviously safe, issues relate to weight loss variability and re operation rate Touli et al. Long term Efficacy of a Lowpressure Adjustable Gastric Band in the Treatment of Morbid Obesity Annals of Surgery Volume 247, Number 5, May 2008
LAGB G.A.Fielding. Laparoscopic adjustable gastric banding for massive superobesity (>60 body mass index kg/m2). Surg Endosc (2003) 17: 1541 1545
LAGB Angrisani et al.obesity Surgery, 12, 846 850. Results of the Italian Multicenter Study on 239 Super obese Patients Treated by Adjustable Gastric Banding
LAGB vs RYGBP superobese Mognol et al. Obesity Surgery, 15, 76 81. Laparoscopic Gastric Bypass versus Laparoscopic Adjustable Gastric Banding in the Super obese: A Comparative Study of 290 Patients 70% of LAGB failed to achieve xs weightloss over 50%
Nguyen et al. A Prospective Randomized Trial of Laparoscopic Gastric Bypass Versus Laparoscopic Adjustable Gastric Banding for the Treatment of Morbid Obesity. Annals of Surgery Volume 250, Number 4, October 2009
RYGBP Suter et al. Results of Roux en Y Gastric Bypass in Morbidly Obese vs Superobese Patients. Arch Surg. 2009;144(4):312 318 Similar Body Weight Loss, Correction of Comorbidities, and Improvement of Quality of Life
Cristou et al.annals of Surgery Volume 244, Number 5, November 2006 Weight Gain After Short and Long Limb Gastric Bypass in Patients Followed for Longer Than 10 Years
Dresel et al. The American Journal of Surgery 187 (2004) 230 232. Laparoscopic Roux en Y gastric bypass in morbidly obese and super morbidly obese patients. Raftopoulos et al. Outcomes of Roux en Y Gastric Bypass Stratified by a Body Mass Index of 70 kg/m2: A Comparative Analysis of 825 Procedures. J GASTROINTEST SURG 2005;9:44 53 Complications no more prevalent but more likely to be converted to mortality.
Sleeve Gastrectomy pretender to the throne Short and Mid term Outcomes of Sleeve Gastrectomy for Morbid Obesity: The Experience of the Spanish National Registry. OBES SURG (2009) 19:1203 1210
St George Data Obesity Surgery. 2009 vol. 19 (7) pp. 827 32 and 2008 vol. 18 (12) pp. 1575 80 Extra 20% xs weight loss converting sleeve to RYGBP
Results for Diabetes Rx Change in medication requirements 100% 90% 80% 70% Change in medication requirements for diabetes by operation type 60% 50% 40% 30% off medication improved unchanged 20% 10% 0% gastric band sleeve gastroplasty gastric bypass overall p < 0.001
Intestinal Bypass DRYGBP, BPD, Scopinaro Sovik et al. Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity. British Journal of Surgery 2010; 97: 160 166
Factors involved in decisions St George Surgery since 2003 2, now 4 surgeons Started with open RYGBP and LAGB, lap RYGBP and sleeve since 2004 Unit caseload > 2500 cases Infra structure 270 bed private hospital with 24 hr ICU/radiology/CCU/residents/registrars, colocated with large Tertiary referral teaching hospital
Decision Operative risk vs Failure For most BMI 50 patients it probably doesn't matter, patients will be offered whichever procedure they prefer Over BMI 60, and/or with increasing social, economic, cultural, behavioural and medical risks the patients will be offered sleeve gastrectomy after medical optimisation