all about Bariatric Surgery

all about Bariatric Surgery

What is Bariatric Surgery? Obesity Definitions Bariatric surgery is performed with the intention of inducing weight loss. It encompasses a range of medical operations which are very different from cosmetic operations like liposuction and abdominoplasties. Body mass index (BMI) is a medical calculation used by doctors as a guide to determine a person s weight in relation to size and this is used as a measure of a person s health risk. BMI is calculated by dividing weight (kg) by height (metres squared): BMI = kg/m 2. Classification BMI (kg/m 2 ) Risk of co-morbidities Introduction Surgery is increasingly being recognised as the only consistently effective treatment for severe obesity. However, long term weight loss involves long term lifestyle changes and varying degrees of risk. Please read this booklet prior to making a decision for surgery, as there is no one operation which suits all patients. Equipping yourself with knowledge before the surgery will be the best preparation before embarking on a journey to better health. Underweight <18.5 Low (but possibly increased risk of other clinical problems Normal range 18.5-24.9 Average Overweight 25.0 Pre-obese 25.0-29.9 Increased Obese I 30.0-34.9 Moderate Obese II 35.0-39.9 Severe Obese III 40.0 Very severe Waist circumference has also been used as an indicator of the risk of health problems. Research has shown that Asian males with a waist circumference of >85cm and females >80cm are at a higher risk. 2 3

Worldwide Demographics Problems Associated with Obesity Obesity is a worldwide epidemic weight registries have shown that the prevalence of overweight (BMI>25) individuals in USA and Australia are 66.3% and 49% respectively, and that of obese (BMI>30) individuals being 32.2% and 16.4%. Obesity is directly associated with a wide variety of medical and social complications. It is also associated with a higher risk of death compared to a person of a lower BMI. These complications are directly proportional to the level of obesity. Local Demographics Medical Conditions Locally, the prevalence of obesity has been steadily rising through the years, being 6.9% in 2004, compared to 5.1% in 1992. There also seems to be a racial disposition of obesity, as illustrated in the following chart from the 2004 National Health Survey. Crude prevalence (%) of obesity among Singapore residents aged 18-69 years, by gender and ethnic group, 2004 % 30 1. Diabetes 2. Hypertension 3. High cholesterol 4. Coronary artery disease 5. Gallbladder disease 6. Severe pancreatitis 7. Liver cirrhosis 8. Gastroesophageal reflux disease 9. Menstrual irregularities 10. Infertility 11. Degenerative arthritis / joint pain 12. Venous stasis ulcers / lymphoedema 13. Intertrigo and other skin infections 14. Sleep apnoea, snoring 15. Increased risk of cancer 16. Increased risk with any surgery 17. Hernia 18. Accident proneness 19. Pseudotumour cerebri 25 20 15 10 5 0 16.9 8.1 4.5 Males 21.4 18.8 19.1 13.4 3.9 4.2 Females Total Chinese Malay Indian Social Conditions 1. Clothing limitations 2. Limitation in performing activities of daily living, poor hygiene and sanitation 3. Limited access to chairs, seats and passage ways 4. Limitation in walking, climbing stairs, public transport 5. Social withdrawal 6. Sexual limitations 4 5

Economic Conditions 1. Cost of dieting 2. Cost of treating various medical conditions due to obesity 3. Lack of insurance coverage or increased premiums 4. Cost of special clothing and devices for activities of daily living 5. High rate of school drop out 6. Difficulty obtaining or holding onto good jobs 7. Cost of extra food consumed Psychiatric Conditions 1. Depression 2. Neurotic disorders 3. Eating discorders Reduction of Mortality Weight loss through surgery has been shown to increase life expectancy. 14 Cumulative Mortality (%) 12 Control 10 8 Surgery 6 4 P=0.04 2 0 0 2 4 6 8 10 12 14 16 Years Number at risk Surgery 2010 2001 1987 1821 1590 1260 760 422 169 Control 2037 2027 2016 1842 1455 1174 749 422 156 Unadjusted Cumulative Mortality. The hazard ratio for subjects who underwent bariatric surgery, as compared with control subjects, was 0.76 (95% confidence interval, 0.59 to 0.99; P=0.04), with 129 deaths in the control group and 101 in the surgery group. 6 7

Management Overview Multi-disciplinary Approach The management of obesity is tailored to the BMI of the patient. Medical and conservative measures are effective for those with a lower BMI, bearing the lowest risks of complications. However, surgery is the only treatment that has been able to reliably allow the morbidly obese (BMI>32) to lose enough weight to treat their medical problems. Dietary compliance, regular exercise and behaviour modification are still essential postoperative strategies to maintaining a healthy weight loss following surgery. Cosmetic and reconstructive procedures such as liposuction and abdominoplasties (tummy tuck) are not weight loss operations and have no effect on long term weight. Therefore, they are not included in the list of medical operations for weight loss. In Changi General Hospital, we have a team of medical specialists and allied health care professionals to help you achieve your weight loss goals. The team includes: 1. Bariatric surgeon 2. Endocrinologist 3. Sports physicians 4. Respiratory physicians 5. Dieticians 6. Clinical psychologists 7. Sports physiotherapists Indications for Surgery Medical and Conservative Management Non-surgical means of weight loss include the following modalities: 1. Diet 2. Exercise therapy 3. Behaviour modification 4. Medication BMI is used as criteria for those wishing to have bariatric surgery. 1. BMI >37 2. BMI >32 with obesity-related problems These modes of treatment are all important in maintaining a healthy weight, either as part of a surgical weight loss programme, or on itself for the management of overweight. 8 9

Types of Surgery There is no one operation which will suit all, as all treatment will be tailored to the needs, expectations and health of the individual. It is important to consider your own weight loss goals, health problems and expectations before deciding which operation is best for you. Laparoscopic gastric banding Laparoscopic sleeve gastrectomy The sleeve gastrectomy is a relatively new procedure, where the stomach is stapled along the outer edge, leaving a small remnant. The stomach is converted into a tube, which is smaller than before, and allows small meal portions. New stomach pouch (Gastric sleeve) Adjustable Band Port Patients who undergo this operation can eat a wider variety of food choices post-operatively compared to the other operations. The other advantage is that it can also be converted at the later stage into a gastric bypass for patients who require further weight loss. It is also good for patients who want to avoid the risk of a device failure or vomiting which comes with a gastric band. Stomach removed The gastric band is a procedure where a restrictive band is placed at the upper end of the stomach which allows people to feel satisfied after taking a small amount of food. The band can also be adjusted such that it takes longer for the food to reach the rest of the stomach, slowing down its journey and eating less than what others can do at the same amount of time. Gastric banding offers the lowest risk of mortality (risk of death) as a result of surgery, being 1 in 1000 to 5000 patients. However, it requires effort to be effective, and has a significant rate of band erosion and slippage which requires repeat surgery. It has been estimated that up to 20% of bands are removed post-operatively. 5-year excess weight loss ranges between 30-50% in most long term studies. The risks of operation, however, are higher than that of a band, having a risk of a leak and bleeding. This might mean a complicated repeat operation, resulting in an overall 0.2% mortality risk. Long term risk of a tube narrowing is very low, but this can be managed with non-invasive methods. Being a relatively newer operation, 5-year data is currently lacking, although studies on 4-year results report an average of 64.6% excess weight loss. 10 11

Benefits of Laparoscopic Surgery Bypassed segment Laparoscopic gastric bypass The gastric bypass is the standard which all other bariatric operations have been judged against. It has been the most reliable bariatric operations in the USA. In this operation, the stomach is reduced to a small tube which in turn is rewired to a segment of small intestine. The smaller stomach allows small meals to be taken, similarly to a sleeve gastrectomy. The rewiring makes it unpleasant to consume food of high sugar content, resulting in abdominal bloatedness and faintness. The result of the rewiring has also been found to be beneficial in helping patients with diabetes decrease their reliance on medication. 5-year excess weight loss ranges between 50-70%. Being a more complicated procedure, the risks are higher including leakage, bleeding and intestinal obstruction. The risk of having a repeat operation within 30 days of a gastric bypass has been estimated to be 5.4%. There are also long term risks of malnutrition, intestinal obstruction and ulceration. These 3 operations are all done via laparoscopic (key-hole) surgery, where the access to the abdominal cavity is through small incisions on the abdominal wall. It offers smaller scars, less pain, quicker recovery compared to the conventional operation. Choosing an Operation 5mm for liver retractor 10-12mm Camera The incision location, number of incisions and the incision size may vary from surgeon to surgeon. It is important to understand that there is no operation which will lead to weight loss without a sensible diet and exercise. Choosing an operation will depend on your needs, your medical condition and your lifestyle. 12 13

Overview Slide Pre-operative Care Gastric Band Gastric Bypass Gastric Sleeve Meal Size Entrée Entrée Entrée Quality of Eating Often no bread, rice, fibrous fruits or chicken Dumping with fats and sweets Normal Supplementation Multivitamins Monitor B12, iron and calcium Multivitamins, B12, iron and calcium Multivitamins Monitor B12, iron and calcium Rate of Weight Loss 0.5-1kg/week 1-2kg/week 1-2kg/week Mean EWL @ 5yrs (excessive caloric intake WILL defeat 30-50% 45% (4yr RCT vs LGB) 50-70% 68% (4yr RCT vs LAGB) 64.6% (4yr) 3yr RCT vs LAGB: 66% vs 48% all procedures) Failure (<50% EWL) 1 in 4 1 in 10 1 in 10 (11.5% n=3/26 @5yr) Resolution- DM HPT OSA Dyslipidemia 47.9% 43.2% 95.0% 58.9% 83.7% 67.5% 80.4% 96.9% 66% 88% 87% 30-day Mortality 0.1% 0.5% 0.2% Hospital Stay 1-2 days 4-5 days 4-5 days Time Off Work 1 week 2 weeks 2 weeks Potential Problems Our Recommendation Slow weight loss, requires the most effort Slippage, erosion, infection Port problems, device malfunction Reoperation rate 25-50% at 5 years Best for patients who enjoy participating in an exercise program and are more disciplined in following dietary restrictions. Leak, stricture, ulcers, anaemia Vitamin/mineral defeciences Intestinal obstruction Best for insulindependent type II diabetic patients and those with reflux problems. Nausea, vomiting, heartburn Stricture, leak Excellent for lower BMI patients, or as a firststage for high risk or very heavy patients. Patients wishing to undergo bariatric surgery will be required to undergo endoscopy of the stomach (gastroscopy) to exclude any incidental gastric problems. There will be reviews by the Anaesthetist and other members of the bariatric team, if necessary. Patients will also be required to undergo a very low caloric diet (VLCD) 2 weeks prior to operation, where meals are entirely replaced by liquid beverages. The purpose of this is to decrease the size of the liver which can potentially hamper the view during the operation. Post-operative Care The operations are all performed under general anaesthesia, with only the heaviest patient requiring post-operative ICU care. Fluids generally start 1-2 days after surgery, and maintained until 2 weeks where a soft diet is started. Normal food is normally allowed starting from 4 weeks after surgery. The average length of stay is 1 day after gastric banding and 5 days after a sleeve gastrectomy or gastric bypass. Post-operative Follow-up After discharge, the first follow-up is normally at 2 weeks after with the surgeon and dietician. A visit to the sports physician is recommended at 4 weeks after surgery. 14 15

Ask-a-CGH Nurse Internet Service Changi General Hospital has an Ask-a-CGH Nurse Service on our Internet website. This service is an additional avenue for you to ask questions about health-related concerns. The service is provided by our team of experienced nurses, in consultation with our medical specialists and paramedical staff. This service is not intended to substitute medical advice or consultation. To use this service, go to our website at http://www.cgh.com.sg and click Ask-a-CGH Nurse to submit your question. You will hear from us within three working days. Interactive Patient Guide www.cgh.com.sg/ipg CGH is pleased to introduce the Interactive Patient Guide (IPG) Singapore s first online interactive health education system. Developed by our team of clinical specialists, IPG provides an exciting multimedia alternative to health-related information. IPG features a list of common medical conditions, treatments, procedures, post procedures and aftercare through videos and printable text. The video clips allow you to see exactly how a procedure is carried out or details of a health condition. For greater convenience, print-friendly versions are also available so that you can print and read at your own pace. With IPG on the Internet, you can explore it anytime you want, in the comfort of your own home and even share it with your family and friends. Log on today! Interactive Patient Guide www.cgh.com.sg/ipg Organisation Accredited by Joint Commission International 11/2010 16