Bariatric surgery

Sheila MacNaughton, Team Lead Dietitian ( Surgery)Glasgow and Clyde Weight Management ServiceNovember 2013- Weight Management Training

Outline Types of Bariatric surgery Evidence Clinical Guidelines Current and Future NHS GGC Surgery criteria

and selection of candidates Gastric banding- how does it work? Keys to success for gastric banding Band Adjustments Case studies Conclusions

Types of Bariatric Surgery

Adjustable Gastric Band (LAP-BAND) Sleeve Gastrectomy Gastric Bypass Endobarrier

Evidence Swedish Obese Subjects - Mortality: up to 40% lower

risk over 10years(Sjöström et al.,2007)

Diabetes: >70% remission after 2 years (in recently diagnosed)

(Sjöström et al.,2004) (Dixon et al., 2008)

Improvement in HR-QoL

Other benefits but harder to measure e.g. mobility, blood pressure, lipids

NICE Obesity Guidelines 2006 BMI >40kg/m2 or BMI >35kg/m2 with co-morbidities

that could be improved with weight loss

All appropriate non surgical measures have failed to achieve clinically significant weight loss

Intensive management in specialist obesity service

Commit to the need for long term follow up

Consider first line for BMI >50kg/m2

SIGN Obesity Guidelines 2010 BMI ≥35kg/m2, bariatric surgery should be considered

on a individual case basis following assessment of risk/benefit and the patient fulfilling the following criteria:

• presence of one or more severe co-morbidities which are expected to improve significantly with weight reduction (e.g severe mobility problems, arthritis, type 2 diabetes)

• evidence of completion of a structured weight management program involving diet, lifestyle, psychological and drug interventions, not resulting in significant and sustained improvement in the co-morbidities

SIGN Obesity Guidelines 2010

should be included as part of an overall clinical pathway for adult weight management

Part of a programme of care delivered by multidisciplinary team including Surgeons, Dietitians, Psychologists, Nurses, Physicians

Specialist psychological/ psychiatric opinion should be sought as to which patients require assessment/treatment prior to and following surgery

•Completion of GCWMS structured program

•18- 60 years of age

•BMI<60 and without any condition deemed as a clinical risk by surgeon

•who fail to lose 5kg.

• Must not gain weight (>5kg)

•40 procedures a year

•Only Gastric bands

Present - Developed in conjunction with NHSGGC surgeons

• Completion of GCWMS structured program

•< 45 years of age

• BMI of 35 - 40

•Diagnosed Diabetic < 5 Years

•HbA1c < 9%

•> 5kg weight loss

•108 procedures by 2014

•2 types - Gastric band and Sleeve in NHSGGC

New - National Planning Forum Guidance Developed in conjunction with Health Boards across Scotland (Accepted 2nd June 2012 NHSGGC )

Bariatric Surgery Criteria

Criteria for Bariatric Surgery?

Criteria varies throughout the UK Variation through NHS boards in Scotland SCOTS- Severe & Complex Obesity Treatment

Service, multidisciplinary group of clinicians. Ensure the equitable access to high quality, multi-disciplinary

treatment for people with severe or complex obesity National Planning Forum- NHS boards and Scottish

Government aim for consistent approach and criteria

GCWMS Pathway to Bariatric Surgery

16 week Lifestyle programme

Anti obesity medication – 12 weeks

Low calorie diet programme 12 weeks

<5kg weight loss

<5kg weight loss

BMI >40kg/m2 or BMI >35kg/m2

with co-morbidities

Referral to GCWMS Surgical Team

An adjustable prosthesis is placed at the upper part of the stomach. The stoma of the prosthesis is calibrated with saline introduced via a subcutaneous access port. (Diagram courtesy of Johnson and Johnson Medical.)

Gastric band

Each bite should pass across the band before anotherbite is swallowed

Waves through the food pipe generate feeling of not being hungry- satiety

Signal message tobrain that no morefood is needed- satiation

Mode of action of gastric band

Mode of action of Gastric banding

Band is placed at top of stomach which creates a small pouch

Reduction in intake, quicker and longer satiety

Intraluminal pressure and semi solid swallows- transit across resistance of LAGB- peristaltic contractions.

- Proposed that compression of vagal afferent nerves in band area mediates satiety effect (O’Brien, 2010)

Activation of peripheral satiety mechanism without physically restricting meal size (Burton& Brown, 2011)

Sleeve Gastrectomy

70% of Stomach removed

Mode of Action of Sleeve

Restrictive Alters hormone signals from stomach to

brain

Pre Surgery- Psychology assessment

Clinical interview & standardised measures:

Psychological functioning (current & past) Eating behaviour Level of social support Coping skills Motivation /expectations Appraisal of the surgical process Social and cognitive functioning

Pre Surgery- Dietetic Dietetic assessment

Dietary changes to date Dietary patterns, portion sizes Eating habits which may improve with gastric

banding surgery Triggers for eating- energy dense food choices

Hunger v’s non hunger Expectations from surgery 2 week Assessment diet Refer onto surgeons if patient successful and still

wishes to proceed

Weight Loss Expectations

Majority of weight loss within the first 2 years post op

LAGB- ~50-60% EWL ( Weiner et al., 2003)

RYGB- greatest weight loss 2years post op 60-70% EWL

Overall, LAGB and RYGB not different 3-8years post op-both ~50-60% EWL (O’Brien, 2010)

Weight Loss Expectations

Case Study Patient weighs 170kg (26 stone 10lbs), BMI

54kg/m2

Height- 1.78m Ideal body weight, BMI of 25kg/m2 - 80kg Excess body weight of 90kg Weight loss approx 50% of his excess body weight

following surgery Could expect to lose in the region of 45kg (7stone) Target weight for surgery to be deemed a success -

125kg (19st 9lbs) over 2 year period- BMI 39kg/m2

GCWMS Group Support Programmes

Support & skill-based: monthly rolling programmes

Pre-Surgery group Preparation for surgery- Identify eating, activity and

behavioural changes and emotional factors to be addressed in order to achieve success with weight loss surgery

Post-Surgery Group Encouragement of adherence, support new coping

techniques in high risk situations, relapse prevention, interpersonal learning & support

Pre Operative-Liver Reduction Diet

Diet before and after surgery

2 weeks pre op diet to shrink the liver~800kcal low CHO, low fat

Post operative progression Fluids only for 2 weeks post surgery Soft diet gradually progressing to solid textures- week 2-6

post surgery Weeks 6 onwards- Solid food

Importance of progressing to solid diet to achieve satiety and satiation from band

Aiming for approx 1000-1200kcal/day when in “Green Zone”

Adjustment of band

Acrobat Document

Adjustment of patient- the 10 Keys to Success

1. Eat three small main meals per day2. Focus on balance of nutritious solid food 3. Limit serving size4. Do not graze between meals5. All drinks should be zero calories6. Eat slowly and stop when no longer hungry7. Chew foods thoroughly8. Avoid drinking with meals, sips only- do not gulp9. Be active for 30 minutes every day10. Always attend follow up

Chew thoroughly

20/20/20 rule

20p coin bite size

Chew 20 times

Wait 20 seconds

Adjustment of band

Consultation to determine if adjustment needed. General progress, weight loss Eating, appetite, hunger, satiety Activity Range of food intake and nutrition Any symptoms e.g. reflux, heartburn, vomiting

Requirement for further advice on eating and activity

Decision made on need for adjustment

Adjustment of band

First adjustment dependent on centre - ~ 6weeks post surgery, every 6 weeks

thereafter Target - find the “Green Zone” Incremental increase in saline to right volume,

right pressure Linear relationship between follow up and

weight loss outcomes. ( Dixon et al., 2009)

Adjustment of band

Not a case of the more the better Dangers of “Red Zone”- maladaptive eating

Narrow range of foods Soft foods slide through- energy dense- high

sugar, high fat soft/ liquid foods

Preserve the “precious pouch”

Eating too quickly?

Eating too much?

Not chewing food well

Leads to stretching of area above band

-Enlargement of “new” stomach

-Risk of band slippage

Patient 1 P1s1 wt 115.9kg BMI 48.2 (attended 1:1 due to anxiety) Referral to surgery wt 118.1kg BMI 49.1 Comorbidities

Fatty liver Disease Extreme anxiety and depression Elevated cholesterol (suicidal, CMHT input) High Blood pressure Type 11 Diabetes Angina Joint pain

Patient 1

Attended all group sessions Responded well to diet and activity advice Engaged with GCWMS psychology and community

mental health services 1 year post op 89kg BMI 37 (29.1kg wt loss since

surgery) ‘ I work with my band, I eat solid textures, I follow the

10 keys to success, they are stuck to my fridge, and I learn from my mistakes’.

Patient 1

Patient now attends GCWMS group based exercise class Bought new clothes Looks after herself in a way she never thought she could Nov 16th 2012 Liver function tests normal, Cholesterol

normal, U&E’s normal, HbA1c 37 (5.5%)

Aim of 50% EBW at 2 years 89kg – Achieved

Patient 2

P1S1 wt 149.6kg, BMI 59.9

Referral to surgery wt 145.4kg, BMI 58 (-4.2kg during programme)

Co morbidities – Reported borderline Diabetes but nothing diagnosed

No psychology input

Patient 2

Good attendance during Phase 1 Poorer attendance during phase 2 Struggled with motivation and main focus was to get

gastric surgery 2 weeks post op137.9kg, BMI 55.2 6 weeks post op 135.8kg, BMI 54.3 1 year post op 135.8kg, BMI 54.3

Patient 2

Out for meals in 1st 6weeks - ‘its part of my lifestyle which I’m unable to change’

No change in activity level – ‘I’m too tired after work’ Unrealistic expectations that band would do work for

her Continued to have small amounts of high calorie foods

‘this approach works for me’ Moistening foods with gravy/sauces for ease of intake Poor attendance at follow up appointments

Patient 2

1 hour for meals Frequent holidays Snacking in evening on chocolate, crisps and

biscuits

Aim of 50% EBW at 2 years 103kg – Not on target

Conclusion

Remember the band has to be be worked with,

not something to conquer

Needs to be adjustment of the patient combined with adjustment of band

Multi disciplinary Surgery team support is a key determinant in surgery outcomes

Further considerations

Implementation of new surgery criteria from 1st of April 2013 (date delayed ,awaiting confirmation)

Disseminate and increase awareness of new criteria to referrers

With increased number of surgeries allocated to NHSGGC what other groups of patients should be considered for bariatric surgery