Weight Loss Surgery

Consultant SurgeonSalford Royal Hospital

Family Doctors Association – July 2015

Introduction

Definition• BMI = weight (kg) height (m)2

• Classification:BMI (kg/m2) Description

<18.5 Underweight18.5-24.9 Desirable25-27 Mildly overweight27-30 Moderately overweight30-40 Obese40-50 Morbidly obese 50 Superobese

Prevalence of obesity among UK adults 1993 to 2007

Obesity-related morbidityDisease RR-women RR-menType-II Diabetes 12.7 5.2Hypertension 4.2 2.6Myocardial infarction 3.2 1.5Colon cancer 2.7 3.0Angina 1.8 1.8Gallbladder disease 1.8 1.8Ovarian cancer 1.7 -Osteoarthritis 1.4 1.9Stroke 1.3 1.3

Tackling Obesity in England, NAO, February 2001

Prevalence of significant morbidities per weight

Mokdad et al. JAMA 2002*Call et al. New Engl J Med 2003

Per

cent

affl

icte

d

60%

4%

18%

3%7%

24%

0%

15%

32%

15%

26%

44%

52%

23%

10%14%

28%

16%

41%

51%

0%

10%

20%

30%

40%

50%

Diabetes Asthma Arthritis High BloodPressure

Cancer*

BMI <25 25-30 30-40 BMI >40

Severe and complex obesity:Impact on morbidity

Waist circumference and risk of long-term health problems

NICE risk criteria

Obesity-related mortalityThose naturally fat are more liable to sudden death than the thin. Hippocrates Aphorisms

• A BMI of 30-35 cuts life expectancy by up to 4 years• A BMI of 40 or more cuts life expectancy by up to 10 years

Who should be referred or not referred?

NICE guidance

BMI of 40 kg/m2, or 35-40 kg/m2 + other significant disease that could be improved if they lost weight (e.g. type 2 diabetes or hypertension) Dec 2006

GP referral process

Update on surgical techniques

2 state-of-the-art Endosuites Range of procedures

Laparoscopic surgical options

• Gastric restriction:– Gastric banding – Sleeve gastrectomy– Vertical banded gastroplasty

• Gastric restriction + malabsorption:– Gastric bypass

• Severe malabsorption:– Biliopancreatic diversion (BPD)– Duodenal switch (DS)

Bariatric Procedures

Laparoscopic gastric banding

Lap sleeve gastrectomy

Laparoscopic gastric bypass

Roux-en-Y gastric bypass Omega loop (mini) gastric bypass

Biliopancreatic Diversion

+Duodenal

Switch

Bilio-pancreatic diversion (BPD)

Vertical banded gastroplasty

Laparoscopic Gastric Imbrication

Gastric Balloon

GP support after surgery

GP support

• Prescription: – vitamin and minerals, PPI

• Annual blood tests:– FBC (e.g. anaemia)– U&E– LFTs (e.g. hypoalbuminaemia)– Fe, Ferritin (e.g. consider referral for iron infusion)– B12, Folic acid– Vitamin D, PTH (e.g. secondary

hyperparathyroidism)

GP support

• Consider referral to:– Psychologist– Bariatric surgeon (e.g. suspected complications)– Gastroenterologist:

• Chronic diarrhoea (dietary, bacterial overgrowth, bile salt malabsorption, pancreatic exocrine insufficiency)

• Reactive hypoglycaemia• Malnutrition

– Plastic surgeon

• Maintain diabetic on the register for annual HbA1c and retinal checks

What’s gone right?

Is bariatric surgery beneficial?

Obesity surgery & co-morbidities

• 295 patients (mean BMI 45 kg/m2) laparoscopic gastric banding 4-year FU

Co-morbidity Frequency Cure ImprovementHypertension 52% 58% 42%Diabetes 20% 75% 08%Dyspnoea 85% 85% 12%Arthralgia 89% 52% 24%Reflux 57% 79% 11%Self-esteem 95% 45% 39%Physical perform 96% 58% 33%

Frigg et al. Obesity Surgery 2004

Resolution of sleep apnoea

• 56 patients with OSA on polysomnography – mean preop duration of OSA 44 ± 55 months– severity: severe 50%, moderate 30%, mild 20%

• Mean BMI 49 kg/m2 LRYGBP• Results:

– Epworth Sleepiness Scale (ESS) score decreased:13.7 5.3 @1 month (p<0.05) and maintained below the threshold level (<7) for the entire 12 months of follow-up

– CPAP: 29 (52%) patients preop 4 (14%) @ 3 months and 0 @ 9 months

– %EWL: 73 ± 3% @ 12 months

Varela et al. Obes Surg 2007

Co-morbidities: meta-analysis• 136 studies, 22094 patients

– 72.6% women. Age 39 (16-64) yr. BMI 46.9 (32.3-68.8)

• %EWL: mean (95% CI):– 61.2% (58.1-64.4%) for all patients

• Co-morbidities:

Buchwald et al. JAMA 2004

Co-morbidity ResolvedResolved or improved

Diabetes 76.8% 86%Hyperlipidaemia 70%Hypertension 61.7% 78.5%OSA 85.7% 83.6%

Bariatric surgery reduces cancer incidence

• Swedish Obesity Subjects (SOS) study– 2010 bariatric surgery patients – 2037 matched obese controls treated conventionally– Started 1987, cancer incidence reported until Dec 2005– Cancer follow-up: rate 99.9%, median 10.9 (range, 0-18.1) years

• Weight changes over 10 years: – −19.9 kg (SD −15.6 kg) vs. +1.3 kg (SD +13.7 kg)

• First-time cancers: – 117 vs. 169 patients (HR 0.67, 95% CI 0.53-0.85, p=0.0009).– In women: 79 vs. 130 patients (HR 0.58, 0.44-0.77; p=0.0001)– In men: 38 vs. 39 patients (HR 0.97, 0.62-1.52; p=0.90)

Sjöström et al. Lancet Oncol 2009

Gastric bypass in chronic renal failure and renal transplant

• 41 morbidly obese patients (25 on dialysis) with CRF:– 68% mean EWL at 12m– 5 stabilised or resolved their kidney disease – 9 underwent successful TL

• 10 patients who became morbidly obese after TL:– 70% mean EWL

• No operative mortality• Co-morbid conditions associated with morbid obesity

improved in all patients and permitted eligibility for TL

Alexander & Goodman. Nutr Clin Pract 2007

Recovery of sexual dysfunction in men

• Significant (p<0.05) sexual dysfunction compared with published normative controls approached normal postop.

• The amount of weight loss independently predicted the degree of improvement in all BSFI domains

• BMI correlated positively with oestradiol and negatively with total and free testosterone

• After 2 yr. the lap bypass group had significant in BMI and oestradiol and in total and free testosterone

Dallal et al. J Am Coll Surg 2008

Weight loss cures infertility Effective treatment of polycystic ovarian syndrome with Roux-en-Y gastric bypass

Eid et al. Surg Obes Relat Dis 2005

• 24 women with PCOS:– 100% Normal menstrual cycle at mean FU of 3.4m

• Resolution of hirsutism:– complete 52% at mean FU of 8m– moderate 25% at mean FU of 21m

• 5 women conceived without clomiphene

Bariatric surgery & QoL

• Comparative study:– 50 operated (at 5 years post-surgery) vs.

78 non-operated morbidly obese patients• Results:

significant improvement in health-related QoL and co-morbidities

Sanchez-Santos et al. Obes Surg 2006

• Surgery (n=1035) vs. Control (n=5746) morbidly obese subjects:– Age & sex matched– Subjects with other medical conditions excluded– 5 year FU

• Results:– Significant risk reductions for developing cardiovascular,

cancer, endocrine, infectious, psychiatric and mental disorders

– Mortality rate 0.68% vs. 6.17% ( RR of death by 89%)– Absolute mortality reduction of 5.5%

Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients

Christou et al. Ann Surg 2004

Sjostrom et al. Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. New Eng J Med 2007

Mortality and risk reduction

Adjusted hazard ratio 0.71

Weight loss & prescriptions1. 78 patients, 6 months post lap gastric bypass

– Average preop prescription cost $369– 6 and 24 month cost: $119 (↓68%) and $105 (↓72%)

Snow et al. Obes Surg 2004

2. 50 patients, 6 months post lap gastric bypass– 52% EWL at 6 months– Average prescriptions (not over-the-counter) per patient:

3.7 1.7 (p<0.05)Gould et al. J Gastrointest Surg 2004

Obesity surgery: is it cost-effective?

• HTA cost-effectiveness study • Systematic review of clinical trials of surgery vs.

medical therapy– Surgery greater wt loss (+ 23-37 kg), maintained at 8 yr– Surgery improved quality of life and co-morbidities– Surgery more cost-effective at £11,000 per quality-

adjusted life year

Clinical and cost effectiveness of surgery for morbid obesity: a systematic review and economic evaluation.

Clegg et al. Int J Obes Relat Metab Disord 2003

Bariatric surgery and prevention of T2D in Swedish Obese Subjects

• 1658 patients had bariatric surgery (band 19%, VBG 69%, bypass 12%) vs. 1771 obese matched controls

• 15 year follow up (36.2% dropped out, 30.9% not reached 15 years)

• T2D incidence rates: 6.8 vs. 28.4 cases/1000 person-years (adjusted HR with bariatric surgery, 0.17; 95% CI, 0.13 to 0.21; p<0.001)

Carlsson et al. New Engl J Med 2012

Bariatric surgery reduces MI in Swedish patients with T2D

• 345 diabetics underwent bariatric surgery vs. 262 diabetic obese controls

• Mean (IQR) follow-up: 13.3 (10.2-16.4) years • Bariatric surgery reduced the incidence of myocardial

infarction (MI): adjusted HR 0.56, 95% CI 0.34-0.93; p=0.025

• The effect of surgery in reducing MI incidence was stronger in individuals with higher serum total cholesterol and triglycerides at baseline (interaction p=0.02 for both traits).

Romeo et al. Diabetes Care 2012

Salford Royal Hospital: results

• October 2008 – March 2016• 1234 procedures:

– Gastric bypass 773 (62.6%)– Sleeve gastrectomy 256 (20.7%)– Gastric band (new/repositioned) 73 ( 5.9%)– Band removal 73 ( 5.9%)– Revision procedures 39 ( 3.1%)– Intragstric balloon 10 ( 0.8%)– Reversal procedures 8 ( 0.6%)– Duodenal switch 2 ( 0.2%)

Morbidity & MortalityAll Wales

Morbidity @ 2 years 65 (5.3%) 6 (6.6%)Mortality 2 (0.16%) 0

Bleeding/haematoma 11/2Anastomotic leak/perforation: GJA/JJA 3/3Anastomotic stricture: GJA/JJA 8/2Venous thromboembolism 3Pneumonia 5Acute renal failure 3Bacterial overgrowth 2Organ injury (colon, spleen) 2Wound infection (SSI) 5Others 16

Excess weight loss (%EWL)

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80%

6 weeks 6 months 12 months 24 months

Bypass

Sleeve

% FU91% 87% 75% 51%94% 88% 60% 25%

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omor

bidi

ties

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80%

6 months 12 months 24 months

Diabetes

Hypertension

OSA

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60%

70%

6 months 12 months 24 months

Diabetes

Hypertension

OSA

BYPASS

SLEEVE

What’s gone wrong?

Complications of bariatric surgery

Band complicationsDysphagia & vomiting:

• Band too tight• Food bolus• Band slippage, pouch dilatation• GORD, oesophageal dysmotility

Refer to bariatricsurgeon

Acute abdominal pain:• Peritonitis (band erosion)• Biliary colic• Tube detachment

Refer to bariatricsurgeon

Port infection or erosion Refer to bariatricsurgeon

GORD Refer to bariatricsurgeon

Long-term band managementWeight regain

No NHS funding

Normal Bolus obstruction Pouch dilatation

Band slippage

Oesophageal dysmotility Oesophageal dilatation

Band erosionPort Leak, Infection,

Erosion

Gastric bypass complicationsAcute abdominal pain:

• Anastomotic leak (within 2 weeks)• Gallstones: colic, cholecystitis,

pancreatitis• Ulcer perforation• Intestinal obstruction

• Refer to A&E• USS: ?gallstones

Chronic abdominal pain:•Biliary colic•Marginal ulceration•Internal small bowel hernia (Petersen’s)

Urgent referral to bariatricsurgeon

Chronic diarrhoea:•Dietary: fat or CHO indulgence•Bacterial overgrowth•Bile salt malabsorption•Pancreatic exocrine insufficiency

• Dietary advice• Empirical 1-2 weeks

Ciproxin + Metronidazole • Faecal elastase-1, Creon• Refer to Gastrenterologist

Gastric bypass complicationsChronic marginal ulcer:

• Smoking• NSAID• H. pylori

• No smoking• Avoid NSAID + PPI prophylaxis• Stool for H. pylori antigen;

eradication therapy• Refer to Gastroenterologist or

Bariatric SurgeonAnaemia:

• Fe deficiency• Folate deficiency• B12 deficiency• GI blood loss

• Check Fe, Folate, B12• Stool for occult blood• Correct deficiencies• Refer to a Gastroenterologist

Excessive hair loss (alopecia):• Zinc and Selenium deficiency• Fe deficiency

• Check Zn, Se & Fe• Correct deficiencies

Gastric bypass complications

Malnutrition:• Dietary• Bacterial overgrowth• Malabsorption

• Nutritional supplements• Dietary advice• Referral to bariatric

service: ?reversal

Neurological complications:•Thiamine (B1), B12, Folate, Cupper deficiencies•Alcoholism (Wernicke’s encephalopathy)

• Check B1, B12, Folate & Cu

• Correct deficiencies• Refer to a Neurologist

Muscle and bone pain, muscle weakness:•Vitamin D deficiency

• Check PTH and vitamin D• High dose vitamin D • Refer to Rheumatologist

Sleeve complicationsAcute abdominal pain:

• Gastric leak (within 2 weeks)• Gallstones: colic,

cholecystitis, pancreatitis

• Refer to A&E• USS of abdomen: ?gallstones

Vomiting and reflux:• Dietary• Hiatus hernia, GORD• Stricture within the sleeve

• PPI therapy. Anti-emetics• Dietary advice.• Refer to a Gastroenterologist or

Bariatric Surgeon

Anaemia:• Fe, Folate, B12 deficiencies• GI blood loss

• Check Fe, Folate, B12• Stool for occult blood• Correct deficiencies• Refer to a Gastroenterologist

Excessive hair loss (alopecia):• Zinc and Selenium deficiency• Fe deficiency

• Check Zn, Se & Fe• Correct deficiencies

Future service aspirations

1. Single site for Greater Manchester2. 24/7 on-call service for bariatric

surgery3. Long term follow up @ MWM service