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Obesity Conquered!
Dr. Abeezar I. Sarela MSc (Lon) MS (Bom) MD (Leeds) FRCS (Glasg)
Consultant in Bariatric & Metabolic Surgery
What is Obesity?
• Body Mass Index
– BMI = Weight in kg/(Height in m)2
• Overweight: BMI > 23 kg/m2
• Obese: BMI > 25 kg/m2
What causes obesity?
• Many inter-connected causes: life-style, culture, environment, society– Mechanised transport, labour-saving devices,
sedentary jobs, easy availability of “fast-food”
• Basic issue: energy intake exceeds energy expenditure
• Genetic predisposition
• Specific hormonal problem is rare
Why all this fuss about obesity?
• Increasingly common problem – Epidemic!
• Obesity is a “slow-killer”
• Shortens life-span
– 30 yr old man with BMI > 40 will die 15 years sooner than normal-weight counterpart
• Spoils quality of life
Obesity causes life-threatening disease
• Diabetes
• High blood pressure
• High cholesterol– Heart-attack, stroke, kidney-failure
• Severe breathing difficulty– Obstructive sleep apnea, asthma
• Cancer– Kidney, colon, breast
Obesity Impairs Quality of Life
• Musculoskeletal problems
– Exacerbation of arthritis in weight-bearing joints
• Depression
• Decreased libido & Infertility
• Migraine
• Skin infections
Do not ignore obesity!
Chronic disease that needs scientifically-based medical treatment –
like any other chronic disease
Taking control of obesity
• Prevention of obesity
– Healthy lifestyle: diet and exercise
• Treatment of established obesity
– Needs an effective tool to return to normality
and then maintain a healthy lifestyle
How can the severely obese lose weight?
Sjostrom L et al. Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. N Engl J Med 2007;357:741-52.
What are the aims of treatment?
• Cure existing obesity-related diseases
• Reduce the risk of developing a obesity-
related disease in the future
• Improve quality of life
• Target BMI – as close as possible to 23
Indications for weight loss surgery?
• If BMI is 37.5 - 50 (Morbid Obesity)– Recommend surgery if committed life-style
change for 6 months has been unsuccessful
• If BMI is between 32.5 – 37.5 and there is diabetes or another illness– Recommend surgery if committed life-style
change for 6 months has been unsuccessful
• If BMI is > 50 (Super-Obesity)– Recommends surgery as “first-line” treatment
The Story of Bariatric Surgery
Bariatrics (created circa 1965)
• Branch of medicine that deals with causes, prevention, and treatment of obesity
• Greek roots: – bar- ("weight," as in barometer)– suffix -iatr ("treatment," as in paediatrics)– suffix -ic ("pertaining to")
• Encompasses diet, exercise, behavioural therapy, pharmacotherapy and surgery
Jejuno-Ileal Bypass
• 1950s
– University of Minnesota
• Malabsorption by bypass of most of the intestine
• Stomach intact
Gastric Bypass
• Open
– Mason & Ito
– 1960s
• Laparoscopic
– Wittgrove & Clark
– 1994
Vertical Banded Gastroplasty (VBG)
1970s
Biliopancreatic Diversion & Duodenal Switch
Open Biliopancreatic DiversionScopinaro, 1970s
Biliopancreatic Diversion+ Duodenal SwitchOpen: Hess, 1986
Laparoscopic: Gagner, 2002
Magenstrasse & Mill Operation
Prof David JohnstonThe General Infirmary at Leeds1980s
Laparoscopic Sleeve Gastrectomy
Adjustable Gastric Banding
Open- Kuzmak,1986Laparoscopic - 2000
Bariatric SurgeryJejuno-ileal bypass c. 1950 Abandoned
Open gastric bypass c. 1960 Currently performed
Vertical banded gastroplasty
c. 1970 Largely abandoned
Laparoscopic adjustable gastric band
c. 1990 Popular
Laparoscopic
Roux-en-Y gastric bypass
c. 1994 Gold standard
Laparoscopic sleeve gastrectomy
c. 2000 Selected indications
Bariatric Surgery: What is the Evidence that it Works?
• USA• 1984-2002• 7925 gastric bypass patients vs. 7925
weight and risk matched controls• Significantly ↓ mortality in bypass patients
– Overall mortality ↓ 40%– Coronary disease related mortality ↓ 56%– Diabetes related mortality ↓ 92%– Cancer related mortality ↓ 60%Long-Term Mortality After Gastric Bypass Surgery
NEJM 2007;357:753-61
Bariatric Surgery: What is the Evidence that it Works?
• 11 years follow-up• Bariatric surgery 2010 patients vs.
Conventional treatment 2037 patients• Weight loss
– Bypass: 2 years, 32%; 10 years, 25%– Banding: 2 years, 20%; 10 years, 14%
• Risk adjusted hazard ratio for death: bariatric surgery vs. conventional treatment – 0.70Effects of Bariatric Surgery on Mortality in Swedish Obese Patients
NEJM 2007;357:741-752
Bariatric Surgery: What is the Evidence that it Works?
• 22,094 patients• Excess weight loss
– Bypass: 60-75%– Band: 55-65%
• Operative mortality– Bypass: 0.5%– Band: 0.1%
• Diabetes: Resolved in 77%• Hypertension: Resolved in 62%• Obstructive Sleep Apnea: Resolved in 86%
Bariatric Surgery. A Systematic Review and Meta-Analysis. JAMA 2004;292:1724-1737
Effects of Bariatric Surgery on Type 2 DM A Systematic Review and Meta-analysis
• 621 studies: 1990-2006
• 135, 246 patients
• Women: 80%
• Mean BMI 48 kg/m2
• Resolution of T2DM : 78%
• Resolution or improvement: 84%Buchwald et al. Am J Med 2009;122:248-256
“I have got back my life after a bypass!”
• Diabetes, high blood pressure, high cholesterol, obstructive sleep apnea – cured in > 80%
• Average loss of 35-40% of initial weight in 12-18 months
• Vast improvement in mobility, vitality and enjoyment of life
How does bariatric surgery work?
• Restriction
• Conditional behaviour change
• Gut hormonal changes
• Increased energy expenditure
Components of Intestinal Bypass Procedures
Goldfine et alNature Med2009;15:616
Murphy & BloomNature2006;444:854
Gut Hormones
Anti-Incretins:The Effect of Duodenal Exclusion
Rubino & GagnerAnn Surg 2002
Perioperative Safety in Bariatric Surgery
• Surgeon
• Site
• Operation
• Patient
Obesity Surgery-Mortality Risk Score
Risk Factors
1. BMI≥50kg/m2
2. Male gender
3. Hypertension
4. Risk of PE
5. Age≥45y
Category No. of factors
Reported Mortality
A46-49%
0-1 0.2-0.3%
B48%
2-3 1.2-1.9%
C3-5%
4-5 2.4-7.6%
DeMaria et al. SOARD 2007DeMaria et al. Ann Surg 2007
Incidence of Composite
End-Point by OS-MRS
Class A: 4%229 patients
Class B: 6%137 patients
Class C: 23%15 patients
One death7% of OS-MRS C
0.3% of total
How to chose your surgeon?Questions you should ask?
• Did you get specialised training in bariatric surgery?– Where, for how long, were you an observer or
an appointed trainee?
• How many operations have you done?– Ask specifically about band, bypass & sleeve
• What complications have you seen?• What are the facilities in your hospital?
– Fully equipped operating theatre, team from different specialties, ICU
About your SurgeonDr Abeezar I. Sarela
• Program-appointed Higher surgical trainee in UK (1995-2000) and USA (2001-2002)
• Consultant Surgeon practising in UK since 2003• Trained with two bariatric surgery pioneers in
Leeds, UK– First laparoscopic gastric bypass in UK – Leeds, 2000– First laparoscopic sleeve gastrectomy in the world –
Leeds, 2000• How many operations?
– Bypass > 100, Sleeve > 100, Band > 100• Complications?
– One death after bypass – very high risk patient
Abeezar I. Sarela MSc MS MD FRCS
Consultant in Bariatric & Metabolic Surgery
e-mail: [email protected]
Phone: 9004426263