Developments In Gastrointestinal Therapies

Bariatric surgery

Who, why and how?

Learning objectives

• On completion of this workshop, you should be able to:

– Understand surgical procedures available for patients who are

morbidly obese or severely obese with serious comorbidities

– Identify patients in your practice that may be appropriate for

bariatric surgery

– Confidently communicate risk versus benefit of bariatric

surgery options to patients

– Understand the importance of multidisciplinary care for

patients who are morbidly obese or severely obese with

serious comorbidities

Why consider surgery for patients

who are morbidly obese or severely

obese with serious comorbidities?

Obesity and mortality risk

1. NHMRC, 2003.

Mortality risk

doubles at

BMI 35 kg/m2

Relative risk of co-morbidities, conditions

and risks associated with obesity

Relative risk >5 Relative risk 25 Relative risk 12

Type 2 diabetes All cause mortality Cancer mortality

Dyslipidaemia Hypertension Breast cancer

Obstructive sleep apnoea Myocardial infarction and stroke Prostate and colon cancer in men

Breathlessness Endometrial carcinoma in women and hepatoma in men

Impaired fertility

Excessive daytime sleepiness Gallstones and complications including cancer

Obstetric complications including foetal abnormalities

Obesity hypoventilation syndrome

Polycystic ovary syndrome Asthma

Idiopathic intracranial hypertension

Osteoarthritis (knees) Gastroesophageal reflux

Non-alcoholic steatohepatitis Gout Anaesthetic risk

1. Dixon, 2002.

Age-adjusted relative risk for

co-morbidities and mortality by BMI

Women in the US Men in the US

1. NHMRC, 2003.

Burden of obesity on patients

and the healthcare system

• The net cost of lost

well-being due to obesity:1

– $21.0 billion in 2005

– $58.2 billion in 2008

1. Access Economics, 2008.

2. Access Economics, 2006.

DWL=deadweight loss.

Financial costs of obesity in 20052

Weight-loss treatments in

overweight or obese adults

6.75.5

1.8

7.55.6

46

53

41

31

1.1

6.5

1.33.1

42

54

25

34

0

10

20

30

40

50

60

Low energy

diet

Meal

replacement

Physical

activity

Diet + activity Sibutramine* Gastric bypass Biliopancreatic

bypass

Non-adjustable

gastroplasty

Adjustable

gastric

banding

Weig

ht

loss (

kg

)

Over 1-2 years

Over >2 years

1. NHMRC, 2003.

*Long-term sibutramine

data not provided.

Surgery

NHMRC recommendations:

surgery

• Evidence-based statement

– Surgical procedures in motivated, morbidly obese patients can

result in weight losses of from 1643% (varying between 2263

kg) that are reasonably well maintained over 38 years

• Recommendation: level B

– Surgery is the most effective treatment for morbid obesity: for

most procedures and most patients, good weight maintenance

has been observed 38 years after surgery

1. NHMRC, 2003.

Bariatric surgery: risk vs benefits

• Previously, surgical procedures for obesity had unacceptably high morbidity and mortality rates. The resulting stigma still persists to some degree1

• Advances in the type of procedures available have decreased the risks of bariatric surgery2

• Risks of surgery are usually lower than the risks of remaining obese3

1. NHMRC, 2003.

2. Pories, 2008.

3. US National Institutes of Health, 1998.

Medical comorbidities resolved

after bariatric surgery

1. Wittgrove & Clark, 2000.

Type 2 diabetes

98%

Hypertension

92%

Triglycerides

99%

Arthritis

90%

Sleep apnoea

98%

Reflux

disease

98%

Stress

incontinence

97%

Cholesterol

97%

Bariatric surgery reduces

mortality due to comorbidities

• 48% reduction in

death due to MI

• 38% reduction in

cancer mortality

1. Sjöström et al, 2007.

129 deaths

101 deaths

Hazard ratio 0.76 (p=0.04)

Unadjusted cumulative mortality

Medical co-morbidities resolved

after bariatric surgery: diabetes

1. Pories, 1995.

Medical co-morbidities resolved

after bariatric surgery: diabetes

1. Dixon et al, 2008.

13%

73%

0

20

40

60

80

Adjutable gastric banding Conventional therapy

Pa

tie

nts

(%

)Patient who underwent remission of type 2 diabetes in an unblinded, randomised, controlled trial (n=60)

Risks of bariatric surgery

Minor complications (requiring <7

days post-operative hospitalisation)

Major complications (requiring >7 days

post-operative hospitalisation)

• Respiratory

• Wound infection

• Splenic injury

• Other

• Hepatic or cardiac

• Pulmonary embolism

• Subphrenic abscess

• Gastrointestinal leaks

• Evisceration,

dehiscence

• Gastrointestinal

bleeding

• Deep vein thrombosis

• Neurologic

• Renal

• Wound seroma

• Small bowel obstruction

• Death has also been

reported following bariatric

surgery

As with any surgery, there are operative and long-term

complications and risks associated with bariatric surgical

procedures. Reported risks include (but are not limited to):

1. Mason et al, 1997.

“Bariatric surgery is remarkably safe”

Outcome Patients, n (%)

Hospital mortality 76 (0.14%)

Operative mortality at 30 days 165 (0.29%)

Operative mortality at 90 days 196 (0.35%)

Re-admissions 1956 (4.75%)

Re-operations 887 (2.15%)

Data from 272 US centres of excellence with 495

surgeons reporting outcomes in >110,000 patients*1,2

1. Pories, 2008.

2. Pratt et al, 2009.

3. O’Brien et al, 2005.

*60% of bariatric surgeries performed were gastric bypasses.2 Gastric bypass is less

commonly performed in Australia and is associated with a higher risk of complications

than the more commonly performed gastric sleeve procedures.3

Which of your patients are

suitable for bariatric surgery?

Who is eligible for

bariatric surgery?

NORMAL

ADULTS

BMI 18.524.9 kg/m2

OVERWEIGHT

ADULTS

BMI 2529.9 kg/m2

OBESE

ADULTS

BMI 3034.9

kg/m2

SEVERELY OBESE

ADULTS

BMI 3539.9 kg/m2

MORBIDLY OBESE

ADULTS

BMI 40 kg/m2

1. World Health Organization, 2008.

2. NHMRC, 2003.

With serious medical

co-morbidities

Who is eligible for bariatric surgery?

1. NHMRC, 2003.

Population education and awareness raising

Individual education and skills training

Behaviour modification

Medical, surgical, Rx

Intervention

A stepped model for clinical management of overweight and obesity

General population

Overweight / obese(with disordered eating patterns or cognitions)

Target population

Overweight or obese with risk factors(BMI >30 or BMI >27 with risk factors)

Overweight / obese

Who is eligible for

bariatric surgery?

• Bariatric surgery should be considered only for

well-informed, motivated adult patients with acceptable

operative risks

• Candidates for surgical procedures should be selected

after careful evaluation by a multi-disciplinary team with

medical, surgical, psychiatric and nutritional expertise

1. US National Institutes of Health, 1998.

Discussion

What systems do you have in

place in your practice to ensure

obesity is addressed?

Communicating bariatric surgery

benefits and risks to your patients

• Patients frequently make decisions about the risks of medical treatments, but without a completely objective understanding of such risks

• Risk perception is affected not only by individual factors, such as the patient's sex, prior beliefs, and past experience, but also by how risk information is presented

• A mix of techniques accommodating varying preferences and abilities of different patients should be used

1. Sabin et al, 2005.

What should the patient

understand before proceeding?

• Surgery should not be considered until all other options have been

evaluated

• Surgery is in no way to be considered as cosmetic. It does not involve

the removal of adipose tissue by suction or excision

• A decision to elect surgical treatment requires an assessment of the risk

and benefit to the patient and the meticulous performance of the

appropriate surgical procedure

• The suggested weight loss surgical procedure may not be reversible

• The success of surgery is dependent on long-term lifestyle changes in

diet and exercise

• Problems may arise after surgery that may require reoperations

What procedures are

currently available?

Procedures available in Australia

• Restrictive procedures: produce weight loss by

limiting intake

– Laparoscopic adjustable gastric banding (LAGB)

– Laparoscopic sleeve gastrectomy (LSG)

• Malabsorptive procedures: induce weight loss by

interfering with digestion and absorption

– Gastric bypass roux-en-Y (RYGBP)

– Biliopancreatic diversion (BPD; rarely performed in Australia)

1. Pories, 2008.

Annual number of bariatric procedures

performed in Australia, 19942008

1. Medicare Australia, 2009.

0

2000

4000

6000

8000

10000

12000

1994

/199

5

1995

/199

6

1996

/199

7

1997

/199

8

1998

/199

9

1999

/200

0

2000

/200

1

2001

/200

2

2002

/200

3

2003

/200

4

2004

/200

5

2005

/200

6

2006

/200

7

2007

/200

8

Nu

mb

er

of

pro

ce

du

res

LAGB + LSG

Gastric bypass

LAGB=laparoscopic adjustable gastric band

LSG=laparoscopic sleeve gastrectomy

Comparison of key attributes of

an ideal bariatric procedure

Attribute LAGB BPD RYGPB

Safe +++ + ++

Effective* ++ +++ ++

Easily and fully reversible Yes No No

Side effects + ++ ++

Durable (effective over time) ++ +++ ++

Minimal invasiveness +++ + ++

Controllable/adjustable Yes No No

Low re-operation / revision rate + + +

1. O’Brien et al, 2005.

*Substantial weight loss, improved health and quality of life.

Prevalence of complications

with bariatric procedures

48.2%

22.8%

7.4%6.6%

0

20

40

60

Adjutable

gastric band

LSG RYGBP BPD

To

tal

co

mp

lic

ati

on

s (

%)

1. Lee et al, 2007.

Comparison of efficacy

of bariatric procedures

1. Lee et al, 2007.

Restrictive procedure: laparoscopic

adjustable gastric banding (LAGB)

• A hollow silicon band is placed around the proximal stomach,

creating a small pouch and a narrow passage into the larger

remainder of the stomach

• The band is then inflated with saline. It can be tightened or loosened

over time to change the size of the passage by increasing or

decreasing the amount of saline

• Optimal pouch capacity: 30 mL

• Typical weight loss: 5060% of excess weight lost in 2 years

1. Obesity Surgery Society of

Australia and New Zealand, 2008.



Lower section

of stomach

Upper section

of stomach

Gastric band

Stomach

Injection port

Swedish adjustable gastric band



Advantages Disadvantages

• Effective with good long-term

weight maintenance

• Can adjust the degree of

restriction

• Easily reversible

• Maintains gastric integrity

• Longer operation, and there can be early

major complications

• Weight loss can be inadequate in some

patients

1. NHMRC, 2003.



Video demonstration: laparoscopic


Click here to play video

LAGB.wmv


sleeve gastrectomy (LSG)

• Involves removing the lateral

part of the stomach with a

stapling device leaving a

narrow tube instead of a

stomach sack

• The residual stomach

capacity is ~200 mL

• Not reversible




sleeve gastrectomy (LSG)

• Stomach tube may stretch over time leading to late weight regain

(extent currently unknown)

• The amount of weight reduction is in the region of 4060% of excess

weight lost over the first 12 years

• Requires little post-operative follow up or nutritional supplements

(therefore, a good option for people living in remote areas)

• If weight is regained, gastric bypass roux-en-Y or a duodenal swicth

can be performed



Malabsorptive procedure:

Gastric bypass roux-en-Y (RYGBP)

• A small stomach pouch is created to restrict food intake and then a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, duodenum and first portion of the jejunum. This reduces absorption of nutrients

• Residual stomach capacity: 3050 mL

• Estimated weight loss: 6070% over 2 years




Gastric bypass roux-en-Y (RYGBP)

Gastric bypass roux-en-Y (RYGBP):

advantages and disadvantages


• Very effective with good long-term

weight maintenance

• Few failures

• Higher earlier complication rate

• Potential for vitamin B12

deficiency, incisional hernia,

depression, staple-line failure,

gastritis, cholecystitis

1. NHMRC, 2003.


Biliopancreatic diversion (BPD)

• Rarely performed in Australia

• Combines removal or exclusion of

two-thirds of the stomach and a

long intestinal bypass which

significantly reduces the absorption

of fat

• The capacity to eat is greater than

with other procedures, and the

eventual weight loss is greatest

• However, diarrhoea and foul flatus

result if fatty foods are overeaten




Biliopancreatic diversion (BPD)


• Very effective with good long-term

weight maintenance

• High success rate and low revision

rate

• Potential for mineral and vitamin

malabsorption

• Potential for diarrhoea

• Relatively invasive

• Early major complications

1. NHMRC, 2003.

Demonstration of

surgical procedure

Questions?

Post-surgery follow-up care:

what the GP needs to know

Some of the complications that may

present in general practice after LABG

• Port sepsis

– Complication of port access for

adjustment

– Typical erythema, tenderness,

cellulitis

– Requires urgent intervention to

avoid band related sepsis

• Overly restrictive band

– Patient unable to manage

unprocessed solids

– Resort to fluids = uncontrollable

– Frequent vomiting ± reflux

– Needs elective withdrawal of fluid

• Band Slip

– Vomiting

– Dysphagia to fluids

– No response to evacuation of the band

– Stomach viability threatened - LUQ pain

– Requires urgent surgical attention

• Erosion

– Failure of weight loss, despite adequate

band filling

– Low grade sepsis

– May be managed electively

Note: this list is not exhaustive. 1. Chapman et al, 2002.

Other potential problems

after surgery

• Reflux symptoms

• Nutritional deficiencies

• Weight gain

• Loose skin

• Gallstones

1. Chapman et al, 2002.

Post-surgery diet

• Patients can be encouraged to see a registered dietitian

both before and after surgery

• If the patient is not seeing a registered dietitian or other

counsellor post-surgery, GPs may wish to advise patients

to keep a food and exercise diary that can be reviewed

during office visits

1. US National Institute of Health, 2000.

Example LABG post-surgery diet

• Weeks 1 & 2: fluid diet plan

– Day 1 after surgery: clear fluids

– Day 2 to Day 14: full fluids

• Weeks 3, 4 & 5: pureed diet plan

• Week 6 onwards: introduction of solids

– Emphasise the need to chew ALL foods to baby food consistency

– In the long term, patients should try to eat as normally as possible

but in smaller quantities

Exercise

• It is important following obesity surgery to not only alter

eating habits, but also level of physical activity

• The bariatric surgeon will advise the patient on an

individual exercise program appropriate to their

individual circumstances

• Patients are generally recommended to start exercising

slowly. As weight loss is achieved, physical activities will

gradually become easier

Weight loss surgery

support groups

• Support groups can provide weight loss surgery patients

an excellent opportunity to discuss their various personal

and professional issues

• Bariatric surgeons can advise patients of support groups

to assist with short- and long-term questions and needs

Going back to work

• The ability to resume pre-surgery levels of activity will

vary according to physical condition, the nature of the

activity and the type of weight loss surgery performed

• Many patients return to full pre-surgery levels of activity

within 6 weeks of their morbid obesity procedure

• Patients who have had a minimally invasive laparoscopic

procedure may be able to return to these activities within

a few weeks

Pregnancy

• It is important to inform women that fertility may be increased post-surgery1

• Although pregnancy after bariatric surgery appears to be safe, extra care should be taken to properly monitor post-operative pregnant patients for appropriate weight gain and nourishment2

• In patient who have undergone LAGB, the band can be deflated during pregnancy to reduce the incidence of reflux and to ensure adequate nutrition particularly if hyperemesis is present2

• Women do not appear to be at increased risk for poor perinatal outcomes post-surgery, and their risks for many obesity-related gestational complications are reduced2

1. Beard et al, 2008.

2. Karmon & Sheiner, 2008.

Long-term follow-up

• US NIH follow-up recommendation: lifelong medical surveillance after surgical

therapy is essential

• Routine monitoring (performed by a bariatric surgeon):

– Patients should be seen within 24 weeks of surgery to monitor efficacy and side effects

– Visits every ~4 weeks are adequate during the first 3 months if the patient has a

favourable weight loss and few side effects; more frequent visits may be required,

particularly if the patient has complications

– Blood pressure, pulse and weight should be monitored each visit, with waist

circumference measured intermittently

– Less frequent follow-up is required after the first 6 months

– Patients who do not maintain an adequate intake of vitamins and minerals may develop

deficiencies of vitamin B12 and iron with anaemia. Thus, indices of inadequate nutrition

should be monitored

1. US National Institute of Health, 2000.

Summary

• Surgery is the most effective treatment for morbid obesity (NHMRC)

• Candidates for surgical procedures should be selected after careful

evaluation by a multi-disciplinary team with medical, surgical,

psychiatric and nutritional expertise

• Risks of surgery are usually lower than the risks of remaining obese

• Procedures currently available in Australia are:

– Laparoscopic adjustable gastric banding (LAGB)

– Laparoscopic sleeve gastrectomy (LSG)

– Gastric bypass roux-en-Y (RYGBP)

– Biliopancreatic diversion (BPD)

Learning objectives

• You should now be able to:

– Understand surgical procedures available for patients who are

morbidly obese or severely obese with serious comorbidities

– Identify patients in your practice that may be appropriate for

bariatric surgery

– Confidently communicate risk versus benefit of bariatric surgery

options to patients

– Understand the importance of multidisciplinary care for patients

who are morbidly obese or severely obese with serious

comorbidities

Questions?

References1. Access Economics, 2008. The growing cost of obesity in 2008: three years on. Available at:

http://www.accesseconomics.com.au/publicationsreports/getreport.php?report=102&id=139. Accessed January 2009.

2. Access Economics, 2006. The economic costs of obesity. Available at: http://www.accesseconomics.com.au/publicationsreports/getreport.php?report=102&id=139. Accessed January 2009.

3. Chapman A et al. Systematic review of laparoscopic adjustable gastric banding for the treatment of obesity : Update and re-appraisal. ASERNIP-S Report No. 31, Second Edition. Adelaide, South Australia: ASERNIP-S, June 2002.

4. Dixon JB et al. JAMA 2008;299:316-23.

5. Dixon JB. Obes Surg 2008 Nov 13. [Epub ahead of print].

6. Lee CM, Cirangle PT, Jossart GH. Surg Endosc 2007;21:1810-6.

7. Mason EE et al. Obes Surg 1997;7:189-97.

8. Medicare Australia. Available at: https://www.medicareaustralia.gov.au/statistics/mbs_item.shtml. Accessed February 2009.

9. National Health and Medical Research Council (NHMRC), 2003. Clinical practice guidelines for the management of overweight and obesity in adults. Available at: http://www.health.gov.au/internet/main/publishing.nsf/Content/obesityguidelines-guidelines-adults.htm. Accessed January 2009.

10. O’Brien PE, Brown WA, Dixon JB. Med J Aust 2005;183:310–4.

11. Obesity Surgery Society of Australia and New Zealand, 2008. Available at: http://www.ossanz.com.au/lapband.asp. Accessed January 2009.

12. Pories WJ. Ann Surg 1995;222:339-50.

13. Pories WJ. J Clin Endocrinol Metab 2008;95:S89-S96.

14. Pratt GM et al. Surg Endosc 2009 Jan 30. [Epub ahead of print].

15. Sabin J et al. Obes Res 2005;13:250-3.

16. Sjöström L et al. N Engl J Med 2007;357:741-52.

17. US National Institutes of Health. Clinical Guidelines on the Identification, Evaluation, and Treatment of Obesity in Adults: The Evidence Report. NHLBI Obesity Education Initiative. Expert Panel on the Identification, Evaluation, and Treatment of Obesity inAdults. Washington, DC: U.S. Department of Health and Human Services, 1998. Available at: http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf. Accessed February 2009.

18. US National Institutes of Health. Expert Panel on the Identification, Evaluation, and Treatment of Overweight in Adults. Am J Clin Nutr 1998;68:899–917.

19. Wittgrove AC, Clark GW. Obes Surg 2000;10:233-9.

20. World Health Organization, Global database on Body Mass Index. Available at: http://www.who.int/bmi/index.jsp. Accessed January 2009.

Health & Medicine

Developments In Gastrointestinal Therapies