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Weight loss surgery safe & effective


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Weight loss surgery safe & effective

  1. 1. Obesity Conquered! Dr. Abeezar I. Sarela MSc (Lon) MS (Bom) MD (Leeds) FRCS (Glasg) Consultant in Bariatric & Metabolic Surgery
  2. 2. What is Obesity? <ul><li>Body Mass Index </li></ul><ul><ul><li>BMI = Weight in kg/(Height in m) 2 </li></ul></ul><ul><li>Overweight: BMI > 23 kg/m 2 </li></ul><ul><li>Obese: BMI > 25 kg/m 2 </li></ul>
  3. 3. What causes obesity? <ul><li>Many inter-connected causes: life-style, culture, environment, society </li></ul><ul><ul><li>Mechanised transport, labour-saving devices, sedentary jobs, easy availability of “fast-food” </li></ul></ul><ul><li>Basic issue: energy intake exceeds energy expenditure </li></ul><ul><li>Genetic predisposition </li></ul><ul><li>Specific hormonal problem is rare </li></ul>
  4. 4. Why all this fuss about obesity? <ul><li>Increasingly common problem – Epidemic! </li></ul><ul><li>Obesity is a “slow-killer” </li></ul><ul><li>Shortens life-span </li></ul><ul><ul><li>30 yr old man with BMI > 40 will die 15 years sooner than normal-weight counterpart </li></ul></ul><ul><li>Spoils quality of life </li></ul>
  5. 5. Obesity causes life-threatening disease <ul><li>Diabetes </li></ul><ul><li>High blood pressure </li></ul><ul><li>High cholesterol </li></ul><ul><ul><li>Heart-attack, stroke, kidney-failure </li></ul></ul><ul><li>Severe breathing difficulty </li></ul><ul><ul><li>Obstructive sleep apnea, asthma </li></ul></ul><ul><li>Cancer </li></ul><ul><ul><li>Kidney, colon, breast </li></ul></ul>
  6. 6. Obesity Impairs Quality of Life <ul><li>Musculoskeletal problems </li></ul><ul><ul><li>Exacerbation of arthritis in weight-bearing joints </li></ul></ul><ul><li>Depression </li></ul><ul><li>Decreased libido & Infertility </li></ul><ul><li>Migraine </li></ul><ul><li>Skin infections </li></ul>
  7. 7. Do not ignore obesity! Chronic disease that needs scientifically-based medical treatment – like any other chronic disease
  8. 8. Taking control of obesity <ul><li>Prevention of obesity </li></ul><ul><ul><li>Healthy lifestyle: diet and exercise </li></ul></ul><ul><li>Treatment of established obesity </li></ul><ul><ul><li>Needs an effective tool to return to normality and then maintain a healthy lifestyle </li></ul></ul>
  9. 9. 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.
  10. 10. What are the aims of treatment? <ul><li>Cure existing obesity-related diseases </li></ul><ul><li>Reduce the risk of developing a obesity-related disease in the future </li></ul><ul><li>Improve quality of life </li></ul><ul><li>Target BMI – as close as possible to 23 </li></ul>
  11. 11. Indications for weight loss surgery? <ul><li>If BMI is 37.5 - 50 (Morbid Obesity) </li></ul><ul><ul><li>Recommend surgery if committed life-style change for 6 months has been unsuccessful </li></ul></ul><ul><li>If BMI is between 32.5 – 37.5 and there is diabetes or another illness </li></ul><ul><ul><li>Recommend surgery if committed life-style change for 6 months has been unsuccessful </li></ul></ul><ul><li>If BMI is > 50 (Super-Obesity) </li></ul><ul><ul><li>Recommends surgery as “first-line” treatment </li></ul></ul>
  12. 12. The Story of Bariatric Surgery
  13. 13. Bariatrics (created circa 1965) <ul><li>Branch of medicine that deals with causes, prevention, and treatment of obesity </li></ul><ul><li>Greek roots: </li></ul><ul><ul><li>bar - (&quot;weight,&quot; as in barometer) </li></ul></ul><ul><ul><li>suffix - iatr (&quot;treatment,&quot; as in paediatrics) </li></ul></ul><ul><ul><li>suffix - ic (&quot;pertaining to&quot;) </li></ul></ul><ul><li>Encompasses diet, exercise, behavioural therapy, pharmacotherapy and surgery </li></ul>
  14. 14. Jejuno-Ileal Bypass <ul><li>1950s </li></ul><ul><ul><li>University of Minnesota </li></ul></ul><ul><li>Malabsorption by bypass of most of the intestine </li></ul><ul><li>Stomach intact </li></ul>
  15. 15. Gastric Bypass <ul><li>Open </li></ul><ul><ul><li>Mason & Ito </li></ul></ul><ul><ul><li>1960s </li></ul></ul><ul><li>Laparoscopic </li></ul><ul><ul><li>Wittgrove & Clark </li></ul></ul><ul><ul><li>1994 </li></ul></ul>
  16. 16. Vertical Banded Gastroplasty (VBG) 1970s
  17. 17. Biliopancreatic Diversion & Duodenal Switch Open Biliopancreatic Diversion Scopinaro, 1970s Biliopancreatic Diversion+ Duodenal Switch Open: Hess, 1986 Laparoscopic: Gagner, 2002
  18. 18. Magenstrasse & Mill Operation Prof David Johnston The General Infirmary at Leeds 1980s
  19. 19. Laparoscopic Sleeve Gastrectomy
  20. 20. Adjustable Gastric Banding Open- Kuzmak,1986 Laparoscopic - 2000
  21. 21. Bariatric Surgery Gold standard c. 1994 Laparoscopic Roux-en-Y gastric bypass Selected indications c. 2000 Laparoscopic sleeve gastrectomy Popular c. 1990 Laparoscopic adjustable gastric band Largely abandoned c. 1970 Vertical banded gastroplasty Currently performed c. 1960 Open gastric bypass Abandoned c. 1950 Jejuno-ileal bypass
  22. 22. Bariatric Surgery: What is the Evidence that it Works? <ul><li>USA </li></ul><ul><li>1984-2002 </li></ul><ul><li>7925 gastric bypass patients vs. 7925 weight and risk matched controls </li></ul><ul><li>Significantly ↓ mortality in bypass patients </li></ul><ul><ul><li>Overall mortality ↓ 40% </li></ul></ul><ul><ul><li>Coronary disease related mortality ↓ 56% </li></ul></ul><ul><ul><li>Diabetes related mortality ↓ 92% </li></ul></ul><ul><ul><li>Cancer related mortality ↓ 60% </li></ul></ul>Long-Term Mortality After Gastric Bypass Surgery NEJM 2007;357:753-61
  23. 23. Bariatric Surgery: What is the Evidence that it Works? <ul><li>11 years follow-up </li></ul><ul><li>Bariatric surgery 2010 patients vs. Conventional treatment 2037 patients </li></ul><ul><li>Weight loss </li></ul><ul><ul><li>Bypass: 2 years, 32%; 10 years, 25% </li></ul></ul><ul><ul><li>Banding: 2 years, 20%; 10 years, 14% </li></ul></ul><ul><li>Risk adjusted hazard ratio for death: bariatric surgery vs. conventional treatment – 0.70 </li></ul>Effects of Bariatric Surgery on Mortality in Swedish Obese Patients NEJM 2007;357:741-752
  24. 24. Bariatric Surgery: What is the Evidence that it Works? <ul><li>22,094 patients </li></ul><ul><li>Excess weight loss </li></ul><ul><ul><li>Bypass: 60-75% </li></ul></ul><ul><ul><li>Band: 55-65% </li></ul></ul><ul><li>Operative mortality </li></ul><ul><ul><li>Bypass: 0.5% </li></ul></ul><ul><ul><li>Band: 0.1% </li></ul></ul><ul><li>Diabetes: Resolved in 77% </li></ul><ul><li>Hypertension: Resolved in 62% </li></ul><ul><li>Obstructive Sleep Apnea: Resolved in 86% </li></ul>Bariatric Surgery. A Systematic Review and Meta-Analysis. JAMA 2004;292:1724-1737
  25. 25. Effects of Bariatric Surgery on Type 2 DM A Systematic Review and Meta-analysis <ul><li>621 studies: 1990-2006 </li></ul><ul><li>135, 246 patients </li></ul><ul><li>Women: 80% </li></ul><ul><li>Mean BMI 48 kg/m 2 </li></ul><ul><li>Resolution of T2DM : 78% </li></ul><ul><li>Resolution or improvement: 84% </li></ul>Buchwald et al. Am J Med 2009;122:248-256
  26. 26. “ I have got back my life after a bypass!” <ul><li>Diabetes, high blood pressure, high cholesterol, obstructive sleep apnea – cured in > 80% </li></ul><ul><li>Average loss of 35-40% of initial weight in 12-18 months </li></ul><ul><li>Vast improvement in mobility, vitality and enjoyment of life </li></ul>
  27. 27. How does bariatric surgery work? <ul><li>Restriction </li></ul><ul><li>Conditional behaviour change </li></ul><ul><li>Gut hormonal changes </li></ul><ul><li>Increased energy expenditure </li></ul>
  28. 28. Components of Intestinal Bypass Procedures Goldfine et al Nature Med 2009;15:616
  29. 29. Murphy & Bloom Nature 2006;444:854 Gut Hormones
  30. 30. Anti-Incretins: The Effect of Duodenal Exclusion Rubino & Gagner Ann Surg 2002
  31. 31. Perioperative Safety in Bariatric Surgery <ul><li>Surgeon </li></ul><ul><li>Site </li></ul><ul><li>Operation </li></ul><ul><li>Patient </li></ul>
  32. 33. Obesity Surgery-Mortality Risk Score <ul><li>Risk Factors </li></ul><ul><ul><li>BMI≥50kg/m2 </li></ul></ul><ul><ul><li>Male gender </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Risk of PE </li></ul></ul><ul><ul><li>Age≥45y </li></ul></ul>DeMaria et al. SOARD 2007 DeMaria et al. Ann Surg 2007 2.4-7.6% 4-5 C 3-5% 1.2-1.9% 2-3 B 48% 0.2-0.3% 0-1 A 46-49% Reported Mortality No. of factors Category
  33. 34. Incidence of Composite End-Point by OS-MRS Class A: 4% 229 patients Class B: 6% 137 patients Class C: 23% 15 patients One death 7% of OS-MRS C 0.3% of total
  34. 35. How to chose your surgeon? Questions you should ask? <ul><li>Did you get specialised training in bariatric surgery? </li></ul><ul><ul><li>Where, for how long, were you an observer or an appointed trainee? </li></ul></ul><ul><li>How many operations have you done? </li></ul><ul><ul><li>Ask specifically about band, bypass & sleeve </li></ul></ul><ul><li>What complications have you seen? </li></ul><ul><li>What are the facilities in your hospital? </li></ul><ul><ul><li>Fully equipped operating theatre, team from different specialties, ICU </li></ul></ul>
  35. 36. About your Surgeon Dr Abeezar I. Sarela <ul><li>Program-appointed Higher surgical trainee in UK (1995-2000) and USA (2001-2002) </li></ul><ul><li>Consultant Surgeon practising in UK since 2003 </li></ul><ul><li>Trained with two bariatric surgery pioneers in Leeds, UK </li></ul><ul><ul><li>First laparoscopic gastric bypass in UK – Leeds, 2000 </li></ul></ul><ul><ul><li>First laparoscopic sleeve gastrectomy in the world – Leeds, 2000 </li></ul></ul><ul><li>How many operations? </li></ul><ul><ul><li>Bypass > 100, Sleeve > 100, Band > 100 </li></ul></ul><ul><li>Complications? </li></ul><ul><ul><li>One death after bypass – very high risk patient </li></ul></ul>
  36. 37. Abeezar I. Sarela MSc MS MD FRCS Consultant in Bariatric & Metabolic Surgery e-mail: [email_address] Phone: 9004426263