A presentation by Dr Jacob Chisholm on Developments In Gastrointestinal Therapies.
Jacob Chisholm is an upper gastrointestinal and general surgeon with an interest in weight loss and metabolic surgery. Jacob received his undergraduate degree (MBBS) from the University of Adelaide, a postgraduate research degree (Masters of Surgery) from Flinders University and is a Fellow of the Royal Australasian College of Surgeons. He trained in surgery at the Royal Adelaide and Flinders Medical Centre before completing a bariatric fellowship in 2007. Jacob was appointed chief surgical resident at Flinders Medical Centre in 2008 and has been a consultant surgeon at that institution since 2010. Jacob joined the Adelaide Bariatric Centre in 2010.
Rationale for Bariatric surgery: Medical & Financial Argumentsforegutsurgeon
This document summarizes the rationale for bariatric surgery from both medical and financial perspectives. It provides evidence from several studies that bariatric surgery results in significant and sustained weight loss, resolution of diabetes and other comorbidities in the majority of patients. Cost-effectiveness analyses also indicate that while more expensive initially, bariatric surgery provides better health outcomes and is cost-effective compared to non-surgical weight loss treatments. However, more research is still needed to fully understand long-term impacts and complications.
This document discusses adjuvant therapy for endometrial cancer and provides guidelines and recommendations. It summarizes incidence rates and risk groups for endometrial cancer. It then provides recommendations for adjuvant radiation therapy, brachytherapy, chemotherapy, or a combination based on histology, grade, myometrial invasion, lymphovascular space invasion status, and other risk factors. Ongoing randomized studies evaluating different adjuvant treatment approaches are also mentioned.
This chapter discusses the surgical management of obesity. It begins with an overview of the obesity epidemic, noting that over one-third of US adults are obese and rates are projected to rise further. Obesity is associated with numerous health conditions and significant economic costs to the healthcare system and workforce. Bariatric surgery has been shown to be an effective treatment for severe obesity, resulting in substantial and durable weight loss as well as improved health outcomes. The various bariatric procedures are reviewed, including Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding. Patient selection factors, pre-operative evaluation and preparation, and post-operative management are also covered.
The Mini-Gastric Bypass (MGB) results in excellent excess weight loss of 82% with fewer complications compared to other weight loss surgeries like RNY. Data from over 4,500 patients followed for up to 15 years found that 31.6% reported some complication, with most being minor like dyspepsia or anemia. Major complications requiring hospitalization occurred in only 5.2% of patients. The document argues that the fear of gastric cancer or bile reflux gastritis from the MGB is misplaced and minimal, as the lifetime risk is less than that from a single CT scan and no studies have found concerning findings even out to 15 years.
The document discusses the mini-gastric bypass (MGB) procedure for weight loss surgery. It provides the background and experience of Dr. Rutledge, who has performed over 6,000 MGB cases. It outlines criteria for an "ideal" weight loss surgery and argues that the MGB meets more of these criteria than other procedures like Roux-en-Y gastric bypass and gastric banding. Specifically, it notes the MGB's low risk, significant weight loss, ease of performance, and minimal complications like marginal ulcers. The document ultimately concludes the MGB is the best choice for weight loss surgery based on meeting objectives and success criteria.
Management of lower Gastrointestinal malignanciesAnimesh Agrawal
This document discusses the management of lower gastrointestinal malignancies involving the colon, rectum, and anal canal. It provides details on:
1. Staging criteria for colon cancer according to the TNM system and AJCC guidelines.
2. Treatment options including surgery, chemotherapy, and radiotherapy depending on the cancer stage, location, and patient factors. The primary treatment is surgery to completely remove the tumor.
3. Adjuvant chemotherapy regimens including FOLFOX, CapeOx, and 5-FU based therapies are recommended for stage III disease and sometimes for high-risk stage II based on trial evidence showing improved survival outcomes.
4. The FOLFOX regimen of
This document discusses balanced treatment approaches for esophageal cancer. It recommends that surgery plus additional therapy is required for pT3 N1 tumors. Definitive chemoradiotherapy is an acceptable standard for squamous cell carcinoma. Preoperative and postoperative combination chemotherapy is also an acceptable approach for resectable esophageal or GEJ adenocarcinoma. Preoperative concurrent chemoradiotherapy is a standard for resectable adenocarcinoma of the esophagus or GEJ. The role of preoperative chemotherapy alone for resectable squamous cell carcinoma is unclear and not recommended.
Gastric cancer debate adjuvant chemoradiotherapyMohamed Abdulla
This document summarizes a presentation on adjuvant chemo-radiotherapy for gastric cancer. It discusses key facts about gastric cancer incidence and survival rates. It reviews clinical trials like Intergroup 0116 and ARTIST that showed improved survival with adjuvant chemoradiotherapy for patients with positive lymph nodes or incomplete nodal dissection. The presentation concludes that multimodal treatment including surgery and adjuvant therapy is superior to single modality treatment, and that radiation therapy may improve outcomes for patients with intestinal-type cancer and positive lymph nodes.
Rationale for Bariatric surgery: Medical & Financial Argumentsforegutsurgeon
This document summarizes the rationale for bariatric surgery from both medical and financial perspectives. It provides evidence from several studies that bariatric surgery results in significant and sustained weight loss, resolution of diabetes and other comorbidities in the majority of patients. Cost-effectiveness analyses also indicate that while more expensive initially, bariatric surgery provides better health outcomes and is cost-effective compared to non-surgical weight loss treatments. However, more research is still needed to fully understand long-term impacts and complications.
This document discusses adjuvant therapy for endometrial cancer and provides guidelines and recommendations. It summarizes incidence rates and risk groups for endometrial cancer. It then provides recommendations for adjuvant radiation therapy, brachytherapy, chemotherapy, or a combination based on histology, grade, myometrial invasion, lymphovascular space invasion status, and other risk factors. Ongoing randomized studies evaluating different adjuvant treatment approaches are also mentioned.
This chapter discusses the surgical management of obesity. It begins with an overview of the obesity epidemic, noting that over one-third of US adults are obese and rates are projected to rise further. Obesity is associated with numerous health conditions and significant economic costs to the healthcare system and workforce. Bariatric surgery has been shown to be an effective treatment for severe obesity, resulting in substantial and durable weight loss as well as improved health outcomes. The various bariatric procedures are reviewed, including Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding. Patient selection factors, pre-operative evaluation and preparation, and post-operative management are also covered.
The Mini-Gastric Bypass (MGB) results in excellent excess weight loss of 82% with fewer complications compared to other weight loss surgeries like RNY. Data from over 4,500 patients followed for up to 15 years found that 31.6% reported some complication, with most being minor like dyspepsia or anemia. Major complications requiring hospitalization occurred in only 5.2% of patients. The document argues that the fear of gastric cancer or bile reflux gastritis from the MGB is misplaced and minimal, as the lifetime risk is less than that from a single CT scan and no studies have found concerning findings even out to 15 years.
The document discusses the mini-gastric bypass (MGB) procedure for weight loss surgery. It provides the background and experience of Dr. Rutledge, who has performed over 6,000 MGB cases. It outlines criteria for an "ideal" weight loss surgery and argues that the MGB meets more of these criteria than other procedures like Roux-en-Y gastric bypass and gastric banding. Specifically, it notes the MGB's low risk, significant weight loss, ease of performance, and minimal complications like marginal ulcers. The document ultimately concludes the MGB is the best choice for weight loss surgery based on meeting objectives and success criteria.
Management of lower Gastrointestinal malignanciesAnimesh Agrawal
This document discusses the management of lower gastrointestinal malignancies involving the colon, rectum, and anal canal. It provides details on:
1. Staging criteria for colon cancer according to the TNM system and AJCC guidelines.
2. Treatment options including surgery, chemotherapy, and radiotherapy depending on the cancer stage, location, and patient factors. The primary treatment is surgery to completely remove the tumor.
3. Adjuvant chemotherapy regimens including FOLFOX, CapeOx, and 5-FU based therapies are recommended for stage III disease and sometimes for high-risk stage II based on trial evidence showing improved survival outcomes.
4. The FOLFOX regimen of
This document discusses balanced treatment approaches for esophageal cancer. It recommends that surgery plus additional therapy is required for pT3 N1 tumors. Definitive chemoradiotherapy is an acceptable standard for squamous cell carcinoma. Preoperative and postoperative combination chemotherapy is also an acceptable approach for resectable esophageal or GEJ adenocarcinoma. Preoperative concurrent chemoradiotherapy is a standard for resectable adenocarcinoma of the esophagus or GEJ. The role of preoperative chemotherapy alone for resectable squamous cell carcinoma is unclear and not recommended.
Gastric cancer debate adjuvant chemoradiotherapyMohamed Abdulla
This document summarizes a presentation on adjuvant chemo-radiotherapy for gastric cancer. It discusses key facts about gastric cancer incidence and survival rates. It reviews clinical trials like Intergroup 0116 and ARTIST that showed improved survival with adjuvant chemoradiotherapy for patients with positive lymph nodes or incomplete nodal dissection. The presentation concludes that multimodal treatment including surgery and adjuvant therapy is superior to single modality treatment, and that radiation therapy may improve outcomes for patients with intestinal-type cancer and positive lymph nodes.
This study analyzed 103 cases of aggressive histologic variants of endometrial carcinoma, including uterine papillary serous carcinoma, uterine clear cell carcinoma, and mixed tumors, treated at a single cancer center between 1984 and 1994. The median age was 67 years. Various treatment approaches were used including surgery alone, surgery with radiation therapy, and surgery with chemotherapy. The study found that lymphvascular space invasion and stage were independent prognostic factors. Radiation therapy significantly reduced pelvic recurrence for Stages I-III. Chemotherapy improved overall survival but not distant relapse rates. Stage Ia cases treated with surgery alone had a low risk of relapse.
The document discusses the experience with robotic gastrectomy for gastric cancer at a hospital in Grosseto, Italy between 2000-2011. It found that robotic gastrectomy is a safe and effective procedure for gastric cancer that allows for adequate lymph node dissection and resection of tumors. Complication and conversion rates decreased with increased surgeon experience. Long-term follow-up showed 5-year survival rates of 100%, 84.6%, 76.9%, and 21.5% for stages IA, IB, II, and III respectively. Robotic surgery was found to be a valid alternative to open or laparoscopic gastrectomy for early stage gastric cancer.
This study compared outcomes of 61 gastric cancer patients treated with postoperative chemoradiotherapy using either intensity-modulated radiotherapy (IMRT) or 3-dimensional conformal radiotherapy (3D CRT). The 2-year overall survival rates were 51% for 3D CRT and 65% for IMRT, with no significant difference. Locoregional failure occurred in 15% of 3D CRT patients and 13% of IMRT patients. Both the 2-year disease-free survival and local control rates were similar between the two groups. Overall, the study found no significant differences in outcomes between IMRT and 3D CRT for adjuvant therapy of gastric cancer.
1. Resection offers the only chance for cure of pancreatic cancer, but most patients are unresectable at diagnosis. For resectable patients, surgery without delay followed by adjuvant chemotherapy and radiation improves survival compared to surgery alone.
2. For unresectable locally advanced disease, chemoradiation provides a survival benefit over chemotherapy alone. Median survival is approximately 11-12 months with chemoradiation versus 9 months with chemotherapy.
3. Post-operative chemoradiation following pancreatic cancer resection reduces the risk of recurrence and improves long-term survival compared to surgery or chemotherapy alone. The 2-year survival rate is approximately 40-50% with adjuvant chemoradiation versus 20-30
Radiation therapy is an important treatment for esophageal cancer. It can be used preoperatively to downstage tumors and improve resection rates, definitively for inoperable locally advanced cancers, or palliatively to relieve symptoms like difficulty swallowing. The document discusses optimal radiation targets, doses, and limits to nearby organs. Combined modality approaches using chemotherapy with radiation have significantly improved survival compared to radiation alone.
Surgery of the primary tumor in metastatic breast cancer remains controversial. Several studies have found no survival benefit to surgery, while others have found potential benefits in certain subgroups. The TMH trial found no difference in overall survival between locoregional therapy plus systemic therapy versus systemic therapy alone. However, some retrospective studies have shown improved survival when surgery was performed after systemic therapy, especially in ER-positive tumors. Ongoing trials continue to evaluate the potential benefits of surgery in select patient populations.
1) The PORTEC-1 and PORTEC-2 trials compared pelvic radiotherapy to no additional treatment or vaginal brachytherapy for patients with endometrial carcinoma. PORTEC-1 found pelvic radiotherapy reduced vaginal recurrence while PORTEC-2 found vaginal brachytherapy achieved excellent vaginal control with fewer side effects compared to pelvic radiotherapy.
2) The PORTEC-3 trial randomized 686 patients with high risk endometrial cancer to chemoradiotherapy or radiotherapy alone. It found chemoradiotherapy improved failure-free survival compared to radiotherapy alone, especially for stage III patients, but with increased toxicity.
3)
1. Management of carcinoma of the pancreas involves staging and treatment based on whether the cancer is resectable, borderline resectable, locally advanced, or metastatic.
2. For resectable disease, surgery with lymph node dissection followed by adjuvant chemotherapy or chemoradiotherapy is recommended.
3. Borderline resectable disease may be treated with neoadjuvant therapy to potentially make the tumor resectable followed by surgery.
4. Locally advanced and unresectable disease can be treated with chemotherapy alone or chemoradiotherapy.
Has Survival following Pancreaticoduodenectomy for Pancreas (Print)Ahmed Salem MD
This study analyzed 216 patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma between 1999-2012 to determine if survival has improved over time. Patients were divided into era 1 (1999-2005) and era 2 (2006-2012). Overall operative mortality was similar between groups. Patients in era 2 presented with more advanced pathological features but had fewer positive margins, likely due to increased venous resection. Median survival was not significantly different between eras based on univariate analysis. After adjusting for pathological factors, there was no association between era and improved survival, suggesting survival has not improved over time despite advances. However, perioperative outcomes like blood loss and margin negativity did improve in era 2 with no increase in mortality.
This document provides an overview and table of contents for a textbook on endoscopy in obesity management. The textbook covers the history of bariatric surgery, indications for endoscopy, anesthesia considerations, anatomy of procedures, and management of complications. It aims to provide clinicians knowledge on treatment options and endoscopic management of obese patients. The textbook includes 14 chapters covering topics like acute bleeding, leaks, obstructions, and future endoscopic procedures for obesity.
A Coliseum with frail foundations: a critical analysis of the state-of-the-ar...Marco Lotti
Some considerations that made me convinced that the Coliseum HIPEC technique cannot be considered an adequate technique for the delivery of Hyperthermia.
Neoadjuvant therapy, including chemotherapy and chemoradiotherapy, is being investigated for the treatment of esophageal cancer. While some studies have shown improved survival rates with neoadjuvant therapy compared to surgery alone, the evidence from clinical trials remains conflicting. Achieving a complete pathological response after neoadjuvant therapy is associated with significantly improved long-term survival. Further research is still needed to determine the optimal neoadjuvant approaches and to improve outcomes by reducing distant metastases.
The document discusses treatment regimens for gastric cancer including preoperative and postoperative chemotherapy, preoperative chemoradiation, postoperative chemoradiation, and chemotherapy for metastatic or locally advanced cancer. It provides dosing details for various chemotherapy drugs and combinations such as DCF (docetaxel, cisplatin, 5-fluorouracil), ECF (epirubicin, cisplatin, 5-fluorouracil), and trastuzumab with capecitabine or 5-fluorouracil for HER2-positive cancers. The regimens may include both FDA-approved and unapproved uses and clinicians must choose treatments based on individual patients.
This document summarizes an upcoming conference on precision oncology. It discusses changing standards of care, scenario-based clinical trial enrollment forecasting and validation, the global footprint of oncology trial activity and key opinion leader rankings, the transition away from longitudinal drug development, and factors influencing future trial locations. Immunotherapy is highlighted as a rapidly evolving field, and challenges like patient accrual and increasing cancer complexity are noted. Global trends in early and late phase lung cancer trials are examined. The continuous development of drugs and diagnostics is presented as a new paradigm.
Malnutrition is common in cancer patients, affecting 40-80% during their disease course. It negatively impacts treatment outcomes, mortality, and quality of life. Early screening and nutritional interventions can help prevent weight loss and treatment interruptions. A multidisciplinary team approach is needed to address nutritional status from diagnosis onward through cancer treatment. Screening tools help identify at-risk patients who need comprehensive assessment and individualized nutritional support through diet, oral supplements, enteral feeding, or parenteral nutrition as needed. Exercise should also be encouraged to preserve muscle mass. Prioritizing nutritional care represents good clinical practice that can optimize cancer treatment.
Breast surgery for Metastatic Breast Cancer : Cochrane Analysis Kundan Singh
The document discusses two studies that evaluated the effects of breast surgery plus systemic therapy versus systemic therapy alone for 624 women with metastatic breast cancer. The average age was 49 years. The studies found no evidence of a difference in overall survival between the two treatment groups. Subgroup analysis found no difference in overall survival based on HER2 or estrogen receptor status, or for those with only bone metastases. Breast surgery plus systemic treatment may improve local progression-free survival but result in shorter distant progression-free survival compared to systemic treatment alone. The document calls for prospective trials and guidelines on the expanding role of surgery for stage IV breast cancer.
This document describes the development of a novel intratumoral drug delivery system using interstitial chemotherapy devices. The system aims to deliver chemotherapy drugs directly into solid tumors via implantable polymeric devices to achieve higher drug concentrations and more homogeneous distribution compared to systemic chemotherapy. The document outlines the design of biodegradable polymer implants loaded with cisplatin as a model drug. In vitro studies show sustained release of cisplatin from the implants over 1 month in a rate dependent on drug loading. The system has the potential for localized treatment with fewer systemic side effects.
This document summarizes the molecular biology of esophageal and gastric cancers. It discusses common genetic alterations in these cancers, including oncogenes and tumor suppressor genes. For esophageal cancer, it describes alterations in EGFR, cyclin D1, p53, E-cadherin and other genes. For gastric cancer, it discusses differences between intestinal and diffuse subtypes and common mutations in genes like p53, CDH1 and mismatch repair genes. The document also summarizes proposed molecular classifications of gastric cancer from TCGA and ACRG and their prognostic implications, along with targeted therapies in development or approved for treatment.
The document outlines the recommended pre-operative workup for bariatric surgery patients. It includes: 1) completing a medical history and physical exam; 2) conducting routine lab tests, nutritional screening, and women's health evaluations; 3) assessing patients psychosocially and for any endocrine, pulmonary, cardiovascular, or gastrointestinal conditions that could impact surgery. The goal is to optimize patient health and identify any risks prior to their bariatric procedure.
This document discusses advances in bariatric surgery. It covers indications for surgery such as BMI over 40 or 35 with comorbidities. The most common procedures are Roux-en-Y gastric bypass, sleeve gastrectomy, and gastric banding. Newer techniques like mini gastric bypass and endoscopic procedures are also discussed. Complications include leaks, bleeding, and nutritional deficiencies. The conclusion discusses the mechanisms of weight loss involving gut hormones, microbiota, and bile acids.
This study analyzed 103 cases of aggressive histologic variants of endometrial carcinoma, including uterine papillary serous carcinoma, uterine clear cell carcinoma, and mixed tumors, treated at a single cancer center between 1984 and 1994. The median age was 67 years. Various treatment approaches were used including surgery alone, surgery with radiation therapy, and surgery with chemotherapy. The study found that lymphvascular space invasion and stage were independent prognostic factors. Radiation therapy significantly reduced pelvic recurrence for Stages I-III. Chemotherapy improved overall survival but not distant relapse rates. Stage Ia cases treated with surgery alone had a low risk of relapse.
The document discusses the experience with robotic gastrectomy for gastric cancer at a hospital in Grosseto, Italy between 2000-2011. It found that robotic gastrectomy is a safe and effective procedure for gastric cancer that allows for adequate lymph node dissection and resection of tumors. Complication and conversion rates decreased with increased surgeon experience. Long-term follow-up showed 5-year survival rates of 100%, 84.6%, 76.9%, and 21.5% for stages IA, IB, II, and III respectively. Robotic surgery was found to be a valid alternative to open or laparoscopic gastrectomy for early stage gastric cancer.
This study compared outcomes of 61 gastric cancer patients treated with postoperative chemoradiotherapy using either intensity-modulated radiotherapy (IMRT) or 3-dimensional conformal radiotherapy (3D CRT). The 2-year overall survival rates were 51% for 3D CRT and 65% for IMRT, with no significant difference. Locoregional failure occurred in 15% of 3D CRT patients and 13% of IMRT patients. Both the 2-year disease-free survival and local control rates were similar between the two groups. Overall, the study found no significant differences in outcomes between IMRT and 3D CRT for adjuvant therapy of gastric cancer.
1. Resection offers the only chance for cure of pancreatic cancer, but most patients are unresectable at diagnosis. For resectable patients, surgery without delay followed by adjuvant chemotherapy and radiation improves survival compared to surgery alone.
2. For unresectable locally advanced disease, chemoradiation provides a survival benefit over chemotherapy alone. Median survival is approximately 11-12 months with chemoradiation versus 9 months with chemotherapy.
3. Post-operative chemoradiation following pancreatic cancer resection reduces the risk of recurrence and improves long-term survival compared to surgery or chemotherapy alone. The 2-year survival rate is approximately 40-50% with adjuvant chemoradiation versus 20-30
Radiation therapy is an important treatment for esophageal cancer. It can be used preoperatively to downstage tumors and improve resection rates, definitively for inoperable locally advanced cancers, or palliatively to relieve symptoms like difficulty swallowing. The document discusses optimal radiation targets, doses, and limits to nearby organs. Combined modality approaches using chemotherapy with radiation have significantly improved survival compared to radiation alone.
Surgery of the primary tumor in metastatic breast cancer remains controversial. Several studies have found no survival benefit to surgery, while others have found potential benefits in certain subgroups. The TMH trial found no difference in overall survival between locoregional therapy plus systemic therapy versus systemic therapy alone. However, some retrospective studies have shown improved survival when surgery was performed after systemic therapy, especially in ER-positive tumors. Ongoing trials continue to evaluate the potential benefits of surgery in select patient populations.
1) The PORTEC-1 and PORTEC-2 trials compared pelvic radiotherapy to no additional treatment or vaginal brachytherapy for patients with endometrial carcinoma. PORTEC-1 found pelvic radiotherapy reduced vaginal recurrence while PORTEC-2 found vaginal brachytherapy achieved excellent vaginal control with fewer side effects compared to pelvic radiotherapy.
2) The PORTEC-3 trial randomized 686 patients with high risk endometrial cancer to chemoradiotherapy or radiotherapy alone. It found chemoradiotherapy improved failure-free survival compared to radiotherapy alone, especially for stage III patients, but with increased toxicity.
3)
1. Management of carcinoma of the pancreas involves staging and treatment based on whether the cancer is resectable, borderline resectable, locally advanced, or metastatic.
2. For resectable disease, surgery with lymph node dissection followed by adjuvant chemotherapy or chemoradiotherapy is recommended.
3. Borderline resectable disease may be treated with neoadjuvant therapy to potentially make the tumor resectable followed by surgery.
4. Locally advanced and unresectable disease can be treated with chemotherapy alone or chemoradiotherapy.
Has Survival following Pancreaticoduodenectomy for Pancreas (Print)Ahmed Salem MD
This study analyzed 216 patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma between 1999-2012 to determine if survival has improved over time. Patients were divided into era 1 (1999-2005) and era 2 (2006-2012). Overall operative mortality was similar between groups. Patients in era 2 presented with more advanced pathological features but had fewer positive margins, likely due to increased venous resection. Median survival was not significantly different between eras based on univariate analysis. After adjusting for pathological factors, there was no association between era and improved survival, suggesting survival has not improved over time despite advances. However, perioperative outcomes like blood loss and margin negativity did improve in era 2 with no increase in mortality.
This document provides an overview and table of contents for a textbook on endoscopy in obesity management. The textbook covers the history of bariatric surgery, indications for endoscopy, anesthesia considerations, anatomy of procedures, and management of complications. It aims to provide clinicians knowledge on treatment options and endoscopic management of obese patients. The textbook includes 14 chapters covering topics like acute bleeding, leaks, obstructions, and future endoscopic procedures for obesity.
A Coliseum with frail foundations: a critical analysis of the state-of-the-ar...Marco Lotti
Some considerations that made me convinced that the Coliseum HIPEC technique cannot be considered an adequate technique for the delivery of Hyperthermia.
Neoadjuvant therapy, including chemotherapy and chemoradiotherapy, is being investigated for the treatment of esophageal cancer. While some studies have shown improved survival rates with neoadjuvant therapy compared to surgery alone, the evidence from clinical trials remains conflicting. Achieving a complete pathological response after neoadjuvant therapy is associated with significantly improved long-term survival. Further research is still needed to determine the optimal neoadjuvant approaches and to improve outcomes by reducing distant metastases.
The document discusses treatment regimens for gastric cancer including preoperative and postoperative chemotherapy, preoperative chemoradiation, postoperative chemoradiation, and chemotherapy for metastatic or locally advanced cancer. It provides dosing details for various chemotherapy drugs and combinations such as DCF (docetaxel, cisplatin, 5-fluorouracil), ECF (epirubicin, cisplatin, 5-fluorouracil), and trastuzumab with capecitabine or 5-fluorouracil for HER2-positive cancers. The regimens may include both FDA-approved and unapproved uses and clinicians must choose treatments based on individual patients.
This document summarizes an upcoming conference on precision oncology. It discusses changing standards of care, scenario-based clinical trial enrollment forecasting and validation, the global footprint of oncology trial activity and key opinion leader rankings, the transition away from longitudinal drug development, and factors influencing future trial locations. Immunotherapy is highlighted as a rapidly evolving field, and challenges like patient accrual and increasing cancer complexity are noted. Global trends in early and late phase lung cancer trials are examined. The continuous development of drugs and diagnostics is presented as a new paradigm.
Malnutrition is common in cancer patients, affecting 40-80% during their disease course. It negatively impacts treatment outcomes, mortality, and quality of life. Early screening and nutritional interventions can help prevent weight loss and treatment interruptions. A multidisciplinary team approach is needed to address nutritional status from diagnosis onward through cancer treatment. Screening tools help identify at-risk patients who need comprehensive assessment and individualized nutritional support through diet, oral supplements, enteral feeding, or parenteral nutrition as needed. Exercise should also be encouraged to preserve muscle mass. Prioritizing nutritional care represents good clinical practice that can optimize cancer treatment.
Breast surgery for Metastatic Breast Cancer : Cochrane Analysis Kundan Singh
The document discusses two studies that evaluated the effects of breast surgery plus systemic therapy versus systemic therapy alone for 624 women with metastatic breast cancer. The average age was 49 years. The studies found no evidence of a difference in overall survival between the two treatment groups. Subgroup analysis found no difference in overall survival based on HER2 or estrogen receptor status, or for those with only bone metastases. Breast surgery plus systemic treatment may improve local progression-free survival but result in shorter distant progression-free survival compared to systemic treatment alone. The document calls for prospective trials and guidelines on the expanding role of surgery for stage IV breast cancer.
This document describes the development of a novel intratumoral drug delivery system using interstitial chemotherapy devices. The system aims to deliver chemotherapy drugs directly into solid tumors via implantable polymeric devices to achieve higher drug concentrations and more homogeneous distribution compared to systemic chemotherapy. The document outlines the design of biodegradable polymer implants loaded with cisplatin as a model drug. In vitro studies show sustained release of cisplatin from the implants over 1 month in a rate dependent on drug loading. The system has the potential for localized treatment with fewer systemic side effects.
This document summarizes the molecular biology of esophageal and gastric cancers. It discusses common genetic alterations in these cancers, including oncogenes and tumor suppressor genes. For esophageal cancer, it describes alterations in EGFR, cyclin D1, p53, E-cadherin and other genes. For gastric cancer, it discusses differences between intestinal and diffuse subtypes and common mutations in genes like p53, CDH1 and mismatch repair genes. The document also summarizes proposed molecular classifications of gastric cancer from TCGA and ACRG and their prognostic implications, along with targeted therapies in development or approved for treatment.
The document outlines the recommended pre-operative workup for bariatric surgery patients. It includes: 1) completing a medical history and physical exam; 2) conducting routine lab tests, nutritional screening, and women's health evaluations; 3) assessing patients psychosocially and for any endocrine, pulmonary, cardiovascular, or gastrointestinal conditions that could impact surgery. The goal is to optimize patient health and identify any risks prior to their bariatric procedure.
This document discusses advances in bariatric surgery. It covers indications for surgery such as BMI over 40 or 35 with comorbidities. The most common procedures are Roux-en-Y gastric bypass, sleeve gastrectomy, and gastric banding. Newer techniques like mini gastric bypass and endoscopic procedures are also discussed. Complications include leaks, bleeding, and nutritional deficiencies. The conclusion discusses the mechanisms of weight loss involving gut hormones, microbiota, and bile acids.
This document outlines considerations for obesity and surgery. It defines obesity metrics like body mass index and discusses increased risks obesity poses for surgery like higher morbidity and technical challenges. Pre-operative assessment of obesity-related medical conditions and intra/post-operative management strategies are reviewed. Both non-operative and operative treatment options for obesity are presented, with bariatric surgery shown to have better long-term outcomes than diet/exercise alone for severe obesity.
The document summarizes the results of a study on 6436 consecutive mini-gastric bypass procedures performed over 16 years. Key results include a mean excess weight loss of 78% at 10 years post-surgery. Complications were low, with an 0.05% mortality rate and 4.9% early complication rate. The conclusion is that the mini-gastric bypass is an effective, low-risk, and durable bariatric procedure.
Bariatric surgery guidelines have been updated based on long-term studies demonstrating its effectiveness in treating severe obesity and related conditions. The guidelines now recommend considering bariatric surgery for patients with a BMI ≥30 who have obesity-related medical issues, especially if other treatments have failed. Bariatric procedures lead to greater weight loss than other options and higher remission rates of diabetes and other metabolic conditions. Risks of bariatric surgery are low with mortality rates below 1% for most patients.
This document discusses obesity, its causes and health risks, and the evidence that bariatric surgery is an effective treatment option. It provides details on different types of bariatric surgeries performed since the 1950s and their effectiveness based on clinical studies. It also outlines patient selection criteria and risks for bariatric surgery, and discusses how surgery works to induce weight loss and resolve obesity-related diseases through hormonal and other physiological changes.
Geriatric surgical patients have higher risks of complications like delirium, infections, and mortality. A thorough preoperative assessment is needed to identify individual risk factors and optimize health. This includes screening for cognition issues, nutritional status, medical comorbidities, and social support. Proper management of medications is also important. During surgery, techniques like epidural anesthesia can help prevent postoperative delirium in high-risk elderly patients.
This document summarizes the results of a study on 6,385 patients who underwent mini-gastric bypass (MGB) surgery over 15 years. The mean preoperative weight was 143kg and BMI was 47. Complications occurred in 4.9% of patients, with 0.7% having leaks. Long-term follow up found 78% excess weight loss on average and only 4.9% weight regain after 10 years. The study concludes MGB is an effective and low-risk bariatric procedure that can also be easily revised if needed.
This document summarizes the results of a study on 6,385 patients who underwent mini-gastric bypass (MGB) surgery over 15 years. The mean preoperative weight was 143kg and BMI was 47. Complications occurred in 4.9% of patients, with 0.7% having leaks. Long-term follow-up found 78% excess weight loss on average and only 4.9% weight regain after 10 years. The study concludes MGB is an effective procedure with relatively low risks and failures that can also be easily revised.
The Obstetric Gynaecologis - 2011 - Biswas - Surgical risk from obesity in ...Amer Raza
- Obesity increases surgical risks for gynecological procedures due to technical difficulties, anesthesia challenges, and increased risk of complications like infection and blood clots.
- When surgery is necessary, careful preoperative planning including assessing cardiac and pulmonary risk factors can help reduce risk. Regional anesthesia and prophylactic blood thinners are recommended.
- Alternative, non-surgical treatments should be considered when possible for obese patients, like weight loss programs, medications, or pessaries. Surgery should only be performed if more conservative options fail or for urgent conditions like cancer.
This paper argues that a multidisciplinary team is not necessary for bariatric surgery, specifically mini-gastric bypass surgery. The author studied results from over 7,000 patients who underwent mini-gastric bypass without a multidisciplinary team. The results were excellent, with over 80% of patients losing over 50% of their excess weight and a failure rate of only 1.7%. The author concludes that the critical factor for successful outcomes is performing an excellent, low-risk surgical procedure, not use of a multidisciplinary team. He compares it to cholecystectomy for gallbladder disease, where a team is also not necessary because the operation cures the underlying problem.
This document summarizes the safety of bariatric surgery based on a presentation. It discusses the history and evolution of bariatric procedures, common procedures and their complications. It reviews evidence from large studies like LABS-1 and a 2014 meta-analysis that showed bariatric surgery has low 30-day mortality rates of 0.3-0.8% and major complication rates of 4.3-17%. While gastric bypass has higher weight loss, gastric banding and sleeve gastrectomy have lower mortality and complication risks. The document concludes bariatric surgery is very safe, with gastric bypass having a 30-day mortality risk one-tenth of cardiovascular surgery.
A 48-year-old man who lost 200 kg through diet and exercise underwent a lower body lift. During the 4-hour, 2-surgeon procedure, he required repositioning 3 times and 6 drains. Post-operatively he developed hemorrhages requiring exploration. He was discharged after 8 days requiring weekly drainage of seromas. The document discusses nutritional deficiencies common after bariatric surgery that can impact wound healing for body contouring procedures. It notes diet and exercise patients have higher complication rates than those who had bariatric surgery. Careful patient evaluation and counseling is important due to the risks and limitations of massive weight loss body contouring.
The document discusses body contouring surgery for a 48-year-old man who lost 100 kg through diet and exercise and presents various risks and considerations for patients undergoing massive weight loss such as nutritional deficiencies that can impact wound healing, higher complication rates for those who lose weight through diet and exercise compared to bariatric surgery, and the importance of patient counseling on the risks, benefits, and limitations of body contouring procedures.
This document discusses bariatric surgery for obesity. It provides an overview of obesity as an epidemic and the causes. It describes different types of bariatric procedures including restrictive, malabsorptive, and combined. Evidence from studies like the Swedish Obese Subjects Trial show significant long-term weight loss and reduction in comorbidities with surgery compared to medical treatment. Complications, nutritional deficiencies, and choices of procedures like lap band, sleeve, and bypass are reviewed. Strong indications for surgery include BMI over 32.5 with comorbidities or over 37.5. Bariatric surgery is proven to save lives by preventing or improving conditions like diabetes and is more cost effective than medical therapy alone.
This document provides an overview of bariatric surgery in Odisha, India. It begins with definitions of bariatric surgery and classifications of BMI. It then discusses the comorbidities of obesity and guidelines for determining who is a suitable candidate for bariatric surgery. The document outlines various bariatric procedures including restrictive, malabsorptive, and combination procedures. It also discusses pre-op assessment, investigations, tools used in bariatric surgery, pathophysiology including the role of GI hormones, and videos demonstrating sleeve gastrectomy and Roux-en-Y gastric bypass procedures.
The Swedish Obese Subjects trial was a prospective study that compared outcomes of 2010 obese patients who underwent bariatric surgery to 2037 obese control patients who received conventional treatment. Over 20 years of follow up, bariatric surgery was associated with greater and longer-lasting weight loss compared to the control group. Bariatric surgery also reduced mortality by 29%, cardiovascular events by over 50%, diabetes incidence by at least 75%, and cancer incidence compared to conventional treatment alone. However, weight loss effects lessened over time, and some diabetes remission was not maintained after 10 years. The results provide evidence that bariatric surgery can improve health outcomes through weight loss, but weight-independent effects require further study.
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3. 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
4. Why consider surgery for patients
who are morbidly obese or severely
obese with serious comorbidities?
6. 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.
7. Age-adjusted relative risk for
co-morbidities and mortality by BMI
Women in the US Men in the US
1. NHMRC, 2003.
8. 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
9. Weight-loss treatments in
overweight or obese adults
6.7
5.5
1.8
7.5
5.6
46
53
41
31
1.1
6.5
1.3
3.1
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
Weightloss(kg)
Over 1-2 years
Over >2 years
1. NHMRC, 2003.
*Long-term sibutramine
data not provided.
Surgery
10. 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.
11. 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.
12. 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%
13. 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
15. 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
Patients(%)
Patient who underwent remission of type 2 diabetes
in an unblinded, randomised, controlled trial (n=60)
16. 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.
17. “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
18. Which of your patients are
suitable for bariatric surgery?
19. 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
20. 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
21. 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.
23. 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.
24. 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
26. 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.
27. Annual number of bariatric procedures
performed in Australia, 19942008
1. Medicare Australia, 2009.
0
2000
4000
6000
8000
10000
12000
1994/1995
1995/1996
1996/1997
1997/1998
1998/1999
1999/2000
2000/2001
2001/2002
2002/2003
2003/2004
2004/2005
2005/2006
2006/2007
2007/2008
Numberofprocedures
LAGB + LSG
Gastric bypass
LAGB=laparoscopic adjustable gastric band
LSG=laparoscopic sleeve gastrectomy
28. 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.
29. Prevalence of complications
with bariatric procedures
48.2%
22.8%
7.4%6.6%
0
20
40
60
Adjutable
gastric band
LSG RYGBP BPD
Totalcomplications(%)
1. Lee et al, 2007.
31. 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.
32. Restrictive procedure: laparoscopic
adjustable gastric banding (LAGB)
Lower section
of stomach
Upper section
of stomach
Gastric band
Stomach
Injection port
Swedish adjustable gastric band
33. Restrictive procedure: laparoscopic
adjustable gastric banding (LAGB)
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.
36. Restrictive procedure: laparoscopic
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
1. Obesity Surgery Society of
Australia and New Zealand, 2008.
37. Restrictive procedure: laparoscopic
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
1. Obesity Surgery Society of
Australia and New Zealand, 2008.
38. 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
1. Obesity Surgery Society of
Australia and New Zealand, 2008.
40. Gastric bypass roux-en-Y (RYGBP):
advantages and disadvantages
Advantages 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.
41. Malabsorptive procedure:
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
1. Obesity Surgery Society of
Australia and New Zealand, 2008.
42. Malabsorptive procedure:
Biliopancreatic diversion (BPD)
Advantages Disadvantages
• 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.
46. 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.
47. Other potential problems
after surgery
• Reflux symptoms
• Nutritional deficiencies
• Weight gain
• Loose skin
• Gallstones
1. Chapman et al, 2002.
48. 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.
49. 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
50. 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
51. 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
52. 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
53. 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.
54. 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.
55. 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)
56. 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
59. References
1. 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 in
Adults. 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.