Anti-Obesity Surgery

Joint Hospital Surgical Grand Round

17th May 2008

Dr. YuhMeei ChengDepartment of Surgery

United Christian Hospital

Obesity Classification

WHO Asia Pacific

Class Caucasian Asian Risks of co-morbidities

Underweight < 18.5 < 18.5 Low

Normal 18.8 – 24.9 18.5 – 22.9 average

Overweight >25 >23 increased relatively

Obese I 30 – 34.9 >25 Moderate

Obese II 35 – 39.9 >30 Severe

Obese III > 40 No such classification Severe

WHO guidelines, Asia Pacific Perspective 2005

Morbid Obesity

Definition

• BMI > 40

• BMI ≥ 35 + at least 2 co-morbidities

www.doctorsweightsolutions.com

Metabolic syndrome

Obesity Management

Aim• Loose weight• Minimize complication• Improve self image

• Improve quality of life

Management – Approach• Dieticians• Physiotherapists• Clinical Psychologists/ Psychiatrists• Endocrinologists• Bariatric Surgeons

Multidisciplinary

Obesity Management

Lifestyle change

Drug therapy

Interventional bariatric procedures

Indication for Surgery

Asia- Pacific Perspective National Institute of Health (NIH)

> 32 BMI + DM or co-morbidity

> 35 BMI + 2 co-morbidity

> 37 BMI > 40 BMI

Bariatric Surgery

Options

predominantly Restrictive BioEnterics Intragastric Balloon Laparoscopic Adjustable Gastric Banding Sleeve Gastrectomy

predominantly Malabsorptive Biliopancreatic Diversion +/- Duodenal Switch

combination Roux–en–Y Gastric Bypass

Gastric volume • gastric resection

• non – gastric resection

Bariatric Surgery

Options

predominantly Restrictive BioEnterics Intragastric Balloon Laparoscopic Adjustable Gastric Banding Sleeve Gastrectomy

predominantly Malabsorptive Biliopancreatic Diversion +/- Duodenal Switch

combination Roux–en–Y Gastric Bypass

Diversion of GI content•diversion of food from duodenum•diversion of biliopancreatic secretions

Intragastric Balloon

Restrictive procedure Endoscopic placement

•Doldi BS et.al, Intragastric balloon: 4-year experience. Obesity Surgery 2002;2:477•W mui et. al, Intragastric Balloon in ethnic obese Chinese: •initial experience. Obesity Surgery 2006;16:308-313

BioEnterics Intragastric Balloon

• stomach volume

•↓ dietary intake

•↑ satiety

• modify eating habit

Intragastric Balloon

Doldi et.al, Intragastric balloon in obese patients. Obese Surg 2000; 10: 578-81W mui et. al, Intragastric Balloon in ethnic obese Chinese: Initial experience. Obesity Surgery 2006;16:308-313

Advantages Disadvantages

More acceptable Short term

Repeatable Rebound

Reversible Poor weight reduction

Serious complications

Adjustable Gastric Banding Restrictive procedure Laparoscopic operation

Lap-band system

most common procedure in Asia-Pacific

Laparoscopic Adjustable Gastric Banding

Consensus Conference Statement: Bariatric surgery for morbid obesity: Health implications for patients, health professionals. H. Buchwald, J Am Coll Surg 2005; 200: 593-604

Gastroenterology. Klein et.al. 2002; 123: 883-932

Advantages Disadvantages

Less invasive Permanent band placement

Low operative complication Frequent band adjustments

Maintain normal food passage Poor quality of life

Reversible Persistent bowel problems

Reasonable weight reduction Difficult revision surgery

Sleeve Gastrectomy Restrictive procedure Laparoscopic or open

approach Increasing popularity

• 4th most common surgery in Asia-Pacific regions

www.gastricsleevepatient.com

Sleeve Gastrectomy

Himpens J et al. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006; 16(11):1450-6

Advantages Disadvantages

Better weight loss ? long term results

Faster and sustained weight reduction Serious complications

Reduction in serum ghrelin level decrease appetite

Irreversible

Preserve normal food passage

Less nutrient and bowel problems

Second stage operation if necessary

Roux-en-Y Gastric Bypass Restrictive + malabsorptive Diversion of food passage Gold standard procedure in

USA 2nd most common in Asia-

Pacific region Roux -limb

Common limb

www.healthsystem.Virginia.eduAsia-Pacific Perspective 2005

Roux-en-Y Gastric Bypass

Advantages Disadvantages

Better and more predictable weight loss

More serious operative complications

Long lasting effect Long term nutritional complications

Significant improvement in co-morbidities

Persistent bowel problems

Effective in super-obese patients

Difficult reversal surgery

Other- Biliopancreatic Diversion

Predominantly malaborptive

Gastrectomy

Food passage diverted from duodenum

Mostly done in Europe

100-150ml

200cm

300-400cm~ 60% SB

50-100cm from IC valve www.weightlosssurgery.com.au

American Modification

Preserve pylorusNormal food

passage to duodenum

Biliopancreatic Diversion +/- Duodenal Switch

Advantages Disadvantages

Best weight loss High operative complications

Longer lasting effect Long term metabolic complications

2-stage procedure in high risks, extreme obesity patient (BMI > 60)

Essentially irreversible

Consensus Conference Statement: Bariatric surgery for morbid obesity: Health implications for patients, health professionals. H. Buchwald, J Am Coll Surg 2005; 200: 593-604

Comparisons

1. Efficacy in reducing weight

2. Effective in improving co-morbidities

3. Risks and complications

% Morbidity % Weight loss

Intragastric balloon

Sleeve Gastrectomy

Gastric banding

Gastric bypass

Biliopancreatic diversion

+/- duodenal switch

• Laparoscopic sleeve gastrectomy is superior to endoscopic intragastric balloon as a first stage procedure for super-obese patients (BMI > or =50). L. Milone et.al, Obes Surg 2005; 15(5):612-7. • Bariatric Surgery. A systemic Review and meta-analysis. H. Buchwald et.al, JAMA 2004-Vol 292, No.14• Meta-Analysis: Surgical Treatments of Obesity. M. Maggard et.al, Ann Intern Med 2005; 142: 547-59• A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. J. Himpens et.al, Obes Surg 2006; 16(11):1450-6.

Co-morbidity Outcome

BIB SleeveGastrectomy

Gastricbanding

Gastric bypass BPD +/- DS

% resolved

DM

HT

Hyperlipidaemia

• Effectiveness of Laparoscopic Sleeve Gastrectomy (First Stage of Biliopancreatic Diversion with Duodenal Switch) on Co-Morbidities in Super-Obese High-Risk Patients. G. Silecchia et.al, Obes Surg

• Bariatric Surgery. A systemic Review and meta-analysis. H. Buchwald et.al, JAMA 2004-Vol 292, No.14

• BioEnterics Intragastric Balloon: The Italian Experience with 2515 patients. A Genco et.al, Obes Surg 15, 1161-64

Conclusions

Bariatric surgery is effective in weight reduction and resolving co-morbidities.

Needs careful patient selection to achieve optimal outcome.

Multidisciplinary approach is essential for successful treatment.

Treatments should be tailored to individual needs, as there are no universal protocols yet.

Thank you

5-6 June 2008