Bariatric Surgery in the Waikato:The 360o View

J Wu*, D Schroeder,**B Gibbison,* J McClymont*Waikato Adult Weight Management Programme*Surgical Obesity Service**

Roux-en Y Gastric Bypass Surgery

Restrictive: – 15ml gastric

pouch

Malabsorptive– Bypass to ~50 cm

distal to DJ flexure

Quantity & Demographics

45 patients (2005-2009) 31% men: 69% women Age: 25-64 y/o (48+/-10) BMI: 44 +/-6. Ethnicity:

NZ Europ. 60.0%

NZ Maori 31.1%

Pacific Is. 6.7%

Unspecified 2.2%

Obesity Related Disorders

Diabetes: 90%– Diet: 4%– Orals: 30%– Insulin: 66%

IGT: 7% OSA: 40% HTN: 93%

Patient Tracking post Surgery

Weight Loss Health Benefits Quality of Life (SF36) (2007 onwards) Complications

Avg % Baseline Weight Loss

0

5

10

15

20

25

30

35

0 0.5 1 1.5 2 2.5 3 3.5 4

Time in Years

% W

eigh

t Los

s

Weight Loss

Peaks at 1 yr at ~25% of Baseline Weight Loss Trend to regain some weight long term. At > 2Y post surgery:

% Base. Wt. <10% >10 - <20 >20 - <30 >30

% of Patients 13 60 20 7

Good Losers vs Poor Loosers:What’s the difference?

Formally compared weight loss between:– Ethnic groups– +/- previous AWMP participation– Male vs. Female– Age groups– Baseline Quality of Life Measurements (SF36)

What’s the difference?

Formally compared weight loss between:– Ethnic groups - none– +/- previous AWMP participation– Male vs. Female– Age groups– Baseline Quality of Life Measurements (SF36)

What’s the difference?

Formally compared weight loss between:– Ethnic groups - none– +/- previous AWMP participation - none– Male vs. Female– Age groups– Baseline Quality of Life Measurements (SF36)

What’s the difference?

Formally compared weight loss between:– Ethnic groups - none– +/- previous AWMP participation - none– Male vs. Female - none– Age groups– Baseline Quality of Life Measurements (SF36)

What’s the difference?

Formally compared weight loss between:– Ethnic groups - none– +/- previous AWMP participation - none– Male vs. Female - none– Age groups - Yes– Baseline Quality of Life Measurements (SF36)

% Base. Wt. Loss with Time in > 50 y/o vs < 50 y/o

0

5

10

15

20

25

30

35

40

45

3M 6M 1Y 2Y 3Y 4Y

Time in Months & Years

% B

asel

ine

Wei

ght L

oss

> 50 Y/O

< 50 Y/O

*

*

* *

What’s the difference?

Formally compared weight loss between:– Ethnic groups - none– +/- previous AWMP participation - none– Male vs. Female - none– Age groups - Yes– Baseline Quality of Life Measurements (SF36) -

Yes

Physical Function & Bodily Pain Scores:Negative Correlation with Future Wt Loss?

0

20

40

60

80

100

120

140

160

180

200

0 5 10 15 20 25 30

% Baseline Wt Loss

r = - 0.68 (rsq=0.47) Increased physical

limitations & bodily pain may predict better future weight loss.

Role Limitation due to Emotional & General Mental Health Sum of Scores:Positive Correlation with Future Wt Loss?

r = 0.52 (rsq = 0.27)

Suggests that poor mental health may carry a risk of poor future weight loss.

50

70

90

110

130

150

170

190

0 5 10 15 20 25 30

% Baseline Weight Loss

Additional Observations

Patient who tend to lose weight well in the first year, tend to do better long term.

Patients selected early in the programme tended to achieve less overall weight loss than those selected later in the programme.– Formally compare weight loss at 1 Y for patients

who received surgery from 2005-7 with those who received surgery in 2008.

% Base. Wt. Loss @ 1 Y: 2005-7 vs 2008 Surgeries

0

10

20

30

40

50

60

<10% 10-20% 20-30% >30%

% Baseline Weight Loss Categories

% o

f Pat

ient

s

2005-7

2008

2008 vs 2005-2007 Surgeries

Age: No difference SF36 QOL:

– Physical Function Score:– 65 (2005-2007 group) vs 28 (2008 group):

p=0.0004 Addition of Behavioural Therapist at the end

of 2007 @ the Surgical Obesity Service. Better selection of patient?

Health Improvements: Diabetes

Cure rate (as assessed by HBA1c)– Diet alone: 100%– Oral Rx: 73% (88%: able to D/C meds)– Insulin: 0%

60%: able to D/C insulin and onto orals or diet 40%: decrease insulin usage by 62%

Improvement in HBA1c of those not cured:– 8.9+/-2.3% to 7.4+/-1.5% (p=0.02)

Health Improvements:

OSA:– 41% were able to discontinue CPAP machine.

Hypertension– 26% D/C meds– 139/79 to 126/71: p=0.0003

Urine Microalbumin:Cr– 46% had normalisation of ratio

CRP– 9.8 to 2.8 mg/L: p=0.015

Health Improvements: Lipids

  Total C LDL-C HDL-C Tg

Baseline 4.43 2.56 1.16 2.09

> 1Y Post-Surgery 4.34 2.47 1.26 1.33

p value 0.68 0.6 0.05 0.0003

SF36 QOL Improvements

0

10

20

30

40

50

60

70

80

90

100

PF RL BP SF GMH RLE VEF GHP HCLY

Sc

ore Baseline

1Y

2Y

* **

**

** *

*

*

*

*

*

*

Surgical Complications

No mortalities Post-operative infections: 6% Abdominal surgery: 4% (adhesions) OGD for symptoms of obstruction:16%

– 29% of OGD were normal-no cause found

Nutritional Deficiencies

Routine supplementation:– All: MVI – Women: Ca & Fe/Folate

No detectable deficiencies

– < 16%

Nutrient % of Patients

Vitamin B12 52

Vitamin D 29

Iron 16

Protein 16

Vitamin E 2

Other Complications

Post-operative gout attack: 7% Renal Nephrolithiasis: 4% Bilateral Peripheral Neuropathy: 2% Psychological: 16%

– DSM Psychological Disorders with MH involvement: 44%

– Referral to psychologist privately: 56%

Roux en Y Gastric Bypass Surgery:Weight Loss

~13% fail to lose weight effectively (~20% in literature)

Tendency to regain some weight at 2 Y.

– Younger adults do better– Increased perceived bodily pain & poor physical

function prior to surgery – may do better.– Decreased mental health affecting function – may

do worse.*

Sugerman et al., Am. J. Surg. 1989. 157:93;Brolin et al., Surgery. 1989. 105:337. Maclean et al., Am. J. Surg. 1993: 165:155.*Herpertz et al., Obesity Res. 2004. 12: 1554.

Roux en Y Gastric Bypass Surgery:Health Benefits

Diabetes OSA Hypertension Lipids Markers of CV risk Quality of Life

Roux en Y Gastric Bypass Surgery:Complications

Of the patients who continue to f/u with > 1 Y data, 12% have had no complications to date.

Category % of Patients

Surgical 26

Nutritional 84

Psychological 16

Other 13

Roux en Y Gastric Bypass Surgery:Conclusions

Care with patient selection Care with patient preparation for best results

& expectations Continued monitoring for complications

– Surgical– Nutritional– Psychological

Acknowledgements

Waikato Diabetes Service

– Peter Dunn– Susie Ryan

Adult Weight Management Programme

– Sharon Moore

Surgical Obesity Service

– Carol Stidolph– Andrea Schroeder– Ann Monahan– Donna Southwick– Zola McDonald