Bariatric Surgery Outcomes in Singapore · Lap gastric plication in January 2017 R Bte Pre-Surgery...
Transcript of Bariatric Surgery Outcomes in Singapore · Lap gastric plication in January 2017 R Bte Pre-Surgery...
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Bariatric Surgery Outcomes in Singapore
OBES21st October 2017
Dr Chun-Hai TanMBBS, Masters of Medicine (Surgery), FRCS (Edinburgh)
Consultant SurgeonMetabolic & Bariatric Surgery,
Minimally Invasive Upper GI Surgery
Department of General SurgeryKhoo Teck Puat Hospital
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Conflict of Interest
• No conflict of interest to declare
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Outline
• Obesity and Diabetes is a Singapore problem, and also a global health problem.
• Landmark papers around the world
• Diabetes remission and weight loss is durable after Bariatric Surgery– Other improvements: hypertension, hyperlipidemia, OSA, GERD
symptoms
• Our own local data– Outcomes for our own Randomized control trial– Outcomes of our Diabetic patients who underwent Diabetes Surgery
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Khoo Teck Puat Hospital, Singapore
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Diabetes: A global emergency
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Diabetes around the world
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Diabetes – The Singapore Problem
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National Day Rally 2017
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A Global Health problem
• T2DM and its related complications are a major cause of morbidity and mortality. This remains a problem for global health care
• Bariatric & Metabolic surgery is highly effective in the treatment for not just obesity, but also T2DM
• Other co-morbidities such as hypertension, hyperlipidemia, OSA also resolve after Bariatric Surgery
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Outcomes of Bariatric SurgeryWeight loss
Diabetes Remission
Papers from around the world
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No Surgery
DSS-II Summary
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• Landmark STAMPEDE trial
– 3 year outcome Bariatric Surgery vs Intensive Medical Therapy, NEJM 2014
STAMPEDE Trial – 3 year results
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STAMPEDE Trial – 5 year results
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Bariatric Surgery improves overall risk of mortality
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Conclusion –Bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality
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Bariatric & Metabolic Surgery- Resolution of OSA
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- All the procedures achieved profound effects on OSA- Over 75 % of patients saw at least an improvement in their sleep apnea- BPD was the most successful procedure in improving or resolving OSA
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Bariatric & Metabolic Surgery- Resolution of GERD Symptoms
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All common bariatric procedures improve GERD. Roux-en-Y gastric
bypass is superior to adjustable gastric banding and sleeve gastrectomy
in improving GERD. Also, the greater the loss in excess weight, the
greater the improvement in GERD score
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Our own Singapore/KTPH data
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2004 2005 2006 2007 2008 2009 2010 2011-2012 2013 2014 2015 2016
Adjustable gastric banding
102 131 52 12 15 17 87 8 3 2 1 0
Roux-en-Y bypass
0 0 0 1 2 9 25 69 70 103 93 79
Sleevegastrectomy
0 0 3 3 5 27 100 192 189 193 252 248
Scopinaro BPD 0 0 0 0 0 1 2 1 0 1 0
BPD DS 0 0 0 0 0 0 0 0 1 0 1 0
Gastric plication 0 0 0 0 0 0 0 0 1 0 1 1
Mini gastricbypass
0 0 0 0 0 0 0 27 14 0 0 0
Others 0 0 0 0 0 0 3 1 0 3 0 7
Total 102 131 55 16 22 54 215 259 282 308 349 335
Singapore OMSSS data
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Randomized Control Trial in Khoo Teck Puat Hospital, Singapore
• We aimed to show that Roux-en-Y Gastric Bypass (RYGB) is superior to best medical treatment in reaching well defined treatment end points in Asian subjects of BMI 27 to 32 with T2DM.
• We also aimed to show that successful surgical treatment of T2DM results in reduced resource utilization over medium to long term.
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Baseline Characteristic Comparison Between Both Treatment GroupsMEDICAL SURGICAL P Value
Gender Male 28.5% Male 80% -
Age (Mean ± SD) 47.1 ± 7.4 37.8 ± 10.8 0.052
DM Duration (years) 5.6 ± 3 5.2 ± 2.6 0.747
Weight (kg) 76.3 ± 9.5 76.7 ± 10 0.921
BMI (kg/m2) 29.7 ± 1.4 29.2 ± 1.7 0.520
Waist Circumference (cm)
96.7 ± 6 101.8 ± 6.2 0.102
F. Glucose (mmol/L) 10.5 ± 2.2 12.5 ± 2.1 0.073
HbA1c (%) 9.1 ± 0.7 9.9 ± 1.2 0.134
Total DM Drugs 2.7 ± 0.8 3 ± 0.7 0.550
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Data Comparison between both Treatment Arms
• Treatment over time interaction is significant *P <0.05
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• Treatment over time interaction is significant *P <0.05
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Data Comparison between both Treatment Arms
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KTPH DM Data (2012 – 2014)
Pre-op 6 months 12 months
Age (years old) 45 ± 11 - -
Race (%) Chinese 34%Malay 42%Indian 24%
- -
Sex (%) Male 59%Female 41%
- -
Weight (kg) 116.3 ± 29 82.1 ± 15 80.2 ± 13
BMI (kg/m2) 41.7 ± 7.9 37.2 ± 6.2 34.2 ± 5.8
Glycated Hb (%) 8.3 ± 1.9 6.7 ± 1.4 6.3 ± 1.2
LSG : RYGB 12 : 29 - -
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Weight and BMI change
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HbA1c trend post Bariatric Surgery
Pre-operative 6 months* 12 months*
Series1 8.3 6.7 6.3
0
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A1
c%
*P < 0.05
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Partial Remission rate for DM
6 months 12 months
Sleeve gastrectomy 41.7% 66.7%
RYGB 44.8% 65.5%
Overall 43.9% 65.8%
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Remission rates for DM – Sleeve / RYGB
Overall (%) of DM remisssion
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Our own patients
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Mr ARoux-en-Y Gastric Bypass in March 2015
PBW Pre-Surgery Post-Surgery
Weight 92 kg 76 kg
Hyperlipidemia Simvastatin 10mg ONFenofibrate 300mg OM
Off medications
Type 2 DM (7 years) HbA1c 9.6%Metformin 850mg TDSGlipizide 10mg OM, 5mg OA, 10mg ONCanagliflozin 300mg OMLiraglutide 1.8 mg ONInsulin detemir 10u/6u
HbA1c 6.2%Off medications
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Ms BLap gastric plication in January 2017
R Bte Pre-Surgery Post-Surgery
Weight 92 kg 83.5 kg
Hypertension Nifedipine 30mg OM Off medications
Hyperlipidemia Simvastatin 10mg ONFenofibrate 300mg OM
Rosuvastatin 5mg ON
Type 2 DM (4 years) HbA1c 9.2%Metformin 850mg BD
HbA1c 5.5%Off medications
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Roux-en-Y Gastric Bypass on 11 January 2016
I T Pre-Surgery Post-Surgery
Weight 161 kg 120 kg
Hypertension Valsartan 160mg OMAtenolol 50mg OMAmlodipine 10mg OM
Valsartan 160mg OMAtenolol 50mg OM
Hyperlipidemia Simvastatin 10mg ONFenofibrate 300mg OM
Off medications
Type 2 DM (9 years) HbA1c 10.8%Metformin 500mg TDSGlimeperide 4mg ONLiraglutide 1.8 mg ONInsulin detemir 10u/6u
HbA1c 5.8%Metformin 500mg OM
Mr C
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Mr D52% excess weight loss achieved over 15 months!
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Laparoscopic Sleeve Gastrectomy on 14 Sept 2015
68% excess weight loss over 15 months!
Pre-Surgery Post-Surgery
178.8 kg 107 kg
Mr E
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Lap Sleeve Gastrectomy on 2 April 2012
W K K Pre-Surgery Post-Surgery
Weight 171 kg 76 kg
Hypertension On Micardis Off medications
Mr F
94% excess
weight loss maintained over 5 years!
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Roux-en-Y Gastric Bypass on 4 May 2015
Mr G
K S Pre-Surgery Post-Surgery
Weight 104 kg 69 kg
Type 2 DM (3 years) HbA1c 9.6%Metformin 850mg TDSLiraglutide 1.2mg OMCanagliflozin 100mg OM
HbA1c 6.3%Metformin 500mg OM
100% excess
weight loss achieved over 19 months!
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Bioenteric Intragastric Balloon inserted on 30 January 2014
Mr H
98% excess weight
loss achieved over 6 months and maintained 3 years on!
J Pre-Procedure Post-Procedure
Weight 95.5 kg 72 kg
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Roux-en-Y Gastric Bypass on 14 September 2015
Mr I
79% excess weight
loss achieved over 15 months!
Pre-Surgery Post-Surgery
Weight 164 kg 94 kg
Hypertension Amlodipine 10mg OMEnalapril 2.5mg OM
Off medications
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Conclusion
Bariatric & Metabolic Surgery, Diabetes Surgery
• Bariatric & Metabolic surgery is indicated for weight loss, treatment of
metabolic syndrome, including diabetes in a select group of patients
• Established guidelines in the world, and in Singapore
• Long term, durable results achieved with Bariatric & Metabolic surgery
• Sustained weight loss
• Diabetes remission
• Resolution of co-morbidities such as OSA, Hypertension,
Hyperlipidemia, NAFLD, NASH, Arthropathy
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Conclusion
Bariatric & Metabolic Surgery, Diabetes Surgery
• Our own local data shows similar results. (Singapore Population)
• DM remission rates of 60-70% at 1 year
• We can do more to promote awareness of Bariatric & Metabolic Surgery,
“Diabetes” Surgery
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