a physician’s guide to bariatric & metabolic surgery

A physician’s guide to Bariatric & Metabolic Surgery

Nick Carter Consultant Upper GI & Bariatric Surgeon

Portsmouth Hospitals NHS Trust

Royal College Physicians GP Update Southampton April 2017


• What it is

• How we do it

• What is the evidence

• What are the results

• What are the problems

Professor Rachel Batterham BBC 2

April 2017

Obesity and related co-morbidities

[1] Adapted from Ashrafian H et al. Circulation 2008;118:2091–102.

Obesity

T2D

CV

Retinopathy

Neuropathy

Nephropathy

Hypertension

Hypercholesterolaemia

IHD/TIA/CVA

Obstructive Sleep Apnoea

Musculo-skeletal problems

Idiopathic

intracranial

hypertension

GORD

PCOS

ED/Male infertility

Thromboembolic

disease

Nutritional deficiencies Ferritin Folate Vit D

Gallstones, Urinary stress incontinence Dysmenorrhea or amenorrhea Osteoarthritis, Depression Cancer : Colon, Breast, Endometrial, Oesophageal, Gallbladder

How do you refer a patient for surgery?

• NICE criteria

• Local Tier 3 program • Weigh Ahead (Spire NHS service) - Southampton

• Integrated Complex Obesity Service (ICOS) - Portsmouth

Bariatric surgery is a treatment option for anyone with a BMI≥40 Offer an expedited assessment for people with a BMI≥35 with onset of type 2 diabetes in past 10 years Consider an assessment for people with a BMI of 30-34.9 with onset of type 2 diabetes within 10 years Consider an assessment for people of Asian origin with onset of type 2 diabetes at a lower BMI than other populations Bariatric surgery is the option of choice for adults with BMI >50 when other interventions have not been effective People fitting the above criteria are also required to be receiving or to receive assessment in a specialist weight management service before referral to a surgical team

Tier 4

MDT

Physician

Anaesthetist

Dietitian Specialist

Nurse

Psychologist Surgeon

Surgery

• 2 week liver reducing diet

• Laparoscopic surgery

• 3x12mm, 2x5mm ports

• 1 – 1½ hours

• Drinking same day

• Sloppy diet day 1 post op

• Home day 1 or 2

• 8 week post operative diet

Bariatric Surgery Follow Up

• 2/52 LMWH, 3/12 PPI

• LRGYB/LVSG – Multivitamins, Calcium, Iron

• 2 year follow by hospital

• 3/12 visits

– Dietitian, Nurse specialist, Surgeon, Physician

• Monitor vitamin levels

22 randomised controlled trials of bariatric surgery found that it is more effective and cost effective for the treatment of severe obesity than non-surgical measures after two years.

Review of the key results from the Swedish Obese Subjects (SOS) trial - a prospective controlled intervention study of bariatric surgery.Sjöström L. J Intern Med. 2013 Mar;273(3):219-34. doi:

10.1111/joim.12012. Epub 2013 Feb 8. Review.

http://www.ncbi.nlm.nih.gov/pubmed/23163728





2500 surgical patients, 7400 matched controls

JAMA. 2015;313(1):62-70. doi:10.1001/jama.2014.16968

Review of the key results from the Swedish Obese Subjects (SOS) trial - a prospective controlled intervention study of bariatric surgery.Sjöström L. J Intern Med. 2013 Mar;273(3):219-34. doi:

10.1111/joim.12012. Epub 2013 Feb 8. Review.






Body of Evidence High Quality (Level I & II-1,2) Studies on Bariatric / Metabolic Surgery in Diabetic Patients

Investigator Study Type # Diabetic Patients Primary Endpoint Study Duration

Carlsson Non-randomized, prospective,

controlled 3429 pts, 2 arms (1658 surgery)

Rate of incident type 2 diabetes mellitus

15 years

STAMPEDE (Schauer)*

RCT, single center 150 pts, 3 arms HbA1c < 6 with or w/o meds Year 1 of

5-year study

Mingrone RCT, single center 60 pts, 3 arms HbA1c < 6.5 without meds 2 years

Buchwald* Systematic Review &

Meta-Analysis 135,000 pts, 621 studies,

888 arms Effect of bariatric surgery on

Type 2 diabetes N/A

Klein* Matched Cohort, Claims data 1600 pts, 2 arms Economic impact & clinical benefits of bariatric surgery

3 years

AHRQ (Segal)* Matched Cohort, Claims data 8400 pts, 2 arms (2100 surgery)

Impact of surgery to reduce utilization of CV meds

Year 1 of 3-year study

Bolen* Matched Cohort, Claims data 14,000 pts, 2 arms

(6300 surgery) % Obesity-related co-

morbidities between groups 5 years

Cohen Non-randomized, prospective 66 pts, 1 arm Safety and % of patients experiencing diabetes

remission

5 years (median)

342 patients, median 48.6 months follow up

For patients with a body mass index (BMI) ≥40, the incremental cost effectiveness ratios for surgery ranged between £2000 and £4000 per quality adjusted life year (QALY) gained over 20 years

Bariatric surgery is a treatment option for some patients with severe obesity, particularly those with type 2 diabetes. Such patients should be assessed for their suitability for this treatment

In patients with diabetes the cost of surgery will be recouped within three years through reduced prescriptions.

Obesity (2011) 19, 581–587

Rates of bariatric surgery per 100,000

0 20 40 60 80 100 120 140 160

UK

Greece

Italy

Czech Republic

Finland

Portugal

Iceland

Austria

USA

France

Sweden

Belgium

Israel

Post Bariatric Surgery Complications

• Gastric Bands – red flags

– Infection over port site

– Epigastric pain

– Reflux

– Dysphagia/vomitting


• Bypass surgery – red flags

– Recurrent severe LUQ pain

– Bowel obstruction

– Nutritional deficiencies

– Ulcers

– Pregnancy


• Sleeve Gastrectomy– red flags

– Reflux

– Vomiting

– Pregnancy

Diagnosis: Initial morbid obesity, weight 192.6 kilos, BMI 59 Treatment: Laparoscopic gastric bypass February 2012. Current weight 114 kilos, BMI 34.

Bile Salt theory

Microbiome theory

a physician’s guide to bariatric & metabolic surgery

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