Obesity Conquered!

Dr. Abeezar I. Sarela MSc (Lon) MS (Bom) MD (Leeds) FRCS (Glasg)

Consultant in Bariatric & Metabolic Surgery

What is Obesity?

• Body Mass Index

– BMI = Weight in kg/(Height in m)2

• Overweight: BMI > 23 kg/m2

• Obese: BMI > 25 kg/m2

What causes obesity?

• Many inter-connected causes: life-style, culture, environment, society– Mechanised transport, labour-saving devices,

sedentary jobs, easy availability of “fast-food”

• Basic issue: energy intake exceeds energy expenditure

• Genetic predisposition

• Specific hormonal problem is rare

Why all this fuss about obesity?

• Increasingly common problem – Epidemic!

• Obesity is a “slow-killer”

• Shortens life-span

– 30 yr old man with BMI > 40 will die 15 years sooner than normal-weight counterpart

• Spoils quality of life

Obesity causes life-threatening disease

• Diabetes

• High blood pressure

• High cholesterol– Heart-attack, stroke, kidney-failure

• Severe breathing difficulty– Obstructive sleep apnea, asthma

• Cancer– Kidney, colon, breast

Obesity Impairs Quality of Life

• Musculoskeletal problems

– Exacerbation of arthritis in weight-bearing joints

• Depression

• Decreased libido & Infertility

• Migraine

• Skin infections

Do not ignore obesity!

Chronic disease that needs scientifically-based medical treatment –

like any other chronic disease

Taking control of obesity

• Prevention of obesity

– Healthy lifestyle: diet and exercise

• Treatment of established obesity

– Needs an effective tool to return to normality

and then maintain a healthy lifestyle

How can the severely obese lose weight?

Sjostrom L et al. Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. N Engl J Med 2007;357:741-52.

What are the aims of treatment?

• Cure existing obesity-related diseases

• Reduce the risk of developing a obesity-

related disease in the future

• Improve quality of life

• Target BMI – as close as possible to 23

Indications for weight loss surgery?

• If BMI is 37.5 - 50 (Morbid Obesity)– Recommend surgery if committed life-style

change for 6 months has been unsuccessful

• If BMI is between 32.5 – 37.5 and there is diabetes or another illness– Recommend surgery if committed life-style

change for 6 months has been unsuccessful

• If BMI is > 50 (Super-Obesity)– Recommends surgery as “first-line” treatment

The Story of Bariatric Surgery

Bariatrics (created circa 1965)

• Branch of medicine that deals with causes, prevention, and treatment of obesity

• Greek roots: – bar- ("weight," as in barometer)– suffix -iatr ("treatment," as in paediatrics)– suffix -ic ("pertaining to")

• Encompasses diet, exercise, behavioural therapy, pharmacotherapy and surgery

Jejuno-Ileal Bypass

• 1950s

– University of Minnesota

• Malabsorption by bypass of most of the intestine

• Stomach intact

Gastric Bypass

• Open

– Mason & Ito

– 1960s

• Laparoscopic

– Wittgrove & Clark

– 1994

Vertical Banded Gastroplasty (VBG)

1970s

Biliopancreatic Diversion & Duodenal Switch

Open Biliopancreatic DiversionScopinaro, 1970s

Biliopancreatic Diversion+ Duodenal SwitchOpen: Hess, 1986

Laparoscopic: Gagner, 2002

Magenstrasse & Mill Operation

Prof David JohnstonThe General Infirmary at Leeds1980s

Laparoscopic Sleeve Gastrectomy

Adjustable Gastric Banding

Open- Kuzmak,1986Laparoscopic - 2000

Bariatric SurgeryJejuno-ileal bypass c. 1950 Abandoned

Open gastric bypass c. 1960 Currently performed

Vertical banded gastroplasty

c. 1970 Largely abandoned

Laparoscopic adjustable gastric band

c. 1990 Popular

Laparoscopic

Roux-en-Y gastric bypass

c. 1994 Gold standard

Laparoscopic sleeve gastrectomy

c. 2000 Selected indications

Bariatric Surgery: What is the Evidence that it Works?

• USA• 1984-2002• 7925 gastric bypass patients vs. 7925

weight and risk matched controls• Significantly ↓ mortality in bypass patients

– Overall mortality ↓ 40%– Coronary disease related mortality ↓ 56%– Diabetes related mortality ↓ 92%– Cancer related mortality ↓ 60%Long-Term Mortality After Gastric Bypass Surgery

NEJM 2007;357:753-61

Bariatric Surgery: What is the Evidence that it Works?

• 11 years follow-up• Bariatric surgery 2010 patients vs.

Conventional treatment 2037 patients• Weight loss

– Bypass: 2 years, 32%; 10 years, 25%– Banding: 2 years, 20%; 10 years, 14%

• Risk adjusted hazard ratio for death: bariatric surgery vs. conventional treatment – 0.70Effects of Bariatric Surgery on Mortality in Swedish Obese Patients

NEJM 2007;357:741-752

Bariatric Surgery: What is the Evidence that it Works?

• 22,094 patients• Excess weight loss

– Bypass: 60-75%– Band: 55-65%

• Operative mortality– Bypass: 0.5%– Band: 0.1%

• Diabetes: Resolved in 77%• Hypertension: Resolved in 62%• Obstructive Sleep Apnea: Resolved in 86%

Bariatric Surgery. A Systematic Review and Meta-Analysis. JAMA 2004;292:1724-1737

Effects of Bariatric Surgery on Type 2 DM A Systematic Review and Meta-analysis

• 621 studies: 1990-2006

• 135, 246 patients

• Women: 80%

• Mean BMI 48 kg/m2

• Resolution of T2DM : 78%

• Resolution or improvement: 84%Buchwald et al. Am J Med 2009;122:248-256

“I have got back my life after a bypass!”

• Diabetes, high blood pressure, high cholesterol, obstructive sleep apnea – cured in > 80%

• Average loss of 35-40% of initial weight in 12-18 months

• Vast improvement in mobility, vitality and enjoyment of life

How does bariatric surgery work?

• Restriction

• Conditional behaviour change

• Gut hormonal changes

• Increased energy expenditure

Components of Intestinal Bypass Procedures

Goldfine et alNature Med2009;15:616

Murphy & BloomNature2006;444:854

Gut Hormones

Anti-Incretins:The Effect of Duodenal Exclusion

Rubino & GagnerAnn Surg 2002

Perioperative Safety in Bariatric Surgery

• Surgeon

• Site

• Operation

• Patient

Obesity Surgery-Mortality Risk Score

Risk Factors

1. BMI≥50kg/m2

2. Male gender

3. Hypertension

4. Risk of PE

5. Age≥45y

Category No. of factors

Reported Mortality

A46-49%

0-1 0.2-0.3%

B48%

2-3 1.2-1.9%

C3-5%

4-5 2.4-7.6%

DeMaria et al. SOARD 2007DeMaria et al. Ann Surg 2007

Incidence of Composite

End-Point by OS-MRS

Class A: 4%229 patients

Class B: 6%137 patients

Class C: 23%15 patients

One death7% of OS-MRS C

0.3% of total

How to chose your surgeon?Questions you should ask?

• Did you get specialised training in bariatric surgery?– Where, for how long, were you an observer or

an appointed trainee?

• How many operations have you done?– Ask specifically about band, bypass & sleeve

• What complications have you seen?• What are the facilities in your hospital?

– Fully equipped operating theatre, team from different specialties, ICU

About your SurgeonDr Abeezar I. Sarela

• Program-appointed Higher surgical trainee in UK (1995-2000) and USA (2001-2002)

• Consultant Surgeon practising in UK since 2003• Trained with two bariatric surgery pioneers in

Leeds, UK– First laparoscopic gastric bypass in UK – Leeds, 2000– First laparoscopic sleeve gastrectomy in the world –

Leeds, 2000• How many operations?

– Bypass > 100, Sleeve > 100, Band > 100• Complications?

– One death after bypass – very high risk patient

Abeezar I. Sarela MSc MS MD FRCS

Consultant in Bariatric & Metabolic Surgery

e-mail: a.sarela@leeds.ac.uk

Phone: 9004426263