Bariatric surgery prevents cardiovascular events

Transcription

B
ISSUE 10 | January 2012
ARIATRIC
NEWS
A snapshot of
THE NEWSPAPER DEDICATED TO THE TREATMENT OF OBESITY FOR THE HEALTHCARE PROFESSIONAL
IN THIS ISSUE...
Jacqueline
Jacques discusses
the nutritional
deficiencies in
obese and postoperative patients. Patients who undergo gastric bypass surgery are less likely to die from cardiovascular events than people who receive
more conventional treatment for their weight condition, according to the latest results from the Swedish Obese Subjects
(SOS) study. The research was recently published in the Journal of the American Medical Association Source (Sjostrom et
al. JAMA 2012; 307: 56-65).
4
ASMBS updates SG position
statement
The Association has updated its position
on sleeve gastrectomy. 6
Coffee Time
We talk to Professor
Philip James about
his achievements
and the battle
against the obesity
pandemic. The Halo effect
11
IFSO 2011
14
EBT white paper
A joint TaskForce has released a white
paper on endoscopic bariatric therapies
“Bariatric surgery was associated
with about a 30% reduction in the incidence of both
heart attacks and strokes,” said researcher Professor Lars Sjostrom, University of Gothenburg, Sweden. “While pre-surgery BMI did not predict surgical
health outcomes, having diabetes or risk factors for diabetes was a strong indicator of surgical benefit. This
could have implications for selecting candidates for
weight loss surgery.”
Swedish Obese Subjects
The SOS study is an on-going, non-randomised, prospective, controlled study conducted at 25 public surgical departments and 480 primary health care centres
in Sweden, and includes 2,010 obese participants who
underwent bariatric surgery and 2,037 matched obese
controls who received usual care (control group). The
research is testing the hypothesis that bariatric surgery
is associated with a reduced incidence of cardiovascular events and examining the relationship between
weight change and cardiovascular events.
Patients were recruited between September 1987
and January 2001. The date of analysis was December
2009, with median follow-up of 14.7 years. Inclusion
7
A report from
the 2011 IFSO
meeting in
Hamburg, Germany. Bariatric surgery prevents
cardiovascular events
Vector Created by: Matt Ward/Echo Enduring Media - www.echoenduring.com
(c) 2009; Distributed under the Creative Commons lisence.
Nutrition
According to
research, family
members of
patients who have
undergone bariatric
surgery have
reported weight loss
and improvements
in their lifestyles. pages 12–13
18
Product news 20
News in Brief 21
Calendar of events 22
criteria were age 37 to 60 years and a body mass index of at least 34 in men and at least 38 in women. Surgery patients underwent gastric bypass (13.2 per cent),
banding (18.7 per cent), or vertical banded gastroplasty (68.1 per cent), and controls received usual care in
the Swedish primary health care system. Physical and
biochemical examinations and database cross-checks
were undertaken at pre-planned intervals.
The average changes in body weight after 2, 10,15,
and 20 years were 23 per cent, 17 per cent, 16 per cent,
and 18 per cent in the surgery group and 0 per cent, 1
per cent, 1 per cent, and 1 per cent in the control group,
respectively.
Continued on page 3
Complications and costs of bariatric surgery
According to two recently published papers in the British
Journal of Surgery (October 2011; 98 [10]), long-term
complications and further surgery are not uncommon,
but despite these disadvantages surgery is a more costeffective way of tackling rising morbid obesity rates than
non-operative care.
The first paper entitled, ‘Man-
agement of late postoperative complications of bariatric surgery’ (Hamdan
et al.) examined the increasing number
of patients presenting to non-specialist
units with complications following bariatric procedures and outlined the management of the most common late post-
operative complications that are likely
to present to the general surgeon.
“In England, there are more than
30,000 deaths a year attributed to obesity alone, taking an average of nine years
off a person's normal life expectancy,”
said the lead author of the paper, consultant surgeon Mr Khaled Hamdan, Di-
gestive Diseases Unit at Brighton and
Sussex University Hospitals. “As a result of the current, largely ineffective,
non-surgical options for treating obesity, the past decade has witnessed an exponential increase in the number of bariatric operations performed.”
Therefore, the researchers undertook a literature search for late postoperative complications after bariatric
surgery using PubMed, Embase, OVID
and Google search engines, and combinations of the terms bariatric surgery, gastric bypass, gastric banding
or sleeve gastrectomy, and late or delayed complications. Only studies with
follow-up longer than six months were
included.
Complications
The most common long-term complications after gastric banding include band
slippage (which affects 15% to 20% of
patients) and erosion (which can affect
up to 4% of patients). Following gastric bypass, complications such as internal hernia (5% to 10%), adhesions and
anastomotic stenosis were found to be
common causes of intestinal obstruction. Megaoesophagus (dilation of the
esophagus), a rare but well reported late
complication occurs in one in every 200
patients after LAGB and hepatobiliary
complications were another particular
challenge, the researchers noted.
The study found that functional disContinued on page 4
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BARIATRIC NEWS 3
Surgery reduces events
Continued from page 1
Mortality
During follow-up, there were
49 cardiovascular deaths among
the patients in the control group
and 28 cardiovascular deaths
among the patients in the surgery group (adjusted hazard ratio [HR], 0.47; 95% CI, 0.760.29; p=0.002). In total (fatal
and non-fatal), there were 234
cardiovascular events among
patients in the control group
and 199 cardiovascular events
among patients in the surgery
group adjusted HR, 0.67; 95%
CI, 0.54-0.83; p<0.001). After
adjustment for a number of variables, bariatric surgery was associated with a reduced number
of fatal cardiovascular deaths
and a lower incidence of total
cardiovascular events.
Bariatric surgery was associated with reduced number of
fatal heart attack deaths (22 in
the surgery group vs. 37 in the
control group), with analysis indicating that bariatric surgery
was related both to reduced fatal heart attack incidence and total heart attack incidence. Also,
bariatric surgery was associated
both with reduced number of fatal stroke events and total stroke
events.
Interestingly, the researchers found no significant rela-
tionship between weight change
and cardiovascular events in the
surgery or control group. They
suggest that the lack of association between weight loss and reduction of cardiovascular events
could be related to inadequate
statistical power to detect this
relationship.
“Alternatively,
following relatively modest weight
loss induced by bariatric surgery, there is no further risk reduction attributable to greater, subsequent weight loss,”
the authors note. “Our negative findings also emphasise the
need to explore weight loss independent of effects of bariatric surgery."
“In conclusion, this is the
first prospective, controlled intervention to our knowledge reporting that bariatric surgery is
associated with reduced incidence of cardiovascular deaths
and cardiovascular events.
These results - together with
our previously reported associations between bariatric surgery and favourable outcomes
regarding long-term changes
of body weight, cardiovascular
risk factors, quality of life, diabetes, cancer, and mortality demonstrate that there are many
benefits to bariatric surgery and
that some of these benefits are
independent of the degree of the
surgically induced weight loss."
Editorial
In an accompanying editorial in JAMA (2012; 307 8889), Dr Edward H Livingstone,
University of Texas Southwestern Medical Center, Dallas, argues that the benefits from bariatric surgery are not related
to weight loss, the main reason these operations are performed. He also adds that the
absolute difference in cardiovascular events and deaths between the surgery and non-surgery groups in these latest SOS
data was small.
“Obese patients who are
otherwise healthy should not
have bariatric surgery, because the expected health benefits do not necessarily exceed
the risks of weight-loss operations,” he concludes. “People
with abdominal obesity may
be at higher risk for heart problems than people with higher
fat mass in the trunk and legs.
It may be time for experts to reconsider the criteria for recommending bariatric surgery and
to rigorously assess the available evidence and provide updated recommendations for
bariatric procedures for the
treatment of obesity.”
Target surgical outcome depends
on disease severity
The optimum bariatric operation
depends on the disease severity and the type of
outcome that best suits patients with type 2 diabetes mellitus (T2DM), according to research
published online in the October 2011 issue of
the Annals of Surgery. The study, conducted by
investigators at the University of Minnesota in
Minneapolis, concluded that after one year of
follow-up, Roux-en-Y gastric bypass (RYGB)
was superior to non-surgical controls (NSC)
and laparoscopic adjustable gastric band surgery (LAGB) with respect to weight loss and improvement in diabetes.
“This study provides an important perspective
about the comparative efficacy of LAGB, duodenal switch (DS), and NSC to the RYGB for treatment of T2DM among obese patients,” said lead
author Dr Robert B Dorman. “We concluded that
if the endpoint is to improve HbA1c, then the DS
is the superior operation compared to the RYGB
for patients with a high BMI.”
Although it is known that RYGB resolves
T2DM in a high proportion of patients and is
considered the standard operation for T2DM
resolution in morbidly obese patients, no data
exists comparing the efficacy of medical management and other bariatric operations to the
RYGB for treatment of T2DM in comparable
patient populations.
Study design
As a result, investigators designed the study to
compare the relative efficacy of medical management, DS, and LAGB to RYGB for treatment of T2DM. They performed a retrospective
case-matched study of 86 morbidly obese patients with T2DM who had undergone medical
management (nonsurgical controls [NSC]; n=29),
LAGB (n=30), or DS (n=27) and were compared
with matched T2DM patients who had undergone
RYGB.
Matching was performed with respect to age,
sex, body mass index, and hemoglobin A1C
(HbA1C). Outcomes assessed were changes in
body mass index, HbA1C, and diabetes medication scores at one year.
Results
At one year, RYGB produced the greater weight
loss, HbA1C normalisation, and medication score
reduction compared to both NSC and LAGBmatched cohorts. However, DS led to significantly greater improvements in HbA1c and diabetes
medication scores and a higher rate of diabetes
resolution (81.5% vs 48.1%; p=0.02), despite no
greater weight loss at one year.
Complication rates at one year were 10% for
LAGB, 15.1% for RYGB, and 40.7% for duodenal switch. One-year readmission rates were 6.7%
for LAGB, 11.6% for RYGB, and 14.8% for duodenal switch. There were no deaths.
According to the researchers, RYGB should remain the gold standard for treatment of severe or
greater obesity in the setting of type 2 diabetes, as
the procedure has better outcomes than both medical management and the laparoscopic banding.
However, they added that for super-obese patients
(BMI> 50kg/m2), the duodenal switch should be
considered, although only performed by experienced surgeons and centres.
Message from the editor
Welcome to the
first edition of Bariatric News of 2012 and I
would like to take this
opportunity to wish
you all the very best for
2012!
This month’s cover
article
features
the latest data from
the Swedish Obesity
Study.
Our second cover story highlights two studies
from the British Journal of Surgery that highlight the
complications and cost effectiveness associated with
bariatric surgery.
In this issue’s ‘Coffee Time’ section we are
pleased to feature an interview with Professor Philip James, a world-renowned campaigner of obesity
awareness and current President of the IASO.
Following the recent XVI IFSO meeting in Hamburg, we report the highlights from the meeting, We
also feature a subsequent report from International Bariatric Club.
In this issue we also feature a position statement
update on sleeve gastrectomy from the ASMBS, as
well as a white paper joint published by the ASMBS
and ASGE on endoscopic bariatric therapies.
The 'Snapshot' feature in this edition highlights
Canada, and a new report describing rates of obesity
and those most at risk.
There is also news from SOBA (the UK's bariatric
anaesthetist organisation), and BAPRAS (a UK plastic surgery group), who are calling for body contouring guidelines.
There are also a study from Canada that recommends a new scoring system for predicting risk from
bariatric surgery.
As ever, we also report the latest product news
If you would like to contact the editor, please email: [email protected]
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2012 Copyright ©: Dendrite Clinical Systems Ltd. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any other means, electronic, mechanical,
photocopying, recording or otherwise without prior permission in writing of the Managing Editor. The views,
comments and opinions expressed within are not necessarily those of Dendrite Clinical Systems or the Editorial
Board.
and clinical trial updates, as well as quick look at the
latest news in our 'News in Brief' section.
We hope you find this issue an interesting and informative read. If you would like to comment on any
of the articles or have an article suggestion please do
not hesitate to contact us.
Owen Haskins, Editor
4 BARIATRIC NEWS
Obesity: A state of malnutrition?
Jacqueline Jacques, ND
Obesity is commonly referred to in
textbooks of nutrition and medicine
as “over-nutrition.” It is easy, even
for trained physicians, to look at a
severely obese patient and assume that
an excess of stored calories must mean
an excess of (or at least adequate)
vitamins and minerals. However, the
more study we do in this area, the
more we see quite a different picture
emerge. Obesity places great physiologic strain on the
human body – and that strain takes a toll on many systems
including on nutritional status.
Studies
increasingly
demonstrate significant defi-
ciencies in many nutrients in those suffering from morbid obesity. These include, but are not limited to Vitamin E1,
Vitamin A and the Carotenoids2, Zinc3,
Selenium3 and Thiamine4. The most
recent data from the Third National
Health and Nutrition Examination Survey (NHANES III: 1988–1994) showed
that higher BMI was associated with deficiency of vitamins, A, E, C, D, selenium, folate and carotenoids.5 Vitamin
D deficiency is so common in morbid
obesity that it should most likely be considered a comorbidity.6
Despite emerging research, we have
still limited knowledge of the true nutritional status of obese individuals.
Most industrialized countries general-
ly favour calorie-dense, nutrient-poor
diets that supply less than the recommended amounts of many vitamins
and minerals. We have growing reason to believe that obesity and some
of its common co-morbid conditions
like diabetes create greater nutritional demands on the body, perhaps contributing to deficiency. Thus, individuals with obesity may have nutritional
requirements that are over and above
the normals on which the recommended intakes are based. Limited studies
that have looked at overall nutritional
status in obese populations have demonstrated that this is likely to be true,7
but more data is needed to determine
what nutritional challenges are a direct
result of obesity, versus those that may
correlate with other factors such as age
or economic status.
Why is this important?
Good nutritional status is a marker for
good health. When patients are preparing for a major surgical procedure, their
nutritional status may have an impact
on both short and long-term outcomes.
Good nutritional status is important for
Complications and costs
of bariatric surgery
Continued from page 1
orders such as reflux and dumping, and
nutritional deficiencies are common and
should be differentiated from conditions
that require urgent investigations and timely surgical intervention. Up to one-third of
patients experience intermittent gastrointestinal disturbances, particularly if they do
not adhere to the dietary advice and nutritional supplements they are given after surgery. Between 13% and 36% of patients develop cholesterol gallstones after surgery,
due to rapid weight loss, but only 10% develop symptoms requiring surgical intervention.
Less than 5% to 10% of patients have
chronic problems with dumping syndrome,
which can cause facial flushing, light-headedness and diarrhoea after eating carbohydrate-rich meals. Most patients find that reducing their intake of carbohydrates and
avoiding drinking liquids half an hour before and after eating improves their symptoms.
The authors note that complications after
bariatric surgery should be thoroughly assessed and investigated. They highlight the
fact that a patient's symptoms may not necessarily relate to their gastric surgery and
stress that the attending surgeon should be
familiar with bariatric procedures and gastrointestinal alterations following surgery.
“Managing these patients can be challenging for a non-bariatric surgeon and timely
liaison with a bariatric unit is advisable,”
the authors emphasized. “In addition, functional problems affecting the gastrointestinal tract may pose a diagnostic conundrum,
requiring specialist intervention and liaison
with specialists in the field when necessary
to spare patients unnecessary surgical interventions.”
The researchers stressed that long-term
complications should be taken into consideration when deciding what type of surgery
to undertake.
Cost-effectiveness
The second paper entitled ‘Cost-utility of
bariatric surgery for morbid obesity in Finland’ (Mäklin et al) from the Finnish Office
for Health Technology Assessment reported that bariatric surgery is more cost-effective as it increases health-related quality of
life and reduces the need for further treatment, and total healthcare costs among patients who are very obese.
“Our study compared bariatric surgery
with the current practice in treating morbid obesity in Finland, which is ordinary
treatment ranging from intensive conservative treatment to brief advice from a doctor to lose weight,” said Ms Suvi Mäklin,
lead author. “This was evaluated using data
on healthcare resource use in patients with a
body mass index of 35 kg/m2 or more from
a large representative population survey.”
The study evaluated the cost–utility of
the following bariatric surgery procedures
– gastric bypass, sleeve gastrectomy and
gastric banding – compared with ordinary
treatment. Mäklin explained that an analysis was performed from a healthcare provider's perspective using a combination of
a decision tree and a Markov model, with
a time horizon of ten years. Health-related
quality of life was estimated from a representative population survey, and other parameter values were based on registers,
systematic reviews, controlled studies and
expert opinion.
The results showed that in the base-case
analysis, bariatric surgery was more effective and less costly than the ordinary treatment. The mean costs of treating an obese
patient with bariatric surgery in Finland
was €33,870 compared with €50,495 for
non-operative treatment. These cost savings
are due to reductions in other health conditions after surgery.
The research team also reported that bariatric surgery also increased the number of
quality-adjusted life 7.63 vs. 7.05, for bariatric surgery and ordinary treatment, respectively, during the ten-year time frame
they studied. Uncertainty around the parameter values was tested comprehensively
in sensitivity analyses, and the results were
robust, said the researchers.
“Surgery for morbid obesity improves
health-related quality of life and reduces the need for further treatments and total
healthcare costs,” the researchers concluded. “The present results suggest that, compared with surgical treatment, non-operative care will on average be more costly for
the Finnish healthcare system five years after surgery.”
normal wound healing, immunity and
recovery times, and some of the specific nutrients that have been shown to be
impaired in obesity, are directly correlated with these outcomes8-12. Following
bariatric surgery, the early weeks and
months present patients with varying
degrees challenges to nutrient intake,
which may be complicated by episodes
of vomiting and dumping. Moreover,
risk for nutrient deficiencies continues
to increase over time in patients with
malabsorptive procedures such as gastric bypass. Increasing our understanding of pre-operative nutrition may lead
not only to better patient health and improved recovery, but also to predictive
models of who may be at greatest risk
for early onset of post-operative nutritional deficiencies. This kind of information could eventually help to answer
questions about why some patients develop acute nutritional problems, while
others remain deficient. Finally, healthier patients with better outcomes are
good for the entire bariatric surgery
community. The more that can be done
to assure patient health, the more successful everyone is.
References:
1. Ohrvall M, Tengblad S, Vessby B. Lower tocopherol serum
levels in subjects with abdominal adiposity. J Intern Med
1993;234:53±60.
2. Pereira S, Saboya C, Chaves G, et al. Class III Obesity and
its Relationship with the Nutritional Status of Vitamin A in
Pre- and Postoperative Gastric Bypass. Obes Surg. 2008
Apr 8. [Epub ahead of print]
3. Madan AK, Orth WS, Tichansky DS, et al. Vitamin and
trace mineral levels after lap§ohill BC, et al. Associations
between body mass index and the prevalence of low micronutrient levels among US adults. MedGenMed. 2006
Dec 19;8(4):59.
6. Wortsman J, Matsuoka LY, Chen TC, et al. Decreased
bioavailability of vitamin D in obesity. Am J Clin Nutr. 2000
Sep;72(3):690-3.
7. Ledikwe JH, Smiciklas-Wright H, Mitchell DC, Jensen GL,
Friedmann JM, Still CD. Nutritional risk assessment and
obesity in rural older adults: a sex difference. Am J Clin
Nutr. 2003 Mar;77(3):551-8.
8. Swartz-Basile DA, Rubin DC, Levin MS. Vitamin A status
modulates intestinal adaptation after partial small bowel
resection. JPEN J Parenter Enteral Nutr 2000;24:81–8.
9. Thomas DR. Specific nutritional factors in wound healing.
Adv Wound Care 1997;10:40–3 [review].
10.Senapati A, Slavin BM, Thompson RPH. Zinc depletion and
complications of surgery. Clinical Nutrition 1990;9:341–6.
11.Zunic J, Stavljenic-Rukavina A, Granic P, et al. Changes in
vitamin E concentration after surgery and anesthesia. Coll
Antropol 1997;21:327–34.
12.Thomas DR. Specific nutritional factors in wound healing.
Adv Wound Care 1997;10:40–3 [review].
6 BARIATRIC NEWS
Mechanisms of action of the adjustable gastric band:
Induction of satiety, not physical restriction
Wendy A. Brown, Paul R. Burton, Paul
E. O’Brien Centre for Obesity Research and
Education, School of Public Health, Monash
University Australia
The laparoscopic adjustable gastric band
(LAGB) is ideally placed on the cardia
of the stomach, just below the oesophagogastric junction. In the past it was assumed that the presence of a band in this
position caused a meal to accumulate in
the pouch of stomach proximal to it, before gradually being released into the remainder of the gut. Thus, the band was
thought to work by restricting the volume of food ingested to that able to be
a
e
b
f
accommodated in the proximal pouch.
This small volume of food was thought
to stretch the stomach and cause early
satiety. Gradual emptying of the proximal pouch into the infra-band stomach
was though responsible for prolonged
inter-meal satiation.
Recent studies by our group, lead by
Dr Paul Burton, confirm that mechanism
of action of LAGB is the induction of
early and prolonged satiety, however,
the intraluminal events that lead to this
are far more complex than simple retention of food in the proximal pouch.
By combining high resolution video manometry1-4 with nuclear studies of
c
g
d
gastric emptying5, 6, we have demonstrated that the expected physiology of a
LAGB at its optimal volume does not
cause a food bolus to rest above the band
in the proximal pouch. Rather, the bolus
will transit across the band in stages over
a period of 45-60 seconds due to 4-6 repeated contractions of the lower oesophagus. The infra-band stomach subsequently empties normally (figure 1)7.
The increased activity of the lower oesophagus and upper stomach appears to be critical to the sensation of
satiety achieved with a small meal. Animal studies modelling the human situation performed by Dr Brian Oldfield’s 8
group suggest that the vagus is an important mediator of this sensation, and the
flow of food past an optimally activated
band may be triggering these afferents.
If a band is over-adjusted, or if patients engage in inappropriate eating behaviour, eating too quickly or too big a
volume, food will accumulate within the
proximal pouch. The patient will experi-
ence significant adverse symptoms, including discomfort and regurgitation.
These symptoms are caused by vigorous
peristaltic contractions that hyper-pressurise the proximal pouch in an attempt
to transit the bolus across the band. Over
time, this increase in pressure can lead to
pathological proximal pouch formation9.
If a band is underfilled, there is no
limitation to transit of food across the
LAGB and therefore the proximal stomach and lower oesophagus are not stimulated. The patient will not be satiated
a small meal and be able to eat bigger
volumes. Unsurprisingly, weight loss is
then difficult to achieve and maintain.
Dr Burton’s work has helped us to
understand the optimal intraluminal
pressure milieu in the presence of a band
(figure 2) 1. Ideally we would use these
data to objectively calculate an optimal
adjustment for an individual patient, but
as yet we lack technology to permit this.
Understanding how an AGB affects
the intraluminal pressures and flow of
1. Distal oesophagus: Peristalsis
High pressure – 100+ mmHg
h
2. Lower Oesophigal Sphincter:
Attenuated – 11mmHg
Relaxation, then after-contraction
3. Proximal stomach:
Sensory (the IGLEs) + tonic contraction
Figure 1: Diagram depicting how a bolus of food transits across the band. The food is ingested and
reaches the proximal pouch via primary peristalsis (a-b); a small amount of food transits the band and
the remaining bolus refluxes back into the oesophagus before a contraction of the lower oesophagus
pushes it back into the proximal pouch (c-e). The process is repeated until the bolus completely transits
the band (f-g).
4. Gastric band optimally adjusted:
Basal pressure 25-30 mmHg
Figure 2: The correct position of a LAGB and optimal intraluminal pressure milieu
food with eating has allowed us to improve our patient education. We work
closely with our patients, explaining the
critical importance of eating small volumes of food slowly. We also aim to adjust the band only to control hunger. We
hope that this improved patient education
along with better band adjustments will
help improve our outcomes, both in terms
of weight loss and complication rate.
References:
1. Burton PR, Brown W, Laurie C, Richards M, Afkari S,
Yap K, Korin A, Hebbard G, O'Brien PE. The effect of
laparoscopic adjustable gastric bands on esophageal
motility and the gastroesophageal junction: Analysis
using high-resolution video manometry. Obes Surg.
2009;19:905-914
2. Burton PR, Brown WA, Laurie C, Richards M, Hebbard
G, O'Brien PE. Effects of gastric band adjustments on
intraluminal pressure. Obes Surg. 2009;19:1508-1514
3. Burton PR, Brown W, Laurie C, Lee M, Korin A, Anderson M, Hebbard G, O'Brien PE. Outcomes, satiety, and
adverse upper gastrointestinal symptoms following laparoscopic adjustable gastric banding. Obes Surg. 2010
4. Burton PR, Brown WA, Laurie C, Hebbard G, O'Brien
PE. Mechanisms of bolus clearance in patients with
laparoscopic adjustable gastric bands. Obes Surg.
2010;20:1265-1272
5. Burton PR, Yap K, Brown WA, Laurie C, O'Donnell M,
Hebbard G, Kalff V, O'Brien PE. Effects of adjustable
gastric bands on gastric emptying, supra- and infraband
transit and satiety: A randomized double-blind crossover
trial using a new technique of band visualization. Obes
Surg. 2010;20:1690-1697
6. Burton PR, Yap K, Brown WA, Laurie C, O'Donnell M,
Hebbard G, Kalff V, O'Brien PE. Changes in satiety, supra- and infraband transit, and gastric emptying following
laparoscopic adjustable gastric banding: A prospective
follow-up study. Obes Surg. 2010
7. Burton PR, Brown WA. The mechanism of weight loss
after laparoscopic adjustable gastric banding: Induction
of satiety not restriction. International Journal of Obesity.
2011;35
8. Kampe J, Brown WA, Stefanidis A, Dixon JB, Oldfield
B. A rodent model of adjustable gastric band surgeryimplications for the understanding of underlying mechanisms. Obesity Surgery. 2009;19:625-631
9. Burton PR, Brown WA, Laurie C, Korin A, Yap K, Richards M, Owens J, Crosthwaite G, Hebbard G, O'Brien
PE. Pathophysiology of laparoscopic adjustable gastric
bands: Analysis and classification using high-resolution
video manometry and a stress barium protocol. Obes
Surg. 2010;20:19-29
ASMBS update sleeve gastrectomy position statement
The American Society for
Metabolic and Bariatric Surgery (ASMBS) has published an updated position
statement on the use of sleeve gastrectomy (SG). The position statement update was published as the Clinical Issues
Committee and Executive Council have
determined that since the 2009 position
statement on SG was issued, there have
been substantial changes to the published literature regarding the procedure
and that the number and quality of the
publications evaluating SG warrant publication of an updated statement.
Following a review of published literature, the ASMBS concluded that
there is now substantial comparative
and long-term data demonstrating durable weight loss, improved medical comorbidities, long-term patient satisfaction, and improved quality of life after
SG. The ASMBS therefore recognizes
SG as an acceptable option as a primary
bariatric procedure and as a first stage
procedure in high risk patients as part
of a planned staged approach. The position statement states that based on the
current published literature, SG has a
risk/benefit profile that lies between the
laparoscopic adjustable gastric band
and the laparoscopic Roux-en-Y gastric bypass.
The recommendations of the 2009
position statement was based on a systematic literature review and reported overall mean percent excess weight
loss (%EWL) after SG of 55% (average follow-up less than three years) and
complication rates in large single cen-
tre series (n>100) ranged up to 15%.
The reported leak, bleeding, and stricture rates in the systematic review
(which included high risk patients) were 2.2%, 1.2%, and
0.63%, respectively, and the
post-operative 30-day mortality rate was 0.19% in the published literature.
An updated search of the literature revealed 69 studies published since the last position statement, which provides relevant outcome
data to support updated recommendations. This new literature includes several randomised controlled trials that generally show equivalence or superiority
of the laparoscopic SG to currently accepted procedures (Roux-en-Y gastric
bypass, RYGB, and laparoscopic adjustable gastric banding, LAGB) with short
and medium-term follow-up periods.
In addition to the randomized trials,
there are several matched cohort, prospective and case control studies that demonstrate weight loss outcomes, diabetes
remission rates, improvements in inflammatory markers and cardiovascular risk,
and improvements in a variety of obesity-related comorbidities after SG that are
equivalent to or exceed RYGB and LAGB
procedures. Remission rates of type 2 diabetes after SG are typically reported between 60% and 80% depending on the patient population and length of follow-up.
A systematic review of diabetes remission
rates after SG included 27 studies and
673 patients. At a mean follow-up of 13
months, diabetes had resolved in 66% of
patients and improved in 27%.
There was a mean decrease in blood
glucose of -88 mg/dL and a mean decrease in HbA1c of -1.7%. In addition
to improvements in many clinical parameters, several studies have also demonstrated significant improvements in
quality of life after SG.
While there are several case control
and retrospective series that have demonstrated superiority of RYGB over SG
with regards to weight loss, comorbidity
reduction, or diabetes remission, 39 randomised studies have demonstrated superiority or equality to RYGB and superiority of LSG over LAGB in terms of
weight loss (EWL 66% vs 48%), comorbidity reduction, or diabetes remission.
A review of published complications after SG demonstrates major complication rates that are equal to or less
than those reported in the 2009 statement and no new safety concerns have
emerged. Staple line leaks and bleeding
after SG continue to be the most serious complications and occur in
1-3% of patients in large published series.
The development of
gastroesophageal reflux
(GERD) after sleeve gastrectomy is reported in
several publications, but
a recent systematic review evaluating the effect
of SG on GERD reported inconsistent outcomes. The statement confirms that further studies of
the long-term effects of SG on GERD
symptoms and the role of SG for patients with hiatal hernia are necessary
in order to draw more definitive conclusions. There are also studies that report
SG results in fewer nutritional deficiencies but the statement states that there
is insufficient evidence to draw any definitive conclusions and more evidence
is needed regarding the effect of SG on
long-term vitamin, mineral, and nutritional deficiencies.
Several large registries have also reported weight loss and complication
data after SG. The American College of
Surgeons Bariatric Surgery Center Network longitudinal database (n=28,616)
recently reported 30-day, six-month, and
one-year outcomes of LSG, LAGB, and
RYGB including morbidity and mortality, readmissions, and reoperations as
well as reduction in body mass index
(BMI) and weight-related comorbidities. This study reported that the LSG
has higher risk-adjusted morbidity, re-
admission and reoperation /intervention
rates compared to the LAGB, but lower reoperation/intervention rates compared to the LRYGB and open RYGB.
There were no differences in mortality
between groups. However, LSG patients
had a higher BMI and higher risk profile
than LAGB patients. Reduction in BMI
and most of the weight related comorbidities after the LSG also lies between
those of the LAGB and the RYGB.
The Michigan Bariatric Surgery
Collaborative (MBSC) evaluated 30
day complication rates for 62 bariatric surgeons in 25 hospitals and reported the risk of serious complication after LSG to be 2.2% compared to 0.9%
for LAGB and 3.6% for RYGB. Another publication from MBSC used a registry of 25,469 bariatric patients to develop a risk prediction model for serious
complications after bariatric surgery
and found the risk of SG to fall between
LAGB and RYGB.
A large prospective national registry in Spain reported outcomes of 540
SG patients from 17 centres. Morbidity rate was 5.2% and mortality rate
0.36%. Complications were more common in super obese patients, males, and
patients >55 years old. Mean percent excess BMI loss (EBL) was 72.4 +/- 31%
at 24 months and Bougie caliber was an
inverse predictive factor of %EBL at
12 and 24 months. In this patient population, diabetes remitted in 81% of the
patients and hypertension improved in
63.2%. A second-stage surgery was performed in 18 patients (3.2%).
BARIATRIC NEWS 7
Coffee time with Philip James
The ‘Coffee Time’ segment in Bariatric News is dedicated to experts
from national and international obesity, bariatric and metabolic societies. In this issue, we talk to Professor Philip James, co-founder
of the International Obesity Task Force and current President of the
International Association for the Study of Obesity...
Why did you decide to enter Belsen or Auschwitz prisoners as
medicine?
he was Jewish, and this taught me
I came from a small village in Wales
where you could either become a
teacher, a Minister of Religion, a solicitor
or a doctor. All my family were teachers
so I opted to become a medic.
I went to the University College
Hospital (London, UK) in the early
1960’s, where I studied science and
then medicine. I told my boss at the
time, Lord Rosenheim, that I thought
that medicine was terrible, that doctors
were using medieval approaches to
their clinical problems and did not have
a clue what was causing them. I said
that I was leaving and commented that
I may go abroad to do some research.
He promptly arranged for me to get a
job with the Medical Research Council
in Jamaica!
This position enabled me for the first
time to learn about nutrition. At this
stage I was a paediatrician dealing with
gastroenterological problems, and I
spent this part of my career developing
new lumen tubes for measuring
absorption. It was at this time I also
helped generate the data for the
glucose-saline treatment of children
with diarrhoea, which has been hugely
beneficial to countless children around
the world.
Who have been your
greatest influences and
why?
Without question, the single greatest
influence was, Lord Rosenheim. He
was a brilliant doctor who worked
incredibly hard. He was not pompous
or filled with self-importance, he
admitted immediately if he didn’t know
anything and most importantly, he only
believed in the very highest quality of
work.
He looked after many complicated
patients, quite often they were former
that you need to treat people exactly
the same, but some people require
sensitive care for special problems. All
of these principles I still try to uphold
everyday.
What experience in your
training has taught you the
most valuable lesson?
The first time I took charge of a clinical
group in Cambridge establishing the
MRC Dunn Clinical Nutrition Centre.
It was at this time that I realised just
how difficult it was to manage a group
of doctors with different personalities,
working on very diverse projects with
distinctive demands and requirements.
directing The Rowett Institute of
Nutrition and Health at the time. So I
arranged for my son to move house
for us and agreed to meet Tony Blair
in Inverness the following day. Within
the hour I was being briefed by Alistair
Campbell who wanted something on a
Food Standards Agency that was ‘as
straight as a die’, something that the
public would trust.
Two hours later I was Talking to the
BBC, The Times, The Telegraph as
well as appearing on Radio 4’s ‘Today’
programme the following morning.
Needless to say, the whole thing blew
up with hours. That was my most
searing experience.
Tell us about one of your
most memorable career
experiences?
You helped to established
the International Obesity
TaskForce in 1996, how has
the TaskForce evolved over
the past 15 years?
Probably when I was phoned by the
Shadow Minister for Agriculture, when
Tony Blair was leader of the opposition.
At that time there was a major news
story about the e-coli epidemic and
all these horrid implications such as
food poisoning and toxicology. This
was also at the time when Bovine
spongiform encephalopathy (BSE,
mad-cow disease) was still very much
in the headlines.
The Shadow Minister for Agriculture
said he had several questions to ask:
Firstly, could I advise the Labour Party
on what to do about these big clinical
problems and how to prevent them? I
said yes, of course.
Secondly, could I make it (advising the
Labour Party) public? I said yes, if any
political party contacts me, I will do all I
can do to help.
Thirdly, can you meet Tony Blair
tomorrow? I was supposed to
be moving house that day from
Cambridge to Aberdeen, as I was
We started the TaskForce as we were
continually being asked to appear on
the television and the radio to tell all
doctors that they had to take obesity
seriously. I said that making endless
appeals to doctors was completely
the wrong way to go about it and
that the World Health Organisation
(WHO) should become involved.
Having worked with the WHO as an
academic-medic for a few years, I
knew how to go about it.
The International Obesity TaskForce
essentially put global obesity ‘on the
world map’ for the first time. Then,
one of the first tasks was to identify
the criteria for defining childhood
obesity, as no proper definition existed.
However, what really changed the
medical and governmental approach
was when the TaskForce published
a report following three years of
calculating how much of a health
problem in terms of diabetes, cancer,
heart disease etc obesity really was.
Suddenly, obesity became the sixth
highest risk factor in the world, it was
truly ground-breaking.
Subsequently, the TaskForce has
developed strategies for governments
around the world to help them combat
obesity and helped the UK Chief
Scientist to develop ‘The ForeSight
Report’ (2007) that looked at the
underlying social and economic
causes, and the costs of obesity
in the UK. The TaskForce has also
helped to develop a European platform
to work with the European Union and
push the food industry to help combat
the obesity epidemic.
The TaskForce's original report to the
WHO included waist measurements
for clinical practice and the criteria
for bariatric surgery. The data were
subsequently used by the National
Institutes of Health in the United States.
Indeed, Dr Pi-Sunyer (Chair of the First
Federal Obesity Clinical Guidelines),
insisted that I attend the report’s launch
as many people in the US were angry
because the TaskForce was defining
body mass index >25 as overweight,
when the Americans wanted the BMI
at >28.
So, over the past 16 years we have
been on a rollercoaster ride. But, the
TaskForce has had some excellent
people on-board. In particular, Neville
Rigby, a former journalist who worked
with us for ten years and who’s insights
into public relations and lobbying
proved invaluable.
national rate of obesity and diabetes
by identifying people with glucose
intolerance, this work is very significant
and establishes the case for a national
(UK) programme against obesity.
I personally believe that the UK’s
National Health Service is ill prepared
for the obesity epidemic and that
bariatric provisions are insufficient
given the huge demands for those
resources. However, the government
today is not willing to face up to the
magnitude of the problem.
You are currently President
of the International
Association for the Study of
Obesity, what are the aims
of the organisation?
The IASO was originally established as
an academic grouping assigned with
the task of improving research into and
educating professionals about obesity.
We are now an English charity, so must
operate within a certain remit. Our
aims are now to change the medical
and governmental approaches to the
treatment and management of obesity.
What are you current areas
of research?
I have been heavily involved with salt
and, along with Claudio SanchezCastillo, developed the ‘lithium
technique’ tracker method that
showed 85% of salt in the UK diet
comes from processed food. As a
result, we have developed strategies
to reduce salt intake and therefore
How should we tackle the
the rates of hypertension, which is
obesity pandemic?
now considered the top risk factor
Some colleagues of mine from the
across the world. I am also working
Organisation for Economic and
with the World Action on Salt and
Cooperation and Development in Paris, Health (WASH) and Consensus.
have looked at this very issue and have Action on Salt and Health (CASH) on
calculated health economic costs.
how to reduce the salt intake in poor
They report that we need to completely countries, where they do not have a
change our approach to both the
lot of processed food but still have
prevention and management of
high levels of salt intake.
obesity. As a result, we have assisted
Away from surgery, how do
the French and Nordic governments
you relax?
in restricting how the food industry
By reading the newspapers, I am an
markets their products to children.
obsessive newspaper reader. I have
On a clinical basis, we still have to
been fortunate enough to travel to
convince people that if you reduce
most parts of the world, but for a
your weight just a bit you can prevent
holiday we enjoy cycling in France and
a whole host of obesity-related health
problems. In Finland, they have cut the have been there for the last 13 years.
BMI is a significant predictor of mortality following surgery
A study examining the relationship
between body mass index (BMI) and 30-day mortality risk has reported that BMI is a ‘significant
predictor’ of mortality within 30 days of surgery,
even after adjusting for the contribution to mortality risk made by type of surgery and for a specific patient's overall expected risk of death. The
researchers from the University of Virginia, Charlottesville, also noted that patients with a BMI of
less than 23.1 appear to be at highest risk of death
with 40% higher odds compared with patients in
the middle range for BMI (26.3 to <29.7).
To examine the relationship BMI and 30-day
mortality risk among patients, the investigators
utilised the database of the American College of
Surgeons National Surgical Quality Improvement
Program. A multi-variable logistic regression
analysis was used to assess the statistical significance of the relationship between BMI and mortality, with adjustments for patient-level differences in overall mortality risk and principal operating
procedures. Odds ratios
per cent) among patients with
with 95% CIs were cala BMI less than 23.1 was over
culated to measure the
twice that of the percentage of
“These results
relative difference in
deaths (1 per cent) among paindicate that BMI is a tients with a BMI of 35.3 or
mortality by BMI quintile, with reference to
Additionally, patients
significant predictor higher.
the middle quintile of the
with a BMI of less than 23.1
BMI. The overall signifhad statistically significant inof mortality within
icance of the BMI and of
creased risk of death, with 40
30 days of surgery”
the other covariates was
per cent higher odds of death
measured using the Wald
than patients with mid-range
2 test statistic. A separate
BMI (between 26.3 and 29.6).
multivariable logistic regression model was develWhen examining data by procedure category,
oped to assess the significance of the interaction the authors also found that patients who underbetween BMI and primary procedure.
went exploratory laparotomy had the highest perThe data included 189, 533 cases of general centage of death (13.9 per cent) compared with
and vascular surgical procedures reported in 2005 patients in all other categories of principal surand 2006 for patients with known overall prob- gery, and patients who underwent breast lumpecabilities of death. Among these, 3,245 patients tomy had one of the lowest overall mortality perdied within 30 days of their surgery (1.7%). The centages (0.1 per cent).
authors found that the percentage of deaths (2.8
The researchers also noted a statistically sig-
nificant interaction between BMI and procedure
category, indicating that the association between
BMI and mortality was statistically different for
patients who underwent these procedures (including colostomy, wound debridement, musculoskeletal system procedures, upper gastrointestinal procedures, colorectal resection, hernia repair, among
others), compared with patients who underwent
laparoscopy.
“These results indicate that BMI is a significant predictor of mortality within 30 days of surgery, even after adjusting for the contribution to
mortality risk made by type of surgery and for a
specific patient's overall expected risk of death,"
the authors conclude.
The study was published online by Archives
of Surgery, one of the JAMA/Archives journals
(The Relationship Between Body Mass Index
and 30-Day Mortality Risk, by Principal Surgical Procedure. Turrentine et al. Arch Surg. November 2011).
8 BARIATRIC NEWS
International Bariatric Club – a worldwide
web network of bariatric surgeons
Mr Haris Khwaja Laparoscopic Oesophagogastric/Bariatric Surgeon,
United Kingdom Director:
International Bariatric
Club
The International Bariatric Club (IBC) is currently the
third largest bariatric organisation after the American Society of Metabolic
and Bariatric Surgery (ASMBS) and the
Brazilian Society for Bariatric Surgery.
In 2008, the concept of the IBC was
born through the visions of Dr Tomasz
Rogula, Assistant Professor of Surgery
(Cleveland Clinic, Ohio, USA), Dr.
Raul Rosenthal, Professor of Surgery
(Cleveland Clinic, Florida, USA) and
Dr. Philip Schauer, Professor of Surgery
at the Cleveland Clinic, Ohio.
Initially the IBC consisted of onehour talks given by the Cleveland Clinic
Bariatric Fellows, broadcast over the internet to an on-line audience. The talks
were based on 1–2 recently published,
high quality bariatric papers and were
built within the educational curriculums
of the Fellowship in Advanced Laparoscopy/Bariatric Surgery of both Cleveland Clinic campuses. These webinars
initially attracted a small on-line audience but allowed for questions to be put
to the speaker.
I presented a webinar in 2009 during
my Fellowship at the Cleveland Clinic – a review of the paper ‘Prevalence
of Thrombophilias in Patients Presenting for Bariatric Surgery’ [Overby et al.
Obes Surg. 2009 Sep;19(9):1278-85].
The paper had just been published and
clearly was of great educational value
to all attendees including on-line audience which on that occasion included
surgeons from throughout the United
Table I: Activities of the International Bariatric Club in 2011
Date
Presenter
Title of Talk
May 13th, 2011
Dr. Mohammad Talebpour (Iran)
11 years Experience of Laparoscopic Greater Curvature Plication and
its Modifications
May 25th, 2011
Prof. Harvey Sugarman (USA)
What Procedure is Best for T2DM in High and Low BMI Patients?
June 29th, 2011
Dr. Manoel Galvao Neto (Brazil)
Endoluminal therapy for obesity and T2DM is acceptable
July 27th, 2011
Dr. Chih-kun Huang (Taiwan)
Laparoscopic adjustable gastric banded plication: technique and
preliminary results
Sept. 1st, 2011
IBC at IFSO (Hamburg, Germany)
Dr. Jaime Ponce (USA)
Prof. Phil Schauer (USA)
Prof. Mohammad Talebpour (Iran)
Prof. Michel Gagner (USA)
Prof. Chih-Kun Huang (Taiwan)
Prof. Mervyn Deitel (Canada)
Bands no more?
Bypass kills diabetes
Plication kills sleeve
Sleeve kills bands
Bands on bypass and plication
I can do it from inside
What’s new in metabolic surgery?
Sept. 28th, 2011
Dr. Shashank Shah (India)
T2DM in the Indian Population
Oct. 26th, 2011
Dr. Ariel Ortiz (Mexico)
Live Demonstration: Laparoscopic Greater Curvature Plication
Nov. 26th, 2011
IBC at IIIrd Romanian Bariatric Symposium (Bucharest)
Prof. Mervyn. Deitel (Canada)
Dr. Marius Nedelcu ( France)
Dr. Tomasz Rogula (USA)
Dr. Gianfranco Sillechia (Italy)
Prof. Catalin Copăescu (Romania)
States, Brazil and China. It was clear to
me that at this embryonic stage of the
IBC that it had the potential to expand
into a powerful educational medium for
the exchange of bariatric knowledge
globally. Indeed from these early days,
IBC has grown significantly in terms of
membership and its’ range of activities.
The club still remains a free, non-profit
making organisation open to all bariatric surgery/medicine professionals and
easily accessible on-line to registered
participants.
In November 2010, the IBC Facebook Page was set up with the aim of
promoting free discussion with bariatric professionals throughout the world
Why Diabetes Does Not Resolve in Some Patients after Bariatric
Surgery?
Short Review of the Literature for Metabolic Surgery for Patients with
BMI under 35
New Data about Cardiac Risk Factor after Bariatric Surgery
Gastro-Esophageal Reflux after Bariatric Surgery
Gastric Imbrications – Complication Rates, Leaks, Increased Salivation, Weight Regain. Is It Worth It?
His Angle Fistula on Sleeve Gastrectomy Endoscopic Treatment,
Dealing with a Nightmare
on a daily basis. Following this the
membership of the IBC expanded exponentially such that as of December
20th, 2011 there are 399 members from
Europe, Asia, Africa Australia, North
and South America. The aims of the
IBC are outlined in the sidebar at the
end of this article.
Webinar Activities
The monthly webinar in conjunction
with WebEx web conferencing based at
the Cleveland Clinic, Ohio, USA usually takes place the last Wednesday of
the month at 17.00 (GMT) subject to
occasional variation. It provides an opportunity for all members of the IBC to
listen and/or see a high quality presentation by a national/international expert
in bariatric surgery with the chance to
ask questions to the speaker. These lectures are also recorded and so can be
watched anytime. The club has also attracted global bariatric surgery leaders
such as Professors Ariel Ortiz (Mexico),
Manoel Galvao Neto (Brazil), Harvey
Sugerman (USA), Michel Gagner (Canada), Philip Schauer (USA), Chih-Kun
Huang (Taiwan) and Mohammad Talepbour (Iran). Table 1 (above) lists the
presentations from 2011 which were not
only informative but provided a great
opportunity for an interactive on-line
verbal discussion.
In addition, the inaugural non-virtual IBC Symposium took place at the
XVI World Congress of the International Federation for the Society of Obesity & Metabolic Surgery (IFSO) in Hamburg Germany in September 2011. The
event was supported by former IFSO
President, Professor Rudolph Weiner.
A similar event is being organised for
the IFSO-European Chapter (IFSO-EC)
Meeting in Barcelona, Spain in April
2012 and at the next IFSO-World Congress in New Delhi, India, in September
2012 by the IBC organising committee.
Future Aims
The expansion of the IBC has been
clearly enhanced by the internet. We
are currently concentrating our efforts
on maintaining the high standard of
monthly Webinars with an increasing
number of live webinars from the operating theatre. The IBC website will be
ready by February 2012 and will allow
any bariatric professional easy access to
the latest IBC activities, video library
and newsletter. We have already organised the next IBC non-virtual meeting
in April 2012 at IFSO-EC in Barcelona, Spain with Professors Jacques Himpens (Belgium), Michel Gagner (Canada) and Rudolph Weiner (Germany)
already confirmed speakers.
These presentations will of course be
broadcast live over the internet for any
registered member to access. Long-term
the IBC will, through multi-centre cooperation, be organising randomised controlled clinical trials in relation to bariatric surgery. This has only been possible
through the recruitment of large number
of enthusiastic, dedicated bariatric professionals as well as the involvement of
world experts within the IBC.
Membership
Membership to the International Bariatric Club can be made by sending an
email to Dr Tomasz Rogula, President of
the IBC based at the Cleveland Clinic,
Ohio, USA. ([email protected]). A link inviting you to attend the monthly Webinar
via WebEx video conferencing provided
by the Cleveland Clinic will be sent to
you prior to the presentation. After registering you will receive a confirmation
with the details of the upcoming International Bariatric Club Videoconference.
Access to the live Webinar can be made
via computer (PC or Mac) with a webcam or with a smart phone (iPhone, iPad,
Android, Blackberry).
Membership to the IBC from February 2012 will be possible through the
IBC website.
Aims of the International
Bariatric Club
Rudolph Weiner (IFSO Congress President 2011) and Michel Gagner at the IBC Symposium, XVI World Congress of IFSO, Hamburg,
Germany (September 2011)
Philip Schauer (left) (Past President ASMBS) and Tomasz Rogula (IBC President)
at the IBC Symposium, IFSO (September 2011)
1
Promotion and exchange
of knowledge, ideas and
experiences related to
the pre-operative, intraoperative and postoperative care of the
bariatric patient with
bariatric professionals
throughout the world
2
Sharing of bariatric
surgery videos relevant
to management of intraoperative and postoperative complications
3
Promotion of the monthly
Webinar coordinated by
the Cleveland Clinic in
association with WebEx
4
Mohammad Talebpour (Iran) – ‘Father’ of the Laparoscopic Greater Curvature Plication at the IBC Symposium, IFSO
(September 2011)
Chih-Kun Huang (Taiwan) – Presentation on ‘Bands on Bypass & Plication’ attracted great
interest at the IBC Symposium at IFSO (September 2011)
Promotion and Involvement
in National and International
Meetings relevant to
Bariatric & Metabolic
Surgery
Bariatric Surgery
Database Software
Imagine being able to track
all your bariatric surgery cases
with ease and recall any record
almost instantly…
Now you can with just a
‘click’ of a button
Dendrite’s innovative software:
reveal interpret improve
Station Road
Henley-on-Thames
RG9 1AY
United Kingdom
Phone: +44 1491 411 288 – e-mail: [email protected]
www.e-dendrite.com
St Elsewhere’s Hospital
NHS Trust
AttAch
PAtient
Sticky
here
Bariatric operation:
Pre-op weight:
109 kg
38.9 kg m-2
Pre-op BMI:
Current weight:
76.4 kg
27.2 kg m-2
Current BMI:
Total weight loss:
Excess weight loss:
Vitamins / mineral supplem
ents:
Regular monitoring
(blood test):
Clinical evidence of
malnutrition:
Weight loss and excess
120
P
F
F
F
F
F
F
F
32.6 kg
83.9 %
Yes
Yes
No
weight loss
Excess weight loss
F
Weight loss
F
FFF
F
Weight / kg
100
120
80
100
60
80
40
60
20
40
20
0
0
250
Current comorbidity
status
Type 2 diabetes:
Hypertension:
Sleep:
Asthma:
Functional:
Back / leg pain from
OA:
GORD:
PCOS:
Menstrual:
Apron:
Any other information
Current progress:
Next appointment:
Time after surgery /
500
days
Impaired glycaemia
or impaired glucose
tolerance
No indication of hyperte
nsion
No diagnosis or indicatio
n of sleep apnoea
No diagnosis or indicatio
n of asthma
Can climb 3 flights of
stairs without resting
Intermittent symptom
s; no medication
Intermittent medicat
ion
No indication / diagnos
is; no medication
Regular menstrual cycle
No symptoms
for the notes / GP
Satisfactory, as expecte
d
months
NHS
Gastric band (on 09 /
04 / 2008)
08 / 07 / 2009
23 / 07 / 1967
Clinic date:
Date of birth:
%
• Creates graphs
displaying Excess
Weight Loss over
time
• Links to hospital
systems
to pre-populate
demographic fields
• Allows the easy export
of data to national/
international registries
• Simplifies the data
collection process
• Maintains patient
anonymity and confidentiality
(safe and secure)
Excess weight loss /
• Allows the tracking of
procedures and outcomes from
all type of bariatric procedures
(including bands, balloons,
Roux-en-Y, gastric sleeve,
duodenal switch and BPD)
• Details tracking of
comorbid conditions
• Facilitates longitudinal
follow-up
• Automatically identifies followup breaches
• Reduces the workload by
automating production
of patient reports, operation
notes and follow-up letters
Unsatisfactory (specify)
750
0
P
RP
R
Primary
Revision as a primary
Revision
S
Planned 2 nd stage
F
Follow up
10 BARIATRIC NEWS
Travelling scholarship 2009 presentation
Advanced Laparoscopic Fellowship at the Cleveland Clinic, Ohio, USA
Haris Khwaja Post-CCT Gravitas Bariatric Surgery Fellow, Liverpool, United Kingdom
The Bariatric and Metabolic Institute at the Cleveland
Clinic, Ohio, USA is considered one of the leading bariatric
surgery units in the world. I was fortunate to be selected
after competitive interview whilst a Fourth Year SpR for
the one year Advanced Laparoscopy/Bariatric Fellowship
commencing from July 1, 2009 to June 30, 2010.
The unit is headed by Professor Philip R Schauer, a global leader in bariatric surgery and four Attending Surgeons:
Drs Tomasz Rogula, Stacy Brethauer, Bipan Chand and Matthew Kroh. The unit
performs between 600–700 laparoscopic bariatric surgery cases per year and integral to its success is a dedicated multidisciplinary team consisting of bariatric
physicians, anaesthesists, dieticians, psychologists, endocrinologists and bariatric
nursing staff. The majority of the surgical
workload is focused on the laparoscopic Roux-en-Y gastric bypass (LRYGB),
sleeve gastrectomy (LSG) and revisional bariatric surgery including the banded
bypass. The uniqueness of the Fellowship was the high frequency of super-super morbidly obese patients (BMI >60kg/
m2) who underwent surgery (the highest
being a BMI=108kg/m2), as well as the
acuity of the patients in terms of significant cardiovascular, respiratory and liver
problems. These patients had often been
turned down for bariatric surgery by other units in the United States and throughout the world. The unit is also at the forefront of clinical bariatric surgery research
conducting the Laparoscopic Greater
Curvature Plication (LGCP) trial and the
Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) randomized study. The latter is
comparing the effectiveness of advanced
medical therapy alone for Type 2 diabetes
mellitus versus surgery (sleeve gastrectomy or gastric bypass) and medical therapy combined.
There are four Fellows selected per
year with two on the one year Clinical Fellowship track and two on the two year Research/Clinical track. The Fellowship is divided into four three-month periods with
each Fellow starting on a different part of
the track. My Fellowship timetable is outlined in Table 1.
The Fellowship is demanding compared to most Advanced Laparosco-
Haris Khwaja (left) with Dr Tomasz Rogula (Attending
Surgeon) at the Fellows Graduation Dinner, June 19
2010
py/Bariatric Fellowships in that there are
no junior staff on the service so all ward
rounds, electronic medical record documentation, admission/discharge paperwork and post-operative issues are undertaken by the Fellow. The advantage
however is that all the surgeries are done
by the Fellow. Average work days were 16
hours/day with a 1:5 on-call for Bariatric
Surgery from home. There are on average
twice weekly surgery days with theatre
from 07:15–18:00 and twice weekly bariatric clinics from 08:30–17:00.
In the one year Fellowship, I performed 349 cases consisting of 602 surgical procedures with the main cases outlined in Table 2.
Postgraduate teaching is facilitated by
a weekly Fellow’s Presentation on a topic
based on the American Society of Metabolic and Bariatric Surgery (ASMBS) Curriculum, monthly Advanced Laparoscopy
National/International Teleconferences, a
monthly Bariatric Webinar (thorough the
International Bariatric Club) and weekly
Hepatobiliary Surgery meetings.
The Fellowship allowed me to gain
Haris Khwaja (right) in theatre with Dr Philip Schauer the Director of the Bariatric and Metabolic Institute, Cleveland Clinic
Table 1 – Timetable of Clinical Fellowship Track
Time Period
Workload
Attending (Consultant)
Experience
July 1 – Sept. 30, 2009
Minimally Invasive Surgery (2 full days/wk)
Bariatric Surgery (2 full days/wk)
Clinical Research (1 full day/wk)
Dr. Philip Schauer
Dr. Tomasz Rogula
Dr. Steven Rosenblatt
• Lap Roux-en-Y Gastric Bypass
• Lap Sleeve Gastrectomy
• Lap Splenectomy
• Single Incision Lap
Cholecystectomy
• Lap Incisional/ Inguinal Hernia
• Abstracts prepared & submitted to
SAGES & ASMBS
Oct. 1 – Dec. 31, 2009
Bariatric Clinics (2 full days/wk)
Dr. Philip Schauer
Dr. Tomasz Rogula
• Lap/Open Revisional Bariatric Surgery
Jan. 4 – March 31, 2010
Bariatric Surgery (1 full day/wk)
Minimally Invasive Surgery (1 full day/wk)
Diagnostic/Therapeutic OGD (0.5 day/wk)
Bariatric Clinic (0.5 day/wk)
Dr. Stacy Brethauer
Dr. Matthew Kroh
• Lap Gastric Band
• Revisional Bariatric Surgery
• Single Incision Lap Gastric Band
• Lap Gastric Pacemaker
• OGD/PEG Insertion
• Book Chapter written
April 1– June 30, 2010
Bariatric Clinics (2 full days/wk)
Dr. Philip Schauer
Dr. Tomasz Rogula
•Lap Roux-en-Y Gastric Bypass
•Lap Sleeve Gastrectomy
•Lap/Open Revisional Bariatric
Surgery
•Lap Greater Curvature Plication
• Presentations at SAGES & ASMBS
The Cleveland Clinic, Ohio
Table 2: Summary of the Main Advanced Laparoscopic/Bariatric Surgeries & Endoscopy
Experience
Operation
Supervisor Trainer
Supervisor Trainer
Unscrubbed
Scrubbed
Lap Roux en Y Gastric Bypass
5
48
35
Lap Sleeve Gastrectomy
1
19
5
Lap Greater Curvature Plication
-
2
4
Lap Revisional Bariatric Surgery
-
2
15
Lap Total Gastrectomy
-
2
3
Lap Splenectomy
4
4
1
Lap Nissen Fundoplication
-
15
4
SILS/Lap Cholecystectomy
-
9/37
3/2
OGD/PEG Insertion
123/12
-
1
the necessary technical skills and case
volume to overcome the learning curve
of the various bariatric surgeries and be
able to undertake these surgeries independently. It also set me up for my Final
Year as a SpR at Chelsea & Westminster
Hospital, London (a premier UK bariatric surgery centre), where I performed an
additional 69 laparoscopic gastric bypasses, 23 sleeve gastrectomies and 45
adjustable gastric bands.
I would encourage any trainee with an
interest in Advanced Laparoscopy/Bariat-
Assisting
ric Surgery to undertake a Fellowship. The
American Fellowships do require planning
ahead in terms of doing the necessary
American USMLE exams in good time, attending interviews in America (I had 12 interviews but decided to attend two) and
sorting out the visa requirements once
a Fellowship has been granted. However the experience gained in working in a
high-volume bariatric unit in terms of surgical training and pre/post-operative management of the morbid obese patient
made it an extremely valuable year.
Does bariatric surgery
have a Halo effect?
According to a study by researchers at Stanford University School
of Medicine, family members of patients who have undergone
bariatric surgery have reported weight loss and improvements in
their lifestyles. This so-called ‘Halo effect’ is believed to be a result
of the family’s close association with the patient. The findings were
published in the October 2011 issue of the Archives of Surgery
(Collateral Weight Loss in Patients' Family Members, Woodard et
al. Arch Surg. 2011;146(10):1185-1190).
“Family members
were able to lose weight
comparable to being part of a
medically controlled diet simply by accompanying the bariatric surgery patient to their
pre- and post-operative visits," said senior author Dr
John Morton, Associate Professor of Surgery at Stanford and Director of Bariatric
Surgery at Stanford Hospital & Clinics. “Bariatric surgery programs should encourage family involvement in
support groups and education
sessions to capitalise on these
Halo effects.”
Although it has been established that bariatric surgery is an effective treatment
for morbid obesity, it is increasingly recognised as a familial disease and healthy behaviour transmission could be
John Morton
enhanced by family relationships. Therefore, the researchabolic equivalent task–hours
drinks per month to one drink
ers decided to investigate
(equivalent to consuming
per month; p=0.009).
whether changes in weight
1kcal/kg body weight/hour;
It is important to note that
and healthy behaviour in pap=0.005), and from 13 to 22
all the study participants actients who underwent Rouxmetabolic equivalent task–
companied the patients to all
en-Y gastric bypass surgery
of their pre- and post-operahad any subsequent impact on hours (p=0.04), respectively.
Eating habits, which were
tive clinical visits, where they
their family members.
received dietary and lifestyle
The study ran from January measured by the Three-Factor Eating Questionnaire, also counselling. These sessions
2007 to December 2009 and
improved among adult famwould emphasise a high-proincluded 85 participants (35
tein, high-fibre, lowpatients, 35 adult famfat and low-sugar diet
ily members, and 15
and small, frequent
children younger than
“Family members were
meals. The sessions
18 years). Of the adult
also set daily goals for
family members of
able to lose weight
exercise and stressed a
the surgery recipients,
comparable to being
good night's sleep, al60% were obese pricohol moderation and
or to the procedure, as
part of a medically
less time in front of the
were 73% of the chilcontrolled diet simply
television.
dren of the patients.
Surgery was combined
by accompanying the
Conclusion
with dietary and lifebariatric surgery
“In the US, we do
style counselling.
roughly 200,000 barpatient to their pre- and
Results
iatric surgery cases a
post-operative visits…
After 12 months, the
year, and we struggle
researchers observed
with how to deal with
Bariatric surgery
a weight loss in adult
the obesity epidemic in
programs should
family members, from
society. Can you imaga mean of 234lbs to
ine if every one of these
encourage family
a mean of 226lbs
bariatric patients were
(p=0.01). Children of
an ambassador for good
involvement in support
patients trended tohealth?” added Morgroups and education
ward lower body mass
ton. “You would have a
indices, from 31.2 kg/
huge, grassroots movesessions to capitalise on
m2 (expected, based
ment with bariatric surthese halo effects.”
on growth projections)
gery providing a vehicle
to 29.6 kg/m2 obfor healthy change for
served (p=0.07). The
patient and family alike.
researchers also noted an inObesity is a family disease and
ily members, including a recrease in daily activity levels
bariatric surgery sets the taduction in uncontrollable eatamong adult and child family
ble for future, healthy family
ing (from a score of 35 to 28;
members, as measured by the
meals.”
p=0.01), a reduction in emoSeven-Day Physical ActiviThe study was funded by
tional eating (from 36 to 28;
ty Recall questionnaire, with
0=0.04), and a reduction in al- the school’s Medical Scholars
changes from eight to 17 met- cohol consumption (from 11
Program.
BARIATRIC NEWS 11
12 BARIATRIC NEWS
A snapshot of
In this issue, our ‘Snapshot’ features Canada and a joint report released by the
Canadian Institute for Health Information (CIHI) and the Public Health Agency of
Canada (PHAC), entitled ‘Obesity in Canada 2011’. The comprehensive new report
examines how obesity rates vary across Canada, who is most at risk and possible
actions to address it. Based on body mass index (BMI) calculations, the study
reports that more than one in four adults (estimates range from 24.3%-25.4%) in
Canada and just less than one in 11 children are considered obese. Between 1981
and 2009, obesity based on BMI data roughly doubled across all adult age groups
and tripled for children (age 12 to 17). Alarmingly, the report states that ‘not only has
the prevalence of obesity increased over time, but obesity is becoming more severe
and fitness levels are decreasing as well’.
N
“
ot surprisingly, this report
shows that improving lifestyle
behaviours, such as healthy
eating and physical activity,
can have a significant impact on reducing
the waistlines and improving the health of
Canadians. However, obesity is complex,
and there are many other factors that contribute beyond lifestyle habits,” says Jeremy Veillard, Vice President of Research and
Analysis at CIHI. “By shedding light on the
factors most closely associated with obesity and how they play out across Canada, policy-makers and health providers can
better target prevention and treatment options to meet the needs of the population.”
ty across health regions within Canada is
large, ranging from a low of 5.3% in urban/suburban Richmond, British Columbia, to a high of 35.9% in the northern
Mamawetan/Keewatin/Athabasca region
of Saskatchewan (see Figure 1). Among
both adults and youth, the proportion of
overweight tends to be higher in rural areas than in metropolitan areas. In particular, in all the Canadian regions considered, obesity has been found to be most
prevalent among boys in small town regions of 2,500 to 19,999.
Furthermore, the investigation also
demonstrates that self-reported obesity
remains more prevalent among Aboriginal
peoples than in the Canadian non-Aboriginal adult population. For example, 25.7%
among off-reserve Aboriginal adults compared with 17.4% among non-Aboriginal
adults in Canada. On-reserve First Na-
tions groups tend to have a higher prevalence still, with over one-third (36.0%)
estimated as obese, based on 2002/03
data. Self-reported obesity among adults
is similar for Inuit, off-reserve First Nations, and Métis populations (23.9%,
26.1% and 26.4%, respectively), whereas childhood obesity varies from 16.9%
among Métis to 20.0% among off-reserve
First Nations to 25.6% among Inuit.
Sex and age
For both men and women, the report shows that the prevalence of obesity generally increases with each successive age group up to age 65. After age
65, the prevalence of obesity declines. In
the 2007/08, obesity was more prevalent
among men than women, with the exception of the oldest age group (Figure 2).
Based on direct measures, findings from
the 2007-2009 CHMS show that, while
obesity increased with age, it was not always higher among men than women.
For example, in the population aged 20
to 39, 19% of males and 21% of females
were obese, and among those aged 40
to 59, 27% of males and 24% of females
were obese.
Distribution of BMI
There has been a marked shift in the
distribution of BMI over time, the greatest increases occurring in the heaviest
weight classes (Figure 3: Distribution of
BMI Categories by Sex, Ages 18 to 79,
2007-2009). For example, the proportion
of adults falling into obese class I (BMI
30.0-34.9 kg/m2) increased from 10.5%
in 1978/79 to 15.2% in 2004. The pro-
portion in obese class II (BMI 35.0-39.0
kg/m2) doubled between 1978/79 and
2004, increasing from 2.3% to 5.1%.
The proportion falling into obese class
III (BMI≥40kg/m2) , while small, also appears to have increased over time. In
1978/79 obese class III made up 0.9% of
the population and increased three-fold,
to 2.7%, by 2004. Although females appear more likely than males to be within the normal weight group and less likely to be in the overweight group, they are
more likely to fall into obese classes II
and III.
Socio-economic status
or Created by: Matt Ward/Echo Enduring Media - www.echoendur
09; Distributed under the Creative Commons lisence.
Regional and ethnic variation
New analyses from the research
shows a variation in self-reported obesi-
Variations in obesity by socioeconomic status were much more
pronounced in some regions than in
others. In Halifax, Nova Scotia, for ex-
BARIATRIC NEWS 13
Vector map created by: Matt Ward/Echo Enduring Media – www.echoenduring.com © 2009; Distributed under the Creative Commons lisence.
ample, 11% of the population in the
highest socio-economic range was
obese, compared with close to 26%
in the lowest socio-economic areas. Similarly, in Thunder Bay, Ontario, 10% of the population in the highest socio-economic areas was obese,
compared with 20% in the lowest socio-economic areas. While most cities had a gap, it was not always significant.
Some cities, like Vancouver, BC,
and Oshawa, Ontario, showed almost
no difference in obesity between the
highest and lowest socio-economic areas. In addition, research summarized in the report has shown that access to recreational facilities and food
retail outlets and the price of nutritious
foods can all have an association with
obesity.
ring.com
Gender and income
The report also notes that women in higher income brackets were significantly less likely to be obese than their
lower-income counterparts, a difference
not found for men. This trend was seen
for all Canadian women, although it was
most pronounced among Aboriginal females, where 16.3% of Aboriginal women
in households making C$100,000 or more
were considered obese, compared with
26.8% of Aboriginal women in households
with incomes of less than C$20,000 a year.
Costs
It has been estimated that obesity costs
the Canadian economy approximately
C$4.6 billion in 2008, up C$735 million
(19%) from C$3.9 billion in 2000 (this
estimate is limited to those costs
associated with the eight chronic diseases
most consistently linked to obesity,
an additional study using comparable
methodology and looking at 18 chronic
diseases estimated the cost to be even
higher, at close to C$7.1 billion).
“Reducing obesity levels and
promoting healthy weights is critical to
the prevention of ill health,” says Dr Judith
Bossé, Assistant Deputy Minister, Public
Health Agency of Canada. “Obesity
increases the risk of a number of chronic
conditions, including type 2 diabetes,
hypertension and some forms of cancers.
That’s why we’re examining options to
address the factors that lead to obesity,
and we are working with various levels
of government, non-governmental
organisations and other stakeholders on
this issue.”
Source: The report ‘Obesity in Canada’ is available to download from
the Public Health Agency of Canada:
www.phac-aspc.gc.ca
14 BARIATRIC NEWS
XVI World Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders
Highlights from IFSO 2011
The XVI World Congress of the International Federation
for the Surgery of Obesity and metabolic disorders (IFSO)
was held in Hamburg (August 30–September 3), under the
auspices of the German Society for the Surgery of Obesity
of the German Society for Visceral and General Surgery.
The Congress was official-
ly opened in an ceremony hosted by the
Congress President, Professor Rudolf A
Weiner and IFSO President, Professor
Karl Miller. Overall, there were ten plenary sessions, ten symposia, one keynote lecture, six integrated health sessions and consensus conferences and 23
scientific sessions including video sessions allowing participants to focus on
key topics including: implications of severe obesity; new technologies; metabolic surgery; controversies with interactive debate; lap revisional surgery;
bariatric surgery and the law; and several multidisciplinary symposia.
From 922 submitted abstracts a total
of 589 abstracts were presented, this included 85 videos and 323 posters. The
total number of oral presentations, videos and posters) was a record 784.
The IFSO 2011 World Congress reflected the importance of metabolic
surgery and began with the postgraduate course. As well as behavioural and
medical approaches, various types of
surgery on the gastrointestinal tract and
new endoscopic techniques were highlighted. Many of the discussions concerned the ability of these new techniques to resolve diabetes not only in
patients with severe obesity, but in patients considered of normal weight.
In addition, there were several presentations focusing on the surgical approaches to type 2 diabetes mellitus
(T2DM) that reported how surgery can
help normalise blood glucose levels,
thereby reducing or avoiding the need
for medications, and providing a potentially cost-effective approach to treating the disease. An interdisciplinary
plenary session with endocrinologists
focused on research into surgery for the
resolution of diabetes as well as looking at the non-weight-loss effects on
glucose tolerance.
Awards
Several awards and scholarships were
also presented, including:
The best posters awards: 1st Poster
prize: Kirstin Carswell (UK), 2nd Poster prize: James Rink (UK) and 3rd Poster prize (shared by two surgeons with
the same ranking in the blind peer review): Conor Magee (UK), Susanne
Richter (Germany). Three scholarships
were also awarded to the following
young surgeons: Maria Dolores Frutos
(Spain), Jayashree Todkar (India) and
Marco Bueter (Switzerland).
A new concept for the Hamburg
meeting was the electronic voting system in all Plenary sessions. The questions were established by the Scientific
Committee together with the Chairman
and voted on by the audience.
Gastric Plication
A special session focused on Gastric
Plication Session and included experts
from around the world, Chaired by Dr
Phil Schauer. The session began with
Dr Talebpour (Iran) presenting a
multi-centre experience of over 800
procedures. Additional presentations
included Dr Ramos (Brasil) who de-
scribed plication as a ‘rescue technique’ following the failure of a previous procedure. There was relative
agreement in the session that plication
does have its merits, and has a place
in the armamentarium of the surgeon,
but surgeons performing the procedure
should have formal training before attempting this technique.
Dr Henry Buchwald gave several presentations that encompassed topical subjects including the ‘Guidelines
for metabolic and bariatric surgery and
the Center of Excellence concept – data
on the efficacy of Center of Excellence
in enhancing outcomes and decreasing
complications. In addition, he looked
into the future as he assessed 'Micro
Orifice' surgery.
Tantalus
There were also several updates from
device-related clinical studies. Professor Arthur Bohdjalian, Medical University of Vienna, presented favourable benefit-risk profile of the Diamond
Henry Buchwald
(Tantalus) System. This is a minimallyinvasive gastric stimulator for treatment
of Type 2 Diabetes and its metabolic comorbidities. Bohdjalian stated that the
system brings significant glycaemic and
metabolic improvement with mostly
mild to moderate adverse events.
In the meta-analysis of 80 obese
T2DM patients treated with the Diamond system for at least six months after failing on oral anti-diabetics, the results showed a mean reduction of 0.9%
in HbA1c accompanied by significant
weight loss, waist circumference reduction, lowering of blood pressure (systolic and diastolic) and an improvement in
blood lipid profiles. In addition, the majority of adverse events reported were
not related to the device and resolved
within four weeks of implantation without sequelae.
“Diamond’s safety and efficacy are
due to the fact that it acts physiologically, enhancing the normal metabolic processes and not causing any metabolic
dysfunction,” said Bohdjalian. “Therefore it is an attractive alternative treatment for managing Type 2 Diabetics
who have exhausted oral medications.”
Maestro
EnteroMedics also presented data their
VBLOC-DM2 ENABLE (DM2) tri-
Congress President Professor Rudolf A Weiner and IFSO President Professor Karl Miller
al evaluating the second generation
Maestro RC System in the treatment
of obesity, diabetes and hypertension.
In an oral presentation entitled ‘Treatment of Obesity-Related Co-Morbidities with VBLOC Therapy,’ Dr Miguel
Herrera Hernández, Instituto Nacional
de la Nutrición, Mexico, said the results reflect a statistically significant
and sustained improvement in glycaemic control and blood pressure, as well
as clinically meaningful weight loss in
obese, diabetic patients using the Maestro RC System.
The 18-month data showed that excess weight loss (EWL) of approximately 24.6% (n=22), a mean reduction
in HbA1c of 1.2 percentage points from
a baseline of 8.1% (n=13), a change in
fasting plasma glucose of -38.4 mg/dl
from a baseline of 151.4mg/dl (n=12).
In hypertensive patients (n=10), there
was a reduction in mean arterial pressure of 13.0mmHg from a baseline
Philip Shauer
of 99.5mmHg and a reduction in diastolic blood pressure of 15.9mmHg
from a baseline of 87.2mmHg (n=10).
Through 18 months, no change in mean
arterial pressure was observed in patients that did not present with hypertension (n=10).
abilitI launch
Also at IFSO, IntraPace, the developer of the innovative abiliti implantable
obesity management system, launched
its lifestyle management portal and support network. A unique online resource,
my.abiliti allows its users to track personal eating and exercise performance,
set and achieve goals, receive individual coaching, access educational resources and benefit from a valuable
support network. They can also share
personal experiences and achievements
at their discretion with peers, friends
and family, and experienced healthcare
professionals.
The abiliti system is an implantable device that uses proprietary eating
event sensors to initiate gastric stimulation that helps patients feel full sooner
than they otherwise would. Additionally, the device automatically records information on those eating and drinking
events, as well as frequency and duration of exercise. IntraPace claims that
the my.abiliti portal is the only online
destination and community that can
utilise objective behavioural data, collected and stored by the abiliti device
and wirelessly retrieved with the connect.abiliti Wand. This accurate information enables intelligent weight loss
management based on routine self
monitoring.
Record attendance
IFSO 2011 was attended by 2,230 participants from 74 countries and as well
as 425 exhibitors, the highest number in
the history of the IFSO World Congress.
BARIATRIC NEWS 15
Commercial vs. NHS-based weight loss programmes
According to a study published in at bmj.com (BMJ, 2011; 343),
commercial weight loss programmes are
more effective and cheaper than National Health Service-based services led by
specially trained staff.
Researchers at the University of
Birmingham compared the effectiveness of several commercial weight
loss programmes of 12 weeks' duration
with primary care-led programmes and
a control group.
A total of 740 obese and overweight
men and women took part in the study.
Follow-up data were available for 658
(89%) participants at the end of each
12-week programme and 522 (71%) at
one year.
The programmes included in the
analyses were Weight Watchers; Slimming World; Rosemary Conley; a
group-based dietetics programme; general practice one to one counselling,
pharmacy one to one counselling; or a
choice of any of the six programmes.
A control group was provided with 12
vouchers enabling free entrance to a local leisure (fitness) centre.
All programmes achieved significant
weight loss after 12 weeks, with the average weight loss ranging from 4.4kg
(Weight Watchers) to 1.4kg (general
practice provision). The primary care
programmes were no better than the
control group at 12 weeks.
At one year, statistically significant weight loss occurred in all
groups apart from the one to one
programmes in general practice and
pharmacy settings. However, Weight
Watchers was the only programme to
achieve significantly greater weight
loss than the control group.
All groups showed some increase in
physical activity, although the smallest increase was in those allocated to
the general practice programme. Attendance seemed to be an important factor; the highest attendance rate was in
Weight Watchers and the lowest for the
primary care programmes. The primary care programmes were also the most
costly to provide.
“Our findings suggest that a 12-week
group-based dedicated programme of
weight management can result in clinically useful amounts of weight loss that
are sustained at one year,” the authors
note. “Commercially provided weight
management services are more effective
and cheaper than primary care-based
services led by specially trained staff,
which are ineffective.”
Diet Express
offers franchises
in Dubai
The British diet company, Diet Express,
has begun trading in Dubai, offering dieting packages in health clubs throughout the United Arab
Emirates (UAE).
Diet Express have been working to secure contracts in the UAE since September 2011, and are
currently offering their products through six health
clubs in the city of Dubai.
Chris Donaldson, Managing Director of Diet
Express, said “after a slow start, coming up to
Christmas things have really taken off.”
The company offers packages and dietary supplements to franchise holders promoting a low-glycemic diet, including the “diet in a box”, which includes a body fat monitor, a journal, and a low-GI
meal plan. They also provide materials to allow
franchise operators to run more in-depth packages, including one-to-one consultations and weekly
weigh-in groups.
While Diet Express has in the past promoted
their products based on their claims to help users
lose weight, they have recently been advertising the
role of a low-GI diet in preventing and controlling
diabetes.
The company is hoping to build on their recent
expansion, and they are planning for new contracts
that will see their products sold in health clubs in
Egypt and Uganda in the new year. Until recently, they have only operated in the UK and Ireland.
In 2010, the company worked with Belfast City
Council to create a weight loss programme for
families in the city. They have also partnered with
Northern Ireland’s South Eastern Health and Social
Care Trust to help offer dieting advice and support
for the region’s diabetes patients.
Obesity is a serious problem in the Emirates:
while 75% of UAE residents surveyed in Philips’ recent Health and Wellbeing Index believed
that they were not overweight, the Health Authority-Abu Dhabi’s Weqaya study found that 34% of
Emirati adults are overweight and a further 36% are
obese. Research has also shown that 25% of Emirati adults are at risk of developing diabetes.
16 BARIATRIC NEWS
iBariatrics – patients go digital
Simon Monkhouse Specialist Registrar, South West
announces
name change
SOBA, formerly known as the Soci-
ety Of Bariatric Anaesthetists, has announced that
it has changed its name to the Society for Obesity and Bariatric Anaesthesia, effective December
2011.
SOBA is the largest specialist society for anaesthesia for the morbidly obese in the world.
One of its roles is to facilitate excellence in the
management and safety of obese patients in a
much wider field than just bariatric surgery. There
is significant demand for teaching and training in
the care of the obese patient non bariatric surgery (and critical care) as in bariatric surgery, and
SOBA believes the Society for Obesity and Bariatric Anaesthesia much better reflects the wider
aims of the Society.
SOBA runs three scientific meetings per year.
Spring and late Autumn meetings held in the
north (York in 2012) and London respectively,
are aimed at anaesthetists who are just starting a
bariatric service, are planning to become involved
in the field and also non-specialist bariatric anaesthetists with an interest in anaesthesia for the
obese patient. The third meeting, held in late September is a specialist bariatric anaesthesia meeting, and has an international profile. In 2012 this
meeting will be held in Taunton.
For further details about SOBA please visit
www.sobauk.com
SOBAUK
No longer do patients have to trawl through hundreds of websites
on the internet or browse the health section of the local book
store, all they need to do is download an app.
Sally Norton (Consultant Bariatric Surgeon, Bristol),
Sharon Bates (Obesity Nurse Specialist and counsellor, Bristol) and Simon Monkhouse (Specialist Registrar,
South West) have combined forces
to create a unique series of apps for
weight loss surgery patients. There is
an app for each operation – ideal for
those who have just had surgery. For
those who are thinking about surgery
the series of apps will be a useful addition to their mobile phones.
myGastricBand, myGastricBypass, myGastricSleeve and myGastricBalloon all have an eye catching,
similar format which will guide the
user through their post-surgery journey. Every app has five subsections
resulting in a comprehensive post surgery information and reference resource.
myProfile allows documentation
of date of surgery, type of surgery or
procedure and location, together with
personal details such as age and BMI.
There is a visual description of the operation they have just had and an opportunity to document their goals. Do
they want to fit into a particular dress
by Christmas? What is their target
weight? It includes space for emer-
Sally Norton and Simon Monkhouse
gency contact numbers and appointment details. This is a useful source
of reference for them to keep close at
hand.
A weight loss and clothes size
tracker is included in myProgress to
give them visual record of their progress. In myGastricBalloon a monthby-month programme also provides
the opportunity to gain gold stars
as goals are ticked off one by one –
Pavlov and his dogs would be happy!
myHealth section is the back bone
of the app with tips and tricks on how
to keep fit and well post surgery – in
mind as well as body. Information
on psychology and exercise are provided along with advice on vitamins
and other supplements. Importantly, this section also warns patients of
the potential (though thankfully rare)
SOBAUK
Society for Obesity and Bariatric Anaesthesia
Safe anaesthesia for the morbidly obese patient
The Hospitium, Museum St, York YO1 7FR
Friday 20th April 2012
9:20 Registration & Coffee
9:50 Introduction and Welcome: Aims of the Day
10:00 Treating Obesity - Why and how?
10:30 Practicalities of managing the obese patient
- Staff, Organisation, Equipment and positioning
11:00 Coffee
11:30 Pre-operative assessment
12:40 Lunch
13:30 The Airway & Ventilation
14:00 Pharmacokinetics of Obesity: Induction, Maintenance, Analgesia
14:30 Regional anaesthesia in the obese
15:00 Afternoon Tea
15:30 The obese parturient
16:00 Postoperative care and DVT prophylaxis
16:30 Meeting close
5 CPD Points applied for
SOBA Members and trainees £125 Non-members £150
For registration and further information visit www.sobauk.com
Joining SOBA is just £25 per annum and gives discounted entry to all our meetings and seminars
as well as a host of other benefits.
late complications of weight
loss surgery, guides the user
to recognise the early warning
signs and advises on when to
seek help.
myQuestions is full of
helpful hints on how to eat
out, what to eat, how to recognise feeling full
and is written
from a very personal perspective.
Evidence-based
information combined with personal anecdote make
this section friendly yet informative.
The More section gives patients
the opportunity to
contact weight loss
professionals together with the opportunity to enter
forums and meet
like-minded individuals.
This is an exciting
development
in patient support.
Look out for the
apps in the iTunes App Store
in the very near future.
For more information visit
www.weightlosssurgeryclinic.co.uk
BAPRAS call for body
contouring guidelines
A British plastic surgery association is pushing for national guidelines for the
commissioning of body contour surgery in
the NHS.
The British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS)
are currently inviting stakeholder organisations to an initial consultation. They hope to
establish the key points to be considered for
the development of guidelines for body contour surgery.
NICE currently offer no such guidelines,
and BAPRAS claim that this has created a
postcode lottery in body contour commissioning. Simon Kay, Professor of Hand Surgery at
the University of Leeds and BAPRAS’ communications chair, said “In some parts of the
country you can have this operation done on
the health service, in other parts you have to
go before a panel, and in other parts there’s a
complete ban on it.”
While Kay described the evidence supporting the use of the surgery as “sporadic”, he said that he hoped the planned consultation would consolidate the existing
evidence base. A pilot study presented at
BAPRAS’ Winter Meeting by Mark Soldin,
consultant plastic surgeon at Kingston and
St Georges University Teaching Hospitals,
indicated significant improvements in patients’ physical and emotional wellbeing
following the surgery.
However, he was keen to emphasise that
BAPRAS was not lobbying for the supply
of body contouring surgery on the NHS;
rather, they were seeking greater nationwide consistency in its provision.
“We want to act as an informed adviser,
rather than a lobbyist,” said Kay. “We don’t
act for one group or another but we’ve realised that when the commissioning groups
are making decisions about commissioning
they may need authoritative advice.”
Excess skin following heavy weight loss
can result in conditions including soreness,
recurrent infections, functional problems, depression, difficulty with sexual function and
poor body image. “Very often the weight loss
will result in a patient whose diabetes is reversed, whose risk of arthritis is reduced,
whose heart attack risk is reduced, but who
won’t re-enter society, as it were, because of
the stigmatising skin redundancy,” said Kay.
BAPRAS are hoping to attract a number
of stakeholder groups to take part in the consultation, representing medical providers, patients and the Department of Health. Kay said
that while he expected the patient groups to
be very supportive of the commissioning, the
government organisations might not consider
the benefits to be worth the price of the surgery.
“The cost implications are quite considerable,” said Kay. “If you do fund the surgery,
the plastic surgery after dramatic weight loss
is substantially more expensive than the bariatric surgery, in terms of the length of stay,
the complications, and the operating time.”
A recent study carried out by BAPRAS
showed that only 45% of British GPs support the NHS offering body contouring surgery following bariatric surgery. However,
Kay said he hopes that this will rise with increased awareness of the implications of the
surgery. “They may not understand what’s involved – what the implications are, what the
costs are, what the stress for the patient is,”
said Kay. “They may not understand the utility and the benefits.”
BARIATRIC NEWS 17
Researchers from the Universi-
ty of Alberta claim that their risk assessment scoring system, the Edmonton obesity staging system
(EOSS), improves on current methods in helping
to predict the risk of death in overweight and obese
people. The study has been published in the Canadian Medical Association Journal (Padwal et al.
CMAJ October 2011;183;14).
According to the researchers, anthropometricbased classification schemes for excess adiposity
(such as body mass index [BMI]) do not include
direct assessment of obesity-related comorbidity
(numerous conditions that may be associated with
excess weight) and functional status, and cannot
distinguish between lean and fat tissue. Therefore,
BMI has limited clinical utility.
The EOSS, originally proposed by Dr Arya
Sharma from the University of Alberta, ranks overweight and obese people on a five-point scale according to their underlying health status and the
presence or absence of underlying health conditions. It is a clinical staging system that ranks people with excess adiposity on a five-point ordinal
scale, while incorporating obesity-related comorbidities and functional status into the assessment
(Figure 1).
0
No apparent risk factors (e.g., blood pressure, serum
lipid and fasting glucose levels within normal range),
physical symptoms, psychopathology, functional
limitations and/or impairment of well-being related
to obesity.
1
Presence of obesity-related subclinical risk factors
(e.g., borderline hypertension, impaired fasting
glucose levels, elevated levels of liver enzymes),
mild physical symptoms (e.g. dyspnea on moderate
exertion, occasional aches and pains, fatigue), mild
psychopathology, mild functional limitations and/or
mild impairment of well-being.
2
Presence of established obesity-related chronic
disease (e.g., hypertension, type 2 diabetes, sleep
apnea, osteoarthritis), moderate limitations in activities of daily living and/or well-being.
3
Established end-organ damage such as myocardial
infarction, heart failure, stroke, significant psychopathology, significant functional limitations and/or
impairment of well-being.
4
Severe (potentially end-stage) disabilities from
obesity-related chronic diseases, severe disabling
psychopathology, severe functional limitations and/or
severe impairment of well-being
Figure 1: Arya Sharma's five-point scale ranking overweight and
obese people according to their underlying health status.
EOSS has previously been used to predict death
using data from a population-representative survey
of 8,143 people in the 1988-1994 and 1999-2004
US National Health and Human Nutrition Examination Surveys (NHANES).
In this latest study, researchers undertook a rigorous examination of EOSS and assessed its ability in predicting mortality independent of anthropometric indices in a large, nationally representative
US sample.
The investigators analysed data from NHANES
III (1988–1994) and the NHANES 1999–2004,
with mortality follow-up through to the end of
2006. Adults (age ≥20 year) with overweight or
obesity who had been randomised to the morning session at the mobile examination centre were
scored according to the Edmonton obesity staging
system. They examined the relationship between
staging system scores and mortality, and Cox proportional hazards models were adjusted for the
presence of the metabolic syndrome or hyper-triglyceridemic waist (waist circumference ≥90cm
and a triglyceride level ≥ 2mmol/L for men; and
≥85cm and ≥1.5mmol/L for women).
More than 75% of the cohort with overweight
or obesity were given scores of 1 or 2. Scores of
4 could not be reliably assigned because specific
data elements were lacking. The survival curves
clearly diverged when stratified by scores of 0–3,
but not when stratified by obesity class alone.
Within the data from the NHANES 1988–1994,
scores of 2 (hazard ratio [HR] 1.57; 95% confidence interval [CI] 1.16 to 2.13) and 3 (HR 2.69;
95% CI 1.98 to 3.67) were associated with increased mortality compared with scores of 0 or 1,
even after adjustment for body mass index and the
metabolic syndrome. The researchers found similar results after adjusting for hypertriglyceridemic waist, as well as in a cohort eligible for bariatric surgery.
The study found that within a nationally representative cohort, higher EOSS scores were a
strong predictor of increasing mortality in both
the overall population and in a cohort of people
eligible for bariatric surgery, independent of BMI
and the presence of metabolic syndrome or hypertriglyceridemic waist. Moreover, even within strata of BMI categories, there was clear separation of survival curves (Figure 2), the authors
noted.
Padwal R S et al. CMAJ 2011;183:E1059-E1066. ©2011 by Canadian Medical Association
EOSS predicts risk of death for bariatric patients
Figure 2: Comparison of staging system and anthropometric classification scheme for predicting all-cause mortality among people with
overweight and obesity.
Limitations
Despite the results from the study, the authors do
acknowledge that the study does have some limitations. For example, comorbidities were arbitrarily
assigned to be equivalent in terms of their burden
of illness although it is not yet clear whether certain comorbidities should receive a higher weighting. Moreover, the researchers made no distinction
between types of diabetes (of Americans with diabetes, 90%–95% have type 2 diabetes). However, both subtypes would require management in an
overweight or obese cohort and were thus judged
appropriate for inclusion.
CMS Lap-Band change reduced
costs and increased safety
According to a study featured in the journal Annals of Surgery (December 2011;254;6;860–865), the February 2006 decision by the Centers for
Medicare and Medicaid Services (CMS) to restrict reimbursement for bariatric surgery to accredited centres and include coverage for laparoscopic adjustable gastric band (LAGB), reduced the cost of procedures and increased safety measures.
Prior to the 2006 changes, the CMS only reimbursed gastric bypass surgeries. As a result, Dr David Flum, the study's lead author and a Professor
at the University of Washington, and colleagues decided to investigated the
impact of the CMS’ bariatric surgery national coverage decision on the use,
safety and cost of care for CMS beneficiaries.
Study design
The researchers established a cohort study using nationwide Medicare data
(2004–2008) evaluating rates of bariatric procedures/100,000 enrolees, 90-day
mortality, readmission rate and payments.
Table 1: Procedure rates pre- and post-NCD
ORYGB*
LRYGB**
Pre-NCD
56.0%
35.5%
LAGB***
n/a
Post-NCD
12.8%
48.7%
36.7%
*Open roux-en-y gastric bypass (ORYGB)
**Laparoscopic roux-en-y gastric bypass (LRYGB)
Table 2: 90-day mortality rate pre- and post-NCD
ORYGB
LRYGB
LAGB
Total
Pre-NCD
1.8%
1.1%
n/a
1.5%
Post-NCD
1.7%
0.8%
0.3%
0.7%
p value
<0.001
Table 3: 90-day re-admission, re-operation and payments pre- and post-NCD
Re-admission
Re-operation
Payments
p value
Pre-NCD
19.9%
3.2%
US$24,363
<0.001
Post-NCD
15.4%
2.1%
US$19,746
<0.001
A total of 47,030 patients underwent procedures at 928 sites
pre-NCD and 662 post NCD.
The procedure rate/100,000 patients dropped after the NCD
to 17.8 (from 21.9 in 2005) increasing to 23.8 and 29.1 in
2007 and 2008, respectively.
Pre and post NCD data are seen
in Tables 1, 2 and 3
Conclusions
The NCD was associated with
Adjustable gastric band
a temporary reduction in procedure rate and a shift in types of procedures and patients undergoing bariatric
surgery. It was associated with a significant decrease in the risk of death, complications, readmissions, and per patient payments.
The research revealed that out of every 1,000 people who had weight loss
surgery before the CMS decision died within 90 days of the procedure. After
the rules change, seven out of every 1,000 people died after the surgery. Furthermore, re-admission and reoperations also dropped, as did the cost of the
procedure.
The NCD limited reimbursements to hospitals that receive a particular accreditation through the American College of Surgeons or the American Society
for Bariatric Surgery by performing a certain number of procedures each year
and by having staff and facilities that meet certain standards.
Before Medicare's new requirement for accreditation in 2006, patients received surgery at 928 sites. Afterward, patients went to 662 facilities for surgery. This resulted in a decrease in access in places that were not accredited;
however, the authors support the notion of accreditation standards around safety or volume, as this has been proven to improve outcomes.
The CMS’ current coverage for weight loss surgery excludes sleeve gastrectomy (see page 6) and officials are seeking input on whether there are
enough data on its effects and safety to include the procedure.
Conclusion
Nevertheless, the investigators concluded that the
EOSS is a strong predictor of increasing mortality independent of BMI, metabolic syndrome and
hypertriglyceridemic waist. It independently predicted increased mortality even after adjustment
for contemporary methods of classifying adiposity.
The authors proposed that this system should
be considered adjunctive to current anthropometric classification systems in assessing obesity-related risk, determining prognosis and guiding potential bariatric surgery treatment options.
FDA warning
for misleading
Lap-Band
adverts
The Food and Drug Administration (FDA) has sent
a warning letter to several companies for using misleading advertising to promote Lap-Band weightloss surgery. The Agency said the companies have
failed to sufficiently convey the serious risks carried
by weight-loss surgery. The warnings are in response
to complaints from a public health agency and Allergan, which manufactures the Lap-Band device.
“FDA’s concern is that these ads glamorise the
Lap-Band without communicating any of the risks,”
said Steven Silverman, Director of the Office of
Compliance in FDA’s Center for Devices and Radiological Health. “Consumers, who may be influenced
by misleading advertising, need to be fully aware of
the risks of any surgical procedure.”
The FDA regularly issues warning letters to companies that do not follow regulations for manufacturing and promoting drugs and medical devices. The
letters are not legally binding, but the FDA can take
companies to court if they are ignored.
“The decision to undergo a gastric banding procedure should be done in close consultation between a patient and his or her health care provider,”
said Dr Kimber Richter, Deputy Director for Medical
Affairs in the Office of Compliance in the FDA’s Center for Devices and Radiological Health. “It is important for the patient to fully understand both the risks
and the benefits of the procedure and for the health
care provider to be sure the procedure is appropriate for the patient.”
18 BARIATRIC NEWS
ASGE/ASMBS TaskForce publishes EBT white paper
A joint TaskForce from the American Society for Gastrointestinal Endoscopy (ASGE) and
the American Society for Metabolic and Bariatric Surgery (ASMBS) has recently published
a white paper concerning endoscopic bariatric therapies (EBTs). Specifically, the white
paper is intended to provide a framework for, and a pathway towards, the development,
investigation, and adoption of safe and effective EBTs.
“The two societies
formed a joint task force to identify opportunities where endoscopic treatments may play a role
in improving patient outcomes
and reducing costs,” said Dr GreGregory Ginsberg
gory G Ginsberg, ASGE president and Chair of the ASGE/ASMBS Task Force on EBTs. “The
white paper establishes the criteria for success as new technologies and procedures are developed.”
The white paper entitled, ‘A
Bipan Chand
Pathway to Endoscopic Bariatric Therapies’, states that EBTs
may have various roles in the treatment of the obesity epidemic, including primary therapy, early intervention, bridge therapy, and metabolic therapy.
They will also have varying degrees of intensity,
durability, and repeatability and therefore should be
evaluated based on intent of therapy and their overall risk/benefit, stated the white paper.
“Endoscopic therapy has the potential to be applied across the continuum of obesity and metabolic disease,” said Dr Bipan Chand, Chairman,
ASMBS Emerging Technology and Procedure
Committee, and Co-Chair of the ASGE/ASMBS
Task Force. “However, it is generally expected that
endoscopic modalities achieve weight loss superior
to that produced by medical and intensive lifestyle
interventions, have a favourable risk/benefit profile
and have scientific evidence to support its use.”
The white paper addresses a number of issues
including endoscopic bariatric therapy treatment
classification, potential indications, efficacy endpoints (threshold for weight loss and study design
etc) and secondary efficacy endpoints (reduction in
obesity-related co-morbidities, changes in quality
of life, safety, durability and repeatability etc), the
adoption of EBTs in the context of global patient
care, training and credentialing, cost effectiveness
and government and industry relations.
The white paper emphasises that any new surgical, endoscopic or nonsurgical weight loss intervention should include a defined threshold of efficacy, balanced with risks of the intervention. EBT
potentially offers an ambulatory weight loss procedures with a superior safety and cost profile compared to bariatric surgery, and if it is shown to be
feasible, safe, and effective, EBT therapy could
be appropriate for intervention to individuals with
lower classes of obesity (ie, Class I).
Treatment mechanism
Several EBTs are currently in different stages of
development, and include a variety of methods to
induce weight loss and reduce obesity-related comorbidities. EBT technologies can be categorised
broadly according to the intended mechanism of
action: gastric restriction or manipulation, malabsorption, neuro-hormonal alterations, or some
combination.
Some EBTs attempt to decrease effective stomach capacity. These technologies include spaceoccupying devices and those that alter gastric
anatomy. According to the white papers, these
space-occupying devices most commonly take the
form of temporarily placed prosthetic balloons,
which effectively restrict intake, thereby enhancing
satiety and instigating weight loss.
Weight loss and improvements in metabolic
comorbidities after malabsorptive surgical procedures are more profound than after purely stomach
altering restrictive operations, and have prompted
the development of endoscopic devices to induce
malabsorption. These therapies are designed to create a physical barrier between food, the intestinal
wall and biliopancreatic secretions. One such device is the duodenal-jejunal barrier sleeve, which
may be placed temporarily or left in-situ indefinitely. These impermeable fluoropolymer sleeves open
at both ends, are placed endoscopically, and anchor
in the proximal duodenum or at the gastroesopha-
geal junction. They prevent chyme from contacting the proximal intestine while bile and pancreatic secretions pass along the outer wall of the liner
and mix with chyme in the distal jejunum.
Other EBTs, still in early stage development,
aim to modulate satiety and food intake through
neuralhormonal mechanisms. Evidence suggests
that gut hormones act in conjunction with the complex enteric nervous system to coordinate and regulate gastrointestinal satiety signals, motility, and
digestive processes. Novel endoscopic devices
seek to take advantage of this interaction by manipulating neural-hormonal signals to induce satiety. Their intended mechanism of action is to interfere with vagal signals between the brain and
gastrointestinal tract, through a variety of techniques such as gastric stimulation or pacing, neuromodulation, and vagal resection.
Intent of endoluminal therapies
The primary goal of EBT is to induce enough
weight loss to decrease obesity related metabolic
co-morbidities and improve quality of life. Compared to current surgical interventions, EBTs are
expected to yield substantial improvements and
achieve a favourable risk/benefit profile. However, while a lower risk EBT must achieve this primary goal, its threshold for efficacy should be lower than a higher risk intervention. With this concept
in mind, endoluminal therapies have many potential applications as primary, adjunctive or revisionary bariatric procedures.
Intragastrinal balloon
Specifically, the indications for EBT include primary therapy, early intervention/pre-emptive therapy, bridge therapy, and metabolic therapy. For each
of these indications, the white paper considered the
minimum threshold for efficacy, risk profile, durability and repeatability.
Primary therapy
An EBT with morbidity and mortality comparable
to laparoscopic adjustable gastric banding should
hold similar efficacy, with the potential to achieve
approximately 40% excess weight loss. Alternatively, lower efficacy is acceptable for an EBT with
a lower risk profile. Such treatments would be considered for patients with severe obesity
Early intervention/preemptive obesity therapy
patients with Class I and II obesity are at risk for
disease progression, have a higher cardiovascular
risk profile, and have a substantially increased relative risk of all-cause mortality. There is evidence
that patients with Class I obesity respond well to
surgical intervention. Prospective trials of both
sleeve gastrectomy and adjustable gastric banding
in patients with Class I obesity have demonstrated
significant weight loss and resultant improvement
in or resolution of many obesity related co-morbidities. Several other non-randomized studies have
confirmed similar results.
As a result, the FDA recently approved the use of
gastric banding for patients with Class I obesity and
at least one associated obesity related co-morbidity. The durability or repeatability of an EBT will be
important. For a procedure to be repeatable, the patients’ anatomy must have minimal permanent alteration and be amenable to future intervention.
Bridge therapy
The intent of ‘Bridge Therapy’ is to promote weight
loss specifically to reduce the risk from a subsequent intervention, including bariatric surgery. Patients with Class III obesity and those with metabolic co-morbidities present greater technical
challenges and surgical risk than less obese, healthier patients. Furthermore, these effects are more
pronounced in patients with BMI>60 where there
is a greater risk of morbidity or mortality than patients with BMI 45-60.
Metabolic therapy
EBT may be justified in patients with less severe
obesity (Class I), where improvement in metabolic illness is the primary concern. In particular, comorbidities such as type II diabetes, hyperlipidemia, and hypertension, may improve or resolve
with even modest weight loss.
Procedures which aim to effect metabolic dis-
ease should have a lower risk profile and greater
durability compared to therapies which specifically aim to induce massive weight loss. Substantial weight loss may not be necessary in order to
achieve metabolic benefits in less severely obese
individuals. Obese patients who lose 5% of their total body weight benefit from significant reductions
in diabetes and cardiovascular risk factors including hypertension and dyslipidemia. Therefore, The
TaskForce advocates using 5% of total body weight
lost as the absolute minimum threshold for any
non-primary EBT (eg, early intervention, bridging
or metabolic therapy).
Comparison of nonsurgical and operative interventions is limited by differences in the primary outcome measure: nonsurgical interventions
typically use actual weight lost or % of total body
weight, whereas operative therapies traditionally
use %EWL.
Threshold for weight loss for endoscopic
therapies
The weight loss threshold for the adoption of any
new endoscopic procedures should be balanced
against the risk of that procedure. Currently there
are no established thresholds for endoscopic bariatric interventions. However, in general it is expected
that endoscopic modalities should achieve weight
loss superior to that anticipated with medical and
intensive lifestyle interventions.
Pharmacologic agents such as orlistat have been
FDA approved despite their modest effects because 1) lifestyle interventions have even lower efficacy and poor durability/compliance and 2) small
amount of lost weight (5% of total body weight
or less) can lead to significant reductions in obesity-related co-morbidities. Therefore, based on
available evidence and expert opinion, the TaskForce recommends that an EBT intended as a primary obesity intervention should achieve a mean
minimum threshold of 25% EWL measured at 12
months. This goal will vary depending on the category or intent of endoscopic bariatric procedure.
EBT should also be compared to a second treatment group, not necessarily a sham. Sham groups
in comparative trials evaluating the efficacy of bariatric therapies have shown considerable variability
in weight loss (3-13% EWL).
In addition to the absolute threshold of weight
loss, the mean %EWL difference between a primary EBT and control groups should be a minimum of
15% EWL, and be statistically significant. For other categories of EBT, the amount of EWL and durability of the effect may vary by type and intent of
the EBT. As previously described, EBT may be performed for early intervention, bridge therapy, and
as a metabolic therapy. In these instances, the primary endpoint may include, but not be limited to,
an improvement or resolution in metabolic illness,
decreasing the risks associated when performing
another planned intervention, and preventing the
progression to greater severity of obesity with its
associated risks.
The Tantalus System (above) and
the VBLOC (left)
BARIATRIC NEWS 19
Study design
As a device is designed and modified to address a
specific clinical need various types of studies are typically required as part of the regulatory process. Following rigorous preclinical evaluation, a feasibility
study in humans is often the appropriate next step.
The concept of such feasibility studies is well described in the FDA guidance documents. These are
typically small studies performed in a limited number of subjects to confirm design and operating specifications. The emphasis is on technical feasibility
and safety. Device modification is often necessary in
this phase and flexibility is emphasized. There are
typically no efficacy targets and the final results are
generally used to calculate sample size and establish
parameters for a larger pivotal trial.
Clinical studies have shown that sustained
moderate weight loss achieved through dietary and lifestyle intervention lowers blood
pressure, improves glucose control, prevents diabetes, and improves dyslipidemia,
haemostatic and fibrinolytic factors. Obese patients who lose 5% of their total body weight benefit from significant reductions in diabetes and cardiovascular risk factors including hypertension and
dyslipidemia.
Therefore, the TaskForce advocates using 5%
of total body weight lost as the absolute minimum
threshold for any EBT intended for anything but a
primary bariatric intervention (eg, early intervention,
bridging or metabolic therapy). Given that weight
has significant metabolic effects, a 5% reduction
could result in an improvement in or resolution of
obesity-related co-morbidities such as diabetes mellitus, hypertension, obstructive sleep apnea and nonalcoholic fatty liver disease. If an endoscopic intervention proves to have a significant impact on one or
more of these co-morbidities with a negligible risk
profile, the threshold for intervention may extend to
Class I obese individuals (BMI 30-35kg/m2).
In addition to lowering the prevalence of co-existent obesity-related metabolic illnesses, there is potential for an EBT to primarily prevent these comor-
Join
bidities by promoting weight loss in mildly obese
individuals. In this population, it is important that
improvement/resolution of comorbidities be significantly better for endoscopic therapies compared to
that of control groups, given the risks associated with
any intervention despite how minimal they may be.
Improvement and resolution of comorbidities should
be defined using objective and standardised criteria.
The safety of an EBT at a moderate intensity level implies a higher incidence of bleeding, perforation and other complications, similar
to that observed with interventional endoscopic
procedure such
as therapeutic
endoscopic ret-
Endobarrier
rograde cholangio-pancreatography
with sphincterotomy. The safety of EBT at a high intensity level would be similar to that seen perioperatively with low risk operative procedures such as the
adjustable gastric band. They would typically employ general anaesthesia (endotracheal intubation)
as well as extended observation periods.
Durability and repeatability
The goal of primary bariatric surgical therapies is
to induce substantial and sustainable weight loss
with associated metabolic benefits. These same expectations apply to EBT, as a primary weight loss
therapy. However, an EBT with reduced durability may be offset by repeatability of the intervention; EBT is particularly suited to this approach.
Low risk EBT may be repeated at varying intervals
Your colleagues in beautiful San Diego for
the 29th Annual Meeting of the ASMBS.
This year’s program will exceed all expectations. Anticipate more collaborative
postgraduate courses designed for both the surgeon and the integrated health teams.
You’ll see more symposiums, debates and videos. Plan to participate in lively and
interactive discussions in both the Integrated Health Main Session as well as the
Plenary Session.
This year’s Mason Lecturer, Dr. John Birkmeyer, will speak on Composite Measure in
Bariatric Surgery, and Basic Science invited lecturer, Dr. Robert O’Rourke, will speak
on Obesity Inflammation and Cancer.
YoU Don’t WAnt to MiSS it! SEE YoU in SAn DiEgo!
Visit www.2012.asmbs.org for more information
to achieve durable effect, whilst remaining cost effective compared to surgical alternatives or a lengthy period of pharmacological agents and supervised lifestyle
interventions.
Training/credentialing
Evidence demonstrates that higher quality patient care is associated with high volume bariatric units. Recognition of this prompted the process of credentialing Centers
of Excellence in bariatric surgery. The white paper stresses that
training and skill acquisition with
EBT techniques and technology are mandatory before clinical application is undertaken, and
must include didactic as well as hands–on practical education. In addition, any practitioner who
is interested in performing an EBT should also be
educated in the clinical management of obese patients. The duration and type of training is likely to
depend on the complexity of a particular EBT.
The ASGE Interactive Training & Technology center (ITT) and Masters Series courses represent appropriate venues for focused training in the
procedural aspects of EBT. EBTs of greater complexity may also require proctoring during the first
several clinical applications by a new practitioner.
EBTs of the highest complexity may require a focused training programme (ie, 'mini-fellowship'),
or longer. For all EBTs, early studies should evaluate its learning curve in order to guide the subsequent training and credentialing process. These
procedures should be included as a part of a comprehensive obesity programme and not performed
in isolation.
Cost effectiveness
The costs of bariatric surgery and its associated complications may be offset by consequential reductions
in weight and obesity-related co-morbidities. However, there are also data to support surgical intervention among Class II and Class I obese individuals with concomitant type II diabetes. Therefore, the
TaskForce suggests that elements of a cost effectiveness analysis in EBT include the direct cost of a proposed device and the associated health care utilisation
required for its implementation (eg, sedation requirements, time of hospitalisation, physician fees).
An EBT which decreases obesity-related
co-morbidities for a sustained period of time
is likely to reduce long term health care consumption; therefore, accurate data on this
secondary outcome are paramount. Additional measures of indirect costs include
consequential improvements in quality of life
and work productivity secondary to weight loss
from an EBT. Therefore, the white paper states
that cost effectiveness studies in EBT require long
term data on weight loss, obesity-related co-morbidities, impact on quality-of-life, and the possible
need for repeated EBT in order to sustain these outcome measures. For these reasons, studies evaluating the cost effectiveness of EBT are expected to be
phase III or IV clinical trials.
Government and industry relations
The white paper also states that the development
of EBT should be done in collaboration with government regulating agencies (eg, FDA) to establish
thresholds for safety and efficacy (primary and secondary endpoints). While this is a complex process
for new devices with widely different risk and efficacy profiles, a clear and transparent process is needed
to stimulate development of innovative EBT.
The white paper appears online in both GIE: Gastrointestinal Endoscopy, the peer-reviewed scientific journal of the ASGE and Surgery for Obesity and
Related Diseases (SOARD), the peer-reviewed scientific journal of the ASMBS.
LoDging inforMAtion
Rising 30 stories above the edge of San Diego Bay
the Hilton San Diego Bayfront hotel is downtown
San Diego’s newest waterfront hotel.
San Diego Bayfront Hotel
1 Park Boulevard
San Diego, California| USA 92101
Tel: +1-619-564-3333
Fax: +1-619-564-3344
Reserve your room now at
www.2012.asmbs.org
The American Society for Metabolic and Bariatric Surgery designates this educational activity for a maximum of 35.75 AMA PRA Category 1 Credit(s)™ . Physicians should only claim credit commensurate with the extent of their participation in the activity.
Nursing Credits (up to 39.25 CE contact hours) are provided by Taylor College, Los Angeles, California (possibly may not be accepted for national certification).
APA credits and NASW credits for the ASMBS Masters in Behavioral Health Course are pending approval by Amedco. This course will be co-provided by Amedco and American Society for Metabolic and Bariatric Surgery.
20 BARIATRIC NEWS
Product News EnteroMedics’ Maestro System gains Australian approval
EnteroMedics has stomach. The Maestro RC Sysreceived approval from tem is powered by an internal,
the Australian Therapeutic
Goods Administration (TGA)
of the critical active implantable
medical device (AIMD) components of the Maestro System.
TGA approval was granted for the Maestro Implant Kit,
which is comprised of a rechargeable neuro-regulator, anterior and posterior leads and a
clinician transmit coil, as well
as the individual implantable
rechargeable
neuro-regulator
component, both of which were
AIMD applications.
In addition, TGA approved
the two class I applications for
the AC battery charger and the
programmer cable. The TGA is
currently reviewing individual
class III components, including the mobile charger, multiple versions of the patient
transmit coil and the clinician
programmer.
The Maestro RC System delivers VBLOC vagal blocking therapy via two small electrodes that are laparoscopically
implanted and placed in contact
with the trunks of the vagus
nerve just above the junction between the oesophagus and the
rechargeable battery. The battery is recharged via an external
mobile charger and transmit coil
that the patient uses for a short
time each week.
EnteroMedics
developed
VBLOC vagal blocking therapy to offer bariatric surgeons
and their patients a less invasive alternative to existing surgical weight loss procedures
that may present significant
risks and alter digestive system anatomy, lifestyle and food
choices. VBLOC Therapy is designed to target the multiple digestive functions under control
of the vagus nerves and to affect the perception of hunger
and fullness.
“The implantable AIMD
components of the Maestro
System are the heart of our system and of EnteroMedics' revolutionary approach to obesity
treatment. Their approval by the
TGA, therefore, marks a major
milestone for EnteroMedics and
a significant accomplishment
for both our company and our
many collaborators in the Australian healthcare community,”
said Dr Mark B Knudson, En-
teroMedics' President and Chief
Executive Officer. “The Maestro System is the only surgical intervention to individually
address each patient's path toward weight loss without compromises in safety, lifestyle or
anatomy. We look forward to
completion of the review of
the balance of the system components and the opportunity to
provide the Australian bariat-
Crospon receives FDA clearance
for EF-800 accessory
Crospon
has
announced that it has received
FDA clearance for its EF-800 external channel endoscopic accessory. The device provides an external 4mm channel that can be
applied to a diagnostic or therapeutic endoscope to allow the user
to deploy endoscopic accessories
whose diameter exceeds the typical channel diameter of such endoscopes.
Commenting on the FDA clearance, John O’Dea, CEO of Crospon said, “This general purpose
channel may be used to deploy
the company’s EndoFLIP catheters into hard to access parts of the
gastrointestinal tract, for example
for measurement of stomas in the
stomach created during bariatric
surgery procedures. Equally it will
be useful for a variety of other endoscopic accessories, for example
larger dilation catheters, graspers
or imaging probes.”
The company has previously
announced FDA clearance to the
EndoFLIP EF-900 Gastric Tube.
This is intended for use in bariatric surgical procedures to provide
a sized support bougie for sleeve
gastrectomy, and to permit stomach decompression, gastric fluid
drainage and removal. It can also
be used to aid deployment of the
company’s range of EndoFLIP
catheters within the oesophagus
and stomach.
Medical Center, Dallas, TX. “I use it in
all of my gastric sleeve and gastric
bypass cases when I need another
tissue layer of security. It passes smoothly through tissue
like a polypropylene suture
with a desirable degree of
approximation that’s uniform throughout the suture
line.”
The V-Loc 180 device, launched in October 2009, was the first
surgical device of its kind
to feature uni-directional
barbed suture technology.
The device's unique and proprietary self-anchoring loop
and barb combination enables
surgeons to close wounds quickly and securely without tying knots or
changing standard closure techniques.
Since the introduction of V-Loc device technology, surgeons have adopted the product in a wide
variety of procedures for secure, fast and effective
wound closure. Testing and research indicate that
the use of the absorbable V-Loc device technology
can decrease the time needed to close surgical incisions by up to 50%, when compared to standard suturing techniques.
“With this new addition to our knotless suture portfolio, surgeons have an even broader array of choices for closing surgical incisions safely, quickly and
effectively,” said Peter Schommer, Vice President,
Global Product Marketing, Wound Closure, Covidien. “We are committed to consistently developing innovative devices to improve patient outcomes, as well
as surgeons’ experiences while they operate.”
The V-Loc PBT non-absorbable wound closure
device has been cleared for one-time use by the United States Food and Drug Administration and is currently available in the US.
Covidien
launches unique
uni-directional
knotless suture
Covidien has announced the launch
of the first non-absorbable, uni-directional barbed
suture, part of its range of V-Loc wound closure devices. The V-Loc PBT (Polybutester) non-absorbable wound closure device allows surgeons to securely close incisions without the need to tie knots.
Non-absorbable sutures are used to permanently close internal and external wounds. The V-Loc
PBT joins the V-Loc 90 and V-Loc 180 absorbable
wound closure devices currently available to healthcare professionals.
“The V-Loc PBT device allows for accurate oversewing of all staple lines, in both bariatric and general surgery cases,” said Dr David Kim, Forest Park
ric care community with a new,
safe and sustainable option for
addressing the epidemic of obesity in this important market.”
BARIATRIC NEWS 21
Product News
Ethicon launch new powered Laparoscopic stapler
Ethicon Endo-Surgery has launched a new laparoscopic
stapler, designed to reduce tissue damage through inadvertent movement
of the distal tip.
The company claims that the Echelon Flex Powered Endopath Stapler
allows 63% reduction in tip movement during tissue cutting and stapling,
compared to their competitors Covidien’s Endo GIA and Endo GIA Universal devices.
According to Ethicon, the new instrument is the
first powered endocutter with system-wide compression
and stability, delivering a uniform gap in the jaws from the instrument’s proximal end to distal tip, helping the surgeon create consistent, properly formed staples. The powered operation reduces the force
required to fire the instrument, leading to less movement of the tip and potentially lower trauma to the patient.
Robin Blackstone, Medical Director and Bariatric Surgeon at the Scott-
sdale Healthcare Bariatric Center, USA, said of the stapler “I can see how
it will be of enormous value in procedures that involve thick tissue and
challenging angles.”
Ethicon have also announced that they have received 510(K) clearance
for their line of Enseal tissue sealers, allowing them to market the instruments in the US.
AMI launch new organ retraction system
Agency for Medical While organs including the stom- from the operating site.
Innovations (AMI) have released a
new laparoscopic device for holding organs away from the surgical
site during surgery.
AMI claim that their EndoSAIL,
launched at September’s IFSO meeting in Hamburg, has been designed
to provide a safe, atraumatic way to
hold organs away from the surgical site during laparoscopic or single-port surgery. AMI intend for the
instrument to be introduced through
an existing trocar, reducing trauma
to the patient. The absence of a rigid retractor also reduces the amount
of interference the surgeon suffers
from surrounding instruments.
Consisting of four instruments,
the EndoSAIL combines a singleuse monofilament polypropylene
mesh designed to hold organs up
hammock-style with a multi-use
nickel-titanium alloy introducer.
ach, large intestine and mesenterium can be suspended using the device, its intended most common use
is to suspend the liver, allowing bariatric surgeons to operate in the upper abdomen.
The EndoSAIL kit also comes
with a suture catcher, for retrieving the sutures used to suspend the
mesh, and a funnel to allow smoother mesh insertion in smaller trocars.
In use, the curved EndoSAIL introducer can straighten to enable insertion of the mesh through trocars
5mm or thicker. When the introducer is inside the abdominal cavity,
the elastic properties of its alloy allow it to adopt its original shape and
properly place the mesh. The triangular mesh can then be secured with
the suspension sutures attached to
each of its points, allowing the obstructing organ to be secured away
AMI also promote the suture
catcher as a useful instrument in
its own right, allowing surgeons to
place and retrieve sutures in other abdominal cavity operations,
as well as placing fascial sutures
to close larger port-site incisions
after laparoscopic surgery. They
claim that its 1mm diameter creates less trauma for the patient
than similar products.
JAiMY 5mm Motorized Articulated Instrument
JAiMY is Endocontrol brand new product which is about to revolutionize the
world of laparoscopic surgery.
Have you ever dreamt of an instrument matching
your band movements? Monet had his brushes, surgeons now have JAiMY, the world’s first 5mm motorized instrument for laparoscopic surgery. Operating
becomes a real art.
What is JAiMY?
A handheld motorized articulated instrument designed for the purpose of grasping, retracting, mobilizing, dissecting and suturing of tissues and vessels under endoscopic visualization during surgical
procedures.
Laparoscopic suturing and knot tying in minimal access surgery is an advanced skill. Mastering
this skill is a difficult process, especially when the
angle between the needle holder and suture line is
unparallel and triangulation is limited. Conventional needle holders just allow for limited movements
within the operating field while JAiMY offers fully
articulating tip for easy maneuverability and unparalleled access.
With the handle, surgeon activates three movements simultaneously:
n
Full bending of the end effector
n
Unlimited rotation of the end effector
n
Opening/closing of the jaws
is designed to enable surgeons to overcome the
unique challenges presented by single incision and
conventional laparoscopic surgery.
What is iD intelligent Dexterity?
Intelligent Dexterity enables surgeons to extend
their hands and to picture movements as if they
were inside the patient’s body. Intelligent dexterity is about matching surgeon’s hand movements
perfectly for improved efficiency.
JAiMY, the first motorized articulating laparoscopic instrument with ID-intelligent Dexterity,
NEWS IN BRIEF
Gastric bypass reduces blood
pressure
According to a paper from the Sahlgrenska
Academy at the University of Gothenburg,
the kidneys play an important role in the
regulation of blood pressure by adjusting the production of urine after eating or
drinking, which could explain why gastric
bypass surgery for obesity also markedly
reduce blood pressure.
The study includes 1,750 patients who
underwent gastric bypass or gastric banding. The results show that the elimination
of urine increases after gastric bypass surgery, explained by the fact that food and
drink no longer come into contact with
the upper part of the digestive tract, thus
breaking the link between this part of the
digestive system and the kidneys.
After ten years the decreased blood
pressure following a gastric bypass was
not related to the reduced weight and was
markedly larger than after gastric banding.
The investigators believe that this could be
important when deciding between surgical
methods for people who are overweight
and have high blood pressure.
Weight-loss operations up by
50% in three years
Bariatric procedures in Scotland have increased dramatically over the last few
years, some 309 bariatric surgeries were
performed in 2009/10, compared to 203 in
2007/8, an increase of 52%. The rise has
been driven partly by the rolling out of the
service from five to eight health boards.
Moreover, obesity-related deaths in Scotland have increased by more than 40% in a
five-year period, with the number of Scots
aged 16-64 classed as obese up 10%
compared to 15 years ago. With obesity
predicted to cost the Scottish economy as
much as £3 billion by 2030, advocates of
bariatric surgery argue it delivers savings
far outstripping the original cost within two
or three years. Duff Bruce, Chairman of the
Scottish Complex Obesity Treatment Service, said the surgery will become routine
within a generation.
However, there is also evidence from the
figures that cost pressures may already
be putting the squeeze on the two health
boards which have led the way in providing weight-loss surgery in Scotland. Bruce
believes the pattern is driven by a process
of ‘rationalisation’ likely to be repeated by
other health boards as they too expand the
service.
Australian position paper for
adolescent bariatric surgery
n
Reusable for improved economics and cost containment.
n
Provides intelligent dexterity with seven degrees
of freedom for unparalleled access, superior tissue manipulation, and easy triangulation in even
the most challenging cases.
n
Benefits to a wide variety of surgical procedures
in different clinical specialties, including urology,
gynecology, bariatric surgery, general surgery,
and cardiothoracic surgery.
A position paper from several the Australia
nand New Zealand associations has recommended that adolescents should be at
least 15 years of age and have a BMI>40 if
they are to be eligible for bariatric surgery.
They should also have associated complications such as Type 2 diabetes and have
persistent problems despite undertaking
lifestyle programs.
The paper also recommends the creation
of a national registry follow adolescent
cases as part of National Bariatric Surgery
Registry being developed by OSSANZ
and the Royal Australasian College of Surgeons. The position paper was published
in the December 2011 issue of the ANZ
Journal of Surgery.
22 BARIATRIC NEWS
Calendar of events
January 19-20
March 22-25
May 9-12 May
June 23-26
BOMSS 3rd Annual Scientific Meeting
2nd Latin America Congress on
Controversies to Consensus in
Diabetes, Obesity and Hypertension
2012 (CODHY 2012)
European Association for the Study of
Obesity 19th European Congress 2012
(ECO-EASO 2012)
Endocrine Society's 94th Annual Meeting
Bristol, UK
www: bomss.org
February 20-25, 2012
Minimally Invasive Surgery Symposium
(MISS)
Salt Lake City, Utah
www.miss-cme.org
Rio De Janeiro, Brazil
www: codhy.com/LA/2012
April 11-13
OSSANZ
March 7-10
Society of American Gastrointestinal and
Endoscopic Surgeons
San Diego, CA
http://www.sages2012.org/
Darwin, Australia
www: ossanz.com.au
email: [email protected]
April 20
SOBA
York, UK
www: sobauk.com
March 11-14
10th International Anniversary Expert
Meeting for the Surgery Obesity and
Metabolic Disorders
Saalfelden, Austria
www: obesity-online.com/expertmeeting
April 20-21
Second International Symposium
on Non-invasive Bariatric Surgery
Lyon, France
Phone: 00 33 (0)4 72 01 45 00
Fax: 00 33 (0)4 72 01 45 05
Lyon, France
Phone: +44 20 8783 2256
Fax: +44 20 8979 6700
www: easo.org/eco2012
May 23-27
American Association of Clinical
Endocrinologists Annual Meeting 2012
Philadelphia, PA
http://am.aace.com
June 17 - 22
American Society for Metabolic and
Bariatric Surgery 29th Annual Meeting
San Diego CA
www.asmbs.org
June 20-23
20th International Congress of the
European Association for Endoscopic
Surgery (EAES)
Brussels, Belgium
www.eaes.eu
Houston, Texas
www.endo-society.org
September 11-15
IFSO
New Delhi, India
www.ifsoindia2012.org
September 20-24
Obesity 2012
San Antonio, Texas
www.obesity.org
1-5 October
European Association for the Study of
Diabetes
Berlin, Germany
www.easd.org
October 24-26
The 4th Conference on Recent Advances
in the prevention and Management of
Childhood and Adolescent Obesity
Halifax, Nova Scotia, Canada
http://interprofessional.ubc.ca/obesity/
If you would like to place your meeting details here, please email: [email protected]
The next issue of Bariatric News is out in March 2012
Editorial deadline: 28 February 2012
Advertising deadline 28 February 2012
If you are interested in submitting an article for the newspaper, please contact
the editor of Bariatric News: [email protected]
If you are interested in advertising in Bariatric News, please contact our
Industry Liaison Manager: [email protected]
If you would like to submit press release, please email:
[email protected]
EDITORIAL BOARD
Henry Buchwald
BARIATRIC NEWS
Editorial and advertising
Owen Haskins
Simon Dexter
[email protected]
John Dixon
News editor
MAL Fobi
[email protected]
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Peter Myall
Designer
Peter Williams
[email protected]
Publisher
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2012 Copyright ©: Dendrite Clinical Systems Ltd. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, transmitted
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Bariatric surgery prevents cardiovascular events

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