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Sat_room7_0830_Stubbs - Choices around Bariatric surgery
Obesity Surgery in a Nutshell Choices Around Bariatric Surgery What should you know? Richard Stubbs MD FRCS FRACS Wakefield Obesity Clinic, Wellington Richard S Stubbs MD Obesity Surgery in a Nutshell 152 kg / BMI 59 Richard S Stubbs MD 74 kg / BMI 29 Obesity Surgery in a Nutshell Indications (NIH Consensus Statement 1991) BMI BMI Richard S Stubbs MD > 40 > 35 with co-morbidities Obesity Surgery in a Nutshell Co-morbidities type 2 diabetes hypertension dyslipidaemia G-O reflux back/joint problems infertility sleep apnoea asthma Pickwickian syndrome depression self esteem self confidence Richard S Stubbs MD Obesity Surgery in a Nutshell Gastric Band Richard S Stubbs MD Gastric Sleeve Gastric Bypass Obesity Surgery in a Nutshell Evolution Today’s procedures open Fobi Pouch gastric bypass laparoscopic gastric bypass laparoscopic adjustable gastric banding laparoscopic gastric sleeve Richard S Stubbs MD Obesity Surgery in a Nutshell advantages ease for patient ease for surgeon simple procedure least expensive few micronutrient issues adjustable band Richard S Stubbs MD Obesity Surgery in a Nutshell disadvantages unpredictable weight loss poor long-term results high reversal rate (>50%) high maintenance (10% pa) adjustable band Richard S Stubbs MD Obesity Surgery in a Nutshell advantages ease for patient ease for surgeon few micronutrient issues no bowel obstructions cost – a little risk – similar to bypass sleeve gastrectomy Richard S Stubbs MD Obesity Surgery in a Nutshell disadvantages less data available variable weight loss less reliable than bypass G-O reflux revision rate high (40-60%) sleeve gastrectomy Richard S Stubbs MD Obesity Surgery in a Nutshell Not all gastric bypasses are the same (Roux-en-Y procedure = gastric bypass) Richard S Stubbs MD Obesity Surgery in a Nutshell Gastric bypass pouch – size and shape not all gastric bypasses are the same Richard S Stubbs MD Obesity Surgery in a Nutshell advantages Shorter hospital stay Quicker recovery No large incision Metabolic benefits Similar cost Similar risk Laparoscopic GB Richard S Stubbs MD Obesity Surgery in a Nutshell disadvantages More variable weight loss Not so durable weight loss Late bowel obstruction (5-10%) Major weight regain ≈ 20% Laparoscopic GB Richard S Stubbs MD Obesity Surgery in a Nutshell advantages More predictable weight loss More durable weight loss Very few bowel obstructions No large incision Metabolic benefits Major weight regain <5% Fobi Pouch GB Richard S Stubbs MD Obesity Surgery in a Nutshell disadvantages One week in hospital 4-6 weeks off work Large scar Incisional hernias Fobi Pouch GB Richard S Stubbs MD Obesity Surgery in a Nutshell Assessing the procedures Richard S Stubbs MD • risk of the surgery • recovery time from surgery • surgical complications • late complications • weight loss – short term (1-5 years) • weight loss – long term • revision rates • reversal rates • ongoing issues Obesity Surgery in a Nutshell Assessing the procedures • risk of the surgery lap band - 0 – 0.5% others - 0.5 – 1.0% • recovery time from surgery laparoscopic - 2-3 weeks open surgery - 4-6 weeks • surgical complications lap band - 5% others - 10-15% Richard S Stubbs MD Obesity Surgery in a Nutshell Assessing the procedures • late complications lap band • Richard S Stubbs MD +++ lap gastric bypass Fobi Pouch + + sleeve gastrectomy ± revision rates lap band 40-50% at 5 years lap gastric bypass Fobi Pouch gastric sleeve low low 40-60% at 5 years Obesity Surgery in a Nutshell Assessing the procedures • Reversal rates Lap band • Richard S Stubbs MD 40-50% by 5 years Lap gastric bypass Fobi Pouch nil nil sleeve gastrectomy not reversable Ongoing issues Lap band lifelong Lap gastric bypass Fobi Pouch sleeve gastrectomy low low low Obesity Surgery in a Nutshell So what about the weight loss? Richard S Stubbs MD Obesity Surgery in a Nutshell Systematic review O’Brien et al Obes Surg 2006 Richard S Stubbs MD Obesity Surgery in a Nutshell Systematic review O’Brien et al Obes Surg 2006 Richard S Stubbs MD Obesity Surgery in a Nutshell Systematic review O’Brien et al Obes Surg 2006 Richard S Stubbs MD Obesity Surgery in a Nutshell Sleeve Gastrectomy vs Gastric Bypass (n=64) 100 % EWL 80 60 LSG LRYGB 40 20 0 0 1 2 3 4 Time post surgery (yr) 5 Zhang et al, Obes Surg, 2014: 24: 1617-1792 Richard S Stubbs MD Obesity Surgery in a Nutshell Obesity Surgery 2015; 25: 19-26 Laparoscopic Sleeve Gastrectomy Versus Laparoscopic Roux-En-Y Gastric Bypass for Morbid Obesity and Related Comorbidities: A Meta-Analysis of 21 Studies. Total n = 18,766 Zhang Y, Ju W, Sun X, Cao Z, Xinsheng X, Daquan L, Xiangyang X, Qin M • Weight loss after 18 months superior in LRYGB patients (p<0.05) • Equivalent improvement in co-morbidities except Type 2 diabetes • Superior resolution rates for Type 2 diabetes for LRYGB (p<0.001) Richard S Stubbs MD Obesity Surgery in a Nutshell Am J Surg. 2014 Dec;208(6):903-10. Is laparoscopic sleeve gastrectomy a lower risk bariatric procedure compared with laparoscopic Roux-en-Y gastric bypass? A meta-analysis. Total n = 15,722 Zellmer JD, Mathiason MA, Kallies KJ, Kothari SN. leak rate: 1.9% for LRYGB vs 2.3% for LSG (p=0.077) mortality: 0.4% for LRYGB vs 0.2% for LSG Richard S Stubbs MD (p=0.11) Obesity Surgery in a Nutshell Systematic review n = 1627 n = 856 O’Brien et al Obes Surg 2006 Richard S Stubbs MD EWL % Obesity Surgery in a Nutshell band n=260 no band n=218 Awad et al Obes Surg 2012, 22: 271-8 Richard S Stubbs MD Obesity Surgery in a Nutshell Systematic Review - 5 studies (n=470 vs 426) Mahawar et al, Obes Surg, 2014: 24: 1771-1792 100 81.7% EWL % 80 62.3% 60 Band 40 No Band 20 0 0 2 4 6 Time after surgery (yr) Richard S Stubbs MD 8 10 Obesity Surgery in a Nutshell Metabolic benefits diabetes / hypertension / lipids heart disease / stroke Pories et al. Ann Surg 1995; 222: 339-352 Richard S Stubbs MD Obesity Surgery in a Nutshell 15 Diabetic Impaired glucose tolerance HOMA 10 Normal glucose tolerance 5 0 Pre surgery Richard S Stubbs MD 6 days 3 6 9 12 months months months months Obesity Surgery in a Nutshell 123 Type 2 diabetics n A B C D unrecognised 22 - 20 2 0 diet controlled 10 - 9 1 0 oral agents 59 - 42 14 3 insulin depend 32 - 14 2 16 100% 32% 70% 15% 15% Totals A - resolved by 3 months C - indeterminate at 12 months B - resolved by 12 mo (FPG < 6 and HbA1c <6) D - not resolved at 12 mo (FPG ≥ 7 or HbA1c ≥ 7) Richard S Stubbs MD Obesity Surgery in a Nutshell 10,251 patients Median duration of diabetes 10 yrs Richard S Stubbs MD Obesity Surgery in a Nutshell Summary • gastric band is the easiest and least reliable • gastric bypass gives superior metabolic benefits • gastric bypass gives most reliable and durable weight loss • gastric sleeve hold an intermediate position • bowel obstruction a problem after lap gastric bypass • Fobi pouch /open surgery most reliable gastric bypass • micronutrients after gastric bypass – multivit, B12, folic acid, Fe Richard S Stubbs MD Obesity Surgery in a Nutshell Conclusions What should determine which operation is done? • ease of operation for the surgeon? • ease of operation for the patient? • long-term results? • need for revision or reversal? Richard S Stubbs MD Obesity Surgery in a Nutshell 105 kg / BMI 39 Richard S Stubbs MD 62 kg / BMI 23 Obesity Surgery in a Nutshell Canadian Study Aim: To evaluate healthcare costs following surgery 1035 patients have bariatric surgery 1996-2002 5746 matched patients not having surgery All direct healthcare costs • Hospital • GP / specialist visits • investigations • prescription costs • auxillary medical services Richard S Stubbs MD Obesity Surgery in a Nutshell Cost ($m) per 1000 patients Cumulative costs Years Richard S Stubbs MD