Bariatric Surgery

Options & Outcomes

Obesity

• Obesity now leading cause of premature death & illness in Australia

• 67% of Australians are overweight or obese

• Australia 4th ‘fattest’ nation in OECD

• Obesity cost Australian society $21 billion in 2005

• Life expectancy 13 years shorter for 30 year old male with BMI >45

Obesity-Related Comorbidities

• Diabetes mellitus

• Arterial hypertension

• Ischaemic heart disease

• Heart failure

• Cardiomyopathy

• Obstructive sleep apnoea

• Gallstones

• Steatohepatitis

• Cirrhosis

• Hypercholesterolaemia

• Hypertriglyceridaemia

• Menstrual disorders

• Polycystic ovary syndrome

• Infertility

• Obstetric complications

• Stress incontinence

• Gastro-oesophageal reflux

• Stroke

• Cancer

• Arthritis

• Psychological disorders

Medical Therapy vs Surgery

• Medical therapy can achieve 10% excess weight loss in short-term

• <5% of medical patients maintain weight loss beyond 5 years

• Bariatric surgery results in average excess weight loss of 61%

• 89% reduction in 5-year mortality with surgery*

• 76% relative risk reduction in cancer observed after surgery*

*Christou NV, Sampalis JS, Liberman M, et. al. Surgery decreases long-term mortality, morbidity, and

health care use in morbidly obese patients. Ann Surg. 2004;240(3):416-423.

Criteria for Bariatric Surgery

• BMI ≥35

• BMI 30-35 with obesity-related comorbidity

• Obesity for more than 5 years

• Failed non-surgical attempts at weight loss

• Fit enough for surgery

• No clinical or psychological contraindications

• Understand risks of surgery

• Be committed to long-term follow-up

Bariatric Procedures

Laparoscopic Adjustable Gastric Band Roux-En-Y Gastric Bypass

Bariatric Procedures

Biliopancreatic Diversion BPD - Duodenal Switch

Bariatric Procedures

Sleeve Gastrectomy Gastric Plication

Laparoscopic Adjustable Gastric Band

Band + Fluid Gastric Pouch

Laparoscopic Adjustable Gastric Band

Follow-Up

• What are you eating?

– Should be solid food

– Liquid diet suggests band too tight

• When are you eating?

– Two (or three) meals per day is normal

– Most will not eat in morning

• How are you eating?

– Should be slowly

– Should take 20 min to eat small meal

Follow-Up

• Are you eating because you are hungry?

– Hunger = adjustment

– Loss of satiety consider erosion or leakage

• How often are you vomiting or having blockages?

– Can occur after eating too fast or certain foods (e.g. bread)

– Persistent vomiting if band too tight or slippage

• Do you regurgitate or reflux at night?

– Danger symptom

– Suggests band too tight or pouch dilatation

1. Eat three or less small meals per day

2. Do not eat anything between meals

3. Eat slowly and stop when no longer hungry

4. Focus on nutritious foods

5. Avoid calorie-containing liquids

6. Exercise for at least 30 minutes every day

7. Be active throughout the day

8. Always keep in contact

The Eight Golden Rules

Anterior Slip / Prolapse

Posterior Slip / Prolapse

Symmetrical Pouch Dilatation

Oesophageal Dilatation

Comorbidities

0

10

20

30

40

50

60

70

80

90

Hypertension Diabetes Obstructive Sleep

Apnoea

Lipids

Comorbidities

Perc

en

tag

e

Pre-op

12 months

Resolution of Comorbidities (1 year)

Comorbidities (n=41) Pre-op 12 months % Resolution

Hypertension 63.4% 41.5% 34.5%

Diabetes 46.3% 26.8% 42.1%

Obstructive sleep apnoea 85.4% 48.8% 42.9%

Lipids 51.2% 41.5% 18.9%

GORD 31.7% 29.3% 7.6%

Congestive heart failure 4.9% 2.4% 51.0%

Ischaemic heart disease 22.0% 14.6% 33.6%

Angina 2.4% 2.4% 0%

Peripheral vascular disease 2.4% 2.4% 0%

Lower extremity oedema 2.4% 0% 100%

Gout hyperuricaemia 4.9% 2.4% 51.0%

Resolution of Comorbidities (1 year)

Weight Loss

Sleeve Gastrectomy

• Initially performed as part of duodenal switch (BPD-DS)

• Substantial weight loss often occurred with SG alone

• Used as part of staged approach in high risk patients

Sleeve Gastrectomy

Change in Comorbidites

Sleeve Gastrectomy

Which Procedure?

Attribute LAGB RYGB Sleeve

Gastrectomy

BPD +/- DS

Weight loss

- Short term

- Medium term

- Long term

++

++

++

+++

++

++

++

++

++

+++

+++

+++

Safe +++ ++ ++ +

Durable ++ ++ ++ +++

Side effects ++ ++ + ++

Reversible easily Yes No No No

Minimally invasive +++ ++ ++ +

Acid reflux control ++ +++ Variable +

Controllable/adjustable Yes No No No

Long-term revision rate High Low Low Low

Requires follow-up +++ ++ ++ ++

Orbera

Orbera

• Endoscopically inserted soft silicone intragastric balloon

• Filled with 700mL of saline

• Remains in situ for maximum of 6 months

• Part of long-term supervised lifestyle management program

• Adults with BMI ≥27

• Average weight loss at removal 14.7kg (12.2% of initial weight)*

• Weight loss 12 months later maintained at 9.6kg

*Imaz I, Martinez-Cervell C, Garcia-Alvarez EE, Sendra-Gutierrez JM, Gonzalez-Enriquez J. Safety and

effectiveness of the intragastric balloon for obesity. A meta-analysis. Obes Surg. 2008;18(7):841–846.