Bariatric Surgery. When does it work and when does it go wrong? PROFESSOR DAVID KERRIGAN CONSULTANT BARIATRIC SURGEON
Bariatric Surgery When does it work and when does it go wrong? P R O F E S S O R D AV I D K E R R I G A N C O N S U LTA N T B A R I AT R I C S U R G E...
Bariatric Surgery When does it work and when does it go wrong? P R O F E S S O R D AV I D K E R R I G A N C O N S U LTA N T B A R I AT R I C S U R G E O N P H O E N I X H E A LT H , C O U N T E S S O F C H E S T E R H O S P I TA L A N D U N I V E R S I T Y H O S P I TA L A I N T R E E
Obesity – the major health challenge in 2016 Two thirds of UK adults either obese or overweight (BMI>25) A quarter UK adults clinically obese (BMI >30)
Obesity and Type 2 Diabetes The NHS spends £1 million per HOUR treating diabetes and its complications: blindness, amputations, dialysis 1 in 6 NHS beds taken up by patients with diabetes & complications
In young women receiving chemotherapy, Obesity is associated with 50% increased risk of death 40% increase in cancer recurrence Study of neo-adjuvant chemotherapy in >1500 ER +ve pre-menopausal women
We desperately need a solution
Courtesy Dr David Haslam
What can we do? Diet and Exercise Who are you kidding?
What can we do? Drugs
The NHS spends £50M a year on obesity drugs No evidence efficacy in severe class 3 obesity
Obesity and Type 2 Diabetes The NHS spends £1 million per HOUR treating diabetes and its complications 1 in 6 NHS beds taken up by patients with diabetes & complications
Xenical in obese type 2 diabetics Barely better than placebo over 12 months
Bariatric Surgery and Type 2 Diabetes •Cost: £5 -7,000 60- 75% patients off treatment within weeks of surgery Due to changes in gut hormones, not weight loss NICE Management Severe and Complex Obesity Guidance CG189, 2015
Bariatric Surgery is Very Cost Effective London School Hygiene and Clinical Medicine / UCLH Study, Dec 2015 GP records used to compare medium term illness rates in 3,882 patients after bariatric surgery vs matched patients no bariatric surgery
After Bariatric Surgery • Nine times more likely to see major diabetes improvement • 70% less likely to have heart attack • Improvements in hypertension, angina and sleep apnoea • Sustained weight loss over 4 years (average 6 stones) vs no weight loss in controls Douglas IJ et al PLoS Med 2015;12:e1001925
What are the other options? A bit of moral fibre? A good telling off? Leave them to their fate as it’s all their own doing? 20% of GPs in recent survey do not think bariatric surgery should be available on NHS
Bariatric Surgery is not Cosmetic Surgery
“I’m not afraid of death; I just don’t want to be there when it happens” Woody Allen
Bariatric Surgery –too risky? High media profile Public perception is: • Dangerous and barbaric • Unnecessary & Self-inflicted
Bariatric Surgery is Safe 5-Year Audit 2007-2014 30 Day Mortality 3 deaths/ 3,620 ops = 0.08% Hip replacement = 0.32% Cholecystectomy = 0.24%
Criteria for access to bariatric surgery 1 9 9 1 N AT I O NA L I N S T I TU TES O F HE A LT H CO N S E N SUS S TAT E M ENT
BMI >40 or >35 with comorbidity Basis of NICE/NHS commissioning guidelines
Criteria for access to bariatric surgery 1 9 9 1 N AT I O NA L I N S T I TU TES O F HE A LT H CO N S E N SUS S TAT E M ENT
No scientific or evidence base Outdated BMI alone poor determinant of medical risk Surgery should not always be treatment of last resort
Types of Bariatric Surgery GASTRIC BAND
Creates partial blockage to passage of food Can eat most things (slowly) Won’t stop sugary drinks or anything that melts or crumbles (choc, crisps, biscuits, cake)
Types of Bariatric Surgery GASTRIC BAND
Safest operation Least invasive Reversible Inexpensive
Band Complications L AT E CO M P L ICATI ONS CO M M O N 15- 20% require corrective surgery within 5 years • erosion +/- infection • port site problems, unbuckling, poor outcomes • slippage +/- pouch stretching
Some centres report 60% band removal rate (failure or complications)
Is the gastric band passé? GASTRIC BAND
48% of all bariatric procedures in 2009 18% of all bariatric procedures in 2011
Complications Gastric Band B A N D S L I P PAG E
Complications Gastric Band B A N D S L I P PAG E Almost always caused by patient factors At least 15-20-% of all band patients will develop a slippage at some time • Dysphagia (even saliva) • Vomiting • Severe acid reflux
Easy to diagnose
Slipped band
POTENTIALLY CATASTROPHIC
Case Report 1 S L I P P ED G A S T R IC B A N D
23 yr old female Private surgery Birmingham Severe vomiting after bolus obstruction 4 months post-op Epigastric/lower chest pain
Private Provider advised attendance local A&E in Kent Provisional diagnosis gastroenteritis made in A&E
Case Report 1 S L I P P ED G A S T R IC B A N D
No general surgical beds, admitted to orthopaedic ward over weekend IV fluids and observation 36hrs later became acutely unwell, with severe pain Septic shock Died within 24 hrs
Infarcted, perforated gastric pouch above slipped band
Band deflation Will get you out of trouble most of the time If not completely better within 24hrs Laparoscopy Unbuckle or remove band
• Do not delay.. Risk of pouch strangulation
Types of Bariatric Surgery G A S T R I C B Y PA S S Been around for more than 30 years Works by controlling appetite • gut hormones • small portions Major malabsorption rare
Types of Bariatric Surgery G A S T R I C B Y PA S S Excellent diabetes treatment • Limits sugar intake • Improves blood sugar control More weight loss More predictable weight loss
Types of Bariatric Surgery G A S T R I C B Y PA S S Higher peri-operative risks than band • Leak • Bleeding • Ulceration and stenosis
Types of Bariatric Surgery G A S T R I C B Y PA S S Serious late complications uncommon • Petersen’s (internal) hernia • Recurrent ulceration and fistula • Smokers • NSAIDs
• Major nutrition problems (in absence of complications) rare
Types of Bariatric Surgery S L E E VE G A S T R ECTO MY An easy operation to do and an easy operation to do badly! Similar early risks to gastric bypass (patients think it is safer!) • Leak –slightly more than bypass • Bleeding
Bariatric surgery trends USA 2011-2014 U S ACA D E M I C CE N T R ES 5 5 , 0 0 0 PAT I E N TS
Sleeve gastrectomy has now overtaken gastric bypass Gastric band reduced
Follow-up Issues LO N G-T ER M F O L LO W-UP E S S E NT IA L