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...
Author: Herbert Gaines
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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

• MDT essential • Achieve equipoise • Nutritional • Psychological

• Early identification of complications

• Who is ultimately responsible – GP or bariatric team? • Patient responsibility vs doctor responsibility • Patient contracts ?

Medical responsibility for healthcare costs T HE R E S P O NS IB LE CCG ?

• Short-term vs long-term view • A duty in the modern NHS? • A duty to the patients? • A duty not to discriminate?