1. Chichester 21 09 2009 J P Mulier1 Risks Costs Benefits When to say No J P Mulier MD PhD Sint Jan Brugge-Oostende www.publicationslist.org/jan.mulier 1150 1850 1947 1977 2010

2. Chichester 21 09 2009 J P Mulier2 No, never operate When morbidity and mortality of surgery is higher than the non surgical treatment When morbidity and mortality of surgery is higher than the non surgical treatment To discuss with the patient: when the improvement in quality of life is a lot better it might outweighing the higher risk. To discuss with the patient: when the improvement in quality of life is a lot better it might outweighing the higher risk. Do you know? General results? Do you know? General results? your surgical mortality / morbidity your surgical mortality / morbidity your surgical results in weight loss your surgical results in weight loss your outcome in higher risk patients your outcome in higher risk patients

3. Chichester 21 09 2009 J P Mulier3 Surgical versus non surgical treatment For all patients and all centers: For all patients and all centers: every surgical procedure is more efficient and mortality is lower Sjostrom every surgical procedure is more efficient and mortality is lower Sjostrom N Engl J Med 2007 ( study not powered to detect mortality difference for type of surgery) We are required to treat people There are many other surgical procedures that do not have such a clear benefit.

4. Chichester 21 09 2009 J P Mulier4 Mortality by procedure 30 day mortality Buchwald Surgery 2007 30 day mortality Buchwald Surgery 2007 Not powered for > 30 day Not powered for > 30 day Not powered for lap revisions (221/85000) sleeve gastrectomy Not powered for lap revisions (221/85000) sleeve gastrectomy

5. Chichester 21 09 2009 J P Mulier5 Frequency of reinterventions Sjostrom 2007 Sjostrom 2007 1338 pt followed for at least 10 years: 1338 pt followed for at least 10 years: Exclusion early reinterventions ( 1 month) for complications Exclusion early reinterventions ( 1 month) for complications

6. Chichester 21 09 2009 J P Mulier6 Mortality of higher risk patients? co morbidities Buchwald study 2007 PrevalenceMortality

7. Chichester 21 09 2009 J P Mulier7 Patient type with a high mortality risk Elderly male diabetes patient with hypertension and being super obese Elderly male diabetes patient with hypertension and being super obese Buchwald 2007 Buchwald 2007 Central abdominal fat, not stopped smoking, alcoholic Central abdominal fat, not stopped smoking, alcoholic General risk General risk Asthma and coronary artery disease Asthma and coronary artery disease xxx xxx

8. Chichester 21 09 2009 J P Mulier8 30 day mortality by study year is decreasing

9. Chichester 21 09 2009 J P Mulier9 No, post pone When you can improve the outcome by waiting, or adapt type of surgery When you can improve the outcome by waiting, or adapt type of surgery Lower body weight with minimum 10kg Lower body weight with minimum 10kg by diet, gastric balloon by diet, gastric balloon Improve liver function Improve liver function Fatty liver Fatty liver Improve lung function Improve lung function Stop smoking Stop smoking Evaluate and improve cardiac function Evaluate and improve cardiac function Hypertension, CAD, edema, Hypertension, CAD, edema,

10. Chichester 21 09 2009 J P Mulier10 Abdominal compliance > 10 kg weight loss no effect muscle relax Mulier Dillemans preliminary data

11. Chichester 21 09 2009 J P Mulier11 How changing abd E : flexion hip Mulier JP, Dillemans B Surg endos 2009 Mulier JP, Dillemans B Surg endos 2009

12. Chichester 21 09 2009 J P Mulier12 No, send to other centers with more surgical expertise If your center starts If your center starts If your surgical time is more than 60 minutes If your surgical time is more than 60 minutes If your surgeon can’t do every patient laparoscopic yet ( unless post laparatomy) If your surgeon can’t do every patient laparoscopic yet ( unless post laparatomy) Exclude patients with one or more risk factors Exclude patients with one or more risk factors Super super obese Super super obese Man with central obesity and no weight loss Man with central obesity and no weight loss Re intervention after failed bariatric surgery Re intervention after failed bariatric surgery Cardiac failure NYH class V Cardiac failure NYH class V Pulmonary hypertension Pulmonary hypertension Respiratory asthma, low vital capacity Respiratory asthma, low vital capacity Other less frequent high risk co morbidity for non obese patients Other less frequent high risk co morbidity for non obese patients Get surgical and anesthesilogic expertise by doing many cases before doing difficult and risk cases. Get surgical and anesthesilogic expertise by doing many cases before doing difficult and risk cases.

13. Chichester 21 09 2009 J P Mulier13 Impact of centre expertise yearno casesMortality % Carucci20069045.3 Marshall20034005.25 DeMaria20022815.1 Ballesta200812004.9 Hamilton20032104.3 Lee200738283.9 Madan20063003.0 Gonzalez200730182.1 Durak200811331.5 agaba200813640.15 carraquiulla200410000.1 Dillemans200926060.04

14. Chichester 21 09 2009 J P Mulier14 Our Results in lap RNY

15. Chichester 21 09 2009 J P Mulier15 No, postpone till Your experienced surgeon and experienced anaesthetist are available Your experienced surgeon and experienced anaesthetist are available To shorten the surgery and the anaesthesia To shorten the surgery and the anaesthesia To take the best preventive measures To take the best preventive measures To have intensive care follow up To have intensive care follow up

16. Chichester 21 09 2009 J P Mulier16 A patient with increased risk in our center is done only by one surgeon and one anaesthetist with sufficient expertise, otherwise postponed. is done only by one surgeon and one anaesthetist with sufficient expertise, otherwise postponed. We have one surgeon and one anaesthetist with long expertise and many cases > 500 We have one surgeon and one anaesthetist with long expertise and many cases > 500 We have two surgeons with less than 200 cases a year We have two surgeons with less than 200 cases a year We have one qualified abdominal surgeon in training for bariatric surgery We have one qualified abdominal surgeon in training for bariatric surgery We have many anaesthetist doing less than 200 cases a year. We have many anaesthetist doing less than 200 cases a year. They will never do the risk patients alone and loose time They will never do the risk patients alone and loose time

17. Chichester 21 09 2009 J P Mulier17 Conclusion No, never No, never When morbidity and mortality of surgery is higher than the non surgical treatment except… When morbidity and mortality of surgery is higher than the non surgical treatment except… No, post pone No, post pone When you can improve the outcome by waiting When you can improve the outcome by waiting No, not now, not here No, not now, not here When the waiting list is too long, no resources When the waiting list is too long, no resources you prefer to postpone you prefer to postpone The highest risk? The highest risk? The estimated longest hospital stay? The estimated longest hospital stay? The lowest or the highest BMI? The lowest or the highest BMI?

18. Chichester 21 09 2009 J P Mulier18 Attend first ESPCOP meeting 14 nov 2009 Ostend Belgium “The sea” from Georges Grard “The sea” from Georges Grard Better known as Better known as “fat Mathilde of Ostend” www.ESPCOP.org

19. Chichester 21 09 2009 J P Mulier19 Scientific meeting

20. Chichester 21 09 2009 J P Mulier20