Anti-Obesity Surgery Joint Hospital Surgical Grand Round 17 th May 2008 Dr. YuhMeei Cheng Department of Surgery United Christian Hospital

Obesity Classification WHOAsia Pacific ClassCaucasianAsian Risks of co- morbidities Underweight < 18.5 Low Normal 18.8 – – 22.9 average Overweight >25>23 increased relatively Obese I 30 – 34.9>25 Moderate Obese II 35 – 39.9>30 Severe Obese III > 40 No such classificationSevere WHO guidelines, Asia Pacific Perspective 2005

Morbid Obesity Definition BMI > 40 BMI ≥ 35 + at least 2 co-morbidities

Metabolic syndrome

Obesity Management Aim Loose weight Minimize complication Improve self image Improve quality of life

Management – Approach Dieticians Physiotherapists Clinical Psychologists/ Psychiatrists Endocrinologists Bariatric Surgeons Multidisciplinary

Obesity Management Lifestyle change Drug therapy Interventional bariatric procedures

Indication for Surgery Asia- Pacific PerspectiveNational Institute of Health (NIH) > 32 BMI + DM or co-morbidity > 35 BMI + 2 co-morbidity > 37 BMI > 40 BMI

Bariatric Surgery Options predominantly Restrictive  BioEnterics Intragastric Balloon  Laparoscopic Adjustable Gastric Banding  Sleeve Gastrectomy predominantly Malabsorptive  Biliopancreatic Diversion +/- Duodenal Switch combination  Roux–en–Y Gastric Bypass  Gastric volume gastric resection non – gastric resection

Bariatric Surgery Options predominantly Restrictive  BioEnterics Intragastric Balloon  Laparoscopic Adjustable Gastric Banding  Sleeve Gastrectomy predominantly Malabsorptive  Biliopancreatic Diversion +/- Duodenal Switch combination  Roux–en–Y Gastric Bypass Diversion of GI content diversion of food from duodenum diversion of biliopancreatic secretions

Intragastric Balloon Restrictive procedure Endoscopic placement Doldi BS et.al, Intragastric balloon: 4-year experience. Obesity Surgery 2002;2:477 W mui et. al, Intragastric Balloon in ethnic obese Chinese: initial experience. Obesity Surgery 2006;16: BioEnterics Intragastric Balloon stomach volume ↓ dietary intake ↑ satiety modify eating habit

Intragastric Balloon Doldi et.al, Intragastric balloon in obese patients. Obese Surg 2000; 10: W mui et. al, Intragastric Balloon in ethnic obese Chinese: Initial experience. Obesity Surgery 2006;16: AdvantagesDisadvantages More acceptableShort term RepeatableRebound ReversiblePoor weight reduction Serious complications

Adjustable Gastric Banding Restrictive procedure Laparoscopic operation Lap-band system  most common procedure in Asia-Pacific

Laparoscopic Adjustable Gastric Banding Consensus Conference Statement: Bariatric surgery for morbid obesity: Health implications for patients, health professionals. H. Buchwald, J Am Coll Surg 2005; 200: Gastroenterology. Klein et.al. 2002; 123: AdvantagesDisadvantages Less invasivePermanent band placement Low operative complicationFrequent band adjustments Maintain normal food passagePoor quality of life ReversiblePersistent bowel problems Reasonable weight reductionDifficult revision surgery

Sleeve Gastrectomy Restrictive procedure Laparoscopic or open approach Increasing popularity 4 th most common surgery in Asia-Pacific regions

Sleeve Gastrectomy Himpens J et al. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006; 16(11): AdvantagesDisadvantages Better weight loss? long term results Faster and sustained weight reduction Serious complications Reduction in serum ghrelin level  decrease appetite Irreversible Preserve normal food passage Less nutrient and bowel problems Second stage operation if necessary

Roux-en-Y Gastric Bypass Restrictive + malabsorptive Diversion of food passage Gold standard procedure in USA 2 nd most common in Asia- Pacific region Roux - limb Common limb Asia-Pacific Perspective 2005

Roux-en-Y Gastric Bypass AdvantagesDisadvantages Better and more predictable weight loss More serious operative complications Long lasting effectLong term nutritional complications Significant improvement in co-morbidities Persistent bowel problems Effective in super-obese patients Difficult reversal surgery

Other- Biliopancreatic Diversion Predominantly malaborptive Gastrectomy Food passage diverted from duodenum Mostly done in Europe m l 200cm cm ~ 60% SB cm from IC valve

American Modification Preserve pylorus  Normal food passage to duodenum

Biliopancreatic Diversion +/- Duodenal Switch AdvantagesDisadvantages Best weight lossHigh operative complications Longer lasting effectLong term metabolic complications 2-stage procedure in high risks, extreme obesity patient (BMI > 60) Essentially irreversible Consensus Conference Statement: Bariatric surgery for morbid obesity: Health implications for patients, health professionals. H. Buchwald, J Am Coll Surg 2005; 200:

Comparisons 1.Efficacy in reducing weight 2.Effective in improving co-morbidities 3.Risks and complications

% Morbidity % Weight loss Intragastric balloon Sleeve Gastrectomy Gastric banding Gastric bypass Biliopancreatic diversion +/- duodenal switch Laparoscopic sleeve gastrectomy is superior to endoscopic intragastric balloon as a first stage procedure for super-obese patients (BMI > or =50). L. Milone et.al, Obes Surg 2005; 15(5): Bariatric Surgery. A systemic Review and meta-analysis. H. Buchwald et.al, JAMA 2004-Vol 292, No.14 Meta-Analysis: Surgical Treatments of Obesity. M. Maggard et.al, Ann Intern Med 2005; 142: A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. J. Himpens et.al, Obes Surg 2006; 16(11):

Co-morbidity Outcome % resolved DM HT Hyperlipidaemia Effectiveness of Laparoscopic Sleeve Gastrectomy (First Stage of Biliopancreatic Diversion with Duodenal Switch) on Co-Morbidities in Super-Obese High-Risk Patients. G. Silecchia et.al, Obes Surg Bariatric Surgery. A systemic Review and meta-analysis. H. Buchwald et.al, JAMA 2004-Vol 292, No.14 BioEnterics Intragastric Balloon: The Italian Experience with 2515 patients. A Genco et.al, Obes Surg 15,

Conclusions Bariatric surgery is effective in weight reduction and resolving co-morbidities. Needs careful patient selection to achieve optimal outcome. Multidisciplinary approach is essential for successful treatment. Treatments should be tailored to individual needs, as there are no universal protocols yet.

Thank you 5-6 June 2008

References Bariatric Surgery: Asia-Pacific Perspective, W-J Lee, Obesity Surgery 15, 2005, Consensus Conference Statement: Bariatric surgery for morbid obesity: Health implications for patients, health professionals. H. Buchwald, J Am Coll Surg 2005; 200: Interdisciplinary European Guidelines on Surgery of Severe Obesity. M. Fried, Obesity Facts 2008; 1: Bariatric Surgery. A systemic Review and meta-analysis. H. Buchwald et.al, JAMA 2004-Vol 292, No.14 Meta-Analysis: Surgical Treatments of Obesity. M. Maggard et.al, Ann Intern Med 2005; 142: Intragastric Balloon in Ethnic Obese Chinese: Initial Experience. L-M Mui et.al, Obesity Surg 16, 2006, Gastrointestinal Quality of Life Following Laparoscopic Adjustable Gastric Banding in Asia. W-J Lee, Obesity Surgery, , Adjustable Gastric banding and Conventional Therapy for Type 2 Diabetes. A randomized controlled trial. Dixon et.al, JAMA, Jan – Vol 299. No.3, A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. J. Himpens et.al, Obes Surg 2006; 16(11): Laparoscopic sleeve gastrectomy is superior to endoscopic intragastric balloon as a first stage procedure for super-obese patients (BMI > or =50). L. Milone et.al, Obes Surg 2005; 15(5):612-7 Effectiveness of Laparoscopic Sleeve Gastrectomy (First Stage of Biliopancreatic Diversion with Duodenal Switch) on Co-Morbidities in Super-Obese High-Risk Patients. G. Silecchia et.al, Obes Surg 2006; 16(9) BioEnterics Intragastric Balloon: The Italian Experience with 2515 patients. A Genco et.al, Obes Surg 15,

Weight Reduction

Risks and Complications

BIB – Results BMI/ kg/m2 Absolute BW loss Absolute BMI loss %EWL Median range Intragastric Balloon in Ethnic Obese Chinese: Initial Experience. L.M Mui et.al, Obesity Surg 16, 2006,

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MeanPre-op6-months post-op1-year post-op Weight (Kg) BMI (Kg/ m2) Hyperglycaemia (%) Hypertension (%) Hyperlipidaemia (%) Gastrointestinal Quality of Life Following Laparoscopic Adjustable Gastric Banding in Asia. W-J Lee, Obesity Surgery, , LAGB – Results

CountryTaiwanJapanSingChina HK Year started VBGYYY GBYYY Y LVBGYY LGBpYYY LAGBYYY Y Others Total no Case /yr Data from Asia Pacific meeting in Feb Bariatric procedures in Asia Pacific regions VBG, open vertical banded gastroplasty; GB, open gastric bypass; LVBG, lap. Vertical banded gastroplasty; LGBp, lap. Gastric bypass; LAGB, lap. Adjustable gastric banding

Milone L et al. Laparoscopic sleeve gastrectomy is superior to endoscopic intragastric balloon as a first stage procedure for super-obese patients (BMI > or =50). Obes Surg 2005; 15(5):612-7

P=