1. Surgical treatment of obesity

2. Size of the problem

3. Associated Morbidities DM Sleep apnoea HT Pulmonary failure –Depression Arthritis Heart Disease Stroke Hernias Reflux Stress incontinence Pulmonary embolism

4. Metabolic Syndrome HT Insulin resistance Dyslipidaemia Cardiovascular disease (Sleep apnoea)

5. Obesity in NZ and Auckland Obesity: increasingly common in adults –198911% –199717% –200221%1 –2006/725% In ADHB, over 8000 adults have BMI over 40 –12006/7 New Zealand Health Survey –2www.moh.govt.nz/obesity2www.moh.govt.nz/obesity

6. Morbid obesity in NZ prevalance

7. Prevalance related to social deprivation Quintiles –538% –426% –323% –221% –121%

8. Obesity and life expectancy

9. What is the best way to manage severe obesity? Exercise / Drugs

10. What is the best way to manage severe obesity? Diet

11. Bariatric Surgery Today Adjustable Band Gastroplasty Restrictive Roux en Y Gastric Bypass Combination Biliopancreatic Diversion w/ Duodenal Switch Malabsorptive

12. What do we do? External Referral Internal Referral Meets criteria Yes No Return to referrer Patient discharged Patient attends Bariatric seminar Patient completes questionnai re MDT discussion Patient accepted onto programme Further investigation required Patient declined - return to GP Patient discharged

13. New patients

15. Discussion Criteria Dietetics Gastroscopy Weight loss Psyche Perioperative management Politics Audit Research

17. Discovery I can cross my legs! I have to tighten the airplane belt I have collar bones I can walk through a turnstile No more sympathetic looks in the boutique clothes shops Stunned looks I did a half marathon!

18. She did the Marathon

19. Outcomes of Gastric Bypass –Weight loss –Improvement in illnesses –Change in life expectancy –Quality of life

20. Weight Loss Rate of weight loss 1-2kg/wk Mean EWL 60-70%* eg patient at weight 140kg, with IBW 70kg expect average final weight: 91-98kg (loss of 42- 49kg) Failure (<50% EWL)1/12 Data Maturity15 yrs

21. Improvement in illnesses Type 2 Diabetes 83.7% High Blood Pressure75.4% High Cholesterol93.6% Obstructive Sleep Apnoea 86.6%

22. Change in Life Expectancy Overall, life expectancy significantly improved Reduced heart disease and cancer Chance of death due to the operation: 1 in 100 to one in 300 (similar to the risk with a knee replacement)

23. Eating and Quality of life Entrée sized meals “Taste buds change”: Normal diet Healthy foods taste better Dumping with fats & sweets Supplements: required lifelong Multivite B12, Fe Ca

24. Outcomes - Diabetes