1. Bariatric surgery Sheila MacNaughton, Team Lead Dietitian ( Surgery) Glasgow and Clyde Weight Management Service November 2013- Weight Management Training

2. Outline Types of Bariatric surgery Evidence Clinical Guidelines Current and Future NHS GGC Surgery criteria and selection of candidates Gastric banding- how does it work? Keys to success for gastric banding Band Adjustments Case studies Conclusions

3. Types of Bariatric Surgery Adjustable Gastric Band (LAP-BAND) Sleeve Gastrectomy Gastric Bypass Endobarrier

4. Evidence Swedish Obese Subjects - Mortality: up to 40% lower risk over 10years (Sjöström et al.,2007) Diabetes: >70% remission after 2 years (in recently diagnosed) (Sjöström et al.,2004) (Dixon et al., 2008) Improvement in HR-QoL Other benefits but harder to measure e.g. mobility, blood pressure, lipids

5. NICE Obesity Guidelines 2006 BMI >40kg/m 2 or BMI >35kg/m 2 with co-morbidities that could be improved with weight loss All appropriate non surgical measures have failed to achieve clinically significant weight loss Intensive management in specialist obesity service Commit to the need for long term follow up Consider first line for BMI >50kg/m 2

6. SIGN Obesity Guidelines 2010 BMI ≥35kg/m 2, bariatric surgery should be considered on a individual case basis following assessment of risk/benefit and the patient fulfilling the following criteria: presence of one or more severe co-morbidities which are expected to improve significantly with weight reduction (e.g severe mobility problems, arthritis, type 2 diabetes) evidence of completion of a structured weight management program involving diet, lifestyle, psychological and drug interventions, not resulting in significant and sustained improvement in the co- morbidities

7. SIGN Obesity Guidelines 2010 should be included as part of an overall clinical pathway for adult weight management Part of a programme of care delivered by multidisciplinary team including Surgeons, Dietitians, Psychologists, Nurses, Physicians Specialist psychological/ psychiatric opinion should be sought as to which patients require assessment/treatment prior to and following surgery

8. Completion of GCWMS structured program 18- 60 years of age BMI<60 and without any condition deemed as a clinical risk by surgeon who fail to lose 5kg. Must not gain weight (>5kg) 40 procedures a year Only Gastric bands Present - Developed in conjunction with NHSGGC surgeons Completion of GCWMS structured program < 45 years of age BMI of 35 - 40 Diagnosed Diabetic < 5 Years HbA1c < 9% > 5kg weight loss 108 procedures by 2014 2 types - Gastric band and Sleeve in NHSGGC New - National Planning Forum Guidance Developed in conjunction with Health Boards across Scotland (Accepted 2nd June 2012 NHSGGC ) Bariatric Surgery Criteria

9. Criteria for Bariatric Surgery? Criteria varies throughout the UK Variation through NHS boards in Scotland SCOTS- Severe & Complex Obesity Treatment Service, multidisciplinary group of clinicians. Ensure the equitable access to high quality, multi- disciplinary treatment for people with severe or complex obesity National Planning Forum- NHS boards and Scottish Government aim for consistent approach and criteria

10. GCWMS Pathway to Bariatric Surgery 16 week Lifestyle programme Anti obesity medication – 12 weeks Low calorie diet programme 12 weeks <5kg weight loss BMI >40kg/m 2 or BMI >35kg/m 2 with co-morbidities Referral to GCWMS Surgical Team

11. e MJA The Medical Journal of Australia HomeHome | Issues | Email alerts | Classifieds | Contact | More... | Topics | Search IssuesEmail alertsClassifiedsContactMore...TopicsSearch → Next article in this issueNext article in this issue → Previous article in this issuePrevious article in this issue → Contents list for this issueContents list for this issue → More articles on SurgerySurgery → More articles on GastroenterologyGastroenterology → Pdf version of this articlePdf version of this article → Search PubMed for related articlesSearch PubMed for related articles → Other articles have cited this articleOther articles have cited this article Abstract Morbid obesity (defined as having a body mass index [BMI] > 40 kg/m2, or BMI > 35 kg/m2 with obesity-related comorbidities) is a medical disorder associated with increased morbidity and mortality. Management guidelines published by the National Health and Medical Research Council and by similar US and UK bodies have recommended surgery as the most effective treatment available for selected patients with morbid obesity. A recent meta-analysis of obesity surgery has documented its safety and effectiveness in resolving some of the major medical comorbidities that occur in obese patients. To date, no intervention other than surgery has proven either effective or cost-effective in treating severe obesity and its associated medical conditions. Targeting patients with metabolic complications of obesity (eg, type 2 diabetes) could lead to substantial cost savings for the public health system. Currently, Medicare pays for privately insured patients to undergo obesity surgery, while uninsured patients are denied access to surgery in public hospitals. This raises significant equity issues that should be addressed. Arecent review and meta-analysis by Buchwald et al1 summarises succinctly the impact of bariatric (obesity) surgery on morbid obesity (Box 1) and its related comorbidities. The percentage excess weight loss in patients who have had bariatric surgery is reported to be 50%–70%, and “cure” or significant amelioration of diabetes, hypertension, hyperlipidaemia and obstructive sleep apnoea is experienced by over 80% of patients, on average, for each condition. The meta-analysis confirms that bariatric surgery is a safe and effective intervention, with positive effects persisting for years or decades. This leads us to consider the current difficulties in providing obesity surgery for Australian patients.1Box 1 Obesity is now epidemic in the Western world, due to a complex range of environmental and genetic factors.3 The AusDiab survey showed a combined prevalence of overweight and obesity of about 60% in Australian adults.4 It would be fair to assume, therefore, that overweight and obesity are now more prevalent risk factors for disease than smoking. Extrapolating from overseas data, the yearly number of deaths in Australia attributable to obesity is in the order of 12 000–17 000.5,6 Over the past 20 years, the prevalence of both obesity and diabetes in Australia has doubled,4 and the upward trend is projected to continue. Unfortunately, poor results of non-surgical intervention mean that there is rarely an exit for patients entering the obese cohort.34564 Treatment strategies for obesity have been exhaustively evaluated, both at a primary-care level and as intensive medical therapies instituted for high-risk patients. Primary-care interventions have either been ineffective or of insufficient duration to assess long-term results.7-9 The National Health and Medical Research Council (NHMRC), after an extensive evaluation of available therapies,10 concluded that obesity is associated with significant morbidity and mortality and that medical treatments for obesity generally result in weight loss of less than 10 kg of variable duration. While a sustained 3–5 kg weight loss may be acceptable for an “overweight” or “Class I” obese patient (Box 1), recommending non-surgical therapy to morbidly obese patients needing more significant weight loss is unsupported by evidence. Surgery is documented as the only consistently effective therapeutic intervention for the morbidly obese.1,10,117910Box 111011 The fact that surgery is not widely advocated by clinicians managing severely obese patients may, in part, be explained by the chequered history of some procedures that have been introduced with enthusiasm, rapidly disseminated, then later abandoned because of either dangerous side effects (eg, jejuno-ileal bypass) or ineffective weight loss (eg, gastroplasty). The number of patients happy to undergo often untested procedures with unknown long-term consequences is testament to the desperation faced by those afflicted with obesity. Current bariatric surgical techniques have evolved to produce highly safe and effective treatments for obesity and are now considered mainstream. Perhaps no other type of surgical procedure has been as extensively scrutinised. Multiple studies have shown that bariatric surgery leads to long-term weight loss with low morbidity and mortality. Indeed, obesity surgery has become one of the most frequently performed major surgical procedures in the United States (with over 120 000 projected cases for 2004), and is the second most frequent upper gastrointestinal surgical procedure (after cholecystectomy) performed in Australia (unpublished Health Insurance Commission data). Bariatric surgery has been evaluated by the NHMRC,10 the UK National Institute for Clinical Excellence (NICE)11,12 and the US National Institutes of Health (NIH).13 These three agencies have explicitly recommended that surgery be made available to selected morbidly obese patients (Box 2). On the basis of a cost-effectiveness analysis of gastric bypass surgery, the NICE has recommended that National Health Service trusts actively promote bariatric surgery. Similar analyses in the United States are prompting the US government to consider more widespread payment, through Medicare, to allow surgery in uninsured patients.10111213Box 2 Worldwide, about 65% of bariatric surgical procedures performed each year are variations of the gastric bypass (Box 3), with the laparoscopic band (Box 4) being the second most common procedure. The latter procedure is the most common performed outside the United States.14Box 3Box 414 In Australia, we have an unusual situation in which Medicare pays for bariatric surgery and postsurgical care for privately insured patients, while non-insured patients are denied the same services in public hospitals. As the prevalence of obesity is significantly greater in lower socioeconomic classes, there are obviously a significant number of obese people excluded from treatment that has been recommended by the NHMRC.10 A surgical approach to obesity treatment is also supported by the Australian Safety and Efficacy Register of New Interventional Procedures — Surgical (ASERNIP-S)15 and the Medical Services Advisory Committee (MSAC).16 The recommendations of the ASERNIP-S and the MSAC were to continue provision of funding for gastric banding in particular, but bariatric surgery in general was also supported.101516 The reason bariatric surgery was allowed to proceed in the UK National Health Service was a cost analysis showing that gastric bypass was cheaper than other interventions on a quality-adjusted-life-year (QALY) basis. Gastric bypass surgery is the only intervention, to date, that has been shown to be cost-effective for treating severe obesity.17,18 It results in lower morbidity, mortality and cost in operated compared with non- operated patients.19,20 Although laparoscopic gastric banding did not appear as cost-effective as gastric bypass when evaluated by the NICE,11,12 modelling analysis suggests it could be cost-effective.21 This seems likely, given the good weight control and comorbidity resolution observed in Australian studies of gastric banding.22 The MSAC report16 costed gastric banding at just over $9000 and gastric bypass at just over $8000 per procedure — figures that accord fairly well with our own estimates (unpublished data), except that our bypass costs were $1000–$2000 higher than banding costs because they included hospital and intensive care unit/high-dependency unit stays. These figures do not take into account the apparent high rate of band removal/replacement,23-25 also reported in Health Insurance Commission data, that would need to be included in cost calculations (Box 5).1718192011122122162325Box 5 Patients with diabetes are of particular interest as a potential target population for bariatric surgery. All studies to date have shown a cure rate of at least 80% for type 2 diabetes after gastric bypass surgery.27-30 There are currently over 900 000 Australians with type 2 diabetes, with the number projected to rise to over 1.2 million by 2010.31 The yearly cost of managing each patient with diabetes averages $10 900 (ranging from $9095 to $15 850, depending on the presence of complications).32 This means that a patient with diabetes having bariatric surgery in a public hospital is likely to have the procedure pay for itself within a year. Existing federal–state funding arrangements are not conducive to promoting obesity surgery as a cost-saving measure. While most of the costs of managing people with diabetes and serious obesity-related comorbidities are borne by the federal government, state-government- funded hospitals bear the costs of surgery. It is unlikely that state governments, without benefiting from the overall savings, would be swayed by cost-effectiveness arguments. The current inequities may, therefore, continue.27303132 Currently, Australia is far behind many Western countries in developing strategies to reduce the future burden of obesity and treat people who are severely afflicted. We have had no open-forum discussions between stakeholders and government of the kind that produced the recent UK House of Commons report on obesity.33 We have no primary-care equivalent of the UK Counterweight Project,8 and no effective treatments available to those who can not afford either drug therapy or surgery. Surgery for obesity is regarded by many people, including clinicians, to be akin to cosmetic surgery, a perception that is likely to persist while it remains solely in the domain of the private system. Although managing obesity is going to be a problem of major proportions, the longer we wait, the more difficult it will be to find solutions that suit the Australian population. The first step will be to acknowledge the severity of the problem and to offer treatment for the morbidly obese based on best available evidence. To do otherwise is to either ignore the evidence or simply discriminate against the obese.338 1 Obesity definitions*22 Competing interests Drs Talbot and Jorgensen received travel assistance from Johnson and Johnson Medical to attend an obesity surgery meeting in 2004. All three authors are bariatric surgeons with public hospital appointments. References 1.Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004; 292: 1724-1737. 2.World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000; 894: i–xii, 1–253. 3.Swinburn B, Egger G. The runaway weight gain train: too many accelerators, not enough brakes. BMJ 2004; 329: 736-739. 4.Cameron AJ, Welborn TA, Zimmet PZ, et al. Overweight and obesity in Australia: the 1999–2000 Australian Diabetes, Obesity and Lifestyle Study (AusDiab). Med J Aust 2003; 178: 427–432. 5.Allison DB, Fontaine R, Manson JE, et al. Annual deaths attributable to obesity in the United States. JAMA 1999; 282: 1530- 1538. 6.Banegas JR, Lopez-Garca E, Gutierrez-Fisac JL, et al. A simple estimate of mortality attributable to excess weight in the European Union. Eur J Clin Nutr 2003; 57: 201–208. 7.Moore H, Summerbell CD, Greenwood DC, et al. Improving management of obesity in primary care: cluster randomised trial. BMJ 2003; 327: 1085-1089. 8.The Counterweight Project Team. A new evidence-based model for weight management in primary care: the Counterweight Programme. J Hum Nutr Diet 2004; 17: 191-208. 9.James J, Thomas P, Cavan D, Kerr D. Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomised controlled trial. BMJ 2004; 328: 1237. 10.National Health and Medical Research Council. Clinical practice guidelines for the management of overweight and obesity in adults. Canberra: NHMRC, September 2003. Available at: www.health.gov.au/internet/wcms/publishing.nsf/Content/obesitygui delines-guidelines-adults.htm/$FILE/adults.pdf (accessed Feb 2005). www.health.gov.au/internet/wcms/publishing.nsf/Content/obesitygui delines-guidelines-adults.htm/$FILE/adults.pdf 11.Clegg A, Sidhu MK, Colquitt J, et al. Clinical and cost effectiveness of surgery for people with morbid obesity. Southampton: National Institute for Clinical Excellence, 2001. Available at: www.nice.org.uk/pdf/AssessmentReport- Surgeryforobesity.pdf (accessed Mar 2005).www.nice.org.uk/pdf/AssessmentReport- Surgeryforobesity.pdf 12.NHS National Institute for Clinical Excellence. Guidance on the use of surgery to aid weight reduction for people with morbid obesity. Technology Appraisal Guidance No. 46. London: NICE, July 2002. Available at: www.nice.org.uk/pdf/Fullguidance-PDF- morbid.pdf (accessed Feb 2005).www.nice.org.uk/pdf/Fullguidance-PDF- morbid.pdf 13.US National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Bethesda, MD: NHLBI, 1998. Available at: www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm (accessed Feb 2005). www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm 14.Buchwald H. 50 years of bariatric surgery. Obes Surg 2004; 14: 898. 15.Chapman A, Game P, O’Brien P, et al. Systematic review of laparoscopic adjustable gastric banding in the treatment of obesity. Update and re-appraisal. Adelaide: Australian Safety and Efficacy Register of New Interventional Procedures — Surgical, Royal Australasian College of Surgeons, June 2002. Available at: www.surgeons.org/asernip- s/systematic_review/LAGBreviewUp0602.pdf (accessed Feb 2005). www.surgeons.org/asernip- s/systematic_review/LAGBreviewUp0602.pdf 16.Medical Services Advisory Committee, Australian Department of Health and Ageing. Laparoscopic adjustable gastric banding for morbid obesity. MSAC reference 14. Assessment report. Canberra: DHA, 2003. Available at: www.msac.gov.au/pdfs/reports/msacref14.pdf (accessed Feb 2005). www.msac.gov.au/pdfs/reports/msacref14.pdf 17.Gallagher SF, Banasiak M, Gonzalvo JP, et al. The impact of bariatric surgery on the Veterans Administration healthcare system: a cost analysis. Obes Surg 2003; 13: 245-248. 18.Craig BM, Teng DS. Cost-effectiveness of gastric bypass for severe obesity. Am J Med 2002; 113: 491-498. 19.Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg 2004; 240: 416–424. 20.Sampalis JS, Liberman M, Auger S, Christou NV. The impact of weight reduction surgery on health-care costs in morbidly obese patients. Obes Surg 2004; 14: 939-947. 21.Clegg A, Colquitt J, Sidhu M, et al. Clinical and cost effectiveness of surgery for morbid obesity: a systematic review and economic evaluation. Int J Obes 2003; 27: 1167-1177. 22.Dixon JB, O’Brien PE. Changes in comorbidities and improvements in quality of life after LAP-BAND placement. Am J Surg 2002; 184(6B): 51S-54S. 23.Biertho L, Steffen R, Branson R, et al. Management of failed adjustable gastric banding. Surgery 2005; 137: 33-41. 24.Tweddle EA, Woods S, Blamey S. Laparoscopic gastric banding: safe and modestly successful. ANZ J Surg 2004; 74: 191-194. 25.Camerini G, Adami G, Marinari GM, et al. Thirteen years of follow-up in patients with adjustable silicone gastric banding for obesity: weight loss and constant rate of late specific complications. Obes Surg 2004; 14: 1343-1348. 26.O’Brien P, Brown W, Dixon J. Revisional surgery for morbid obesity – conversion to the Lap-Band system. Obes Surg 2000; 10: 557-563. 27.Hickey MS, Pories WJ, MacDonald KG, et al. A new paradigm for type 2 diabetes mellitus: could it be a disease of the foregut? Ann Surg 1998; 227: 637-644. 28.Schauer PR, Burguera B, Ikramuddin S, et al. Effect of laparoscopic Roux-en-Y gastric bypass on type 2 diabetes mellitus. Ann Surg 2003; 238: 467-485. 29.MacDonald KG, Long SD, Swanson MS, et al. The gastric bypass operation reduces the progression and mortality of non-insulin dependent diabetes mellitus. J Gastrointest Surg 1997; 1: 213–220. 30.Scopinaro N, Adami GF, Marinari GM, et al. Biliary pancreatic diversion. World J Surg 1998; 22: 936-946. 31.McCarty DJ, Zimmet P, Dalton A, et al. The rise and rise of diabetes in Australia, 1996: a review of statistics, trends and costs. Canberra: Department of Health and Family Services, 1996. 32.Colagiuri S, Colagiuri R, Conway B, et al. DiabCo$t Australia: assessing the burden of type 2 diabetes in Australia. Canberra: Diabetes Australia, 2003. 33.House of Commons Health Committee. Obesity. Third report of session 2003–04. London: Stationery Office, 2004. Available at: www.publications.parliament.uk/pa/cm200304/cmselect/cmhealth/23 /23.pdf (accessed Feb 2005). www.publications.parliament.uk/pa/cm200304/cmselect/cmhealth/23 /23.pdf (Received 28 Oct 2004, accepted 15 Feb 2005) Department of Surgery, University of New South Wales at St George Hospital, Kogarah, NSW. Michael L Talbot, MB ChB, FRACS, Senior Lecturer; John O Jorgensen, MB BS, FRACS, Visiting Surgeon; Ken W Loi, MB BS, FRACS, Lecturer. Correspondence: Dr Michael L Talbot, Department of Surgery, University of New South Wales, Level 3, Pitney Building, St George Hospital, Kogarah, NSW 2217. m.talbotATunsw.edu.au AntiSpam note: To avoid spam, authors' email addresses are written with AT in place of the usual symbol, and we have removed "mail to" links. Replace AT with the correct symbol to get a valid address. Other articles have cited this article: Anna Peeters, Reannan L Cashen and Paul E O’Brien. Inequalities in the provision of bariatric surgery for morbid obesity in Australia Med J Aust 2005; 182 (11): 598-599. [Letters] Paul E O’Brien, Wendy A Brown and John B Dixon. Obesity, weight loss and bariatric surgery Med J Aust 2005; 183 (6): 310-314. [Clinical Update] HomeHome | Issues | Email alerts | Classifieds | More... | Contact | Topics | SearchIssuesEmail alertsClassifiedsMore...ContactTopicsSearch The Medical Journal of Australia e MJA ©The Medical Journal of Australia 2005 www.mja.com.au PRINT ISSN: 0025-729X ONLINE ISSN: 1326-5377www.mja.com.au An adjustable prosthesis is placed at the upper part of the stomach. The stoma of the prosthesis is calibrated with saline introduced via a subcutaneous access port. (Diagram courtesy of Johnson and Johnson Medical.) Gastric band

12. Each bite should pass across the band before another bite is swallowed Waves through the food pipe generate feeling of not being hungry- satiety Signal message to brain that no more food is needed- satiation Mode of action of gastric band

13. Mode of action of Gastric banding Band is placed at top of stomach which creates a small pouch Reduction in intake, quicker and longer satiety Intraluminal pressure and semi solid swallows- transit across resistance of LAGB- peristaltic contractions. - Proposed that compression of vagal afferent nerves in band area mediates satiety effect (O’Brien, 2010) Activation of peripheral satiety mechanism without physically restricting meal size (Burton& Brown, 2011)

14. Sleeve Gastrectomy 70% of Stomach removed

15. Mode of Action of Sleeve Restrictive Alters hormone signals from stomach to brain

16. Pre Surgery- Psychology assessment Clinical interview & standardised measures: Psychological functioning (current & past) Eating behaviour Level of social support Coping skills Motivation /expectations Appraisal of the surgical process Social and cognitive functioning

17. Pre Surgery- Dietetic Dietetic assessment Dietary changes to date Dietary patterns, portion sizes Eating habits which may improve with gastric banding surgery Triggers for eating- energy dense food choices Hunger v’s non hunger Expectations from surgery 2 week Assessment diet Refer onto surgeons if patient successful and still wishes to proceed

18. Weight Loss Expectations Majority of weight loss within the first 2 years post op LAGB- ~50-60% EWL ( Weiner et al., 2003) RYGB- greatest weight loss 2years post op 60- 70% EWL Overall, LAGB and RYGB not different 3-8years post op-both ~50-60% EWL (O’Brien, 2010)

19. Weight Loss Expectations Case Study  Patient weighs 170kg (26 stone 10lbs), BMI 54kg/m 2  Height- 1.78m  Ideal body weight, BMI of 25kg/m 2 - 80kg  Excess body weight of 90kg  Weight loss approx 50% of his excess body weight following surgery  Could expect to lose in the region of 45kg (7stone)  Target weight for surgery to be deemed a success - 125kg (19st 9lbs) over 2 year period- BMI 39kg/m 2

20. GCWMS Group Support Programmes Support & skill-based: monthly rolling programmes Pre-Surgery group Preparation for surgery- Identify eating, activity and behavioural changes and emotional factors to be addressed in order to achieve success with weight loss surgery Post-Surgery Group Encouragement of adherence, support new coping techniques in high risk situations, relapse prevention, interpersonal learning & support

21. Pre Operative- Liver Reduction Diet

22. Diet before and after surgery 2 weeks pre op diet to shrink the liver~800kcal low CHO, low fat Post operative progression Fluids only for 2 weeks post surgery Soft diet gradually progressing to solid textures- week 2-6 post surgery Weeks 6 onwards- Solid food Importance of progressing to solid diet to achieve satiety and satiation from band Aiming for approx 1000-1200kcal/day when in “Green Zone”

23. Adjustment of band

24. Adjustment of patient- the 10 Keys to Success 1. Eat three small main meals per day 2. Focus on balance of nutritious solid food 3. Limit serving size 4. Do not graze between meals 5. All drinks should be zero calories 6. Eat slowly and stop when no longer hungry 7. Chew foods thoroughly 8. Avoid drinking with meals, sips only- do not gulp 9. Be active for 30 minutes every day 10. Always attend follow up

25. Chew thoroughly 20/20/20 rule 20p coin bite size Chew 20 times Wait 20 seconds

26. Adjustment of band Consultation to determine if adjustment needed. General progress, weight loss Eating, appetite, hunger, satiety Activity Range of food intake and nutrition Any symptoms e.g. reflux, heartburn, vomiting Requirement for further advice on eating and activity Decision made on need for adjustment

27. Adjustment of band First adjustment dependent on centre - ~ 6weeks post surgery, every 6 weeks thereafter Target - find the “Green Zone” Incremental increase in saline to right volume, right pressure Linear relationship between follow up and weight loss outcomes. ( Dixon et al., 2009)

28. Adjustment of band Not a case of the more the better Dangers of “Red Zone”- maladaptive eating Narrow range of foods Soft foods slide through- energy dense- high sugar, high fat soft/ liquid foods

29. Preserve the “precious pouch” Eating too quickly? Eating too much? Not chewing food well Leads to stretching of area above band -Enlargement of “new” stomach -Risk of band slippage

30. Patient 1 P1s1 wt 115.9kg BMI 48.2 (attended 1:1 due to anxiety) Referral to surgery wt 118.1kg BMI 49.1 Comorbidities Fatty liver Disease Extreme anxiety and depression Elevated cholesterol(suicidal, CMHT input) High Blood pressure Type 11 Diabetes Angina Joint pain

31. Patient 1 Attended all group sessions Responded well to diet and activity advice Engaged with GCWMS psychology and community mental health services 1 year post op 89kg BMI 37 (29.1kg wt loss since surgery) ‘ I work with my band, I eat solid textures, I follow the 10 keys to success, they are stuck to my fridge, and I learn from my mistakes’.

32. Patient 1 Patient now attends GCWMS group based exercise class Bought new clothes Looks after herself in a way she never thought she could Nov 16 th 2012 Liver function tests normal, Cholesterol normal, U&E’s normal, HbA1c 37 (5.5%) Aim of 50% EBW at 2 years 89kg – Achieved

33. Patient 2 P1S1 wt 149.6kg, BMI 59.9 Referral to surgery wt 145.4kg, BMI 58 (-4.2kg during programme) Co morbidities – Reported borderline Diabetes but nothing diagnosed No psychology input

34. Patient 2 Good attendance during Phase 1 Poorer attendance during phase 2 Struggled with motivation and main focus was to get gastric surgery 2 weeks post op137.9kg, BMI 55.2 6 weeks post op 135.8kg, BMI 54.3 1 year post op 135.8kg, BMI 54.3

35. Patient 2 Out for meals in 1 st 6weeks - ‘its part of my lifestyle which I’m unable to change’ No change in activity level – ‘ I’m too tired after work ’ Unrealistic expectations that band would do work for her Continued to have small amounts of high calorie foods ‘this approach works for me’ Moistening foods with gravy/sauces for ease of intake Poor attendance at follow up appointments

36. Patient 2 1 hour for meals Frequent holidays Snacking in evening on chocolate, crisps and biscuits Aim of 50% EBW at 2 years 103kg – Not on target

37. Conclusion Remember the band has to be be worked with, not something to conquer Needs to be adjustment of the patient combined with adjustment of band Multi disciplinary Surgery team support is a key determinant in surgery outcomes

38. Further considerations Implementation of new surgery criteria from 1 st of April 2013 (date delayed,awaiting confirmation) Disseminate and increase awareness of new criteria to referrers With increased number of surgeries allocated to NHSGGC what other groups of patients should be considered for bariatric surgery