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IN THIS ISSUE...
Nutrition
Jacqueline Jacques
examines how
obesity affects
nutritional status.
Paul Super and Rishi Singhal offer
valuable insights from the Heartlands
Lap-Banding programme.
6
Bariatric surgery in… Qatar
Bariatric News talks
with Michel Gagner
to discuss the
specialty in Qatar.
8
Coffee Time
In this issue we talk
with Antonio Torres.
9
Highlights from the 3rd Annual Meeting.
10-13
Obesity Future
Highlights from the inaugural meeting.
Surgery and adolesence
pages 14–15
Consensus panel publishes
best practices for LSG
Persian
Gulf
Banding – Tips and tricks
A snapshot of
Doha
4
India
ISSUE 11 | March 2012
16-19
20
An international panel of 25 leading bariatric surgeons
has published a consensus paper on the best practices for
performing laparoscopic sleeve gastrectomy (LSG). The
panel’s recommendations on patient selection, proper
surgical technique and prevention, and the management of
complications represents the experiences from 24 centres in
11 countries with more than 12,000 sleeve gastrectomy cases.
There is a misleading perception amongst surgeons and patients that
this procedure is an easy one,” said lead
author and panel chairman Dr Raul J
Rosenthal, Bariatric and Metabolic Institute and the Cleveland Clinic, FL. “Despite its simplicity, laparoscopic sleeve
gastrectomy requires a meticulous technique in order to avoid complications
and maximize procedure outcomes. We
felt the need to create guidelines to help
surgeons prevent complications that are
related, in most cases, to the learning
curve.”
According to the authors, this is the
first time an international panel of experts has reached consensus on the best
practices for performing laparoscopic
sleeve gastrectomy. It is hoped that the
consensus statement will help the surgical community continue to improve
patient outcomes, minimise complications and move toward adoption of
standardised techniques. The consensus paper entitled, ‘International Sleeve
Gastrectomy Expert Panel Consensus Statement: Best Practice Guidelines Based
on Experience of Over
12,000 Cases’ (Rosenthal et al. SOARD
2012. 8;1; 8-19), was
recently published in
the January 2012 issue
of Surgery for Obesity and Related Diseases, the official journal
of the American Society
for Metabolic and Bariatric Surgery.
Although laparoscopic sleeve
gastrectomy (LSG) is a relatively new
surgical approach has been readily adopted by surgeons who have embraced
the ’simplicity’ of the surgical technique, resolution of co-morbidities and
excellent weight loss outcomes. As a
result, an international expert panel was
convened on March 25 and 26 2011 in
Coral Gables, FL, to achieve consen-
Q ATA R
sus regarding various predetermined aspects of LSG and:
(1) conduct discussion and
evaluation of various procedural aspects of LSG (inclusive of indications/contraindications, surgical
technique, and prevention and management of
Qatar
SAUDI
ARABIA
complications) that
included
and considered the
collective
experience
of participants
and
current published data; (2) achieve consensus on
topics in LSG from the discussion and
evaluation; and (3) aid the
surgical community and improve the
safety of performance with minimal morbidity and high efficacy
using the resulting best practice
guidelines.
Panel data
A questionnaire was
sent to
all panellists
before
the consensus
meeting
to
compile various data on
the total number of LSG cases performed by
the group. The total
number of LSG cases
was 12,799, with mean patient age 42 years of whom 26%
were male and 73% female. The
mean body mass index of the patients
was 44±4.47kg/m2. The mean bougie
size was 37F± 5.92F. The average length
of hospital stay was 2.5± 93 days and the
conversion rate was 1.05%±1.85%. On
average, patients experienced a 1.06%
Continued on page 3
Is gastric bypass better than banding?
According to a six rates following gastric banding. come measures were operative ing (17.2% vs. 5.4%; p<0.001), were still severely obese (BMI
The future of obesity
treatment
22
CMS and obesity
screening
23
Product News
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Calendar of events
26
year study featured in the Archives of Surgery (published online 16 January 2012) roux-en-Y
gastric bypass (RYGBP) is associated with better weight loss,
resulting in a better correction of
some comorbidities than gastric
banding. Although bypass was
associated with a higher early
complication rate, this was negated much a higher long-term
complication and re-operation
Lead author, Dr Sébastien
Romy, Department of Visceral
Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne,
Switzerland, and colleagues hypothesised that RYGBP provides
superior results compared with
gastric banding. To test their theory they recruited 442 patients
who were matched according to
sex, age, and with a body mass
index (BMI) <50. The main out-
morbidity, weight loss, residual BMI, quality of life, food tolerance, lipid profile and longterm morbidity, following either
RYGBP or gastric banding.
Results
Follow-up was 92.3% at the end
of the study period (six years
postoperatively) and the early morbidity was higher after
RYGBP than after gastric band-
but major morbidity was similar. Six years later, 19% of the
bypass patients and 41% of the
banding patients reported longterm complications. Weight loss
was quicker, maximal weight
loss was greater and weight loss
remained significantly better after RYGBP until the sixth postoperative year.
Three years after surgery,
22% of the banding patients
of 35 or greater), compared
to 7% of bypass patients and
14% of the banding patients remained morbidly obese (BMI
of 40 or greater) after six years,
compared to 2.4% of bypass patients. At six years, there were
more failures (BMI>35 or reversal of the procedure/conversion)
after gastric banding (48.3% vs.
12.3%; P<0.001), more longContinued on page 6
BARIATRIC NEWS 3
ISSUE 11 | March 2012
Consensus panel
publishes best
practices for LSG
Continued from page 1
leak rate and 0.35% stricture rate, with a postoperative gastroesophageal reflux rate reported as
12.11%±8.97%.
Patient selection
In addition to reaching consensus on LSG as a valid
stand-alone procedure (90%), the panellists identified LSG as a valid treatment option for the following categories of patients: patients considered high
risk (96%); transplant candidates (kidney and liver) (96%); morbidly obese patients with the metabolic syndrome (91%); patients with a body mass
index of 30–35kg/m2 with associated co-morbidities (95%); patients with inflammatory bowel disease (86%); morbidly obese patients in adolescence
(77%); morbidly obese patients who are elderly
(100%); and patients with Child’s A or B liver cirrhosis (78%). As the first stage of a two-step approach, LSG is only appropriate for the super morbidly obese patient (75%) and that the presence of
Barrett’s oesophagus is an absolute contraindication for LSG (81%).
Revisions
In regards to revision procedures, the panellists
agreed that LSG is an acceptable option to convert a successful, but complicated, gastric band
(95%). However, it was acknowledged that Roux-
en-Y gastric bypass, not LSG, is the best option to
convert a failed gastric band (71%). When a patient undergoes conversion from gastric banding to
LSG, the operation can be done in one step, which
is a valid approach (72%). The two-step approach
is also valid (79%). Even assuming that ≤30% of
LSG patients will need a second procedure, the
panel agreed that it is still an excellent procedure
(90%). With regards to staple firings, the last firings (across the thickened site of the previous intervention) should be green or larger (71%). The
transection should begin 2–6cm from the pylorus
(92%); and it is important to be cautious and maintain a reasonable distance from the gastroesophageal junction on the last firings (96%).
Surgical technique
The panel achieved consensus on the technical aspects of the performance of LSG, which were summarised as:
Sizing the sleeve – in addition to it being important when performing LSG to use a bougie to
size the sleeve (100%), the optimal bougie size is
32F–36F (87%). The panel believed that using a
bougie <32F might increase complications significantly and that using a bougie >36F could lead to
the lack of long-term restriction and possible dilation of the sleeve, resulting in failure of weight
loss or long-term weight regain. In addition, in-
vaginating the staple line with sutures might result in temporary or permanent reduction of the
lumen size (83%), depending on the suture type
used (absorbable versus nonabsorbable).
Staple heights and firings – consensus was
achieved for some points including that it is not
appropriate to use staples with a closed height less
than that of a blue load (1.5mm) on any part of a
sleeve gastrectomy (81%). Although panellists
voted against this as they did not agree that anything less than a green load should be used. When
using buttressing materials (79%) and when resecting the antrum, the surgeon should never use
any staple with a closed height less than that of
a green load (2.0mm) (87%), because the gastric
antrum wall is the thickest part of the stomach.
Mobilisation – it is important to completely mobilise the fundus before transection (96%),
otherwise the surgeon could miss a hiatal hernia
and leave behind too much stomach, decreasing
the restrictive component of the operation.
Complications
The panel agreed that leaks, strictures, bleeding,
and gastro-oesophageal reflux disease were the
most prevalent complications observed after LSG.
Consensus was reached on several points regarding leaks, including defining leak classifications
according to observation periods and can be classified into acute, early, late, and chronic (73%). Additional points of consensus included that the use of
a stent is a valid treatment option for an acute proximal leak for which conservative therapy has failed
(95%). The use of a stent is a valid treatment option for an acute proximal leak (93%) and an unstable patient with a contained or uncontained symptomatic leak requires immediate reoperation (86%).
The panel also made some general observations regarding staple line reinforcement, stating
that the use of staple line reinforcement will reduce bleeding along the staple line (100%). Inter-
estingly, they could not agree whether to buttress
or on whether buttressing reduces leaks. The general points of consensus outside the specific areas
of LSG indications, technique, and complications
included hiatal hernias and gastro-oesophageal
reflux disease.
Interestingly, the panel stated that sleeve gastrectomies should only be performed by bariatric
surgeons (85%) and that endoscopy should routinely be performed in patients undergoing sleeve
gastrectomy (70%).
The paper states that the panel reached consensus on almost all topics, providing a basis for
current technical and clinical approaches and
the development of future guidelines. However,
those topics that did not reach consensus (emphasize the need for additional studies and long-term
data, especially within the specific areas of staple
line reinforcement, patient selection, and specific points about the management of complications.
Conclusions
The paper concludes by stating that it is not meant
to establish a standard of practice merely to support and encourage surgeons and surgical societies
to develop standardised guidelines, as well as highlight the areas needing additional study and longterm experience and data.
“This type of consensus meeting is, to our
knowledge, one of the first aimed at standardizing a surgical technique,” explained Rosenthal.
“In these times, when so many new surgical technologies, techniques and procedures are being developed, it is crucial to provide resources for surgeons to learn best practices in a shorter period
of time to achieve the optimal procedure results
while minimising complications.”
The assembly and work of the expert surgeon
panel that developed the consensus was supported by an educational grant from Ethicon EndoSurgery (EES).
Message from the editor
This month’s cover article features the
publication on the
best practices for laparoscopic sleeve gastrectomy, and includes
issues
surrounding patient selection,
revisions,
surgical
techniques and complications.
Our second cover
story highlights a study
from Switzerland comparing the outcomes from gastric bypass and banding, which claims the former is
associated with better outcomes.
We welcome back Dr Jacqueline Jacques, who
provides us with an comprehensive overview of how
obesity affects nutritional status and Drs Paul Super
and Rishi Singhal offer valuable tips and tricks from
the Heartlands’ Lap-Banding programme. Bariatric News is also delighted to feature an interview with
Professor Michel Gagner who discusses his current
bariatric programme in Doha, Qatar.
As the IFSO-EC meeting is upon us, in this issue’s
‘Coffee Time’ section we are pleased to feature an in-
terview with Professor Antonio Torres, who discusses his achievements, concerns and the future of bariatric surgery.
This issue’s ‘Snapshot’ features the city of Mumbai (India) and a study into metabolic syndrome rates
that could have implications for the diagnosis of diabetes and obesity.
Following the recent British Obesity and Metabolic Surgical Society annual meeting and the London 2012: Future of obesity treatment international
sympo, we feature exclusive reports from both conferences.
As ever, we also report the latest product news
and publish the latest event updates.
We hope you find this issue an interesting an informative read. If you would like to comment on any
of the articles or have an article suggestion please do
not hesitate to contact us.
If you would like to contact the editor, please email: [email protected]
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2012 Copyright ©: Dendrite Clinical Systems Ltd. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any other means, electronic, mechanical,
photocopying, recording or otherwise without prior permission in writing of the Managing Editor. The views,
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Board.
A snapshot of
PROFESSIONAL
Bariatric surg
cardiovascularery prevents
events
Vector Created by:
Matt Ward/Echo Enduring
(c) 2009; Distribut
Media - www.ech
ed under the Creative
oenduring.com
Commons lisence.
Jacqueline
Jacques discusses
the nutritional
deficiencies in
obese and postoperative patients. 4
ASMBSupdatesSGpos
ition
statement
The Association has
updated its position
on sleeve gastrectomy.
6
CoffeeTime
We talk to Professor
Philip James about
his achievements
and the battle
against the obesity
pandemic. 7
TheHaloeffect
According to
research, family
members of
patients who have
undergone bariatric
surgery have
reported weight loss
and improvements
in their lifestyles. 11
IFSO2011
Patients who unde
rgo gastric bypass
surgery are less likely
more conventional
to die from cardi
treatment for their
ovasc
weight condition,
(SOS) study. The
according to the latest ular events than people who recei
research was recen
ve
tly published in the
results from the Swed
al. JAMA 2012; 307:
Journal of the Amer
ish Obese Subjects
56-65).
ican Medical Assoc
iation Source (Sjos
“Bar iaTr ic sUrG
trom et
ery
was associated
with about a 30%
reduction in the inciden
ce of both
heart attacks and
strokes,” said researc
her professor Lars sjostrom,
University of Gothen
burg, sweden. “while pre-sur
gery BMi did not
predict surgical
health outcomes, having
diabetes or risk factors
abetes was a strong
for diindicator of surgica
l benefit. This
could have implic
ations for selecting
candidates for
weight loss surgery
.”
Swedish Obese
Subjects
The sOs study is
an on-going, non-ra
ndomised, prospective, controlled
study conducted at
25 public surgical departments
and 480 primary health
care centres
in sweden, and include
s 2,010 obese particip
underwent bariatric
ants who
surgery and 2,037
matched obese
controls who receive
d usual care (contro
l group). The
research is testing
the hypothesis that
bariatric surgery
is associated with
criteria were age 37
a reduced inciden
to 60 years and a
ce of cardiovascular events and examin
body mass in- were
dex of at least 34 in
ing the relationship
undertaken at pre-pla
men and at least 38
weight change and
between gery patient
in women. surnned intervals.
cardiovascular events.
s underwent gastric
The average change
bypass (13.2
patients were recruit
s in body weight after
banding (18.7 per
ed between septem
2, 10,15,
cent), or vertical banded per cent), and 20 years were 23 per
and January 2001.
ber 1987 ty (68.1
cent, 17 per cent, 16
gastroplas- and
The date of analysi
per cent), and control
per cent,
18 per cent in the
s was December
s
2009, with median
receive
surgery group and
d
usual
the swedish primar
care in per cent,
follow-up of 14.7
0 per cent, 1
y health care system
1 per cent, and 1 per
years. inclusion
. physical and respect
cent in the control
biochemical examin
group,
ively.
ations and database
cross-checks
Complications an
Continued on page 3
d costs of bariatri
A report from
the 2011 IFSO
meeting in
Hamburg, Germany.
14
EBTwhitepaper
A joint TaskForce has
released a white
paper on endoscopic
bariatric therapies
ITY FOR THE HEALTHCARE
ry 2012
pages 12–13
Nutrition
Please send an email to communications@e-dendrite.
com stating your full postal address (for a printed copy).
TO THE TREATMENT OF OBES
ISSUE 10 | Janua
18
Productnews
20
NewsinBrief
21
Calendarofevents
22
According to two recen
tly published pape
rs in the British
Journal of Surgery
(October 2011; 98
[10]), long-term
complications and
further surgery are
not uncommon,
but despite these disad
vantages surgery is
a more costeffective way of tackl
ing rising morbid obes
ity rates than
non-operative care.
The firsT pape
r entitled, ‘Management of late postop
erative complications of bariatr
ic surgery’ (hamd
an
et al.) examined the
increasing number
of patients presen
ting to non-specialist
units with complications
following bariatric procedures and
outlined the management of the most
common late post-
c surgery
gestive Diseases Unit
at Brighton and
Complications
sussex University
hospitals. “as a reThe most common
sult of the current
long-term complica, largely ineffective,
tions after gastric
non-surgical options
banding
for treating obesislippage (which affects include band
ty, the past decade
has witnessed an ex15% to 20% of
patients) and erosion
ponential increase
in the number of bar(which can affect
up to 4% of patient
iatric operations perform
s). following gased.”
tric bypass, compli
Therefore, the researc
cations such as interhers under- nal
took a literature
hernia
(5%
to
10%), adhesions and
search for late postanastomotic stenosi
operative
operative complications
s were found to be
that are likely surgery complications after bariatric commo
to present to the genera
n causes of intestin
using pubMed, embas
l surgeon.
al obstruce, OViD tion. Megao
and Google search
“in england, there
esophagus (dilatio
engines, and comare more than
n of the
esophagus), a rare
binations of the
30,000 deaths a year
but well reported late
terms bariatric surattributed to obesicomplication occurs
gery, gastric bypass
ty alone, taking an
in one in every 200
average of nine years
, gastric banding
patients after LaGB
or sleeve gastrectomy,
off a person's normal
and hepatobiliary
life expectancy,”
and late or decomplications were
layed complications
said the lead author
another particular
. Only studies with
of the paper, conchallenge, the researc
follow-up longer than
sultant surgeon Mr
hers noted.
Khaled hamdan, Disix months were
included.
The study found that
functional disContinued on page 4
4 BARIATRIC NEWS
ISSUE 11 | March 2012
An Overview of Nutritional Deficiency and Bariatric Surgery
Jacqueline Jacques, ND
Obesity is commonly referred to in
textbooks of nutrition and medicine
as “over-nutrition.” It is easy, even
for trained physicians, to look at a
severely obese patient and assume that
an excess of stored calories must mean
an excess of (or at least adequate)
vitamins and minerals. However, the
more study we do in this area, the
more we see quite a different picture
emerge. Obesity places great physiologic strain on the
human body – and that strain takes a toll on many systems
including on nutritional status.
As obesity continues to be check not only for anemias, but also for
one of the greatest health struggles of
our time, bariatric surgery is a valuable
therapeutic tool for both the treatment of
morbid obesity and associated co-morbid
conditions. Regardless of the procedure
performed, there are nutritional deficiencies that can occur both pre and post-operatively, and pose a challenge to patient
and clinician alike. This article will review the nutritional risks of bariatric surgery and will also touch on the evaluation and prevention of these problems.
Pre-Operative Nutrition
Studies of bariatric surgery patients presenting for surgery have found significant deficiencies of nutrients. For example, in a 2006 retrospective study of
379 morbidly obese patients, Flancbaum,
et al found that 68.1 percent of their patients were deficient in vitamin D, 39
percent were low in iron, 22 percent had
low hemoglobin, 8.4 percent had low ferritin, and 29 percent were deficient in thiamine.7 In a 2006 comparison of pre and
postoperative nutritional levels in 100
patients, Madan et al found the following
deficiency rates before surgery8:
n Vitamin A – 11%
n Vitamin B12 – 13%
n Vitamin D – 40%
n Zinc – 30%
nIron – 16%
n Ferritin – 9%
n Selenium 58%
n Folate 6%
For some nutrients such as vitamin D and
Selenium, the nutrient levels were significantly before surgery than they were one
year after surgery.
A 2008 study by Ernst at al, found the
following deficiencies in 232 morbidly
obese patients preparing for bariatric surgery9:
n Albumin – 12.5%
n Phosphate – 8%
n Magnesium – 4.7%
n Ferritin and Hemoglobin – 6.9%
n Zinc – 24.6%
n Folate – 3.4%
n Vitamin B12 – 18.1%
n Vitamin D – 89.7%
Researchers looking at individual nutrients have found deficiencies of vitamin
D10, thiamine11, vitamin C12 and others.
Thus, overall we can clear paint a picture
of the morbidly obese patient as having a
high incidence of nutritional deficiency.
This pre-operative status is important
to all forms of bariatric surgery. Regardless of procedure, patients eat less food
after surgery, and even with improved dietary intake, it is not possible for those
who have had bariatric surgery to get all
the nutrition they need from food alone.
Deficiencies left untreated can cause
acute or chronic problems that can be serious if not addressed. While it may not
be cost effective or practical to broadly
assess nutritional status prior to surgery,
it is becoming increasingly common to
common treatable problems such as vitamin D or thiamine deficiency. Increasing
our understanding of pre-operative nutrition may lead not only to better overall patient health, but also to predictive
models of who may be at greatest risk for
early onset of post-operative nutritional
deficiencies. We can also start to see that
nutritional care of bariatric surgery patients is really a peri-operative issue and
not simply a post-operative issue.
Nutrition and Adjustable Gastric
Banding
Because there is no anatomical change to
the digestive system with an adjustable
gastric band, the risk for nutritional deficiency is clearly lower than with other
procedures. With no malabsorption, one
primarily needs to be concerned with the
ways that fewer calories, dietary changes, and weight loss impact long-term nutrition. Fewer calories means less food.
When patients eat less it is simply harder to get all the nutrition they need each
and every day. When it comes to dietary
changes, most people really improve
how they eat after bariatric surgery. But
some of the common changes – for example, eating more protein and less carbohydrate – can result in getting less of
some key nutrients. Finally, weight loss
itself may contribute to some nutritional issues. One good example of this is
bone loss. As people lose weight, some
bone loss seems to be inevitable. Good
nutrition can be used to help reduce the
amount of bone that is lost when you lose
weight.
The following are the primary nutritional concerns after adjustable gastric
banding:
1.Thiamine. Thiamine deficiency is an
established risk with all types of bariatric surgery. This is because most thiamine deficiency does not occur from
malabsorption, but rather from low intake or from vomiting. Current data
suggests that the greatest risk is in the
first 6 to 12 months after surgery, especially in patients who have vomiting for any reason13. There have been
at least two published cases of severe
thiamine deficiency (Wernicke’s Encephalopathy) with adjustable gastric
bands14,15.
2.B12 and Folic Acid. B12 and folic acid
levels have been studied in adjustable
gastric band patients in more than one
trial. One study of nearly 300 patients
examined serum B12, folate and homocysteine16 levels over a two-year
period following AGB placement17.
The researchers found that those undergoing weight loss had significant
elevations of total homocysteine levels compared to controls. Frankly low
B12 or folate levels explained 35 % of
the elevations. In the remainder of cases, higher than normal levels of these
nutrients were required to maintain
normal homocysteine levels. Another
tive Helicobacter pylori infection, and
study conducted in Switzerland, found
an 82 percent incidence of gastritis27.
Maldigestion due to loss of stomach
that by two years following adjustable
functions, and malabsorption due to
gastric banding, folic acid levels had
loss of IF are clear problems. Loss of
declined by 44.1%18.
3.Bone Health. When we think about
hydrochloric acid, gastric churning,
bone, it is important to keep in mind
pepsin and IF are all causes of B12
that we have already identified vitamin
malnutrition. Both partial and total
D deficiency as a common problem in
gastrectomy is considered to be a semorbid obesity. The other major nutririous risk for B12 deficiency – this inent for bone health – calcium – is ofcludes gastric bypass, duodenal switch
ten a problem when it comes to intake.
and gastric sleeves. B12 deficiency is
The American Society of Metabolic
reported to occur in one-third of postand Bariatric Surgery(ASMBS) recop patients after one year, and may inommendation for calcium intake after
crease thereafter depending on nutrigastric banding is 1500 milligrams per
tional compliance. Published data after
day19. The average calcium intake by
RNY estimates a 37 percent deficiency
adults aged 35 to 50 years is only 565
rate, though some studies have shown
milligrams20. If someone is now eatincidence as high as 70 percent28.
ing less after surgery, changes are their 3.Folic Acid. Folate deficiency has been
intake has gone down. Studies have
found after almost all types of bariatshown evidence of bone loss after gasric surgery. Reported levels of defitric banding. A one-year study found
ciency from studies of gastric bypass
that there was significant evidence of
range from close to 40 percent29 to as
low as 1 percent30. Elevated homocysbone loss, especially at the hip21.
teine levels (indicative of folate defiNutritional Deficiency
ciency) are also reported after all types
of procedures31-34 One report suggested
and Gastric Bypass
Gastric bypass surgery changes the anatthat, deficiency was mostly reflective
omy of the digestive system. The stomof compliance with a multivitamin,
ach is resected to a small (approximately
and this appears to be a reasonable as15mL) pouch, and the entire duodenum
sumption based on later data 35. Most
of the time, folate is not part of rouplus a distance of approximately 100 to
tine labs after weight loss surgery, and
150cm of the jejunum is bypassed. Beit is hard to say at this time if it should
cause of this new anatomy, both digesbe. However, due to the special importion and absorption of nutrition form
tance folate in pregnancy, it is probafood is altered. As with the Adjustable
bly a very good idea for women who
Gastric Band, patients have significantwant to have a baby after bariatric surly decreased food intake after gastric bygery to have their folate levels checked
pass, as the very small pouch restricts
– ideally before becoming pregnant.
intake. Additionally, there is altered diLevels might also be checked during
gestion. This occurs because most of the
pregnancy to assure healthy growth
stomach is now bypassed, which means
and development of the baby. Bethat food will no longer come in direct
cause it is unlikely that folate is malcontact with gastric acid, intrinsic factor
absorbed, consuming a daily multivi(required for B12 absorption), or the protamin with 400 to 800 micrograms of
tein digesting enzyme pepsinogen. Finalfolic acid should prevent most defily, the bypassed area of the small intesciency.
tine allows for malabsorption of some
calcium, iron, copper, zinc and several 4.Vitamin D. We have already discussed
vitamin D as a significant deficienB-vitamins. Altogether, between pre-excy and comorbidity of obesity. Generisting deficiency, decreased intake, malally speaking, as people lose fat, they
digestion and malabsorption, it is untend to improve vitamin D status afavoidable that gastric bypass patients
ter surgery in the long run. In studies
will be a risk for nutritional problems in
comparing pre to post-operative levthe absence of preventive care.
els, rates of deficiency tend to decline.
The following are the primary nutriFor example, Madan, and colleagues36
tional concerns after gastric bypass surfound that while 40 percent of their pagery:
tients were vitamin D deficient prior to
1.Thiamine: As we have already dissurgery, only 21 percent were still vicussed, thiamine deficiency has been
tamin D deficient at one year. Similaridentified pre- and post-operatively in
ly, Goode and colleagues37 found that
bariatric surgery patients. Current data
vitamin D in postoperative RNY pasuggests that the greatest risk is in the
tients was higher at six months that it
first 6 to 12 months after surgery, eswas preoperatively. Generally, the impecially in patients who have vomiting
pression results would be confounded
for any reason24. Additional risk factors include use of IV glucose withby the fact that all patients undergoout thiamine and parenteral feeding.
ing gastric bypass are advised to supPatients who undergo more rapid or
plement with vitamin D, so long-term
greater-than-expected weight loss may
data will eventually be very useful in
also be at increased risk. There are reunderstanding how these levels may
ports of chronic deficiency as well, aschange over time. Moreover, the apsociated with alcohol intake, lack of
parent trend of vitamin D status imsupplementation and onset of poor
proving with weight loss should not in
eating habits25. Subsequent developany way diminish the fact that this dement of anorexia or bulimia following
ficiency is still both common and seriweight loss surgery, would be a signifous in its impact.
icant risk for thiamine deficiency, and 5.Calcium. Bone loss and the presence
has been reported in literature26. The
of metabolic bone disease are well
overall incidence of thiamine deficiendocumented after gastric bypass, and
cy with gastric bypass is not known,
both calcium and vitamin D appear to
though it is believed to be low in complay a role in their development. In adparison to others we will discuss. Still,
dition to decreased intake, gastric bybecause of its severity and potential
pass patients may have their calcium
deadliness, it is an important deficienstatus impacted by low stomach acid,
cy for clinicians to be aware of.
lactose intolerance (possibly reducing
2.Vitamin B12. According to the Amerdairy intake), and malabsorption. In
ican Society of Metabolic and Bariata small study measuring calcium abric Surgeons, B12 deficiency occurs
sorption with an isotope-labeled calciin around One study in RNY patients
um load, Reidt and colleagues38, found
that true fractional calcium absorption
found a 25 percent incidence of ac-
decreased from 0.36 (+/- 0.08) to 0.24
(+/- 0.09) after RNY. This was coupled
with an increase in markers of bone
turnover. No fewer than four published
studies have found decreases in bone
mineral density in patients one to ten
years post-operative.
6.Iron. Iron deficiency is a common occurrence after gastric bypass. Incidence of deficiency tends to increase
over time. Studies cite rates of 16 to 26
percent after one year39. Longer-terms
studies have shown incidence as high
as 47 percent40. Iron deficiency develops with RNY due to reduced hydrolysis in the stomach coupled with bypass of the primary absorptive surface
in the duodenum – in other words there
is both malabsorption and maldigestion. Menstruating women and those
who become pregnant are at greatest
risk. There is also increased risk with
those who have problems incorporating meat into their diet, and heavy exercisers.
7.Protein. Protein malnutrition has been
reported with RNY, although not commonly. Little is know about overall incidence, as only around eight percent
of surgeons track labs such as total protein, albumen or prealbumen41. Limited studies suggest that patients with
the most rapid or greatest amounts of
weight loss are at greatest risk42. With
surgical resection of the stomach, hydrochloric acid43. pepsinogen, and normal churning are all significantly reduced or eliminated. Furthermore,
pancreatic enzymes that would also
aid in protein digestion are redirected to a lower part of the small intestine. It is thus likely, that maldigestion,
rather than malabsorption is responsible for many cases. Some studies have
also implicated low intake44.
8.Other Nutrients. There are still many
nutrients that have either not been
studied in post-operative weight loss
surgery patients or that have very minimal data. Some of these include zinc,
copper, magnesium, selenium, vitamin
B6, vitamin B2, niacin, vitamin A, vitamin E, vitamin K, and essential fatty acids. It is important that clinicians
recognize that while there is a known
risk of deficiency for some nutrients,
this does not rule out the possibility of
other deficiencies arising. Thus, it is
imperative that those caring for bariatric surgery patients do not simply
dismiss symptoms as not having nutritional causes simply because a common nutritional cause has been ruled
out. For example, it has already cases of copper deficiency can be missed
(and have been missed) when clinicians have ruled out iron and B12 deficiency and fail to continue to look
for less common causes of the same
symptoms.
Vertical Sleeve Gastrectomy
There is very limited data available on the
impact of the vertical sleeve gastrectomy
(SG) on micronutrient status. Currently,
there are a handful of short-term follow
up papers, which shall be discussed here.
Most literature refers to SG as a purely restrictive procedure (since it is limited to surgical alteration of the stomach),
which may give the impression that there
should be minimal impact on vitamins
and minerals – similar to gastric banding.
However, the position statement from the
ASMBS notes that, “The mechanisms of
weight loss and improvement in co-morbidities seen after SG might be related to
gastric resection, neurohormonal changes related to gastric restriction or gastric emptying, or some other unidentified
factor or factors.”45 Because vitamin and
Continued on page 6
BARIATRIC NEWS 5
ISSUE 11 | March 2012
Non-invasive bariatric
techniques and novel approaches
Editorial from Jerome Dargent (Lyon, France)
Our second “Non-Invasive bari-
atric surgery and new technologies” Meeting in
Lyon is announced for April 20-21, 2012. It will
be an honour to co-chair this meeting with the
former president of IFSO, Karl (“Charlie”) Miller, who hosts an annual expert meeting in the
Austrian Alpes, that few key-opinion leaders actually miss.
Like last year, we will cover the current topics of the ongoing clinical research in this field.
Tremendous updates will be presented on SILS,
neuromodulation, NOTES, endo-jejunal bypass,
endoscopy for bypass failures, etc. Brand new
and highly promising procedures will be highlighted together, and for the first time submitted
to a benchmarking process, and scrutinized by
the prestigious Australian surgeon Paul O’Brien,
or put into the “Asian perspective” by the Indian
leader Pradeep Chowbey. Let us cite: the balloon
that can be swallowed, the re-shape balloon, the
Full Sense restrictive device, the “loaded” microinstrumentation or the powered stapler and needle-holder, and many others.
A vast portion of the obese population does
not take advantage from the surgical possibilities,
which is the reason why clinical research should
be oriented towards less invasive procedures that
could be accepted by the mainstream. The Noninvasive bariatric techniques are not standardized
and sufficiently assessed in 2012, but they are being constantly upgraded.
The programme has been divided into five
parts: 1. Procedures that aim at lowering the ”
surgical trauma “, mostly the single-trocar and
the NOTES approaches. Do we have the instruments we need? Is the upgrade relevant versus
the typical lap-approach? 2. Techniques that are
available through ” natural orifices “, the most
promising provided, if can prove satisfactory and
long-standing. 3. New technologies, like neuromodulation. 4. Transversal issues: the role of the
anesthesiologist, the cooperation of the gastro-enterologist, etc. 5. Guide-lines for the forseeable
evolutions.
Surgical procedures that are well established
(gastric bypass, adjustable band, sleeve gastrectomy) will not be addressed as such, but only from
the perspective of comparison and confrontation
with less invasive procedures.
The programme shall evolve during the forthcoming
weeks. Please check again in order to get the updates!
Friday 04/20/2012, 8:30 am, till 6:00 pm
Saturday, 04/21/2012, 8:30 am till 1:00 pm
Training sessions are scheduled with non-edited
videos
I. Preliminaries:
Welcome address, toward the future! Karl Miller
(Austria) and Jerome Dargent (France)
Benchmarking of novel technologies in bariatric surgery, can we establish guide-lines? Paul
O’Brien (Australia)
II. Mixt and original techniques, state of
the art
nNOTES-inspired
Sleeve
Gastrectomy
(transvaginal), a failure? Elie Chouillard
(France)
n A camera integrated in a magnetic internal
mechanism (MIM) for single access laparoscopy, application in bariatric surgery:
Nicola di Lorenzo (Italy)
nRoutine gastric banding through the SILS
approach: Marie-Cécile Blanchet (France)
n Bariatric SILS for everyone: a field experience: Jean Cady (France)
n SILS, critical considerations: Karl Miller
(Austria).
n Shall micro-instrumentation take over
SILS: Gilles Poncet (France) and Maud
Robert (France), (non-edited video).
nGastric plication: the sleeve killer, Elie
Chouillard (France), (non-edited video).
III. Purely Non-invasive techniques
nRevision of failed bariatric surgery/gastric bypass: Endoscopic rescue after obesity surgery: what are the needs and expectations of the bariatric surgeon in
2012? / Strategy for therapeutic sequences
in bariatric surgery, including Non-invasive and new technologies: Jacques Himpens (Belgium)
nThe endoscopic treatment of post-op complications after bariatric surgery (bleeding,
leaks, stenosis): Elisabeth Mathus-Vliegen
(The Netherlands)
n Primary restrictive endoluminal procedure for obesity, overview: Jacques Deviere
(Belgium)
nThe G-prox “ROSE” and “POSE” for morbid obesity and re-do. Current experience:
Gontrand Lopez-Nava (Spain), Tom Lavin
(USA) Non-edited videos
nThe Barosense Teris device, an endoscopic band? Elisabeth Mathus-Vliegen (The
Netherlands)
nEndoscopic stapling, TOGa: technique and
results: Jacques Deviere (Belgium)
n Satiety Inducing-Full Sense Device for obesity: Randal Baker (USA)
n Stents for staple-line leaks (sleeve gastrectomy): Rudolf Weiner (Germany)
nThe TRIM procedure for obesity: Stacy
Brethauer (USA)
nInjection at the GE junction: Jérôme Dargent, Frédéric Pontette (France)
nIntra Gastric Balloon placement, removal,
and state of the art: Zbigniew Kowalczyk
(Poland)
nEvaluation of several types of balloons:
Elisabeth Mathus-Vliegen (The Netherlands)
nResults of the adjustable gastric balloon:
Christophe Bastid (France)
nThe Gastric Balloon that can be swallowed,
feasibility trial: Frédéric Mion (France)
nThe duodeno-jejunal bypass sleeve: a novel approach for type 2 diabetes: Jan Greve
(The Netherlands)
III. Novel technologies and combined
issues
nEvolution and perspective of neuromodulation in obesity treatments: Scott Shikora
(USA)
nGastric neuromodulation with the V-BLOC
system: Karl Miller (Austria)
nGastric neuromodulation with the TANTALUS system: Rudolf Weiner (Germany)
nGastric neuromodulation with the ABILITI
system: Thomas Horbach (Germany)
nThe position of the anaesthesiologist: 1.
Less invasive approach for anaesthesia in
the obese patient: Jan Mulier (Belgium)
nThe position of the anaesthesiologist: 2.
Anaesthesiology for Non-invasive bariatric
surgery: Sinha Ashish (USA)
nThe cooperation between the bariatric surgeon and the endoscopist: Elisabeth Mathus-Vliegen (Nederlands)
n An original approach for the follow-up
through modern communication systems:
Maxime Sodji (France)
nThe choice of a metabolic operation in Eastern-Asia, new technologies and cost-effectiveness, an economic perspective: Pradeep
Chowbey (India)
V. Panel sessions
Session n°1, chaired by Karl Miller: Surgical approaches in bariatrics. Non-invasive procedures
vs. NOTES vs. single trocar or micro-instrumentation?
Session n°2, chaired by Paul O’Brien: What main
concept will emerge concerning purely Non-invasive techniques?
Based on our meetings, a “Directory of Non-invasive
and new technologies in bariatric surgery” will be
edited at Springer-Verlag by summer 2012.
6 BARIATRIC NEWS
ISSUE 11 | March 2012
An Overview of Nutritional Deficiency and Bariatric Surgery
14.Bozbora A, Coskun H, Ozarmagan S, Erbil Y, Ozbey
N, Orham Y. A rare complication of adjustable gastric
banding: Wernicke’s encephalopathy. Obes Surg. 2000
Jun;10(3):274-5.
Aarts found substantial deficiency in
mineral status can be adversely impacted
their post operative SG patients. Howin the absence of malabsorption, it is not
ever vitamin D deficiency is only a risk
surprising that even the limited available
for, and is not confirmation of changdata begins to indicate some challenges.
es to bone. A small study from Spain
1.B12, Folate and Iron. Perhaps in an
compared both blood chemistries and
effort to compare against Roux-en-Y
bone density findings in SG patients
gastric Bypass (RNY), we have ear(n = 8) to gastric bypass patients (n =
ly data that predominantly focuses
7). Pre-operative data was compared to
on vitamin B12, folic acid and Iron.
post-operative data. Both groups were
Hakeam et al46 followed 61 SG pafound to have similar losses of bone at
tients for one year. Patients were not
all areas measured, though it was gentaking vitamins. Over the course of
erally somewhat less in the SG group.
the study, 4.9% of the patients develSleeve patients lost 4.6%±4.4 in the
oped iron deficiency anemia, 18.1%
lumbar spine, 8.3%±5.2 in the femoral
of patients developed new B12 defineck, 7.1%±3.7 in the total hip meaciency (8.1% had B12 deficiency besurement, 0.2%±9.3 in the proximal
fore surgery, 26.2% at the end of one
radium and 3.2%±6.3 in the distal rayear), and 9.8% of patients developed
dius. Vitamin D levels were found to
new onset folate deficiency. Toh, et al47
increase after surgery, as did N-telocompared pre-op data to one-year data
peptide and bone alkaline phosphain 11 SG patients and found that 15%
tase. Thus, while this was a very small
had low hemoglobin and 25% had elsample size, we have an indication that
evated homocysteine at the conclusion
increased bone loss and turn over are
of 12 months. Aarts et al48 studied 60
likely and should be monitored.
SG patients for one year. Patients were 3.Other Nutrients. Available data on othinstructed to take a multivitamin with
er nutrients is minimal. Toh47 found vitamin D deficiency in 43% of SG pa150% of then RDA three times daily
tients at one year. Aarts4 found vitamin
(exact contents unknown). At the end
D deficiency in 39% of study particof one year, 26% of patients had aneipants and low albumin in 15%. The
mia, 43% had iron deficiency, 15% had
same study also found elevated levfolic acid deficiency, and 9% had B12
els of vitamin A, B1 and B6. The audeficiency. Finally, Gerher et al49 provided 3-year data in 50 SG patients.
thors suggest that these elevations
Patients in this study we all instructed
were most likely due to supplementato take a standardized multivitamin*
tion, but since the contents of the proddaily. At the end of the study, 18% of
uct being taken was not disclosed, the
patients had iron deficiency, 18% had
levels and forms of these nutrients that
B12 deficiency, and 22% had folate
created these results are unknown.
deficiency.
Gehrer49 found low levels of zinc, vitamin D, and albumin at three years.
2.Bone Loss. Evidence for bone loss with
There is also a single published case
non-surgical weight loss and all other
report of an acute thiamine (B1) deficommon forms of surgical weight loss,
ciency (Wernicke’s encephalopathy)
so one would not expect SG to be imin a patient with vomiting due to stricmune. We already know that vitamin
ture50.
D deficiency is very common before
51
bariatric surgery , and both Toh and
levels with weight loss after Lap-Band surgery: higher
folate and vitamin B12 levels required to maintain homocysteine level. Int J Obes Relat Metab Disord. 2001
Feb;25(2):219-27.
15.Homocysteine is a substance in the body that increases
when there is not enough folate and/or B12. High homocysteine is a risk for heart disease and other conditions.
35.Brolin REGorman JH, Gorman RC, Petschnik AJ, Bradley
LJ, Kenler HA, Cody RP. Are vitamin B12 and folate deficiency clinically important after roux-en-Y gastric bypass?
J Gastrointest Surg. 1998 Sept-Oct;2(5):436-42.
Continued from page 4
Conclusions
Nutritional care is an important part of
the long-term health of all weight loss
surgery patients. All bariatric surgery
procedures create some new risk for deficiency that is over and above pre-operative deficiency. It is important for any
practitioner caring for bariatric surgery
patients to establish education, nutritional protocols, and guidelines for follow-up laboratory testing. Clinicians caring for bariatric surgery patients should
have a good understanding of the common potential problems and be aware of
less common deficiencies that can occur.
Perhaps one of the
most successful gastric banding
programmes in the UK is in Birmingham. Bariatric News catches up with the Heartlands Hospital Unit where 75% of weight loss
surgery patients receive bands.
Pre-operative preparation
Pre-op dieting is imperative. We
favour meal replacement shakes
and yogurts (1000kcal diet) for
this pre-operative period. BMI
40-50 have this diet for 2 weeks,
50-60 for 4 weeks and BMI
greater than 60 for 2 months.
Day of Surgery
All patients are admitted on the
day of surgery and when ready,
walk to theatre. No pre-op anticoagulation is given. Port size is kept
to a minimum (12mm, 10mm, and
three 5mm dilating trochars).
Dissection
Early band infection and erosion
are undoubtedly secondary to surgical trauma and micro-perforation occurring during dissection.
All dissection should be gentle
with careful tissue handling. All
dissection in our practice is carried
out with simple hook diathermy.
A 2cm vertical incision is
made in the myomesium over the
medial border of the right crus to
17.Dixon, et al. Elevated homocysteine levels with weight loss
after Lap-Band surgery: higher folate and vitamin B12 levels required to maintain homocysteine level. Int J Obes
Relat Metab Disord. 2001 Feb ;25(2): 219-27.
36.Madan AK, Orth WS, Tichansky DS, et al. Vitamin and
trace mineral levels after laparoscopic gastric bypass.
Obes Surg. 2006 May;16(5):603-6.
37.Goode LR, Brolin RE, Chowdhury HA, Shapses SA. Bone
and gastric bypass surgery: effects of dietary calcium and
vitamin D. Obes Res. 2004 Jan;12(1):40-7.
18.Gasteyger C, Suter M, Calmes JM, Gaillard RC, Giusti V.
Changes in body composition, metabolic profile and nutritional status 24 months after gastric banding. Obes Surg.
2006 Mar;16(3):243-50.
38.Riedt CS, Brolin RE, Sherrell RM, Field MP, Shapses SA.
True fractional calcium absorption is decreased after Rouxen-Y gastric bypass surgery. Obesity (Silver Spring). 2006
Nov;14(11):1940-8.
19.Aillis L, Blankenship J, Buffington C, Furtado M, Parrott J.
ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surgery for Obesity and Related
Diseases. 2008 May: 4(5): S73-S108.
39.Brolin RE, Leung M. Survey of vitamin and mineral supplementation after gastric bypass and biliopancreatic diversion for morbid obesity. Obes Surg. 1999 Apr;9(2):150-4.
20.USDA National Food Consumption Survey 1988
40.Brolin RE, Gorman RC, Milgrim LM, et al. Multivitamin prophylaxis in prevention of post-gastric bypass vitamin and
mineral deficiencies. Int J Obesity 1991;15: 661-7.
1. Ohrvall M, Tengblad S, Vessby B. Lower tocopherol serum
levels in subjects with abdominal adiposity. J Intern Med
1993;234:53±60.
21.Giusti V, Gasteyger C, Suter M, Heraief E, Gaillard R,
Burckhardt P. Gastric banding induces negative bone remodelling in the absence of secondary hyperparathyroidism. Int J Obes Relat Metab Disord. 2003 Jan;27(1):1106.
41.Updegraff TA, Neufeld NJ. Protein, iron, and folate status
of patients prior to and following surgery for morbid obesity. J Am Diet Assoc. 1981;78(2):135–140.
2. Pereira S, Saboya C, Chaves G, et al. Class III Obesity and
its Relationship with the Nutritional Status of Vitamin A in
Pre- and Postoperative Gastric Bypass. Obes Surg. 2008
Apr 8.
22.Flancbaum L, Belsley S, Drake V, et al. Preoperative nutritional status of patients undergoing Roux-en-Y gastric
bypass for morbid obesity. J Gastrointest Surg. 2006 JulAug;10(7):1033-7.
42.Segal A, Kinoshita Kussunoki D, Larino MA. Postsurgical refusal to eat: anorexia nervosa, bulimia nervosa
or a new eating disorder? A case series. Obes Surg.
2004;14(3):353–360.
3. Madan AK, Orth WS, Tichansky DS, et al. Vitamin and
trace mineral levels after laparoscopic gastric bypass.
Obes Surg. 2006 May;16(5):603-6.
23.Vemulapalli P, McGinty A, Lopes J, Goodwin A, Teixaira
J. Nutritional Deficiency in Laparoscopic Gastric Banding.
ASMBS 2004.
4. Flancbaum L, Belsley S, Drake V, et al. Preoperative nutritional status of patients undergoing Roux-en-Y gastric
bypass for morbid obesity. J Gastrointest Surg. 2006 JulAug;10(7):1033-7.
24.Singh S, Kumar A.cmE Wernicke encephalopathy after
obesity surgery: A systematic review. Neurology 2007 Mar
13;68(11):807-11.
43.Behrns KE, Smith CD, Sarr MG. Prospective evaluation
of gastric acid secretion and cobalamin absorption following gastric bypass for clinically severe obesity. Dig Dis Sci.
1994 Feb;39(2):315-20.
References
5. Kimmons JE, Blanck HM, Tohill BC, et al. Associations
between body mass index and the prevalence of low micronutrient levels among US adults. MedGenMed. 2006
Dec 19;8(4):59.
6. Wortsman J, Matsuoka LY, Chen TC, et al. Decreased
bioavailability of vitamin D in obesity. Am J Clin Nutr. 2000
Sep;72(3):690-3.
7. Flancbaum L, Belsley S, Drake V, et al. Preoperative nutritional status of patients undergoing Roux-en-Y gastric
bypass for morbid obesity. J Gastrointest Surg. 2006 JulAug;10(7):1033-7.
8. Madan AK, Orth WS, Tichansky DS, et al. Vitamin and
trace mineral levels after laparoscopic gastric bypass.
Obes Surg. 2006 May;16(5):603-6.
9. Ernst B, Thurnheer M, Schmid SM, Schultes. Evidence for
the necessity to systematically assess micronutrient status
prior to bariatric surgery. Obes Surg 2009 May; 19:66-73.
10.Buffington C, Walker B, Cowan GS Jr, Scruggs D. Vitamin
D Deficiency in the Morbidly Obese. Obes Surg. 1993
Nov;3(4):421-424.
11.Antozzi P, et al. Thiamine deficiency in an obese population
undergoing laparoscopic bariatric surgery. Surg for Obes
and Rel Dis. 2005 May:1(3): 264-65.
12.Riess KP, Farnen JP, Lambert PJ, Mathiason MA, Kothari
SN. Ascorbic acid deficiency in bariatric surgical population. Surg Obes Relat Dis. 2009 Jan-Feb;5(1):81-6. Epub
2008 Jul 9.
13.Singh S, Kumar A.cmE Wernicke encephalopathy after
obesity surgery: A systematic review. Neurology 2007 Mar
13;68(11):807-11.
Tips and Tricks in Successful Lap Band Insertion
Paul Super, Rishi Singhal Heart of England NHS Foundation
Trust, Birmingham, UK
16.Solá E, Morillas C, Garzón S, Ferrer JM, Martín J, Hernández-Mijares A. Rapid onset of Wernicke’s encephalopathy following gastric restrictive surgery. Obes Surg. 2003
Aug;13(4):661-2.
25.Grace DM, Alfieri MA, Leung FY. Alcohol and poor compliance as factors in Wernicke’s encephalopathy diagnosed 13 years after gastric bypass. Can J Surg. 1998
Oct;41(5):389-92.
26.Bonne OB, Bashi R, Berry EM. Anorexia nervosa following
gastroplasty in the male: two cases. Int J Eat Disord. 1996
Jan;19(1):105-8.
27.Renshaw AA, Rabaza JR, Gonzalez AM, Verdeja JC.
Helicobacter pylori infection in patients undergoing gastric bypass surgery for morbid obesity. Obes Surg. 2001
Jun;11(3):281-3.
28.Brolin RE, Leung M. Survey of vitamin and mineral supplementation after gastric bypass and biliopancreatic diversion for morbid obesity. Obes Surg. 1999 Apr;9(2):150-4.
29.Halverson JD. Micronutrient deficiencies after gastric bypass for morbid obesity. Am Surg. 1986 Nov;52(11):5948.
30.Mallory GN, Macgregor AM. Folate Status Following Gastric Bypass Surgery (The Great Folate Mystery). Obes
Surg. 1991 Mar;1(1):69-72.
31.Sheu WH, Wu HS, Wang CW, Wan CJ, Lee WJ. Elevated
plasma homocysteine concentrations six months after
gastroplasty in morbidly obese subjects. Intern Med. 2001
Jul;40(7):584-8.
32.Brolin RE, Leung M. Survey of vitamin and mineral supplementation after gastric bypass and biliopancreatic diversion for morbid obesity. Obes Surg. 1999 Apr;9(2):150-4.
33.Hocking MP, Davis, GL, Franzini DA, Woodward ER. Longterm consequences after jejunoileal bypass for morbid
obesity. Dig Dis Sci. 1998 Nov;43(11):2493-9.
34.Dixon JB, Dixon ME, O’Brien PE. Elevated homocysteine
pulled well below the band).
Gastric Fixation
(tunnellating) sutures.
We firmly believe that gastric
fixation sutures are extremely important to prevent slippage
and to ensure an optimal sized
micro-pouch. We use three such
sutures, all of which plicate some
of the fundus below the band
which is brought up over the
band to the left crus (1st stitch;
‘Birmingham’ stitch) and pouch
(2nd and 3rd stitch)[1]. Elimination of slippage by surgical technique will as a consequence significantly reduce the risk of late
Figure 1. A scatter plot of logit erosion versus logit slippage for 19 studies reporting erosion which is sometimes seen
outcomes after gastric banding that had a minimum of 500 patients and a 2-year many years later. Research carfollow-up period [2]. ried out in our unit demonstrates
this association (figure 1).
reveal the muscle surface. The prolapse is more likely to occur
peritoneal reflection of the angle through the band where there is a Attention to tubing and Port
of His is taken down to reveal the hiatus defect above the band. The Position
left crus. A similar 2cm vertical repair can be anterior hiatoplasty, Paying attention to detail towards
incision made in the myomesi- posterior crural repair or a combi- the end of the procedure has a large
influence on such matters as port
um over the left crus. A retro-gas- nation of both.
rotation, tubing fracture and port
tric dissector now passes easily in
infection. We always re-prep the
front of both crura via the open- Delivery of band
ings made in the muscle sheaths, The band is delivered into the ab- skin with disinfectant at this point.
so producing a tight posterior domen via the 12mm port. Most The band tubing should be delivtunnel for the band and prevents band types when empty will pass ered through the abdominal wall
posterior gastric prolapse. This via a 12mm port. The band is fas- via a 10mm port site. 3 or 4 nonalso means that when the band is tened over the perigastric fat pad absorbable sutures are placed on
delivered, there is an additional which is never resected. Units the sheath and the port fastened to
tissue layer protecting the poste- where excision of the fat pad is the rectus sheath port wound close
rior gastric wall from trauma dur- routine have a measurable early to the 10mm tubing exit wound.
infection and erosion rate prob- This facilitates easy replacement of
ing traction of the band.
able due to trauma during this the tubing into the abdomen. When
Hiatus hernia repair
manoeuvre. Where the fat pad is the adjustment port is attached to
Not infrequently a sliding hia- very large, we would always ad- the tubing it is extremely importus hernia is encountered and vocate a large size band and fix- tant to remove any axial twist in
this must be repaired as gastric ation high on the fat pad (fat pad the tubing so that there are no ax-
ial forces on the port which we believe is the most common reason
for subsequent port rotation. In
band types with a metal connector,
care must be taken to avoid angulation of this section in the abdominal wall which would produce tubing rupture 1-2 years later.
Wound Closure
Heamostasis should be secured
before closure – a detail which
probable reduces early wound infection.
Discharge from Hospital
Early mobilization is encouraged
by same day discharge in more
than 50% of our patients. Insulin
treated diabetics and those suffering sleep apnoea stay overnight.
40mg Enoxaparin is administered 2 hours post op and daily
whilst in hospital.
Follow-up
Lifelong follow-up needs to be
available and a team is required to
deliver this. Too tight a band will
eventually result in oedema and
over-restriction, with an increased
risk of pouch dilatation and gastric
wall prolapse. Having a low threshold for radiology will help in early
detection of band related complications should they still develop.
References
1.Singhal R, Kitchen M, Ndirika S, Hunt K, Bridgwater S, Super P (2008) The "Birmingham
stitch"-Avoiding Slippage in Laparoscopic Gastric Banding. Obes Surg 18:359-363
2.Singhal R, Bryant C, Kitchen M, Khan KS, Deeks
J, Guo B, Super P Band slippage and erosion
after laparoscopic gastric banding: a meta-analysis. Surg Endosc 24:2980-2986
44.Moize V, Geliebter A, Gluck ME, et al. Obese patients have
inadequate protein intake related to protein intolerance up
to 1 year following Roux-en-Y gastric bypass. Obes Surg.
2003;13(1):23–28.
45.Clinical Issues Committee of the American Society for
Metabolic and Bariatric Surgery Updated position statement on sleeve gastrectomy as a bariatric procedure.
Surg Obes Relat Dis. 2010 Jan-Feb;6(1):1-5. Epub 2009
Nov 17.
46.Hakeam HA, O'Regan PJ, Salem AM, Bamehriz FY, Eldali AM. Impact of laparoscopic sleeve gastrectomy
on iron indices: 1 year follow-up. Obes Surg. 2009
Nov;19(11):1491-6. Epub 2009 Jul 15.
47.Toh SY, Zarshenas N, Jorgensen J. Prevalence of nutrient deficiencies in bariatric patients. Nutrition 2009 NovDec;25(11-12):1150-6. Epub 2009 May 31.
48.Aarts EO, Janssen IM, Berends FJ. The gastric sleeve:
losing weight as fast as micronutrients? Obes Surg. 2011
Feb;21(2):207-11.
49.Gehrer S, Kern B, Peters T, Christoffel-Courtin C, Peterli
R. Fewer nutrient deficiencies after laparoscopic sleeve
gastrectomy (LSG) than after laparoscopic Roux-Y-gastric
bypass (LRYGB)-a prospective study. Obes Surg. 2010
Apr;20(4):447-53. Epub 2010 Jan 26.
50.Makarewicz W, et al. Wernicke’s Syndrome after Sleeve
Gastrectomy. Obes Surg. 2007 May;17(5):704-6.
51.Mahlay NF, Verka LG, Thomsen K, Merugu S, Salomone
M. Vitamin D status before Roux-en-Y and efficacy of prophylactic and therapeutic doses of vitamin D in patients
after Roux-en-Y gastric bypass surgery. Obes Surg. 2009
May;19(5):590-4. Epub 2008 Oct 11.
Bypass vs.
banding
Continued from page 1
term complications (41.6% vs.
19%; p<0.001) and more reoperations (26.7% vs. 12.7%; p<0.001)
after gastric banding.
In conclusion, the authors said
“At the present time, Roux-en-Y
gastric bypass seems clearly superior to gastric banding when treating
morbidly obese patients.”
However, in a press release, Allergan, who market the Lap-Band
gastric banding system, said that the
study included ’specific weaknesses’
including:
n Patients receiving an older version of the banding system
(which is no longer used) and
an outdated insertion method
was used which has also been
replaced since the patients in
the study had the procedures;
and
n A failure by the researchers to
include many complications
that have been associated with
bypass surgery in their analysis, including small bowel obstructions, osteoporosis, anaemia and long-term nutritional
complications.
“Although we applaud the high sixyear follow-up rate of these bariatric
patients, it would be inappropriate to
draw conclusions regarding the relative risks and benefits of either procedure based on this single study,”
Allergan said in the statement.
Advert
8 BARIATRIC NEWS
ISSUE 10 | January 2012
Bariatric surgery in…Qatar
Michel Gagner
On November 14th 2011, the International Diabetes Federation launched the 5th edition of the ‘Diabetes Atlas’ to coincide with
World Diabetes Day. The new figures indicate that the number of people living with diabetes is expected to rise from 366 million in 2011
to 552 million by 2030. Nowhere is the increased expected to be more
marked than in the Middle East and North Africa Region. Currently,
32.6 million people (9.1% of the population) have diabetes and this
number is expected to double in less than 20 years. By 2030, 59.7 million people (11% of the population) will be living with diabetes with
more millions undiagnosed. Moreover, six out of the world’s top ten
countries with the highest prevalence of diabetes are in the region. The
new regional figures also show that the prevalence of type 2 diabetes
in the region for younger age groups is substantially higher than the
global average.
Qatar and obesity
According to International Association for the Study of Obesity’s
2012 statistics, Qatar ranks sixth globally in the prevalence of obesity and has the
highest rate of obesity (36.5%) among boys (and 23.6% of girls)
aged 12–17 Qatar is also ranked 5th for having the highest percentage
of people between 20 and 79 with diabetes. Currently 16% of the population is diabetic.
The Hamad Medical Corporation (HMC) is the premier non-profit
healthcare provider in Doha, Qatar. The HMC has an expressed mission to provide the best quality care for all patients irrespective of nationality, in order to create ‘Health For All’ healthcare programme,
as pledged by the State of Qatar. Providing a ‘Health For All’ healthcare programme has resulted in a huge investment in all areas of public health, including diabetes and obesity. Part of the fight against these
debilitating condition will be by a team of bariatric surgeons and specialists at HMC, headed by Dr Michel Gagner (Professor of Surgery
in Montreal, Canada).
“I first came to Qatar when I was Chief of laparoscopic Surgery
at Cornell University in New York (2003-07), and I was invited by
Dr Abdulazim Abdul Wahab Hussain (now Consultant General Surgeon and Medical Director of Al-Ahli Hospital in Doha, Qatar) to assist him with complex cases. I was visiting Qatar two or three times
each year,” explained Gagner. “After Dr Hussain left HMC, the hospital was looking to re-engineer the bariatric programme and I arrived
in February 2011 with the objective of re-establish the HMC’s bariatric programme as a centre of excellence in the region.”
There are many reasons for such high rates of obesity in the country including a lack of exercise and poor diets, as well as cultural traditions. “Lifestyle choices have the greatest impact on a patient’s health.
We need to educate the population on the consequences of not exercising regularly and inform people of the dangers of eating foods that are
high in calories and carbohydrates, and of the benefits of eating fruits
and vegetables,” he said. “These choices are more influential than a
person having genetic pre-disposition to obesity.”
There are also cultural influences as in Qatari society food is often
consumed communally, making it difficult to ensure proper portions
and it is also perceived as normal within society to be obese, with no
stigma associated with obesity.
In the 18 months Gagner has been operating in Qatar, the HMC
team have managed to train local surgeons and specialised bariatric team to perform several bariatric procedures. In fact, the HMC
team have performed over 500 procedures with a zero mortality rate. With obesity and diabetes rates some of the highest in the
world, he argued that the population required and deserved a dedicated bariatric programme. “In our team there is one senior consultant, one junior consultant, a specialist with a couple of finishing
general surgery residents, who are probably going to join the bariatric programme. We are not the only hospital in the region performing bariatric surgery, but I believe we are performing more complex
cases, such as revisions.”
Different procedures
As well as a lack of education and awareness of the causes of obesity, he acknowledged that there is also a general lack of education in
the general population about obesity and in particular bariatric surgery. As a result, most people thought that the Lap-Band was the procedure of choice however, the procedure does have a high rate of failure in the region due to poor patient compliance (poor exercise and
dietary compliance results in the patient returning to hospital to have
their band adjusted).
“As a result, each day we removed bands as they just do not have
the desired effect. The patients eat a lot, become ill and have regained
Persian
Gulf
Doha
QATA R
Qatar
SAUDI
ARABIA
weight,” he explained. “Therefore, there has been a big change in the
types of procedures we perfrom. I think in the last year there have been
two Lap-Band procedures the rest were either bypass or sleeve gastrectomy. In fact, over the last few months we have seen more sleeve
than bypass procedures.”
Sleeve gastrectomy is preferred due to the compliance of the patient to the post procedure regime. Bypass requires supplements and
patients do not always stick to this regime, whereas sleeve the intestine routing is not affected and mineral absorption stays the same.
Gagner explained that there is also the consideration of pregnancy.
“If young women are planning a pregnancy in the future then bypass
will reduce the amount of folic acid produced and could cause certain
neurological deficiencies for the child so we would strongly advise
against bypass.” Although sleeve gastrectomy can cause some vitamin 12 deficiencies in certain cases, it does not have a detrimental effect on the mother or child.
He emphasized that there is a lot to do in terms of educating the patients in regard to other types of bariatric procedures, the associated
risks and complications (leaks and bleeding), as well as dietary, exercise and other life-style changes required.
“We have to make patients aware that although bariatric surgery
can resolve metabolic problems such as diabetes, if they do not comply with their dietary regime they may develop micro-nutrient deficiencies (iron, calcium),” said Gagner. “There is also need to create
and develop bariatric patient support groups so they can help each other before and after surgery, as well as the more general need to educate
the public about the importance of regular exercise.”
Children
Of course bariatric surgery for children should be a last resort, but
Gagner described a vicious cycle in which adolescents unable to lose
weight become withdrawn, trapped, bullied, do not play with other children, spend more time on computers and less time exercising.
“When we speak about bariatric surgery for children, then we have an
obvious problem,” he lamented. “More needs to be done to address
children’s consumption of breakfast cereals, snack foods, dairy products, carbonated beverages, chilled desserts and restaurant foods.”
Registry
There are currently over 1,000 patients on the waiting list for bariatric surgery at the HMC and given the volume of procedures, the HMC
is looking at collecting patients’ data in a clinical database that will
be populated through monitoring their outcomes, treatment efficacy,
safety and complications.
“We are looking to employ a registry in Qatar similar to the one
utilised by bariatric surgeons in the UK. This was a well designed and
developed database that permitted surgeons to collect their data prospectively. If we were to adopt such a system it would allow us to identify outcomes, complications and failures and see how we could improve,” he added. “We could also match our outcomes with the UK
data and see how we compare. There is also the possibility of putting
the data into a larger international registry and see how bariatric surgery in Qatar compares country to country and region to region, to the
benefit of surgeons and patients.”
UK report shows disparities in bariatric surgery provision continue
According to a new report from
the UK’s NHS Information Centre, there
are still inequalities in bariatric care depending on a patient’s location, rather than
need. The report entitled, ’statistics on
Obesity, Physical Activity and Diet: England, 2012’, presents a comprehensive picture of obesity in the country by combining new analyses on the health outcomes
of people who are overweight or obese
with a summary of already published diet,
exercise and weight-related information.
The findings confirm earlier reports
that whether a patient receives bariatric
care is ultimately a ‘postcode lottery’.
For example, data reveals that East Midlands had the highest rate of weight-loss
stomach surgery with 32 procedures for
every 100,000 of the population, compared with the North West had the lowest rate of weight-loss stomach surgery
with six procedures for every 100,000
of the population, followed by the East
of England and South Central with nine
procedures for every 100,000. These
significant regional variations in hospital admissions shows that patients in the
East Midlands are almost six times more
likely to gain access to operations compared with those in the North West and
twice as likely as those in Yorkshire.
In addition, the report also showed
that there had been a slight increase in the
number of bariatric procedures, although
by not the headline figure of 12 per cent
some news sources were reporting. The
number of hospital procedures for bariatric surgery rose to 8,087 in 2010/11 from
7,214 in 2009/10, a rise of 12 per cent.
However, due to changes in procedure
coding practices it is now possible to see
how many procedures were for the maintenance of an existing band. There were a
total of 1,444 such procedures in 2010/11,
meaning the actual numbers of procedures was 6,643, although whether this is
an increase from 2009/10 is unknown. In
Yorkshire, it was noted that the numbers
of patients undergoing surgery decreased
from 866 in 2009/10 to 837 in 2010/11.
“The regional variations in admissions
and surgery are very concerning. Having
examined the variations, the forum believes that they illustrate a postcode lottery which still exists in England. It is
deplorable,” said Tam Fry, from the Na-
Tam Fry
tional Obesity Forum. “Some primary
care trusts abide by National Institute for
Health and Clinical Excellence guidance
in offering bariatric operation to obese patients but others flout it by making it virtually impossible to qualify for the surgery.”
The report also shows that hospital admissions with a primary diagnosis of obesity rose over the past decade
from 1,054 to 11,574. In 2010/11, they
rose 1,003 from 10,571 in 2009/10. The
number of female admissions with a primary diagnosis of obesity (8,654) was
almost three times higher than male admissions (2,919) in 2010/11. Of the regions, the North East had the highest rate
of admissions with a primary diagnosis
of obesity (40 per 100,000 of the population), followed by the East Midlands
(36 per 100,000) and London (35 per
100,000). The South West, South Central and North West had the lowest rates
of admission with 14 admissions with a
primary diagnosis of obesity for every
100,000 of the population.
On prescriptions, the report shows
that 2010 saw the first recorded decrease
in seven years in the number of prescription items dispensed to treat obesity. In the year 1.1 million items were
dispensed, a 24 per cent fall on the previous year when 1.4 million items were
dispensed. The decrease could reflect the
withdrawal from use of two of the three
drugs reported on which had been used
to treat obesity (sibutramine in 2010 and
rimonabant in 2009).
“The report charts the growing impact
of obesity on both people’s health and
NHS resources. It also examines changes
in physical activity and diet,” said Chief
Executive of the NHS Information Centre Tim Straughan. “Those working in
this field may want to examine closely the
findings of the report, including the significant regional variations that appear to exist in both the admissions for obesity and
those for weight-loss stomach surgery.”
In November 2011, UK Health Secretary Andrew Lansley announced a “national ambition” to bring down obesity levels by 2020, although he ruled out
regulating against the food industry (see
page 10) and urged people to take responsibility for their own health.
A Department of Health spokesman
said: “We want people to live healthier
lives so they do not need to resort to surgery. We are working with charities, local government and industry to make it
easier for people to make better choices.
However, campaigners seeking greater
action and increased resources claim the
Government campaign to tackle obesity is
woefully inadequate and amounts to little
more than telling people to eat less.
BARIATRIC NEWS 9
ISSUE 11 | March 2012
Coffee time with Antonio Torres
Bariatric News talks to Professor Antonio Torres,
current president of the International Federation for
the Surgery of Obesity and Metabolic Disorders.
Why did you decide to get
into medicine?
I was born in Malaga, in a little city
close to the sea in the south of Spain,
and we were looking for work to do
in something special. There was no
history in my family of medicine. I was
dealing with this situation in terms of
treating people, helping people.
So you always knew you
wanted to be a surgeon?
Yes. When I was at medical school,
to decide to become a surgeon, I was
attracted by a very nice professor,
Professor A. Suarez . At the time, I
was primarily thinking of becoming a
pharmacologist. Afterwards I decided
to become a surgeon, after this
professor convinced me.
Why a bariatric surgeon?
It was a long history! I only decided
this in 1990. We were asked by a
very good friend of mine, the chief of
the *Endocrinology** Department –
he had some problems with superobese patients. We began to operate
on those patients in an open way –
no laparoscopy. From then until now,
things have been going on. We began
doing the Scopinaro´s procedure –
this is a different procedure, a very
aggressive procedure for super obese
patients. Finally, around the 1990s,
laparoscopic surgery began in terms of
doing lap-cholecystectomy and so on,
and so we go through this approach of
laparoscopic bariatric surgery.
Who would you say
has been your greatest
influence on your career?
Many people, I think. In Spain, there
are many surgeons – Professor
Suarez, my chief of surgery,
influenced me. But overall, American
professors there influenced me,
because I was doing a fellowship,
spending a year and a half in different
universities all over the States, learning
laparoscopic surgery. So there were
many professors there, teaching me
laparoscopic bariatric surgery. There
were many people!
Can you tell us about one
of your most memorable
experiences in your career?
There are three of them. First, when I
got my PhD, it was a very memorable
day for me, because it was the end of
a very large, difficult way of becoming
a philosophical doctor. The second
was when I became a professor of
surgery – the day was the 29th of
February 2000. When I was nominated
as president of IFSO, in Hamburg, last
September, it was memorable.
Can you tell us a bit about
your work as president of
IFSO?
It’s very complicated to explain –
you have to be in contact with many
surgeons in many institutions. Our
federation has four chapters – the
North American chapter, including
USA and Canada, the Latin American
chapter, European chapter, and the
Asian Pacific chapter. I have to be in
contact with every chapter, and every
month we have a conference call,
trying to deal with all our objectives
and our issues. This is a lot of work,
answering many, many emails and
having many commitments, and the
most important thing, I think, is trying
to bring forth the role of the surgery
in dealing with treating patients
with obesity. I used to have a lot of
commitments in terms of attending
meetings in different countries. It’s
tough work, but very nice!
What’s the most important
thing you’ve done as
president of IFSO?
I got the presidency in September,
and I’m very proud of solving a very
important problem we had with our
journal, Obesity Surgery. We had a
very important disagreement in terms
of our next step in this sense, and I
think to solve this problem is going to
be a very tough issue, and I’m very
proud of having to get a resolution.
How do you think bariatric
surgery is going to develop
over the next 10-15 years?
bariatric surgery. The main reason is
because we have to offer the society
a very safe surgery, and a surgery with
as low a complication rate as we can
with no morbidity – no mortality at all
with our patients. I think it’s going to
be very important to prepare as many
units as we can, but at a very highquality level.
Away from surgery, when
you’re not working, how do
you like to relax?
I am very lucky because I have very
good friends. Of course, my wife and
my family are essential for my work
I’m sure that it’s going to be a very, very and for my life; my wife is always
important increase in bariatric surgery
there for support. We enjoy every
procedures all over the world, because minute we have free together with my
now we have a lot of information about three kids. I have two sons and one
how to manipulate the GI tract in a
daughter. But nevertheless we are
very low-invasive way, laparoscopically. also lucky, because we have three
Manipulating the GI tract has a lot of
couples we are very good friends
beneficial influence in improving obesity with – eight people in total – we move
and improving metabolic disorders
during weekends and so on almost
associated with it, like diabetes,
all together, having dinner and so on.
hypertension, hypercholesterolemia,
Friends and family, I’d say, is the best
and other metabolic problems that are way. Of course, I like jogging, I like
associated with obesity.
sports, I used to run every day and my
free time is dedicated to that kind of
What do you think the most thing. I’d say in summary: family first,
important lesson is that you friends second, and sports third!
can teach young bariatric
surgeons?
It’s very important to train people – it’s
essential for the future development of
10 BARIATRIC NEWS
ISSUE 11 | March 2012
The 3rd Annual Scientific Meeting of the British Obesity and Metabolic Surgical Society
The 3rd Annual Meeting of the British Obesity and Metabolic Surgical Society
(BOMSS) was held at the Royal Marriott Hotel, Bristol, UK, 19-20th January
2012. The meeting was attended by 350+ delegates with a specific interest in
bariatric surgery. Topics discussed included, commissioning, training, clinical
trials, obesity economics and international perspectives.
As well as a multi-disciplinary UK-based faculty, the meeting also welcomes
international speakers including the president of IFSO, Professor Antonio Torres (see page 9), and president-elect of the OSSANZ, Professor Wendy Brown.
As well as lectures and keynote addresses, there was also an array of high
quality abstracts and poster presented.
The organisers expressed their gratitude to the exhibitors for supporting
the meeting.
Obesity expert
slams government
and food industry
Professor Philip James, President of
the International Association for the Study of Obesity, has delivered a scathing judgement on the UK
government’s response to the obesity epidemic.
James laid out what he saw as the British government’s public health policy failings, concentrating
on British Health Secretary Andrew Lansley’s relationship with the food industry and a governmental
belief that obesity is a matter of personal, rather than
societal, responsibility.
However, the UK risked “losing out” unless the
government adjusted its attitude towards battling
obesity. “I think that we’re in danger of something
bad”, he said.
The new group replaces the old Obesity Advisory Group, which Lansley disbanded in November 2011. At the time, Oxford epidemiologist Klim
McPherson, who was a member of the group, told
the Guardian “too many of us were giving critical
voice to the responsibility deal and its effectiveness. They ignored us, then rather than ignoring
us, they disbanded us.”
“Businesses can make an enormous contribution,”
said James. “They are said to be the cause; they could
be part of the solution. The question is whether they
should be involved in the actual policy.”
Responsibility deal
Lansley, James said, has violated the World Health
Organisation’s principle that conflicts of interest Food Standards Agency
should play no role in policy making, by involv- James also expressed concern for Lansley reducing
ing senior industry figures in his UK Responsibility the powers of the Food Standards Agency (FSA),
which was created based on James’ guidelines to reDeal advisory group.
Lansley created the Responsibility Deal as an move food safety from direct political oversight.
The FSA developed the “traffic light” food lainitiative to involve the food and drink industry in
reducing obesity through voluntary pledges to cre- belling system, which James described as “the most
dramatic, brilliant system – in all evaluations it
ate healthier products.
Representatives from companies such as Uni- comes out best”. Under Lansley, however, responlever, Tesco, Mars, and Diego, as well as interest sibility for nutrition, including food nutrition labelgroups like the Wine and Spirits Federation, the ling, was moved to the Department for Health, placBritish Retail Consortium, the Food and Drink Fed- ing it back under direct ministerial control.
eration, and the Advertising
Association, says James, are
“organising policy” to deal
with obesity through their
presence on the advisory
group.
Their presence outnumbers representatives from
public health groups, including the Faculty of Public Health, Cancer Research
UK, Which, the National
Heart Forum, nad the Local
Government Association.
Professor Philip James,
The promotion of indusPresident of the International Association for the Study of Obesity
try to advisory roles, he said,
Philip James
ty drugs] Rimonabant and Sibrutamine have been
withdrawn.”
“For decades, doctors and epidemiologists have
actually been assigning no significance to obesity.
If you take blood pressure and cholesterol into account then what does obesity do that is extra and
special to cardiovascular disease?”
GPs, James said, feel “completely inadequate”
in facing the epidemic, believing themselves unable to cope.
James saw these factors as directly affecting government policy. “You’ve got to remember that when
you talk to politicians, they think
like ordinary citizens. And so they
think that, as the PM said before the
getting
election, it’s personal responsibility.”
“Can we start making progress and
obesity rates down? Yes. We might be able to
shame the UK into doing things. Doctors, by
getting organised and being coherent, can
[have an effect], not just for the benefit of
the few, but the many.”
minimised the chance of the
government adopting initiatives like taxes on fatty
foods and tighter regulations on advertising, which
could have a dramatic effect on levels of obesity in
the UK, but would be likely to harm the profits of
food companies.
“British Retail Consortium have, on a personal
basis, attacked every proposal we’ve produced for
20 years,” said James. “Tesco is the only company that refused to meet me as I tried to compose
the Food Standards Agency. Wine and Spirits Federation are a splendid pro-health organisation. Food
and Drink Federation lambasted me for four hours
with 14 chief executives when I said 10 years ago
we should look at whether marketing has any effect
on children’s behaviour. I had a ding-dong battle
with the Advertising Association in a cabinet minister’s discussion as to what should happen during the
last government.”
NHS shakeup
James had gloomy forecasts for controversial proposed changes to the
organisation of the NHS. “What I’m
predicting is chaos in the Health Service with battles, reorganisation,” he
said. “If you need coherent thinking,
it’s not going to come in my view for
quite a long time.”
The changes were announced
in a white paper, “Equity and Excellence: Liberating the NHS”, released in July 2010. In that document, noted James, obesity was not mentioned once.
“It’s not on the agenda,” said James, “because
it’s an extraordinarily difficult societal question. In
the economic crisis, they think it’s more important
to back industry, and say to you: stay thin.“
“The World Health Organisation have said unofficially that this is the biggest setback to public
health,” said James, “because [the FSA] was a clarion call for governments throughout the world.”
“We’ve been talking to the Government for about
20 years about the fact that public health should not
be in the Department of Health,” he said. “It should Coordinated initiatives can battle obesity
be in the Cabinet Office, looking at all aspects of epidemic
In a second Keynote presentation, James claimed
government.”
that rising obesity levels could be stemmed through
Failure of practitioners
coordinated programmes and effective use of new
James also directed fire at what he saw as the med- data. He said that nationwide programmes in Euroical profession’s failure to come to grips with the pean countries had already worked to reverse rates
epidemic. “We as doctors have never put it on the of obesity and diabetes. A combinatory approach
map,” he said. “It’s also become a problem be- including regulation, taxation, and intervention in
cause in medical terms, people are defeatist, apart groups recognised as high-risk could have a real effrom [when it comes to] bariatric surgery. [Obesi- fect on rates of obesity.
Contradictory evidence
Obesity rates have doubled or even tripled in many
countries since 1980. However, said James, some evidence suggests that rates are beginning to stabilise.
In 2008, the Centre for Disease Control in the USA
said that the epidemic in American had stopped; between 2000 and 2008, there was a slight median increase in male obesity, and no increase in women
(Flegal KM et al, JAMA 2010;303: 235-241).
Despite this, said James, diabetes rates are expected to continue to rise. One study (Brown et al,
February 2010: National Heart Forum) has projected that more than 6.6% of the UK population will
have diabetes by 2046. “There isn’t a country in the
world that is going to be able to treat diabetes longterm,” said James.
James also voiced his fears of an “intergenerational amplification” in obesity rates. One study
(Gale et al, J Clin Endocrinol Metab 2008;92:30943911) found a positive correlation between a mother’s pre-pregnancy BMI and her child’s resultant
fat mass index (FMI). The effect was particularly
pronounced in girls: the average FMI for girls with
mothers with BMI between 20.3 and 21.9 was 1.8;
this rose to 2.4 when the mothers’ BMI rose above
24.3 (p < 0.001).
This could lead to an effect whereby current levels of obesity could feed into increased levels of
obesity in the next generation.
European initiatives
James did, however, offer hopeful evidence that these
trends could be reversed. Effective intitiatives, he
said, worked through raising the price of fatty food,
limiting its marketing, or limiting its availability.
Countries in Europe have begun to introduce
initiatives along these lines. Denmark, Austria and
Switzerland have banned trans fats, while Finland
and Hungary have introduced taxes on foods with
high fats, salts and sugars.
In France, the government has taken total control of food and drink in schools, banned marketing
to children, and restricted marketing of foods high
in fat, sugar and salt unless it is taxed and marketed
with a health warning. In 2000, 18.1% of children
were overweight and 3.8% were obese. By 2007,
this had dropped to 15.5% and 2.8% respectively.
Finland’s FINRISK system identifies groups
who are at risk of developing diabetes by observing factors including weight and family history, and
engages them in detailed intervention, encouraging
them to live a heathier lifestyle. Over a period of
five years, says James, they have managed to shift
the distribution of obesity in Finland.
James was less optimistic about the UK government’s attempts to tackle obesity, which are mostly pinned on a voluntary “Responsibility Deal” with
food manufacturers to encourage them create healthier products and inform customers on the risk. “Most
of the measures that have been taken, a lot of them
have been rescinded in the last few months,” he said.
However, he encouraged the British bariatric community to engage in a public debate. “Can
we start making progress and getting obesity rates
down? Yes. We might be able to shame the UK into
doing things. Doctors, by getting organised and being coherent, can [have an effect], not just for the
benefit of the few, but the many,” he said.
The 3rd Annual Scientific Meeting of the British Obesity and Metabolic Surgical Society
BARIATRIC NEWS 11
ISSUE 11 | March 2012
BY-BAND trial hopes
to impact UK surgery
The chief investigator of a three-year trial,
which plans to determine whether gastric bypass
surgery leads to better quality of life and weight loss
than gastric, banding, is hopeful that the study will
have an “enormous impact” on bariatric practice.
Professor Jane Blazeby, professor of surgery at
the University of Bristol, said she hoped that if her
study, named “Gastric BYpass or adjustable gastric BANDing surgery to treat morbid obesity” (BYBAND; ISRCTN00786323), confirms its hypothesis
when it publishes its results it would inform future
NHS commissioning and potentially influence international bariatric practice.
The BY-BAND trial, has received more than
£2.8m in funding from the National Institute for
Health Research Health Technology Assessment
Programme and will begin recruitment in April this
year, plans to establish two points: firstly, wheth-
age BMI (47.5 ± 5.5 vs 45.5 ± 5.4; p = 0.01) between
the bypass and band cohorts, meaning that differences in outcome could be attributed to differences between the patient groups instead of the differences in operations.
It also allowed patients to cross over between
cohorts and did not subsequently undertake an intention to treat analysis, further compromising the
trial’s randomisation. “At this point, there’s almost
no point doing a long-term analysis,” said Blazeby of the study.
While non-randomised studies have produced
a wealth of data, she said, the fact that patients
were deliberately chosen for different operations
means that differences between patients confounds any potential conclusions as to the two operations and their efficacy.
The lack of firm evidence as to the superior procedure has led to enormous variation in the type of
operations carried out, with the decision often coming down to the surgeon’s preference. “There’s variation in the rates between centres in which the procedures are done,” said Blazeby “It’s not as if all
surgeons know which one to select; there’s just this
massive variation.”
Methodology
BY-BAND aims to randomise around 726 patients,
into either the LAGB or RYGB cohorts. An initial pilot phase will take place at two hospitals in Taunton
and Southampton; once this is complete, the trial
will be extended to six further hospitals. The randomisation procedure, which will conceal the patients’ allocation from the investigators, will reduce
the opportunity for selection bias.
The investigators decided to exclude sleeve
gastrectomy from the trial as there is currently insufficient long and medium term data on its use, and
because it currently only makes up around 10% of
bariatric procedures in the UK. The fact that the surgical technique is still changing due to the procedure’s relative novelty also means that it is not suitable for a long-term comparative study.
Jane Blazeby
Patients will be selected for BY-BAND if they
are:
er bypass leads to better quality of life than banding, and secondly, whether it is at least as good as
banding for weight loss. If both are met at three
years after randomisation, then the investigators
will conclude that bypass is the superior operation.
“If we can achieve what we hope to achieve – if
we can really answer the question as to which operation is the most effective and cost-effective – it’s
going to have an enormous impact,” said Blazeby.
“It will put obesity surgery right up there on the political agenda.”
n
Over 18 years of age;
n
Referred for bariatric surgery according to NICE
guidelines;
n
Willing to receive intensive management in a specialist obesity service;
n
Fit for anaesthesia and surgery; they are committed to follow-up and able to complete quality of
life questionnaires; and
n
Able to provide written informed consent.
“We desperately need to know”
The investigators initiated the trial after observing a
lack of good comparative evidence on the two procedures. “We desperately need to know which operation is better, because we need more operations
that are cheaper,” said Blazeby. “We think that BYBAND will provide those answers.”
A systematic literature review carried out by the
investigators identified 26 randomised clinical trials
comparing different bariatric procedures, only two
of which directly compared gastric bypass to banding. They also found methodological issues in those
that were carried out, making their randomisation
questionable.
In one well-known study (Nguyen et al, Ann
Surg 2009; 250: 631-641), there were statistically
significant differences in both the average age (41.4
± 11 years vs 45.8 ± 9.8 years; p < 0.01) and aver-
Patients will be excluded if:
n
They have a history of gastric or obesity surgery;
n
They have a large abdominal ventral hernia;
n
They have a hiatus hernia more than 5cm;
n
They are pregnant;
n
They have Chron’s disease;
n
They have liver cirrhosis and portal hypertention;
n
They have systemic lupus erythematosis;
n
They have a known silicone allergy; or
n
If their surgeon is unwilling for the patient to be
randomised.
The two primary outcome measures are quality of
life, measured by their EQ-5D health state score at
three years, and weight loss, measured by the proportion achieving loss of greater than 50% excess
weight at three years. The investigators will also be
studying a number of secondary outcomes, including time between 50% EWL and first relapse, resource use, nutritional blood tests, binge eating behaviour, adverse health events, and resolution of
co-morbidities.
Commissioners need
data and education
Many NHS commis- attempt “all appropriate non-surPrimary Care Trusts [PCTs]
sioners are keen to encour- gical methods” first.
differ in their rates of bariatric
age more bariatric surgery, but
they “need help” from medical societies to commission the
right operations for the right patients, according to one commissioning manager.
Mike Lander, Senior Commissioning Manager at the South
East Coast Specialised Commissioning Group, said that while
bariatric surgery has been proven
to be both effective and cost-effective, commissioners feel they
don’t have the data that would allow them to refer patients to optimal procedures and maximise
value for money.
Lander gave his talk to explain why only around .3% of eligible patients are referred to bariatric surgery every year.
“I think we are serious about
bariatric surgery,” said Lander.
“We just don’t show it very well,
and we need to learn how we can
show it in a better way.”
Operational choices
While acknowledging that higher
levels of bariatric surgery would
lead to lower long-term costs and
a healthier population, Lander
highlighted the need for cost-effective operations. “We physically cannot give everyone bariatric
surgery,” he said. “So who’s going to benefit the most?”
The National Institute for
Clinical Excellence (NICE) offer
guidelines for bariatric surgery,
which Lander referred to as “the
best guidance around”. However,
he said, many of their guidelines
are not specific enough for commissioning, including advice to
“What constitutes appropriate
non-surgical interventions? I don’t
know what the answer is. You
have to try everything, but what is
everything? Cabbage diet for two
years? Is it running the London
marathon twice? What constitutes
failure to lose weight? It depends
who you ask. For a patient anything less than going from BMI 50
to 28 is probably a failure.”
The range of surgical options
available also presents a problem
to commissioners, Lander said. “I
was at a conference where three
eminent surgeons all said theirs
was the best kind of surgery. One
said band, one said bypass, and
one said sleeve. You’ve now got
new things – TOGA, POSE, Endo-Barrier, FOBI-ring. I have no
idea what to do. Should I just say,
fine, do what you like? Can I just
buy the cheapest?”
“We can’t differentiate on a
cost basis between types of surgery. [Gastric banding] is in the
short term substantially cheaper than [bypass], but in the long
term, are the outcomes the same
for both? We need to continue to
work on that.”
Differing support
Commissioners vary in their support of bariatric surgery. “Up until four years ago, I’d never heard
of bariatric surgery,” said Lander.
“Up until three years ago, I fundamentally disagreed with bariatric surgery as an intervention
– like most of the population,
I thought obesity was the patient’s own fault. I’m not fat, why
should you be?”
surgery commissioning. Each decides its own priorities for healthcare spending, and while many
follow guidelines supplied by the
National Institute for Clinical Excellence, they are not mandated
to do so. Lander noted that there
is no correlation between the rate
of obesity within a PCT’s area
and the number of operations that
the PCT commissions.
Bariatric Surgery is currently defined as a NHS Specialised
Service. Commissioning of the
service is not consistently carried
out by the by the regional Specialised Commissioning Groups
[SCGs], however, remaining instead within the PCT’s budget.
PCTs and SCGs will cease to
exist from April 2013, being replaced the NHS Commissioning
Board, and local Clinical Commissioning Groups. It has not
yet been announced who will be
commissioning bariatric surgery.
Lander’s PCT area has a
slightly higher rate of surgery
than the UK average, at .8%.
However, he said, this was also
limited by another factor: the patients themselves. “It’s not because we’ve done anything to
stop them coming in,” he said.
“We’ve followed the NICE guidance; they’re self-presenting.”
The solution, says Lander, is
to gather more knowledge, and to
better share the knowledge that already exists. “We have to educate
the commissioners,” said Lander.
“We have to educate society. We
have to educate them that obesity’s a problem, and that one of the
solutions is bariatric surgery.”
12 BARIATRIC NEWS
ISSUE 11 | March 2012
XVI World Congress
of 3rd
the International
Federation
for the
of Obesity
andand
Metabolic
Disorders
The
Annual Scientific
Meeting
of Surgery
the British
Obesity
Metabolic
Surgical Society
Vitamin deficiencies “easily avoided”
Vitamin deficiencies in bariatric patients
could be easily prevented with more research and greater use of existing knowledge, according to a nutritional expert.
Nutrition expert Erlend Aasheim of the Department
of Public Health and Primary Care, University of Cambridge, said that symptoms of vitamin deficiencies were
often evident in bariatric patients, but should be easily avoided with careful observation and the use of dietary supplements.
The absorption of nutrients in bariatric patients is
complex, said Aasheim. An operation may bypass the
primary absorption point for a mineral in the GI tract,
or factors can interact, and a deficiency in one nutrient
can lead to deficiency in another.
Existing studies into malabsorption are methodologically problematic, for a number of reasons, said Aasheim. Populations with different characteristics and
diets have been used, surgical methods vary, supplementation regimens and levels of adherence weren’t reported, and there is no standard protocol for changing
the supplement regimen on review of blood tests. Results have accordingly differed substantially.
“It’s extremely difficult to make sense of these studies, in my opinion,” said Aasheim.
However, one study which Aasheim described as
“one of the best” (Gasteyger et al, Am J Clin Nutr 2008;
87: 1128-33) did provide evidence that a multivitamin
is not sufficient for most patients to avoid malnutrition.
The study gave 137 gastric bypass patients a single
multivitamin each and monitored their nutrient levels
at six-month intervals. Patients with low vitamin levels
were given top-up supplements.
After two years, nearly all of the patients in the study
were using supplements. By the end of the study, 80%
of patients were deficient in vitamin B12, 60% were de-
Erlend Aasheim
ficient in iron, 60% in calcium and vitamin D, and 45%
in folic acid.
Following this study, Aasheim recommended vitamin B12 as a baseline supplement, as most patients are
going to become deficient without it.
Compensating
In many cases, said Aasheim, supplementation and other effects can actually lead to increased nutrient levels
in bariatric patients. This can be beneficial, as obese patients often have low vitamin levels before surgery. In a
study (Aasheim et al, Am J Clin Nutr 2008; 87: 362-9)
looking at 110 obese patients before surgery, he found
that 10-40% had deficient levels of vitamins B6, C, D,
and E.
A recently published study (Aasheim et al, Surg
Surgeons need to look at patients’
psychological factors
The psychological condi- from psychology that recall of information of a bariatric patient can be an im- tion is context-specific,” he said. “One
portant indicator of the success of his treatment, according to a psychiatric specialist.
Dr Tom Stevens, consultant general adult and liaison psychiatrist at South
London and Maudsley NHS Trust, said
that psychiatric professionals can help establish whether a patient is psychologically able to cope with the demands of bariatric surgery.
Stevens was presenting with Dr Lisa
McClelland, consultant general adult psychiatrist at Devon Partnership NHS Trust.
Bingeing and bulimia
Stevens identified two main eating disorders that are associated with obesity:
binge eating, and bulimia nervosa.
Binge eating is defined under the
DSM4 as eating, within a discrete period of time, an amount of food that is definitely larger than most people would eat
during a similar period of time and under similar circumstances, coupled with a
sense of lack of control over eating during the episode. These episodes should
occur, on average, at least twice a week
for three months.
Bulimia nervosa has similar symptoms to binge eating disorder, with added
inappropriate compensatory behaviour
to prevent weight gain, like self-induced
vomiting or laxatives.
Diagnosing binge eating, said Stevens, is difficult to define due to the clinician having to rely on the patient’s unreliable recall of their food intake. “We know
of the problems is that people are in the
calm context of the clinic when they are
getting access to their history of eating,
which is undertaken in an emotive state.”
Adverse outcomes and risk
Stevens said that bariatric surgery can
lead to adverse psychiatric outcomes.
Patients who don’t disclose their problems with bulimia before surgery can amplify their self-induced vomiting. Enduring
binge eating, malnutrition, and resultant
psychiatric relapses can all result from
unrealistic expectations of surgery. Also,
while overall most instruments that measure mood show an improvement over the
first 18 months of surgery, there is still an
increased risk of suicide within the group.
These outcomes are controversial,
however, as the evidence supporting
them is largely based on case reports,
rather than studies.
Despite the severity of the risks, there
is no consensus about the exclusion criteria for patients with mental issues. The
American National Institutes of Health
suggest that uncontrolled psychopathology is an exclusion criterion, while NICE
does not offer any guidance.
In response, Stevens and McClelland,
along with Samantha Scholtz, created a
traffic-light system of psychological indications for bariatric surgery (see boxout).
Patients with green indications are generally psychologically able to undergo
bariatric surgery. Those with amber in-
Obes Relat Dis 2011, epub 5 Feb) showed a significant
increase in levels of vitamins B6, folate, B12, A, and
E adjusted for lipids, compared to increases in vitamin
levels provided by lifestyle changes alone.
Wernicke’s Encephalopathy
Aasheim also encouraged doctors to be particularly
careful to watch for Wernicke’s Encephalopathy [WE],
which is caused by vitamin B1 (thiamine) deficiency.
WE has symptoms including an unsteady gait, disturbed
eye movements, and confusion and changes in behaviour. While treatment can reverse the symptoms, the condition is only completely reversible if treated quickly.
In a literature review that Aasheim carried out (Aasheim, Ann Surg 2008; 248: 714-20), he found that
around one in 500 patients who undergo biliopancreatic diversion subsequently develop WE. “It’s potentially lower after gastric bypass, but we don’t know that,”
he said.
Aasheim hypothesised that WE could be brought on
in patients who suffer from frequent vomiting, saying
that it occurred in 90% of the cases in his study, and
generally lasted for around three weeks.
“The body can become deficient in thiamine in 1820 days. It fits very well with the duration of vomiting,”
said Aasheim.
In about 20% of cases, the patient had received intravenous glucose, which can also trigger thiamine
deficiency.
Other symptoms that indicate WE include eye movement signs (70% of cases), mental status changes (64%),
leg neuropathy (60%), and gait ataxia (57%).
Aasheim described investigating to confirm a suspected diagnosis as “a double-edged sword”, as delaying treatment can harm the patient.
“In about 50% of cases in the review had some form
of lasting permanent neurological damage,” said Aasheim. “These people can end up in wheelchairs and in
the nursing home. Two or three of them died, so it’s extremely severe.”
dications are usually able to make an informed choice, but are at risk. “It’s contingent on everybody to optimise their
functioning before they have their operation,” said Stevens.
Red indications, which Stevens described as “probably the most controversial”, mean that “in our opinion you
shouldn’t be proceeding with surgery and
the patient will probably need to be sent
back to a mental health service before
you proceed.”
Overcoming issues
Stevens said that there were some that psychologists and psychiatrists were working
to overcome in the bariatric service.
Despite being able to make recommendations based on a patient’s psychosocial history, psychiatrists cannot predict weight loss. “There’s a real question
mark regarding our role, considering
we’re not able to predict outcomes,” said
Stevens.
Stevens also highlighted the risk that
psychiatrists may block access to treatment and inadvertently discriminate
against patients with mental health problems. The lack of an evidence base to rely
on also presented issues for psychiatrists.
“So there’s this discourse,” said Stevens, “suggesting that if people turn up
to all their appointments, that’s a sign
they’re motivated enough – go ahead
with surgery, as long as they meet the
NICE criteria.”
NICE guidelines, said Stevens, are
vague on the use of psychiatry and psychology in the treatment of obesity. However, mental health professionals can
help to identify patients who, while fitting into the NICE criteria, are mentally
unsuitable for surgery.
Psychological indications traffic
light system
Green
n Appropriate motivation – health
rather than mental health
nGood understanding of procedure
and outcomes
n Appropriate expectations for weight
loss etc
nRegular balanced diet
nInsight into eating and causes of
weight gain.
n Proven compliance
Amber
nIn cases of severe mental illness,
mental state should be stable with
no hospital admissions or act of deliberate self harm for previous 12
months
n History of alcohol or substance
misuse
n History of eating disorder
n Mild learning difficulties
n Poor motivation
n Unrealistic expectations
n Binge eating disorder
nInadequate insight into eating behaviours
n History of poor compliance
Red
n Unstable psychosis
n Active substance misuse and alcohol dependence
n Severe/moderate learning difficulties
nDementia
n Severe personality disorder
n Self-harm within last 12 months
n Active bulimia nervosa
nCurrent non-compliance with
treatment
King Henry
VIII’s gastric
band
Would you give the British Tudor King Henry VIII bariatric
surgery? The answer to that question, says Dr Tom Stevens, speaks
volumes about the importance of
psychiatric observation in bariatric
treatment.
Using measurements from Henry’s suits of armour held in the Royal Armoury, it is possible to estimate his BMI; by the age of 50, he
was massively obese, with a BMI of
around 51. He also had several comorbidities, including diabetes, immobility, and leg ulcers. If surgeons
operated using NICE guidelines in
the Tudor period, they would never have found a more suitable candidate for surgery.
But, says Stevens, would you
want to operate on him? Would you
want to risk a band slippage? Henry had a worrying tendency of killing people who disappointed him.
His eating habits were also less than
healthy: he ate up to 13 meals, and
drank around 13 pints of beer, every
day. He was described as “paranoid,
aggressive and intelligent”, and had
a history of head injury.
Put like that, he suddenly seems
like less of an ideal patient.
“We might suggest neurosyphillis, we might suggest hypothalamic
obesity as a result of the head injury,” says Stevens. “It would probably be a very brave psychiatrist who
would suggest he had a personality
disorder.”
Taking a good psychosocial and
weight history of a patient, says Stevens, can give you a strong idea
about whether a patient is going to
be able to cope with surgery.
Between the ages of 40 and 50,
Henry’s weight grew rapidly. During that time, he went through five
wives, two of which he beheaded;
he was dealing with wars in Europe,
and separating the Church of England from the Catholic Church in
Rome.
Given the situation, says Stevens,
“you have to consider whether he
would be able to control his eating
after bariatric surgery”.
XVI World Congress
of 3rd
the International
Federation
for the
of Obesity
andand
Metabolic
Disorders
The
Annual Scientific
Meeting
of Surgery
the British
Obesity
Metabolic
Surgical Society
Bariatric Surgery
Database Software
Imagine being able to track
all your bariatric surgery cases
with ease and recall any record
almost instantly…
Now you can with just a
‘click’ of a button
Dendrite’s innovative software:
reveal interpret improve
Station Road
Henley-on-Thames
RG9 1AY
United Kingdom
Phone: +44 1491 411 288 – e-mail: [email protected]
www.e-dendrite.com
St Elsewhere’s Hospital
NHS Trust
AttAch
PAtient
Sticky
here
Bariatric operation:
Pre-op weight:
109 kg
38.9 kg m-2
Pre-op BMI:
Current weight:
76.4 kg
27.2 kg m-2
Current BMI:
Total weight loss:
Excess weight loss:
Vitamins / mineral supplem
ents:
Regular monitoring
(blood test):
Clinical evidence of
malnutrition:
Weight loss and excess
120
P
F
F
F
F
F
F
F
32.6 kg
83.9 %
Yes
Yes
No
weight loss
Excess weight loss
F
Weight loss
F
FFF
F
Weight / kg
100
120
80
100
60
80
40
60
20
40
20
0
0
250
Current comorbidity
status
Type 2 diabetes:
Hypertension:
Sleep:
Asthma:
Functional:
Back / leg pain from
OA:
GORD:
PCOS:
Menstrual:
Apron:
Any other information
Current progress:
Next appointment:
Time after surgery /
500
days
Impaired glycaemia
or impaired glucose
tolerance
No indication of hyperte
nsion
No diagnosis or indicatio
n of sleep apnoea
No diagnosis or indicatio
n of asthma
Can climb 3 flights of
stairs without resting
Intermittent symptom
s; no medication
Intermittent medicat
ion
No indication / diagnos
is; no medication
Regular menstrual cycle
No symptoms
for the notes / GP
Satisfactory, as expecte
d
months
NHS
Gastric band (on 09 /
04 / 2008)
08 / 07 / 2009
23 / 07 / 1967
Clinic date:
Date of birth:
%
• Creates graphs
displaying Excess
Weight Loss over
time
• Links to hospital
systems to pre-populate demographic fields
• Allows the easy export of data to national/
international registries
• Simplifies the data collection process
• Maintains patient
anonymity and confidentiality (safe and secure)
Excess weight loss /
• Allows the tracking of
procedures and outcomes from
all type of bariatric procedures
(including bands, balloons,
Roux-en-Y, gastric sleeve,
duodenal switch and BPD)
• Details tracking of comorbid conditions
• Facilitates longitudinal follow-up
• Automatically identifies followup breaches
• Reduces the workload by
automating production of patient reports, operation
notes and follow-up letters
Unsatisfactory (specify)
750
0
P
RP
R
Primary
Revision as a primary
Revision
S
Planned 2 nd stage
F
Follow up
14 BARIATRIC NEWS
ISSUE 11 | March 2012
A snapshot of
India
In this issue,
our ‘Snapshot’
Mumbai
features Mumbai in
India, and a recent report
examined the prevalence of
metabolic syndrome in the city.
In India, epidemiologists and
international agencies have been
sounding an alarm on the rapidly rising
burden of cardiovascular disease (CVD)
for the past 15 years. It is estimated that
by 2020, CVD will be the largest cause of
disability and death in India, with 2.6 million
Indians predicted to die due to CVD.
M
etabolic syndrome (MS) is a complex
web of metabolic factors that are associated with a two-fold risk of CVD
and a five-fold risk of diabetes. Individuals with MS have a 30%–40% probability of developing diabetes and/or CVD within 20 years, depending on the number of components present. MS
consists of an atherogenic dyslipidemia (ie elevated
triglycerides and apolipoprotein B (apo-B) and low
high-density lipoprotein cholesterol (HDL-C)), elevation of blood pressure and glucose, pro-thrombotic
and pro-inflammatory states.
The aim of the report was to assess the prevalence of MS as defined by NCEP ATP III guidelines with a modification to the value for BMI that
is more applicable to the Asian Indian population,
and to look for the differences between the various components constituting MS. Along with the
prevalence of MS, the investigators from Research
Laboratories, PD Hinduja National Hospital & Medical Research Centre, Mumbai, also studied the
prevalence of various risk factors leading to atherosclerotic CVD.
A total of 560 subjects, who attended the free
CARDIAC evaluation camp arranged by PD Hinduja National Hospital and Medical Research Centre
by general advertising, were recruited in the study.
Among the 560 subjects, 548 (302 males and 246 females) who had all the required data for the analysis
formed the study group.
Each participant was interviewed by a group
of research students and completed a standardized questionnaire containing information on demographics, anthropometric profile, individual characteristics associated with the major risk factors
of CVD, past medical history, and biochemical parameters (Table 1). Prevalence of diabetes and hypertension was ascertained based on self-report of
the physician’s diagnosis and/or use of prescription
medications along with medical records of therapeutics. Blood samples were collected and analysis was
performed via an automated clinical chemistry anal-
yser. The prevalence of MS was calculated using the
prevalence rate formula: number of patients per total number of all subjects at the time of study multiplied by 100.
A total of five hundred and forty eight subjects
participated in the study. On applying modified NCEP
ATP III, consensus guidelines for defining obesity in
Asian Indians and ADA, we found out that nearly 95%
of the subjects had at least one abnormal parameter.
The general characteristics of the study population
are given in (Table 3).
Demographic characteristics
The gender distribution was 56.75% males and
46.71% females and the age of the subjects ranged
from 20 to 90 years, with a mean age in males of
54.28 years and in females of 52.67 years. Of these,
18.65% males and 16.02% females were in 20–40
age group, 47.91% males and 57.42% females were
in 41–60 age group, and 33.44% males and 26.56%
females were >60 years old.
Results
The results showed a mean BMI of 25.68 in males
and 26.95 in females, which clearly shows that the
prevalence of BMI ≥23 kg/m2 was significant in females than in males (p=0.008). Both in males and females, the prevalence of overweight BMI (≥23 kg/m2)
shows linear increase with age and was found to be
more in males than females. The overall prevalence
of BMI (≥23 kg/m2) was 79.01%. The prevalence of
obesity was high in 41–60 age group females than
20–40 age group and >60 age group. The prevalence
of obesity is almost the same in 20–40 and 41–60 age
group males but drops down as age advances. The
incidence of abdominal obesity observed was 70.9%
and waist to hip ratio was 73.76%.
It was found in the current study that history of
hypertension and diabetes increases as age advances both in males and females. Prevalence of history
of diabetes was significant in males than in females
(p=0.015). Prevalence of history of hypertension in
both males and females was highly significant in 41–
BARIATRIC NEWS 15
ISSUE 11 | March 2012
Prevalence (%)
80
60
40
20
0
20–40 years
41–60years
>60 years
Total
20–40 years
41–60years
Men
Total
Women
Hypertriglyceridemia
Hyperglycemia
>60 years
LOW HDL-C
Abdominal obesity
80
Females
Prevalence (%)
Males
60
40
20
60 age groups (p=0.001). History of diabetes in 41–
60 age group males was highly significant (p=0.001).
Prevalence of family history of cardiovascular diseases was observed in 27.76% subjects.
Increased fasting blood glucose, hypertriglyceridemia and decreased levels of HDL-C were
found to be more in males with high TG and low
HDL-C to be highly significant (p=0.001). Hypercholesterolemia was highly significant in females
as compared to males. Both males and females in
41–60 age groups showed significantly high levels of impaired glucose levels (p=0.001). On further comparing age wise, prevalence of low HDLC in 20–40 age group males was 64.91% which is
very high as compared to other age groups both
in males and females. In males, the prevalence of
hypercholesterolemia, and hypertriglyceridemia
was found to be more in 41–60 age group. In females, fasting blood glucose, hypertriglyceridemia
and hypercholesterolemia showed a linear increase
with age.
The overall prevalence of MS having ≥3 components was 19.52% by modified NCEP ATP III criteria.
The prevalence of MS in males was almost double
(25.16%) than females (12.6%), and this was highly significant (p=0.008). For age, the distribution of
prevalence of MS was found to be the same in 20–
40 and 41–60 age groups (20.61% and 20.76%), respectively, whereas >60 age group showed a marginal decrease in the prevalence (16.66%). The
prevalence of individual components of MS is reported in Figure 1.
The prevalence of major risk factors of atherosclerotic CVD was 45.25% overweight, 33.75%
obese, 39.96% having impaired blood glucose levels, 39.96% subjects with hypercholesterolemia,
38.13% with hypertriglyceridemia, and 47.97%
with low HDL-C. The prevalence of elevated cardiac markers was 2.18% with high APO B, 1.82% with
increased APO A, 30.65% and 8.39% with elevated
levels of Lp(a) and hsCRP, respectively. The genderspecific prevalence of different atherosclerotic risk
factors is reported in Figure 2.
The development of obesity, or more specifically an increase in abdominal fat, is thought to
be the primary event in the progression of MS. A
tendency to gain fat in the abdominal area, as opposed to the hip, buttock, and limb areas, is linked
to a rise in fatty acids in the blood, which is thought
to lead to insulin resistance, high blood pressure,
abdominal blood lipids, and eventually diabetes.
Asian Indians tend to develop central obesity rather than generalised obesity. About three fourth of
the subjects participated in study were overweight/
obese (BMI≥ 23kg/m2), being a prime determinant
of MS prevalence. Of these around one third of
overweight/obese subjects had impaired glucose
tolerance and many exhibit features of MS. Obesity
reduces HDL-C levels, and obese patients with MS
and atherogenic dyslipidemia almost always have
low HDL-C levels. This study shows that around
35% of subjects had low HDL-C were either overweight or obese.
High APO-B
High APOB/APOA ratio
H/O HTN
Alcohol
Family H/O CVD
High Lp(a)
High FBS
Low HDL-C
Abdominal obesity
BMI (overweight)
High TC
High TG
BMI (obese)
Smoking
H/O diabetes
High hsCRP
Low APO-A
0
Conclusion
The prevalence of MS varies amongst ethnic groups.
Indians are high at risk for CVD and their predispositions. The prevalence of MS was double in males
as compared to females and this study revealed the
increased prevalence of MS to be more prevalent
in 41–60 years, suggesting that this group is at increased risk of developing CAD. The investigators
also reported that the high percentage prevalence of
overweight and obesity was one of the major driving forces in the development of MS. Therefore, they
concluded that an early identification of the metabolic abnormalities and appropriate intervention may be
of primary importance in similar populations.
Source: Apurva Sawant, Ranjit Mankeshwar, Swarup Shah, et al “Prevalence
of Metabolic Syndrome in Urban India,” Cholesterol, vol. 2011, Article ID
920983, 7 pages, 2011. doi:10.1155/2011/920983
16 BARIATRIC NEWS
ISSUE 11 | March 2012
The future of obesity treatment
The inaugural ‘London 2012: Future of Obesity Treatment' meeting was held at the Royal College of Physicians,
London, UK, on 3 February 2012. This state of the art international symposium was attended by general
practitioners, surgeons, physicians, diabetologists, endocrinologists, gastroenterologists, endoscopists,
commissioners and managers, all of whom face their own specific challenges in this evolving field. In addition,
an international multi-disciplinary faculty assessed the factors required to create a multidisciplinary approach
involving and promoting collaboration across different specialities including physicians, surgeons, policy makers,
commissioners and managers, to combat obesity. The faculty reviewed the current status of obesity treatment
and discussed how best to address the challenges in the future.
Mr Gianluca Bonanomi, Chelsea and
Westminster Hospital London, welcomed delegates to the meeting by stating that although there
is an increasing acceptance of obesity there still remains prejudice, discrimination and a lack of appreciation by the general public that obesity can
have an impact of the quality of life as well as lifethreatening consequences.
“This is why we must ask questions about the future of obesity treatment, both in terms of prevention and treatment of this condition,” he stated. “A
more pertinent question maybe: how do we allocate
scarce resources?”
Professor Sir George Alberti, University of Newcastle/Imperial College London, UK, made the first
presentation entitled, ‘How will the International
Diabetes Federation (IDF) statement change the future?’ in which he discussed the guidelines and how
and why the IDF came to its conclusions.
He began by stating that the guidelines were required because there is a global type 2 diabetes epidemic and it is ‘out of control and getting worse’.
For example, in China alone there are an estimated
91 million people with diabetes. He stated that efforts to prevent obesity had failed, partly because
the food industry has a major influence on governmental policy.
The statement was written by 20 leading experts
in diabetes and bariatric surgery who have made a
series of recommendations on the use of weight-loss
surgery as a cost-effective treatment option for severely obese people with type 2 diabetes.
“The reason we issued on a statement was to give
access to patients who without surgery would be
causing a detrimental effect to their health, possibly
reducing their lifespan by 20-30 years,” said Alberti.
According to the statement there is increasing
evidence that the health of obese people with type
2 diabetes, including their glucose control and oth-
er obesity-related comorbidities (conditions), can
benefit substantially from
bariatric surgery under
certain circumstances.
The IDF's Taskforce
on Epidemiology and
Prevention of Diabetes convened the expert
group with specific goals
to:
nDevelop
practical
recommendations
for
clinicians on patient selection and management
nIdentify barriers to
surgical access
n Suggest health policies that ensure equitable access to surgery
nIdentify priorities for
research
“So how will the International Diabetes Federation (IDF) statement change the future
of obesity treatment? I
Gianluca Bonanomi
hope they will impact
upon people’s view that
surgery is a valid option for treating certain patients, specifically in
resolving type 2 diabetes,” concluded Alberti. “Metabolic surgery should be complimentary to medical therapy as it is the most effective
treatment for patients with a BMI >35 and with
a multi-disciplinary team approach including nutritionist, psychologists it can have considerable
long term benefits.”
The medical approach to obesity
Dr David Haslam, Chairman, National Obesity Forum, then outlined the problems of obesity in the
general population and how as a General Practitioner, he faces obese patients on a daily basis. In his
presentation entitled, ‘Obesity: What is the challenge for the community?’ Haslam said that when
trying to communicate with obese patients it is imperative to identify, engage and motivate patients.
“The next step is to try and make them understand that obesity is having an effect on their blood
pressure, cholesterol and their overall quality of
life,” he said. “But no one of this can be achieved
unless you engage with them.”
He added that there was a problem with engaging
the male population, and although the Men’s Health
Forum has done tremendous work by going to factories and work places he said that much more was
required to communications with men.
Centres like the Rotherham Institute of Obesity
(RIO) have shown that dedicated, unique and specialist centres with a multidisciplinary approach to
reducing and maintaining weight loss can have a
successful impact, said Haslam. The centre boasts
that “RIO does not claim to have invented the cure
for weight problems, and cannot guarantee weight
loss for patients, but it brings together all the NHS
approved and evidence-based methods for weight
loss into one Primary care based Centre in the hope
that we can maximise the chances for weight loss.”
RIO forms part of the award-winning NHS Rotherham Weight Management Strategy that won the
2009 NHS Health and Social Care Award for best
commissioned service.
“The role of the primary care GP is badly understood, so my plea to surgeons is following surgery
give the patient as much information as possible
about their post-surgery regime (nutritional supple-
George Alberti
ments etc) and please contact us and advise us on
what we should be monitoring and how often,” concluded Haslam. “Most GPs are not aware of the risk
of post-surgery morbidly obese patients so please
communication the dangers with us.”
In his presentation, ‘Which patients stand to gain
most from obesity treatment?’ Dr Simon Aylwin,
King’s College London, UK, said that this was an
almost impossible question to answer but said he
would explain some of the questions that should be
considered in trying to answer the question.
“Historically, prevention consisted of diet, exercise and risk factor management, however for today’s patients who are aged >55 with co-morbidities
intervention is required. But what intervention?”
asked Aylwin. “There are a whole host of medical therapies available to treat co-morbidities such
blood pressure, diabetes, cholesterol, but there are
no medical therapies available to treat their obesity.”
Even though the Swedish Obese Subjects (SOS)
BARIATRIC NEWS 17
ISSUE 11 | March 2012
David Haslam
study recently reported that patients who undergo
gastric bypass surgery are less likely to have cardiovascular events than people who receive more conventional treatment for their weight condition (Journal of the American Medical Association, Sjostrom
et al. JAMA 2012; 307: 56-65), he suggested that it
is not the number of heart attacks, but whether the
patient survives it.
He argued that the evidence is not there yet to
categorically state that obesity surgery is useful in
preventing death, however it is useful in preventing
disease, dysfunction and dissatisfaction. Another aspect of surgical intervention is economic, and Aylwin presented economic models that showed that if
25% of patients had surgery they would incur less
overall costs than patients who continue with medical therapy only, saving approximately £1billion.
He concluded by asking who is appropriate for
bariatric surgery: “I know who is eligible but who
requires it the most, what about those with psycho-
Simon Aylwin
socio dysfunctionality? Such conditions are the harbingers of medical disease and should be considered
as reasons for intervention.”
In the next presentation, Professor John Wilding, University of Liverpool, UK outlined the current status of obesity and diabetes
treatment. “In the diabetic patient the
important consideration is the prevention or delay in the development of diabetes related diseases and/or conditions,” said Wilding. “However, one of
the most important concerns of a diabetic patient is weight gain as most
of the drugs have the consequence of
making them fatter.”
The overall aim of treatment is to
reduce the burden of diabetes and improve the patient quality of life, whilst
reducing the costs. He cited evidence
that suggests with early intervention
and reducing glucose levels down to almost normal
levels the burden of diabetes related complications
can be reduced, but not completely resolved. However, he warned that there was evidence to suggest
that if this treatment was performed later and with
the wrong agents it may actually cause additional
damage. “If lipid lowering and blood pressure lowering treatment is added to glycaemic control then
this can have a profound effect on cardiovascular
outcomes,” added Wilding. “The take home message is that early intervention works and is most effective for all the risk factors.”
The evidence shows that the more obese the patient becomes their lipid control and blood pressure
worsens. In Wilding’s institution in Liverpool, they
demonstrated that if a patient is a diabetic with a
BMI >35, their coronary artery disease risk is the
equivalent to someone ten years older due to increased risk factors. However, studies show that
patients who lose modest amounts of weight (eg
two stones/28lbs) are associated with the highest
amounts of reduced mortality.
cus on the need to reduce weight and improve the
quality of life.
The Look ahead study that is examining lifestyle management has reported weight loss and lipid reduction, although it does not indicate success-
John Wilding
ing that the National Health Service (NHS) is currently under great economic strain and its resources
are increasingly stretched.
He stated that the cost of bariatric surgery is determined by tariff on the NHS and on average a band
will cost approximately £2,500 and a
bypass up to £8,000 (not total costs but
what the commissioners pay). “Bariatric surgery has lots of evidence that it is
cost effective, our own analysis shows
that over a ten year period the total cost
of treating a patient who is eligible for
bariatric surgery (including surgical
and post-operative care) is £20,000.
By comparison the cost treating a patient who is eligible for bariatric surgery with primary care is approximately £40,000. We need to be very clear
about which is the right surgical treatment and what is the right price.”
It is not sufficient just to look at surgical cost but
to look at the entire patient pathway, follow-up regime, complication rates, re-admissions etc, he added. However, despite the obvious financial advantages, Lander stated that the problem is that the
“Most GPs are not aware of the risk
of post-surgery morbidly obese
patients so please communicate
the dangers with us.”
Trade-off
According to Wilding, there is a trade-off between
the side effects of therapy and a patient’s quality
of life. The evidence shows that if you gain weight
and have lots of hypoglycaemia your quality of life
gets worse, whereas if you lose weight and reduce
your hypoglycaemia, your quality of life improves.
Therefore, he argued, there should be a greater fo-
David Haslam
ful weight loss long term. Such studies demonstrate
that lifestyle management does have a place.
Wilding then examined drug use for weight loss
and looked at the Xenical in the Prevention of Diabetes in Obese Subjects (Xendos) study, which showed
orlistat therapy reduced the incidence of diabetes beyond the result achieved
with lifestyle changes
only, an effect that was especially evident in patients
with baseline impairment
of glucose tolerance.
“Diabetes results in
significant morbidity and
mortality, and we need to
manage all the risk factors
not just glucose”, concluded Wilding. “Obese
patients do less well so we
need to combat the obese
population.”
Economic analysis
Adding an economic aspect to the discussions, Mr
Mike Lander, Commissioner South East Coast
England, asked ‘How can
health care systems afford
obesity and diabetes treatment?’ He began by stat-
Continued on page 18
Steve Bloom
18 BARIATRIC NEWS
ISSUE 11 | March 2012
The future of obesity treatment
Contniued from page 17
evidence does not identify those patients who will
benefit the most. Moreover, he also stressed that
there is a difficulty in understanding and interpreting definitions and endpoint such as ‘clinically significant weight loss’ and ‘failure’, as the perceptions of the clinician and patient vary greatly.
In concluding, he called for greater cooperation
between professional medical societies and associations in developing a consensus of opinion and
asked the audience to remember that ‘more care is
not always the right care’.
Novel therapeutic approaches to obesity
Professor Sir Steve Bloom, Imperial College London, UK, started his presentation entitled, ‘Is the
magic medicine on the horizon?’, by stating that as
far as obesity is concerned the pharmaceutical industry has not done very well. He explained that despite several promising agents, weight loss has not
been sufficient and/or the agents have had severe
side effects. For example, he cited the NPY neurotransmitter and the consequences of what happened when researchers attempted to ‘block’ it as it
is a significant activator of appetite.
It was successful so far as the animal’s appetite was suppressed and weight loss was achieved.
“The problem is that NPY is responsible for a lot
more than appetite, so by using a blocking agent
all the other responses the neurotransmitter affects
were also blocked,” he added. “Therefore, any attempt must be more targeted.”
Gut hormones have been shown to physiologically inhibit appetite as well as inhibiting the hunger hormones ghrelin. Interestingly, the obese subjects in one study
had more endogenous PYY suggesting
they have a lack of satiety signal and further suggesting that this could be the reason they are obese. “Once you get fat and
have a low PYY release, a lack of satiety signal and it will be difficult to lose
weight,” said Bloom. “Therefore, by defusing PYY you are actually rectifying
this deficiency.”
He said that it was also interesting to
note that hormones do activate the appetite areas of the central nervous system
and a combination of hormones produce
a bigger effect than if administered separately. “Therefore, it appears as though
appetite is regulated by these circulatory
gut hormones,” he commented.
Bloom concluded by summarising his
latest research using a combination approach which appears to show greater
weight loss delivered via a single injection, joking that he hoped this would put surgeons
out of work.
tion. For example, endoscopic procedures could be
utilised to treat a patient’s metabolic disease (diabetes) before they become obese, they could be used
to intervene earlier before the patient’s condition
tive, long-term treatment available and is proven safe, “safer in fact that gall bladder surgery,”
he argued.
In his presentation, ‘The future of obesity treatment: how can we influence policy makers?’ Larvin revealed the huge disparities in bariatric surgery provision in the UK, with one Primary
Care Trust (PCT) performing a single procedure
whilst another performed 192, and one in ten PCTs
ignoring National Institute of Clinical Excellence
(NICE) guidelines. “This is despite the National Bariatric Surgery Registry (published in March
2011) not only confirming the safety and effectiveness of surgery, but also that surgery resulted in
the resolution of co-morbidities and cleared demonstrated that surgery was making a real difference
to patient’s lives,” he explained.
“A real concern is localism, leaving it to local
providers to decide provision with no overall national standards. We would not allow this to happen for cancer, so why would we allow this to happen for obesity?” said Larvin. “This could happen
despite the evidence suggesting that over the next
20-30 years obesity-related deaths will reach those
of cancer.”
Christopher Thompson
In conclusion, he surmised that all stakeholders must lobby government to provide an effective
long-term strategy to fight obesity because at the
moment short-term savings were leading to longdic or cardiac patient’s treatment pathway can in- term costs.
clude lifestyle changes, medical therapy, minimallyinvasive intervention (arthroscopy and angioplasty) The good, the bad and the ugly
to major intervention (replacement and bypass). Next, Dr Nicolas Christou, McGill University, MonCurrently, Thompson argued that there treal, Canada, examined the outcomes form bariatric surgery in a presentation entitled, ‘What are the
was no minimally invasive option.
He then explained the step-by-step long term outcomes of bariatric surgery? The good,
methodology of endoluminal verti- the bad and the ugly’. He stated that data from the
cal gastroplasty using a transoral ap- Canadian National Health and Nutrition Examinaproach to suture the anterior and poste- tion Survey (NHANES) has shown an increase in
rior gastric walls. Thompson cited the the average BMI in both men, women and more
series by Dr Roberto Fogal who report- alarmingly, children. “And although the data has
ed 64 patients achieved EWL 58.1% at not yet confirmed this, I believe obesity has now
12 months. He also mentioned the Tran- surpassed smoking at the leading cause of death in
soral Gastric Volume Reduction as an North America,” he added. “There has to be a more
Intervention for Weight Management aggressive approach to obesity, lifestyle changes
(TRIM) which treated 18 patients us- work but only in the short term. Likewise, surgery
ing the RESTORe Suturing System and does work but only when combined with sustained
reported modest decreases in weight, follow-up with lifestyle modifications. But which
BMI and waist circumference. Howev- surgeries are effective?”
In a quick fire summary of the procedures, Chriser, the plications were not durable and
the effects of the procedure varied wide- tou outlined the type of procedure (predominantly
malabsorptive, predominantly restrictive etc), the
ly among the study participants.
Thompson also mentioned the en- operative risk associated with each, as well as the
dosleeve and the
benefits of a new
technology, magnets. These can
be place endoscopically and
can be manipulated to form
shapes and could be particularly helpful in suturing.
“In conclusion, in order to
treat obesity it is necessary
to have a multi-disciplinary
approach and different treatment paradigms to facilitate intervention at a variety
of different stages of the disease,” he concluded. “The
long term efficacy, safety and
cost effectiveness need to be
assessed, but I am hopeful
that they will utilised in the
fight again obesity.”
“Once you get fat and have a low
PYY release, a lack of satiety
signal and it will be difficult
to lose weight. Therefore, by
defusing PYY you are actually
rectifying this deficiency…
Therefore, it appears as though
appetite is regulated by these
circulatory gut hormones.”
Endoscopic therapies
The final speaker of the session was the world leading expert on bariatric endoscopy, Dr Christopher
Thompson, Harvard Medical School, Boston, US,
who asked ‘Can obesity be treated using an endoscope?’
He began his talk by acknowledging that all the
current bariatric procedures are effective on an individual patient basis, although they do have limitations including complications, post-surgical nutritional deficiencies, post-surgery regime compliance
and cost. In addition, he said that lifestyle changes (diet) and medical therapy did not work in the
long term and had so far provide unsuccessful, respectively.
“Therefore, we have surgery which tends to be
more effective but a higher risk and lifestyle of medical therapy which reduce the risk but are less effective,” commented Thompson. “I think the less
invasive endoscopic approaches could provide the
solution as a low risk, highly-effective bariatric procedure.”
He said that there could be an array of endoscopic treatment modalities to treat patient’s condi-
Steve Bloom
worsens (ie. BMI<30) or these newer endoscopic
procedures could be used at a bridge therapy to assist patients in losing sufficient weight so they can
have additional surgery (eg orthopaedic or cardiac
surgery).
Thompson described several different endoscopic approaches currently on the market or under development including suturing devices, gastric balloons, staplers, plicating devices and implantable
sleeves. Each one of there may have a role in certain categories of procedures, for example the suturing device may have a role in bridge therapy or early intervention, he added.
He explained that the aim of bridge therapy is
to achieve significant weight loss over a relatively
short period of time and the durability of the procedure is not of crucial importance as this is a temporary intervention. One such procedure is an intra-gastric balloon (air filled balloons, fluid filled
balloon, double balloons), which has been shown
to lead to effective weight-loss, with few complications.
“For early intervention,” Thompson said, “Safety
is paramount and durability and repeatability do become important for these procedures.” He said that
obesity is missing a component that is seen when
treating other conditions. For example, an orthopae-
The surgical approach to
obesity
Speaking on behalf of the
Royal College of Surgeons,
Mr Michael Larvin stated
that bariatric surgeons are
facing decades of operating
on morbidly obese patients
as surgery is the only effec-
Mike Larvin
BARIATRIC NEWS 19
ISSUE 11 | March 2012
re-operation and complications rates. “No matter
which procedure you choose, the outcomes show
weight loss and improvements in co-morbidities, as
long as patients abide by their post-operative regime
and attend follow-up sessions,” he stated. “What we
must be careful of is that patients do follow post-operative regime and attend follow-up sessions so we
can assess (among other things) any sign of nutritional deficiencies.”
Costs
Christou cited a Canadian study that showed bariatric surgery resulted in the reduction of co-morbidities and that within three and a half years, the cost
of surgery had been paid for by the savings made
in treating the patient’s co-morbidities. Many of the
patients are expected to live for 15, 20 maybe 30
years, so the actual saving over a long period of time
is very substantial, he added.
According to Christou, the perception of surgery
needs to change as at the moment the public and the
has a modest impact on type 2 diabetes.
“There are challenges of creating and running
these trials, particularly costs,” he stated. “And
there are also challenges of recruiting patients to an
arm that we know is not effective (medical therapy).” The case for the safety and efficacy of bariatric
surgery is already proven, said Schauer, with hundreds of thousands of cases over 20 years demonstrating a very low mortality rate and a serious complication rate of 4-5%.
Stampede trial
He added that much needed data will come from
numerous clinical trials currently underway examining the effectiveness of bariatric surgery to reduce type 2 diabetes. One such randomized study
is the Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently (Stampede) trial
at the Cleveland Clinic's Bariatric and Metabolic
Institute. The Principal Investigators are Drs Philip Schauer, Sangeeta Kashyap (an endocrinologist)
and Deepak Bhatt (a cardiologist). The study will compare
the effectiveness of advanced
medical therapy alone versus
bariatric surgery and therapy
combined, for the treatment
of type 2 diabetes during a
five year study period.
Patients with a BMI of 2743 will be recruited and the
primary end point is the rate
of biochemical resolution of
type 2 diabetes at one year,
as measured by HbA1c<6%.
The safety and adverse event
rates will also be compared
between the three arms of the
study. Interestingly, Schauer reported that they screened
thousands of patients as many
refused to be considered for
both treatments strategies.
The final presentation of
the session was by Dr Carel le
Roux, Imperial College London, who asked, ‘What does
basic science today predict for future obesity treatments?’ To answer this question he examined the
physiology behind bariatric procedures. For example, banding works by restriction so how does that
result in patients feeling ‘less hungry’?
“We know that the vagal fibres that sit at the
point where the band presses on, are actually important when it comes to signalling the hypothalamus,” said le Roux. “Therefore, we now believe
that it is the pressure on these fibres at the gastrooesophageal junction that actually allows people to
feel less hungry.”
He added that the change in hunger is not universal and estimates that 20 per cent of patients do
not have a reduction in hunger, compared to 80 per
cent who do have a reduction. “I think restriction is
a side effect of the band and not how it works, people should be losing weight because they are eating fewer calories, not by restriction,” said le Roux.
With regards to bypass, he said that one of the
most common complaints patients have is constipation, but this does not equate with the malabsorptive aspects of gastric bypass. Le Roux said it was
important to look at important role of the alimentary limb, “It appears that operations such as bypass
fixes dysfunctional deficiency and increase the gut
hormones. This does not appear to be the case with
banding.”
Gastric bypass also appears to alter people's food
preferences, suggesting a new mechanism of bariatric surgery. “Patients become hungry for fruits and
vegetables and no longer crave junk food.” He highlighted a recent study that investigated how bypass
affects intake of and preference for high fat food in
an experimental (rats) study. “If we can find out why
this happens, we might be able to help people to eat
more healthily without much effort.”
“We know that the vagal fibres
that sit at the point where the
band presses on, are actually
important when it comes to
signalling the hypothalamus…
Therefore, we now believe that it
is the pressure on these fibres at
the gastro-oesophageal junction
that actually allows people to
feel less hungry.”
Carel le Roux
medical community need to understand that obesity
is a disease and just like cancer, it kills.
The next speaker, Dr Philip R Schauer, Cleveland Clinic, USA, discussed ‘What clinical evidence do we need to move bariatric and metabolic surgery forward?’ He began by stating bariatric
and metabolic surgery has evolved and so the evidence gathered from these procedures is less than
the gold standard randomised controlled trial. Despite this, the guidelines across the national organisations (NICE, NIH etc) show a large consensus and
organisations with an interest also agree about the
benefits of bariatric surgery (such as national diabetes organisations).
“However, despite this recognition of bariatric surgery, the adoption of surgery remains low,”
explained Schauer. “In the US, although there are
200,000 procedures each year that is only 1-2% of
the patients who are eligible.”
Evidence
In order to increase the number of procedures,
Schauer said that it was necessary improve the evidence such a case studies, registries and clinical trials. Such studies should examine operative morality and complications, short and long term outcomes,
weight loss, the effect on co-morbidities, cost of operation and the cost the natural progression of the
disease (of not intervening).
For surgery the evidence is minimal and there
are only three randomised clinical studies that have
examined the outcomes of surgery compared with
non-surgical treatment such as medial therapy, lifestyle changes or modifications (diet, exercise). He
added that the evidence so far from medical therapy
based studies (such as the Look Ahead study) have
shown a decrease in weight loss of some 4%, which
Nicholas Christou
Philip Schaur
Carel le Roux
20 BARIATRIC NEWS
ISSUE 11 | March 2012
‘Last resort’ bariatric surgery beneficial in adolescents
Researchers at Nation- cost and delivery as well as psychosocial
wide Children’s Hospital have report- factors including educational attainment,
ed that their patients have experienced
a significant loss of excess body weight
and showed improvement in many obesity-related diseases within the first one to
two years following surgery. The retrospective study was published in the January 2012 print edition of Pediatric Blood
& Cancer (Pediatr Blood Cancer 2012;
58: 112–116).
“Bariatric surgery in adolescents is
never a cosmetic procedure,” said the
study’s author Dr Marc Michalsky, Surgical Director of Bariatric Surgery at Nationwide Children’s Hospital and faculty member at The Ohio State University
College of Medicine. “These teens are
very sick, they are suffering and they can
benefit from weight loss surgery. Our
study demonstrates the safety and efficacy of weight reduction surgery in morbidly obese adolescents.” He added that
although weight loss surgery can be a
very effective intervention, it should be
a last resort for teenagers.
According to the researchers the pediatric age group are the fastest growing
sub-population of obese individuals in
the US, which has been described as a a
pandemic of the new millennium. In addition to the overall rise in obesity-related diseases in children, a mounting body
of evidence highlights the negative impact of adolescent obesity on healthcare
job absenteeism, depression, and quality of life.
“We do not yet know whether the improvements of these patients will correspond to long-term resolution of weightrelated diseases or reduce their risk for
future weight-related diseases,” said Michalsky who also chairs the American
Society for Metabolic and Bariatric Surgery Pediatric Committee’s best practice
guidelines. “Although our findings suggest that the most significant metabolic
impact occurred within the first post-operative year, findings may differ in studies involving more patients who are followed longer-term."
Study outline
As a result, the investigators performed a
retrospective analysis of patients undergoing Roux-en-Y gastric bypass (RYGB)
between 2004 and 2009 at their institution. Following approval from the Institutional Review Board (IRB), a retrospective analysis of data collected from
the medical records of 15 morbidly obese
adolescents (ten females and 5 males)
who underwent RYGB by two experienced surgeons at Nationwide Children’s
Hospital (Columbus, OH) between February, 2004 and July, 2009 was performed.
Standard pre-operative screening of
Marc Michalsky
all bariatric surgical candidates consisted
of history and physical examination, nutritional screening, psychological evaluation, social work, and physical activity screening. Pre-operative blood work,
overnight sleep study, upper gastrointestinal study with contrast, abdominal ultrasound, bone age and pediatric cardiology evaluation, including transthoracic
echocardiography, were performed. Clinical and demographic data were collected for analysis at baseline, then one and
two years post-operatively. These included age, blood pressure, height,
weight, body mass index (BMI), and
measurement of several metabolic markers including: fasting serum hemoglobin A1C (HbA1C), insulin level, C-reactive protein (CRP), C-peptide, glucose,
and serum lipid profile. Using tables provided by the Centers for Disease Control
(CDC), percentiles were calculated to account for differences in the age of the patients including BMI, total cholesterol,
TG, LDL, and HDL.
Insulin resistance (IR) was determined by calculating HOMA-IR. This
uses fasting glucose and insulin to estimate an index of IR, as well as percentage of pancreatic beta cell function
(%B) and percentage of insulin sensitivity (%S). Post-operative anthropomorphic and laboratory analyses were examined at one year (n = 14) and two years
(n = 9). Percentage excess weight loss
was calculated and followed over time.
This was defined as (weight loss/excess
weight) × 100 where excess weight is total pre-operative weight − ideal weight.
Outcomes
Analysis of baseline clinical data showed
that the mean BMI was 58.8 ± 10.7 kg/
m2 (super morbid obesity) and a longitudinal analysis demonstrated a significant decrease from baseline over the
two-year study period to a mean BMI of
34.9 ± 5.6 kg/m2 (range: 26.7–42.7 kg/m2,
p≤ 0.001) with the most notable change
within the first year (58.8 ± 10.7 kg/m2
vs. 37.6 ± 9.0 kg/m2, p≤ 0.001). The researcher note that although the BMI continued to decrease between the one and
two-year time points, it did not reach statistical significance (37.6 ± 9.0 kg/m2 vs.
34.9 ± 5.6 kg/m2, p= 0.433).
The change in mean weight also
achieved statistical significance over
two years (p≤ 0.001) as did the change
in overall body weight over the first
(179.6 ± 42.5 kg vs. 112.6 ± 29.9 kg,
p≤ 0.001) but not the second
(112.6 ± 29.9 kg vs. 104.9 ± 25.8 kg,
p= 0.184) post-operative year.
Complications
Three of the patients (20%) experienced
short-term including one readmission for
post-operative ileus, one port-site hernia and one revision of the gastro-jejunal
anastomosis secondary to bleeding and
anastomotic leak. Long-term complications included one port-site hernia diagnosed at 14 weeks post-operatively and
one gastrojejunal anastomotic stricture
which responded to a single endoscopic
dilation 14 months post-operatively.
Conclusion
According to the authors, the study demonstrated both safety and efficacy of
weight-reduction surgery in morbidly
obese adolescents and although the results suggest that the most significant
metabolic impact occurred within the
first post-operative year, this may have
been a confounding influence of a low
sample size as well as relatively shortterm follow-up. They concluded that bariatric surgery is a safe and efficacious
treatment option for morbidly obese adolescents with significant obesity-related comorbid conditions and that the early
surgical intervention and management of
comorbid diseases may reduce the longterm burden of physical and psychological chronic disease in morbidly obese adolescents.
“The argument is quite compelling
that we really do need to be doing it this
young to avoid the chronic burden of disease these patients will suffer from if
nothing is done. Bariatric surgical operation in kids is never a cosmetic practice,”
Michalsky concluded. “These youngsters
are pretty sick, they’re suffering and they
are apt to reap the benefits of fat reduction surgical operation. Our study displays the safeness and efficacy of weight
loss surgical operation in morbidly overweight kids.”
First endoluminal revision of
a prior sleeve gastrectomy
There were two bariatric ‘firsts’ reported at the 3rd Annual Apollo Bari-
atric Surgery Conference (ABSCON 2012) in Chennai, India, in January 2012. The
firsts came from one procedure, as the first ever endoluminal bariatric procedure to
be performed in South Asia is also thought to be the first known endoluminal revision of a prior sleeve gastrectomy.
The operation was performed by New York bariatric surgeon, Dr Elliot Goodman, and Dr Rajkumar Palaniappan, Apollo Hospital in Chennai. The operation was
shown via video-link to 80 surgeons attending the ABSCON 2012 conference at the
Hyatt Regency Hotel in Chennai. “This represents a tremendous milestone for the
evolution of GI surgery as it progresses from open to laparoscopic and now incisionfree access,” said Dr Goodman.
The patient was a 27-year-old gentleman who had previously undergone a sleeve
gastrectomy for obesity in 2011. He had lost approximately 15kgs in weight, but
his weight had then stabilised and he had begun to regain weight. He had a history of depression and hypertension and a pre-operative upper GI series showed that
he had significant dilatation of his sleeve, particularly in the mid-portion of the remaining stomach.
Utilising the Overstitch platform (Apollo Endosurgery), the team placed six endoluminal sutures along the sleeve gastrectomy staple line. At the completion of the
operation, the team performed an endoscopy which showed significant reduction in
the size of the gastric reservoir. The procedure lasted about an hour.
“We believe that flexible surgery represents the most exciting innovation in bariatric and gastrointestinal surgery in years and we look forward to offering these incisionless procedures to our patients to help combat obesity and other conditions,”
said Dr Prathap C Reddy, Chairman of Apollo Hospitals Group.
After the successful performance of South Asia’s first endoluminal bariatric procedure, the Apollo Hospital bariatric surgery service will soon perform similar procedures on a regular basis. It is anticipated that the first few cases will be performed
within the next couple of months. These will include sleeve gastrectomy and gastric
bypass revisions for patients who have initially lost weight, but are now regaining
weight due to either sleeve or pouch/stoma dilatation. The Apollo Hospital surgeons
will also be examining the safety and efficacy of primary endoluminal gastroplasty in patients with a BMI of 30-40 as part of a clinical trial sponsored by Apollo Endosurgery.
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22 BARIATRIC NEWS
ISSUE 11 | March 2012
Diabetes Australia support bariatric
surgery for T2DM patients
Diabetes Australia have released a position statement voicing their support for bariatric surgery as a method of managing diabetes.
In line with the UK National Institute for
Clinical Excellence guidelines, Diabetes Australia’s position statement advises that bariatric surgery is a viable weight loss treatment
option for people with type 2 diabetes with
a BMI over 35, where lifestyle interventions
and medical treatments for obesity or diabetes
have not been successful.
The position paper also states that people
who do not already have diabetes but are risk
of developing the condition should only consider surgery if they are very obese (BMI over
40 or over 35 with an obesity-related medical
condition).
The association has deliberately used the
word “manage” rather than “cure” in the
statement, as it is not currently known how
long normal blood glucose levels can be
maintained without medication.
“While bariatric surgery should always be
considered as a last resort, more people have
reached that position than ever before, so surgery is increasingly being viewed as a viable
option – although not without dangers. A key
issue is access for those most in need of the
surgery, as public funding is much lower than
demand,” said Diabetes Australia Chief Executive Officer Lewis Kaplan.
An estimated 1.7 million Australians have
diabetes, and 275 Australians develop the
condition every day. An additional two million Australians are estimated to be at risk of
developing type 2 diabetes. 61% of Australian
adults are overweight, of which 25% of Australians considered obese.
The position paper advocates greater public spending for bariatric surgery, noting its
potential to reduce future health expenditure
by preventing disease, disability and death.
It also states that in Australia the majority of
GLP-1 hormone can result
in ‘clinically beneficial’
weight loss
A study published on bmj.com claims that giving overweight
or obese patients the glucagon-like peptide-1 (GLP-1) hormone can lead
to clinically beneficial weight loss as well as reduced blood pressure and
cholesterol levels, as the result of supressing appetite. Researchers from
the University of Copenhagen, Denmark, wanted to determine whether treatment with agonists of GLP-1 receptor resulted in weight loss in
overweight or obese patients with or without type 2 diabetes mellitus
(T2DM).
The investigators examined randomised controlled trials of adult participants with a BMI> 25; with or without T2DM; and who received exenatide twice daily, exenatide once weekly, or liraglutide once daily at
clinically relevant doses for at least 20 weeks. Control interventions assessed were placebo, oral antidiabetic drugs, or insulin. Three researchers independently extracted and utilised random effects models for the
primary meta-analyses. They also preformed subgroup, sensitivity, regression and sequential analyses to evaluate sources of intertrial heterogeneity, bias, and the robustness of results after adjusting for multiple
testing and random errors.
GLP-1
GLP-1 is one of a group of gastrointestinal proteins called incretin peptides that regulate glucose metabolism through multiple mechanisms.
Because of its ability to regulate blood-glucose levels, treatment based
on GLP-1 has recently been introduced for type 2 diabetes. GLP-1R
drugs work by binding to the surface of cells in the pancreas, increasing their secretion of insulin. Recent trials in patients with diabetes have
also suggested they could result in weight loss. The two GLP-1R agonists, exenatide and liraglutide, are both administered by subcutaneous
injection, and have a restricted licence for people with type 2 diabetes.
A total of 25 trials were included in the study and the analysis showed
that patients in the GLP-1R agonist groups achieved a greater weight
loss than control groups (weighted mean difference −2.9kg, 95% confidence interval –3.6 to –2.2; 21 trials, 6,411 participants). They found evidence of intertrial heterogeneity, but no evidence of bias or small study
effects in regression analyses. The results were confirmed in sequential
analyses.
Recorded weight loss was seen in the GLP-1R agonist groups for
patients without diabetes (–3.2kg, –4.3 to –2.1; three trials) as well as
patients with diabetes (–2.8kg, –3.4 to –2.3; 18 trials). In the overall
analysis, GLP-1R agonists had beneficial effects on systolic and diastolic blood pressure, plasma concentrations of cholesterol, and glycaemic
control, but did not have a significant effect on plasma concentrations of
liver enzymes. GLP-1R agonists were associated with nausea, diarrhoea,
and vomiting, but not with hypoglycaemia.
“This analysis provides convincing evidence that GLP-1R agonists,
when given to obese patients with or without diabetes, result in clinically relevant beneficial effects on body weight. Additional beneficial effects on blood pressure and total cholesterol might also be achieved,”
the authors note. “Intervention should be considered in patients with diabetes who are obese or overweight. Further studies are needed to elucidate the effects of GLP-1R agonists in the treatment of obese patients
without diabetes.”
However, writing a editorial to the study on bmj.com, Professor Raj
Padwal, University of Alberta, states, “While these results highlight the
weight-reducing benefits of GLP-1 agonists, they should not alter current practice, “Modification of diet and lifestyle remains the cornerstone
of the treatment of T2DM…continued and close surveillance of these
new agents using all available data sources is warranted.”
bariatric procedures are done in private hospitals, while obesity and associated medical
disorders affect people from disadvantaged
and low-income backgrounds more frequently than those who are affluent.
“Population-based approaches to prevent
obesity should be a priority and funding to
treat severe obesity with medical and surgical
interventions should be made available more
widely,” says the statement.
Diabetes Australia say that bariatric surgery is not recommended for children and adolescents or those who are not physically or
developmentally mature, citing insufficient
evidence as to the long-term safety and effectiveness of bariatric procedures in young people. They also describe access to regular follow-up care as “vital” and recommend that a
comprehensive service with a team of health
professionals including dietitian, surgeon,
physician and psychologist should be available.
SOBA launches
new web service –
Ask SOBA
SOBA (Society for Obesity and Bariatric Anaesthesia), www.sobauk.com, has launched a new service on its website called Ask
SOBA, a service aimed at answering member’s queries about
anaesthesia and critical care for the obese patient. Aimed primarily at SOBA members, it is also open to non-members with general queries.Please email your questions [email protected].
New members are also welcome, Membership costs only
£25 per year and entitles members to:
nReduced subscription to SOBA events
n Quarterly SOBA newsletter
n Access to the beta SOBA
database project
n Access to the discssion forums and educational materials
BARIATRIC NEWS 23
ISSUE 11 | March 2012
CMS to offer obesity screening and counselling
The Centers for Medicare and Medicaid
Services (CMS) has announced that it will cover
preventive services aimed at reducing obesity. This
new benefit will be available without any cost sharing, as with other Medicare preventive services under the Affordable Care Act.
More than 22 million Medicare beneficiaries in
the US received at least one free covered preventive service in 2011. The preventive services currently offered under the Medicare program complement a new joint initiative by CMS and the Centers
for Disease Control and Prevention called the Million Hearts. Medicare estimates that approximately 30 per cent of beneficiaries are considered obese
and that unhealthy weight can lead to a number of
chronic conditions, including cardiovascular disease and diabetes. CMS believes that by addressing obesity now, it can reduce the number of heart
attacks and strokes over the next five years and improve the health of Medicare beneficiaries.
“Obesity is a challenge faced by Americans of
all ages, and prevention is crucial for the management and elimination of obesity in our country,”
said CMS Administrator Donald M Berwick. “It’s
important for Medicare patients to enjoy access to
appropriate screening and preventive services.”
Obesity screening and counselling for eligible
beneficiaries will be offered by primary care providers in the office setting. Patients with a body
mass index (BMI) of greater than or equal to 30kg/
m2 would receive one face-to-face visit for counselling each week for one month as well as a visit
every other week for an additional five months. In
addition, a beneficiary who has lost at least 6.6lbs
during his or her first six months of counselling is
eligible to receive an additional six face-to-face visits over the course of a six-month period.
The Centers for Medicare and Medicaid Services (CMS) has determined “The evidence is adequate to conclude that intensive behavioral thera-
Join
py for obesity, defined
as a body mass index
(BMI) ≥ 30kg/m2, is
reasonable and necessary for the prevention
or early detection of illness or disability and is
appropriate for individuals entitled to benefits under Part A or enrolled under Part B and
Donald Berwick
is recommended with a
grade of A or B by the
U.S. Preventive Services Task Force (USPSTF).
Intensive behavioral therapy for obesity consists
of the following:
1.Screening for obesity in adults using measurement of BMI calculated by dividing weight in kilograms by the square of height in meters (expressed inkg/‑2);
2.Dietary (nutritional) assessment; and
3.Intensive behavioral counseling and behavioral
therapy to promote sustained weight loss through
high intensity interventions on diet and exercise.
The intensive behavioral intervention for obesity
should be consistent with the 5-A framework that
has been highlighted by the USPSTF:
1.Assess: Ask about/assess behavioral health
risk(s) and factors affecting choice of behavior
change goals/methods.
2.Advise: Give clear, specific, and personalized
behavior change advice, including information
about personal health harms and benefits.
3.Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
4.Assist: Using behavior change techniques (selfhelp and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills,
confidence, and social/environmental supports
Your colleagues in beautiful San Diego for
the 29th Annual Meeting of the ASMBS.
This year’s program will exceed all expectations. Anticipate more collaborative
postgraduate courses designed for both the surgeon and the integrated health teams.
You’ll see more symposiums, debates and videos. Plan to participate in lively and
interactive discussions in both the Integrated Health Main Session as well as the
Plenary Session.
This year’s Mason Lecturer, Dr. John Birkmeyer, will speak on Composite Measure in
Bariatric Surgery, and Basic Science invited lecturer, Dr. Robert O’Rourke, will speak
on Obesity Inflammation and Cancer.
YoU Don’t WAnt to MiSS it! SEE YoU in SAn DiEgo!
Visit www.2012.asmbs.org for more information
for behavior change, supplemented with adjunctive medical treatments when appropriate.
5.Arrange: Schedule follow-up contacts (in person
or by telephone) to provide ongoing assistance/
support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.
For Medicare beneficiaries with obesity, who are
competent and alert at the time that counseling is
provided and whose counseling is furnished by a
qualified primary care physician or other primary
care practitioner and in a primary care setting, CMS
covers:
nOne face-to-face visit every week for the first
month;
nOne face-to-face visit every other week for
months 2-6;
nOne face-to-face visit every month for months
7-12, if the beneficiary meets the 3kg weight
loss requirement as discussed below.
At the six month visit, a reassessment of obesity and
a determination of the amount of weight loss must
be performed. To be eligible for additional face-toface visits occurring once a month for an additional
six months, beneficiaries must have achieved a reduction in weight of at least 3kg over the course of
the first six months of intensive therapy. This determination must be documented in the physician office records for applicable beneficiaries consistent
with usual practice. For beneficiaries who do not
achieve a weight loss of at least 3kg during the first
six months of intensive therapy, a reassessment of
their readiness to change and BMI is appropriate after an additional six month period.
Screening for obesity and counseling for eligible beneficiaries by primary care providers in settings such as physicians’ offices are covered under this new benefit. For a beneficiary who screens
positive for obesity with a body mass index (BMI)
≥ 30kg/m2 the benefit would include one face-to-
face counseling visit each week for one month and
one face-to-face counseling visit every other week
for an additional five months. The beneficiary may
receive one face-to-face counseling visit every
month for an additional six months (for a total of
12 months of counseling) if he or she has achieved
a weight reduction of at least 6.6 pounds (or 3 kilograms) during the first six months of counseling.
“This decision is an important step in aligning Medicare’s portfolio of preventive services
with evidence and addressing risk factors for disease,” said Dr Patrick Conway, CMS Chief Medical Officer and Director of the Agency’s Office of
Clinical Standards and Quality. “We at CMS are
carefully and systematically reviewing the best
available medical evidence to identify those preventive services that can keep Medicare beneficiaries as healthy as possible for as long as possible.”
According to the STOP Obesity Alliance, the
overall costs of being overweight over a five-year
period are $24,395 for an obese woman and $13,230
for an obese man. Thirty-four percent of U.S. adults
are obese, according to the alliance, which expects
that percentage to rise to 50% by 2030.
“As small of a weight loss as 5% to 7% can lead
to a huge health improvement,” said Christy Ferguson, director of the STOP Obesity Alliance.
“This is good news for the millions of Americans who struggle with obesity and its serious consequences and for their doctors who care for them,”
said Gary Foster, director of the Center for Obesity Research and Education at Temple University in
Philadelphia.
Although the rule change means that, technically, Medicare beneficiaries should immediately be
able to start receiving the services without having
to make a copayment, in the absence of billing or
coding guidelines, it may prove difficult for physicians to provide or even refer patients for a particular service, Hughes said.
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the Hilton San Diego Bayfront hotel is downtown
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www.2012.asmbs.org
The American Society for Metabolic and Bariatric Surgery designates this educational activity for a maximum of 35.75 AMA PRA Category 1 Credit(s)™ . Physicians should only claim credit commensurate with the extent of their participation in the activity.
Nursing Credits (up to 39.25 CE contact hours) are provided by Taylor College, Los Angeles, California (possibly may not be accepted for national certification).
APA credits and NASW credits for the ASMBS Masters in Behavioral Health Course are pending approval by Amedco. This course will be co-provided by Amedco and American Society for Metabolic and Bariatric Surgery.
24 BARIATRIC NEWS
ETHICON ENDO-Surgery
launches the first solution
for laparoscopic sleeve
gastrectomy designed to
help minimise leaks
Ethicon Endo-Surgery (EES) has launched
the first comprehensive solution for laparoscopic sleeve gastrectomy designed to help minimise leaks. According to the
company, the EES Sleeve Solution provides surgeons with
cutting-edge EES surgical devices, professional education
and resources aligned with the expert consensus on laparoscopic sleeve gastrectomy (see page 1). The Solution is
designed to help minimise complications, deliver the best
possible patient outcomes and enable cost-effective management of the procedure.
The EES Sleeve Solution includes:
nThe expert consensus on technique – Providing bestpractice guidelines from some of the world’s most experienced sleeve surgeons.
nNEW Sleeve Solution Sets – Complete procedure sets
with all the EES devices needed for this procedure, including the ECHELON FLEX 60 Stapler with the appropriate reloads, HARMONIC ACE 45cm Curved Shears
and ENDOPATH XCEL Bladeless Trocars.
n Professional Education – Surgeon and staff procedure
training, including courses, preceptorships and proctorships, aligned to the expert consensus.
n Support Tools – Materials and services to assist with patient aftercare, practice management and on-going education to optimize the procedure and patient outcomes.
“The EES Solution for Sleeve Gastrectomy is truly built upon
science and surgeon insights to deliver both clinical and economic value while maximising outcomes for patients,” says
Eric Bruno, EES Vice President of Global Marketing. “It is
also the first solution designed to help minimise leaks, which
are a major concern for surgeons in this procedure.”
More information about the EES Solution for Sleeve Gastrectomy is available at www.ees.com/eessleevesolution.
ISSUE 11 | March 2012
Product News
Award-winning Bariatric Training Suit improves bariatric care
Benmor Medical has designed a Bariatric Training Suit which will help nursing
staff develop the specific skills required to
safely and effectively manage bariatric patients, by allowing them to practise techniques using realistic scenarios within a
safe environment.
The prevalence of obesity is increasing at an alarming rate and has
reached epidemic proportions globally. This presents a whole new set
of moving and handling challenges
for nursing staff within their daily
work environment as they are increasingly presented with situations where they need to manually
handle bariatric patients.
This management of the bariatric patient population presents many
challenges for nursing staff and requires specific skills that can be difficult to master without hands on experience.
Realistic Bariatric Scenarios
The Bariatric Training Suit from Benmor
Medical will help nursing staff combat these
difficulties by enabling them to train using realistic scenarios and understand the problems
associated with managing a bariatric patient
without actually facing the multiple weight related risks that would apply if using actual bariatric weight during training procedures.
Designed to be worn during training sessions, the Bariatric Training Suit comprises of 3 realistic body sections (arms, torso and
legs) which allow the wearer to experience first-
hand the mobility restrictions a bariatric patient faces
on a daily basis, whilst providing their colleagues
with a pseudo bariatric patient to practise moving and handling techniques without endangering themselves.
The Bariatric Training Suit mimics the
proportions, shape, movement and weight
distribution of a bariatric patient ensuring
that it is particularly useful for staff training of patient transfers and correct use of
moving and handling equipment.
It allows staff to develop appropriate
skills and confidence in the safe handling
and management of bariatric patients
within their facility ensuring that they develop the practical skills and knowledge
required to enable them to move and handle bariatric patients more efficiently.
Award-Winning Response
Despite only being launched in January 2012,
Benmor Medical are already experiencing a high
demand for the Bariatric Training Suit as healthcare facilities appreciate the benefits it can provide
to their staff in order to reduce musculoskeletal injuries and improve the efficiency of care.
This success has further been recognised by
healthcare specialists during the products launch at
the Moving and Handling Conference 2012 in London where it received the ‘Most Interesting New
Product’ award.
The Bariatric Training Suit is now available
worldwide where it will continue to provide effective bariatric training to enable nursing staff to be
fully proficient with handling techniques and procedures prior to admission of a bariatric patient.
BARIATRIC NEWS 25
ISSUE 11 | March 2012
ReShape Medical launches next generation ReShape Duo intragastric balloon
The ReShape Duoin place
David Ashton presenting at ReShape Medical’s Breakfast Symposium
Alberic Fiennes, Jennifer Epp and Richard Thompson
Southern
California- stomach during a simple, fifteen minute He also spoke about the ease of the pro- thereby limit early removals. The dual- serving as built-in portion control.
based medical device man- out-patient procedure.
cedures for placing and removing the balloon design also helps mitigate risk
ufacturer, ReShape Medical, recently
launched its new ReShape Duo intragastric dual-balloon at the British Obesity and Metabolic Surgery Society’s
(BOMSS), 3rd Annual Scientific Conference 2012 held recently (19th and
20th January 2012) at the Bristol Marriott Hotel Royal, UK.
The ReShape Duo is designed for
those patients who have exhausted
their efforts with diets alone and wish
to avoid, or do not qualify for bariatric surgery. According to the company,
the device comfortably occupies existing space in the stomach for six months,
serving as built-in portion control, so
patients feel full and satisfied with less
food. The Duo can be placed in the
ReShape Duo received the CE Mark
in 2007 and the medical device and its
associated procedure has been refined
in association with Professor Franco Favrettiand his team in Vicenza, Italy. The
company has just launched the product in the UK through Healthier Weight
Centres under the care of Medical Director, David Ashton.
As part of the conference, ReShape
Medical hosted a Breakfast Symposium
at which, Dr David Ashton, Medical Director of Healthier Weight gave a presentation introducing the ReShape Duo.
He provided an overview of its features
and benefits and discussed recent medical experience with the device in Italy
and the US, referring to supporting data.
ReShape Duo, details of its effectiveness, how well it is tolerated by patients
and its excellent safety profile.
“ReShape Duo represents a real step
forward, combining dual balloons with
higher fill volumes for the potential of
better weight loss. The ReShape Duo
offers greater comfort and there’s a lower risk of early removal,” said Ashton.
Dual-Balloon benefits
Filled with evenly distributed 900cc of
saline, the ReShape Duo occupies 60%
more space than a single balloon without over-distending the stomach, and is
designed to conform better to its natural curvature to improve patient comfort during weight loss programmes, and
Benmor Medical launches Aurum
bariatric bed at Arab Health 2012
Benmor Medical recently has
launched its new Aurum bariatric bed at Arab
Health 2012 in the ABHI UK Pavilion. According to the company, obesity levels in the Gulf
States are high and rising fast and the World
Health Organisation claims that approximately
a third of the population of the UAE, Saudi Arabia, Qatar and
Bahrain are
considered
obese (the
same proportion
as
the
United
States) and incidence is expected to rise.
The Aurum
4-section electric profiling bariatric bed has been
designed to facilitate safe
and efficient care of the larger patient whose body weight and/
or size exceeds that of a standard
bed. Combining functionality and aesthetics the Aurum is strong and durable
enough for all bariatric care situations,
whilst providing a comfortable environment for improved patient care and tranquillity,
the company claims.
Key features of the Aurum such as width adjustment, integrated weighing and removable/adjustable safety rails provide a safe environment
within which to improve the moving and handling
of larger patients up to 65stone/910lbs/413kg
and ensure ease of care and safer working conditions for nursing staff and carers.
“We are continually driving innovation and
quality within the bariatric market and have established a firm reputation for excellent cus-
tomer support and class leading products,”
said Peter Staddon, Managing Director. “We
are confident that our range of bariatric products will create significant interest in the Middle East healthcare market and allow us to meet
companies who share a passion for our products
and with whom we can develop fruitful longterm relationships.”
Benmor Medical has been supporting bariatric care since 1996 and was the first company in
the UK specialising in bariatric patient handling
equipment. As pioneers within the UK market for
bariatric equipment Benmor Medical has been at
the forefront of the development of products and
solutions that have helped to raise the standards
of bariatric care within the UK. Now the company is taking its range of innovative bariatric solutions to the Middle East.
of migration and/or obstruction. The ReShape Duo has been used successfully
in Europe since 2007 with patients comfortably losing, on average, one-third of
their excess weight in six months.
ReShape Duo procedures
The ReShape Duo can be placed and removed in fifteen minute outpatient procedures under conscious sedation. The
procedures are completely nonsurgical
– no incisions, sutures or scars.
Placement: the un-inflated balloons
are advanced over a guide wire and precisely placed in the stomach. Each balloon is inflated with saline and independently sealed. The device is released and
remains in the stomach for six months,
ReShape Duo availability
Following ReShape Duo’s launch,
Healthier Weight has confirmed that the
Reshape Duo will be available through
its network of weight loss centres
throughout the UK and beyond in London, Birmingham, Manchester, Southampton and Cardiff.
“We were gratified by the genuine interest shown in the ReShape Duo,” said
ReShape Medical President and CEO,
Richard Thompson. “The meeting confirmed that many UK doctors are seeking nonsurgical alternatives to offer
their patients who do not want or do not
qualify for bariatric surgery.”
ReShape Duo is not yet approved for
use in the US.
26 BARIATRIC NEWS
ISSUE 11 | March 2012
Calendar of events
March 11-14
April 20-21
June 17 – 22
September 20-24
10th International Anniversary Expert
Meeting for the Surgery Obesity and
Metabolic Disorders
Second International Symposium
on Non-invasive Bariatric Surgery
American Society for Metabolic and
Bariatric Surgery 29th Annual Meeting
Obesity 2012
Saalfelden, Austria
www: obesity-online.com/expertmeeting
Lyon, France
Phone: 00 33 (0)4 72 01 45 00
Fax: 00 33 (0)4 72 01 45 05
San Diego CA
www.asmbs.org
March 22-25
May 9-12 May
June 20-23
European Association for the Study of
Obesity 19th European Congress 2012
(ECO-EASO 2012)
20th International Congress of the
European Association for Endoscopic
Surgery (EAES)
Rio De Janeiro, Brazil
www: codhy.com/LA/2012
Lyon, France
Phone: +44 20 8783 2256
Fax: +44 20 8979 6700
www: easo.org/eco2012
Brussels, Belgium
www.eaes.eu
April 11-13
May 23-27
Endocrine Society’s 94th Annual Meeting
2nd Latin America Congress on
Controversies to Consensus in
Diabetes, Obesity and Hypertension
2012 (CODHY 2012)
OSSANZ
Darwin, Australia
www: ossanz.com.au
email: [email protected]
American Association of Clinical
Endocrinologists Annual Meeting 2012
Philadelphia, PA
http://am.aace.com
April 20
June 23-26
Houston, Texas
www.endo-society.org
San Antonio, Texas
www.obesity.org
1-5 October
European Association for the Study of
Diabetes
Berlin, Germany
www.easd.org
October 24-26
The 4th Conference on Recent Advances
in the prevention and Management of
Childhood and Adolescent Obesity
Halifax, Nova Scotia, Canada
http://interprofessional.ubc.ca/obesity/
September 11-15
IFSO
New Delhi, India
www.ifsoindia2012.org
SOBA
York, UK
www: sobauk.com
If you would like to place your meeting details here, please email: [email protected]
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EDITORIAL BOARD
Henry Buchwald
BARIATRIC NEWS
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News editor
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