Bariatric Surgery in the Waikato: The 360 o View

1. Bariatric Surgery in the Waikato:The 360o View J Wu*, D Schroeder,** B Gibbison,* J McClymont* Waikato Adult Weight Management Programme* Surgical Obesity Service**

4. Roux-en Y Gastric Bypass Surgery • Restrictive: • 15ml gastric pouch • Malabsorptive • Bypass to ~50 cm distal to DJ flexure

5. Quantity & Demographics • 45 patients (2005-2009) • 31% men: 69% women • Age: 25-64 y/o (48+/-10) • BMI: 44 +/-6. • Ethnicity:

6. Obesity Related Disorders • Diabetes: 90% • Diet: 4% • Orals: 30% • Insulin: 66% • IGT: 7% • OSA: 40% • HTN: 93%

7. Patient Tracking post Surgery • Weight Loss • Health Benefits • Quality of Life (SF36) (2007 onwards) • Complications

9. Weight Loss • Peaks at 1 yr at ~25% of Baseline Weight Loss • Trend to regain some weight long term. • At > 2Y post surgery:

10. Good Losers vs Poor Loosers:What’s the difference? • Formally compared weight loss between: • Ethnic groups • +/- previous AWMP participation • Male vs. Female • Age groups • Baseline Quality of Life Measurements (SF36)

11. What’s the difference? • Formally compared weight loss between: • Ethnic groups - none • +/- previous AWMP participation • Male vs. Female • Age groups • Baseline Quality of Life Measurements (SF36)

12. What’s the difference? • Formally compared weight loss between: • Ethnic groups - none • +/- previous AWMP participation - none • Male vs. Female • Age groups • Baseline Quality of Life Measurements (SF36)

13. What’s the difference? • Formally compared weight loss between: • Ethnic groups - none • +/- previous AWMP participation - none • Male vs. Female - none • Age groups • Baseline Quality of Life Measurements (SF36)

14. What’s the difference? • Formally compared weight loss between: • Ethnic groups - none • +/- previous AWMP participation - none • Male vs. Female - none • Age groups - Yes • Baseline Quality of Life Measurements (SF36)

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16. What’s the difference? • Formally compared weight loss between: • Ethnic groups - none • +/- previous AWMP participation - none • Male vs. Female - none • Age groups - Yes • Baseline Quality of Life Measurements (SF36) - Yes

17. Physical Function & Bodily Pain Scores:Negative Correlation with Future Wt Loss? • r = - 0.68 (rsq=0.47) • Increased physical limitations & bodily pain may predict better future weight loss.

18. Role Limitation due to Emotional & General Mental Health Sum of Scores:Positive Correlation with Future Wt Loss? • r = 0.52 (rsq = 0.27) • Suggests that poor mental health may carry a risk of poor future weight loss.

19. Additional Observations • Patient who tend to lose weight well in the first year, tend to do better long term. • Patients selected early in the programme tended to achieve less overall weight loss than those selected later in the programme. • Formally compare weight loss at 1 Y for patients who received surgery from 2005-7 with those who received surgery in 2008.

21. 2008 vs 2005-2007 Surgeries • Age: No difference • SF36 QOL: • Physical Function Score: • 65 (2005-2007 group) vs 28 (2008 group): p=0.0004 • Addition of Behavioural Therapist at the end of 2007 @ the Surgical Obesity Service. • Better selection of patient?

22. Health Improvements: Diabetes • Cure rate (as assessed by HBA1c) • Diet alone: 100% • Oral Rx: 73% (88%: able to D/C meds) • Insulin: 0% • 60%: able to D/C insulin and onto orals or diet • 40%: decrease insulin usage by 62% • Improvement in HBA1c of those not cured: • 8.9+/-2.3% to 7.4+/-1.5% (p=0.02)

23. Health Improvements: • OSA: • 41% were able to discontinue CPAP machine. • Hypertension • 26% D/C meds • 139/79 to 126/71: p=0.0003 • Urine Microalbumin:Cr • 46% had normalisation of ratio • CRP • 9.8 to 2.8 mg/L: p=0.015

24. Health Improvements: Lipids

25. SF36 QOL Improvements

26. Surgical Complications • No mortalities • Post-operative infections: 6% • Abdominal surgery: 4% (adhesions) • OGD for symptoms of obstruction:16% • 29% of OGD were normal-no cause found

27. Nutritional Deficiencies • Routine supplementation: • All: MVI • Women: Ca & Fe/Folate • No detectable deficiencies • < 16%

28. Other Complications • Post-operative gout attack: 7% • Renal Nephrolithiasis: 4% • Bilateral Peripheral Neuropathy: 2% • Psychological: 16% • DSM Psychological Disorders with MH involvement: 44% • Referral to psychologist privately: 56%

29. Roux en Y Gastric Bypass Surgery:Weight Loss • ~13% fail to lose weight effectively (~20% in literaturef) • Tendency to regain some weight at 2 Y.fj • Younger adults do better • Increased perceived bodily pain & poor physical function prior to surgery – may do better. • Decreased mental health affecting function – may do worse.* FSugerman et al., Am. J. Surg. 1989. 157:93;Brolin et al., Surgery. 1989. 105:337. jMaclean et al., Am. J. Surg. 1993: 165:155.*Herpertz et al., Obesity Res. 2004. 12: 1554.

30. Roux en Y Gastric Bypass Surgery:Health Benefits • Diabetes • OSA • Hypertension • Lipids • Markers of CV risk • Quality of Life

31. Roux en Y Gastric Bypass Surgery:Complications • Of the patients who continue to f/u with > 1 Y data, 12% have had no complications to date.

32. Roux en Y Gastric Bypass Surgery:Conclusions • Care with patient selection • Care with patient preparation for best results & expectations • Continued monitoring for complications • Surgical • Nutritional • Psychological

33. Waikato Diabetes Service Peter Dunn Susie Ryan Adult Weight Management Programme Sharon Moore Surgical Obesity Service Carol Stidolph Andrea Schroeder Ann Monahan Donna Southwick Zola McDonald Acknowledgements