Bariatric News issue 3

ISSUE 3 | DECEMBER 2009 – JANUARY 2010

HEAD -TOHEAD

Sayeed Ikramuddin vs. Greg Dakin

Sleeve gastrectomy staple lines: oversewing vs. reinforcing strips pages 10 - 11

IN THIS ISSUE...

‘Coffee time with… ’

We talk to Professor John Baxter, President of the British Obesity and Metabolic Surgery Society (BOMSS).

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Guest Interview In this issue we talk to Paul Robinson, Consultant Psychiatrist in Eating Disorders.

Plus many more...

New research reveals that practitioners struggle to effectively manage childhood obesity in the UK Over the past few years, the prevalence of childhood obesity has increased and as a result, not only threatens the future health of the nation, but also places a long-term financial burden on an already strained healthcare system.

In the UK, primary care practi-

8

Assessment of bariatric surgery worldwide Five-year review of bariatric surgery worldwide shows laparoscopic adjustable banding is the most commonly performed procedure.

UK primary care practitioners struggle to tackle childhood obesity

14

tioners are viewed as having a role to play in the management of childhood obesity. However, some practitioners have questioned if primary care is an effective treatment setting for childhood obesity, and whether primary care professionals have the resources to deal effectively with the disease.

In addition few people have explored in detail practitioners’ views and experiences of managing this condition in primary care.

New research, led by Dr Katrina Turner from the University of Bristol, UK, has assessed primary care practitioners’ views and experiences of treating childhood obesity. In a recently published paper, entitled ‘Practitioners’ views on managing childhood obesity in primary care: a qualitative study’ (British Journal of General Practice, 2009), Turner and colleagues Drs Julian Shield and Chris Salisbury (University of Bris-

meaningful impact on the primary care management of childhood obesity.

Previous researchers have assessed the views and experiences of primary care practitioners in treating childhood obesity. However, to date only two studies have employed qualitative research methods to examine these views and experiences in detail. Also, the research undertaken so far in this area has been limited to assessing only the views of GPs and practice nurses, and was carried out before the publication of the obesity care pathway and NICE guidance.

tol, UK), interviewed GPs (n=12), practice nurses (n=10), school nurses (n=4) and health visitors (n=4), to explore their views.

Turner and her team reported that practitioners felt they could not intervene effectively due to lack of expertise, resources, and contact with primary school children, the causes of childhood obesity and the need to work with parents.

Department of Health and NICE guidance In the UK in 2006, the Department of Health produced an obesity care pathway for children and adolescents to be used by primary care practitioners and the National Institute for Health and Clinical Excellence (NICE) published guidance on the management and treatment of obesity. The current study showed that many primary care practitioners are unaware of this guidance, suggesting that it is unlikely to have a

Study results According to Turner, all the participants in the study commented that they were Continued on page 3

Message from the editor Welcome to the final issue of Bariatric News for 2009. This year has been an important one for the publication. We launched in May and after two issues our readership has grown to almost 2,500 worldwide. We have had the opportunity and pleasure to work with a number of key opinion leaders in the field, and have received positive feedback from societies and organisers of national and international meetings.

In this issue, our cover story discusses the impor-

tant issues faced by UK practitioners when dealing with childhood obesity. Mr Paul Super, Birmingham, UK, and Professor Paul Gately have provided commentaries on the topic, which you will see on page 3.

On page 4 we have introduced a new ‘Patient Focus’ segment. This segment enables bariatric surgery patients to voice their opinions on the various procedures that they have undergone. Our first patient discusses his experience with the gastric band.

In our ‘Coffee Time’ segment (page 6), Professor John Baxter, President of the British Obesity and Metabolic Surgery Society (BOMSS), discusses the grow-

ing obesity problem in the UK; what he has achieved as President of BOMSS; and his current areas of research.

Paul Robinson, consultant psychiatrist in eating disorders, is interviewed in our ‘Guest Interview’ segment. He discusses the importance of addressing the psychology behind obesity in order to help patients deal with the repercussions following bariatric surgery.

His interview is featured on page 8.

On pages 12 and 13, we examine the obesity, diabetes and hypertension rates in the West and Mid-West states of the USA.

We hope you enjoy this issue, which is also the last issue I will be editing before I go on maternity leave. I would like to introduce my colleague Owen Haskins, who will be managing the publication while I’m away.

Melissa Griffiths Managing Editor

If you would like to contribute to the next issue of Bariatric News (March Issue), please feel free to contact Owen at: owen.haskins@e-dendrite.com.

BARIATRIC NEWS

ISSUE 3 | DECEMBER 2009 – January 2010

3

UK primary care practitioners struggle to tackle childhood obesity Continued from page 1

concerned about childhood obesity, however, there seemed to be some variation depending on patient population. For example, GPs working in the most deprived areas emphasised that they should address childhood obesity because they had a ‘community responsibility’.

Some participants believed that primary care was an appropriate treatment setting for treating childhood obesity, mainly because it is community-based; because GPs were known to families and could refer patients on to others for further support; and because obesity needed to be addressed before associated clinical complications developed.

One participant explained: “It [childhood obesity] needs to be tackled before the problems arise, otherwise you’re dealing with a child who has clinical problems due to obesity, and we need to be preventing those, we need to be tackling the problem so that those problems don’t arise.”

Primary care as a treatment setting Turner explained that GPs, practice nurses, and health visitors were described by themselves and by others as being able to opportunistically mention a child’s weight and provide advice, support, and follow-up. However, some GPs, practical nurses and a school nurse felt primary care was not a suitable treatment setting. They commented that they and other primary care practitioners did not have the expertise or time to treat childhood obesity, and had no effective treatment to offer.

One practice nurse said: “I haven’t got the expertise in what to do and what not to do, and the time to do it all.”

A school nurse commented: “We deal with so much with child protection and child and adolescent mental health referring that we have very limited time for health promotion. Health promotion is just like the icing on the cake.”

And one GP explained: “I don’t have a way of them losing weight…..I’m motivated to treat things I think I might be able to make a difference with and I think my problem with this is I am not convinced I can make a difference.”

Furthermore, Turner noted that GPs argued about the financial aspect of treating childhood obesity in a primary setting.

Some felt it was “imprudent” to place treatment in primary care; others believed this would create the wrong mindset among patients.

A practice nurse said: “It’s not an illness they’ve got and it’s a life change that they need to make, so I think they don’t need to see it as a come here, get fixed, and then go back to where they were.”

Some school nurses stated that they could not focus on childhood obesity because they needed to prioritise child protection and child adolescent mental health.

One explained: “I’ve got a child that’s going into care…I’ve got another child that’s come to me because he’s hearing voices and they’re telling him to do bad things, you have to prioritise those….childhood obesity becomes way down the list.”

Another issue was the limited appointment times available to treat patients.

“I’ve got ten minutes, or I probably haven’t got ten minutes because they have probably come with something else and we have dealt with that and there’s now two mintues left…you are not going to actually have any lasting impact because that’s two minutes against ten years of life.” – commented one GP. Causes of childhood obesity The participants described the main causes of childhood obesity as an unhealthy diet and lack of physical activity. These in turn were related to factors that were beyond their influence, such as the availability of junk food, unsafe streets, and a lack of family cohesion. Some also believed that foods in supermarkets and pre-packed food, easy to cook foods, were also a contributing factor. Safety was another issue, whereby parents would prefer to pick their child up from school rather than have the child walk home from school.

Conclusions Turner and colleagues concluded that primary care can only play a limited role in addressing the current obesity epidemic. For progress to be made, greater effort needs to be in place to address the causes of childhood obesity and to develop effective interventions that can be delivered outside, as well as within, the primary care setting.

Comment by Mr Paul Super

Comment by Professor Paul Gately

Consultant Surgeon, Spire Parkway Hospital and Healthier Weight Centre, Birmingham, UK

Director of Carnegie Weight Management, Leeds Metropolitan University, UK

The recent study into practitioner’s per-

ception on childhood obesity highlights the problems faced in the UK in dealing with obese children. Whose role should it be to re-educate a generation of young people who are destined to be obese adults of tomorrow?

GPs questioned in the study are too busy and few were aware of the NICE guidance on the pathway of care for obese children. As in most areas of healthcare in the UK there are great pressures to treat existing illness and less investment in healthcare prevention. Tackling obesity (as a risk factor for future obesity related illness in later life) is an example of such health prevention measures and GPs are probably not the best individuals to be doing this.

What this study highlights is the lack of clear strategy and investment in dealing with the problem in the preventative setting. Current resources in primary care are ill equipped and already stretched to deal with such a massive problem. The obese children of today are destined without intervention to become our most obese cases of tomorrow.

Tackling childhood obesity surely must involve better education of parents as well as the children themselves.

The existing environment has to change.

Strategies towards this goal therefore must encompass education of our entire society

with public education and mass media coverage. Perhaps what is really required is hard hitting media coverage which depicts young adults with severe sleep apnoea suffocating in fat, coverage of multiple adolescents self injecting insulin because of type II diabetes and vivid examples of people unable to walk because of their size. Images of young people having strokes and MIs before their parents would be hard hitting and surely influence those watching.

With gradual change there would be some hope that our infants of the future can be borne into a completely different environment with less exposure to those factors which we all know results in the development of childhood obesity.

"What this study highlights is the lack of clear strategy and investment in dealing with the problem in the preventative setting."

EDITORIAL BOARD

BARIATRIC NEWS

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Dendrite Clinical Systems

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Owen Haskins

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2009 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, comments and opinions expressed within are not those of Dendrite Clinical Systems or the Editorial Board.

Obesity has been described as a modern day plague. The findings outlined by Dr Turner provide evidence of some of the challenges associated with addressing this public health issue. Whilst significant effort has been placed on top level reviews of the obesity issue (The Foresight Report in 2007) and a national obesity strategy (Healthy Weight, Healthy Lives 2008), these world leading reports have not yet been built upon to ensure effective local strategies and implementation plans are in order to systematically tackle childhood obesity. Given primary care is operating at this local level the findings of Turner are not surprising. Whilst a few examples exist, namely the award winning strategy developed by NHS Rotherham and adopted by the National Obesity Forum, even this strategy requires further development and a national roll out is clearly necessary. In addition, as Turner outlines there is a serious lack of qualitative research at a primary care level to ensure evidence based practice.

A study by Smith et al showed that 75% of healthcare professionals underestimate overweight children, whilst 50% underestimate the weight category of obese children. This demonstrates a lack of awareness in these key professionals who may seek earlier intervention if they were better informed. This is linked to the point that Turner also highlights that many primary care practitioners are not aware of the availability of effective and evidence based programmes. Our own experience tells us that even if primary care practitioners are made aware of services the referrals from these practitioners are relatively low, thus further work is necessary to support this referral process when evidence based programmes are available.

Despite the shear volume of information associated with weight management in the media, general press and academic literature, many primary care professionals tell us they require further support and training in terms of the confidences and capabilities to identify and target obesity. This should come as no surprise as there is a lack of training for professionals during their initial training or continued professional development in this area.

Turner also highlights the importance of recognising the additional needs of some.

There is clear acknowledgement that obesity is difficult to address as levels of need increase and so does the amount of support required. However, this is often not reflected in many local obesity strategies that tend to focus on a ‘once size fits all approach’. The strategy of NHS Rotherham does appreciate the importance of a care pathway that recog-

nises different levels of need so there is evidence of good practice.

Turner highlighted the difficulty primary care practitioners face as they attempt to balance their priorities. Often when faced with issues such as child protection or mental health problems, obesity is prioritised as less important as there is no perceived immediate need for action. This demonstrates not an unwillingness of the practitioner but a lack of focus within the system. This is even more important given the overwhelming numbers of children that have a weight problem. Using data from the National Child Measurement Programme, which is now collected annually on 5 and 11 year-old children in England, it is estimated that there are 4.5 million children who are overweight or obese, 2.8 million that are obese and 140,000 that would be defined as severely obese in the UK. Turner's study is helpful as it is provides some well needed clarity. It would appear that there is a lack of clear local obesity strategies that are owned by both the Primary Care Trust and Local Authority. There is also a lack of training to support primary care practitioners and the care pathway to effective treatment based on need is not widespread.

Based on these challenges it is unsurprising that primary care practitioners feel that their contribution is not as impactful as they would like it to be. However, it is clear that primary care practitioners are well positioned and can make a significant contribution to tackling childhood obesity if the many barriers to action were removed.

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BARIATRIC NEWS

ISSUE 3 | DECEMBER 2009 – January 2010

Patient Focus Bariatric News up until now has purely focused on technical articles dedicated to the management of obesity and its associated diseases. In this issue, we would like to introduce a new segment that will offer patients who have undergone any surgery the opportunity to tell their story. We feel that providing this information will help bariatric healthcare professionals to understand how the patient feels throughout their experience, and enable better communication between the patient and multidisciplinary team, therefore improving outcomes in the long-term.

Bariatric News welcomes Peter McCarthy from Barnet, Herts, UK, who has kindly agreed to share his story….

“My journey started in January

2006, when after several attempts to try and lose weight I finally went to see my GP. At this point I was 29.5 stone and suffering terribly from back and knee pain. I was unbelievably depressed as my weight stopped me from doing simple things, such as playing ball in the park with my son, walking to the local shop and even affecting my work. I basically became a cripple. My GP advised me on different options and referred me to a gastric surgeon at the Whittington Hospital, London UK. My BMI at this time was 73 so I was classed as morbidly obese. Between seeing my GP and going to the hospital for my first appointment, I researched all the options given to me by my GP and decided that the gastric bypass was my best option. I was pleased to hear that by my first appointment my funding had been agreed by my primary care trust (PCT) (Barnet, UK) and so the process started.

I had several appointments over the next 12 months seeing different doctors and making sure I was mentally aware of the procedure and to see if I indeed was a suitable candidate for surgery. I

was eventually put on the waiting list in March 2007 with a warning from my surgeon that if I put just one pound in weight on, I would be removed from the waiting list. I therefore lost two stone for my surgery.

I was 27 stone at the time of my surgery, which took place on Wednesday 31st October 2007.

The surgery went well and I was sent to the intensive treatment unit (ITU) that evening. I was surprised that I was not suffering from a lot of pain and felt that the surgery was the start of a new ‘me’. I was administered fluids for the two weeks after my surgery and then progressed onto soft foods. I lost nearly two stone within six weeks of surgery and the weight just continued to fall.

For the first 12 months I can honestly say that I did not feel any hunger at all but I ate only because I knew I had to. Now I can only eat small amounts at a time and some days I can eat slightly more than others. I am taking multi-vitamins, iron and calcium supplements every day and I receive a B12 injection every three months from my GP. The hardest part of my journey has been my

attitude towards food, I still think I can eat the big meals but physically I know I can’t and that is very hard to deal with as a person who used to be able to eat very large portions of food. I do miss food very much and to be honest I have struggled a lot to get my thinking around this fact. I have suffered from dumping syndrome on several occasions through trial and error as I discovered what my body could deal with. I am still learning today what I can eat and not eat.

The best thing about my journey is the reaction from friends and family I have not seen for a long time, as they cannot believe it is me, and the fact that I can now buy and fit into my beloved Arsenal Football Top. I currently look and feel fantastic and I am asked do I ever regret it. I reply that my only regret was not doing it sooner.

I have great admiration for my surgeons (Mr Sufi and Mr Heath) and my dietician Mrs. Ella Segaran and last but not least Kirsten McDougall, our nurse. I attend the monthly support meetings and am glad to speak to and pass on my experiences to others thinking of having the surgery done.

The surgery has given me back my life and gave me a stronger bond with my son as we can do more things together and for me that is the best gift of all.

I will be forever grateful to the team at the Whittington Hospital.”

Peter McCarthy

Peter’s stats BEFORE SURGERY Weight:

27 stone

Waist:

56 inches

Neck:

22 inches

Chest:

58 inches

Peter’s stats TODAY Weight:

15.5 stone

Waist:

36/38 inches

Neck:

16.5 inches

Chest:

42 inches

Discussion The surgery For an obese patient to make the decision to undergo surgery in an attempt to loose weight and avoid future obesity-related illnesses, it can be very confusing, confrontational, and frightening.

The surgery itself is daunting, however, what happens afterwards can be even more worrying for the patient. They will have to cope with a considerable lifestyle change, their relationships may also change, and they may not be able to maintain long-term weight loss. Although Peter is now happy that he underwent gastric bypass surgery, he did experience problems during his treatment, and still regularly battles food.

Before Peter decided on which bariatric procedure he wanted, he conducted a lot of research himself. End the end, he chose to have a gastric bypass procedure. He commented, “I did a lot of research via the internet and watching documentaries on the Discovery Channel, so I had already made up my mind as to which procedure I wanted. The surgeon recommended that a gastric band would be the best option but I insisted on bypass surgery. After a few tense minutes of giving my reasons he accepted that I would benefit more from a bypass. I decided to have gastric bypass because of my failures with diets before. With a band you still needed to watch what you eat and the amount you eat, for the rest of your life. The band is also reversible, so if you are weak minded (like me) and missed your treats too much you can simply have it removed. Also the success rate with the band compared to bypass was pretty low. With bypass the results are virtually guaranteed. In my case I wanted something permanent and this was my best option.”

Although Peter occasionally suffers from dumping syndrome, he has never suffered from bleeding, ulcers or any other related problems.

Overall, he seems to be happy with the entire process, although he did have some ideas for improvements. “I feel that people thinking of having the surgery [gastric bypass] should have more counselling both before and after the procedure, and particularly focus on how their relationship with food will be affected. I feel that from the support group that I regularly attend, this seems to be

the main concern that most people share and need support with. Although I had a terrific dietician, I was not made fully aware of how the surgery would affect my eating habits.”

Peter is now enjoying a more active lifestyle since his surgery two years ago, and no longer suffers from pains in his knees and back when he plays football and other activities with his son.

Since the operation, he has become more aware of the wrong and right foods, however, he does admit that his eating habits vary from day to day and his diet is not always healthy. “I would say that I am not eating better but I am eating healthier as my surgery has stopped me from eating sugary things,” he explained. “My eating habits vary but I would say I am enjoying a healthier lifestyle.”

Relationship with food When a patient decides to undergo surgery to combat their problem with obesity, it is inevitable that their relationship with food is affected post-surgery. Some people are capable of ‘retraining’ their minds through various cognitive behavioural therapies and other ‘talking therapies’ to change how they feel about food, however, others still have the psychological attachment to eating the wrong foods and the wrong amounts. Peter explained, “I now feel full after eating but never the satisfying feeling I used to get before the surgery. I sometimes feel nauseous if I have eaten too much and I have on occasion been sick. After eating I do become disinterested in food, but only for a short while. I don’t think that even after two years since surgery I have fully trained my mind into thinking I have had enough. I always think I can eat more than I physically can. I still crave food so much and especially all the foods that made me big in the first place and to be honest, I don’t think that will ever change, The only thing I can try and change is how to handle those cravings. Not easy!”

When asked about why he became obese in the first place, Peter said that it was mainly due to lack of education about food and the affects certain foods can have on weight. “I was affectionately known as ‘Fat Peter’ within the family, as

there were a few ‘Peters’ and this was the way the family identified us. I was always big and not very active and as I grew older, I just accepted that this was the way I am. After a while I basically just stopped caring.”

He also believes that the food industry should bear some of the responsibility for his weight gain. “I think the food industry has a lot to answer for. They created cheap food that is made readily available through their outlets all over the country, and we all know that this cheap food is designed to appeal to a broad spectrum of people. I know now that these same fast food outlets are trying to tap into the healthy options market, but they will always realise that the unhealthy options will produce the most profits so it will always be available to those who want it.”

There have been some significant movements recently within the fast food industry in the UK to support the public in making healthier choices in an effort to reduce rising levels of obesity and dietrelated illness. This was discussed at the National Obesity Forum in October (see page 15). The outcome was that certain food chains will display the number of calories for all their food products, including take-away options. Peter commented, “I am not sure if having calorie information on menus in restaurants will make much difference as I feel that people who go out to a restaurant for a meal do so as a treat and therefore will not take any notice of such information. I have noticed some fast food outlets have produced calorie information on their products but print them on separate leaflets away from the counter – never on the menus!”

Obesity-related illnesses It is commonly recognised that many obese people also suffer from co-morbidities such as type 2 diabetes and hypertension. Peter was a previous sufferer of sleep apnoea but since his operation he no longer suffers from the disorder.

“I have been lucky as I did not suffer from diabetes or hypertension but I did suffer terribly from sleep apnoea and I was a terrible snorer. This caused endless arguments between my wife and I. She said she would hear me stop breathing while

asleep for anything up to 7–10 seconds. I never noticed a thing. Since my surgery I am happy to report that my snoring has stopped completely (much to the delight of the other half) and my sleep apnoea has cured itself completely.”

The future Having surgery to combat obesity is not just simply a ‘quick fix’ option. Patients also have to undergo serious lifestyle changes in order to maintain weight loss in the long-term. Some patients will need ongoing counselling through patient support groups and private psychologists. In addition, most patients will need to take supplements for the rest of their lives. Peter explained, “I don’t know if I will require ongoing help or counselling for the rest of my life but I am happy that help is only a phone call away with Kirsten [bariatric nurse] being available to help in any way possible. Also the support group each month has been fantastic as it helps me to help others, which in a way for me is counselling in itself. As for vitamins and B12 injections, I have been told that I will need to take vitamins and iron supplements for the rest of my life, along with calcium supplements. I have been told that the B12 injections will be every three months for life, but after speaking to others at the support group this may not be the case.”

To conclude, we spoke to Peter about his relationship with his son and whether he now believes that educating him about healthier food options is important. “My lifestyle has changed so much for the better and so has my relationship with my son.

He keeps telling me how much nicer I look and we do so many more things together now. I feel I have bonded with him more, and I like to think he might be proud of his dad. I try to be responsible with him about what he eats but like any parent, I allow him to have treats every now and then, but he is a very active little boy who is mad on football. I identify the foods that are bad for him and explain why, using myself as an example.”

If you have a patient who would like to share their story, please email Owen at: owen.haskins@e-dendrite.com

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BARIATRIC NEWS

ISSUE 3 | DECEMBER 2009 – January 2010

Coffee time with

John Baxter Why did you decide to specialise in bariatric surgery?

I had such good results from some preliminary experience with this type of surgery that I decided to pursue it. Also there was a gross lack of surgeons with this specialty interest which was also a factor.

Who have been your greatest influences and why?

I did not have an early role model but as time went by I was very impressed with Walter Poiries and his published results in relation to diabetes amelioration. I was also impressed with the professionalism of Nicola Scopinaro and his attempts to develop a new operation to maximise the benefits of bariatric surgery.

What experience in your training has taught you the most valuable lesson?

That operating on these patients can rarely lead to serious complications and possible death. This confirmed to me the very real need for careful patient selection and particularly education of the patients prior to surgery.

Tell us about one of your most memorable surgeries?

Operating on a young boy (16) who had uncontrollable diabetes, sleep apnoea and type II respiratory failure. He clearly was unlikely to live more than a few more years. He was

The ‘Coffee Time’ segment in Bariatric News is dedicated to the Presidents of national and international bariatric and metabolic societies. Here, we take the opportunity to highlight the important roles of a President, and we allow them to discuss their achievements, concerns and future ambitions of their society. In this issue, we talk to Professor John Baxter, President of the British Obesity and Metabolic Surgery Society (BOMSS)….

one of my early laparoscopic sleeve gastrectomies and has subsequently resolved all his co-morbidities. He was subsequently on national television which also helped to highlight the effectiveness of this type of surgery.

What are the biggest challenges facing bariatric surgery?

Firstly getting adequate National Health Service funding to allow a fairer distribution of this treatment to the public. Currently around 50% of all bariatric procedures are performed in private which is not ideal for a socialised healthcare system such as ours. New ideas to allow more NHS funding such as part payment should be considered.

Secondly, there is a need for centres performing this surgery to increase their numbers to drive down complication rates.

Thirdly, although there are good data in existence about the effectiveness of bariatric surgery we need more UK-based data about cost effectiveness.

Fourthly, undoubtedly newer treatments will be developed such as incision-less surgery, endoscopic surgery, etc which will bring further pressures to assess their effectiveness.

Fifthly, the passionate debate about restrictive versus bypass surgery needs resolution with further studies in the UK. The selection of the type of surgical procedure to

perform for a given patient is still a dark art which urgently needs some clarification.

How have you seen the speciality change over the last five years?

There has been much more interest from younger surgical trainees in learning to perform this type of surgery which bodes well for the future. The conversion from open to laparoscopic surgery is now almost complete.

How should we tackle the growing obesity problem in the UK? Worldwide?

Clearly there needs to be a multifaceted approach to this approach with public education on the dangers of obesity and more attention paid to prevention of morbid obesity development in those who are predisposed.

Surgery should always be a last resort and I think some borderline patients could avoid surgery with more public resources being put into non-surgical methods of treatment.

What have you achieved as President of BOMSS (British Obesity and Metabolic Surgery Society), and what do you hope to achieve in the near future?

The greatest personal achievement is that of founding the BOMSS which is a good platform for developing the specialty by attracting members who are committed to the principles of the society. We have had

roles in training, developing the national database, establishing the NICE guidelines, establishing the NHS commissioning principles, giving advice to commissioners and other interested parties. We have always run an annual meeting which is well attended and next year will have our first stand-alone meeting. We are also working hard on developing minimum standards for bariatric units which meet our UK requirements.

What are you current areas of research?

I have an active research programme looking into insulin resistance after restrictive and bypass surgery. We are also interested, as many others are, in the precise method of how bypass surgery causing almost immediate cure of type II diabetes.

Would you like to make any additional comments?

I am due to demit office shortly after several years as a council member. Mr Alberic Fiennes (UK) who will take over will bring further skills to building up the BOMSS which has a rapidly rising membership. We are also expanding the BOMSS council to get more representation from members as we have now passed the phase of a fledgling society and now need to mature and take forward the society’s agenda.

Experts in Severe & Complex Obesity (ESCO) taskforce is launched First ever multi-disciplinary group to improve access to treatment for severe and complex obesity in England A taskforce has been set up to promote equitable access and viable funding for the treatment of people with severe or complex obesity on the NHS. The group, called ESCO (Experts in Severe and Complex Obesity) was launched at the National Obesity Forum’s Annual Conference, held in London in October, and called for action to tackle the current situation.

The group, which combines experts in the fields of surgery, endocrinology, dietetics, psychology, gynaecology and health economics, advocates the equitable access to high quality, multi-disciplinary treatment for people with severe and complex obesity in England. The group also aims to work towards full implementation of the clinical guidelines issued by NICE in 2006. These guidelines include evidence-based advice on the value in providing treatment with drugs and bariatric surgery.

ESCO will work towards solutions and improving outcomes for patients being treated for severe or complex obesity, based on pragmatic, evidence based pathways. With official endorsement from influential groups, ESCO will have an authoritative overview for the treatment of the severe and complex obese and will support each group in formulating and promoting its strategy.

Nick Finer, Consultant Endocrinologist and Chairman of ESCO announced the group’s plans: “ESCO will advise on long-term solutions to improve patient monitoring, standards of care and further research in health economics centred on a multi-disciplinary approach. We aim not only to develop achievable solutions but to change perceptions – that these treatments can put conditions like type 2 diabetes into remission, so weight loss alone should not be just seen as an endpoint.”

The Department of Health estimates that around 58% of type 2 diabetes, 21% of heart disease and up to 42% of certain cancers (endometrial, breast, and colon) are attributable to excess body weight.

Severe obesity is defined by NICE as a BMI

Nick Finer

of over 40 or a BMI of 35 and over with an associated condition, such as type 2 diabetes or high blood pressure. Severe obesity and these associated conditions have huge impact on wider society. It has been estimated that the cost of obesity to the NHS in the UK is approximately £4.2 billion and it is predicted that this will more than double by 2050. It is estimated that weight problems already cost the wider economy in the region of £16 billion, and that this will rise to £50 billion per year by 2050 if left unchecked.

“Our focus that evidence-based healthcare should reach that severe and complex obese population who have explored and tried all alternative solutions but without success,” said David Haslam, Chair of National Obesity Forum and ESCO member.

In England, according to NICE, of the 1,010,000 severely and morbidly obese population, there are currently 230,000 people both eligible and willing to have surgery. However this year, fewer than 2% of these patients will actually receive treatment.

Treating severely obese patients with bariatric surgery has been shown to be more cost effective for healthcare systems than the long-term treatment of the chronic obesity-related illnesses such as type 2 diabetes, heart disease and cancer.

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ISSUE 3 | DECEMBER 2009 – January 2010

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Ethical concerns with paediatric bariatric surgery: Reversing co-morbidities is key “Children and adolescents with morbid obesity are high-risk to remain obese in adulthood,” said Dr Donna Caniano, Ohio State University College of Medicine, OH, US, during her presentation at the Chronic Diseases in Childhood Obesity: Risks and Benefits of Early Intervention Symposium, Columbus, Ohio, US. Her research into ethical concerns and bariatric surgery, found that the primary goal when treating childhood obesity should be to reverse co-morbidities of morbidly obese children and the secondary goal to maintain a healthy weight in the long-term.

“The decision to proceed

with bariatric surgery in paediatric patients carries profound ethical burdens for all stakeholders, such as morbidly obese children and adolescents, their parents and families, paediatric physicians and surgeons, paediatric healthcare institutions, and society,” said Caniano.

“Therefore, the decision for bariatric intervention should be made only after it is established that the patient’s co-morbidities could not be treated with less invasive means, the patient has a favourable risk/benefit profile, the patient and her/his family have received extensive pre-operative counselling and given informed consent, and the paediatric bariatric team has a comprehensive system of short and long-term care.”

In the US, it has been found that one third of morbidly obese children are socially disadvantaged, particularly African-American girls, Hispanic and Native American children (Blacksher E Ethical and political challenges to seeking justice. Hastings Center Report 2008; 38:28–35). There are also significant disparities in adults with morbid obesity who undergo bariatric surgery; fewer among African-Americans, Hispanics, males and low-income children.

Given this, Caniano explained that society accords parents broad-decision making power for their children, and rarely intercedes in matters of family choices. She asked, “Could parental

failure to comply with weight reduction either by medical or surgical means be construed as medical negligence?” In response, she referred to two cases from Texas and New Mexico in which morbidly obese children were placed in foster care when parents could not maintain calorie reduction diets and weight loss.

els – community outreach, school lunch programmes, and physical education programmes; oversight for bariatric programmes to ensure appropriate patient selection, safety, and long-term care; and to promote basic science and clinical research in the prevention and treatment of obesity, explained Caniano.

Medical community Today, the medical community should acknowledge obesity as a global epidemic, however, medical care is disproportionate among groups with healthcare access limitations, said Caniano. In order to accept that obesity is now a major healthcare issue, the medical community will require a new way of addressing paediatric healthcare, such as, defining the roles and responsibilities of major paediatric professional organisations, and implementing changes in paediatric medical education. Furthermore, focusing on prevention, as a key priority should also be part of the medical training strategy, as is identifying the morbidly obese and referring them to appropriate paediatric obesity centres. Also, the establishment of transparent mechanisms for review of outcomes, complications, and development of better surgical techniques and operations is a necessary step forward to help provide better standards of care for paediatric patients.

Other medical community ‘responsibilities’ include: advocacy at several lev-

Healthcare institutions In addition, Caniano believes that healthcare institutions should be more involved in combating childhood obesity.

Allocating a provision of adequate resources for high quality bariatric services is one issue that should be managed by such institutions. Others include supporting innovation and research trials, supporting data collection, growing to be a community leader in weight reduction programmes, and provide full support for the medical community’s efforts for oversight and transparency of results and outcomes.

Paediatric bariatric surgeons The role of paediatric bariatric surgeons should uphold the principle of beneficence through thorough assessment of metabolic, and cardiovascular co-morbidities; as well as uphold the principle of non-maleficence, i.e. Can the adolescent patient fully comprehend the risk/ benefit profile for a bariatric operation?

Additionally, a team approach is necessary for assessment of patient maturity

and understanding of the operation, said Caniano.

Informed consent Another important factor to consider is informed consent. This includes educating the patient and their parents or guardians as clearly as possible, when discussing the following:

• Risk/benefit profile • Post-operative compliance and lifestyle • Alternative or no surgical treatment, financial aspects of bariatric surgery • Short- and long-term follow-up • Candidacy for clinical research trial(s) Other factors to discuss include: • The irreversible nature of RYGB • Unknown negative consequences of operation in the future • Understanding of what a serious complication could mean for the patient • Plan for who will care for the patient during later adulthood • The patient’s ability to retain information Role of parents According to Caniano, society assumes that parents are in the best position to make medical/surgical decisions for their child. Society also expects parents to be active participants in their child’s healthcare, and expects parents to support necessary dietary and lifestyle

Donna Caniano

changes for successful post-operative outcomes. “There is an ethical burden of helping a child deal with co-morbid conditions, as well as helping them through the extensive pre-surgical evaluation process,” commented Caniano. She added that there is also an ethical burden of helping and understanding the risk/benefit profile of bariatric surgery, and an ethical burden of decision making for the specific bariatric operation.

Conclusions To conclude, Caniano explained that the primary goal of treating childhood obesity should be to reverse co-morbidities of morbidly obese children and adolescents, and the safest bariatric operation should be chosen to accomplish the goal for each individual patient. However, there should be acknowledgement that a surgical option should not be the first line treatment.

Sleeve gastrectomy growing in popularity as primary procedure More surgeons are using sleeve gastrectomy as a primary operation as well as a first-stage procedure in high-risk or super obese patients A recent systematic review of sleeve gastrectomy (SG) as a staging and primary bariatric procedure has shown that it is an effective weight loss treatment for high-risk or super obese patients, also leading to the reduction in co-morbidities. The review was published in the Surgery for Obesity and Related Diseases journal (2009).

In the study, lead author Dr Stacy Brethauer, Cleveland Clinic, OH, and colleagues Drs Jeffrey Hammel and Philip Schauer, also from Cleveland, evaluated the current evidence regarding weight loss, complication rates, post-operative mortality, and co-morbidity improvement after SG. They explained that the advantages of the SG procedure are that it immediately restricts calorie intake, does not require placement of a foreign body or require adjustments, and can generally be performed in less time than required for bypass procedures. However, the potential disadvantages include irreversibility, increased operative risk compared to other restrictive procedures, and lack of long-term data regarding durability.

Study design According to Brethauer, the review was conducted by searching published data using PubMed, and then statistical analysis was performed only on the extract-

ed data from the selected studies).

After the initial screening of titles and abstracts, 2,968 citations were excluded, and 130 studies were reviewed to determine whether they met the inclusion criteria, explained the authors.

Of the 130 studies, 92 were excluded during this phase, and of the 92 excluded studies, 13 were kin studies, substudies of a larger series, or duplicate patient groups from the same institution or group. In the end, 36 SG studies, including 2,570 patients were included in the current analysis. Of the 36 studies, 16 were from Europe, 11 were from the US, three from Asia, two from Australia, two from South America, and one each from Israel and Saudi Arabia. Furthermore, 32 studies reported the patient gender (n=2,135), in which 64.5% of the patients were women.

Results: Weight loss and co-morbidity reduction According to the authors, the mean %EWL after SG was reported in 24 studies (n=1,662) ranged from 33–85%, with an overall mean %EWL of 55.4%.

They also found that the mean post-operative BMI was reported in 26 studies (n=1,940) and decreased from a baseline mean of 51.2kg/m2 to 37.1kg/m2, postoperatively. “Those studies that did not include the %EWL reported the weight

loss in terms of the BMI decrease, the percentage of BMI lost in terms or the percentage of the total weight lost, and all had significant reductions in weight from the baseline values,” stated Brethauer.

In terms of co-morbidity reductions, ten studies provided detailed post-operative co-morbidity data (n=745) with a follow-up period of 1–5 years. The authors found that more than 70% of patients in these series had improvement or remission of Type 2 diabetes. In addition, significant improvements were seen in the other components of the metabolic syndrome (i.e., hypertension and hyperlipidemia), as well as sleep apnea and joint pain.

Complications and mortality It was reported that the major post-operative complication rate ranged from 0–23.8%. For studies with >100 patients, the major post-operative complication rates ranged from 0–15.3%, said Brethauer. In 33 studies (n=2,367), detailed complication data was provided; including 53 leaks (2.2%), 28 bleeding episodes requiring reoperation or transfusion (1.2%), and 15 post-operative strictures requiring endoscopic or surgical intervention (0.6%). Moreover, the overall mortality rate for all studies that reported mortality data (n=2,570) was

0.19%, with five post-operative deaths (within 30 days of surgery), stated the authors. The authors looked specifically at patients who underwent sleeve gastrectomy as a primary operation in lower BMI and average risk patients compared to a planned first stage operation in high-risk and super obese patients.

The high-risk group had a 0.24% mortality rate compared to 0.17% in the primary group. The leak rates for the highrisk and primary groups were 1.2% and 2.7%, respectively, and the bleeding and stricture rates were not significantly different between groups. “This study demonstrates that the sleeve gastrectomy can be performed with low rates of major complications, even in extremely high risk patients and patients with very high BMIs. This is important for patients who may not be good candidates for gastric bypass or laparoscopic adjustable gastric banding,” stated Brethauer.

Conclusions Sleeve gastrectomy has increasingly gained acceptance among bariatric surgeons over the past five years, and has become a feasible option in the management of morbid obesity. From the current evidence, it seems that the procedure has proven to be an effective weight loss alternative that can be per-

Stacy Brethauer

formed safely as a first stage or primary procedure. “From this large volume of case series data, a matched cohort analysis, and two randomised trials, SG results in excellent weight loss and comorbidity reduction that exceeds, or is comparable to, that of other accepted bariatric procedures,” explained Brethauer. He further concluded that the post-operative major complication rates and mortality rates have been acceptably low. Three- and five-year follow-up data have demonstrated the durability of the SG procedure, but long-term data with large numbers of patients is limited.

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BARIATRIC NEWS

ISSUE 3 | DECEMBER 2009 – January 2010

Guest Interview In this issue we talk to Paul Robinson Consultant Psychiatrist in Eating Disorders

Addressing the psychology behind obesity is an important step in helping a patient deal with the repercussions following bariatric surgery. Many patients seek psychological help before the procedure, however, some believe that it is unnecessary to carry on with treatment once they have undergone surgery. In a number of cases, patients will suffer from depression once the ‘high’ they have achieved from weight loss has worn off as they realise that life’s problems are not just associated with Paul Robinson weight. Some also become depressed because they cannot find another ‘addiction’ to replace their overeating, which suggests that the problem is psychological.

Psychiatrists, psychologists and other eating disorder (ED) specialists are

valuable members of the bariatric multidisciplinary team. Bariatric News recently spoke to Dr Paul Robinson, a consultant psychiatrist in EDs at The Russell Unit and St Ann's Hospital, London, and consultant to the Whittington Hospital Department of Bariatric Surgery, London, UK, about the psychology behind obesity.

Paul Robinson was originally interested in neurology before he became interested in psychiatry. He explained, “I became interested in psychiatry when I noticed that men who had suffered heart attacks sometimes had serious problems of adjustment. I also was asked to give medical opinions on patients at the Maudsley Psychiatric Hospital, and I

decided to retrain as a psychiatrist. My second post at the Maudsley was with Professor Gerald Russell, one of the pioneers in eating disorders psychiatry.

He offered me a research post and I spent the next four years in the Institute of Psychiatry and Johns Hopkins Hospital, Baltimore, with Professor Paul McHugh, studying the role of gastric satiety in eating disorders.”

When asked how an eating disorders psychiatrist differs from a general psychiatrist, he explained, “When I first consult a patient who is interested in bariatric surgery, I ask myself the following questions: 1. Does this person have an eating disorder?

2. Does he/she have any other psychiatric disorders?

Location of excess weight is the key to risk of VTE in obese patients According to a study, published online in Circulation: Journal of the American Heart Association, although obesity increases the risk of venous thromboembolism (VTE), it is where the excess weight resides that makes the difference.

It has been well documented that obes-

ity, measured as body mass index (BMI), is associated with VTE. However, little research has looked at the distribution of body fat.

As a result, researchers from Aarhus University Hospital in Aalborg, Denmark, assessed the association between anthropometric variables and VTE. From 1993 to 1997, a total of 27,178 men and 29,876 women aged 50 to 64 years were recruited into a Danish prospective study (Diet, Cancer, and Health).

During ten years of follow-up, the outcome of VTE events was identified in the Danish National Patient Registry and verified by review of medical records. Body weight, BMI, waist circumference, hip circumference and total body fat were measured at baseline.

The investigators verified 641 incident VTE events and found monotonic dose-response relationships between VTE and all anthropometric measurements in both sexes. In mutually adjusted analyses of waist and hip circumference, they found that hip circumference was positively associated with VTE in women but not in men, whereas waist circumference was positively associated with VTE in men but not in women. These anthropometric measures were bigger players in venous clotting risk than BMI or weight, the researchers said.

Outcomes The researchers found that every 5cm rise in circumference around the waist was associated with up to an 18% increased risk of deep vein thrombosis and pulmonary embolism in

men. For women, risk rose up to 21% when the added girth was put on around the hips. Of those that were classified by VTE type, 58% were deep vein thrombosis and 42% were pulmonary embolism. However, the relationships were the same whether the events were considered idiopathic or provoked by known risk factors (e.g. prolonged travel).

Each of the associations strengthened in an apparent dose-response. For waist circumference, the risk was 92% higher for women in the highest category above 92cm, compared with the lowest quartile of under 77cm.

For men, the risk was doubled for those in the highest quartile compared with the lowest (over 105 versus under 91cm). For hip circumference, the risk was 2.54–fold higher for women in the top quartile of greater than 110cm, compared with less than 98cm.

For men, the risk was lower but still significant at 43% higher for the top versus bottom quartiles of over 105 and under 97cm, respectively.

The gender differences seen in the study might have been due to high correlation between variables or simply because women tend to accumulate fat on the hips, whereas fat concentrates around the abdomen in men, thus making variation highest and most informative in those locations.

The biological link to venous thromboembolism remains unclear, but the group speculated that it could be venous stasis or the fact that fat secrets biologically active substances, including a number with procoagulant activity.

3. What is his/her motivation for surgery? (Including physical complications of obesity and aesthetic considerations) 4. What does he/she know about surgery and its aftermath?

5. Why has he/she become obese and developed a psychiatric or eating disorder?

“Once I know the answers to those questions, I can give a reasonable opinion as to what may be required in order to prepare the patient for surgery.

The eating disorders psychiatrist is clearly trained to answer questions 1 and 5. Eating disorders psychiatrists also have more than average knowledge of medical complications, so may have some more to say on question 3.”

Obese populations According to Robinson, not everyone who becomes obese has an eating disorder or a psychiatric disorder although many may have disordered or at least unwise eating. The most common ED in this population is binge-eating disorder, and a history of childhood or adult trauma is not uncommon in this group.

“Equally a proportion of patients seeking bariatric surgery suffer from depression or anxiety, and over-eating may be a response to these mood states,” he said. “In both eating disordered and depressed patients, there may be a family history of both problems, as well as obesity, so genetics and, perhaps, childhood experience may contribute. For the rest of the obese population, genetic influences, family norms, reduction in exercise, poor eating habits and free availability of high fat, very tasty foods which many people find irresistible all contribute. Looking at how our weight regulating system may have evolved, early humans had too lit-

tle to eat, and suffered long periods without food.

Hence we evolved to store calories during times of plenty, and the way they are stored is in fat.”

Psychological care before and after surgery We asked Robinson about the importance of psychological care before and after surgery. He explained that through the help of the Internet many people are becoming more educated about bariatric surgery and its effects. However, this is not universal, and he believes that an adequate educational programme is essential in order to help patients understand exactly what they are going into.

“This can be done by any profession, especially by nurses and dieticians,” he explained. “Where psychiatry and psychology come in is to pick out the patients who are likely to continue bingeing after surgery, and so have a major impact on their outcome. Studies so far seem to show that psychological or psychiatric input prior to surgery has little effect on outcome. Having seen people with pre-operative bingeing or bulimia coming back with pouch dilatation, intractable vomiting and weight gain suggests to me that the proper studies have not been done. Moreover, I have also seen patients with undetected psychiatric disorder preoperatively coming back more depressed because they have not found another ‘addiction’ to replace their overeating. The worry is that some of those people might turn to alcohol or drugs. More and better research is needed here. My impression is that pre-operative therapy for binge-eating for example can be very helpful and seems to improve outcome. Post-operatively, we need to be aware of bingeing, which of course will be in smaller quantities, as well as depression, and both can be treated, preferably psychologically, but with medication if necessary.”

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Weight loss surgery is becoming more and more popular and is performed to control weight. Weight loss surgery is the first part of a long process, aftercare is the key to success. Support and guidance is ultimately the one part of the patient journey that truly does make a real difference to their end goal.

Multi-disciplinary teams are key to any surgery provider and are necessary to provide a “gold” standard patient focused service. To be successful, patients need to have the care, knowledge and skills to work with the surgical procedure they have chosen to have to achieve the maximum weight loss possible. No two patients requirements are the same and everyone has individual needs, hopes and expectations from their surgery, which is why providers need to invest heavily in post-operative resource.

The Weight Loss Surgery Group stand out in a confused marketplace. The group is owned and managed by like-minded, passionate individuals who have many years experience working with weight loss surgery patients. Their multi-disciplinary team offer aftercare to patients who have had surgery

in the UK or abroad. Wendy Stubbs, Bariatric Nurse Director, is an expert in the pre and post-operative care of weight loss surgery patients and her skills, knowledge, passion, empathy and commitment to the patient is the backbone of their aftercare service.

The group work closely with patients to ‘manage’ their old behaviours because although the patient undergoes surgery to band or bypass the stomach their head does not go through the same change and the patient needs to be re-educated otherwise they may fail. If patients are taking the risk of undergoing weight loss surgery, they need to ensure that all the other behaviours and their lifestyle in general, are supportive of what they are trying to achieve.

The WLS Group provide surgery including three years of aftercare and aftercare only packages to patients who have undergone surgery elsewhere.

For more information visit www.wlsgroup.co.uk or call us on 0800 7879029

BARIATRIC NEWS

ISSUE 3 | DECEMBER 2009 – January 2010

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Dietary Colum Hala El-Shafie is a Specialist Bariatric Surgery Dietician from The Harley Nutrition Clinic in London, and in every issue of Bariatric News she will be speaking to bariatric teams both in the UK and around the globe, bringing you the latest views on nutrition and bariatric surgery.

In this issue, Hala El-Shafie speaks to Australian bariatric dietician, Helen Bauzon, about the importance of education and support for patients undergoing the gastric banding procedure. Helen is also an author, speaker and TV presenter who works independently and with a number of renowned bariatric surgeons in Melbourne. She has recently established a private practice alongside Professor Paul O’Brien's team at the Centre of Bariatric Surgery, and has experience of counselling over 3,000 gastric band patients.

S

ince 2000, Helen has worked as a bariatric dietician focusing on patients who have had a gastric band. She believes that the gastric band works beautifully when used correctly, and helps people gain their lives back by controlling their appetite and enabling them to make better food choices and to lose enough weight to become physically active. Helen's success with this patient group is driven by her passion to help gastric band patients achieve their desired results by offering them an ‘excuse-free’ programme.

According to Helen, the most important factors that contribute to successful patient outcomes in those who have undergone laparoscopic gastric banding are education and support. She commented, “Eating behaviours tend to be unaltered since pre-surgery and can impair the use of the gastric band as an effective weight loss tool. Tackling such eating habits before patients reach the operating table will improve their chances of successful weight loss after surgery, leaving them with one less obstacle to overcome whilst working with their gastric band.”

Understanding the gastric band “Patients need to really understand the gastric band and how it works in order to maximise its potential,” stated Helen. “A common misconception is that the gastric band will work like a sleeve gastrectomy procedure and physically force patients to stop eating after consuming a small amount of food. Patients must be made aware that this is not the case.”

Helen feels that a key factor in this may be related to the patient’s perception of portion size, as well as the change in the capacity of their stomach post-operatively. “Patients may misjudge how small the banded stomach actually is. Often I hear ‘It’s the size of a cup’, in fact, the size of the stomach after gastric band surgery varies between individuals, dependent on several factors such as the amount of fluid in the band.”

Working with the gastric band When educating gastric band patients on what to eat, it is often difficult to persuade them to follow and stick to guidelines. “Whether someone has a band or not, I believe that the basic weight loss advice is the same: eat a little of everything without counting a calorie or point, including a moderate protein to carbohydrate intake, with a focus on low GI carbohydrates,” explained Helen Helen finds that often, bariatric patients have been on so many diets that her job is to go back to basics and 'de-medicalise' the process. She states that making a simple, practical eating plan that the whole family can follow is very helpful and then takes this generalised healthy eating approach and makes it “lap band specific”.

Helen’s advice includes: • A discussion of pre-operative dietary requirements, for example, the Optifast pre-operative diet

ABOUT HALA...

for weight loss and liver shrinkage.

• A discussion of the initial fluid diet phase immediately post-surgery. Helen uses the principle that if you can “liquidise” it and suck it through a straw, it is permitted to “drink your calories”, but this must be nutritionally adequate and should only be used during this period.

• The transition to solid food and how to avoid or overcome common problems.

• Meal ideas, recipes and individualised plans for the different stages of recovery.

In addition, individuals need support to make permanent lifestyle changes, as obesity is a chronic condition and will not be cured by a gastric band operation, explained Helen. Patients need to “unlearn” the dieting mentality, which will help to reduce cravings and over indulging which can otherwise become uncontrolled due to the feeling of guilt.

tion control without needing to counting a single calorie.

However, a band that is too loose is also far from ideal. Helen has found that patients do not do well when their surgeon relaxes the band so that they can eat more on holiday or if they are going to a remote area and the fluid is removed just in case they encounter any problems.

“The issue here is that the individual has had a good taste of the old days when there was a lot more freedom and they could do what they wanted, making it hard for them to get back on track and follow the rules of the banded life essential to succeed. The way I deal with this is by helping patients to remember how they felt when the band was nicely tightened and they were not constantly thinking about food and having to fight temptation all the time. I promote a slow, gradual increase of fluid in the band to allow the individual to get used to eating with the band again, and obviously provide lots of encouragement.”

"I promote a slow, gradual increase of fluid in the band to allow the individual to get used to eating with the band again, and obviously provide lots of encouragement."

Preventing problems Helen aims to prevent problems before they occur by providing comprehensive advice about some of the most common hurdles that patients may encounter. For example, certain foods are generally harder to eat, and being aware of this will enable patients to try them at an appropriate time. By eating foods of the correct texture the band will control the volumes consumed during the meal.

Knowing how much food to eat at a meal-time can be an issue, as overeating may cause nausea and vomiting as well as reducing weight loss. Helen compares the optimal meal size to “eating like a toddler”. Eating outside meals is also a problem – grazing does not promote successful weight loss. This is the case with non-surgical weight loss but also for patients who have had a gastric band as the band resembles a funnel and food can simply continue to slide through.

Patients need to be instructed on how to physically “chew" their food. They may think that 20–30 chews are enough, but it takes more than that. Helen’s recommendation for patients is to take no more than one teaspoon of food per mouthful and focus on tasting and enjoying the flavours and textures the food has to offer, before swallowing.

Tightening the gastric band Helen believes that is important to not overly tighten the gastric band, allowing individuals to consume normal solid food and not maladapt. Knowing about the correct textures of food will help to manage por-

The gastric band versus gastric bypass debate When asked about her position on gastric band surgery compared with gastric bypass surgery, she explained, “Irrespective of the type of surgery chosen by an individual, if the patient does not work with the gastric band or gastric bypass by improving their lifestyle, the results will be limited and the patient is likely to be at a greater risk of malnutrition. I prefer to not remove anything on a permanent basis hence I lean towards the gastric band for this reason.”

Helen’s key tips for success Helen prides herself on her ability to overcome the issue of patients having trouble getting “healthy foods” through their gastric band – by this she means it is preferable to have a band that allows a good volume of “bulky” healthy food options of the right consistency to allow patients to work with their band and obtain the right level of nutrients.

The key to success is ensuring that the individual understands the issues surrounding: • The need to not be stressed.

• To choose the most appropriate times to eat more difficult foods, i.e. a steak in the evening when relaxed rather than at lunchtime during a 15 minute break.

• If the band site is irritated, then moist, soft foods would be better rather than dry, more solid

Helen Bauzon

foods which could aggravate things further.

• The most crucial point is to ensure that the band is not too tight, or life becomes too difficult and people cheat by opting for easier, higher calorie foods for energy.

“I find that the back bone for patient success is having a surgeon who the patient has a good rapport with and is comfortable seeing regularly, even when they have not lost or perhaps even regained some weight; and having a dietician who provides practical, informative education and support on an ongoing basis, including a support group.”

Helen believes that a multidisciplinary team approach is crucial. This is also strongly recognised by the Australian government. Every team should include a dietician, a psychologist, an exercise physiologist, specialist nurses, surgeons and doctors and support meetings to fulfil all patients’ needs. Team members need to have a very good understanding of the complex mind set of this patient group, which often includes elements of food addiction and emotive eating, necessitating multidisciplinary treatment to have any chance of success.

FOR MORE INFORMATION: If you would like to get in touch with Helen Bauzon, please contact her on: info@helenbauzon.com.au or visit her website www.helenbauzon.com.au

Hala trained as a Dietician at Leeds Metropolitan University completing her clinical training at University College Hospital London. She saw her Dietetic career begin with her first clinical paper in the area of eating disorders being published on graduating. Practicing as a Dietician in both the NHS and the Corporate Sector, Hala was integral in helping to set up the Eating Disorders Service in Manchester. As a specialist bariatric dietician experienced in eating disorders, Hala understands clearly the emotional and psychological attachment often associated with food. Hala practices in London at The Harley Nutrition Clinic in Harley Street. She is also a health writer and is often enlisted to speak and lecture on disordered eating and bariatric nutrition. She is also a member of the Health Care Professional Council (HPC), British Dietetic Association, Nutrition Society and the British Obesity and Metabolic Surgical Society (BOMSS).

To contact Hala, please email: info@theharleynutritionclinic.com or call: +44 (0) 207 000 1020 or visit: www.theharleynutritionclinic.com

10 BARIATRIC NEWS

ISSUE 3 | DECEMBER 2009 – January 2010

Welcome to our Head-to-Head segment. This is a regular feature where we ask two expert bariatric professionals to debate against each other on a topical issue.

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Sleeve gastrectomy staple lines: Sayeed Ikramuddin University of Minnesota, Minneapolis, MN

Historically, the typical indications for adjunctive staple line support would be to reduce the incidence of leakage and/or bleeding from the staple line. These are the key outcomes to consider when making a decision whether to utilise buttressing material. The notion that staple line reinforcement may contribute to a reduced incidence of pouch enlargement has not been entertained and thus will not be further discussed.

Bleeding from the staple line is potentially problematic with sleeve gastrectomy. When this occurs it tends to manifest as a slow and continuous ooze with the associated concern that the resultant collection may pose a risk for secondary infection, abscess or later contribution to staple line breakdown.

Leakage, on the other hand, has far more serious consequences. Leakage can result in a prolonged hospital course requiring drainage procedures, need for stenting, or dilatation of distal narrowing – particularly at the angularis incisura.

An evidence-based review of this topic is not possible with the available data. However, there are a number of theoretical considerations surrounding potential deleterious effects of sleeve reinforcement that are worthy of discussion. These include staple line malfunction and serosal separation, uneven formation of the gastric sleeve, persistence of leak, increased post-operative adhesions and increased difficulty in converting to a gastric bypass.

Staple line malfunction With sleeve gastrectomy, the risk of staple line malfunction and/or serosal separation is ever-present. It is important to understand that given the considerable thickness of the stomach between the antrum and the fundus a variety of staple cartridge heights might be necessary to obtain appropriate approximation. Additionally, the added bulk of buttressing material and its inherent inability to compress amplifies the already-present risk of malfunction. In the event of staple line dis-

HEAD

"Oversewing can be used to approximate and reinforce the staple line with a precision that simple staple reinforcement lacks." ruption, especially if the sleeve is narrow and the line lies close to the Bougie, extra material within the staple line makes oversewing much more difficult. Particularly tortuous areas, at particular risk for compromise, lie at the junction of staple lines whether buttressing material is used or not.

Even the most diehard opponent will find it difficult to resist oversewing the staple line in these areas of potential breakdown. Lastly, oversewing can be used to approximate and reinforce the staple line with a precision that simple staple reinforcement lacks.

Uneven formation of the gastric sleeve As previously mentioned, multiple staple lines are used to form the vertical sleeve due to varying tissue thickness. In spite of creating the sleeve over a Bougie it is still quite difficult to have a perfectly uniform tube. Over time, a non-uniform tube can evolve into a rather tortuous pathway with potential

for impeding the passage of solid food as well as the performance of upper endoscopy and the placement of a nasogastric tube (should this become necessary). Oversewing allows for better sizing of the lumen and better contouring of the sleeve itself. Finally, there is the theoretical concern that the buttress material may create some rigidity in the staple line that then results in persistent stenosis with subsequent nausea and vomiting.

Persistence of leak An additional concern is foreign body contribution to persistent leak. Foreign material has the capacity to impede healing and prevent or slow the closure of fistulae until it has completely remodeled or been absorbed. Leaks following gastrectomy occur in a minumum of 1% of patients with the true incidence likely higher. The contribution of buttressing in this regard (if any contribution exists) is unclear at this juncture.

"In the absence of controlled clinical data, the routine use of staple reinforcement has little or no advantage over complete staple line oversewing."

Difficulty in reoperative surgery A final observation of ours, which remains untested, is that an increased inflammatory response occurs with prosthetic material and results in increased adhesion formation in the left upper quadrant. This response has been seen with various inert materials including lap bands and sutures. Likewise, exposed staple lines are notorious for producing dense adhesions. Anyone re-exploring a patient who has previously undergone a laparoscopic bypass has seen this when examining the gastric remnant staple line.

This is particularly relevant when considering those patients who may ultimately need a second stage procedure. In spite of evidence supporting a strong role for the primary use of a sleeve, there continues to be a group of patients who will fail a sleeve and require future conversion. In those patients who undergo revision to gastric bypass, one key consideration is the potential for staple line failure as the stapler comes across the reinforcement at a later date.

This might increase the risk of leak and fistula as well as impeding prompt closure.

Conclusion In the absence of controlled clinical data, the routine use of staple reinforcement has little or no advantage over complete staple line oversewing.

HEAD

Next issue -TO-

In our next issue the debate will be:

Binge-eating disorder is a contraindication to bariatric surgery – yes or no?

If you would like to share your views on the current debate, please send your comments to owen.haskins@e-dendrite.com.

We will publish your comments in the next issue.

BARIATRIC NEWS 11

ISSUE 3 | DECEMBER 2009 – January 2010

In this issue, Dr Sayeed Ikramuddin, US, and Dr Greg Dakin, US, debate whether oversewing the staple line is more effective than reinforcing strips in sleeve gastrectomy.

O - HEAD

Oversewing vs. reinforcing strips Gregory F Dakin Assistant Professor of Surgery, Weill Cornell Medical College, New York, US

The morbidity from a leak at the gastric staple line in sleeve gastrectomy is obviously substantial and is a complication that should be avoided at all cost. The long length of the sleeve gastrectomy staple line, coupled with the variable thickness of gastric tissue, results in significant potential for intra-operative and post-operative bleeding which can lead to increased operating times, transfusion requirements, morbidity, and hospital stay. Several commercially available reinforcing products have been developed to reduce the risk of these complications. While there are generally no studies that directly compare reinforced staple-lines to those that are oversewn, there are several arguments for the use of staple-line reinforcing strips in sleeve gastrectomy. Furthermore, there is evidence that reinforcement with strips may in fact be safer than the alternative of oversewing the staple line.

Reduced bleeding There are numerous lines of evidence that indicate reinforcement of staple lines reduces bleeding, both in sleeve gastrectomy as well as other bariatric operations. One study reported on 20 patients who underwent laparoscopic sleeve gastrectomy with or without duodenal switch (Consten ECJ, 2004).

Study patients (n=10) had the gastric staple line reinforced with an absorbable polymer membrane and were compared to non-buttressed (n=10) staple lines. The buttressed group had significantly less bleeding (120ml vs. 210ml, p<0.05), and showed a trend towards decreased hospital stay (3.8 days vs.

4.6 days). In the non-reinforced group there were two staple-line haemorrhages and one patient developed a sub-phrenic abscess. In a poster-presentation at the ASMBS 25th Annual Meeting, another group compared 46 patients with and without staple-line reinforcement (Chiasson PM, 2008) and showed an increase in the number of transfusions required and ICU admissions for bleeding in the non-reinforced group. Finally, a prospective randomised trial of patients undergoing laparoscopic gastric bypass with and without absorbable reinforcement strips at the staple lines showed a decrease in the number of clips used, higher post-operative haemoglobin levels, and shorter operative time in the reinforced group (Miller KA, 2007).

fusion of dye until visible leak was seen at the staple lines with the reinforced group showing significantly higher burst pressures (83 mmHg vs. 53 mmHg) (Downey DM, 2005). In a cadaveric model of stomach staple-lines, absorbable buttress ma-

plete imbrication. However this is generally not possible with such a narrow diameter sleeve. The presence of staple-line buttressing material allows us to create a very tight, reproducible sleeve while maintaining excellent haemostasis. There is gener-

"While there are generally no studies that directly compare reinforced staple-lines to those that are oversewn, there are several arguments for the use of staple-line reinforcing strips in sleeve gastrectomy." terial significantly increased the pressure required to cause staple line leakage vs. non-buttressed staplelines (Baker RS, 2004). Perhaps more importantly, however, this study also looked at the effect of fullthickness oversewing of staple lines. The authors found that oversewing actually weakened all staples lines (p=0.015), though the exact degree of weakening is not mentioned. They also made the observation that the sites of the sutures leaked when the gastric pouches were distended by instillation of fluid.

Smaller sleeve There is considerable debate over whether the diameter of the sleeve affects weight-loss outcome in either the short- or long-term. We attempted to look at this in a series of our patients who underwent sleeve

ally no need for oversewing or even the placement of haemoclips.

gen during the healing process.

Conclusions Buttress materials are not a substitute for sound surgical judgment. Staple size must be appropriately selected for the tissue on which it is to be used. This is necessary to allow for proper staple formation while achieving the optimal staple-line strength and tissue compression (Baker RS, 2004). In particular along the thick antrum of the stomach, it may be prudent to forego the reinforcement material with the 4.8mm height of currently available staplers.

However, it is clear that staple-line reinforcement has many benefits, including reducing bleeding and increasing the strength of the staple line. These effects may combine to reduce operating time, leak rate, and morbidity. Though comparative cost studies are lacking, it is reasonable to speculate that the potential elimination of even one leak might justify the increase in cost of buttress material over the less expensive alternative of oversewing.

References:

Absorbable buttress materials safe Early studies of staple-line buttress materials involved non-absorbable xeno-materials such as bovine pericardial strips, bovine collagen strips, and non-absorbable expanded polytetrafluoroethylene (ePTFE) to prevent air leaks in lung surgery (Miller JI Jr, 2001), (Itoh E, 2000), (Fischel RJ, 1998) (Murray KD, 2002). There have also been studies looking at non-absorbable buttress materials in bariatric surgery, particularly gastric bypass (Shikora SA, 2003), (Angrisani L, 2004). These studies have reported reduction in staple-line haemorrhage and anastomotic leaks. However some

Angrisani L, L. M. (2004). The use of bovine pericardial strips on linear stapler to reduce extraluminal bleeding during laparoscopic gastric bypass: prospective randomized clinical trial. Obes Surg , 14, 1198-1202.

Baker RS, F. J. (2004). The science of stapling and leaks. Obesity Surgery, 14, 1290-1298.

Chiasson PM, B. S. (2008). Laparoscopic vertical sleeve gastrectomy (LVSG): efficacy of using Gore Seamguard bioabsorbable staple line reinforcement to buttress the staple line. ASMBS 25th Annual Meeting. Washington, DC. Consten EC, D. G. (2004). Intraluminal migration of bovine pericardial strips used to reinforce the gastric staple-line in laparoscopic bariatric surgery.

Obes Surg , 14, 549-554.

Consten ECJ, G. M. (2004). Decreased bleeding after laparoscopic sleeve gastrectomy with or without duodenal switch for morbid obesity using a

"Since we do not advocate routinely oversewing the staple line for fear of causing increased ischaemia, the only option to decrease bleeding with sutures would be via complete imbrication."

stapled buttressed absorbable polymer membrane. Obesity Surgery , 14, 1360-1366.

Downey DM, H. J. (2005). Increased burst pressure in gastrointestinal staple-lines using reinforcement with a bioprosthetic material. Obesity Surgery , 15, 1379-1383.

Fischel RJ, M. R. (1998). Bovine pericardium versus bovine collagen to buttress staples for lung reduction operations. Ann Thorac Surg , 65, 217-219.

Itoh E, M. S. (2000). Synthetic absorbable film for prevention of air leaks after stapled pulmonary resection. J Biomed Mater Res , 53, 640-645.

Lee CM, C. P. (2007). Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results. Surg Endosc , 21, 1810-1816.

Increased tissue strength While the cause of leaks from gastric staple lines is multifactorial, most leaks in bariatric surgery are encountered in the first days following surgery, implicating mechanical or tissue-related factors rather than ischaemia (Baker RS, 2004). Several studies have shown that staple-line reinforcement can increase the strength of staple lines. In one experimental study, pig intestine was divided with and without an absorbable small intestinal submucosa-derived buttress material. The staple lines were subjected to increasing intraluminal pressure by constant in-

gastrectomy with either a 40F or 60F bougie (Parikh M, 2008). In short-term (12-month) follow-up there was a trend towards greater weight loss in the 40F group, though this did not reach statistical significance. Other authors recommend the use of an even smaller (32F) bougie and have reported excellent weight loss results out to two years (Lee CM, 2007).

We currently use a 40F bougie and “hug” it tightly to ensure a small-sized sleeve. Since we do not advocate routinely oversewing the staple line for fear of causing increased ischaemia, the only option to decrease bleeding with sutures would be via com-

complications with non-absorbable reinforcement has been reported, including a report of a patient who had undergone sleeve gastrectomy in conjunction with duodenal switch and vomited small pieces of the buttress material, indicating intraluminal migration (Consten EC, 2004). There have been no reports of intraluminal migration of buttress material since the more widespread use of absorbable materials, and reports of complications of any nature are sparse. Furthermore, many of the new buttress materials may serve as a biologic “scaffold” to promote ingrowth of Type 1 colla-

Miller JI Jr, L. R. (2001). A comparative study of buttressed versus nonbuttressed staple line in pulmonary resections. Ann Thorac Surg , 71, 319-322.

Miller KA, P. A. (2007). Use of a bioabsorbable staple reinforcement material in gastric bypass: a prospective randomized clinical trial. SOARD , 3, 417-422.

Murray KD, H. C. (2002). The influence of pulmonary staple line reinforcement on air leaks. Chest , 122, 2146-2149.

Parikh M, G. M. (2008). Laparoscopic sleeve gastrectomy: does bougie size affect mean %EWL? Short-term outcomes. SOARD , 4, 528-533.

Shikora SA, K. J. (2003). Reinforcing gastric staple-lines with bovine pericardial strips may decrease the likelihood of gastric leak after laparoscopic Roux-en-Y gastric bypass. Obes Surg , 13, 37-44.

12 BARIATRIC NEWS

ISSUE 3 | DECEMBER 2009 – January 2010

A snapshot of

USA

Part 1

Obesity rates in the US are among the highest in the world, costing the healthcare system billions each year. According to a recent survey by the Trust for America's Health and the Robert Wood Johnson Foundation, 25% of adults are now obesse in 31 states, with two-thirds of adults classed as overweight or obese. The survey, entitled, ‘F as in Fat: How obesity problems are failing in America’, also highlights a worrying trend in children aged 10–17, with some 30% classed as overweight or obese in 30 states.

In this issue, we will be examining obesity, hypertension and type 2 diabetes rates in the West and Mid-West states of the US, and in the following issue (Issue 4) we will focus on the remaining Eastern States.

% of the population WA

OR

CA

NV

AZ

NM

TX

LA

AR

OK

MO

KS

7

6.8

8.1

8.1

8.2

7.7

9.3

10

9

10.1

8.2

7.6

Hypertension

25.4

25.5

27.2

26

24.2

24

26.9

30.9

31.5

30.7

29.1

25.6

Obese and overweight children (aged 10-17)

29.5

24.3

30.5

34.2

30.6

32.7

32.2

35.9

37.5

29.5

31

31.1

Prevalence of obesity and overweight adults (aged 55-64)

29.8

29.7

28.3

29.3

29.4

25.1

32.6

35.5

31.9

33.9

33.3

32.9

Prevalence of obesity and overweight adults (aged 65+)

21.6

21

20

18.9

17.6

17.2

21.7

27.3

20

22.5

23.7

21

Obese

25.4

25.4

23.6

25.1

24.8

24.6

27.9

28.9

28.6

29.5

28.1

27.2

Obese and overweight

61.5

61.5

59.7

63.1

61.2

60.2

64.8

64

65.1

65.5

63.9

63.9

Diabetes

BARIATRIC NEWS 13

ISSUE 3 | DECEMBER 2009 – January 2010

Diabetes and hypertension

The report highlighted that obesity and obesity-related diseases such as diabetes and hypertension continue to remain the highest in Southern states, with eight of the ten most obese states in the South. Furthermore, the ten states with the highest rates of diabetes and hypertension are in the South. Adult diabetes rates increased in 19 states in the past year, and in seven states, more than 10% of adults now have type 2 diabetes.

A total of 19 states showed a significant increase in the rates of adult diabetes. West Virginia recorded the highest rate of adult diabetes at 11.6%, compared with Colorado had the lowest rate at 5.5%. The highest rate of hypertension was recorded in Mississippi at 34.5%, with the lowest in Utah, at 20.3%. All ten states with the highest rates of hypertension are in the South.

More than 20 million adult Americans now have diabetes, a doubling in the past decade, from 4.8 people per 1,000 to 9.1 per 1,000. A further 57 million Americans are pre-diabetic (at high risk and likely to develop the disease in 5–10 years).

Obesity and children

In children and adolescents, the report recorded that nearly 32% are overweight or obese, with approximately 60% of obese children aged 5–10 years have at least one cardiovascular disease (CVD) risk factor and 25% had two or more CVD risk factors.

55–64 years and 65+

In these ages groups the report noted that 49 states experienced a significant increase in obesity among 55–64-year olds. The rate of growth was lowest in Alabama at 3.4% and highest in Oklahoma at 12%. The largest increase was in the state of New Hampshire, which experienced a 15.6% increase in obesity rates among adults age 65 and older.

The smallest increase was in Hawaii, which saw a 7% rise in obesity rates in a 20-year period (1987–2007). South Dakota was the only state with data for all 20 years that did not experience a significant increase.

Recommendations

The report also includes recommendations for addressing obesity within health reform and calls for a National Strategy to Combat Obesity. The strategy would define roles and responsibilities for federal, state and local governments and promote collaboration among businesses, communities, schools and families and would seek to advance policies that: • Provide healthy foods and beverages to students at schools; • Increase the availability of affordable healthy foods in all communities; • Increase the frequency, intensity, and duration of physical activity at school; • Improve access to safe and healthy places to live, work, learn and play; • Limit screen time (TV and video games); and • Encourage employers to provide workplace wellness programmes.

Source: ‘F as in Fat: How Obesity Problems Are Failing in America’ - Trust for America's Health and the Robert Wood Johnson Foundation

% of the population CO

UT

ID

MO

WY

NE

IA

MN

SD

ND

AK

HI

Diabetes

5.5

5.9

7.2

6.5

6.9

7.4

8.7

5.8

6.6

6.8

6.2

8

Hypertension

21.7

20.3

25.4

24.5

25.2

25.5

28.1

22.6

25.8

25.1

23.9

26.1

Obese and overweight children (aged 10-17)

27.2

23.1

27.5

25.6

25.7

31.5

29.9

23.1

28.4

25.7

33.9

28.5

Prevalence of obesity and overweight adults (aged 55-64)

21.8

30.7

31.7

27.4

28.6

34.1

33.7

32.3

32.3

32.4

35.3

24.1

Prevalence of obesity and overweight adults (aged 65+)

16.4

21.9

20.8

20.4

21.1

23.7

25.4

23.6

22.1

22.3

29.4

13.6

Obese

18.9

22.5

24.8

22.7

24.3

26.9

27.4

25.3

26.9

26.7

27.2

21.8

Obese and overweight

55.3

57

61.7

60.9

61.9

64.2

63.2

62.5

64.9

65.6

65

56.8

14 BARIATRIC NEWS

ISSUE 3 | DECEMBER 2009 – January 2010

Assessment of bariatric surgery worldwide Five-year review of bariatric surgery worldwide shows laparoscopic adjustable banding is the most commonly performed procedure To understand the influence and impact of bariatric surgery, it is important to regularly assess the field worldwide. Bariatric surgery has now been recognised as metabolic surgery and it is the state of metabolic/bariatric surgery that needs to be examined, explained Professor Henry Buchwald, University of Minnesota, MN, in the recently published paper, ‘Metabolic/Bariatric surgery worldwide’.

In the paper, which was also presented at the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) conference in Paris, France, in August, Buchwald and colleague Dr Danette M Oien, also from the University of Minnesota, MN, commented that the first global survey of metabolic/bariatric surgery (entitled ‘The IFSO and obesity surgery throughout the world’), was published in 1998 (Dr N Scopinaro). In 2004, Buchwald and Dr SE Williams, US, published a five-year follow-up report, entitled: ‘Bariatric surgery worldwide 2003’.

The recent paper is a subsequent fiveyear follow-up to the 2003 report and of-

fers a global perspective of metabolic/ bariatric surgery over the past ten years.

According to Buchwald, “During the accelerating pandemic of global obesity, certain basic questions are being asked by the medical and the lay communities, as well as government and private funders of healthcare, such as: how many metabolic/bariatric procedures are being performed, by how many surgeons, and where?” He added that since there has been a flux in the types of metabolic/bariatric procedures performed, a quantitative evaluation of operations completed and existing worldwide trends in procedures, need to be assessed.

Study design In the study, 36 IFSO nations and national groupings were involved, in which 33 responded. The countries included in the national groupings were: Australia and New Zealand, Belgium and Luxembourg, and the US and Canada. Sweden, Denmark and Norway also participated.

There were two design components to the study; one involved a questionnaire,

Table 1: Number of bariatric surgery operations being done yearly: 2008 and 2003 Number of bariatric surgery operations 2008*

Number of bariatric surgery operations 2003**

Argentina

2,400

200

Australia/New Zealand

11,914

2,750

Austria

1,741

1,396

Belgium/Luxembourg

8,700

6,000

Brazil

25,000

4,000

Chile

1,500

–

900

400

Denmark

2,004

–

Egypt

1,500

2,750

France

13,722

12,000

Germany

2,117

1,100

Greece

2,875

500

Hungary

300

30

India

1,216

–

Israel

2,500

1,000

Italy

4,842

3,000

Japan

80

20

Mexico

13,500

2,500

Netherlands

3,500

800

Norway

1,500

–

Peru

600

–

Poland

814

145

Portugal

1,323

–

Romania

837

–

Russia

750

350

Serbia

10

–

South Africa

400

–

Spain

6,000

2,000

Sweden

2,894

600

Switzerland

850

800

Turkey

500

150

Ukraine

190

150

6,000

600

US/Canada

220,000

103,000

Venezuela

1,242

–

344,221

146,301

Country

Czech Republic

United Kingdom

Total

Source: *Buchwald H, Oien DM. Metabolic/Bariatric surgery worldwide. Obes Surg. 2008. **Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg. 2004;14:115 –64.

which was sent as an email survey and included the questions: 1. Approximately how many bariatric surgery operations are being done in your country yearly?

2. Approximately how many surgeons practice bariatric surgery in your country?

3. What is your estimate as to the relative percentages distribution of bariatric operations in your country? (Adding up to 100%).

The other component involved data analysis.

Results Number of procedures performed in 2008 According to Buchwald, the total number of global bariatric surgery operations was 344,221 for 2008. In 2003, the total number reached 146,301. He explained that the US/Canada grouping performed the majority of operations, totalling 220,000 (103,000 in 2003). Four countries or national groupings performed more than 10,000 operations, including: Australia/ New Zealand, Brazil, France, and Mexico. A further three countries or national groupings performed more than 5,000 operations: Belgium/Luxembourg, Spain, and the UK. Interestingly, Japan and Serbia performed less than 100 surgeries (80 and ten, respectively) (Table 1).

Number of metabolic/bariatric surgeons The global total number of bariatric surgeons was 4,680, explained Buchwald.

The US/Canada national grouping had the majority of surgeons (n=1,625), and

seven other countries or national groupings had the most surgeons, i.e., more than 100, including: Australia/New Zealand (n=118), Brazil (n=700), Chile (n=100), France (n=310), Italy (n=300), Mexico (n=150), and Spain n=400).

Types of procedures performed The most commonly performed procedures in 2008 were laparoscopic adjustable gastric banding (AGB: 42.3%), and laparoscopic standard Roux-en-Y gastric bypass (RYGB: 39.7%), stated Buchwald. He further explained that in 2003, there were no sleeve gastrectomy procedures being performed, and in 2008, the number of sleeve gastrectomies totalled 5.4% (Table 2). Noteworthy, over 90% (91.4%) of bariatric surgery procedures worldwide were performed laparoscopically.

Global trends Given the results, Buchwald concluded that in comparison with the 2003 survey, it appears that all categories of procedures apart from biliopancreatic diversion/duodenal switch, increased in numbers performed. Although, the percentage of RYGB procedures decreased from 65.1% to 49.0%; whereas, AGB increased from 24.4% to 42.3%; and sleeve gastrectomy rose from 0.0% to 5.3%, he explained.

Buchwald also noted that the different world regions varied markedly in their respective five-year trends. “In Europe, though all procedures reported in 2003 increased in numbers in 2008, the relative

Table 2: Distribution of bariatric operations: 2008 and 2003 Distribution of procedures

Percentage 2008*

Percentage 2003**

Open adjustable gastric banding

0.1

0.17

Laparoscopic adjustable gastric banding

42.3

24.16

Open vertical banded gastroplasty

0.7

4.25

Laparoscopic vertical banded gastroplasty

0.4

1.18

Open standard Roux-en-Y gastric bypass

5.7

23.07

Laparoscopic standard Roux-en-Y gastric bypass

39.7

25.67

Open long-limb and very long limb gastric bypass

0.8

7.45

Laparoscopic ling-limb and very long-limb gastric bypass

3.1

8.92

Open biliopancreatic diversion

0.3

0.87

Laparoscopic biliopancreatic diversion

0.6

1.09

Open duodenal switch

0.2

2.03

Laparoscopic duodenal switch

0.6

0.85

Open sleeve gastrectomy

0.3

–

Laparoscopic sleeve gastrectomy

5.1

–

Electronic pacer/blockers

<0.1

–

Laparoscopic gastric pacing

N/A

0.15

Laparoscopic nonadjustable gastric banding

N/A

0.08

Others

0.2

0.06

100.0

100.0

Total

Source: Buchwald H, Oien DM. Metabolic/Bariatric surgery worldwide. Obes Surg. 2008. **Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg. 2004;14:115 –64.

Henry Buchwald

percent of AGB decreased from 63.7% to 43.2%, and the relative percent of RYGB increased from 11.1% to 39.0%,” he said.

Adding, “Though the total number of procedures also increased from 2003 to 2008 in the US/Canada, the trends in the relative percentages of AGB and RYGB were diametrically opposed to those in Europe – AGB increased from 9.0% to 44.0% and RYGB decreased from 85.0% to 51.0%.”

Conclusions It appears that, globally, the laparoscopic approach to bariatric operations is the preferred method over open surgery. Out of all the countries and national groupings that were involved in the study, Buchwald found that the most common procedures were adjustable gastric banding (42.3%), laparoscopic RYGB (39.7%; open plus laparoscopic RYGB 49.3%), and laparoscopic sleeve gastrectomies (5.1%).

According to Buchwald, after conducting the survey, new questions were raised, such as 1. Why, in the face of the accelerating world pandemic of obesity and morbid obesity, has the absolute rate of bariatric surgery decreased over the past five years (135% increase), in comparison to the preceding five years (266% increase); 2. Why are there such diametrically opposed trends for laparoscopic AGB and laparoscopic RYGB in Europe vs. US/Canada; and 3. Why has sleeve gastrectomy captured 5.3% of the global frequency of bariatric procedures?

“In response to the plateau in the number of bariatric procedures, this phenomenon cannot be explained by an overall lack of patients or exhaustion of the residual patient pool, since we operate on less than 1% of morbidly obese patients worldwide,” said Buchwald.

“It is also difficult to believe that only 1% of eligible individuals would elect surgery if it were available to them. The answer, therefore, must be denial of patient access to bariatric surgery by private or governmental payers for healthcare, lack of knowledge of the bariatric surgery option in some communities, misunderstanding about the management of obesity as a disease, and the continuing underlying prejudice against the obese.”

Furthermore, he believes that the differing operative trends between Europe and the US/Canada could be down to “disenchantment” with AGB in Europe, which has had longer experience than the US/Canada. “Over time, essentially all procedures lose some of their early achieved success and lustre,” Buchwald commented.

Overall, he suggested that in the future, in order to increase the accuracy, reliability, and universality of the essential global data, an international IFSO registry should be established.

BARIATRIC NEWS 15

ISSUE 3 | DECEMBER 2009 – January 2010

National Obesity Forum 2009: Improving prevention and management of obesity den cardiac death.

The results demonstrated that GnRH agonist treatment for men with locoregional prostate cancer may be associated with an increased risk of incident diabetes and cardiovascular disease. They concluded, “The benefits of GnRH agonist treatment should be weighed against these potential risks. Additional research is needed to identify populations of men at highest risk of treatment-related complications and to develop strategies to prevent treatment-related diabetes and cardiovascular disease.”

Jones also concluded that larger studies are required to determine the longer-term benefit of testosterone replacement therapy.

David Haslam

Stephen Gough

The National Obesity Forum (NOF)

junct therapy for patients with type 2 diabetes who are not achieving satisfactory glycaemic control using other hypoglycaemic agents. Gough discussed the outcomes of the Exenatide/insulin glargine crossover trial, in which patients (n=114) were randomised into two groups (Exenatide + Sulfonylurea or Metformin; and Insulin Glargine + Sulfonylurea or Metformin) for 16 weeks, then crossed-over to the opposite group for another 16 weeks. It was found that all patients who were in the Exenatide groups lost weight when those in the insulin groups gained weight.

hosted its annual conference in London at the Royal College of Physicians in October. A total of 300 delegates attended the two-day meeting, consisting of general practitioners, bariatric nurses, psychologists, dieticians and healthcare professionals.

Delegates were given the opportunity to take part in discussions with presenters, as well as witness a much-needed debate between food representatives from outlet chains including Pizza Hut, Prêt a Manger, and Subway. The debate, part of a food labelling strategy campaign, lead to the agreement that displaying calorie information on all menus is an important step forward for the food industry to help support the public in making healthier choices.

The intensive programme covered many important topics, ranging from obesity and co-morbidities, the role of testosterone, cancer, psychology of obesity, and childhood obesity. Exciting data was released from Kent primary care trust (PCT) concerning the financial incentive programme that they have commissioned. The programme also included high profile keynote speakers, such as Sir Steve Redgrave, British quintuple Olympic gold medallist rower, who discussed the importance of exercise and weight.

NOF Chair, Professor David Haslam commented: “We are delighted with the quality and breadth of the conference which ranged from the terrible consequences of sleep apnoea, to the benefits of ‘exergaming’ on computers. Feedback has been excellent.

Next year is our 10th anniversary conference, and we hope to make it the best yet!”

Highlights of the NOF 2009 conference are displayed below.

Obesity and diabetes: GLP-1 receptor agonists show improvements in short- and long-term health outcomes Professor Stephen Gough, Professor of Medicine, Birmingham, explained that obesity is a global health concern affecting over one billion people. He added that in Western countries, in almost 90% of cases, type 2 diabetes has developed due to weight gain. “Around two-thirds of patients with type 2 diabetes have a body mass index (BMI) of at least 27kg/m2,” he said.

Weight gain is associated with the majority of treatments used in the management of type 2 diabetes, as well as been a potential barrier to intensifying treatment. According to Gough, approximately 50% of patients are anxious about weight, and some fear the cosmetic effects of weight gain may outweigh the fear of long-term complications.

Gough then explained the mechanisms of glucagon-like peptide-1 (GLP-1), a hormone secreted from enteroendocrine L cells of the intestine in response to food. GLP-1 has shown to have an effect on the gastrointestinal and central nervous system. It delays gastric emptying and causes a reduction in acid secretion, as well as increases satiety therefore suppressing appetite and decreasing food intake, which eventually leads to weight loss. GLP1-based therapies have shown to have a significant impact on blood glucose control in people with type 2 diabetes.

Exenatide and Insulin Glargine Exenatide (Lilly/Amylin) is a GLP-1 agonist has been approved by regulatory agencies as an ad-

LEAD programme Liraglutide (Novo Nordisk) is the first human GLP1 receptor analogue, based on the structure of native GLP-1 with pharmacokinetic properties suitable for once-daily dosing. In the Phase II studies and the Phase III Liraglutide Effect and Action in Diabetes (LEAD) programme, liraglutide has been shown to lower glycated haemoglobin A1c to the same degree or more than other oral antidiabetic drugs.

In a review, entitled ‘Glucagon-like peptide-1 and diabetes treatment’, lead author Dr Tina Vilsboll, University of Copenhagen, Denmark, and colleagues discussed the LEAD studies and explained that liraglutide given as a once-daily injection, as monotherapy and in combination with a range of antidiabetic drugs is associated with significant improvements in HbA1c. Furthermore, in trials of up to one year liraglutide showed maintained weight reduction (up to 4kg in subjects with a high BMI), minimal risk of hypoglycaemia, reductions of up to 3.6mmHg in systolic blood pressure, low and transient incidence of nausea, and negligible antibody formation (Vilsboll et al. 2009).

Conclusions Gough concluded that GLP-1 analogues have proven to improve glycaemic control and have been associated with weight loss by effects on the GI system and GLP-1 receptors in the brain.

The role of testosterone in obesity It has been previously reported that there is a high prevalence of low testosterone levels in men suffering from obesity, metabolic syndrome, type 2 diabetes and cardiovascular disease. Professor T Hugh Jones, University of Sheffield Medical School, and Royal Hallamshire Hospital, Sheffield, UK, discussed the role of testosterone in obesity, diabetes and cardiovascular disease. He explained that hypogonadism is the clinical condition defined as a syndrome complex which includes both symptoms as well as biochemical evidence of testosterone deficiency. “The symptoms are non-specific but includes reduced libido, erectile dysfunction, fatigue, mood changes as well as increased body fat content,” Jones commented. Furthermore, aromatase, the enzyme responsible for metabolising testosterone to oestradiol, has a high activity within fat, particularly in visceral adipose tissue. “Waist circumference significantly correlates erectile dysfunction and lower testosterone with worsening severity of erectile dysfunction.”

According to Jones, testosterone replacement therapy in men with metabolic syndrome and type 2 diabetes has been shown to improve waist circumference and body composition reducing fat and in-

Andrew Hill

creasing lean mass, but has no overall effect on BMI. He added that testosterone also improves insulin resistance, glycaemic control and sexual function in hypogonadal men with diabetes and cardiac ischaemia in men with angina.

Study Jones then discussed a study by Keating et al., 2006, which included 73,196 men who had cancer confined to the prostate. Follow-up took place from 1992–1999. The authors explained that androgen deprivation therapy with a gonadotropin-releasing hormone (GnRH) agonist is associated with increased fat mass and insulin resistance in men with prostate cancer, but the risk of obesity-related disease during treatment has not been well studied. They assessed whether androgen deprivation therapy is associated with an increased incidence of diabetes and cardiovascular disease.

The Cox proportional hazards models was used to assess whether treatment with GnRH agonists or orchidectomy was associated with diabetes, coronary heart disease, myocardial infarction, and sud-

Obesity and depression In an interesting session about the psychology of obesity, Professor Andrew Hill, Leeds University School of Medicine, UK, discussed how many obese individuals are not only medically compromised, but are socially and psychologically disadvantaged. They can also suffer from low self-esteem and depression.

Hill explained that obese women were 17– 31% more likely to be currently depressed, 17– 53% more likely to have diagnosed depression, and 9–17% more likely to have lifetime diagnosed anxiety. He added that the risk of depression increases with the level of obesity.

In men, only those morbidly obese or underweight were at increased depression risk. Hill referred to the Swedish Obese Subjects (SOS) surgical intervention trial and explained that the incidence of depression and anxiety decreases with weight loss.

“However, at ten years the improvement remained only in those who had maintained 25% or more weight loss. For others, depression was no different to that in the non-surgical controls,” he said.

Additionally, prospective studies show depression more than doubles the risk of later obesity in adolescent girls. The opposite has been observed in older adults: obesity doubles the risk of subsequent depression.

16 BARIATRIC NEWS

B y p a s s i n g

ISSUE 3 | DECEMBER 2009 – January 2010

t h e

t i m e

w i t h . . .

If you did not have a career in medicine, what type of career would you most like to have and why?

Ski Instructor / Mountaineer – I love being in the mountains, hard exercise and outdoor lifestyle – this would provide the perfect job. The physical demands required together with the challenges of the weather with the element of risk never far away.

What posters did you have on your bedroom wall when you were growing up?

Olivia Newton John (Take me home country roads single); the girl with the tennis ball (find me a boy in the 70s who did not have that poster on her wall – apparently she was only paid £100 for the picture shoot); and the Sex Pistols (hidden from my mother behind my dressing gown!).

If you could be any animal, what would you be and why?

A lion – hanging around in the sun all day; quick run before grabbing lunch and laying about with your friends at the watering hole afterwards – sounds like the Alpine Obesity Surgery meeting!

If you could be any of the following, who would you like to be and why? a. A woman b. Peter Pan c. Santa Claus d. A time traveller e. Incredible Hulk A time traveller – I would love to go back to the 1950s just after the inception of the NHS [National Health Service]. Rolling up in a Bentley at the hospital with the porter to collect your bags, patients lined up to operate on, lots of nurses and junior staff and no managers and the whole future of laparoscopic surgery to develop. Compare that with our lot now. I’ve never seen the Medical body so dis-enfranchised and disaffected.

The world is about to explode, you have 12 hours to live. What would you do? (keep it clean!)

Well – hopefully we would be on the Alpine Obesity Surgery meeting, in which case we would have to miss the scientific meeting for a change, head up the mountain in Kitzbuhl

Ian Beckingham – ski the greatest run in the world (Run 25 to The Fleckalmbahn at Kirchberg) until we could ski it no more from exhaustion; get lashed at the Brazilian bar, roll on to the Eric Prince bar to watch the finest artistic music video ever and then onto the Londoner to die happy in the knowledge that we had had another of the finest days of our lives.

You are auditioning for X Factor (similar to American Idol in the States), what song would you sing and why?

Born to Run (Bruce Springsteen) – great song, great entertainer (met him at dinner after the 1999 concert in Sheffield) still going strong in his 60s – a great role model. Also he can’t sing very well either!

If you could punch one person (a celebrity), who would it be and why?

Louis Walsh from the X Factor.

‘Ian Beckingham – the Movie’. Who would play you?

George Clooney (from ER days) – good looks, nice life style, lovely wife, nice car and operates all day – shouldn’t have to change much to fit into the role then!

Tell us about your funniest medical moment…

Watching Roger Ackroyd trying to tie IntraCorporeal knots. Not without reason is Sheffield known as “The Land of the Extra-Corporeal Knot Pusher”! (p.s. sorry Rog!).

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BARIATRIC NEWS 17

ISSUE 3 | DECEMBER 2009 – January 2010

Should disordered eating behaviour be a contra-indication for surgery?

Weight loss surgery can lead

to significant changes in eating behaviour and binge-eating disorder (BED) has been associated with unsatisfactory weight loss in obese patients who have undergone bariatric procedures. At the IFSO meeting held in Paris, France, Dr Eva Conceicao, University of Minho, Portugal, discussed how eating patterns can change after surgery. She also discussed eating problems associated with treatment outcomes and the failure of surgery.

In her opening remarks, Conceicao highlighted two important issues relating to eating disordered behaviour over time and after surgery. She stated that, on one hand, eating disordered patterns seem to change with surgery, causing new eating patterns to arise in many cases. On other hand, it is not clear whether the symptomatology present before surgery is related to failure of the surgical procedure.

Eating behaviour change after surgery “Some studies have shown that BED status seems to disappear and eating behaviours improve with the surgical procedure,” said Conceicao. Citing two sudies, she explained that in one long-term study (13–15 years follow-up), Mitchell et al. 20011, presented weight loss results from a cohort of 100 patients who underwent gastric bypass surgery for morbid obesity.

The mean weight loss at long-term follow-up was 29.5kg (range: 13.6 to 93.6kg).

It was reported that three subjects weighed more at long-term follow-up than before the operation, although, overall, 74% of those interviewed indicated that the gastric bypass had benefited them in terms of their physical health. However, 68.8% reported continued problems with vomiting and 42.7% with ‘plugging’, and eight had died. The findings in this study suggest that at long-term follow-up the majority of individuals who have undergone gastric bypass feel that the procedure benefited them, although some complications including difficulties with plugging and vomiting were present at long-term follow-up.

In another study by Larsen et al. 20042, short- and long-term eating behavior after laparoscopic adjustable gastric banding (LAGB) and the relationship of binge eating with weight and quality of life outcome were examined. Two hundred and fifty patients (221 female, 29 male) completed questionnaires to evaluate quality of life and eating behaviour: 93 patients before LAGB, 48 with a follow-up duration of eight through 24 months, and 109 patients 25 through 68 months after LAGB. The results demonstrated that after surgery, about one-third of the patients showed binge-eating problems, which were associated with a worse postoperative outcome. The authors concluded that, “Eating behaviour improves both shortand long-term after surgery for severe obesity. Although LAGB could be a long-term solution to part of pre-operatively eating disordered patients, the identification and treatment of post-operative binge-eating appear critical to promote successful outcome after bariatric surgery.”

In a review by Bocchieri et al. 20023, the authors referred to some studies who reported a general normalisation of eating behaviour, i.e., fewer meals, less food consumed at each meal, less eating between meals and less eating in response to strong emotions at 37 months after surgery (Mills & Stunkard, 19764) and a significant decrease in bulimic episodes, secretive eating and hyperphagia at six months after surgery (Crisp et al, 19775).

Conceicao highlighted controversial data, stating that, “Some studies suggest that behaviours tend to change with surgery (not disappear), and new maladaptive eating behaviours might develop post-operatively.” In other words, despite an apparent improvement in eating behaviours, it is still possible to eat compulsively and some patients

do so although patterns may change due to the surgical restriction. So, given that patients are not physically able to binge eat after surgery, other disturbed and maladaptive eating behaviours seem to appear and result in increased caloric intake. Such behaviour involves grazing and/or continuous snacking and consuming larger quantities of sweet foods and liquid or soft foods, which pass quickly through the bypassed stomach. Also, vomiting, plugging and dumping syndrome are new problems that have emerged related to the surgical procedure and that suggest the presence of problematic eating, said Conceicao.

From this, Conceicao concluded that “Since surgery acts as a mechanism of change, it seems that we should start looking for a larger range of behaviours not just the ones traditionally diagnosed, and focus on behaviours related to loss of control over eating.”

She added “Also, we have to be more sensitive about when we should start screening for these problematic behaviours as the concerning period for re-emergence as maladaptive eating behaviours, after an apparent remission and normalisation of eating disturbances, seem to appear in the long-term (about two years after surgery), and patients seem to start regaining weight two years or more, post-surgery.”

Eating issues and failure of treatment Moving forward to the relation between eating behaviours and treatment success, Conceicao then explained that some studies relate pre-surgery eating behaviour to poorer outcomes. “Pre-surgical eating disturbances may relate to weight regain following surgery, as they tend to persist or re-emerge post-op resulting in poorer outcomes.”

She presented some evidence supporting this, mentioning Hsu6, Sullivan and Benotti (1997), who showed that patients undergoing RYGBP with a pre-surgical eating disorder may experience a short-term improvement following surgery, which usually erodes after two years, leading to weight regain. Also, Sallet et al. (2007)7 reported that at two-year follow-up, non-binge-eaters (NBE) (n=33) showed a higher percentage of excess weight loss (%EWL) than subjective binge-eaters (SBE) (n=64; p=0.003) and BED patients (n=34; p=0.001). Conceicao commented that these studies suggest that “The presence of a history of binge-eating prior to treatment is associated with poorer weight loss in obese patients submitted to RYGBP.” There have also been studies showing that eating behaviour pre-surgery does not differentiate patients after surgery in relation to different psychological variables or weight regain, and that there are more distinct differences between the BE and NBE groups before surgery, which are largely impossible to differentiate at post-surgery. As patients show similar outcomes in terms of improved depression scores, binge-eating behaviour, and health-related quality of life regardless of their binge-eating severity before surgery (e.g. Malone, 20048; Green 20049).

According to Conceicao, other studies have shown that only eating behaviours after surgery relate to poor outcomes. She added that despite the impact of pre-surgical binge-eating status on outcome remains to be determined, it is “The development or re-emergence of maladaptive eating-related cognitions and behaviour (loss of control, disinhibition, etc) after surgery that is more likely related to poor outcomes than bingeeating status prior to surgery.”

In a study that accessed 149 participants at pre-surgery and at least 12-month post-surgery, Burgmer et al. (2005)10, showed that patients with a distinct craving for sweets after surgery lost significantly less weight, stated Conceicao. She added, “Patients with binge episodes or ‘grazing’ before surgery did not differ in average weight loss from patients

Eva Conceicao

without binge episodes or ‘grazing’. Therefore, the authors suggested that post-operative, not pre-operative eating behaviour, is of predictive value for the extent of weight loss after gastric restriction surgery.”

Does weight regain mean failure of surgical treatment?

Conceicao explained that binge-eaters show a significantly smaller %EWL at followup than non-binge-eaters, but they still lose significant amounts of weight after surgery, which leads to many positive psychosocial and life changes. “Data from different studies does not support the idea of exclusion just based on eating disturbances pre-surgery.

However, it is important to access eating behaviours after surgery (monitor the patients progress), particularly in the the long-term (two years after surgery).”

She added that bariatric surgery may be viewed as an intervention that changes bingeeating symptoms and improves most psychological functioning, resulting in a normalisation of eating patterns, for an important period of time. Therefore, research suggests that binge-eating should not be a negative indicator for surgery.

Conclusion To conclude, Conceicao said that if eating patterns tend to change after surgery and over time, “It is important to investigate a wide variety of maladaptive eating behaviours. The presence of psychological disorders cannot be taken as an absolute criterion for the exclusion of candidates for obesity surgery and we should focus on the long-term, when patients need to cope with new eating challenges and difficulties.

“It is the ability of the patients to adjust their eating behaviour and their complicance to adequate dietary rules that will determine long-term results.”

References: 1. Mitchell JE, Lancaster KL, Burgard MA, Howell LM, Krahn DD, Crosby RD, et al. Long-term follow-up of patients’ status after gastric bypass. Obes Surg 2001;1:464–468.

2. Larsen JK, van Ramhorst B, Geenen R et al. Binge eating and its

NEWS IN BRIEF Waist-hip ratio better indicator of obesity than BMI readings for older adults New research by UCLA endocrinologists and geriatricians suggests that waist-hip ratio is a better indicator of obesity than body mass index (BMI) readings for older adults. The researchers from the David Geffen School of Medicine at UCLA said that the ratio of waist size to hip size may be a better indicator when it comes to people over 70 years of age. They found that the waist-to-hip circumference ratio was a better yardstick for assessing obesity in high-functioning adults between the ages of 70 and 80, presumably because the physical changes that are part of the aging process alter the body proportions on which BMI is based. The study has been published online in the peer-reviewed journal Annals of Epidemiology (ANI).

AHA supports childhood obesity recommendations The American Heart Association (AHA) has commended the Institute of Medicine and National Research Council for recommending a solid array of meaningful community actions in their new report ‘Local Government Actions to Prevent Childhood Obesity’. With US childhood obesity rates on the rise, youngsters have substantially greater risks for developing and dying from chronic illnesses such as heart disease and stroke in early adulthood. The Association believes it can play a ‘critical role’ in helping children live longer, healthier lives by reaching them where they live and play through increased physical activity and improved nutrition. As a result, the AHA will implement many of the report's recommendations such as advancing menu labelling legislation, implementing safe routes to school, improving nutrition and physical activity in beforeand-after school programmes, increasing access to healthy and affordable foods, and making changes to the built environment that increase availability of walking and biking trails and recreational facilities.

Opinions differ over food advertising Researchers at the International Association for the Study of Obesity, based in London, have reported that key players in the argument over advertising junk food to children are unable to agree what should be done.

The research reveals deep divisions between economic interests (the food industry and the advertising agencies) and health interests (consumer groups, family organisations and public health bodies).

Senior members of UK national organisations expressed differences of opinion over the strength of the evidence, the likely impact of advertising on children, the value of voluntary measures by the food industry and the need for government regulation. ‘Views were deeply split,’ said project director Dr Tim Lobstein. ‘The opportunities for finding common ground look slim at present, and we urge the government to take a clear lead on how to move the issue forward.’

relationship to outcome after laparoscopic adjustable gastric banding. Obes Surg 2004; 14: 1111-7.

3. Bocchieri LE, Meana M, Fisher BL. A review of psychosocial outcomes of surgery for morbid obesity. J Psychosom Res 2002; 52: 155-65.

4. Mills MJ, Stunkard AJ. Behavioral changes following surgery for obesity. Am J Psychiatry 1976;2:239–43.

5. Crisp AJ, Kalucy RS, Pilkington TR. Some psychological consequences of ileojejunal bypass surgery. Am J Clin Nutr 1977;30:109– 20.

6. Hsu LKG, Sullivan SP, Benotti PN. Eating disturbances and outcome of gastric bypass surgery: A pilot study. Int J Eat Disord 1997; 21: 385-90.

7. Sallet PC, Sallet JA, Dixon JB, Collis E, Pisani CE, Levy A, et al.

Eating behavior as a prognostic factor for weight loss after gastric bypass. Obes Surg 2007;17:445–451.

8. Malone M, Alger-Mayer S. Binge status and quality of life after gastric bypass surgery: a one-year study. Obes Res 2004; 12: 473-81.

9. Green AE-C, Dymek-Valentine M, Pytluk S et al. Psychosocial outcome of gastric bypass surgery for patients with and without binge eating. Obes Surg 2004; 14: 975-85.

10. The influence of Eating Behavior and Eating Pathology on weight loss after gastric restriction Operation.

Study claims obesity causes 100,000 annual cancer cases According to research by the American Institute for Cancer Research, obesity causes more than 100,000 incidents of cancer in the US every year. The group, which funds research on the link between diet and the disease, said 49% of endrometrial cancers, which originate in the womb, and 35% of oesophageal cancers are linked to excess body fat. “It’s clearer than ever that obesity’s impact is felt before, during and after cancer, it increases risk, makes treatment more difficult and shortens survival,” said Laurence Kolonel of the Cancer Research Center of Hawaii.

Researchers have yet to pin down the exact link between obesity and cancer, but some have suggested that fat tissue may produce heightened levels of sex hormones that spur cancer growth or that fat lowers immune function.

18 BARIATRIC NEWS

ISSUE 3 | DECEMBER 2009 – January 2010

CALENDAR OF EVENTS January 21– 22

LAPAROSCOPIC TRAINING FOR BARIATRIC SURGEONS – THINKING OUTSIDE THE BOX? Conor J Magee , Jonathan Barry Rob Macadam David Kerrigan * Gravitas Bariatric Surgery Ltd * to whom correspondence should be addressed T:

+44 151 929 5407

F: +44 151 929 5410 E: david.kerrigan@gravitas-ltd.co.uk

BOMSS has grown from a small group of enthusiastic pioneers into a national organisation with its inaugural conference just around the corner. After a long and difficult adolescence, obesity surgery in the United Kingdom has matured with surgical units here producing results comparable to the best centres in the world. Two British units have recently been recognised by IFSO as Bariatric Centres of Excellence and there is no doubt that more centres will gain this accreditation over the next few years.

Surgical training in the United Kingdom is also going through a period of change caused by the European Working Time Directive and increasing sub-specialisation. In this time of change there may be opportunities for a specialist society such as ours to take the initiative and advance innovative training opportunities. The senior bariatric surgeons of today have learnt their craft through hard won lessons that come with experience, but how are next generation of “metabolic and obesity” surgeons to be trained?

There are currently very few formal NHS training programmes in bariatric surgery in the United Kingdom. Trainees with an interest in bariatric surgery must hope that they find themselves in the fortunate position of working in a recognised NHS bariatric centre, attend courses that give a flavour of the field or arrange for ad hoc periods of mentorship and training from experienced surgeons. However, it is clear that in order to attain an adequate standard of surgical expertise, those who wish to become the bariatric sur-

geons of tomorrow must be prepared to invest a considerable period of time to hands-on training in recognised high volume centres that practise bariatric surgery to the highest standards.

But how?

In recent years a number of formal fairly shortterm bariatric fellowships have been introduced such as the BOMSS-administered scheme sponsored by Ethicon Endosurgery Ltd. With NHS-funded bariatric training posts so scarce, this collaborative approach with industry may create an opportunity to harness private sector funding for surgical training. The scheme run by our organisation Gravitas, is another good example of how beneficial this kind of innovative approach can be. Gravitas (who were awarded the prestigious Association for the Study of Obesity award for best practice in obesity care earlier this year) is a bariatric surgeon-led collaborative treating both NHS and private patients. It was established with the aim of creating self-financing, highly sub-specialised bariatric units within the UK (similar to that seen in Europe and the USA), which run in parallel and in partnership with the NHS, preserving the key aims and functions of a high volume teaching hospital department and retaining research and training at its core.

The Gravitas Fellowship The Gravitas Fellowship was introduced in 2007.

It aims to provide senior surgical trainees with firsthand experience and training in advanced laparoscopic bariatric surgery in a well-established multidisciplinary environment. Through one-to-one teaching in theatre, graduates of the Fellowship are expected to leave with the ability to practise independently as bariatric surgeons on completion of the training programme, confident in performing gastric banding, laparoscopic gastric bypass and sleeve gastrectomy. Fellows are also exposed to more complex work such as

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duodenal switch and revisional/endoluminal surgery, but despite the heavy theatre schedule (up to seven bariatric operating sessions per week), a key element which is constantly reinforced during their training is the importance of the acquisition of non-operative skills essential for safe patient selection and the management of postoperative problems both routine and esoteric.

Fellows are expected and encouraged to perform clinical research and contribute to ongoing projects within the department with a view to presentation of their work at national and international meetings. During 2009, as well as presenting at AUGIS, ASGBI and various specialist meetings, Gravitas Fellows attended the International Federation for Surgery of Obesity meeting in Paris to deliver no fewer than twelve presentations, more than any other single unit worldwide.

Now in its third year, the Gravitas Fellowship has provided comprehensive training for two (now well-established) bariatric surgeons and a further senior trainee. As a financially independent organisation, Gravitas benefits from a flexibility in decision-making which is often impossible in larger organisations such as NHS Trusts. This has allowed us to reinvest profits and increase the number of bursaries available in 2009/10 to fund between two and four full time trainees per year during the final year of their pre-consultant training. The duration of training funded by the bursaries varies from 6–12 months depending on previous experience. Our current Fellows have performed in excess of 220 level 3 major bariatric procedures this year (often as first operator) in addition to assisting in more complex revisional surgery cases. The next round of Fellowships for 2010/11 will be advertised in early summer and we would invite all potential candidates to contact current and past Fellows for further information, or visit our website at www.gravitas-ltd.co.uk.

British Obesity and Metabolic Surgery Society (BOMSS) Croydon, London T: +44 (0)20 7973 0301 F: +44 (0)20 7430 9235 E: shopwood@asgbi.org.uk W: www.british-obesity-surgery. org/2010conference

March 14–17 8th International Obesity Surgery Expert Meeting Saalfelden, Austria T: +43 664 4027645 E: g.wesely@sbg.at W: www.obesity-online.com/Expertmeeting

June 20–25 27th Annual Meeting of the ASMBS Las Vegas, NV T: +1 352 331 4900 F: +1 352 331 4975 E: info@asmbs.org W: www.asmbs.org

July 11–15 XI International Congress on Obesity Stockholm, Sweden T: +44 20 7467 9610 F: +44 20 7636 9258 E: ico2010@iaso.org W: www.ico2010.org/contact If you would like to advertise your meeting here, please e-mail the editor: melissa.griffiths@e-dendrite.com