Wednesday, October 20, 2010

moving towards Bariatric Surgery...

Im doing my second month of ambulatory clinic rotation ...and Im getting bored with saying  " You got to lose weight" many times each day. And I ask them to follow a diet... exercise everyday ... blah.. blah.....well..they dont... and I agree ..its a tough task. So I have thought about getting surgery to help them.

In most of the studies done on weight reduction with diet &/or exercise..the drop out rate of participants has been quite high. And almost all the studies are of duration less than 2-3 years ..and weight reduction has not achieved targets.For the Diabetic Prevention Program Study (NEJM 2002)..analysis of 1079 pts with ave BMI of 33 showed only a 5.6 kg reduction in weight with intensive lifestyle changes(diet & exercise ) for mean of 2.8 years. Adding Orlistat to a population similar to the in XENDOS study again showed a modest 5.6 kg wt loss over 4 years. Based on UKPDS data...a reduction of 7-8% of body weight is needed to reduce a HbA1C from 8 to 6 !!   hardly achievable

With this modest effects of lifestyle and medications on weight loss ( not to mention the compliance issue), bariatric surgery seems to be a reasonable option. Bariatric surgeries are of 2 types:

1. Malabsorptive procedures - eg. jejunoileal bypass(no longer done), biliopancreatic diversion and the biliopancreatic diversion with duodenal switch. The aim is to shorten the functional length of small intestine.
2. Restrictive procedures - eg. vertical banded gastroplasty, gastric banding. simpler to perform. The aim is to make stomach smaller so you get early sateity.
3. Roux-en-Y gastric bypass -  this is the most common procedure in US. It is a combination the above two.

A meta-analysis from 2005 showed a significant 20-40 kg weight loss from bariatric surgery which persisted at 10 years. This was mostly in pts with BMI>40...which translates into a 15- 30% weight reduction. Another review in JAMA also showed extensive weight loss with surgery...and a greater proportion of reduction in obesity related complications (diabetes, OSA, Hypertension, dyslipidemia etc). The perioperative mortality(30 day) is anywhere between 0.3% to 2%. Common long term complications are gall bladder disease, GI ulcers, dumping syndromes.

So..who is eligible....

BMI>39 or BMI>34  with significant obesity-related  co morbidities (severe OSA, Cardiomyopathy, severe diabetes, interfering with work), age 16 to 65 years, acceptable operative risks, documented failure at non surgical approaches at weight loss(atleast 6 mon of supervised weight reduction programs), motivated pt, absence of active psychosis and untreated severe depression, no substance abuse.

A recent analysis of cost effectiveness(CE) of bariatric surgery showed CE ratios of $7000 - $12,000/QALY in obese pts with diabetes. Medicare in US covers the cost for the surgery....and they infact dont need patients to specifically go for all non medical qualify! But still Insurance coverage will be a limiting factor in our 40 ish age group. Bariatric surgery at age 40 prolongs survival by 5-6 years . 


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