Bariatric Surgery

1
Bariatric Surgery

• Shirley Devine
• Public Health Strategy Manager
• Shirley.Devine_at_derbyshirecountypct.nhs.uk
• 01773-525049

2
Definition of Morbid Obesity

• Morbid obesity is defined as a BMI (body
  mass index) of 40 kg/m2 or more, or of 35 kg/m2
  or more in the presence of significant
  co-morbidities.

3
Core Aspects of Provider Service

• Specialist multidisciplinary assessment and
  treatment
• Provision of bariatric surgery
• Long term follow up and support of patients

4
Multi-disciplinary Team

• A multidisciplinary team (MDT) should include
• skilled upper GI surgeons with bariatric surgery
  experience who conform to British Obesity Surgery
  Society standards
• specialist nurses with experience of supporting
  severely obese patients peri- and post
  operatively,
• a specialist endocrine physician
• a dietitian

5
Referral to Bariatric Surgery

• In the first instance, bariatric surgery is
  recommended as a treatment option for people with
  obesity if all of the following criteria are
  fulfilled
• Have a BMI of 50 kg/m2 or more, or 40 kg/m2 and
  at least one other significant disease that
  could be improved if they lost weight. These
  conditions are
• Established ischaemic heart disease
• Type 2 diabetes requiring oral medication or
  insulin
• Life-threatening sleep apnoea
• Severe uncontrolled hypertension
• Benign intracranial hypertension
• History of transient ischaemic attacks or stroke
• Other co-morbid condition which has been agreed
  by the Specialist Services team as exceptional,
  on an individual patient basis

6
Referral to Bariatric Surgery (2)

• Aged 18 65 years old
• Not smoked for at least 6 weeks before surgery
• All appropriate non-surgical measures have been
  tried and documented, but have failed to achieve
  or maintain adequate, clinically beneficial,
  weight loss for at least 12 months
• The patient has been receiving intensive
  management in a specialist obesity service
• The patient is generally fit for anaesthesia and
  surgery
• The patient has realistic expectations of the
  outcomes of surgery, and understands that
  cosmetic plastic procedures to remove excess skin
  folds will not be funded by the NHS.
• The patient commits to the need for long-term
  follow-up.

7
Contraindications

• Peri-operative risk of cardiac complications
• Poor myocardial reserve
• Significant chronic obstructive airways disease
  or respiratory dysfunction.
• Non-compliance with medical treatment
• Psychological disorders of a significant degree
  which would be exacerbated by, or interfere with,
  the long-term management of the patient after the
  operation
• Eating disorders of significance
• Severe hiatus hernia/gastroesophageal reflux.

8
Follow-up

• Patients should receive specialist dietetic
  follow-up and support post-operatively. Patients
  who have undergone gastric banding will require
  additional out-patient appointments for
  adjustment of the band.
• Once patients are stable, long term follow-up and
  support should be on a shared care basis with
  local obesity services, and in primary care.
• Close working links should be maintained between
  providers of bariatric surgery and non-surgical
  obesity services, in order to ensure seamless
  patient care.

9
Referral to Specialist Care (not Surgery)

• Approximately 50 of patient are not eligible for
  surgery (
• Patients who fulfil all the referral criteria but
  who have been assessed as not eligible will
  require support
• Patients will require medical and non-medical
  care from a specialist multidisciplinary team to
  manage and maintain their weight loss

10
Key outcomes to measure effectiveness

• Weight loss
• Proportion of patients achieving required weight
  loss at 6 months, 12 months and 2 years after
  bariatric surgery. Expected weight loss should be
  at least 10 kg over the first 12-month period and
  60 of excess weight at 2 years.
• Reduction in co-morbidities
• Changes in co-morbidities for each patient at 6
  months and 12 months after undergoing bariatric
  surgery, with the expectation of improvement in
  these parameters e.g. better diabetic control.
• Readmission rates
• Readmissions and length of stay for each patient