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We will lead with perspectives on leadership and advocacy from the President-Elect of the ASMBS Teresa LaMasters and hear about the expansion of Sleeve Plus procedures in Asia and around the world as alternatives to Gastric Bypass before local Authors present the Best of submitted Free Papers.
Leading at home, leading at work, leading in advocacy. How to steer the ship during a crisis. The world as we know it has changed. In this presentation I will discuss principles in leading through crisis.
Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
With the increasing prosperity and Westernization of lifestyle, obesity has become an important health topic in Asia. Compared to Caucasian, the Asian population is more likely to develop metabolic syndrome and type 2 diabetes at a lower BMI, which leads to a rapid upsurge of bariatric and metabolic surgery in the last 10 years. In the past, Roux-Y gastric bypass (RYGB) used to be considered a gold standard of bariatric surgery in the west. Although its popularity reduces after the introduction of sleeve gastrectomy (SG), it is considered superior to SG on achieving long term weight loss and diabetes remission. However, the major drawbacks of RYGB in Asia are problems of dumping, stomal ulcers and the excluded gastric remnant. In countries with a high incidence of gastric cancer (Japan & Korea), RYGB is not recommended by many gastric surgeons.
As more bariatric surgeons are familiar with sleeve gastrectomy, the concept of Sleeve-Plus surgery is getting increasing attention in recent years. With excision of the greater curve and preservation of antrum and pylorus, it obviates the issue of remnant gastric cancer and adds the potential benefit of reducing dumping symptoms. In addition the PLUS procedure, usually a bypass component, enhances the anti-diabetic effect which is important for diabetes patients. We have recently performed a randomized control study in comparing the anti-diabetes effect as well as the gastrointestinal side effects between RYGBP and Sleeve Gastrectomy plus loop duodenojejunal bypass (SGDJB). Our preliminary results showed that anti-diabetes effect and gut hormone profile are similar between these two operations. Although SGDJB resulted in longer operating time, higher short-term morbidity and more GERD symptoms after surgery, they have less anastomotic ulcers, less severe dumping symptoms and lesser degree of iron deficiency.
In order to overcome the complexity of SGDJB but retain its superior anti-diabetes effect, more variant of “plus” procedure is being investigated, by either a gastro-intestinal bypass (gastric bipartition) or jejunojejunal bypass. However, none of these novel procedures should be recommended as a “better” procedure before its safety and efficacy are tested under ethics-approved studies and surgeons who perform these novel procedures have the responsibility in following up and evaluate them in the long term.
**We would like to acknowledge the Research Grant Council, Education Bureau, Hong Kong SAR Government in supporting our research work.
Purpose. To explore general practitioner attitudes, perceptions, treatment patterns and barriers to referrals for obesity specialist services, including both public and private obesity and/or bariatric metabolic surgery (BMS) clinics.
Methods. 810 general practitioners with a specific interest in obesity management (GPwSIO) were invited to participate in an online survey.
Results. 15.3% completed the survey. 55% of GPwSIO reported that “patients lacked motivation or interest in adopting healthier lifestyle habits”. GPwSIO viewed “the society we live in and eating habits” as most important contributors to serious obesity. 55.2% of GPwSIOs initiated treatment for obesity including dietary advice, very low calorie diets (VLCDs), and pharmacotherapy in less than 10 patients in the preceding 3 months. GPwSIO report referring patients with severe obesity to private BMS obesity management clinics (42.1%), to allied health practitioners -dieticians mainly (39.5%) and to endocrinologists (14.9%).
65% of GPwSIO stated that BMS is effective long term treatment. 68.3% would consider referring patients for bariatric surgery, however only 34% GPwSIO s are referring eligible patients for BMS. GPwSIO referred < 5 of patients within the past 3 months to a public bariatric clinic (41.7%) vs private BMS clinic (68.8%).
Only 57.9% of GPwSIO were comfortable in providing ongoing care for their bariatric patient. GPwSIO’s reported being not well supported in the both the medical and/or surgical problems post BMS from either their private (43.5%) or public (49.5%) bariatric clinic respectively. Communication between the bariatric clinic and the GPwSIO was reported “good to adequate” by only 54.9% of GPwSIO’s.
Conclusions. There is a lack of understanding of the physiological and genetic basis of obesity, with an emphasis on obesity being a “lifestyle choice” even by GPwSIO. This is manifested by inertia in the utilisation of treatments such as VLCDs and obesity pharmacotherapy. GPwSIOs report a lack of confidence in referring and managing the long term care of the bariatric patient. Further education and up-skilling are required.
BACKGROUND Gastro-esophageal reflux (GERD) post-SG is a critical issue due to symptom severity, impact on quality of life, requirement for re-operation, and potential for Barrett’s esophagus. The pathophysiology is incompletely delineated. We aimed to to evaluate the mechanisms associated with reflux events following sleeve gastrectomy (SG).
METHODS Post-SG patients, stratified into asymptomatic and symptomatic, underwent protocolized nuclear scintigraphy (n=83), 24-hour esophageal pH monitoring, and stationary manometry (n=143) to characterize reflux patterns. Ten patients underwent fasting and post-prandial concurrent manometry and pH for detailed analysis of reflux events.
RESULTS Baseline demographics between cohorts were similar: Age 47.2±11.6 vs. 44.1±11.3 years (p=0.121); females 73.2% vs. 90.8% (p=0.005); excess weight loss (EWL) 53.8±28.1% vs. 57.4±25.5% (p=0.422), follow-up duration 12.3 vs. 7.4 months (p=0.503). Nuclear scintigraphy delineated bolus-induced deglutitive reflux events (29.6% vs. 62.5%, p=0.005) and post-prandial reflux events (4(IQR2) vs. 4(IQR 3) events, p=0.356). Total acid exposure was significantly elevated in the symptomatic population (7.7% vs. 3.6%, p<0.001), especially fasting acid exposure (6.0% vs.1.3%, p<0.001). pH/manometry analysis demonstrated acute elevations of the gastro-esophageal pressure gradient (>10mmHg) underpinned most reflux events. Swallow-induced intragastric hyper-pressurization was associated with individual reflux events in most patients (90% in fasting state and 40% post-prandial).
CONCLUSIONS We found reflux to be strongly associated with SG and identified three unique categories. Bolus-induced deglutitive and post-prandial reflux occurred in most patients. Elevated fasting esophageal acid exposure mediated symptoms. Frequent, significant elevation in the gastro-esophageal pressure gradient was the mechanism of reflux and appeared to relate to the non-compliant proximal stomach.
BACKGROUND Revisional malabsorptive procedures are indicated when primary bariatric operations have failed, particularly multiple times. There are significant surgical risks and potential for severe nutritional deficiencies if follow up is inadequate. There is limited data available on long term nutritional parameters and attrition rates in this cohort of patients.
METHODOLOGY Analysis of prospectively recorded data for all patients who had a revisional biliary pancreatic diversion (BPD) +/- duodenal switch (DS) over a 16 year period at multiple centres.
RESULTS A total of 102 patients were identified who had undergone a revisional BPD +/- DS, with a mean of 2.5 (range 1-7) prior bariatric procedures. Median follow up was 7 years (range 2-17 years). There were 23 (22.5%) patients permanently lost to follow up at a median of 5 years postoperatively. At the time of revisional BPD +/- DS mean BMI (SD) was 46.4m²/kg (8.7). Mean percentage total weight loss (SD) of 22.95% (13.37), 20.06% (10.47), and 17.55% (5.66) was recorded at 5,10 and 15 years respectively. At baseline, 24 patients had diabetes and 16 had hypercholesterolaemia with remission of these occurring in 20 (87%) and 7 (43%) patients respectively. Minor nutritional deficiencies occurred in 82 (80.4%) patients, with 10 (9.8%) patients having severe deficiencies requiring periods of parenteral nutrition with 6 patients requiring limb lengthening procedures. 16 (15.7%) patients experienced a complication within 30 days, which included 3 (2.9%) anastomotic leaks. Elective surgery was required in 42 (41.2%) patients for late complications.
CONCLUSION Revisional malabsorptive bariatric surgery induces significant long term weight loss and comorbidity resolution. Patients lost to follow up is of major concern, given the high prevalence of nutritional deficiencies. The risk of serious perioperative complications remains low, however the overall risk of requiring further surgery is high. This data is of relevance to any procedure that incorporates a malabsorptive component.