Post on 08-Jul-2020
Bariatric Surgery Outcomes in Singapore
OBES21st October 2017
Dr Chun-Hai TanMBBS, Masters of Medicine (Surgery), FRCS (Edinburgh)
Consultant SurgeonMetabolic & Bariatric Surgery,
Minimally Invasive Upper GI Surgery
Department of General SurgeryKhoo Teck Puat Hospital
Conflict of Interest
• No conflict of interest to declare
Outline
• Obesity and Diabetes is a Singapore problem, and also a global health problem.
• Landmark papers around the world
• Diabetes remission and weight loss is durable after Bariatric Surgery– Other improvements: hypertension, hyperlipidemia, OSA, GERD
symptoms
• Our own local data– Outcomes for our own Randomized control trial– Outcomes of our Diabetic patients who underwent Diabetes Surgery
Khoo Teck Puat Hospital, Singapore
Diabetes: A global emergency
Diabetes around the world
Diabetes – The Singapore Problem
National Day Rally 2017
A Global Health problem
• T2DM and its related complications are a major cause of morbidity and mortality. This remains a problem for global health care
• Bariatric & Metabolic surgery is highly effective in the treatment for not just obesity, but also T2DM
• Other co-morbidities such as hypertension, hyperlipidemia, OSA also resolve after Bariatric Surgery
Outcomes of Bariatric SurgeryWeight loss
Diabetes Remission
Papers from around the world
No Surgery
DSS-II Summary
• Landmark STAMPEDE trial
– 3 year outcome Bariatric Surgery vs Intensive Medical Therapy, NEJM 2014
STAMPEDE Trial – 3 year results
STAMPEDE Trial – 5 year results
Bariatric Surgery improves overall risk of mortality
Conclusion –Bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality
Bariatric & Metabolic Surgery- Resolution of OSA
- All the procedures achieved profound effects on OSA- Over 75 % of patients saw at least an improvement in their sleep apnea- BPD was the most successful procedure in improving or resolving OSA
Bariatric & Metabolic Surgery- Resolution of GERD Symptoms
All common bariatric procedures improve GERD. Roux-en-Y gastric
bypass is superior to adjustable gastric banding and sleeve gastrectomy
in improving GERD. Also, the greater the loss in excess weight, the
greater the improvement in GERD score
Our own Singapore/KTPH data
2004 2005 2006 2007 2008 2009 2010 2011-2012 2013 2014 2015 2016
Adjustable gastric banding
102 131 52 12 15 17 87 8 3 2 1 0
Roux-en-Y bypass
0 0 0 1 2 9 25 69 70 103 93 79
Sleevegastrectomy
0 0 3 3 5 27 100 192 189 193 252 248
Scopinaro BPD 0 0 0 0 0 1 2 1 0 1 0
BPD DS 0 0 0 0 0 0 0 0 1 0 1 0
Gastric plication 0 0 0 0 0 0 0 0 1 0 1 1
Mini gastricbypass
0 0 0 0 0 0 0 27 14 0 0 0
Others 0 0 0 0 0 0 3 1 0 3 0 7
Total 102 131 55 16 22 54 215 259 282 308 349 335
Singapore OMSSS data
Randomized Control Trial in Khoo Teck Puat Hospital, Singapore
• We aimed to show that Roux-en-Y Gastric Bypass (RYGB) is superior to best medical treatment in reaching well defined treatment end points in Asian subjects of BMI 27 to 32 with T2DM.
• We also aimed to show that successful surgical treatment of T2DM results in reduced resource utilization over medium to long term.
Baseline Characteristic Comparison Between Both Treatment GroupsMEDICAL SURGICAL P Value
Gender Male 28.5% Male 80% -
Age (Mean ± SD) 47.1 ± 7.4 37.8 ± 10.8 0.052
DM Duration (years) 5.6 ± 3 5.2 ± 2.6 0.747
Weight (kg) 76.3 ± 9.5 76.7 ± 10 0.921
BMI (kg/m2) 29.7 ± 1.4 29.2 ± 1.7 0.520
Waist Circumference (cm)
96.7 ± 6 101.8 ± 6.2 0.102
F. Glucose (mmol/L) 10.5 ± 2.2 12.5 ± 2.1 0.073
HbA1c (%) 9.1 ± 0.7 9.9 ± 1.2 0.134
Total DM Drugs 2.7 ± 0.8 3 ± 0.7 0.550
Data Comparison between both Treatment Arms
• Treatment over time interaction is significant *P <0.05
5
6
7
8
9
10
Bas
elin
e
3 m
6 m
9 m
12
m
15
m
18
m
Medical Surgical
* * **
5
7
9
11
13
Bas
elin
e
3 m
6 m
9 m
12
m
15
m
18
mMedical Surgical
* * 0
1
2
3
4
Bas
elin
e
3 m
6 m
9 m
12
m
15
m
18
m
Medical Surgical
**** *
*
• Treatment over time interaction is significant *P <0.05
55
60
65
70
75
80
Bas
elin
e
3 m
6 m
9 m
12
m
15
m
18
m
Medical Surgical
*** **
*
22
24
26
28
30
Bas
elin
e
3 m
6 m 9 m
12
m
15
m
18
mMedical Surgical
** **
**
80
85
90
95
100
Bas
elin
e
3 m
6 m
9 m
12
m
15
m
18
m
Medical Surgical
** ****
Data Comparison between both Treatment Arms
KTPH DM Data (2012 – 2014)
Pre-op 6 months 12 months
Age (years old) 45 ± 11 - -
Race (%) Chinese 34%Malay 42%Indian 24%
- -
Sex (%) Male 59%Female 41%
- -
Weight (kg) 116.3 ± 29 82.1 ± 15 80.2 ± 13
BMI (kg/m2) 41.7 ± 7.9 37.2 ± 6.2 34.2 ± 5.8
Glycated Hb (%) 8.3 ± 1.9 6.7 ± 1.4 6.3 ± 1.2
LSG : RYGB 12 : 29 - -
Weight and BMI change
HbA1c trend post Bariatric Surgery
Pre-operative 6 months* 12 months*
Series1 8.3 6.7 6.3
0
1
2
3
4
5
6
7
8
9
10
Hb
A1
c%
*P < 0.05
Partial Remission rate for DM
6 months 12 months
Sleeve gastrectomy 41.7% 66.7%
RYGB 44.8% 65.5%
Overall 43.9% 65.8%
Remission rates for DM – Sleeve / RYGB
Overall (%) of DM remisssion
Our own patients
Mr ARoux-en-Y Gastric Bypass in March 2015
PBW Pre-Surgery Post-Surgery
Weight 92 kg 76 kg
Hyperlipidemia Simvastatin 10mg ONFenofibrate 300mg OM
Off medications
Type 2 DM (7 years) HbA1c 9.6%Metformin 850mg TDSGlipizide 10mg OM, 5mg OA, 10mg ONCanagliflozin 300mg OMLiraglutide 1.8 mg ONInsulin detemir 10u/6u
HbA1c 6.2%Off medications
Ms BLap gastric plication in January 2017
R Bte Pre-Surgery Post-Surgery
Weight 92 kg 83.5 kg
Hypertension Nifedipine 30mg OM Off medications
Hyperlipidemia Simvastatin 10mg ONFenofibrate 300mg OM
Rosuvastatin 5mg ON
Type 2 DM (4 years) HbA1c 9.2%Metformin 850mg BD
HbA1c 5.5%Off medications
Roux-en-Y Gastric Bypass on 11 January 2016
I T Pre-Surgery Post-Surgery
Weight 161 kg 120 kg
Hypertension Valsartan 160mg OMAtenolol 50mg OMAmlodipine 10mg OM
Valsartan 160mg OMAtenolol 50mg OM
Hyperlipidemia Simvastatin 10mg ONFenofibrate 300mg OM
Off medications
Type 2 DM (9 years) HbA1c 10.8%Metformin 500mg TDSGlimeperide 4mg ONLiraglutide 1.8 mg ONInsulin detemir 10u/6u
HbA1c 5.8%Metformin 500mg OM
Mr C
Mr D52% excess weight loss achieved over 15 months!
Laparoscopic Sleeve Gastrectomy on 14 Sept 2015
68% excess weight loss over 15 months!
Pre-Surgery Post-Surgery
178.8 kg 107 kg
Mr E
Lap Sleeve Gastrectomy on 2 April 2012
W K K Pre-Surgery Post-Surgery
Weight 171 kg 76 kg
Hypertension On Micardis Off medications
Mr F
94% excess
weight loss maintained over 5 years!
Roux-en-Y Gastric Bypass on 4 May 2015
Mr G
K S Pre-Surgery Post-Surgery
Weight 104 kg 69 kg
Type 2 DM (3 years) HbA1c 9.6%Metformin 850mg TDSLiraglutide 1.2mg OMCanagliflozin 100mg OM
HbA1c 6.3%Metformin 500mg OM
100% excess
weight loss achieved over 19 months!
Bioenteric Intragastric Balloon inserted on 30 January 2014
Mr H
98% excess weight
loss achieved over 6 months and maintained 3 years on!
J Pre-Procedure Post-Procedure
Weight 95.5 kg 72 kg
Roux-en-Y Gastric Bypass on 14 September 2015
Mr I
79% excess weight
loss achieved over 15 months!
Pre-Surgery Post-Surgery
Weight 164 kg 94 kg
Hypertension Amlodipine 10mg OMEnalapril 2.5mg OM
Off medications
Conclusion
Bariatric & Metabolic Surgery, Diabetes Surgery
• Bariatric & Metabolic surgery is indicated for weight loss, treatment of
metabolic syndrome, including diabetes in a select group of patients
• Established guidelines in the world, and in Singapore
• Long term, durable results achieved with Bariatric & Metabolic surgery
• Sustained weight loss
• Diabetes remission
• Resolution of co-morbidities such as OSA, Hypertension,
Hyperlipidemia, NAFLD, NASH, Arthropathy
Conclusion
Bariatric & Metabolic Surgery, Diabetes Surgery
• Our own local data shows similar results. (Singapore Population)
• DM remission rates of 60-70% at 1 year
• We can do more to promote awareness of Bariatric & Metabolic Surgery,
“Diabetes” Surgery