1. Berkshire Weight Loss Surgery Royal Berkshire Hospital, Reading James Ramus, Consultant UGI & Bariatric Suregon

2. Background Obesity epidemic – 25% UK (no.5) Predicted 50% by 2050 ‘metabolic syndrome’ – (x20 risk of DM if BMI>35) NBSR 2010 – 27.5% DM

3. Treatment of obesity Diet/exercise Drugs Surgery – sustained weight loss 85.5% ‘resolution’ of DM (2 years) 0.1% overall mortality average 57.8% EWL

4. Surgery for obesity Laparoscopic gastric (‘roux en Y’) bypass Laparoscopic gastric band (Laparoscopic sleeve gastrectomy) Endoscopic gastric balloon

5. Normal Stomach

6. Gastric band

8. 50-60% EWL within 2 years NBSR Day case – 1 night stay 50-75% ‘resolution’ of type 2 DM NBSR

9. Gastric bypass

10. Gastric bypass steps

11. Gastric bypass 60-85% EWL 2 years NBSR 2-4 night stay 60-90% ‘resolution’ of DM at 2 years NBSR

12. Sleeve gastrectomy

13. 50-70% EWL 1-3 night stay DM resolution good but ?not quite as good as post bypass

14. Gastric balloon

15. ?primary weight loss procedure Sedation/ ‘light GA’ - Day case Need to remove/replace after 6 months 20-30% EWL 6 months

16. Berkshire weight loss service Referral to consultant endocrinologist Assessment by full weight loss team Commencement of non surgical ‘tier 3’ management as necessary Referral to bariatric MDT clinic Surgery Lifelong follow-up by MDT

17. Criteria for surgery NICE BMI >35 & comorbidity BMI >40 Clinical Commissioning Policy: Complex and Specialised Obesity Surgery; April 2013 – advises commissioning based on NICE guidelines

18. SIGN 2013 ‘Obese adults with T2DM should be offered individualised interventions to encourage weight loss (including lifestyle, pharmacological or surgical interventions) …..’

19. ADA 2013 ‘Bariatric surgery may be considered for adults with T2DM with BMI >35 ……in particular if diabetes or associated comorbidities are difficult to control with lifestyle and pharmacological therapy..’

20. NICE 2012 prevention of DM July 2012 – ‘…if the above weight management interventions have been unsuccessful, refer people to a specialist obesity management service (see NICE guidance on obesity)…’

21. Economic impact Obesity has been estimated to cost the NHS £4.3 billion a year. Figures published by the office of health economics in 2010 calculated that by operating on just 5% of the eligible bariatric population, the economic impact on the UK would be a saving of approximately £191 million a year.

22. Berkshire Weight Loss Surgery James RamusConsultant Surgeon Marianne SampsonConsultant Surgeon Usha AyyagariConsultant Endocrinologist Kathy KrzeminskaConsultant Anaesthetist Kath Hallworth-CookSpecialist Bariatric Nurse Lisa LovellSpecialist Bariatric Dietitian Rachael BrastockConsultant Clinical Pyschologist Please refer to Dr Usha Ayyagari, Berkshire Weight Loss Surgery, Department of Endocrinology, Royal Berkshire Hospital, Reading

23. References The National Bariatric Surgery Registry. March 2010. Dendrite Clinical Systems Ltd. Oxon Shedding the pounds. Obesity management, NICE guidelines and Bariatric Surgery in England. Nov 2010. Office of Health Economics. London Scottish Intercollegiate Guidelines Network, Healthcare improvement Scotland. SIGN March 2010 American Diabetes Association. ADA. Standard of medical care in diabetes – 2013. Diabetes Care. 2013;36 (suppl 1): S11-S66