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

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• Treatment over time interaction is significant *P <0.05

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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

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A1

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*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