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Adult obesity and bariatric surgery

BMI classification

  • Healthy weight = 18.5 - 24.9
  • Overweight = 25 – 29.9
  • Obesity I = 30 – 34.9
  • Obesity II = 35 - 39.9
  • Obesity III = 40 or more

Morbid obesity is defined as a BMI over 50, or over 45 with significant co-morbidity.

For management of childhood obesity please refer to the NICE guidelines – reference below.

Red Flag Symptoms

No red flags per se but significant co-morbidity associated with obesity can obviously be life limiting/life threatening.

Lifestyle measures

  • Use clinical judgement as to when to measure weight and height (BMI)
  • Tell the patient their obesity classification and risks
  • Smoking cessation advice
  • Dietary advice – fibre rich and starchy foods, 5 portions of fruit and veg per day, low fat, eat breakfast, limit portion size and avoid alcohol
  • Physical activity – 30 mins, moderate exercise 5 days per week, build up slowly, decrease TV watching and computer use, incorporate activity into daily life (stairs, gardening, cycling etc.)
  • Commercial programs – OK if balanced diet, regular exercise and not more than 1kg weight loss per week

Medical treatments

  • Consider only after dietary exercise and behavioural approaches started and evaluated or if weight loss has plateaued
  • Consider for patients with BMI >30 or BMI 28 plus co-morbidities
  • Orlistat: Lipase inhibitor, reduces fat absorption, 120mg TDS (before, during or 1 hour after a meal), watch for fat soluble vitamin deficiency (ADEK)
  • Side effects – oily leakage from rectum, flatulence, faecal urgency, abdominal distension
  • Alli OTC orlistat (60mg)
  • Evaluate at 3 months and only continue if 5% body weight loss
  • At 12 months with successful weight loss continue as weight maintenance

Surgery

  • Consider if BMI >40 or >35 with co-morbidities if above measures have failed
  • Consider first line if BMI>50

Options

Laparascopic adjustable gastric banding (LAGB or AGB)

Laparascopic approach with inflatable silicone band placed around fundus of stomach. A port is then injected through the skin to inflate the and. The upper pouch created and narrowing in the stomach limits the oral intake. Adjustments are made by varying the amount of saline. Complications: partial or complete dysphagia if inflation excessive, normal oral intake if inflation not adequate. Relatively non-invasive and the band can be removed if problems ensue.

Silicon Intragastric Balloon (IGB)

Available in Leeds. Balloon device placed in stomach to decrease stomach volume and promote early satiety. Can be used as first stage prior to definitive procedure in super obese.

Laparoscopic or open sleeve gastrectomy

This involves dividing the stomach vertically along the greater curve and reducing the stomach volume by up to 75%. This reduces oral intake. It is non-reversible.

Laparoscopic or open Roux-en-Y Gastrectomy

Stomach divided in fundus to make a small upper pouch. Jejunum divided and brought up to join this small pouch. Food follows this track. Remaining stomach, duodenum and proximal jejunum joined to distal jejunum so digestive enzymes can flow down this route. Works by smaller volumes of food and the fact that digestive enzymes are in contact with food for less time and hence reduces nutrient absorption. It is non-reversible.

Follow-Up

  • Surgery requires patients and the surgical team to commit to lifelong follow up
  • Depending on clinical judgement, urgent out-patient follow up or acute admission should be considered if problems develop post-op

Management

Referral to Secondary Care Services is restricted to the following criteria:

NB: North Yorkshire & York do not routinely commission body contouring surgery following substantial weight loss, and that this can only be considered in cases of exceptional clinical need.

Currently, NHS Scarborough and Ryedale CCG will consider funding for surgery for patients with:

  • BMI of 50 or over
  • BMI of 45-50 with co-morbidities such as diabetes, ischaemic heart disease, sleep apnoea, hypertension and musculoskeletal problems

Each case is considered on the basis of whether conservative treatment options have been exhausted and whether there has been adequate input earlier in the pathway of psychology, dietetic and specialist nurse interventions.

Because we will prioritise the above patients, consideration will be given to the funding of surgery for patients with a BMI of 40-45 only in very exceptional circumstances.

Revision/re-do Surgery

Revision/re-do surgery will not be routinely commissioned unless there is deemed to be a clinical ‘urgent’ reason i.e. causing significant pain/discomfort and/or the patient is unable to tolerate solid foods. Patients must be advised this is part of the informed consent process. The need for revision/re-do surgery will be determined by the specialist services MDT.

Non-designated providers or private funding

Specialist post-operative and locality MDT weight management support will not be routinely funded for patients who have chosen to receive their bariatric surgery from a provider who is not a designated Y&H provider of morbid obesity surgical services or where surgery has been privately funded.

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