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Hello, everybody. My name is Martha. I'm one of the organizers of the back to the future course. Back to the future is a 12 week program which is designed for foundational year doctors for medical students and also, for course, surgical Panou. As you have seen every week, we have brought either a consultant or a surgical registrar in order to speak about one surge. They're surgical specialty. Today we are on week 11 and we have the pleasure to listen to Miss Cardura. She's one of our surgical registrar at trial. Sorry, County Hospital, and she will be speak about bariatric surgery before all of these, I would like to thanks once again M D U N asset for sponsoring Gaza and also medal for giving us the opportunity to upload the recorded videos on their platform in order for you guys to watch it as many times as you as you want or if you have missed the session Before giving the word to Miss Kagura, I would like to share a small video, a short video on excision of a sebaceous cyst. Um, so give me just one second and we'll share my screen sebaceous cyst excision. Excision of the sebaceous cyst requires some care, as we ideally want to remove the cyst without damaging or breaking the integrity of its capsule. Start by identifying the margins of your cyst. You should plan to make a slim elliptical incision to include the punked. Um, if this is visible, there should be no more than a few millimeters in width. Make your incision over the top of the cyst, being careful not to go so deep as to puncture the capsule. Once in the subcutaneous tissue, it's preferable to use blunt dissection to gently dissect down to the capsule before working your way around the margins. Okay. Okay, guys. Sorry. I think we've got an issue within the video. Mhm. Mhm. So I will try once again if we will not be able to upload it, we can upload on our social media. Let's see it. Let's try once again, Sebaceous cyst excision. Excision of the sebaceous cyst requires some care, as we ideally want to remove the cyst without damaging or breaking the integrity of its capsule. Mhm. No. Sorry. That's I cannot share the video. I'm so sorry. Treasure experience out of a party. Your window. Okay, I can try it. Uh, the problem is that I cannot see my, uh, folder. I cannot see actually the video when I asked to share it. Let's see, once again, no subs know, maybe it's one now. No, it's not a days one. No. Okay, that's not an issue. We can always, uh, share it on our social media. Sorry about this technical issue. Because as you guys all know, it's not me. That usually does these technical things so we can actually go on with the Ms Kaur presentation. And we will upload the video either on next session or we can upload it. Uh, just one second and give mm. The word to Basha Just one second that I give her the word. Okay. Uh, OK, ok, give the word to you, then. Fantastic. So I'll just go back to Sheen screen sharing. Can everyone see my, uh, power point? Yes. I don't mind if you unread. The participants were quite nice to speak to people. Okay, I don't mind if anybody wants to ask the question or whatever. You can put your hand up and you can talk. It'll be quite nice to speak to people. Um, I'm going to stop my video and just focus on the presentation. Um, fine. So let's start. So I'm just going to talk a little bit about bariatric surgery and obesity. I'm sure none of these topics that are going to be completely new to anyone here, but certainly do ask me questions if you feel you like to. I think I'd like to start just by showing this data, which is from the Department of Health in 2019. And as you can see, quite staggeringly, three quarters of people age 45 to 74 in England are either overweight or obese, which I think is really quite shocking. I mean, we know that obesity is a problem, but this really, really put into perspective about how large problem it really is no pun intended, and unfortunately, the rest of the world we see a very, very similar pattern. England is by far it's certainly not an anomaly by far, and the figures are rising steadily rising indeed. Um, W h o estimate that currently over, nutrition is a bigger problem than malnutrition, which has always been the bigger problem than over. But now we're faced with obesity being a bigger problem than, uh, under nutrition. And we've now declared obesity a pandemic. Um, so if you think about what What exactly is obesity? Obesity is a chronic, a progressive multifactorial disease, and I've purposely used the word disease because currently across the world, some countries and the W. H. O recognized obesity as a disease. But in England, we choose to recognize obesity as a lifestyle choice. Um, in all my years of doing bariatric, I've not had a single patient who has said to me that they have chosen to be obese. It's quite different from choosing to smoke cigarettes. I've never met anyone who's ever chosen to be obese, and I feel obesity should be labeled the disease. And I hope that I can, um, convince you to believe the same. Um, and though the disease of obesity results in patient's having excessive and widespread deposition of fatty tissue throughout the organs and obesity affects every organ system, I purposely chose this picture where you can see lots of small writing just to really demonstrate how it affects every single organ system in the body, and not just cardiovascular or cancer risk you know, it's a It's a huge effect on an an entire physiology of a patient. Um, and it can. It increases the risk of developing a lot of comorbid conditions like heart disease and, um, more concerning Lee. It increases the risk of patient succumbing to premature death. And this is clearly evident in the recent pandemic when patient's who were obese were the ones who did worse in the pandemic. Uh, besides patient's wellderly, if you were to think about what kind of things cause obesity, I think most people come up with these four sort of things. Diseases, uh, conditions that might predispose you are some drugs, perhaps sedentary lifestyle, eating, unhealthy food and a genetic predisposition. But if I were to ask you today, which one of these do you think is the most or the most common reason for obesity? What? What would you say? Anyone. We have One answer on lt food, uh, unhealthy food. Do you think that that's the most? The most common reason. But I think that is certainly a major reason. Um, well, that's a real lifestyle. Yeah. Yeah. I'll see whether these responses Yeah. I can let you know which are the response is it's in the charter box. Uh, moving too. Sedentary lifestyle Stress Stress is a good one. Yeah. Lack of physical activity. And you're quite right. All of these things. Um uh, sorry. Can we go back to that one? All of these things do do contribute to obesity, but I I feel that we we often put it down as something as simple as you know, eat less, do more with help with obesity. But I think obesity is a far more complex problem and mean for a complex problem, you need a sophisticated solution and eat less, do more. It's not a sophisticated solution for this very complex problem. I think we need something more. Um, uh, more more intelligent treatment strategy to me. Personally, I think that poly genetics or epigenetic, is probably the main reason for obesity. And this is how our environment, or how our diets, how our gut microbiome, um, interacts with our genes. So it's true to say that genetically humans have not changed in, you know, hundreds of years, So why would our genes suddenly cause obesity? But in the last hundreds of years, we've never had um environmental insult like we have at the moment, and how those environmental insults and how the excessive the excess food that we have available now interact with our genes is what has changed. And that is why we're seeing more obesity now, because genetically, humans are programmed, as some humans are programmed to retain, food to hold on to nutrition. And we call this the thrifty gene phenotype. It's a genetic phenotype where patient's will, um, conserve nutrition to avoid starvation in the future. And it comes from when we were cavemen and we had to conserve food because we don't know where their next meal will be. And over time we have evolved to propagating that genetic. Um uh, survival of the fittest to patient's Who had that gene were more likely to have Children and propagate, Um, but now we don't need that anymore. But we still have those genetic traits. So when patient's who have a stronger link to those genetic traits are exposed to an unhealthy lifestyle or unhealthy food or sedentary lifestyle, they're more likely to develop these obesity traits that we see. Um, so then that brings us to the next thing is how How do we say who's obese and who's not? The most common thing, obviously which most people will be fully aware of, is the use of body mass index, and this is a very easily reproducible measure. But it's a very crude measure, so you can say it's a good Maybe a good screening tool is definitely better than using someone's weight by itself. Using UM weight by the square of the height gives you a measure of, um, excess weight. But a couple of times when we might overestimate or underestimate someone's fatness for people who are body builders, for example, they might have more muscle mass, and we might over s we might overestimate their fatness or, um not appreciate that they lean tissue rather than fat tissue. The concern, however, is when we underestimate someone's fatness. So someone who's elderly, for example, who's lost a lot of fat mass they might be lighter lots of, uh, muscle mass. They might be lighter than um than they were previously, but there might be more unhealthy because they have more fat tissue. Similarly, people from South Asian or East Asian backgrounds tend to have a more visceral, fat and less subcutaneous fat and visceral fat is much worse for you. Cardiovascularly. Um and although we use B M I quite a lot quite widely, a better measure of, uh, fatness is actually the waist to hip ratio. And if in men, a waist to hip ratio, which is below 0.9, is healthy in women below 0.85 and anyone, men or women with a waist to hip ratio above one increases your risk of ischemic heart disease. And obviously there are things like bio electrical impotence or dexa scans. But these are expensive ways of measuring someone's fat. So I think b m I is, although not perfect, probably the best way of measuring, um, people's degree of fatness. Um, abdominal girth. The reason why I brought up the waist to hip ratio is because abdominal girth is actually also one of the measures for metabolic syndrome, together with hypertension hypertriglyceridemia and things like that. So going back to. So The reason I put this one picture in is because one, my main uh, concern, as for healthcare from doctors or anyone who works in health healthcare, is that there's still a lot of stigma around? Uh, obesity. Uh, I think doctors are a huge, um, need to have a huge mind shift. We need to shift that that focus and stigma around the culpability around the blame factor of obesity away from the patient and think of it more as a biological problem. And if I were to have one takeaway message from this for you doctors who are coming into the field and who have a chance to make a difference as to how obesity is managed, it will be this, no matter what you do, whether you are a surgeon or a G p or regardless of what your future, uh, career takes you, I think that my one huge favor to ask you or my one huge takeaway that hope you learn from this is to shift that focus, shift the blame away from the patient and put it down to biological blame. This is not a disease of choice in the city before, and people with obesity do not choose to eat more or do less what the problem is. The mechanisms which propagate obesity and these are other to you before are complex, and we need complex solutions and I'll come to that next. Um so some of you elucidated about how it's a disease of abnormal energy balance and then involuntary physiological kind of auto regulation, like a homeostatic mechanism. So for all our human function, whether it's like your sodium levels or fluid balance, you have a homeostatic mechanism. You have something like a feedback mechanism In patient with obesity. This feedback mechanism has shifted. It's shifted from one way to another, and, uh, it's it's instead of being in, it's promoting fat deposition. Um, I put this up because I often say that obesity is a disease of the brain. And when I say that I don't mean your cortical, you're thinking part of the brain. I don't mean your conscious part of the brain. I mean your hypothalamic, your satiety centers things that you can't control. And that is why I say it's a disease of the brain is not a disease of the pancreas or disease of the gut is a disease of the brain. And even with the best will in the world, you cannot think yourself thin. But and you know, for example, if you have, if someone who is thin, it's unlikely that it's they have made themselves thin. I mean, there is a possibility, but generally people who are quite lean, Arlene and people who are more fat are fat. And this has to do with the society. Centers and the court. Sort of mechanisms Underlying obesity are rooted in biology. If you compare the mitochondria of someone who is obese to the mitochondria of someone who's lean, even at that cellular level, mitochondria behaves differently. The mitochondria fatigues easily. People who are fact have lower a T P production, um, their muscles that they're lean muscles have increased fertig ability. They have lower exercise capacity, Um, and this increased hunger simulation. And I think 11 way to think about this is that people who are obese are not obese because they overeat, but they overeat because they are obese. So they they've just drawn a bad hand. And if you ask me, why are some people obese and others not? It's purely luck. It's very much just the hand that you've been drawn, Um, for the vast, um, the majority of external stimuli that we mentioned before in our current climate is very much obesogenic. We live in an environment of plenty. People are walking less. You know, we have more reliance on public transport. We travel further. We want to travel faster. No one's walking around as much as previously. Our food is very, very energy dense. We eat larger portions. The quality of the food is poorer. A lot more processed food. Um, and stress is to something else. We fetal insult our childhood insults, play play a huge role in obesity. Um, so all of these things have resulted in the world becoming fatter, so that will bring us down to treatment. What kind of options do we have for someone who is obese? If you see someone in clinic where What what? What do you say to them? What kind of treatments do we have? Um, And while I'm on this, I'm just going to quickly tell you about people who say they are fat and fit, that they don't need treatment because they're fat and fit. And I will probably see something a bit controversial and that I don't believe there's such a thing as fat and fit. Everybody who has who is obese will eventually, even if not at that moment, will eventually have the complications of obesity, even in they haven't when they're 25 they might not, and the 35 they may start having it. But when by the time they're 45 50 they will have. They will have an effect of obesity. Obesity is a disease, and it will have an effect. So when people say to you the fat and fit, it's just that the fat and fit at that point in time and eventually it will have an effect. So people who are fat do need treatment. They need treatment, which is effective, and treatment, which is sustained. So the most common thing we talk about is lifestyle management. Right, we say, because this is obviously a cheap thing. So government will propagate using the cheapest treatment option, particularly when there's so many people who are obese. So we say lifestyle management. So you have to eat healthy, and this is for a government. This is a good thing to say to people. Firstly, it puts the responsibility of care back in the hands of the patient, and the cost of care is a lot cheaper, but it is a sustainable, effective treatment for obesity. uh, it is, but in a very small percentage of patient's in majority, um, less than five. So when we used very low calorie diet V L C D diets, which, uh, I think a few years ago was all over the news about, um v L C D. Curing diabetes the data that was presented showed that 50% of patient's who on the V L C D diet diet had a good diabetes resolution or remission. What they didn't say to you was that of the patient's who were recruited. Less than 5% actually managed to stay on the V L C D diet. So the animals 1950% was actually something like three or 4%. So it's a much smaller parental people. Um, but most people can maintain that weight loss for 6 to 12 months much, much fewer can maintain it beyond that. And this is the I. I find this graph very helpful. So there was this after the World War two when, um, patient's, you know, went through significant starvation and stuff when the war ended. A few patient's who were involved in the war, um, volunteer to take part in this study. Now this If this is a study and we look at this graph, I'll explain to you why, when people go and your your diet. So people who go on diet often are more likely to gain weight in the longer term. So if you see, can you see my my, um um, mouse? Yes. So if you if you follow this, this red line is fat free mass. Okay, so this is your lean tissue, your muscle tissue. This is the fat mass. Okay, they put people. It was a very small study on the end of 12, and it was all in men. They put people on a diet, and for this few weeks, the patient's were asked to starve and they starved and they lost a lot of weight. They lost a lot of fat mass, and they lost a lot of fat free mass. They didn't lose as much muscle. They lost mainly fat, which you think is a very good thing. But nobody can maintain starvation for a prolonged period of time. So once they went back on a more normal diet, initially they went back on a restricted diet, a sort of semi diet kind of diet. So they were going. They were still eating, but they weren't eating as much. And when they went back in the restricted diet, look how quickly the fat mass regained the fat free mass much slower. And then they went on at Liberty. Mad Liberte means they were allowed to eat whatever they wanted. So here the fat free mass continues to increase. The fat mass has overshot. And until the fat free mass is back to its baseline level, patient's were continuing to gain fat mass. So they started off here. They went in a diet. And when they've gone back to getting back the normal, uh, muscle mass, they have overshot significantly. Do you see that? And this is part of homeostasis Patient's human bodies will try to maintain their level of muscle mass. And in doing so, you overshoot your, um, fat mass. And this is why patients who go on diet ended up being larger than they did 10 years ago. And you hear people think all the times I'm constantly on a diet, but I'm getting fatter every day. You know, I've I'm flattened out that I was five years ago when I started dieting. But this is exactly why So I hope this kind of shows you why patient's should not be on on diet. You know, it's such a it's it's such an easy thing to say. Oh, we should start going on diets. But it should not be a diet. It should a sustained change in how you eat. And that's a forever change that might make someone lose weight but anything, Um, which is six weeks or 10 week diet. It's not going to work, and it's going to make you much worse off than you were when you first started, which is a real shame. Um, so that's diet, and obviously the things that exercise, um, you know, again, this has to be a sustained change. Uh, sleeping well has a huge impact. I think people Patient's asleep. Well, if you don't have good quality sleep, you're more likely to have hyperphagia and eat lots more. You decrease your leptin levels, your neuromodulator levels, Um, and similarly stress is something else. So someone mentioned stress that stress can cause weight gain. Stress can cause significant weight gain. It decreases you, you will will be like your, um fight or flight of mechanism. Your body will decrease your energy expenditure. You will increase your fat storage just in case you have to go into a fight or flight mode. You increase your ghrelin release so you eat more. You get hungrier and you have higher cortisol levels which will promote fat deposition and increase your fat and sugar intake. And you will selectively choose to eat junk food. You will selectively choose to eat food with higher fat, fat and sugar levels, which is not not surprising because you are biochemically endocrinologically, uh, promoting that that, um, diet choices. Um, when you look at the different types of pharmacological medications that is available for weight loss, and I've listed them here, and these are the ones with the FDA approved and largely the same as what we have in the NHS. But not not all, um, this is certainly you can't say that they're not not useful. They certainly do have positive effects and all leased. That especially, is I mean, a lot of patient's use, but in terms of weight loss, if you're obese and you can get something like 5% weight loss with orlistat. That's it's not going to make the hugest dent in your B m I, um, And also, the effect tends to plateau after a while so you may not have a sustained effect, Um, in in some patient's. And that's that's why pharmacological actions don't Drugs don't tend to have a day the best of outcomes, and we don't see it having, um, long term use. So what What is the most effective option that we have available for patient's who are obese? Anyone? Anyone surgery? They're saying, Uh, yeah, exactly. So it has to be bariatric surgery, isn't it? Um, and you'd be quite right. Uh, waste so bariatric surgery in the in the UK Um, we use the nice guidelines. Um, anyone who is overweight will not qualify for Barrett surgery. So if your b m I is below 30 you won't qualify. If your B m I is between 30 and 34 you have newly diagnosed diabetes for less less than 10 years in some CCGs, you may qualify for surgery in majority of CCGs. This nice guideline, which is I mean, this guidelines certainly in the nice guidelines. But most CCGs do not, um, uh, respect this girl, and they they don't go along with it, so this is largely ignored. Most guidelines use this This part, the last three here. So people with B m I above 35 who have co morbid disease is, uh, which are obesity related and can improve with surgery. Um, and this will be things like hypertension, diabetes, ischemic heart disease, sleep apnea. Um, some people will Some CCGs include, um, joint problems. Most CCGs don't. So it's usually to do with cardiovascular or respiratory health. Impatient with a B m I above 40. You can certainly get, uh, surgery irrespective of your comorbidities. If your b m i b 40 regardless of whether or not you have, Even if you're fat fit, you can certainly qualify for surgical management. Um, if your b m I is above 50 you don't need to go into tier three. Tier three is a lifestyle and exercise program where you demonstrate to the trust. That's, um, taking over your care that you have made all you've taken all, um, actions available to try to lose weight. And you are you sure commitment to wanting to undergo surgery and by that, it means that you understand that your lifestyle will change after surgery. You have to show that you will take on a different eating pattern, which is a lifelong change, not just for a short term. You will take multivitamins, and then that number of different stop smoking. You have a number of different kind of things that you take on. And you can, uh, evidence this this change to the trust is going to that's going to take on your care. Um uh, and this is just to say that the reason why we think it's very important because even if you reduce the risk of being a weight on Visa one year, we can decrease, um, cancers and a lot of other health problems. Um, so you may have heard about the tears in in obesity care. So Tier one is, uh, community management. Um, of patient's are overweight. Tier two is when your G P puts patient's on a lifestyle and weight management service, and patient's who do lose weight on those tears will exit. Don't have to go on to the next one. Very few patient's unfortunately actually, um, move on from tier tier two out, um uh, of tier two, because patient do not lose weight. Um, from to just purely lifestyle does not actually work are very, very, very, very, very rarely works. Um So most people will then progress to tier three or they may choose not to undergo surgery, surgery, and may May may just choose to continue being overweight, um, and avoid surgery. And you'd be surprised that only 1% of patient's who qualify for bariatric surgery actually ever get referred and undergo surgery in the UK less than 1% which I I find that quite a shocking number. I'm not sure whether you you feel the same, but I I feel this is the most effective treatment strategy that we have for a B. C. And only 1% of patient to qualify actually have this effective treatment strategy. I think it's insane. So anyway, patient's who qualify for Tier three will undergo assessment by a multidisciplinary team. Most MBTs in the UK will include, um surgeon, physicians, specialist, nurse, dietician and psychologist. Not all will have a psychiatrist, but psychiatrists will can be included if required. Most will also have an anesthetist. Um, this is a an example of a tear tree pathway in a in a certain in one particular trust that includes talks you through how how patient will be assessed. And, um, the timelines important thing to note here is that patient's have to have a particular, um, assessment, depending on the B m. I. But patient's with the B m I below 50 will have to undergo usually about 12 months of Tier three programs and counseling before they can progress to surgery. While patient's who have a higher BM I, in most trust now will go straight to surgery if they want. In some trust, you have six months of assessment before you progress to surgery. Um, and in many trust now we have a one stop clinic where patients come in and they see all the different, um, specialties like surgeons, dieticians all in one clinic, and they will edit the waiting list. And when it's they, One reason why Tier three management is helpful as well is that we have very long waiting list and bariatric surgery about a year, and instead of just saying that on a waiting list, we put them on this program to help them lose weight. Um, and to get make sure they're committed to the surgery. Before we start, most patients will go on. Um, the surgery will will have to be we for women. We tell them that they should avoid getting pregnant for 1 to 2 years. Post operatively. This is not something that you can mandate, but most people tend to comply because, um, there is a high risk of, um, uh, the pregnancy being complicated if they have pregnant to get pregnant in the first two years. Post operatively smoking. We tell patient's not to smoke for at least six months pre operatively, especially if they're having a gastric bypass as as a much, much higher risk of, um, complications for this patient. And again, it doesn't mean that we can mandate in the US we do blood test to check for, um, tobacco levels. But in the UK, we don't. But we do tell patient's not to smoke. Uh, if pigeons choose to smoke, some trust will choose not to operate well. Other trust will say fine, but you take on the risks of having a storm ulcer or and and that's what you break down patient's who drink more than 14 units a week are often turned down for surgery because of the increased risk of complications. Um, psychological contraindications is an interesting one because many, many, many patient's with obesity also have, um, psychological issues. And, um, as long as it's not an issue which is going to affect their ability to comply with management, we tend to, um, not, um, uh, avoid them having surgery, have any Have you heard of the liver shrinkage diet? I'm not sure if you have, but the liver is in good diet is something that we often use for patient's with high, high BMs who are undergoing surgery that's high up in the stomach. So in the hiatus, and if the liver is very big, it gets in the way of our operation. We cannot, um, see the hiatus very well. We can't access it very well. It's difficult to lift the liver up with, uh, knee since, um um with the Nathan's in retractor. And, um, there's a higher risk of liver injury. The Nissenson retractor, the liver made of soft fat like, you know, it's quite soft, and the Nathan's can go through the liver so for that, we often tell patient's to go in the liver shrink, get diet for usually two weeks in the pre op period. We tell them exactly what to take. There are a few different options, Um, and they and it helps to decrease. And we can tell when patients have This is an example the liver shrinkage diet. We can tell when patient's have a haven't, because when the liver shrinks, it leaves a little white line around the edge so we can tell when patient's have complied and have, uh, gone on with the liver shrinkage diet. Um, so just a little bit about the different types of surgery. I think most of you would probably be aware of this. But the first type of surgery is something called an intragastric balloon, which is often used as a temporary or abridging procedure. So we insert this balloon endoscopically, Um, and when we once we fill it with about five or 600 mils of, uh, fluid, which is normally stained blue with methylene blue, Um, and then we pull out the the top layer and we leave just the balloon in the stomach and patient normally have the balloon for about six months, and this is the patient's who are very large, very high. B m. I such that we cannot proceed with an operation straight away. So we put the balloon in with the hope that they can lose some weight and then to make the surgery more accessible. Most wages go home the same day, or they might go home the next day and, um, come back six months later and we empty the balloon out. Has anyone seen this procedure being done before I first one, I never seen it. Uh, it's It's, uh it's certainly it's an interesting one. Um, and it's quite quick. People can lose up to 20 to 30% of their weight. The the problem or the downside of this procedure is that, um once the balloon is out, they will gain weight again. And this only works as a as a space filling, um, stump in the stomach. The people don't want to eat as much because they have the sensation of fullness. But once the balloon is out, they start eating again, Um, the down. But in the first two weeks, patient have a lot of trouble or Often people complain of severe abdominal cramps and pain, and they have to take a PPI because they'll be increased acid production from having something sitting in the stomach. Um, and we they have to mention that they keep well hydrated because they're eating less. They might be drinking less, and there's a higher risk of dehydration. Um, the worrying thing, The reason why we put blue dye in the balloon is so that if there was a rupture, uh, patient will see that the urine has changed or change of green. So the they come in the hospital. And that's quite important because if the balloon ruptures, you'll leave a very thin balloon like structure, which will leave the which will, you know, be able to leave the stomach and go into the small bowel. And it said, uh, it's a risk of causing obstruction in the small bowel, Um, very, very rarely. When the balloon sits at the bottom end of the get displaced and sit at the bottom end of the stomach, blocking the pylori is the gastric, Um uh, stomach and the stomach can become quite distended, and it can cause gastric rupture, and patients die It's extremely, extremely rare that that happens, but it's something that patients need to be aware of. Um, because if they have significant pain, they should come in hospital quite quickly. Um uh, we have a question regarding intragastric balloon. Uh, they're asking if this can't be considered as a long term option. No, no, it's not a long term option, because it can only be in for six months, and then we take it out. Thank you. It's not. Not a long term solution, so it's It's more like a bridging procedure for people who do need a surgery. We put it in, um, just to allow us to, um, uh, get their weight down. So then they can qualify for bariatric surgery. Yeah. Um, so this is something that most is probably the most common operation that we do in the U. K. Um, it's called a roux en y gastric bypass. I suspect most of you would have come across it at some point. Even if you haven't seen it, you would have heard about it. Um, So what we do is we make a small pouch of stomach at the top. Here we divide, We go underneath the stomach. We put a stapler across and we divide the stomach. And once we divided the stomach, we look for the ligament of tried's and which is not normally were here. And we follow this down, usually about 50 centimeters. And we divide the small bowel there and this bit of small bowel that we've divided we lifted up. We form a gastrojejunostomy an an estima assis put in the stomach and the small bowel. And then we count about 100 centimeters from here, and we and ST most here we do a, J J and S m a jejunum the jejunum and sm OSIs. This rule limb is the A of the elementary limb where food will go through. This is the B limb, the bile limb. And this is the Selim, the common channel. And this will only be bile, and this will only be food, but the digestion will only start here. Initially, we often thought that the reason ruined why gastric bypass worked was because there was, uh it was a malabsorptive effect and that the the main effect was from malabsorption. Now we know that it's more to do with duodenal exclusion So the duodenum is like the accelerator for weight gain and by excluding the duodenum from nutrition Um, um, from new nutrition, the body re, um, your humans have a different, um, hormone profile a hormone, um, response when there's no nutrition there and when. When the new nutrition is introduced more distantly in the gut, the hormone profile changes and the body thinks, Oh, we shouldn't be exposed to, um, sugar high sugar levels here. So they put the brakes on and I'll, um, is more like the brakes for the for for food absorption. And because of that, there's a there's a decrease, Um, Hohmann response and the feedback mechanism to the brain will say to your body, All stop absorbing. And that's why um, it works. It doesn't work because of malabsorption, but it works because the brain is a more sophisticated way to overcome diabetes. Overcome obesity because it changes how how we respond to, um, nutrients in a small bowel. Lumen. And it works very well in Britain. Too obese. We have something like 75% excess weight loss. Um, some patients do regain weight. Um uh, five years. But the numbers are small. numbers higher at 10 years, but again like 30%. So most patient's will still have a good response. And every year that you can avoid obesity was it's better for outcomes. So although we do note, we do know now the patient's can gain weight if it gives them 10 years of being lean. That's 10 years of improved health and not having the operation. Um, and it does improve called it. I've often say Paretic surgery is like, uh, the orthopedics of general surgery, because patient's can walk again. They can do things and they can have a healthy lifestyle. But after an operation like this, but we do see a mortality rate of 0.4% and this is quite similar to having a lab Cali, for example. So although it sounds like it's quite high, it's actually the same as a lot of other operations. Um, Patient's do also have, um, other problems. Um, we do see patients have pas and clots, um, partly because patients may not want to walk around as much after an operation. So now we make we often make patient's walk as soon as they, um the day after the operation. We do see staple line leaks from the operation. Um, and this is probably the biggest concern. Um, because the patient's can may require going back to surgery, and that can be a more more difficult procedure. Um, anemia and mineral deficiency is something that might occur in the longer term, usually after about 18 to 20 to 24 months, all patient's who have barrack surgery have to take lifelong vitamin supplements. Um, and this is very, very important. Dumping syndrome is, um, when patient's may have We opened up it to avoid high sugar food because high sugar might still be absorbed directly without needing the biliopancreatic juice. And, um, it can go right into the blood supply and make patient's have symptoms of dumping syndrome where they might feel faint or lightheaded. Um, and um, this is something that can occur. So it's another reason why patients may have to comply with the post bypass diet. Um, losing weight in cost patient to have to form Goldstone Duffin an operation like this. But as you can see, if someone has Goldstone escapes down into the common bile duct in the normal anatomy, you can access it through the stomach and do an ercp in someone like this. You can't do a normal ercp because you'll have to go up all the way here and all the way there. So not quite a straightforward. I mean, if you think about it, it's not impossible, but it's not something that most people want to do. So then the other option is that you have to do a laparoscopy, uh, laparoscope. Make a hole in this part of the stomach, put your, um, scope down a port site and do an ERCP. There's a lot more complex. And this is why, if someone has gallstones, um, before their bypass, we often take the gold that out in the 12 months when they're waiting for the operation. Has anyone seen that procedure where we put a port site and take out gallstones before through the ercp? Nope. None of the ones that they're attending the course at the moment. No, it's, uh um and certainly an interesting and interesting an operation to see. Um, sleeve gastrectomy are the operation that's done most commonly and most widely worldwide. Um, it's, I guess, a bit more straightforward. We remove this so this is taken out of the body with this patient. Don't have that anymore, and they're left with this banana shaped part of the stomach. Um, initially, we used to think that because there's a smaller stomach, patient's can't eat as much and that this is a restrictive operation, and this is why people lost weight. Now we know that it's the effect is more through the duodenum, as I mentioned before and here because there's fast transit through the duodenum because the stomach is smaller, there isn't time for it to sit in the reservoir and be pumped out. The, um, new nutrition goes quite quickly through the duodenum, and this decrease, um, food contract to the duodenum is why patient lose weight, we think. But patient's can lose a significant amount of weight. Something like 50 to 60% of excess weight loss. There is some regain of weight similar to the bypass. Uh, but it does have long term effects in patients. Do well from it. We do not. If someone has reflux disease preoperatively, we won't give them a sleeve because the symptoms can be a lot worse because there's a high risk of, um, reflux. Um but again, it will work very well. Initially, there was a lot of maybe, even still, we say that maybe patients with diabetes should have a you have bypass rather than sleeve. We do know that patients with sleeves do have diabetes resolution, but this is less less long term or less significant than with the bypass. Uh, many, many units now are reversing on that decision. But in the UK, especially, we still choose to give patient's bypass if they're. If they're diabetic, uh, the mortality rate is less. The complication rate can be a bit more severe. There's a, uh, particularly at the top of the of the stable lines up here. That can be a higher risk of leak and the leak here very difficult to manage. We've been to require long term, um, stand and a scopic management in the hospital for a long time. Um, but we have fewer patient's who have a vitamin and mineral deficiency again. Patient's have to be in a lifelong multivitamins, Um, but if visions have gallstones, for example, from weight loss, you can still access it the normal way. Um, and generally most patient's do quite well. But unlike a gastric bypass, which is reversible asleep is irreversible because we take this part of stomach out completely, and you cannot then rejoin this because this is this is gone. Um, the fourth procedure is going to talk about today is something called gastric bands, which is possibly the least commonly used procedure that we use these days. It used to be the one that's most commonly used, but since over the last 110 15 years, we've seen that gastric bands are plagued with complications. And, um, now we do more band removals than ban insertions. But essentially what the band is, you make a little tunnel around the stomach. You put a little color around, um, the stomach, and then you you lock it and this port is then buried somewhere on the patient's, um, abdomen is usually the left side just underneath the ribcage. And as doctors, you will then inject this with the Huber needle, a special needle into this middle part of this port around this like a metal ring, and you'll feel it. You can inject this and the fluid will go in here and fill this this band when pigeons have some like seven mills or something gives them a bit of restriction. Uh, but most people, the effect. The effect doesn't last very long. Many, many people will gain weight after that. Uh, but when it when it works, you can People can lose a significant amount of weight. Um, they have to keep going back for a band adjustment, usually in the first few months. Um, but the problems with band is that bands can there. There's a lot of, um, issues where the band can slip up the stomach above It can become, um, necrotic, uh, or they can erode into the into the stomach wall. Uh, this pouch can dilate, Um uh, or the support can. This port can flip a twist. It's basically it's it's played. I would certainly would Wouldn't want to do if any of my patient's, um when If you were asked to see someone in a need, for example, and they say, Oh, someone's got banned. The bottom of the band is in the right place. This angle between the vertebrae and the band should be between four and 58 degrees. If it's either acutely like this or if it's down here then it's the wrong wrong angle. And that would mean that it often requires removal. If someone has issues with the band, the thing to do The first thing to do is to get a Huber needle and deflate the band. Don't use a normal needle because you might destroy the band, and particularly if they've done it privately, they might not be very grateful. You do use a Huber needle so you can still preserve the band if they want to keep it. Um, once patient's had the surgery most, most hospitals followed them up for about 12 months. Um, or 24 months, Um, and they usually go back and see the rest of the M D. T as well, not just the surgeon, just to make sure that they comply with all the different parts of postoperative care that they need to. Um, this is not not not so important, but just to say that patients do need to, um, continue on particular kinds of, uh, supplements. And, um, this is the hope that patients who have their surgery go back to being a normal bm i but has issue before some patient's can gain weight. Um and they should have continued monitoring in the community with blood tests. Um, this is this is important to to know that patient's who do have surgery should avoid, um, anything that you can increase the risk of, um, storm ulcers. So, like nonsteroidals or steroids? Um, anything which is going to be time released, um, to usually make sure that they see a pharmacist before. So the medication, the medication has to be altered appropriately. Uh, I think they contained sugar. Could that have dumping syndrome? And we need to be aware about the risk of nutritional deficiencies. Uh, B 12 deficiency especially, can result in, uh, irreversible preferable neuropathy sufficient Have to start it before they have an operation. Um, and if you're seeing someone and you're not, you don't work in a bariatric center or if you work in the community. If you see anyone who have had who has had surgery before with a new biochemical deficiency, make sure you referred to a bariatric center or any kind of unusual symptoms that you're not sure about or in order becoming pregnant that you refer them back to us so we can speak to them about how to manage things. I think this is a very useful, um uh, graph about how how to manage or who who to refer. And I think this is actually probably a better one. Um, this is probably a better one about when to refer patient. And when it's urgent, when it's, um, semi urgent and when it can wait for a bit longer. Um, that's it. Actually, I I hope that's what you were looking to have a child about today. I'm not sure if anyone's any questions. I'm happy to talk to anyone, um, with any questions. Now, hope that wasn't too long, actually. Personally enjoy it a lot also because, uh, I don't know a lot about bariatric surgery, so thank you for introducing me, actually to to do the surgical specialty. Guys, Have you got any questions regarding the presentation? That's him. I actually have got to one question about, uh um okay, I I think it's the same question that they have just asked is a ruin. Why the most effective form of bariatric surgery? So that that's an interesting question. So if you ask someone who's a sleeve proponent, they'll say that sleeves and bypass are are similar, but ruin Y has a slightly higher access weight loss. Um, so if you if you think of it as in terms of weight loss, then probably yes. Um, but it might also has a slightly higher complication risk. Overall, our the surgical options has a fairly low complication. Risk is tend to be fairly safe surgery, and very few people have long term issues from it if they comply with all the things that we ask them to do. Um, but it's very similar, ruined by and sleeve. Mm. And, uh, then I've got all the question in case in which, of course, surgical trainee would like to pursue his or her career in a bariatric surgery. What will be the most appropriate pathway? Probably the upper GI surgery pathway. So the thing to do would be to, um, make sure they're very good laproscopic skills, All all the procedures done in better laproscopic even a revision to laproscopic Um, that would be the first thing. The second thing is, which is? They've got good scoping skills because patient's often we often scope our own patient's, um, will be the follow the general surgery pathway. Get the basic competencies and then get their laproscopic competencies. Um, and two align themselves to a bariatric unit so they get very familiar with the operations and the, uh, suturing and things like that. Um, most people who do bariatrics end up doing a PhD, so that's something else to consider if you want to do biometric system Longer term career in the UK anyway, Not not not everywhere. Thank you. And, uh, have you guys got any other question? Uh, mhm. So just to recap What? You've just said the course surgery are training than a general surgery, uh, specializing in the upper gi and then bariatrics, uh, is that correct? Ok. Mhm. Okay, I guess that didn't have any more question. Uh, so, guys, I'm just gonna paste the feedback form here so you can grab your certificate. I'm also gonna upload now this video on to medal. And as always, um, once that you have to fill out your feedback form, you can receive your certificate them. Okay? I've really enjoyed this session of Bashar. Thank you very much for your time. And, uh, for these Amazing the webinar. I guess that everyone has enjoyed as well I hope so. I hope it's helpful. Um, if anyone have any questions, I don't mind being contacted of any anything like that to to let me know. Perfect them. Uh, things that are most important is that don't, um, don't stigmatize people with obesity. It's not their fault. It's a biological condition. And I hope you're convinced that it is a disease that requires treatment. Yeah, that is what we should keep in mind every day as doctors. Yeah. Okay. Thank you very much. Bash. And thanks for everyone to be here today. Thank you. Everyone. Have a lovely evening. Bye.