Preoperative Treatment with Very Low Calorie Diet
Adelaide Circle of Care, Flinders Private Hospital/Flinders University of South
Australia, South Australia, Australia
Lilian Kow
Obesity is the most significant risk factor for the development of non-alcoholic fatty
liver disease (NAFLD), a term that encompasses a spectrum of liver pathology ranging
from fatty liver alone(hepatic steatosis) to concomitant hepatic inflammation (non-alcoholic steatohepatitis
or NASH).
NAFLD is estimated to occur in 30 to 100% of obese adults and is associated with
hepatic enlargement (hepatomegaly), elevated serum aminotransferaselevels and insulin
resistance.
In morbidly obese patients, any abdominal surgery is difficult because of reduced
intraabdominal space due to an enlarged liver and an increased amount of
intraabdominal fat. The enlarged left liver lobe obscures the gastro-esophageal
junction and makes the dissection at the gastroesophageal junction and proximal
stomach difficult. Furthermore, traction to a fatty liver may cause trauma withincreased risk for bleeding. Technical difficulties due to an enlarged liver are oneof the most common reasons for abandonment of the laparoscopic procedure and often
leads to conversion to an open procedure. The successful laparoscopic bariatricprocedure is associated with less postoperative pain, reduced risk of incisional
hernia, better postoperative pain, reduced risk of incisional hernia, better
postoperative pulmonary function, as well as shorter postoperative care when comparedto open bariatric procedures.
There are different preoperative dietary regimens recommended to reduce liver size.
Most studies support that a preoperative very low calorie diet induces moderate weightloss resulting in a significant reduction of intrahepatic fat content and liver volume.
This moderate weight loss and reduction in liver volume facilitates the laparoscopic
bariatric procedure by improving the exposure of the gastroesophaeal and proximal
stomach region.

Optimizing Nutrition After Bariatric Surgery
Nicholas Wray
Adelaide Circle of Care
Flinders Private HospitalSouth Australia
Australia

Bariatric surgery is an extremely effective weight loss tool which can result insignificant and sustained weight loss.
Implementing a structured post-surgicaldietary protocol and managing the nutritional deficiencies that can result from such
surgery, are essential to any bariatric surgical practice.
There are 4 critical stages after bariatric surgery where dietary manipulation andintervention are essential for weight loss success.
1. Post-surgical healing phase (liquid diet) – enables healing to occur from thesurgery and minimizes patient discomfort whilst lessening the risk ofstretching the new stomach pouch.
2. Progression of diet back to solids – semi-solid meals are introduced thengradual progression back to solid diet. The soft texture diet enables thestomach to get used to foods again, and the patient begins the learning processof how much they can safely eat.
3. Normal diet – dietary intervention during the longer time period from postsurgical period right through to target weight. Dietary guidance and regularcontact with the patient is essential to continue a steady but adequate rate ofweight loss and minimize nutritional deficiencies.
4. Maintenance of target weight – ongoing dietary review to ensure weight lost is
maintained.
An experienced bariatric dietitian is a critical team member in each of these stages.
The nutritional consequences of bariatric surgery must be considered on an individual
basis, as both macronutrient and micronutrient deficiencies can occur. Deficiencies
must be screened for and appropriate supplementation provided.

Multidisciplinary Approach in Adolescent Bariatric Surgery
A/Prof Wendy Brown
Centre for Obesity Research and Education
Monash University
Melbourne, Australia
Bariatric surgery has been shown to be an effective, and cost-efficacious, tool in the
management of adolescent obesity.
However, adolescence is a unique period in an
individual’s life, whereby identity is established and risk taking behaviour is common.
They are not children, nor “little adults”.
Patient selection, perioperative andpostoperative management of the adolescent patient requires that their special needs are
acknowledged, and a multidisciplinary team is required to maximise outcomes.

Taiwan's Experience of Multidisciplinary Approach in Bariatric Surgery

Kong Han Ser, M.D., WeiJei Lee, M.D.,PhD.
MinSheng General Hospital, Taoyuan county, Taiwan.

Morbid obesity is a serious disease as it is accompanied by substantial co-morbidity
and mortality. The prevalence is increasing to an alarming extent. In the past few decades,
bariatric surgery has developed and gained importance. Bariatric surgery is proved tobe the only treatment permitting significant and long lasting results for patients
suffering from morbid obesity with indications of BMI>40 kg/m(2) or BMI >35 kg/m(2)associated with one or multiples comorbidities. Bariatric care should be delivered
within credentialed multidisciplinary systems. Roux-en-Y gastric bypass (RGB),
adjustable gastric banding (AGB), and biliopancreatic diversion with duodenal switch(BPD + DS) are validated procedures that may be performed laparoscopically. Laparoscopic
sleeve gastrectomy (LSG) also is a promising procedure proved in recent literatures.
We would like to report our experience in multidisplinary approach in Taiwanese morbidly
obese patients.

Obesity Conference; Understanding of psychological aspects of obese patients are essential
for good follow-up after bariatric surgery

Atsuhito Saiki
Center of Diabetes, Endocrine and Metabolism, Toho University Sakura Medical Center

The pre- and post-operative management of bariatric surgery patients is
multidisciplinary. Especially, physician should be responsible for the treatment ofobesity, nutrition, risk factors and complications for the long-term follow-up together
with nutritionist and nurse. On the other hand, it is also essential to understand thepsychological aspects for good follow-up after bariatric surgery. Because bariatricsurgery requires a considerable change in eating behaviors and patients will experience
psychosocial change post-operatively.
Our institution holds a monthly “Obesity Conference” for more than 15 years.
It is the multidisciplinary case conference and consists of not only physicians,
nutritionists, nurse and physiotherapists, but also psychiatrist and clinicalpsychologists. Since 2010, our team has invited surgeons and has become a bariatric surgery
multidisciplinary one. A highlight of the conference is to discuss the findings frominterview, intelligence test and psychological test such as Rorschach Test (Comprehensive
System) and Egogram performed by Mental-health professionals. We first understand andsympathize with the patient’s familial social background, past history, psychologicalstress and psychic reality as much as possible. Subsequently, we evaluate the personality
traits and whether the patient has mental disorder and/or eating disorder. Then, thecomprehensive strategy for follow-up after bariatric surgery is discussed and consented.
In our team, physician mainly coordinates the conference and pre- and post-operative
management including mental-health.
Our conference established a “high lambda” personality (Rorschach Test), which
was highly detected in Japanese severe obese patients. High lambda is characterized as
avoidance of complexity and the patients are often resistant against their behavior
modification. To understand this personality is helpful to predict their “dropout” after
bariatric surgery.
Understanding of “patient” with psychological aspects is essential to successin bariatric surgery. Obesity Conference must improve to popularize such an excellent
bariatric surgery in Japan and to make more obese patients happy with the surgery!

The Role of the Dietitian in Bariatric Surgery Team

Yotsuya Medical CubeEri Kikkawa

The basic principle of treatment for obesity is that the consumption of energy overcomesthe intake of energy. However, the obesity cannot be treated only by negative balance ofenergy. There are a number of problems with obese patients, such as eating habits, living
conditions and social lives. Therefore, the multidisciplinary team approach with
sufficient expertise to manage the interplay of these behavioral, nutritional,
psychological, medical and surgical issues would seem imperative.
Our institution has performed nearly 200 bariatric cases since 2006. Our team consistsof bariatric surgeons, nurses, social worker, and national registered dietitian for the
management of bariatric patients. The main role of dietitian is nutritional management
before and after surgery for the purpose of bettering the outcome of surgery. For example,
the preoperative nutritional assessment and education of the patients plays an importantrole in reducing the risks of surgery and the postoperative instructions from the dietitianare provided for weight loss induced effectively and prevention of nutritional deficiency
and malnutrition.
The postoperative excess weight loss was 22.9% at 1 month, 41.5% at 3 months, 58.5%
at 6 months, 70.4% at 12 months, and 73.6% at 24 months. The dietician has given the patientsthe details about nutrition and guided them properly. Therefore, there was no patient
suffering from nutritional deficiency and malnutrition after surgery. In addition to that,
our result shows that our multidisciplinary approach was successful for morbidly obese
patients in Japan.

Psycho-Social approach by the social worker for bariatric patients in Japan./ A model toensure the success of bariatric surgery

Tetsuya Nakazato
Yotsuya Medical Cube

Morbid obesity is a new but rapidly increasing social problem in Japan. More than200

patients have underwent bariatric surgery since 2006 at Yotsusya Medical Cube.
We have organized the multidisciplinary Team which consists of surgeons, a nutritionist,a pharmacist, nurses, and a social worker. The team approach plays an important role inthe success of treatment for bariatric patients. In this approach, the social worker isin charge of the psycho-social support for patients. For example, there are two kinds of
psycho-educational groups organized by the social worker: 1) Pre-surgery orientation groupwith post-surgery patients as supporters every Wednesday and Thursday; 2) Post-surgery
patient group meeting every December, the counseling has also been provided on individual
basis as well as in group settings for pre-surgery and post-surgery patients.
As social work is a profession for those with a strong desire to help improve people’s
lives,, social workers are in an important position to help bariatric patients by helping
them cope with and solve issues in their everyday lives, such as family and personal
problems, relationships, and social problems. Therefore, as the patients can focus on their
physical problems and treatment, this intervention has lead to the success of bariatricsurgery in our hospital.
I will speak about effects of the social worker intervention for bariatric patients withmy experiences and research.

A multidisciplinary approach to obesity treatment

Takashi Oshiro
Department of Surgery, Toho University Sakura Medical Center, Chiba, Japan

Open and laparoscopic bariatric surgeries have been performed in Japan since 1981 and 2000,
respectively. But because of the low rate of obesity in the population (the percentageof the population with a BMI over 30 is 3.2%), and even medical personnel have little
interest in trying to understand weight loss surgery. Although more than 90% of bariatricsurgery is performed laparoscopically in the world, health insurance coverage is applied
only for open surgery in Japan at this time. With regard to gastric bypass for Japaneseobese patients, no consensus has yet been reached among domestic societies for thetreatment of obesity due to the high risk of gastric cancer. For these complex reasons,only a few hospitals perform bariatric surgery routinely in Japan. However, consideringthat there has been an increase in obesity-related diseases in Japan, and since obesity
continues to increase, it appears that there are many patients who would be candidates
for bariatric surgery.
It is well known that the implementation of a presurgical patient assessment and dietprograms by a multidisciplinary team can lead to optimal results after bariatric surgery.
Ourmultidisciplinary

team,

includingphysicians,

psychologists,

nurses,psychotherapists, dietitians and physical therapists has worked for years on obesity
treatment. Surgeons joined this team in 2010, and we started performing both open andlaparoscopic bariatric surgeries. We herein present our multidisciplinary approach to pre-,peri- and postoperative care.

Diabetes control and lessened cerebral cardiovascular risks after gastric bypass surgery in Asian
Taiwanese with a body mass index <35 kg/m2

1

Cardiovascular Department of internal Medicine, Min-Sheng Hospital, Taoyuan, Taiwan, ROC 2Departmentof surgery, Min-Sheng Hospital, Taoyuan, Taiwan, ROC
Jih-Hua

Wei1,Wei-Jei Lee2,Shu-Chu Chen2,Yi-Chih Lee2,Yen-How Su2

Background: Morbid obese patients with type 2 diabetes mellitus (T2DM) and a body mass index(BMI) >35
kg/m2 benefit greatly from Roux-en-Y gastric bypass surgery (RYGB). Whether the patients with T2DM anda body mass index (BMI)<35kg/m2 also profit from this surgical procedure is not known. In Asian Taiwanese,
the risks associated with T2DM and cardiovascular diseases occur at a relatively lower BMI levels. We
examined the safety and efficacy of RYGB in Asian Taiwanese patients with T2DM and a BMI of 22-35 kg/m2
in a referral medical center.Methods: A total 62 consecutive patients with T2DM and a BMI of 22-35kg/m2
underwent RYGB between 2003 and 2009. The data were prospectively collective before surgery and at 3,
6 and 12 months after operation. Results: Of the 62 patients, 15 were men and 47 were women (age 40.1
± 10.1 years). Their preoperative characteristics were BMI 30.2 ± 3.2 kg/m2, body weight 81.8 ± 11.8kg, waist circumference 100.6 ± 10.4 cm, and duration of T2DM 5.9 ± 6.0 years. There was no mortality,
major surgical morbidity, or excessive weight loss experienced. The BMI decreased postoperatively by
20%, from 30.2 ± 3.2 kg/m2 to 24.0 ± 2.8 kg/m2 (P <.001). The fasting blood glucose level decreased
from 194.7 ± 70.4 mg/dL to 99.8 ± 28.4 mg/dL (P <.001), and the hemoglobin A1c decreased from 9.1%
± 1.7% to 6.0% ± 0.9% (P <.001). The 10-year cerebral and cardiovascular disease risk was estimatedwith UKPDS risk engine before and after RYGB. The risk for fatal and nonfatal stroke and coronary heartdisease decreased essentially. Conclusion: RYGB safely and effectively remits T2DM in Asian Taiwanesewith a BMI <35 kg/m2. It also lessens the 10-year cardiovascular cerebral disease risks. More larger,
longer term, prospective and randomized studies are needed to confirm these effects.

Prevalence of nonalcoholic steatohepatitis (NASH) in morbidly obese Japanese patients who underwent
bariatric surgery

Yosuke Seki
Yotsuya Medical Cube

1) Division of weight loss surgery, Department of minimally invasive surgery, Yotsuya Medical Cube, Tokyo,
Japan2) Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Gunma,Japan

Yosuke Seki1), Kazunori Kasama1), Satoru Kakizaki2), Hideharu Shimizu1)

Background:Non-alcoholic fatty liver disease (NAFLD) is increasingly being recognized to occur more commonly inthe obese with a clinicopathologic entity that extends beyond uncomplicated steatosis to steatohepatitis(NASH), advanced fibrosis, liver failure and hepatocellular carcinoma. In our previous report, we showedthat racial difference between Japanese and Western people in terms of NAFLD and related liver
dysfunction. There are few reports investigating the prevalence of NASH in morbidly obese Japanese.
Methods:
Twenty-eight consecutive morbidly obese Japanese who underwent bariatric surgery in Yotsuya Medical Cubefrom October 2009 to July 2010 were enrolled. There were 16 females and 12 males (mean age: 40.3±11.2).
Mean pre-operative weight was 114.4±22.3kg and mean BMI was 41.9±6.9kg/m2. A trucut liver biopsy was
performed from left lobe of the liver at the time of surgery and analysed by a single pathologist. The
liver biopsies were assessed by applying histopathological criteria that are accepted in the pathology
literature.
Results:
Eighty-nine percent (25 in 28) of the patients undergoing bariatric surgery were found to have steatosis.
And 71.4% (20 in 28) were found to have NASH. One patient was found to have established cirrhosis.
Conclusion:
Hepatic steatosis was very prevalent in our cohort of patients presenting for bariatric surgery. The
prevalence of NASH was much higher in Japanese morbidly obese patients than the reported prevalence of
NASH in Western individuals. These findings support that Asian are more prone to central obesity and,thus, have increased risk for obesity-related comorbidities.

The Feasibility: SILS port Roux-en-Y Gastric Bypass for Low BMI Diabetes Mellitus

1

Bariatric & Metabolic International Surgery Center,E-Da Hospital,Taiwan 2International Minimally

Invasive Surgery Training Center 3General Surgery
Chih-Kun Huang1,2,3,Chi-Hsien Lo1,3

Background: Single Incision Laparoscopic Surgery has been expanded to bariatric surgery. Laparoscopic
Roux-en-Y gastric bypass is already accepted as one of the most effective procedure for the treatmentof type 2 diabetes mellitus. Hereby, we described our experience using SILS Port to performed Roux-en-Y
gastric bypass in nine patients with type 2 diabetes mellitus patients.Methods: After getting approvalof E-Da Institutional Review Board, 9 cases with diagnosis of Type 2 Diabetes Mellitus patients withlow body mass index (BMIless than 30) underwent Roux-en-Y gastric bypass using the SILS Port from August2010 to November 2010. Standard Roux-en-Y gastric bypass was performed with 25ml of gastric pouch, 100cm
of alimentary and biliopancreatic limb. Results: Four female and five male patients with mean BMI 27.15
and average of diabetes history of 10.2 years, underwent SILS Port Roux-en-Y gastric bypass. Novel liversuspension technique was performed in all patients. Mean operation time was 135 min. And two patientsneeded additional trocars intra-operatively, related to the difficulty in the dissection of gastric pouchand gastrojejunostomy suture. There was no surgical complication or mortality. At the first month
postoperatively, mean AC sugar dropped from 198mg/dL to 116.1mg/dL, and mean HbA1c decreased from 9.71%
to 8.18%. Conclusion: Laparoscopic Roux-en-Y Gastric Bypass with SILS Port is feasible and reproducible,
but should be performed under strict indication and by an experienced surgeon. Even in low BMI patients,
it showed high technical skill demands, increased operation time and high conversion rate.

Early Resolution of Type 2 Diabetes Mellitus by Laparoscopic Ileal Transposition with Sleeve Gastrectomy
Surgery in 23 to 35 BMI Patients

1

Bombay Hospital 2Center of Metabolic Surgery, Levioza Clinic, Pushpanjali Building, Santacruz(W),Mumbai, India
Ramen Goel1,Pravin Amin1,Madhu

Goel2,Sanjeet Marik1

Introduction: Diabetes is considered a life style disease. 56% diabetic patients with BMI greater than
7 are at high risk of diabetes related complications. Bariatric surgery results in diabetes resolution
in over 84% patients. Based on hindgut hypothesis suggesting role of incretins like GLP-1, early trialsof ileal interposition surgery have displayed consistent HbA1c levels below 7 in over 80% patients withover 30 kg/m2 BMI. In developing countries majority of T2DM patients are not morbidly obese and surgicalprocedures are to be evaluated for their efficacy in this group. In this study we have assessed the efficacy
of ileal transposition with sleeve gastrectomy (SGIT) in 23 to 35 BMI T2DM patients.Method: Afterinstitutional

ethicalcommittee

approval&

IndianCouncilofMedicalResearch

registration(CTRI/2008/091/00206), selected T2DM patients [HbA1c over 7, C Peptide more than 1] underwent
Lap SGIT by a single surgeon. Data of first five patients with minimum 6 months follow up was analyzed
for glycemic control, reduction/ discontinuation of diabetes medication.Results: The study target (HbA1cless than 7) was achieved in 60 % patients within 1 month , and in 100% patients within 6 months. Requirementof medicines reduced significantly within 6 months and their HbA1c levels reduced from 9.65% to 6.22%.
Conclusion: Laparoscopic SGIT represents a new paradigm, for the treatment of T2DM even in non morbidly
obese patients. Conflict of Interest: None.Funding: Research related to this study was funded by Bombay
Hospital trust, Mumbai, India.

Is Laparoscopic Duodenojejunal bypass with Sleeve an effective alternative to Roux en Y gastric bypass:A Randomized Trial

1

Department of Bariatric and Metabolic Surgery,Gem Hospital and Research Centre,Coimbatore,India

Praveen Raj1,Palanivelu Chinnusamy1

Background:The incidence of Obesity and related metabolic disorders including Carcinoma Stomach in India
is one of the highest in the world .Hence one requires a procedure that allows postoperative surveillanceof the stomach with the best outcomes in terms of weight control and resolution of comorbidities .Here
we compare one such procedure,Duodenojejunal bypass with Sleeve against the standard Roux-en Y gastricbypass.Methods:52 patients were randomized into 2 groups of Laparoscopic Duodenojejunal bypass with
Sleeve (DJB) and Laparoscopic Roux en Y gastric bypass (RYGB) of 26 patients each. Results:The mean BMI
at the end of 6 months and 1 year was 35.16, 29.25 in RYGB and 34.51, 28.10 in DJB. The %excess BMI loss
at 6 months and 1 year were 52% ±19 and 77% ±24 in RYGB and 58% ±14 and 82% ±19 in DJB, which was
not statistically significant.14/26 patients in the RYGB and 19/26 in the DJB group had Type II
Diabetes .In RYGB

12 had complete resolution and 2 had improvement and 16 patients in the DJB had complete

resolution and remaining 3 had improvement . There was 100% resolution of Dyslipidemias in both groups.
There was 1 patient in the DJB group who presented with internal herniation 1 month post-op was managed
surgically. Conclusion:Laparoscopic Duodeno-jejunal bypass with Sleeve, which combines the principles
and advantages of Sleeve Gastrectomy and RYGB is a safe and effective alternative to gastric bypass inweight reduction and resolution of comorbidities.Also, with the possibility that the procedure can bemade less restrictive by altering the size of the sleeve, it can be employed as a procedure to treat
Metabolic Syndrome even in the lower BMI group. But, a long term follow up is necessary to establish
it as a standard procedure.

Overview of Laparoscopic Sleeve Gastrectomy (LSG).
Clinical Professor of Surgery, Montreal, QC CANADA
Michel Gagner, M.D. FRCSC, FACS, FASMBS, FICS, AFC(Hon.)
Sleeve gastrectomy (SG) has been a simpler bariatric operation, which shows goodresolution of co-morbidities and provides excellent weight loss. Laparoscopic SG was
initially performed for high-risk patients (in 2000) to enable increased safety forboth operations. However, indications for SG as a primary procedure have been
increasing. The Third International Consensus Summit for SG was held in New York City,
Dec 2-4, 2010, to evaluate techniques and results.
Methods: A questionnaire was filled out at the Second ICSSG March 19-22, 2009 in Miami
Beach and compared to the recent one in NYC in 2010.
Results: Findings are based on 106 questionnaires, representing a total of 14,776 SG.
In 86.3%, SG was intended as the sole operation and 81.9% of the surgeons reported noconversions from a laparoscopic to an open SG. Mean ± SD %EWL: 1 yr 60.7 ± 15.6, 2
yrs 64.7 ± 12.9, 3 yrs 61.7 ± 11.4, 4 yrs 64.6 ± 10.5, >4 yrs 48.5 ± 8.7. Bougie
size was median 34.0 Fr., (range 16-60). The dissection commenced 5.0 ± 1.4 cm(median 5.0, range 1-10) proximal to the pylorus.
Staple-line was reinforced in
65.1%; of these, 50.9% over-sew, 42.1% buttress and 7% do both. Post-op, a high leakoccurred in 1.5% and a lower leak in 0.5%, hemorrhage in 1.1%, splenic injury in 0.1%,
and later stenosis in 0.9%. Post-op GE reflux (~3 months) was reported in 6.5% (range
0-83%). Mortality was 0.2 ± 0.9% (total 30 deaths in 14,776 patients). This year, 5
years results showed a mean of 50% EWL, a higher result than with gastric banding, but
comparisons with gastric bypass are still pending. Conclusion: SG for morbid obesity
should be recognized as a primary operation.

Rise of Sleeve gastrectomy in Asia

Muffazal Lakdawala

Abstract
Bariatric surgery is an ever evolving field. There have been several discoveries that havechanged the way bariatric procedures are carried out. This has led to a lot of enthusiasm
within the surgical community. Many of the bariatric surgical procedures have not beenable to stand the test of time and have been replaced with newer, simpler and more effective
procedures rendering the older ones obsolete.
Sleeve gastrectomy is a relatively new procedure. What was initially started as the firststage of a duodenal switch surgery in super super obese patients has now come of age tohave its place as a standalone procedure in bariatric surgery.
in the surgical community about this procedure.

There is a lot of excitement

Its popularity can be attributed to its

favourable early results. Hence surgeons from across the world are now offering it to anincreasing number of patients. The benefits of sleeve gastrectomy seem to far outweighits risks. It is a technically easier procedure with a lower learning curve. There areless chances of developing nutritional deficiencies and the remnant stomach is always
accessible for examination which is of great significance for stomach cancer endemic
countries like Japan and Korea.. Asian studies have already suggested better results interms of weight loss and resolution of co-morbidities after a sleeve gastrectomy.
Increasing proficiency of Asian surgeons in Single Incision surgery has led to further
increase in the popularity of this procedure in Asia.
The only word for caution for complete adoption of LSG is that long term results are still
awaited and leaks from staple lines are difficult to treat.

Long term results of laparoscopic sleeve gastrectomy for Korean

Gangnam CHA medical center, CHA university, Seoul, Korea
Sang-Moon Han

Purpose: In Asia, its types and the main causes are different from than in thewestern society. Therefore, the treatment plan should be different, and the surgery
for morbid obesity should be carefully chosen. Long term results of the isolated
laparoscopic sleeve gastrectomy which was performed for the Korean are reported.
Methods: We retrospectively reviewed 168 patients who underwent LSG from January 2003
to January 2011. One hundred thirty nine of these patients had more than 6 months offollow-up, and they are subjects of this report. Sleeve gastrectomy was performed
laparoscopicaly using Endo-GIA stapler to create a lesser curve gastric tube over a
48-Fr bougie. The longest follow up time is 8 year.
Results: Preoperative Body Mass Index (BMI) is 36.7±5.4 (30.0-59.1). The percentageof excess weight loss (%EWL) in the postoperative first, third, fifth, and seventh
year was 71.4±22.1, 66.0±29.9, 67.8±27.6, and 60.4±29.3. The percentage of excess
BMI loss (%EBMIL) was 73.1±24.3, 67.8±31.0, 73.4±32.1, and 62.2±29.7. However,the follow up rate is decreased by postoperative time. The follow up rate in thirdyear is 62.5% and fifth year is 30.2%. There was no 30-day peri-operative mortality.
Three major complications (1 delayed bleeding, 2 leakage) occurred.
Conclusion: Isolated laparoscopic sleeve gastrectomy has been an effective weightloss operation in the most of the Korean patients. However, the more follow up rate
after LSG is needed.

Sleeve Gastrectomy in Banding country.

Consultant Bariatric Surgeon St George Hospital Sydney
Dr Ken Loi MBBS Bsc(med) FRACS

Laparoscopic gastric banding has been the dominant bariatric procedure in Australia forthe last 10 years. Most bariatric surgery are performed in private hospital and there isno database to allow us to examine adequately the trend of different operations. Overall
the numbers of bariatricprocedures increased from 500 per year to 15000 last year.

However, from medicare data documented by government, we are able to estimate there isa decline in numbers of lap band performed and increase in numbers of sleeve gastrectomy.
The presentation will examine the possible reasons behind it and illustrate the problems
that will be facing australian bariatric surgeons in the next 5 to 10 years.

Laparoscopic sleeve gastrectomy in Japan

Masayuki Ohta, MD, Seigo Kitano, MD
Department of Surgery I, Oita University Faculty of Medicine, Oita 879-5593, Japan

In Japan, laparoscopic bariatric surgery was introduced in 2000, and laparoscopic sleeve
gastrectomy(LSG)

has been performed since 2005. Since

gastric cancer is afrequently-occurred disease in Japan and the excluded distal stomach after laparoscopic
Roux-en-Y gastric bypass (LRYGB) cannot be checked by usual endoscopy, LRYGB is probably
not so suitable for Japanese patients. Therefore, a number of LSG is rapidly increasing.
Japan Research Society for Endoscopic and Laparoscopic Treatments of Obesity (JELTO) which
was organized 5 years ago carried out a nationwide survey on laparoscopic bariatric surgery
in 2010. From 2000 to 2009, total 340 laparoscopic bariatric operations were performedby 9 Japanese institutes, and 102 of the operations (30%) were LSG. In 2009, 70 morbidly
obese patients underwent laparoscopic bariatric surgery, and 50 of the 70 patients (71%)
did LSG. There was no mortality and the postoperative complication rate was 7.8% in the
102 cases. Major complications were staple-line leakage in 4 cases (3.9%) andintra-abdominal bleeding (reoperation required) in 3 (2.9%). Percent excess weight loss
after LSG was 66% at 12 months and 68 % at 24 months, respectively. According to the weight
loss, 91% of patients with type 2 diabetes achieved remission, hypertension were resolvedin 62% of patients, and dyslipidemia were resolved in 53%. This survey showed the safety
and effectiveness of LSG in Japanese morbidly obese patients. In addition, LSG has been
approved as a special advanced technique in some Japanese institutes by the Ministry of
Health, Labour and Welfare since this year, which is partly covered by the government healthinsurance. Now, LSG has been rapidly spread in Japan and will play an important role intreatments for morbid obesity.

Update in the outcomes of over 800 sleeve gastrectomies with 6 years of followup.

1

Mercy Bariatrics

Perth Australia

Leon Cohen1,Jon Armstrong1,Harsha Chandraratnah1

Since 2004 we have performed over 850 sleeve gastrectomies. This is a heterogenous group that includes
770 primary cases and 80 revisional sleeves.

The first 107 sleeves were calibrated against a 50fr bougie

and the next 680 against a 40 Fr bougie. We are now using a 36 Fr bougie (63)in our largest series of 618,

in most cases. Results

40 Fr primary sleeves show an excess weight loss that peaks at 18 months

at 74% and is now at 61% out to 4 years. In the earlier 50 Fr
at 24 months and had fallen to 42 %by 60 months. So far inseries the weight loss peakedat 62 %

the earlier 50 fr series 12 of the patients

have been re sleeved with their EWL returning to an average of 55 % EWL at 24 months. Only one

40 frpatient has required resleeve so far.Impact of sleeve size , surgical technique, commencement BMI, age
and sexon outcomes will be discussed.

Conclusion:
We believe that sleeve gastrectomy produces robust weight loss in the medium term providing anappropriate size bougie is selected.( no more than 40Fr)

Late weight regain is in line with the natural

history of other bariatric approaches and can be adequately managed by resleeve gastrectomy.

Single Incision Transumbilical Laparoscopic Sleeve Gastrectomy (SITU-LSG), How I Do it?
*

Bariatric & Metabolic International Surgry Center, E-Da Hospital, Kaohsiung, Taiwan
Department of General Surgery, E-Da Hospital, Kaohsiung, Taiwan‡
Department of Chemical Engineering, Institute of Biotechnology and Chemical
Engineering, I-Shou University, Kaohsiung, Taiwan
Chih-Kun Huang, MD*†‡, Chi-Hsien Lo, MD*, Jer-Yiing Houng, PhD‡, Yaw-Sen Chen, MD†,
Po-Huang Lee, MD††

BACKGROUND: Sleeve gastrectomy has been recently proposed as a sole bariatricprocedure because of the resulting considerable weight loss in Asian morbidly obese
patients. Traditionally, laparoscopic sleeve gastrectomy requires 5-6 skin incisions
to allow for placement of multiple trocars. With the progression of scarless concept,
multiple abdominal procedures have been performed using a single incision transumbilical (SITU) incision, with good cosmetic outcomes.
METHODS: We retrospectively reviewed our patients receiving sleeve gastrectomy from
November 2008 till September 2010 .A total of 27 consecutive patients underwent
laparoscopic sleeve gastrectomy with single incision and trans-umbilical approach.
Three trocars were inserted via the umbilical incision after pneumoperitoneum.
RESULTS: Of the 27 patients, 19 were women and 8 were men, with a mean age of 32 years(range, 20-46). The mean preoperative body mass index was 35.9 kg/m (range,32.4-42.3).
The mean operative time was 70 minutes (range, 30-170). Intra-operative novel liversuspension tape was used in all patients, and no perioperative or postoperativecomplications happened. No conversion or need for adding trocar during the procedure
was found.No mortality was noted.
CONCLUSIONS: SITU laparoscopic sleeve gastrectomy is safe, technically feasible, andreproducible. Intra-operative modification of liver retraction is the key element in
improving surgical field and decreasing operation time.

Possible mechanisms of rapid improvement of glucose tolerance and insulin secretion after
laparoscopic sleeve gastrectomy (LSG)

Hiroshi Yamamoto
Departments of Surgery, Shiga University of Medical Science【Objective】 LSG has been designed as the first of a two-stage procedure for the high-risk,
super-obese patient. Recently LSG has been applied as a single-stage procedure becauseof excellent weight loss and low incidence of complications. More recently, theaccumulating data suggested that LSG produces remission or cure of type 2 diabetes mellitus(DM). To investigate the mechanism which LSG improves glucose tolerance, oral glucose
tolerance test (OGTT) was performed at preoperative and 3 months after surgery.
【Methods】 We performed LSG on two diabetic patients, one patient with impaired glucose
tolerance (IGT) and two non-diabetic patients. Plasma glucose, insulin and Glucagon-like
peptide-1 (GLP-1) levels during OGTT were measured. Fasting ghrelin levels were alsomeasured. To assess gastro-intestinal motility during OGTT, we used cine MRI.
【Results】 Diabetic patients discontinued oral hypoglycemic agent or insulin immediately
after surgery. HbA1c was improved in diabetic patients. OGTT showed that great improvementof glucose tolerance with enhancement of insulin and GLP-1 secretion in diabetic patients.
Area under the curves (AUC) for insulin and GLP-1 were increased after LSG. Fasting ghrelinlevels were decreased in all patients. Cine MRI during OGTT revealed that gastro-intestinal
motility was remarkably induced after LSG.
【Conclusion】 These results suggest that LSG can lead to rapid improvement of glucose
tolerance and insulin secretion. Increased GLP-1 secretion and decreased fasting ghrelinlevels may play a role of improvement of glucose tolerance and insulin secretion after
LSG. Induced gastro-intestinal motility during OGTT may lead to increased GLP-1 secretion
after LSG.

Complications after laparoscopic sleeve gastrectomy for morbid obesity
Akira Sasaki1, Kazunori Kasama2, Toru Obuchi1, Shigeaki Baba1, Akira Umemura1, Go
Wakabayashi1
1Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan2

Department of Weight Loss Surgery, Yotsuya Medical Cube, Tokyo, Japan

Background: Laparoscopic sleeve gastrectomy (LSG) is a quick and relatively simple
type of bariatric surgery which shows good resolution of co-morbidities and goodweight loss. We report on complications after LSG as a single-stage bariatric surgery
and the results of a survey on LSGs conducted by the Japan Research Society for
Endoscopic and Laparoscopic Treatments of Obesity.
Methods: Data were collected on all patients undergoing bariatric surgery between
January 2005 and December 2009, which included 340 patients from nine hospitals inJapan. We evaluated short-term morbidity in 102 patients undergoing LSG and excluded
patients undergoing LSG with duodenojejunal bypass.
Results: A total of 102 LSGs were successfully performed without conversions to an
open surgery. In 2004, there were no LSGs reported. In 2009, the mostcommonly-performed procedures were LSG (50 patients), laparoscopic gastric bypass(8), LSG with duodenojejunal bypass (8), and laparoscopic adjustable gastric banding(4). Approximately 8% of patients had perioperative complications. The most common
complications were staple line leaks (4%). Reoperation occurred in seven patients (7%),
four with bleedings and three with staple line leaks. No mortalities occurred. In oureight LSG patients, late gastric leak occurred in one patient; and it was treated with anendoscopic mucosal closure after failed attempts to treat the percutaneous abdominal
drainage.
Conclusion: The frequency of serious complications among patients undergoing LSG
was relatively low. It is a safe single-stage bariatric surgery for Japanese morbid obesity.

Is LSG perfect for Asian?
Ruby Hall Clinic, Pune, Maharastra , India
Dr. Shashank Shah
Laparoscopic Sleeve Gastrectomy(LSG) was initially introduced as a primary stage insuper obese patients to optimize their medical / anaesthesiological fitness and also
to ease the surgical technique for the index bariatric operation at a later date.
With evolving technique it has become popular stand alone procedure with provenresults of an efficient Bariatric operation in terms of effective excess weight loss ,co morbidity evolution and improvement in the quality of life. Our center has
performed more than 700 LSG till date. The longitudinal data analysis of them ispresented
at multiple
International BariatricandMetabolicconferences.
With Asian peculiarities of high adiposity, prone for type 2 diabetes, highcarbohydrate diet ,these studies have highlighted LSG with a favorable effect on
hyperglycemia ,with difficulty to monitor or treat nutritional deficiencies. Before
we call it as an ideal Bariatric operation, some facets need to be thrown light on:
like longevity of the results, recidivism etc. Long term data with the large
population and comparative studies with the existent bariatric operations is awaited.

National report: treatment of morbid obesity from Australia

President, Obesity Surgery Society of Australia and New Zealand(OSSANZ)
Lilian Kow

Obesity is considered the greatest public health challenges confronting Australia. Amongst developed nations,
Australia is one of the most overweight, with over 60% of adults and 25% children overweight or obese.

PREVALENCE OF OBESITY BY AGE AND GENDER, 2008

Age Group

Males (%)

Females (%)

Males

Females

Total(‘000)(‘000)(‘000)

0-4

0%

0%

0

0

0

5-19

7.8%

6.2%

165.4

124.9

290.3

20-24

11.1%

9.3%

84.7

68.2

152.9

25-34

19.4%

13.5%

281.8

193.0

474.8

35-44

19.9%

21.2%

301.5

324.6

626.1

45-54

23.2%

29.2%

338.6

430.8

769.4

55-64

28.5%

35.6%

344.9

431.7

776.6

65-74

22.2%

31.9%

164.4

244.2

408.6

75+

14.2%

16.9%

79.6

134.3

213.9

Total

16.5%

18.5%

1,760.8

1,951.8

3,712.5

5% of Australians have Type 2 diabetes. Of these, 10.8% are as a result of being obese.
OSSANZ (est 1980) represent the obesity society in Australia and New Zealand.

Membership: 350 healthprofessional: surgeons, physicians and Allied Health.

The OSSANZ Bariatric Surgical Standards(OBSS) are the credentialing guidelines . A National registry is being
set up. The average cost for bariatric surgery in Australia is about $15000-20000

National Report from Taiwan (Republic of China)
Wei-Jei Lee, M.D., Ph.D.
Dept. of Surg., Min-Sheng General Hospital, National Taiwan University, Taiwan

In the past decade, the incidence of obesity (BMI > 27) increased from 10.5%
to 19% in male Taiwanese.

Among them, those with moderate or severe obesity

increases more rapidly, from 2.4% to 6%.
in rural than in urban area.

This alarming phenomenon is more common

Although the incidence of overweight remained

stationary (20.3% to 19.3%) in female Taiwanese, the incidence of mild obesity
still increased from 7.6% to 10.5%.

More importantly, diabetes ( Glucose > 126

mg/dl) incidence increased from 4.6% to 9.3% of adult male in the past decade.
Bariatric surgeries steadily increased in the past 5 years in Taiwan.
Taiwan chapter was founded in 2009.
centers now in Taiwan.

IFSO

There are more than 5 comprehensive bariatricIn a survey from IFSO Taiwan chapter, the total registerednumber of bariatric surgeries increased from 255 cases in 2005 to 726 cases in 2009.
Laparoscopic gastric bypass is the most commonly performed procedure, followed bysleeve gastrectomy and gastric banding.

The results of bariatric surgery in Taiwan

are comparative to international standard.

1

National report of treatment of obesity and metabolic disorder from (India).
Dr. Mahendra Narwaria, MS, FICS.
President, Obesity and Metabolic Surgery Society of India
Asian Indians exhibit unique features of obesity; excess body fat,abdominal adiposity, increased subcutaneous and intra-abdominal fat, anddeposition of fat in ectopic sites (liver, muscle, etc.). Obesity is a major driver for
the widely prevalent metabolic syndrome and type 2 diabetes mellitus (T2DM) in
Asian Indians in India and those residing in other countries. Based on
percentage body fat and morbidity data, limits of normal BMI are narrower andlower in Asian Indians than in white Caucasians. A consensus statement, waspublished for revised guidelines for diagnosis of obesity, abdominal obesity, themetabolic syndrome, physical activity, and drug therapy and bariatric surgery forobesity in Asian Indians after consultations with experts from various regions ofIndia belonging to the various medical disciplines representing reputed medical
institutions, hospitals, government funded research institutions, and policy
making bodies.
According to National Family and health Survey (NFHS), approximately
7.1% of Indian population is under obesity risk. Almost 65% of adult urban
Indian are –either over weight, obese or have abdominal obesity. The highest
incidence is observed in North western (Punjab) part of India (M: F- 30.3/37.5%),
followed by South (M: F-24.3/34%) and North east (M: F-17.3/21%).
With an estimated 50.8 million people living with diabetes, India has theworld’s largest diabetes population, followed by china with 43.2 million. The
prevalence of type II DM in adult population ranges from 9% to 16%, with 14.2 %of male and17.5 of female.
The Obesity and Metabolic Surgery Society of India was established in 2001.
The indication for surgery is generally in accordance with guidelines using the
WHO standard for obesity on Asia, i.e. BMI >37.5/32.5 with co-morbidities. There
are few no of bariatric and metabolic surgeries carried out outside the standard
guidelines for obesity surgery but they are mainly as part of some clinical trials.
There are about 80 surgeons (certified general, GI surgeons with training
and experience) performing bariatric surgery regularly in India, carrying out
2000 procedures per year.
There are 5 high volume centres and few of them applied for centre of
excellence (ICE) certification from ASMBS.OSSI is jointly working with SRC todevelop centre of excellence in India. Cost of bariatric treatment depends uponthe types and location of the operative procedure. We accept and operate theinternational patients.
Refrences:

IDF-Diabetes Atlas, 4th edition, Oct 2009.



G. Vijaykumar et.al; JAPI, Aug 2009, Vol-57.



A. Mishra, P.Chowbey, BM Makkar, NK Vikram et.al; JAPI, Feb 2009.

Current status of Bariatric surgery in Korea
Dr. Lee’s Bariatric Surgery Center in Seoul, Korea(The Korean Metabolic and Bariatric Surgery Society)
Hongchan Lee, M.D., Ph.D

Obesity is not only a health problem in western countries, but also in Korea. According to2009 Korean National Health & Nutrition Examination Survey(KNHANES), prevalence of obesityin adults was 32.4% which is a big change over the last 10 yeas. More alarming is the
problem of children and adolescent. From 2003 to 2009, number of bariatric procedures wasincreased in 622%.
All surgeries were performed through laparoscopic procedures. 63.3% adjustable gastricbandings, 12.6% gastric sleeve resections, 5.9% VBGs(with or without sleeve resection)
were the restrictive operations performed. 12.0% Roux-en-Y gastric bypass, 12.6% Minigastric bypass, 2.6% Duodeno-jejunal Bypass were the malabsorptive(both restrictive)
procedures since 2003.
Based on the statistics, the surgeon were performed in most hospitals when the BMI wasover 35kg/m2 while more than 2 significant obesity related co-morbidities were found withBMI over 30kg/m2. Currently the bariatric surgery in Korea is still at a developing level,
and has not been performed very much compared with the number of patients who need it.
As the bariatric surgery will gain more important as the number of obesity people
increases every day, physicians need to make more efforts to help the public to havecorrect understanding about the bariatric surgery. Insurance coverage is another concern
in my country because bariatric surgery is not covered by National Health Insurance in
Korea. So, it became an expensive surgery, not accessible for everybody. As obese people
are often from middle to lower socioeconomic class, access to surgery is very limited. As
these people are in need, we have to raise our voice about reimbursement for bariatricpatients.

BARIATRIC & METABOLIC SURGERY in the Philippines
President, Philippine Society for Metabolic and Bariatric Surgery
Hildegardes C. Dineros, MD, FPCS FACS
Third world countries like the Philippines was not immune to the epidemic of Obesity,with a progressively rising prevalence, one in four being overweight and one out oftwenty is obese. Roughly, there are 4 million obese Filipinos and close to a million
are morbidly obese. Of about 90 million population, the extrapolated prevalence ofDiabetes is 5 million, more than 90% of which belong to Type 2 category.
The Philippine experience in Bariatric Surgery started in 2001 as VBG. The following
year, Open Gastric Bypass was performed and 5 years later, Laparoscopic techniques
were done for RYGBP, Gastric Banding, BPD-DS, and Sleeve Gastrectomy. Class II Obesity,
defined as BMI 30kg/m2 was the baseline criterion for weight loss surgery since atthis level, co-morbid conditions are already observed.
The Philippine Society for Metabolic and Bariatric Surgery was established in 2007,
composed of about 25 surgeon members, half of which are doing bariatric surgicalprocedures already, and majority doing mostly Gastric Banding. Certified General
Surgeons with training and experience in laparoscopic bariatric surgery, have up to
the present, performed close to 600 bariatric operations. Surgery for Non-obese Type 2
Diabetes was first done in 2008using LSG with Loop DJB.

National report from Hong Kong

Wilfred Mui
Hong Kong Bariatric and Metabolic Institute

Bariatric surgery is a new specialty in Hong Kong and it is growing from its infancy
stage. It was introduced in Hong Kong in 2001 and the development was very rapid in thepast ten years. Bariatric procedure in Hong Kong is evolving from a single surgicalprocedure (gastric banding) to the full package of both endoscopic and laparoscopic
surgeries. The primary procedures in Hong Kong at the moment are restrictive procedures(intragastric balloon, gastric banding, sleeve gastrectomy and sleeve plication),whereas malabsorptive procedures (mini-gastric bypass and sleeve gastrectomy with DJB)
are reserved as second-line therapy. Initially, we encountered difficulties in
persuading patients and even doctors in accepting such an invasive treatment for obesity.
Now, more and more physicians and patients understand the importance of weight control
in severe obesity and agree that the beneficial effect of surgery seems out-weighted
its risk in selective group of patients. We will report the development of this specialty
in Hong Kong.

National Report from Malaysia
Professor Dr Chin Kin Fah (Presenter), Dr Pok Eng Hong
Department of Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia.
In Malaysia, a developing country, the increasing prevalence of obesity and associatedmetabolic syndrome has created major healthcare problem due to the adoption of morewesternized lifestyle and diet. Population surveys have found the prevalence of obesity has
rapidly increased 3 folds in recent decade. The National Health & Morbidity Study in 1996 and2006 revealed that the prevalence of overweight (BMI 25-30) rose from 16.6% to 29.1%. The
prevalence of obesity (BMI>30) increased from 4.4% to 14%. It was also showed our female
population, ethnicity of Indian & Malay and house wife tend to be obese. It was noted theprevalence of diabetes mellitus in this population also increased from 8.3% to 14.9% with
substantially portion of them undiagnosed. There is an estimated about 1.5 million diabetes
patient (5.7%) which is a significant healthcare burden in Malaysia with a small populationof about 26 million people in 2006. Although the bariatric surgery has been prove to be costeffective treatment of obesity and associated co-morbidity especially DM, the adoption ofthis advanced surgery is still slow in Malaysia. Currently, only hospitals with qualified andexperienced laparoscopic surgeon are routinely offering this procedure. The lack of surgicaltraining opportunity, public awareness and no insurance coverage for obesity might be thefactors that hinder the progress of this surgery. Lastly, we foresee, with the risingprevalence of T2DM affecting younger age group and the promising effectiveness of bariatricsurgery as a form of metabolic procedure, the most cost effective therapy for early obese
T2DM should be surgery, as a first line modality in future.

National Report on Bariatric Surgery from Japan

Department of Weight Loss Surgery, Yotsuya Medical Cube, Tokyo, Japan
Kazunori Kasama MD, FACS

Obesity among adults is defined as a BMI of 25 or higher in Japan. The obesity prevalence(BMI ≧ 25) has increased to 28.6% in male and 20.6% in female over the past decade. Obesity
prevalence (BMI ≧ 30) is 3.2%.
The prevalence of diabetes mellitus with HbA1c >6.5 or under treatment has increased from
6.9 million in 1997 to 8.9 million in 2007.
Recently, one of our bariatric societies (Japanese Society for Surgery of Obesity andMetabolic disorders) has announced a statement on BMI criteria for bariatric surgery inJapan. The criteria recommends bariatric surgery for people who have BMI ≧ 35 or BMI ≧32 with obesity-related comorbidities. But bariatric surgery for people with BMI between
32 to 35 remained to be positioned on a clinical trial.
From 2000 to 2009, totally, 340 laparoscopic bariatric procedures were performed in 9
institutes. The most popular procedure was laparoscopic Roux-en-Y gastric bypass (LRYGB,
n=147), then the second one was laparoscopic sleeve gastrectomy (LSG, n=102) and the third
one laparoscopic adjustable gastric banding (LAGB, n=55). However, the number of LRYGB
has decreased and in contrast, the number of LSG has rapidly increased.
The medical cost of bariatric surgery is approximately 10.000-20.000 dollars. It depends
on the types of procedures.
There are several problems to prevent and treat obesity. Modern lifestyle and foods areout of alignment with true health. Nation’s recognition of obesity is an obstacle tocivilization and enlightenment of bariatric surgery in Japan.
In conclusion, we are still ill-equipped to deal with the crisis of obesity and diabetes
mellitus. It is essential to establish the international network in APC for developmentin this field.

National report on surgical treatment of obesity and metabolic disorder in Singapore
KTP Hospital Singapore
Dr Anton Cheng
According to the Singapore National Health Survey 2004, obesity rate ( BMI > 30) in Singapore
was 7.3% in female and 6.4% in male. Among the three major racial groups in Singapore, 4.2%of Chinese, 19.3% of Malays and 13.4% if Indians are obese. In 2004, 8.2% of the population
was diabetic , with 8.9% of male and 7.6% of female. The latest unpublished data showedobesity rate has gone to 10.8% of the population in the 2010 National Health Survey, With the
Malay population showing 25% obesity. DM rate however, has not changed over the last 12
years.
The Obesity and Metabolic Surgery Society of Singapore is registered as of January 2011. A
national database is being set up. Indication for surgery is generally in accordance with theSingapore Ministry if Health guidelines using the WHO standard for obesity on Asia, i.e. BMI> 37.5 or BMI > 32.5 with obesity associated co-morbidities. There is no metabolic surgery
carried out outside the standard guidelines for obesity surgery.
There are about 10 surgeons performing bariatric surgery regularly in Singapore, carrying out
about 200 procedures per year. 80% of these, divided equally, are sleeve gastrectomies andgastric bands. There are smaller numbers of bypass and other procedures.
There is no certified center of excellence in Bariatric surgery in Singapore. Cost varies
according to where these procedures are carried out. A lot of those performed in government
hospitals are heavily subsidised.

National report of treatment of morbid obesity and metabolic disorder from Thailand countries

Suthep Udomsawaengsup

Slide-1---

Obesity and overweight prevalence in adults in your country
Grade I Obesity

=

15.4%

Grade II Obesity

=

2.2%

Obesity prevalence in children in your country
Age 2-5=

7.9%

Age 6-12=

6.7%

Gender and age distribution (possibly)*use most recent statistics

Slide-2
T2DM prevalence in adults in your country
9.6%

4.8% previously diagnosed and 4.8% newly

diagnosed diabetes

Gender and age distribution (possibly)
Male 33.8%
Mean age =Female 66.2%

60.9 + 11.5 and duration of diabetes 10.5+ 7.6 years,

Slide-3-

Do you perform bariatric surgery in your country?
Yes-

If yes, who is a candidate for bariatric surgery?
BMI >40kg/m2 or >35 with co-morbidity and had try non surgical Rx-

Do you have a bariatric society in your country?
Yes

Thai Society of Metabolic and Bariatric Surgery (TSMBS)
http://www.thaibariatric.org

Slide-4-

Approximately how many bariatric surgery operations are being done in your country yearly 100-

What is your estimate as to the relative percentages (adding up to 100%) distribution of bariatric
operations in your country

RYGB 63%

LAGB 29% Sleeve 8%

Slide-5-

Who performs bariatric surgery in your country
general surgeon- endoscopic surgeon 9 , certified bariatric surgeon 6

-Approximately how many surgeons practice bariatric surgery in your country?
= 15 surgeons

Slide-6-

Is there any credential system (surgeon, facility)?
Yes, For Surgeons: the Royal College of Surgeons of Thailand and the Medical Council of Thailand
Facility: Hospital credential-

If any, what type of professional education or training currently exists for the bariatric surgeon?
Yes Clinical fellow in Bariatric surgery (2 institute / 4 regular fellow a year)

Slide-6-

Is there any nationwide database for sharing the pre- and post-operative data results to provide
a cumulative picture of the success of bariatric surgery?
Not yet applied

Slide-7-

Roughly, what is the average cost for bariatric surgery in your country?
*In US dollars
RYGB = 6000 USD(Government)

20000 USD (private)

LAGB = 5000 USD (Gov)

15000 USD (pri)Lap Sleeve =3000 USD (Gov)-

13000 USD (pri)Are insurances (government, public, private) paying for the cost of surgery?
Yes

Partially

Slide-8-

Do you perform metabolic surgery for the patients with lower BMI (beyond indication for bariatricsurgery) in your country? Yes for Some-Do you perform revision bariatric surgery in your country?
Yes-

Do you accept patients from overseas (so called “medical tourist”) in your country?
Yes

Slide-9-Which are the problems you face in your country to prevent the obesity disease from spreading?
Availability and advertising of Junk foodPhilosophy of Living, Some Believe such as Obese is asign of Wealthy-

Which are the problems you face in your country to treat the obesity disease?
Reimbursement system, Acceptance for medical co-worker, Cost of Treatment-

Which are the needs?

Slide 10-

Your favorite topics,
Metabolic result of Bariatric Surgery in Thais-

Particularity of your country regarding Bariatric/Metabolic surgery.

Slide-11-Your conclusions to the obesity problems in your country
The incidence of obesity in Thailand is increasing. Prevention is certainly important. Public has
been alerted more about effect and hazard of obesity. Media takes more involvement and helps verymuch in distributing medical information-

Recommendations

National report of treatment of morbid obesity and metabolic disorders from Turkey

Alper Celik, M.D.
Yeniyuzyil University Faculty of Medicine
Department of General Surgery,
Istanbul / Turkey.

Slide-1*Approximately 66% of whole Turkish population is under obesity risk.
*The incidence of obesity is 24% for males and 31% for females.
*The highest incidence is observed in Southeastern part of Turkey (61%), followed by
mid-Anatolia (55%), Northern west (50%), and West parts (15%)*The percentage of normal weight adults is 13.6% in females and 20% males.
*The incidence of overweight children is 24% for females and 31% for males.
*The incidence of obesity among children below age 15 is 9% for females and 12% for males.

Slide-2*The prevalence of T2DM in adult population (35-70 y) is 14.7%*The prevalence of Glucose Intolerance in adult population is 9.6%.
*T2DM prevalence increases with age, 50 years being the cut-off point. After age 50, T2DM
prevalence reaches 30%.

Slide-3*We have a national bariatric and metabolic surgery society in Turkey.
*I perform both metabolic and bariatric surgery.
*For bariatric surgery purposes my indication is BMI over 40*For patients with T2 Diabetes or Metabolic Syndrome, BMI (unless over 20) is not alimitation in my surgical practice.

Slide-4*The annual number of bariatric operations is estimated to be around 500 cases.
*I performed 76 operations within 2 years on my own (7.6%).
Slide-5*There are no specified or certified bariatric surgeons in Turkey.
*The number of surgeons mainly doing bariatric surgery is around 10.

Slide-6*There is no credential system in Turkey and bariatric surgery is not regarded as a
specification.

Slide-6*There is no nationwide database for sharing the pre- and post-operative data of bariatricsurgery.

Slide-7*The average cost for bariatric surgery in Turkey varies between 5000 and 20000 USD,
depending on the type and location of the operative procedure.
*The government only pays 30-40% of the bill if the patient obtains a multidisciplinary
council approval. (The council mainly consists of endocrinologists!)

Slide-8*For patients with T2DM, I operate on all patients with a BMI above 20, if they meet the
metabolic criteria for the operation.
*I did 4 revision bariatric surgeries. (1 anastomotic stricture, two band removals with
sleeve and one band removal with BIB).
*I work at a private university and its private hospitals in Istanbul. We accept and operate
on overseas patients.

Slide-9*The main problem, also affecting my country from obesity pandemic is the so called“Coca-colonization”, which refers to global standardization of refined or saccharified
food.
*From my (surgical) aspect, the main problem is internists and endocrinologists who aretrying to discover America once again.
*The main need is education and social awareness.

Slide-10*Protection is more important than treatment. I personally believe that we should worldwide
keep away from refined and saccharified food. However, these products are easy to keep,
suitable for overseas transport and unfortunately, they are tasty.

*Each government should establish their policy for nationwide food supplies andconsumption of childhood food products.
*Turkish people like to eat bread with spaghetti and/or rice. I think that we should atfirst educate people, than we should raise a social awareness about the global food industry,metabolic syndrome and the importance of physical exercise.
*For those with already settled metabolic syndrome, the importance and affectivity ofsurgical treatment should be emphasized, with particular notation on the advantages oflaparoscopic surgery.

Slide 11
*From bariatric point of view, the importance of a team work has always been emphasized.
I have recently moved to a new institute in Istanbul and am trying to settle my own team.
*From metabolic point of view, I operate on T2DM patients with end-organ damage. I haveoperated on 46 non-obese, overweight or type 1 obese (BMI=30-35) patients with T2DM. I
believe that we should also emphasize and try to produce a global awareness for surgicaltreatment of Diabetes.

National report
Bariatric surgery in Brazil: Current status
Joel Faintuch , Francisco Karkow,
Fernanda Pezzi (Sao Paulo University Medical
School and Fatima Faculty, Caxias do Sul)
Introduction
Obesity is a growing epidemic not only in industrialized countries but also inthe developing world. The main difference in places like Brazil is the phenomenon ofnutrition transition. Till the recent past undernutrition was the main problem. The
rapid shift toward excessive body weight resulted in the relatively frequentcoexistence, in the same family and in the same house, of examples of the two
derangements, namely undernourished children with obese parents, or the opposite
association.
Antiobesity procedures were started in this country in the 1970´s, in the formof jejunoileal bypass. Multiple modalities were tested along the years, especially in
Hospital das Clinicas, Sao Paulo, which was the pioneer institution, till thecreation of the Brazilian Society of Bariatric and Metabolic Society (BSBMS) in 1999,
by Artur Garrido Jr.
Yearly congresses have been organized since that time, and the Society counts
more than 900 members including surgeons as well as allied health professionals.
Current president is Ricardo Cohen. A Bulletin was created in 2000 by Joel Faintuch
and Artur Garrido Jr and converted into a quarterly Journal five years later. Now the
Journal has merged with the Brazilian Archives of Digestive Surgery, which also
appears every three months.
Acceptance of the specialty
Until the early 1990´s just a few dozen surgeons had interest in bariatric
operations and very few surgical residents had exposure to such the techniques.
However after the establishment of BSBMS growth has been exponential, notably after
government and private health providers accepted reimbursing the operations. At thismoment such procedures are very well established all over the country, and actively
sought by obese patients. Indeed, public hospital often suffer with long waiting
lines.
Surgical residents in large academic hospitals and also in certain private
ones have the chance of operating bariatric candidates during their rotations, and acouple of Centers of Excellence in Bariatric Surgery has been created in Sao Paulo,with a tendency to grow towards other cities as well.
Surgical procedures
The most practiced modality in the country is the Roux-en-Y gastric bypass(RYGB), which is the first intervention recognized and funded by the Federal Social
Security System. Approximately 75% of the candidates undergo this treatment, burmultiple other options are endorsed by BSBMS, namely vertical banded gastroplasty,
sleeve gastrectomy, gastric banding, Scopinaro procedure and duodenal switch, alongwith the endoscopically placed intragastric balloon.
Patient care and hospital facilities
A national consensus signed by six surgical and clinical professional societies
in 2007 established directives for most routines and indications concerning bariatricinterventions, from patient selection to hospital equipment and postoperative care.
Current statistics
Brazil has roughly 190 million inhabitants of which between 2 and 4 million are
morbidly obese, depending on the estimate. About 30 000 bariatric procedures are
conducted each year, of which 25-300 % are payed by the Federal Social Security
System, 60-70% by commercial Health Providers, and around 5 % privately financed.

Distribution of morbid obesity
A national survey under the initiative of BSBMS revealed that though morbid
obesity doesn´t spare any of the regions of Brazil, distribution is not homogeneous.
The two poorest areas, namely the North and Northeast, display the lowest proportion(2%). The rich Southeastern region, which includes Sao Paulo, wasn´t bad either with
2.5% prevalence. The highest rates corresponded to the Western region and to theSouth, both with 5% values.
As concerns the South there is a rather obvious explanation. This area is quite
affordable, there is strong immigrant influence especially from Italian and German
people, and the population appreciates hearty meals. The Western region was asurprise and no obvious explanation is available, though meat is particularly
abundant in that area because of vast cattle-raising farms.
Metabolic surgery
In the last five years several groups have engaged in standard bariatric or
tailor-made operations for non-morbidly-obese diabetics, with variable results.
Animal investigations were atarted
in a number of University laboratories, andMaster´s as well as PhD theses are going on . Some controversy occurred when acouple of teams started performing such interventions on a routine basis. A consensus
established in 2009 decided that these treatments are still experimental and should
be conducted under approval of an Ethical Committee, for the purposes of scientificinvestigation only.
References
Monteiro CA et al.. The burden of disease from undernutrition to overnutrition incountries undergoing rapid nutrition transition: a view from Brazil. Am J Public
Health. 2004 ;94 :433-4
Morais AA, Faintuch J, Leal AA, Noe JA, Bertollo DM, Morais RC, Cabrini D.
Inflammation and biochemical features of bariatric candidates: Dos gender matter ?
Obes Surg. 2010 Feb 2.
Ribeiro AG, Costa MJ, Faintuch J, Dias MC. A higher meal frequency may be associatedwith diminished weight loss after bariatric surgery. Clinics (Sao Paulo).
2009;64 :1053-8
Dalcanale L, Oliveira CP, Faintuch J, Nogueira MA, Rondó P, Lima VM, Mendonça S,
Pajecki D, Mancini M, Carrilho FJ. Long-term nutritional outcome after gastric bypass.
Obes Surg. 2010 ;20 :181-7.
de Souza SA, Faintuch J, Fabris SM, Nampo FK, Luz C, Fabio TL, Sitta IS, de Batista
Fonseca IC. Six-minute walk test functional capacity of severely obese before andafter bariatric surgery. Surg Obes Relat Dis. 2009 ;5 :540-3
Faintuch J, Dias MC, de Souza Fazio E, de Oliveira FC, Nomura RM, Zugaib M,
Cecconello I. Pregnancy nutritional índices and birth weight after Roux-en-Y gastricbypass. Obes Surg. 2009 ;19 :583-9
Faintuch J, Marques PC, Bortolotto LA, Faintuch JJ, Cecconello I. Systemi8c
inflammation and cardiovascular risk factors: are morbidly obese subjects different ?
Obes Surg. 2008 ;18 :854-62
Cintra W Jr, Modolin ML, Gemperli R, Gobbi CI, Faintuch J, Ferreira MC. Quality oflife after abdominoplasty after bariatric surgery. Obes Surg. 2008 ;18 :728-32.
Brazilian Society of Bariatric and Metabolic Surgery < www. sbcb.org.br >Metabolic Surgery in Asia
Wei-Jei Lee, M.D., Ph.D.
Dept. of Surg., Min-Sheng General Hospital, National Taiwan University, Taiwan

Type 2 diabetes mellitus (T2DM) is now a global health priority.

It wasestimated that more than 240 million people in the world are affecting with T2DM
and that number is expected to 360 million by the year 2025.

More than 60% of theworld’s population with diabetes comes from Asia and the incidence of T2DM in Asia
is increasing more rapid than the rest of the world.

In Taiwan, the T2DM incidenceof adult male increased more than double from 4.6% to 9.3% in the past decade.
Unlike in the west, where older population is most affected, the burden of diabetes
in Asian countries is disproportionately high in young to middle-age adults.

For

those early onset T2DM patients, the incidence rate of diabetic nephropathy isalarmingly high, especially in those not well controlled patients.

In Asia, 55%of newly diagnosed end staged renal disease patients are due to T2DM.

How tocontrol this chronic and deliberating disease will be a very important health issue
in Asia.
There are strong evidences that bariatric surgery can cure most of theassociated T2DM morbid obese patients (BMI > 35 Kg/m2).

However, the mechanism fordiabetes remission after gastric bypass remained speculative.

Optimal outcomes fordiabetes remission after metabolic surgery will occur if the mechanism isunderstood and patients best suited to the surgery are selected and those who will
predictably have a poor result are excluded. To be able to make such decisions, weneed a collaborative study from Asia for the Asian.

This information is helpful

for applying gastric bypass surgery as metabolic surgery for type 2 diabetes
treatments in the future.

1

"Asian particularity on Obesity and Metabolic disorder"
The personality of the patients with morbid obesity

Kohji Shirai
Internal Medicine, Sakura Hospital, Toho University, JAPAN.

Bariatric surgery might become indispensable for the therapy of morbid obesity.
Metabolic disorders could be well improved by bariatric surgery. In some cases, weight
reduction relief the insulin therapy in obese type 2 diabetes mellitus. But, following
up term after operation is very important, because actual body weight reduction can beobtained in this term. The trouble in this term seems to be not so few. One is psychologicalunstableness. We had already experienced them during semi-starvation therapy. For example,
depression, refusal diet, trial of suicide, solitary and so on.
To understand the causes for that unstableness, personalities of the patients wereanalyzed using Rorschach test by applying Ender’s methods. In many cases, depression andorganic psychological diseases were concealed. One of conspicuous features was high lambda
style, in which, passive attitude, superficial understanding, apparent obedience wereobserved. Those people were controlled well in the hospital, but, they easily show rebounds
once outside of the hospital. The percentage of high lambda style is increasing as thedegree of obesity.
Before operations of the patients, we had better understand the personality of thepatient, beforehand. Moreover, psychotherapy such as enforcement will improve the benefitof surgery. And, how to understand the personality of the patients need further studies.

Bariatric surgery in Asia. A literature review.

Department of Weight Loss Surgery, Minimally Invasive Surgery Center, Yotsuya Medical
Cube, Tokyo, Japan
Yosuke Seki, Kazunori Kasama, Hideharu Shimizu

Like in Western countries, bariatric and metabolic surgery in Asia has been steadily
gaining popularity although the pace of spread is gradual. The purpose of the present
review is to evaluate the current evidence regarding weight loss, complication rates,
postoperative mortality, and co-morbidity improvement after bariatric surgery for Asians.
Pubmed was searched for citations.

1
Laparoscopic Roux-en-Y Gastric Bypass for Normal Weight Type II Diabetes Mellitus*

Bariatric & Metabolic International Surgry Center, E-Da Hospital, Kaohsiung, Taiwan
Department of General Surgery, E-Da Hospital, Kaohsiung, Taiwan‡
Department of Chemical Engineering, Institute of Biotechnology and Chemical
Engineering, I-Shou University, Kaohsiung, Taiwan
Chih-Kun Huang, MD*†‡, Chi-Hsien Lo, MD*, Jer-Yiing Houng, PhD‡, Yaw-Sen Chen, MD†,
Po-Huang Lee, MD††

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) can dramatically ameliorate
type 2 diabetes mellitus (T2DM) in morbidly obese patients. However, little evidence
supports the effectiveness of LRYGB in normal weight patients.
Methods: After getting E-Da IRB approval, twelve normal weight patients with T2DM
underwent LRYGB. Data, including patient demographics; BMI; co-morbidities; anddetails of diabetes mellitus, including disease duration, family history, medicationuse, and remission were prospectively collected and analyzed.
Results: The mean age of 5 men and 7women was 51 years (range, 35–65 years); mean BMI,
23.6 (range, 22.9–24.7 kg/m2); and mean duration of T2DM onset was 11 years (range, 3–
20 years). Mean operation time was 89 min (range, 46-229). Mean hospitalization was 2days (range, 1-4). There was no mortality. One patient received laparoscopic repair ofPeterson’s defect due to symptoms from internal hernia 6 months later after surgery.
The result of diabetic remission would be reported.
Conclusions: In this preliminary report, LRYGB is safe in normal-BMI Diabetic patients;
result of long-term follow up for diabetic remission is expectable.

Ileal Interposition for Control of Type-2 Diabetes
Dr Surendra Ugale,
Kirloskar Hospital,
Hyderabad, India
Ileal Interposition is a specific surgery directed to control type -2 diabetes & can be
performed for patients of any weight. We present 48 cases of Ileal Interposition surgeries
for control of type-2 diabetes done since Feb.2008 under clinical protocol after
Institutional Ethics Committee approval.
Selection of patients was done after checking C-Peptide levels and Insulin resistance with
HOMA-IR and excluding any cases of LADA. All procedures were completed laparoscopically with
6 ports, performing 3 transections, 3 anastomosis, closure of all 3 mesenteric gaps and avariable sleeve gastrectomy depending on BMI levels. The ileal segment was 170 cms long withtransections at 30 cms proximal to I-C junction and 20 cms distal to Lig of Trietz to performthe Standard procedure utilizing the hindgut hypothesis mainly. A Diverted option, using
duodeno-jejunal bypass was added for the difficult diabetic situations to also include theforegut hypothesis.
In a follow up of 18 months we have found significant improvement in blood glucose, HbA1c,
triglycerides &microalbuminuria. Results were statistically significant for Blood glucose,
HbA1c, triglycerides & microalbumin at all times upto 24 months. Malabsorption as measured
Vit B12, Ca+2, Iron-- was not observed.
We conclude that Ileal Interposition can be done with safety & is effective in controllingtype -2 diabetes in patients with any BMI, without any malabsorption.

Title: Laparoscopic Sleeve Gastrectomy with Duodenojejunal Bypass for Type 2 diabetes withBMI under 35 kg/m2

Kazunori Kasama MD,FACS. Yosuke Seki MD, Hideharu Shimizu MD,

Abstract:
BackgroundWe introduced laparoscopic sleeve gastrectomy with duodenojejunal bypass (LSGB) forJapanese obese patients with a risk of gastric cancer in 2007. Forty-three patients
underwent LSGB from April 2007 to December 2010. Regarding anti-diabetic effect, theremission rate of Type 2 diabetes (T2DM) was 93%. This result showed that LSGB could achieve
comparable or better remission of T2DM, compared with other bariatric procedures. The
metabolic surgery for patients with BMI lower than 35 kg/m2 is still controversial. We
evaluated the effect of LSGB on T2DM with BMI under 35.
Methods
Seven patients with T2DM underwent LSGB. The preoperative mean BMI and weight were 33.4
±1.5 kg/m2 and 97.4 ±11.0kg, respectively. There were six patients with T2DM and one
patient with IGT. The data on T2DM, lipid profile and blood pressure of the subjects werestudied before and 12 months after surgery.
Results
The mean excess weight loss at 12-month follow up point was 82.7%. The mean fasting plasma
glucose and HbA1c before and 12 months after surgery were 154.7 mg/dl, 8.1% and 128.5 mg/dl,
6.1%. The remission rate of T2DM was 83%. The mean systolic blood pressure and LDL before
and 12 months after surgery were 147.5 mmHg, 158.4 mg/dl and 131.0 mmHg and 140.0 mg/dl.
There was one patient who could not achieve the remission of T2DM with 20- year history
and preoperative insulin required status (more than 100 U/day). The other CVD risk factors
related to T2DM were improved clinically.
Conclusion
This result showed that LSGB for low BMI patients with T2DM could achieve the considerable
remission rate of T2DM and reduce the other CVD risk factors.

Metabolic surgery in Korea : Remission of hyperglycemia with modified mini-gastricbypass for the patients with BMI less than 30 kg/m2
Kyung Yul Hur, M.D.
Department of Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
Background: Type 2 Diabetes mellitus (T2DM) has become an epidemic health problem.
Compared to western countries, Asian T2DM occurs in patients with lower body mass index(BMI) due to central obesity and decreased pancreatic β-cell function. The efficacy oflaparoscopic mini-gastric bypass (LMGB) in obese patients with T2DM is proven bynumerous studies. Treatment outcomes of LMGB for non-obese T2DM patients are also
estimated to be excellent. The aim of our pilot study was to evaluate the efficacy andsafety of LMBG in non-obese T2DM patients (BMI < 30 kg/m2).
Methods: Eighty-eight patients underwent LMGB at Soonchunhyang University Hospital from
August 2009 to November 2010. Preoperative data including glycosylated hemoglobin(HbA1c), fasting plasma glucose (FPG), and 2-hour post prandial glucose (2-hr PPG) werecompared with data collected at 1, 3,6 and 12 months postoperatively.
Results: All procedures were completed laparoscopically. Mean age was 47.1 years, mean
BMI was 25.3 kg/m2, mean operative time was 96.2 minutes, and mean postoperative
hospital stay was 4.6 days. Neither mortality nor major complications occurred. Mean
preoperative HbA1c, FPG, 2-hr PPG, and C-peptide level were 9.7%, 222 mg/dl, 343 mg/dl,
and 2.78 ng/ml, respectively. 12months follow-up was possible in13 patients. HbA1c, FPG,
2-hr PPG, and C-peptide level at 12th post-operative month were 6.3%, 124 mg/dl, 194
mg/dl, and 2.18 ng/ml, respectively.
Conclusion: The present preliminary study demonstrated resolution of hyperglycemia in
non-obese T2DM patients (BMI < 30 kg/m2). Although long-term follow-up data are required,
early operative outcomes were satisfactory in terms of glycemic control and safety ofthe procedure.

Metabolic Surgery in Hong Kong

Wilfred Mui
Hong Kong Bariatric and Metabolic InstituteAsians have higher fat content and different indications for bariatric surgery ascompared to western population. In response to DSS in Rome, Asia Consensus Meetings on
Metabolic Surgery, endorsed by the Asia Pacific Bariatric and Metabolic Surgical Society
were held at Trivandrum in India in 2008 and Taipei 2010 to discuss the situation in
Asia. Most experts agreed that Asians are more prone to develop diabetes at lower BMI
and early consensus for the use of metabolic surgery to treat Type II diabetes mellitus
in Asia were laid and stated as the followings:
1.

Bariatric/Gastrointestinal Metabolic surgery should be considered as a treatment
option for obesity in people with Asian ethnicity with a BMI more than 35 kg/m2
with or without co-morbidities.

2.

Bariatric/Gastrointestinal Metabolic surgery should be considered as a treatment
option for obesity in people with Asian ethnicity above a BMI of 30 if they havecentral obesity (waist circumference more than 80 cm in females and more than 90
cm in males) along with-at least two of the additional criteria for metabolic
syndrome: raised triglycerides, reduced HDL cholesterol levels, high bloodpressure and raised fasting plasma glucose levels or Type II diabetes mellitus
patients who are inadequately controlled by life-style and medical therapy.

3.

A surgical approach may also be appropriate as a non-primary procedure alternative
to treat Type II diabetes mellitus patients with BMI >27 and central obesity (waist
circumference more than 80 cm in females and more than 90 cm in males) who are
inadequately controlled by life-style and medical therapy.

Most clinicians and patients in Hong Kong at present are not aware of the optionof surgery for treating Type II diabetes. Increasing evidences demonstrate that
gastrointestinal surgery including current bariatric surgery has a specific andindependent effect on the disease. We have introduced metabolic surgery to treat TypeII diabetes since 2008 in Hong Kong. At the moment, we limit our patients to BMI >27
with poorly controlled DM. Options would be sleeve gastrectomy vs. gastric bypass vs.
sleeve gastrectomy with DJB.

Experience of diabetes surgery in India

Muffazal Lakdawala

Abstract
Diabetes is believed to be a quintessential medical disease. The notion that surgery iseffective and can lead to a virtual cure is a revolutionary concept that evolved when longterm results of bariatric surgery started coming in. This led to a major shift in the goalof treatment from improving life with diabetes towards curing it. These reports have far
reaching implications for a country like India which is the diabetic capital of the world.
It is postulated that by 2025 there will be 57 million Indians suffering from type 2 diabetes
mellitus. Almost 70% of the diabetics are overweight.
It is a well known fact that Asians have a higher body fat percentage as compared to theirwestern counterparts. Asians are metabolically obese and tend to develop comorbidities
like type 2 diabetes at a much lower weight. Visceral fat as measured by the waist
circumference holds a lot more importance in Asians. In the wake of these observations
1st Asian consensus meeting on metabolic surgery was organized to contend the existing
NIH criteria for defining obesity in the Asian perspective.
Presently laparoscopic roux-en-y gastric bypass (RYGB) and laparoscopic sleeve
gastrectomy (LSG) are the most commonly performed bariatric procedures in India. Indianstudies have shown about 98% resolution of type 2 diabetes after RYGB in morbidly obese.
Recent reports suggest comparable results after LSG albeit it takes longer than after RYGB.
Presently these procedures are being recommended for patients with a BMI of 32 and above
with type 2 diabetes mellitus. It has also been recommended for patients with a BMI of
30 and above in conjunction with waist circumference and presence of comorbidities.
The contention is whether the same results can be simulated in diabetics who are not obese.
Whether metabolic procedures like ileal transposition and duodenojejunal bypass will standthe test of time is yet to be seen. Trials are going on in various parts of the world.
India has the biggest diabetic load and stands to benefit the maximum from any positive
outcomes. There is immense hope riding on this concept as any positive results would prove
to be a boon to the millions of diabetics who can then hope of a pill or insulin free life.

Overview of Metabolic Surgery Worldwide
Karl Miller, MD, FACS, Hallein Clinic, Austria
Henry Buchwald, Department of Surgery, University of Minnesota USA
An email survey was sent to the leadership of the 36 International Federation for theSurgery of Obesity and Metabolic Disorders nations or national groupings, as well as
Denmark, Norway, and Sweden. Responses were tabulated; calculation of relative prevalenceof specific procedures was done by weighted averages. Out of a potential 39, 36 nations or
national groupings responded. In 2008, 344,221 bariatric surgery operations were performed
by 4,680 bariatric surgeons; 220,000 of these operations were performed in USA/Canada by
1,625 surgeons. The most commonly performed procedures were laparoscopic adjustable
gastric banding (AGB; 42.3%), laparoscopic standard Roux-Y gastric bypass (RYGB; 39.7%),
and total sleeve gastrectomies 4.5%. Over 90% of procedures were performed
laparoscopically. Comparing the 5-year trend from 2003 to 2008, all categories ofprocedures, with the exception of biliopancreatic diversion/duodenal switch, increased inabsolute numbers performed. However, the relative percent of all RYGBs decreased from
65.1% to 49.0%; whereas, AGB increased from 24.4% to 42.3%. Markedly, different trends
were found for Europe and USA/Canada: in Europe, AGB decreased from 63.7% to 43.2% and
RYGB increased from 11.1% to 39.0%; whereas, in USA/Canada, AGB increased from 9.0% to
44.0% and RYGB decreased from 85.0% to 51.0%. The absolute growth rate of bariatricsurgery decreased over the past 5 years (135% increase), in comparison to the preceding 5
years (266% increase). Bariatric surgery continues to grow worldwide, but less so than in
the past. The types of procedures are in flux; trends in Europe vs USA/Canada arediametrically opposed.

System of Obesity Surgery: overview
Adelaide Circle of Care, Flinders Private Hospital/Flinders University of South Australia,
South Australia, Australia
Lilian Kow
Obesity is a disease in which fat has accumulated to the point where health is impaired.
It is a rapidly growing problem not only in the western society but also more recently in
the Asia Pacific region.Worldwide, the incidence of morbid obesityhas doubled, and about
300 million people are now considered obese.
Obesity surgery started more than 50 years ago. Tremendous advances have been observed inthis practice of surgery. New techniques, new procedures, minimally invasive access andimprovements in preoperative management have transformed the system of obesity surgery
into a subspecialty of its own. To date,there is no effective diet ordrug therapy
available to treat the morbidly obese.On the other hand, bariatric surgery has been provento be effective, providingmarked and lasting weight loss, ranging from 47.5%to 70.1% ofexcess body weight.These resultsare achieved in relative safety, with operative
mortalityequal or less than that for other major operativeprocedures (about 0.5%).The
weight loss outcome, results in dramatic improvement on the co-morbidconditions of morbid
obesity.
The major medical co-morbid conditions can be divided into thosewhere reversal or
improvement has been proven such as type 2 diabetes, hyperlipidaemia, hypertension,
obstructive sleep apnea,etcand those where reversal or improvementare reasonable andpresumed such as cardiac and peripheral vascular disease, incidence of thrombophlebitis
and pulmonary emboli and various carcinomas.
The ameliorating effects of bariatric surgery are not limited to medical co-morbidities.
Socially, quality of life is vastly improved, as are body image, personal hygiene, andsexual activity.Many of the economic deprivations of the morbidly obese are reversed aftermarked weightloss due to increased employment opportunities advancement potential, and level ofincome.The sum total of these co-morbidity benefits is anincrease in longevity.

Role of incretins in metabolic surgery-induced remission of type 2 diabetes.

Chikashi Shibata, Takeshi Naitoh, Fumie Ikezawa, Hirofumi Imoto, Masayuki Kakyo, Makoto Kinouchi,
Naoki Tanaka, Iwao Sasaki.
Department of Surgery, Tohoku University School of Medicine, Sendai, Japan.

Two hypotheses are proposed as a mechanism for remission of type 2 diabetes (T2DM) in metabolic
surgery; one is foregut hypothesis associated with the exclusion of the duodenojejunum from thenutrient exposure, while another one is hindgut hypothesis associated with the rapid exposure of
the ileum to the bike and nutrients. These hypotheses are tested using rat models of T2DM, including
Goto-Kakizaki rats and obese Zucker rats. Two most representative procedures of metabolic surgery
in rats are ileal interposition (II) and duodenojejunal bypass (DJB). II is considered as a modelfor hindgut hypothesis, whereas DJB as a model for foregut and partly hindgut hypothesis. These
2 procedures improve glucose metabolism, and there are no differences in T2DM remission effects
between 2 procedures. Incretins including GIP and GLP-1 are assumed to play an important role inremission of T2DM in these procedures. Most studies reported that II does not affect fasted plasma
GLP-1 levels but increases those after glucose or meal administration. Effects of II on the fasted
and postprandial plasma GIP levels are still controversial. The effects of DJB on plasma GLP-1 and
GIP levels are also controversial, and mechanisms independent of incretin are assumed in DJB-induced
remission of T2DM. Clinically, ileal interposition with sleeve gastrectomy (II-SG) and ileal
interposition with diverted sleeve gastrectomy (II-DSG) are being attempted. More than 90% of
patients achieved adequate glycemic control (HbA1C<7%). Plasma levels of GLP-1, GIP, and PYY
significantly increased, while plasma levels of ghrelin significantly decreased, after II-SG and
II-DSG in the fasted and postprandial states. These results indicate the important role of incretinsin metabolic surgery-induced remission of T2DM, but mechanisms other than incretins are also likely.

From the Aspect of Mental health

Tetsuya Nakazato
Yotsuya Medical Cube

Morbid obesity is a not only physically but also psycho-socially complicated disease.
It is important to focus on the environment of the patients.

For example, familial

relationships, friendships, work relationships and other relationship.
Surgical treatments for morbid obesity have started in our institution since June 2006.
The objective of the treatment is to improve quality of life (QOL). For improvement of
QOL, physical, psychological, and social supports are important through pre- andpost-treatment. Our multidisciplinary team consists of doctors, nurses, nutritionist, andsocial worker. This multidisciplinary approach is necessary to achieve highly effective
treatment for obesity. To defeat the complexity of obesity, approach from different aspects
is important. The key to success lies in a multidisciplinary team to empower the patients.
As the profession of social worker is to establish interaction between patients and theirenvironments, The roles of the social worker in bariatric surgical team start from thefirst intake of all clients, conducting support groups, making an assessment of
psycho-social problems and counseling.
The term “Mental illness” encompasses a wide variety of problems. The presence of
psychiatric disorders is not an absolute contraindication to weight loss surgery.
The lecture will be regarding behavioral and psychological factors in the assessment andthe treatment of bariatric surgery patients.

From the aspect of Nutrition; Formula diet

Atsuhito Saiki
Center of Diabetes, Endocrine and Metabolism, Toho University Sakura Medical Center

Formula diet is a powdered preparation and is composed of high-protein,low-carbohydrate, low-fat, vitamins and minerals. Formula diet is safe, convenience andeffective in weight loss for treatment of obesity. However, the nutritional efficacy is
not fully explored.
We compared the effects of partial use of formula diet (MicroDiet®; 170kcal/pack,protein 21.5g/pack, fat 2.4g/pack, carbohydrate 16.5g/pack) and conventional subcaloric
diet on weight reduction, body fat distribution and related metabolic variables in obese
patients with type 2 diabetes for 24 weeks. In formula diet group, weight reduction,
visceral fat reduction, decrease in systolic blood pressure, HbA1c, triglyceride andincrease in HDL-C was greater than in conventional diet group. Interestingly, improvements
in visceral fat, HbA1c, triglyceride and HDL-C per reduced body weight were higher informula diet group. These findings have given us a hypothesis that formula diet has specificnutritional effect, which is independent of calorie restriction. To clarify the hypothesis,
we investigated the effects of formula diet on visceral fat, metabolic parameters andadipokines expression in Zucker diabetic fatty rats (low-calorie diet; 56kcal/g,
P:F:C=25:15:60, formula diet (MicroDiet®); 56kcal/g, P:F:C=50:14:36). The changes in bodyweight were not different between groups, however in formula diet group, decrease invisceral fat volume and improvement in triglyceride and HDL-C were greater. Adiponectin,
LPL, PGC-1α and PPARγ mRNA/protein expression in visceral fat tissue were higher informula diet group. On the other hand, formula diet also led to greater reduction of liver
fat content in Zucker rat.
Formula diet may be useful for prevention of malnutrition and long-term weightgain after bariatric surgery. Furthermore, the potent effect on liver fat reduction is
also useful before surgery, because enlarged fatty liver in obesity compromises surgicalaccess to gastroesophageal junction. Pre- and post-operative formula diet may be a key
nutritional option when bariatric surgery is performed.

Consensus of Asian Diabetic Surgery Summit (ADSS) and APBSS
Wei-Jei Lee, M.D., Ph.D.
Dept. of Surg., Min-Sheng General Hospital, National Taiwan University, Taiwan

2005 APBSG consensus meeting has modified the indication of bariatricsurgery for Asian people to
1. Obese patients with their BMI over 37
2. Obese patients with their BMI over 32 in the presence of diabetes or other two
significant obesity related co-morbidities.
3. Have been unable to lose or maintain weight loss by dietary or medical measures.
4. Age of patient > 18 years and < 65 years.
*

Under

specialcircumstanceandinconsideration

with

a

pediatrician,bariatric surgery may be used in children under age 18
2010 ADSS meeting in Taipei has proposed the indication of metabolic surgery
for Asian diabetes people
1. Metabolic surgery should be recommended for diabetes patients with their BMI
over 37
2. Metabolic surgery should be considered for diabetes patients with their BMI over
32 and not well controlled (HbA1c > 7.5%) after intensive medical treatment.
3. Metabolic surgery may be considered for diabetes patients with their BMI over 27
with many co-morbidities and not well controlled (HbA1c > 7.5%) after intensive
medical treatment.
4. Age of patient > 18 years and < 70 years, with acceptable surgical risk andwithout end-organ damage.
*The patient should be cared and followed by multi-discipline medical team andpre-operative B-cell function evaluation is indicated1Concensus of Diabetic Surgery Summit (DSS)
Impact on Asian population

Wilfred Mui
Hong Kong Bariatric and Metabolic Institute

Background: The purpose of the Summit, led by Prof. Rubino is to formulate new consensus
for surgical intervention for Type II diabetes mellitus in western population. It createdtremendous impact on Asian population and in response to DSS guidelines, ADSS and ACOMOMS
guidelines were developed specifically for Asian population.
Method: Multidisciplinary voting delegates around the world gathered at Roma in March
2007 for the 1st DSS. During the meeting, available scientific evidence were examinedand discussed by the entire group. Consensus for diabetic surgery for western population
was established.
Results and Conclusions:
1. GI surgery should be considered for the treatment of T2DM in acceptable surgicalcandidates with BMI >35kg/m2 who are inadequately controlled by lifestyle andmedical therapy.
2. A surgical approach may also be appropriate as a non-primary alternative to treat
inadequately controlled T2DM in suitable surgical candidates with mild-to-moderate
obesity (BMI 30–35 kg/m2). RYGB may be an appropriate surgical option for diabetes
treatment in this patient population.
3. Although novel GI surgical techniques (eg, duodenal-jejunal bypass, ileal
interposition, sleeve gastrectomy, endoluminal sleeves) show promising results forthe treatment of T2DM in early clinical studies, they should currently be used onlyin the context of IRB-approved and registered trials.
4. To improve quality of medical evidence, the development of standards for measuring
clinical and physiological outcomes of surgical treatment for T2DM is a highpriority.
5. Randomized controlled trials are strongly encouraged to assess the utility of GI
surgery to treat T2DM.
6. Development of a standard registry/database is a high priority for research in thisarea. In addition to clinical trials, animal studies can provide useful information
about the efficacy and mechanisms of GI metabolic surgery to treat T2DM.

National report of treatment of obesity and metabolic disorder from (India).
Dr. Mahendra Narwaria, MS, FICS.
President, Obesity and Metabolic Surgery Society of India
Asian Indians exhibit unique features of obesity; excess body fat,abdominal adiposity, increased subcutaneous and intra-abdominal fat, anddeposition of fat in ectopic sites (liver, muscle, etc.). Obesity is a major driver for
the widely prevalent metabolic syndrome and type 2 diabetes mellitus (T2DM) in
Asian Indians in India and those residing in other countries. Based on
percentage body fat and morbidity data, limits of normal BMI are narrower andlower in Asian Indians than in white Caucasians. A consensus statement, waspublished for revised guidelines for diagnosis of obesity, abdominal obesity, themetabolic syndrome, physical activity, and drug therapy and bariatric surgery forobesity in Asian Indians after consultations with experts from various regions ofIndia belonging to the various medical disciplines representing reputed medical
institutions, hospitals, government funded research institutions, and policy
making bodies.
According to National Family and health Survey (NFHS), approximately
7.1% of Indian population is under obesity risk. Almost 65% of adult urban
Indian are –either over weight, obese or have abdominal obesity. The highest
incidence is observed in North western (Punjab) part of India (M: F- 30.3/37.5%),
followed by South (M: F-24.3/34%) and North east (M: F-17.3/21%).
With an estimated 50.8 million people living with diabetes, India has theworld’s largest diabetes population, followed by china with 43.2 million. The
prevalence of type II DM in adult population ranges from 9% to 16%, with 14.2 %of male and17.5 of female.
The Obesity and Metabolic Surgery Society of India was established in 2001.
The indication for surgery is generally in accordance with guidelines using the
WHO standard for obesity on Asia, i.e. BMI >37.5/32.5 with co-morbidities. There
are few no of bariatric and metabolic surgeries carried out outside the standard
guidelines for obesity surgery but they are mainly as part of some clinical trials.
There are about 80 surgeons (certified general, GI surgeons with training
and experience) performing bariatric surgery regularly in India, carrying out
2000 procedures per year.
There are 5 high volume centres and few of them applied for centre of
excellence (ICE) certification from ASMBS.OSSI is jointly working with SRC todevelop centre of excellence in India. Cost of bariatric treatment depends uponthe types and location of the operative procedure. We accept and operate theinternational patients.
Refrences:

IDF-Diabetes Atlas, 4th edition, Oct 2009.



G. Vijaykumar et.al; JAPI, Aug 2009, Vol-57.



A. Mishra, P.Chowbey, BM Makkar, NK Vikram et.al; JAPI, Feb 2009.

Consensus of OSSANZ National Report from Australia
President, Obesity Surgery Society of Australia and New Zealand
Lilian Kow
The OSSANZ Bariatric Surgical Standards (OBSS) was developed to ensure that all surgeons
who undertake to perform Bariatric Surgery within any Health Service (Public or Private)
are properly credentialed and have the scope of providing a quality bariatric surgicalservice in accordance with both their level of skill and experience and the capability of
the Health Service.The following are the recommended OSSANZ Bariatric Surgical Standards
for defining the scope of clinical practice for Bariatric Surgery.
An Australian standard has been developed to guide the process of credentialing anddefining the scope of clinical practice (www.safetyandquality.org).
These recommendations have been developed to ensure the delivery of high quality bariatricservice within any Health Service. It is recommended that these OBSS assists Credentialing
Committees of Health Services to ensure their bariatric surgeons are performing operationscommensurate with their skill and are also providing a quality bariatric service to theirpatients as defined below.
These OBSS apply to all surgeons who are practicing or considering bariatric surgery. They
are guidelines recommended for Credentialing Committees of Health Services in thecertification and recertification of bariatric surgeons in Australia and New Zealand.
For surgeon members, the process of their application for clinical practice of bariatricsurgery (operation specific) within any Health Service should be of the following 3
categories:

1.

Provisional Bariatric Surgical Accreditation

Provisional Bariatric Surgical is the first step for surgeons with FRACS or equivalent,
who wish to become fully accredited Bariatric Surgeons in any Health Service. This is theagreed step to be taken when undergoing and completing training in bariatric surgery, andmentoring of cases, before being accredited as Bariatric Surgeon for a specific bariatricprocedure:
a.
b.
c.
d.

e.
2.

Nominated by 2 surgeons experienced in Bariatric Surgery.
Successful completion of, and proof of, approved Bariatric Surgery Training or
a Bariatric Course.
Documentation of minimum of 3 mentored cases by another Bariatric Surgeon,with written approval by the mentor.
The surgeon may then proceed to documenting 20 bariatric cases, (Logbook)which is to be forwarded to, and to be approved, by the Credentialing
committee.
Agree to contribute to the OSSANZ Bariatric Registry.

Full Bariatric Surgical Accreditation
Bariatric Surgical Service is applied for after fulfilling the requirements of
the Provisional Bariatric Surgical Accreditation.
a.

Has fulfilled the criteria of Provisional Bariatric Surgeon andreceived the necessary written approvals.

b.

c.
d.
e.

3.

Maintains and updates clinical skills and bariatric knowledge which
includes one bariatric surgical meeting (national or international)
yearly.
Continues to contribute to the ongoing OSSANZ Bariatric Registry andfollow-up.
Maintains surgical skills by at least 20 bariatric operations annually.
Reviewed/renewed triennium.

Grandfather Clause
Surgeons already performing Bariatric surgery will need to provide the following
when applying for recertification as Bariatric Surgeons by their Health Service
a.
b.
c.
d.
e.

Fully qualified and recognized General Surgeon
Evidence of successful completion of a Bariatric Course or Training
Evidence/experience and explanation of Bariatric Training
Name of 2 referees – experienced in Bariatric Surgery.
Evidence of having performed 100 Bariatric Cases and complication rate

JSSO Consensus Statement 2010

Chairman of the JSSO guideline committee, Isao Kawamura

JSSO, as a body member of IFSO, had been formulating its guidelines for about 3 years in order to enact
them.

These were completed and released as Statement 2010 in 2010.

The basis of the guidelines wasestablished by complying with the IFSO guidelines 2008, in consideration of the state of affairs inJapan and characteristics of obesity patients. However it also takes account of the flexibility tohandle future revision if necessary.

The first feature of JSSO is the fact that surgeons should havean idea the treatment of morbidily obese patients lasts a lifetime, does not end with surgical treatmentonly. Those are compared to lines and points. In other words, the treatment of morbid obesity needs
multidisciplinary treatment with a team which includes physicians, psychiatrists, dieticians,
counselors and so on.

Surgical indications characterize the second feature of JSSO. Indications forbariatric surgery is applied for the patients with BMI ≧35, because the criterion of Japanese obesity
is defined by BMI≧25.

We have defined the indication for metabolic surgery by BMI≧32 and havepositioned it as clinical study.

It obliges a through follow-up for the patients under the rigid

registration system. Our report mainly consists of these details.

ACMOMS I

Muffazal Lakdawala

Abstract
Background: The Asian consensus guidelines were the outcome of a two day deliberation that wasorganized in Trivandrum, India on the 9th and 10th August 2009.
Methods: Asian Consensus Meeting on Metabolic Surgery (ACMOMS) was the first ever meeting of its
kind in Asia where 52 professionals involved in the field of bariatric surgery, metabolic surgery,diabetes, and medical research from countries across Asia and the GCC met at Trivandrum, India
to vote for and create a new set of guidelines for the Asian phenotype, which were different fromthe NIH guidelines set for bariatric surgery. The aim was to set culturally, geographically, andgenetically relevant standards for the management of obesity and metabolic syndrome.
Results: It is known that Asians have higher adiposity for a given level of obesity, and this isvisceral obesity as compared to other populations. Currently, worldover guidelines set by NIH in
1991 are being followed for bariatric surgery. Surgeons believe that NIH guidelines need to berevisited and modified. It is in light of these observations that the genesis of ACMOMS took place.
At ACMOMS, it was recommended that the NIH guidelines are not suitable for Asians, and the BMI
guidelines should be lowered for indication of surgery. Waist or waist–hip ratio must gainsignificance as compared to BMI alone for Asians. The recommendations were as under:•

Bariatric/Gastrointestinal Metabolic surgery should be considered as a treatment option
for obesity in people with Asian ethnicity with a BMI more than 35 kg/m2 with or without
co-morbidities.

•

Bariatric/Gastrointestinal Metabolic surgery should be considered as atreatment option

for obesity in people with Asian ethnicity above a BMI of 32 kg/m2 with co-morbidities.
•

Bariatric/Gastrointestinal Metabolic surgery should be considered as a treatment option
for obesity in people with Asian ethnicity above a BMI of 30 kg/m2 if they have central
obesity (waist circumference more than 80 cm in females and more than 90 cm in males) alongwith at least two of the additional criteria for metabolic syndrome: raised triglycerides,
reduced HDL cholesterol levels, increased LDL levels, high blood pressure and raised fasting
plasma glucose level.

•

Any surgery done on diabetic patients with a BMI less than 30 kg/m2 should be strictly done
only under study protocol with an informed consent from the patient. The nature of thesesurgeries should be considered as yet purely experimental only as part of research projects
with prior approval from the ethics committee.

Conclusions: The collective recommendations were submitted as a report to the executive committee
for approval. These guidelines have now been accepted by the Asia Pacific Metabolic and BariatricSurgery Society (APMBSS) and IFSO Asia Pacific Chapter and have been published in the journal of
Obesity surgery.

Bariatric Training and Education
Hallein Clinic, Austria
Karl Miller, MD, FACS
Obesity surgery is not only a craft but it also signifies consideration of the disease asa whole. An Operation Primer undertakes the task of communicating
basic surgical techniques. Only someone who knows all the technical possibilities andprocedures is in a position to react flexibly and adequately in different situations.
About 50 different surgical methods have been developed in obesity surgery in the past 50
years. It is obvious from this that the optimal surgical method for the obese patient does
not exist. Experience has shown that peri- and postoperative complications can be reducedwith with simplified working steps. An Operation Primer is an ideal format forcommunicating new operative methods but it does not replace training by an experienced
surgeon. A surgeon cannot rest on his laurels but must always keep up with the latest
techniques. I would therefore like to take this opportunity to thank the Industry formaking Mental Training, training on the computer simulator and operations in thelaboratory possible. First-class surgery is possible only through careful acquisition ofknowledge, regular training and quality control. Additional mental training is aneffective way of optimizing the outcomes of further training for laparoscopic procedures.
It is associated with fewer costs and with better outcomes in some crucial assessment
scales than additional practical training.

Bariatric Surgery clinical fellowship in the USA

Seiichi Kitahama, MD
Minimally Invasive Surgery Fellow
Michael E. DeBakey Department of Surgery
Baylor College of Medicine, Houston, TX

Bariatric surgery has been gaining popularity worldwide.? It is still
not easy to master the comprehensive perioperative bariatric patientcare and advanced laparoscopic skills including intracorporeal hand-sewn
anastomosis.

Currently there are 62 bariatric surgery fellowship training programs in
the USA according to the Fellowship Council ([a:http://www.
fellowshipcouncil.org/]http://www.fellowshipcouncil.org).? The
organization monitors individual fellowship training and regulates thematching process to ensure high volume and high quality training. ?

I completed one year clinical laparoscopic bariatric surgery fellowship,
predominantly LRYGB and LAGB, with some LSG at Legacy Good Samaritan
Hospital in Portland, Oregon.? Subsequently I am undergoing anotherclinical MIS/bariatric surgery fellowship predominantly LRYGB and LSG,
with some LAGB at Baylor College of Medicine in Houston, Texas. ?Bothhospitals are accredited as Bariatric Surgery Center of Excellence by
Surgical Review Corporation.

I would like to share my experience with 7 bariatric surgeons anddiscuss the way to organize a bariatric training program.

Bariatric Fellowship in Australia
Dr Benjamin Woolven
St George Private Hospital
General Surgical Training in Australia requires a six year undergraduate or 4 year post
graduate medical degree and two years of post graduate experience before commencement.
General surgical training is undertaken over a minimum of 5 years and requires successful
completion of a two part clinical examination. Further post fellowship training is at thediscretion of the individual surgeon though non compulsory two year programs in uppergastrointestinal, colorectal and hepatobiliary surgery have been established. There is nocentrally administered training program in bariatric surgery though a number of individual
institutions offer one year fellowship programmes.
The authors experience is of a one year programme undertaken at St George Private Hospitalin Sydney in Upper Gastrointestinal and Bariatric Surgery. During the fellowship there
were 275 bariatric operations including 52 laparoscopic adjustable bands, 158 laparoscopic
sleeve gastrectomies, 29 laparoscopic gastric bypasses and 61 revisional operations. There
were 433 non bariatric operations. International candidates from Singapore, New Zealandand the United Kingdom have previously completed the programme. Future international
candidates are welcome to apply for the St George Fellowship program and other bariatrictraining programmes throughout Australia.

Bariatric Fellowship Training in a Center of Excellence, Taiwan Experience

1

Bariatric & Metabolic International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan.

2

Department of General Surgery, E-Da Hospital, Kaohsiung, Taiwan.

3

Department of Chemical Engineering, Institute of Biotechnology and Chemical

Engineering, I-Shou University, Kaohsiung, Taiwan.
Chi-Hsien Lo1, Chih-Kun Huang1,2,3

Background: Bariatric surgery has gained more popularity in Asia-Pacific area. But, themultiple co-morbidities of morbid obesity and steep learning curve make comprehensive
training program to be looked-for in recent years. Hereby, we present the fellowshiptraining program in a unique International Bariatric Surgery Center of Excellence(BSCOE) in Taiwan.
Methods: From July 2009 to July 2010, fellowship training process, learning curve,
patients demographic data, operation time and surgical complications were all collectedfrom different stages of the learning. According to the bariatric training protocol of
the institution, data was analyzed and compared.
Results: In this one-year period, totally 346 laparoscopic bariatric operations were
performed in the BMI Surgery Center, E-Da Hospital. As a primary surgeon, the fellowshipperformed 169 bariatric cases independently after 43 assistance. Different type of
bariatric surgeries were performed, as gastric banding with or without gastric plication,
sleeve gastrectomy and Roux-en-Y gastric bypass. There were only 5 surgicalcomplications (3.55%). There was no mortality. In this journey, we reviewed different
stages of the fellowship training, as being from a mere assistant, progressed to primary
surgeon, and then supervisor.
Conclusion: Low complication rates came from excellent supervised bariatric training
program and we proposed a bariatric surgery training guideline in Asia-pacific area.

Better Short-term Weight Loss for Patients with Group Therapy after Gastric Banding

Digestive and Bariatric Surgery Division, Taipei Medical University Hospital, Taipei,
TaiwanWeu Wang M.D.

Background:
Adjustable gastric band surgery is one of the standard surgeries for the treatment ofmorbid obesity. The results between, however, varies. Post-operative intensively
follow-up and group therapy may offer the patients better concept of eating behavior
and life style change, and further lead to better weight loss.

Materials and Methods;
From January 2008 to Dec 2009, 156 patients had received gastric banding surgery. Amongthese, 31 patients joined the post-operative group therapy including nutritionalcounseling, aerobic exercise and diet education willingly. Another 31 patients was
selected without post-operative group therapy as comparative group. The data wascollected retrospectively.

Results;
The mean BMI was 43.6+5.3 kg/m2 in the study group and 42.8+6.5 kg/m2 in comparison.
The BMI at one year after surgery was 32.8+3.6 kg/m2 and 34.2 + 4.6 kg/m2 respectively.
The average adjustment was 5.2 times in study group comparing to 3.8 times. The study
group has better loss of body fat and higher percentage of muscle component.

Conclusion:
Post-operative group therapy is effective for better weight loss and greater improvementof body fat percentage for patients undergo gastric banding.

Laparoscopic adjustable gastric banding in a Japanese instituteDepartment of Surgery I, Oita University Faculty of Medicine, Oita, Japan.
Masayuki Ohta, MD, Teijiro Hirashita, MD, Yukio Iwashita, MD, Tadashi Ogawa, MD, Kazuhiro
Yada, MD, Takashi Masuda, MD, Hidetoshi Eguchi, MD, Seigo Kitano, MD

Background/Aim: Although bariatric surgery has not been popular in Japan, the most popularbariatric procedure is now laparoscopic sleeve gastrectomy. In 2005, we introduced
laparoscopic adjustable gastric banding (LAGB) into Japan, and here, our data were
presented and evaluated.
Methods: Between August 2005 and December 2010, 31 morbidly obese patients (18 women /13 men, mean age of 39yr) received LAGB in our institute. All patients were morbidly obese(BMI>35 kg/m2), and the averaged weight was 118 kg and BMI was 43 kg/m2. In regard to LAGB
devices, LAP-BAND® (Allergan Medical) was used in 29 patients and SAGB® (OBTECH MedicalGmbH) in 2 patients. All procedures of LAGB were performed through the pars flaccida pathway
with band fixation using gastric-to-gastric sutures. Averaged follow-up duration was 35
months.
Results: All the procedures were completed laparoscopically. Two complications wereexperienced (postoperative bleeding and port trouble), and reoperations were needed in
the patients. Weight loss and % excess weight loss on the average were 25kg and 44% after
1 year, 33 kg and 57% after 3 years and 29 kg and 51% after 5 years. Accordingly,
comorbidities were frequently improved, and type 2 diabetes and metabolic syndrome wereresolved in 9 of 10 patients (90%) and in 14 of 17 patients (82%), respectively.
Conclusions: LAGB is safe and effective in Japanese patients with morbid obesity, and ourdata seem to be equivalent to those previously reported in Western countries.

Patient Selection for Laparoscopic Adjustable Gastric Banding
Centre for Obesity Management and Surgery, National University Hospital, Singapore
Asim Shabbir, Litang Chen, Raymond Lim, Jia-yan Wee, Lifeng Zheng, Davide Lomanto,
Jimmy BY So.
Surgery is the most effective treatment for morbid obesity. Various bariatric
operations are available but the ideal operation remains unknown. Laparoscopic
Adjustable Gastric Banding (LAGB) is one of commonest bariatric operations. It issimple, adjustable, reversible and minimally invasive. However, the outcome of weightloss is highly variable and band-related complications occasionally occur. To achieve
the best outcomes, careful patient selection and a committed follow-up program areessential. Our centre started LAGB since 2004. In 2007 and 2008, we introduced
laparoscopic sleeve gastrectomy (LSG) and gastric bypass (LRYGB) respectively. We
reviewed our patients who underwent bariatric surgery in the past 6 years, andcompared the results among these 3 procedures. We investigated potential predictors ofoutcomes after LAGB and we also reviewed published date for additional predictors.
Till 2010, we had 72 patients who underwent bariatric surgery (42 LAGB, 22 LSG, 8
LRYGB). The median age was 44(range: 24-68) and the BMI was 41 (range: 30-57). Medianfollow-up among the three procedures was 45, 8 and 6 months respectively. The medianexcess weight loss (EWL) was 29, 34, 44% respectively. Among patients who underwent
LAGB, 29 patients (69%) defaulted follow-up in long-term. Twenty-two (52%) patients
had unsatisfactory weight loss (<30%EWL) and 6 (14%) patients developed band
complications and required band removal. In general, predictive factors for pooroutcomes include age, unwilling to change lifestyle habits and loss of follow-up. In
conclusion, long-term results of LAGB are unsatisfactory in unselected patients.
Careful patient selection is essential in achieving good outcomes in LAGB.

Lap banding in Thailand
Institute: Bunrungrad International Hospital, Bangkok
Professor Paisal Pongchairerks
Laparoscopic Gastric Banding was the first bariatric procedure done in Thailand in
2003. Its preference decreased gradually as Thai surgeons acquired more expertisein other more difficult procedures. The popularity of laparoscopic sleeve
gastrectomy also seemed to contribute to this trend. However, banding still
entertained the benefit of being a relatively easy procedure among all. Surgeons
seemed to come across more long-term complication after more years of follow-up,
including esophageal dilatation, reflux with or without esophagitis, slippage andband erosion. Some cases of reoperation were experienced. Nowadays, Thai surgeons
have different opinions as for the indication of gastric banding.

Gastric Band in India
Bombay Hospital Fortis Hospitals, Mumbai, India
Ramen Gyanendra Goel
Bariatric surgery started late in India. VBG was introduced in late 1990s. First gastric band
surgery in India was done in 2000 & subsequently till 2005 almost all surgeons started
bariatric career with gastric band. Most of experienced laparoscopic surgeons could adept
gastric band comfortably & numbers of band surgeries increased rapidly till realization
started settling in that band is not effective in almost 25% - 35% with 3 year explantation
rates of 20% - 30% in different hands.
Introduction of gastric bypass & sleeve gastrectomy has led to further decline in gastricband surgery’s fortunes in India. Gastric band now accounts for less than 1% of proceduresin most of bariatric practices. Few recent centers have shown renewed interest in gastricband implantations with successful outcomes.
Various reasons attributed to poor results seen by Indian surgeons may be attributed to poor
follow up due to failure to get regular adjustments due to long distances, incompletelydeveloped bariatric program, high rate of oesophageal dilatation etc. Lack of patience, due
to slow weight loss results, compared to other bariatric surgeries may also attribute to highexplanation rate.
Gastric band surgery accounts for almost 50% of bariatric procedures in USA, but only longterm follow up will show whether fate of bands will follow the Indian graph. As gastricsleeve is becoming the procedure of choice amongst bariatric surgeons & patients in India,
the future of gastric band surgery in India is bleak.