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 insulinresistance.
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 ismaintained.
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 individualbasis, 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 areacknowledged, 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. Laparoscopicsleeve 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 essentialfor 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 ismultidisciplinary. 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 (ComprehensiveSystem) 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” afterbariatric 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, livingconditions and social lives. Therefore, the multidisciplinary team approach withsufficient 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 themanagement 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’slives,, 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 personalproblems, 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 obesitytreatment. 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.