EBM

Ahmad A. Gudal

The Patient
Mr. Saeed is a 50 y/o, k/c of DM, HTN & OSA, presented to GS clinic complaining of obesity. Hx: Type 2 DM 8 years on OHD, HTN: 4 years with no medication, OSA 1 year. Mr. Saeed complained of signs and symptoms of depression. O/E: BMI=41 (Obese class 3).

What is Obesity
Obesity is defined as abnormal or excessive fat accumulation that presents a risk to health. BMI 30. Mortality: Obesity decrease life expectancy by 6-7 years on average. Morbidity: Obesity is well known to be associated with DM, HTN, dyslipidemiaetc.

Management Options for Obesity

Diet & physical exercise. Medications (orlistat). Bariatric surgery.

Bariatric Surgeries
Gastric band

Gastric bypass
Gastroplasty Biliopancreatic diversion

Factors Affecting Choice of treatment for Obesity

Patients preference. Stage of obesity. Co-morbidities. Local resources.

Clinical Question
Does the choice of specific bariatric surgery procedure effect the co-morbidity outcome?

Outcome of Interest
Diabetes Mellitus. Hypertension. Hyperlipidemia. Obstructive sleep apnea.

Hierarchy of Evidence
Meta-analysis of all RCTs
Meta-analysis of all published RCTs 2 or more confirmatory RCTs
1 Randomised Controlled Trial (RCT) Non-randomized controlled study

Uncontrolled experiences of
Geographically-defined populations Multiple treatment centres One treatment centre One clinician A patient

Search Strategy
National Center for Biotechnology Information website was visited. PubMed database was selected. Limitation: Meta-analysis, English and published in the last 10 years. Display sitting was changed to title.

Article Selected

Study Design

Results
Diabetes mellitus: When defined as the ability to discontinue all diabetes-related medications and maintain blood glucose levels within the normal range, strong evidence for improvement in type 2 diabetes and impaired glucose tolerance was found across all the surgery types:
Biliopancreatic diversion: reduced by 98.9% (95% CI, 96.8%-100%) Gastric bypass: reduced by 83.7% (95% CI, 77.3%-90.1%) Gastroplasty: reduced by 71.6% (95% CI, 55.1%-88.2%)

Gastric band: reduced by 47.9% (95% CI, 29.1%-66.7%)

Results
Hyperlipidemia: The outcome categories of hyperlipidemia, hypercholesterolemia, and hypertriglyceridemia were significantly improved across all surgical procedures (including the mixed and other bariatric surgery groups). The percentage of patients improved was typically 70% or higher
Biliopancreatic diversion: reduced by 99.1% (95% CI, 97.6%-100%) Gastric bypass: reduced by 96.9% (95% CI, 93.6%-100%)

Results
Hypertension: hypertension significantly improved in the total patient population and across all surgical procedures. The percentage of patients in the total population whose hypertension resolved was 61.7% (95% CI, 55.6%-67.8%).
The rank order of efficacy among the surgical groups was variable for both resolution or improvement.

Results
Obstructive Sleep Apnea: Diagnoses of sleep apnea, sleep-disordered breathing, and pickwickian syndrome were combined as representative of obstructive sleep apnea. The percentage of patients in the total population whose obstructive sleep apnea resolved was 85.7% (95% CI, 79.2%-92.2%).
Evidence for changes in OSA was primarily available for gastric bypass patients: reduced by 33.9 per hour (95% CI, 17.4-50.2 per hour).

Conclusion
Effective weight loss was achieved in morbidly obese patients after undergoing bariatric surgery. A substantial majority of patients with diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea experienced complete resolution or improvement.

Strengths of the Research

Systematic review. 136 studies were included. Reported the overall impact of bariatric surgeries on weight loss, mortality and co-morbidities. Reported a comparison between common bariatric surgery procedure. Strict inclusion and exclusion criteria (>10 patients, >30 days follow-up, case reports..etc).

Weakness of Research
Some included studies didnt report some clinical comorbidities (asthma, CAD, degenerative joint disease) which effected comparison between important variables. Comparison between surgery procedures in regard to comorbidities out come were not thorough except for DM. Some conflicting data (in ranking) were reported.

Level of Evidence
1a (center for evidence based medicine)

The Patient
Mr. Saeed is a 50 y/o, k/c of DM, HTN & OSA, presented to GS clinic complaining of obesity. Hx: Type 2 DM 8 years on OHD, HTN: 4 years with no medication, OSA 1 year. Mr. Saeed complained of signs and symptoms of depression. O/E: BMI=41 (Obese class 3).

Implication for My Patient

My patient is k/c DM, HTN, OSA and depressed. There are many factors that influence the choice to approach his health in holistically. As GS, Mr. Saeed is a candidate for surgical intervention (BMI>40 +/-comorbidity). However, his preference is crucial. If he decide to go for surgery, I would explain principles, advantages and disadvantages of each procedure theoretically. However, I would recommend biliopancreatic diversion because it was superior compared to other procedures.

Unanswered Question
Does bariatric surgery have an effect on depression?

Summary
Clinical question: Does the choice of specific bariatric surgery procedure effect the comorbidity outcome? Systematic review of 136 studies. All bariatric surgery procedures resolve/improve outcome of interest with biliopancreatic diversion superior compared to other procedures.

Thank

You