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obesity and cosmetic clinic LONDON 2017-2018

Dear Custumors,

Our new office at Devonshire place 35 in London is ready . We've moved to the first floor in close corporation with The Harley Street Dermatologic Clinic to improve our services. The clinic will be open every other Friday with exception of Friday 27/10 . We will organize a clinic on Wednesday 25/10 from 10am till 2pm .

Looking forward to welcome you all at our new facilities in the future.



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Cost-effective bariatric surgery under-utilised in the UK

A keynote session at the 22nd World Congress of IFSO (International Federation for the Surgery of Obesity and Metabolic Disorders) in London, has called for an increase in bariatric surgery in the number of procedures in the UK, as procedure numbers revealed the UK is behind other countries, including near neighbours in Europe.

More than 2,000 experts from around the world have gathered in the capital for the World Congress to share expertise on tackling the global obesity crisis, with the British Obesity and Metabolic Surgery Society (BOMSS) as the host association.

As part of the Congress, a panel of UK clinicians, scientists and policy makers attended a special session on Friday 1st September to debate why more surgery is not being commissioned in the UK against a background of successful surgical interventions and rising obesity levels. They questioned why a treatment that is both medically- and cost-effective is under-utilised, and asked whether barriers to access include social stigma along with misconceptions about how people become obese and then how difficult it is to lose excess weight.

The UK ranks 13th out of 17 in a table of European countries which measure bariatric surgery by number; it is 6th out of eight G8 countries and 4th out of G8 countries ranked by size of economy.

In France, which has a similar population size to the UK, more than 37,000 surgeries are carried out each year, compared to around 5,000 in the UK. Belgium (population 11.3 million) performs approximately 12,000 surgeries and Sweden (population 9.9 million) more than 7,000 surgeries a year. Italy, a little smaller than the UK population at 60.6 million, carries out more than 8,000 surgeries a year.

Mr Richard Welbourn

“The annual volume of bariatric/metabolic procedures is five to ten-fold lower when compared to other European countries with similar population sizes and disease prevalence,” said Mr Richard Welbourn, Consultant Bariatric Surgeon at Musgrove Park Hospital, Taunton and President of IFSO 2017. “Increasing surgery rates would have major benefits for patient health and reduce direct healthcare expenditure within two years.”

Headline figures from the National Bariatric Surgery Registry (NBSR), which collects information on bariatric surgery, shows that bariatric surgeons in the UK are highly successful at helping people control their weight - even though patients are increasingly overweight and have more health complications at the point of surgery, including diabetes, arthritis, depression and sleep apnoea.

But despite these successful results - and the fact that bariatric surgery has been judged as very safe with a mortality rate of less than 1 in 1,000 according to latest HES figures - many people in the UK find it difficult to access surgical treatment for obesity.

A freedom of information request published earlier in 2017 revealed that some Clinical Commissioning Groups either require patients to stop smoking or to have a BMI>50, despite NHS England and the National Institute for Health and Care Excellence (NICE) guidance stating bariatric surgery is cost-effective and should be considered for patients with BMI>35 with an obesity-related disease co-morbidity (such as such as high blood pressure, high cholesterol levels, osteoarthritis, depression) or a BMI>40 without a related disease.

In patients with Type 2 diabetes, both NICE recommendations and international guidelines - endorsed by over 50 organisations including Diabetes UK and all relevant British professional societies - advise considering metabolic surgery for patients with inadequately controlled diabetes and a BMI>30 (or 27 for patients of Asian descent).

The NBSR - which will next report fully in early 2018 - has data on 18,528 operations which were performed between 2015 and 2017, and shows that UK surgeons are operating on an increasing sick and older population. Of the people treated, the average BMI47.2, (almost twice the weight people should be for their height). Some 65.4% of men and 64.4% of women had what is known as functional impairment - eg, they couldn’t climb three flights of stairs without resting. One year after surgery, well over half of those patients (58.3%) no longer had any functional impairment.

The results for diabetes resolution are startling and could offer a solution to the increasing cost burden on the NHS of treating the condition. Some 51.6% of patients with Type 2 diabetes at the point of surgery showed no indication of diabetes one year after surgery, coming off costly diabetic medications. NBSR results are consistent with a large body of evidence including 12 randomised clinical trials showing that surgery is more effective than other available treatment options in controlling diabetes in obese patients.

“The UK data is overwhelming - surgery makes a difference to people’s health and we want commissioners to acknowledge this and act accordingly,” said Mr Marco Adamo, Consultant Surgeon at UCH and Chair of the NBSR. “Severe and complex obesity is a serious, life-long condition associated with many major medical conditions, the cost of which threatens to bankrupt the NHS.”

Despite its proven health benefits and cost-effectiveness, surgical treatment for obesity or diabetes remain largely underutilised in the UK. 2.6 million British people would be eligible for surgery under guidelines covering BMI and co-morbidities.

Professor Francesco Rubino

“When clinical evidence of efficacy and safety, high cost-effectiveness, NICE guidelines and international consensus by all relevant professional organisations are not sufficient to ensure appropriate access to bariatric/metabolic surgery, then it becomes clear that misconceptions and the stigma of obesity are the main barriers,” said Professor Francesco Rubino, Chair of Metabolic and Bariatric Surgery at King’s College London. “Whenever possible, prevention is obviously better than cure. But for people who are morbidly obese or have already developed diabetes, prevention is obviously no longer an option. Focusing on prevention alone and denying access to treatment to the many patients already suffering from clinically severe obesity or Type 2 diabetes is a sure way to inflict damage to patients and to the healthcare system at the same time.”

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MGB and one-anastomosis gastric bypass are on the rise

The MGB-OAGB 4th Annual Consensus Conference was held in Naples, Italy July 3-4, 2017 under the superb organisation of Professor Mario Musella, at a beautiful site on the Mediterranean seaside. The meeting was attended by 169 experienced surgeons from bariatric teams in 29 countries, where important studies were presented and discussed.

This article was authored by Mervyn Deitel, MD, SFASMBS, FACN, Director MGB-OAGB Club, Toronto, Canada

A French group reviewed their 2,014 MGBs; abscesses had occurred in 2.2% and were treated by endoscopic or percutaneous drainage, with no mortality. Methylene blue test has been important for operative detection of leaks. Revision for GE bile reflux or malnutrition was rarely necessary in the long-term. The operations were highly effective for excess weight loss. Studies suggested that the length of the bypassed limb may only influence weight loss in the early months after surgery. Bypasses of 150-250 cm were performed, depending on BMI and sociocultural conditions, but with the longer bypasses, total bowel length should be measured to be certain that 300 cm of common limb is left distally.

Figure 1: MGB with a long gastric pouch, starting from below the crow’s foot, and going proximally to the left of the angle of His. An anterior wide gastrojejunostomy is constructed 180-200 cm distal to Treitz’ ligament.

MGB or OAGB was performed safely as both a primary operation or a revision for failed gastric banding or sleeve gastrectomy (SG). Improvement in quality of life and co-morbidities resulted, with resolution of type 2 diabetes in >95%.

Cady of Paris, with 3,500 cases (using a 175-200 cm bypass limb), found that under-nutrition occurred in 1.5%, and if there is no quick result from replenishment, reversal is necessary to avoid death. The French group from Cornevarrieu-Toulouse reported that in their series of 2,400 patients with a 150-cm biliary limb, had 0.04% severe malnutrition (only 1 patient) requiring reversal. Weight loss after MGB-OAGB depends mainly on malabsorption. Malnutrition in patients in India (where 50% are vegetarian) is avoided by a bypass no greater than 200 cm and proper diet.

Figure 2: OAGB with long, narrow gastric pouch (15-18 cm) and an antecolic antegastric latero-lateral anastomosis between pouch and afferent enteric loop which is suspended ~8-10 cm above the anastomosis through an initial continuous suture which secures the afferent limb to the gastric pouch’s staple-line and with final fixation of the loop’s apex to the excluded stomach. Biliopancreatic limb averages 250-350 cm.

With the usual MGB gastric channel constructed 2-3 cm distal to the crow’s foot, bile GE reflux was negligible. The Kazakhstan group found that a longer gastric pouch significantly reduced postop bile reflux. Tolone’s group from Naples (S Tolone SOARD 2016), using multiple scientific studies, confirmed that GE reflux does not occur after MGB (unlike after SG which maintains the pylorus).

Carbajo of Spain and Luque-de-Leon of Mexico presented their outcomes from 2,850 OAGBs since 2002, with negligible bile reflux, marginal ulcer in <1%, and EWL and EBMIL >75%. Again, the OAGB was an excellent rescue after other failed operations. Long-term %EWL and co-morbidity resolution after OAGB were similar to the best results obtained with more aggressive and complex operations.

The importance of differentiating type 1 (auto-immune) diabetes (T1D) in the adult from type 2 diabetes was emphasised. Obesity can occur in type 1 if the patient takes excessive insulin, becomes hypoglycaemic, and then has to eat more (a vicious cycle). This can be controlled by dietary surveillance; if not, bariatric surgery for obese T1D will decrease weight, lower HbA1c, and lower insulin requirement. However, the T1D patient will always require insulin.

Unlike following other bariatric operations, carcinoma in the gastric channel or esophagus has not occurred. Some workers are performing robotic MGB, and note speed and technical ease.

A number of long-term studies comparing MGB-OAGB with SG and RYGB were presented. SG was followed by occasional serious high leaks, GE reflux, Barrett’s esophagus, and weight regain. Most MGB and OAGB surgeons had previously performed RYGB for many years. RYGB took longer to perform, was more complex, had longer learning curve, more marginal ulcers, increased internal hernias and bowel obstruction, more hypoglycemia, late weight regain and more difficulty to revise.

In comparison, MGB was relatively simple, rapid, safe, and had greater elevation of GLP-1, durable weight loss, ease of revision and reversal, and resolved GERD. With both RYGB and MGB, watch for iron deficiency anemia and hypoalbuminemia.

In many countries outside USA, MGB and OAGB have become the most common bypass operation for bariatric patients.

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Ireland 2017 available for all patients