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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).

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

• Bariatric surgery.Management Options for Obesity • Diet & physical exercise. . • Medications (orlistat).

Bariatric Surgeries • Gastric band • Gastric bypass • Gastroplasty • Biliopancreatic diversion .

. Co-morbidities. Stage of obesity. Local resources.Factors Affecting Choice of treatment for Obesity • • • • Patients’ preference.

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

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

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 .

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

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Article Selected .

Study Design .

3%-90.9% (95% CI. 55.1%-66. 29.6% (95% CI. 96. strong evidence for improvement in type 2 diabetes and impaired glucose tolerance was found across all the surgery types: – Biliopancreatic diversion: reduced by 98.7%) .7% (95% CI.8%-100%) – Gastric bypass: reduced by 83.1%) – Gastroplasty: reduced by 71.9% (95% CI. 77.1%-88.Results • Diabetes mellitus: When defined as the ability to discontinue all diabetes-related medications and maintain blood glucose levels within the normal range.2%) – Gastric band: reduced by 47.

97.9% (95% CI.6%-100%) . The percentage of patients improved was typically 70% or higher – Biliopancreatic diversion: reduced by 99. and hypertriglyceridemia were significantly improved across all surgical procedures (including the mixed and other bariatric surgery groups). hypercholesterolemia.6%-100%) – Gastric bypass: reduced by 96.Results • Hyperlipidemia: The outcome categories of hyperlipidemia. 93.1% (95% CI.

The percentage of patients in the total population whose hypertension resolved was 61. .Results • Hypertension: hypertension significantly improved in the total patient population and across all surgical procedures. 55. – The rank order of efficacy among the surgical groups was variable for both resolution or improvement.7% (95% CI.6%-67.8%).

2%-92.4-50. and pickwickian syndrome were combined as representative of obstructive sleep apnea.Results • Obstructive Sleep Apnea: Diagnoses of sleep apnea. – Evidence for changes in OSA was primarily available for gastric bypass patients: reduced by 33. . sleep-disordered breathing. The percentage of patients in the total population whose obstructive sleep apnea resolved was 85.9 per hour (95% CI.2 per hour). 17.7% (95% CI. 79.2%).

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

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

. • Some conflicting data (in ranking) were reported. 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. CAD.Weakness of Research • Some included studies didn’t report some clinical comorbidities (asthma.

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

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

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

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. .

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Thank You .