As obesity and type 2 diabetes have reached epidemic levels in Asia, we have gradually realized that the western diagnostic criterion for obesity and metabolic syndrome do not hold true for the Asian population. Asians tend to develop diabetes with a lesser degree of obesity at younger ages, suffer longer with complications of diabetes and hence die sooner than people in other regions. The first Asian consensus meeting was organized to review the scientific data relevant to specific geographical populations. The existing guidelines for bariatric surgery in the Asian population were reviewed with the goals:

1. To set culturally, geographically, and genetically relevant standards for the management of obesity and metabolic syndrome.
2. To identify the usefulness of BMI as a principal criteria for identification of obesity in the Asian population.
3. To identify waist circumference or waist–hip ratio as additional criteria for defining obesity in the Asian population.
4. To set parameters to identify visceral or central obesity versus truncal obesity.
5. To develop recommendations for development of ethical clinical studies for antidiabetes surgery.

Following a series of presentations by eminent speakers, the members voted for a renewed set of guidelines and recommendations defining the BMI criterion in the Asian population.

Guidelines:

1. Bariatric/gastrointestinal metabolic surgery should be considered as a treatment option for obesity in people with Asian ethnicity with BMI more than 35 kg/m2 with or without comorbidities.
2. Bariatric/gastrointestinal metabolic surgery should be considered as a treatment option for obesity in people with Asian ethnicity above a BMI of 32 kg/m2 with comorbidities.
3. 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) along with at least two of the additional criteria for metabolic syndrome: raised triglycerides, reduced HDL cholesterol levels, high blood pressure and raised fasting plasma glucose levels.
4. 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 these surgeries should be considered as yet purely experimental only as part of research projects with prior approval of the ethics committee.

The consensus statement was published in the Obesity Surgery Journal.
Please find the link below:
http://www.bmihk.info/download/Consensus.pdf

Metabolic surgery is an ever evolving field. The advent of Sleeve Gastrectomy has led to a lot of enthusiasm within the surgical community.

Its popularity can be attributed to favourable early results. Hence surgeons from across the world are now offering it to an increasing number of patients. The benefits of sleeve gastrectomy seem to far outweigh its risks. It is a technically easier procedure with a lower learning curve. There are less chances of developing nutritional deficiencies and the stomach is always accessible for examination. Asian studies have already suggested better results in terms of weight loss and resolution of co-morbidities after a sleeve gastrectomy.
There exists an immense amount of data on the subject; however the cause for concern is that most of it is unorganized. Each surgeon has an individual series of a few hundred patients, the data on these patients is unconsolidated.

The aims of the second ACOMOMS summit were to collate the data on Asian patients and

1. Redefining indications for Sleeve Gastrectomy for Asians
2. Evaluation and standardization of techniques
3. Evaluation of results- EWL, resolution of comorbidities
4. Assessment of complications
5. Assessment of newer developments- Gastric imbrication, SILS, NOTES, Endobarrier Sleeve
6. Setting up of training modules

A total of 1,464 cases were reported by surgeons from all across Asia and Middle East. The data revealed that the weight loss results after sleeve gastrectomy were similar to roux en y gastric bypass at the end of 2 years. Resolution of comorbidities such as type 2  diabetes and hypertension was 88% and 93% respectively. The total complication rate including GERD was 3.21%.
Consensus Summary:

1. LSG is a SAFE and EFFECTIVE bariatric procedure
2. LSG is an acceptable PRIMARY bariatric procedure in most cases without comorbidities
3. BOUGIE size   32-36   &  4-6 cm antral  preservation must be done
4. LSG is the procedure of choice for BMI ≥ 60 & age ≥ 65 and adolescents
5. In Type 2 Diabetics LSG has shown results comparable to RYGB at 1 year
6. Severe GERD may be a contraindication
7. SILS is here to stay

Link to CODS publications on sleeve gastrectomy:
http://www.ncbi.nlm.nih.gov/pubmed/19802646
http://www.ncbi.nlm.nih.gov/pubmed/21789509

Revisional surgeries pose the biggest challenge to any bariatric surgeon. It is a test of not only one’s surgical skills but also a test of confidence and integrity. To say the least, the exultation felt by a surgeon after a revisional surgery cannot be compared. The third ACMOMS was centered around revisional bariatric surgeries.

The goals of this meeting were to discuss the indications for revisional surgeries as well as understand the mechanisms for failure of various bariatric procedures. The technical challenges of performing these difficult surgeries were addressed alongwith management of complications.

Ten Asian countries and 26 surgeons contributed a total data of 6,600 bariatric cases. Total number of revisional surgery cases reported was 214. Failure to lose more weight was the most common reason for revisional surgery and gastric band was the most commonly revised procedure.

 

Link to CODS publication on Revisional Surgery:
http://onlinelibrary.wiley.com/doi/10.1111/j.1758-5910.2010.00062.x/abstract;jsessionid=CFDD2E1E3D5B82FDA02377B13C1B617A.d01t03?userIsAuthenticated

Bariatrics is an imperfect science. Few occupations require near perfection of their practitioners as does bariatric surgery. In the life of every bariatric surgeon there comes a time when science is ambiguous, information is limited, stakes are high and yet the decision needs to be made.  The law of averages always manages to catch up with surgeons and all of us face ‘surgical complications’ at some or the other point in our careers. The real caliber of a surgeon is tested when he/she rises up to the moment with complete honesty and provides the best possible care to the patients.

The 4th Asian Consensus meeting was on Complications in Bariatric Surgery. It was a 2 day convention. The highlights of this meeting were:

1. Etiology of complications in bariatric surgery.
2. How can we avoid complications?
3. Management of complications after bariatric surgery.
4. Technical pearls from experts on prevention of complications
5. The ICE Capsule- How to become an International Center for Excellence?

This was a path breaking summit where the first ever Bariatric Nutrition Master Class was organized in India. It was very well received by the aspiring bariatric nutritionists and has become an integral part of the ACMOMS summits from now on.

The first Asian Metabolic Surgery Task Force Meeting (ACMOMS 5) was held on 6th and 7th of July 2012 at Fortis Memorial Research Institute in Gurgaon. This was the first time in India that experts from endocrinology, diabetology, research and epidemiology gathered together to brainstorm on the pros and cons of bariatric surgery. The meeting had representation from WHO, IDF, DASG and RSSDI. It was endorsed by multiple societies like AETF (Asia Endosurgery Task Force), IFSO APC (International Federation for the Surgery of Obesity and Metabolic Disorders- Asia Pacific Chapters), APBSS (Asia Pacific Bariatric and Metabolic Surgery Society), IEF (International Excellence Federation), ESLES (Emirates Society of Laparoendoscopic Surgeons), IAGES (Indian Association of Gastrointestinal Endosurgeons), AMASI (Association of Minimal Access Surgeons of India, OMSSS (Obesity and Metabolic Surgery Society of Singapore), TSMBS (Thai Society for Metabolic and Bariatric Surgery, TSMBS (Taiwan Society for Metabolic and Bariatric Surgery.

The meeting was chaired by Dr. Muffazal Lakdawala and Dr. V. Mohan. The idea was to bring forth the current concepts in worldwide research in metabolic surgery and to dispel the myths associated with it.

After two days of deliberations, didactic lectures, debates and symposia the following guidelines were proposed:

Criteria for metabolic surgery

1. Type two diabetic patients with a BMI between 35 to 40 are eligible for surgery and must be prioritized for surgery. (BMI points may be dropped by 2.5 for Asian patients)
2. Type two diabetic patients with a BMI between 30 to 35 are eligible for surgery conditionally. (BMI points may be dropped by 2.5 for Asian patients)
3. Type two diabetic patients less than a BMI of 30 must be offered surgery only under experimental protocol. (BMI points may be dropped by 2.5 for Asian patients)

The other recommendations were:

1. Metabolic surgery team must be a multidisciplinary team that includes a bariatric surgeon, bariatric nutritionist, endocrinologist/diabetologist/ bariatric physician, bariatric anesthetist and a psychologist.
2. Patients who undergo surgery need a lifelong follow up and surveillance by the diabetologist/endocrinologist/bariatric physician and a nutritionist
3. High risk bariatric procedures must be performed only at high volume centres performing more than hundred procedures in a year.
4. Any patient with a BMI < 30 (BMI points may be dropped by 2.5 for Asian patients) must be operated only as part of a research study approved by the IRB.

Proposal for a prospective trial:

Prospective trial comparing the results of surgery with medical management to see the effects on micro and macro vascular complications of diabetes in these patients