As an internist, it continues to be difficult to accept that the most effective treatment for severe obesity today is surgery (even if there remains an important role for internists to play in manageing these patients).
Nevertheless, for anyone, who remains skeptical despite the rapidly accumulating data on the safety, success and cost-effectiveness of obesity surgery, I would like to refer you to the latest systematic review on this subject, just published in Health Technology Assessment.
The report was commissioned by the UK Health Technology Assessment (HTA) programme, part of the National Institute for Health Research (NIHR), which directly influences decision-making bodies such as the National Institute for Health and Clinical Excellence (NICE) and the National Screening Committee (NSC).
For this report Joanna Picot and colleagues from the University of Southampton, UK, identified a total of 5386 references of which 26 were included in the clinical effectiveness review: three randomised controlled trials (RCTs) and three cohort studies compared surgery with non-surgical interventions and 20 RCTs compared different surgical procedures.
Bariatric surgery was consistently more effective for weight loss than non-surgical options. In one large cohort study weight loss was still apparent 10 years after surgery, whereas patients receiving conventional treatment had gained weight. Some measures of QoL improved after surgery, but not others. After surgery statistically fewer people had metabolic syndrome and there was higher remission of Type 2 diabetes than in non-surgical groups. In one large cohort study the incidence of three out of six comorbidities assessed 10 years after surgery was significantly reduced compared with conventional therapy.
Gastric bypass (GBP) was more effective for weight loss than vertical banded gastroplasty (VBG) and adjustable gastric banding (AGB). Laparoscopic isolated sleeve gastrectomy (LISG) was more effective than AGB in one study.
Comorbidities after surgery improved in all groups, but with no significant differences between different surgical interventions.
Mortality ranged from none to 10%. Major adverse events following surgery, some necessitating reoperation, included anastomosis leakage, pneumonia, pulmonary embolism, band slippage and band erosion.
Based on an economic model developed by the authors, surgical management was more costly than non-surgical management, but resulted in improved outcomes.
For morbid obesity, incremental cost-effectiveness ratios (ICERs) (base case) ranged between 2000 pounds and 4000 pounds per Quality-Adjusted Life Year (QALY) gained and remained within the range regarded as cost-effective from an NHS decision-making perspective even when assumptions for deterministic sensitivity analysis were changed.
The report concludes that bariatric surgery appears to be a clinically effective and cost-effective intervention for moderately to severely obese people compared with non-surgical interventions.
Nevertheless, uncertainties remain regarding several important aspects including impact on patient quality of life, impact of surgeon experience on outcome, late complications leading to reoperation, duration of comorbidity remission, and resource utilisation.
Patients struggling with severe obesity can only hope that the responsible decision makers will take this report into account as they hopefully rapidly ramp up access to this much-needed management option.