According to some reports, bariatric surgery is now the second most common abdominal surgical procedure performed in the US.

However, despite the well-documented beneficial outcomes, critics continue to question the safety of this treatment option for severe obesity. There is also oft-cited concern about the quality of treatment provided across centres.

These questions were now addressed in a study by Nancy Birkmeyer and colleagues on behalf of the Michigan Bariatric Surgery Collaborative, published in a recent issue of JAMA.

The study looks at complications occurring within 30 days of surgery across 25 hospitals and 62 surgeons statewide, in 15,275 Michigan patients undergoing common bariatric procedures between 2006 and 2009.

Overall, 7.3% of patients experienced perioperative complications, most of which were wound problems and other minor complications.

Serious complications were most common after gastric bypass (3.6%), followed by sleeve gastrectomy (2.2%), and laparoscopic adjustable gastric band (0.9%) procedures.

Mortality occurred in 0.04% of laparoscopic adjustable gastric band, 0 sleeve gastrectomy, and 0.14% of the gastric bypass patients.

After adjustment for patient characteristics and procedure mix, rates of serious complications varied from 1.6% to 3.5% across hospitals.

Average annual procedure volume was inversely associated with rates of serious complications at both the hospital level (< 150 cases, 4.1%; 150-299 cases, 2.7%; and > 300 cases, 2.3%) and surgeon level (< 100 cases, 3.8%; 100-249 cases, 2.4%; > 250 cases, 1.9%).

Adjusted rates of serious complications were similar in accredited Centres of Excellence (COE) and non-COE hospitals.

The study makes three important points:

1) The overall early complication rates of bariatric surgery are surprisingly low.

2) Both centre and surgeon volume are important determinants of risk.

3) COE accreditation does not appear to be relevant for short-term outcomes.

While this study only addresses the safety and not the long-term efficacy of bariatric surgery, it should at least allay any concerns about the surgical risks of these procedures.

With the accumulating evidence on the positive long-term outcomes of surgery (e.g. the recent blog post on surgical remission of type 2 diabetes), it is very likely that we will continue seeing exponential increases in bariatric surgery numbers in many countries and jurisdictions around the world.

Indeed, individuals who remain opposed to expanding the provision of bariatric surgery to severely obese patients citing safety concerns, should ask themselves whether their objections to expansion of this useful and effective treatment is ideological and a reflection of anti-weight bias and discrimination rather than based on a sound understanding of the available data.

AMS
Edmonton, Alberta

You can now also follow me and post your comments on Facebook

Birkmeyer NJ, Dimick JB, Share D, Hawasli A, English WJ, Genaw J, Finks JF, Carlin AM, Birkmeyer JD, & Michigan Bariatric Surgery Collaborative (2010). Hospital complication rates with bariatric surgery in Michigan. JAMA : the journal of the American Medical Association, 304 (4), 435-42 PMID: 20664044

For patients with obesity and type 2 diabetes, bariatric surgery is by far the most effective treatment - it is, indeed, the only form of treatment that can put patients into full long-term remission.

But is surgery really a cost-effective option for health systems looking to contain the immense economic and health burden of diabetes?

A paper by Martin Makary and colleagues from Johns Hopkins University, Baltimore, just published in the Archives of Surgery, looks at the annual health care costs in patients with type 2 diabetes before and after bariatric surgery.

The researchers examined administrative claims data from 2235 adults with type 2 diabetes who underwent bariatric surgery in the US during from January 1, 2002, through December 31, 2005.

Surgery eliminated the use of anti-diabetes medication therapy in 75%, 81%, and 85% of patients at 6 months, 1 and 2 years, respectively.

Although the median cost of the surgical procedure and hospitalization was abut $30,000, in the 3 years following surgery, total annual health care costs, which increased by about 10% in the first year after surgery, decreased by around 35% in year 2 and by over 70% in year 3 compared to costs before surery.

As the authors point out, “Because weight loss following bariatric surgery has been observed to be sustained for decades, we believe that the protective effect against complications of diabetes is also likely to be long-term.”

This study of administrative data also supports the remarkable safety of bariatric surgery, which in this populations had an in-hospital mortality rate of only 0.3%.

The authors do not fail to point out the tremendous public health implications of these findings,

“Most concerning are the deferred health consequences and costs associated with obesity, auguring the presentation of complications decades into the future. Current trends in rates of obesity and diabetes threaten to overwhelm the already strained health care resources in many countries. Thus the obesity epidemic has created a deferred influx of demand for diabetes-related health care services not yet realized. Until a successful non-surgical means for preventing and reversing obesity is developed, bariatric surgery appears to be the only intervention that can result in a sustained reversal of both obesity and type 2 diabetes mellitus in most patients receiving it.”

An important limitation of the study is that it does not consider the long-term costs of diabetes complications like heart disease, renal failure, and amputations, that are likely to be prevented or at least substantially deferred as a result of surgery.

The report also does not consider the substantial additional savings that could incur from the prevention of obstetric and gynecological complications, such as gestational diabetes and poor fetal outcomes.

In addition, the weight loss experienced may prevent, stabilize, or improve other obesity-related conditions, such as urinary incontinence and osteoarthritis.

Bariatric surgery may also decrease complications after other surgical procedures (ie, orthopedic procedures).

Finally, there is also good evidence to support the notion that obesity surgery prevents cancers.

In light of these finding the authors conclude, “Health insurers, private and public, should pay for bariatric surgery for appropriate candidates, recognizing a potential annualized cost savings in addition to the benefit to health.”

Exactly how health service systems can rapidly increase availability of bariatric surgery for eligible patient (with all the necessary pre- and post-surgical management resources) remains to be seen.

However, any health care system that fails to look at this issue now, is likely to go under in the wake of the tremendous obesity costs that are poised to overrun all other health care costs in the foreseeable future.

AMS
Toronto, ON

You can now also follow me and post your comments on Facebook

Makary MA, Clarke JM, Shore AD, Magnuson TH, Richards T, Bass EB, Dominici F, Weiner JP, Wu AW, & Segal JB (2010). Medication utilization and annual health care costs in patients with type 2 diabetes mellitus before and after bariatric surgery. Archives of surgery (Chicago, Ill. : 1960), 145 (8), 726-31 PMID: 20713923

Prof. Edward Shang

As the demand for bariatric surgery increases across Europe, there is increased recognition that this rapidly evolving field of medical care will require the same expertise, training, research and resources as other fields of medicine.

It was therefore only a matter of time before a leading German university would announce the appointment of a Full Professor and Chair for Bariatric Surgery.

This credit now goes to the University of Leipzig, which yesterday announced the formal appointment of Dr. Edward Shang, as the first Full Professor for Bariatric Surgery. The position is a cornerstone of the newly funded Integrated Research and Treatment Centre for Obesity, funded by the German Federal Ministry for Education and Research.

As blogged before, the University of Leipzig is now well poised to take the lead in obesity research and management for Germany, a clear first in the rather conservative German academic landscape.

Shang will head the new Division for Obesity Surgery in the Department of Visceral, Transplantation, Thorax and Vascular Surgery, which will deliver comprehensive multi-disciplinary care for patients with severe obesity.

Shang’s expertise in modern minimally invasive surgery, including natural orifice surgery (NOTES), which includes performing complex bariatric surgery without having to cut open the patient, will offer a wide range of opportunities for cutting-edge (no pun intended) research in this rapidly evolving field.

As a member of the Scientific Advisory Board to this German Centre of Excellence, i congratulate Dr. Shang on this distinction and very much look forward to meeting him on my next trip to Leipzig.

AMS
Lincolnshire, IL

Click here to follow me and post your comments on my FaceBook page

For most patients with severe obesity, the decision to undergo bariatric surgery is one of the most important decisions they will make in their lifetime.

But once they have decided to go down this route, several important issues need to be considered, not least the choice of operation.

Apart from the surgical risk (complications at the time of surgery), patients are of course interested in how much weight they will lose. Many patients also consider the long-term outcomes (will the weight stay off?).

Interestingly, however, few patients appear well aware that if the surgery does not work, their only option may be to have another operation performed (often another type of surgery).

As of course very few patients want to have more than one operation, the question of whether or not a given operation is indeed a “definitive” procedure, that will last them a lifetime, is of considerable significance.

And this is where there are indeed important differences between the various types of bariatric surgery.

For e.g., in a paper from our group just published in OBESITY SURGERY, we review the literature on the laparoscopic sleeve gastrectomy (LSG) and note, based on a systematic review of 15 studies (940 patients), that despite sustained weight loss up to 3 years, it is presently not clear if weight loss following LSG is sustainable in the long term. We conclude that it is, therefore, not possible to determine what percent of patients may require further revisional surgery following LSG (e.g. conversion to gastric bypass).

Similarly, a paper just published in the same issue of OBESITY SURGERY by Monika Lanthaler and colleagues from Innsbruck, Austria, suggests that a significant proportion of patients undergoing laparoscopic adjustable gastric banding (LABG) may need reoperation.

In their experience with 276 patients, who underwent LABG a minimum of 9 years ago, despite good initial weight loss, 146 (52.9%) patients had at least one complication requiring reoperation.

Presently, only 148 (53.6%) patients still have their original band, 49 (17.8%) had their original band replaced with a new one, and 79 (28.6%) had their band removed. A Roux-en-Y gastric bypass was eventually done in 39 patients, and 6 patients underwent sleeve gastrectomy.

What makes this study important is the fact that the investigators managed to collect outcomes on 80% of their study population. Most surgical centres lose track of their patients and frankly have no idea what proportion of patients they operate on experience weight regain, have long-term complications, and/or end up having revisional operations.

I wonder how many patients would opt for a procedure, which although safe and relatively simple, is also associated with a 1 in 3 chance of requiring a reoperation?

Health professionals likely need to tell their patients that certain procedures may be less “definitive” than others - something that certainly must be considered in the overall risk (and cost) of any given procedure.

AMS
Duchesnay, Quebec

You can now also follow me and post your comments on Facebook

Shi X, Karmali S, Sharma AM, & Birch DW (2010). A review of laparoscopic sleeve gastrectomy for morbid obesity. Obesity surgery, 20 (8), 1171-7 PMID: 20379795

Lanthaler M, Aigner F, Kinzl J, Sieb M, Cakar-Beck F, & Nehoda H (2010). Long-term results and complications following adjustable gastric banding. Obesity surgery, 20 (8), 1078-85 PMID: 20496124

The key to long-term success with bariatric surgery is certainly life-long dietary modification.

While most guidelines focus on the immediate needs of patients undergoing bariatric surgery, long term nutrition continues to be an important issue, even in weight-stable patients.

As people with bariatric surgery tend to eat far fewer calories than before and (depending on the type of surgery) may be more prone to certain deficiencies, a “balanced” diet for them will look very different from that recommended for the general population.

This issue is now addressed in a paper by Violeta Moize from the University of Barcelona, Spain, just published in OBESITY SURGERY.

Based on the current knowledge of dietary strategies and behaviors associated with beneficial long-term nutritional outcomes in post-bariatric surgery patients, the researchers have developed a “bariatric food pyramid”, that can be used as a teaching tool and reminder to patients.

Given the nature of the operation and the physiological demands of this very special patient population, it is not surprising that there is a strong focus on high-quality protein, balanced with nutrient-dense complex carbohydrates and healthy sources of essential fatty acids.

Hopefully this tool will help both therapists and patients better understand nutrition recommendations for a healthy long-term post-op diet.

AMS
Station Touristique Duchesnay, Quebec

You can now also follow me and post your comments on Facebook

Moizé VL, Pi-Sunyer X, Mochari H, & Vidal J (2010). Nutritional Pyramid for Post-gastric Bypass Patients. Obesity surgery, 20 (8), 1133-41 PMID: 20401543