How Safe is Bariatric Surgery?

In light of the global obesity epidemic, several 100,000s of bariatric operations are currently being performed worldwide each year – indeed, bariatric surgery is by several orders of magnitude the fastest growing field of surgery around the world.

I have previously blogged about the manifold and significant benefits and health cost savings to be derived from successful surgery, benefits that seek their rivals in much of other types of surgery (e.g. a 60% reduction in all cancers or a 90% reduction in diabetes complications!). But surgery is surgery and severely obese patients are often not the healthiest to begin with – so how risky is surgery, at least in a best case scenario (high volume centres of excellence in the US)?

This question was addressed in a paper published in this week’s issue of the New England Journal of Medicine by David Flum and colleagues on behalf of the US Longitudinal Assessment of Bariatric Surgery (LABS) Consortium.

This prospective, multicenter, observational study describes the 30-day outcomes in consecutive patients undergoing first-time bariatric surgical procedures at 10 clinical sites in the United States from 2005 through 2007.

Of the 4776 patients who had a first-time bariatric procedure (mean age, 44.5 years; 21.1% men; mean BMI 46.5) 3412 patients received a Roux-en-Y gastric bypass while 1198 patients underwent laparoscopic adjustable gastric banding (166 patients underwent other procedures and were not included in the analysis).

The 30-day rate of death for all patients was 0.3%; a total of 4.3% of patients had at least one major adverse outcome.

Risk was highest for patients with a history of deep-vein thrombosis or pulmonary embolus, a diagnosis of obstructive sleep apnea, impaired functional status and extremely high BMIs.

Thus, at least the short-term perioperative risk of bariatric surgery is not higher than the risk of other types of major surgery in severely obese patients. While there were significant differences in the complication and death rates between bypass and banding (risk was lower in banding patients), early outcomes are only one (and perhaps not even the most important) criterium for comparing the outcomes of different types of bariatric surgery.

In an accompanying editorial, Malcolm Robinson correctly notes that,

“all the bariatric surgeons in this study were “LABS-certified” as being highly skilled. The operations were performed in high-volume bariatric centers. Hence, the LAB data may represent a best-case scenario that may not be widely reproducible. However, as the number of bariatric surgeries has increased, so has the quality. This has been due in part to the establishment of bariatric-surgery fellowships and the publication of evidence-based standards for bariatric care.”

That said, it is also important to remember that while important, the quality of the surgery itself represents only a small technical step in the complex management of a chronic illness that often requires ongoing multidisciplinary preparation and follow-up.

As blogged before – obesity surgery is about more than just surgery.

AMS
Edmonton, Alberta