Why I Support Bariatric Surgery

Let me start this post with a few disclaimers:

1) I am not a surgeon and do not get paid based on whether any of my patients decides for or against surgery.

2) The average BMI of patients seen in our program is 49.7 kg/m2 – the average patient is just below 40 years of age. Most have substantial health problems – many cannot work or perform even simple tasks of daily living because of their weight – most have tried every commercial diet or pill they could lay their hands on – they are all ‘experts’ on weight loss.

3) Many have significant psychosocial problems and mobility issues that may have contributed to their weight gain – these are dealt with by an interdisciplinary team of psychiatrists, psychologists, occupational and physiotherapists, nurses and dietitians – treatments that start months before any patient is considered a candidate for surgery.

4) I do not for once believe that bariatric surgery addresses any of the ‘root causes’ of severe obesity and I am sure that none of my surgical colleagues believe it does. As I often tell my patients, “the surgery is on your gut and not your head”.

5) Our program regularly talks patients, who come to us wanting surgery, out of surgery, if we feel that it is not in their best interest or unlikely to have a successful outcome – to these patients we offer the best non-surgical care we can – but of course, many are disappointed.

And yet, our program regularly performs bariatric surgery and prepares patients for it in a process that can often take 6 months or longer. We proactively discuss surgery with all patients, who meet the criteria for surgery – both the pros and the cons. We offer comprehensive dietary, psychological and medical support to all patients who decide to undergo surgery but make it very clear that surgery is not a ‘cure’ and that patients have to make substantial lifestyle changes in order to be ‘successful’ (we measure ‘success’ in improvement in comorbidities and quality of life – not in pounds lost!).

With these caveats out of the way, I would today like to dispel some common myths about bariatric surgery and discuss why for many patients with severe obesity, it is in fact a very realistic and successful option.

The first common and pervasive misconception relates to risk – both short-term and long-term risk.

Let me begin by paraphrasing the concept of risk according to Seth Godin’s Poke the Box:

“Risk, to some, is a bad thing, because risk brings with it the possibility of failure. It might be only temporary failure, but that doesn’t matter so much if the very thought of it shuts you down. So for some, risk comes to equal failure (take enough risks, and sooner or later, you will fail). Risk is avoided because we’ve been trained to avoid failure. I define anxiety as experiencing failure in advance…and if you have anxiety about initiating a project, then of course you will associate risk with failure.”

So, why do people with cancer opt to expose themselves to sublethal doses of radiation, radical surgery, or deadly chemotoxins? Because they reckon that the risk of these aggressive treatments is probably less than the risk of simply living with their cancer (even if the cancer grows slowly and may never kill them).

In many cases these patients are just ‘buying’ a few months of additional life – much of it spent in hospital or dealing with the often considerable adverse effects of treatment – yet they perceive the ‘risk’ of undergoing treatment to be lower than the ‘risk’ of not being treated – because they are ‘hoping’ for success.

Readers, who find this comparison to cancer seemingly far fetched, may be interested in noting that the reported quality of life of many patients (both kids and adults) with severe obesity is comparable or worse than that of people living with cancer. Add the social stigma of obesity and every day becomes a struggle with zero sympathy from family and friends. And I am not even mentioning the potential health and economic risks of severe obesity.

So what is the risk of being severely obese? Interestingly, for some people not much.

In our program we see a significant, albeit small proportion (~15%) of severely obese individuals, who have no detectable health problems – they feel good about themselves – eat healthy diets – are physically very active – have been weight stable for years – have great jobs and families – all power to them, I say!

But for the other 85% the picture is not all that rosy. Here we see everything from fatty livers, severe sleep apnea, intractable back and joint pain, urinary incontinence, diabetes, lymphedema, and countless other health problems, which get worse with progressive weight gain (stable weights in this population are the rare exception) and so much better with weight loss (although not in every case).

All of these conditions have some very real risk – our own research shows that when obesity (even moderate obesity) is associated (note the use of the word ‘associated’!) with a single comorbidity with clinical signs of end-organ damage (e.g diabetic kidney disease), 20-year life expectancy drops to 50% in absolute terms. And this is in patients receiving all the usual conservative treatments for whatever comorbidity they may have.

A 50% chance of dying in the next 20 years is an annual risk of about 2.5% per year. This means that out of 100 obese patients WITH end-organ damage, statistically speaking, 2.5 will die every year. This is a 1 in 40 risk of death per year or a 1 in 2 risk of death in just 20 years.

Obviously, for someone with obesity, who has a comorbidity (e.g. diabetes) but does not (yet) have end-organ damage (e.g. no kidney damage), the risk of dying is substantially lower – only about 20% over 20 years or about 1 in 100 per year or 1 in 5 over 20 years.

Without any sign of obesity-related comorbidity (irrespective of BMI), the risk of dying is less than 5% over 20 years – only about 1 in 400 per year or 1 in 20 over 20 years.

So, if risk of dying was your only criteria for deciding for or against surgery, you would need to first understand the risk of not having surgery. As explained above, this risk is very much dependent on whether or not there are any comorbid health problems – the more existing health problems and the more severe these are, the greater the risk of simply sticking with what you are doing and hoping for the best.

This makes all the difference when considering the risks of surgery – both in the short and long term – because any discussion about the risk of surgery is meaningless without first fully understanding the risk of not having surgery.

As previously blogged, a recent analysis of over 15,000 cases of laparoscopic bariatric surgery found a mortality risk of less than 0.04% of laparoscopic adjustable gastric band, 0.0% sleeve gastrectomy, and 0.14% of the gastric bypass patients.

Even if we assume the worst and say that surgical mortality risk is as high as 0.2% – this translates to a risk of 1 death in 500 patients undergoing surgery – a risk of 0.1% would be 1 in 1,000 – a risk of 0.05% would be 1 in 2,000.

Compare this to the annual risk of not having surgery in an obese patient with end-organ damage of 1 in 40 and that of an uncomplicated obese patient of 1 in 400.

So if risk of death is all that you care to consider, let us be clear that an obese patient with end-organ damage is over 10 times more likely to die within one year without surgery than from having surgery.

In contrast, an uncomplicated obese patient is just about as likely to die within one year without surgery as from surgery!

Thus, amazing as it may seem to some readers (given all the talk about the apparent ‘riskiness’ of bariatric surgery), the risk of not having surgery actually substantially exceeds the short-term risk of having surgery in patients with comorbidities and end-organ damage and may even have a slightly favourable risk in uncomplicated patients – this, perhaps goes to show just how safe modern bariatric surgery has actually become.

But of course, the risks of bariatric surgery are not limited to simply the actual risk of surgery – there is no doubt that even after recovering from the surgery itself, there may well be an increased risk of nutritional, psychological, and other complications that may result from having had surgery.

But one can make very similar calculations as I have made for mortailty, and in every case, the risk (even the long-term risks) of surgery come nowhere close to the risks of not having surgery (just take a minute to compare the very real risks of hypoglycemic shock from insulin treatment or falling asleep at the wheel due to sleep apnea to the risk of having to have annual blood tests and taking daily protein or vitamin supplements).

Of course, any discussion of risk is meaningless without also discussing the possible benefits – after all, no one wants to have surgery simply because it is relatively safe unless it also provides some very real benefits (or at least has a statistically substantial chance of delivering such benefits).

So tomorrow, we will look at the data on the benefits of surgery compared to ‘conventional’ treatments – without which, even the safest bariatric surgery would be useless.

For today, let me leave you with this advice from Harvard Business Review:

“Every important decision inevitably involves a trade-off. Knowing what you can’t pursue is as valuable as articulating what you will. But how do you know which trade-offs are acceptable and which are losing propositions? Here are three ways to help make the distinction:

– Get input on pros and cons. List advantages and disadvantages and ask others for their perspective on which carries the heaviest weight [sic].

– Balance short term with long term. Determine what you’d be willing to give up in the long run for some important short-term gain — and vice versa.

– Gauge support. While weighing alternatives, think about who will support a particular idea and who will oppose it. Ask whose support you can live without, and whose backing and buy-in you absolutely need.

Edmonton, Alberta

Disclosures: I have received consulting and speaking honoraria from makers of surgical devices used for bariatric surgery