Saving Lives With Bariatric Surgery ?

In all of my years of working with patients who have undergone bariatric surgery, the most common regret I got to hear was, “I regret waiting so long before deciding to have it”.

While people who have had surgery often look back on the years of good life lost due to their obesity, the good news is that we now have an increasing body of evidence showing that having bariatric surgery does likely increase your life expectancy, thereby increasing your overall lifespan. 

Case in point is the recent paper by Aristithes Doumouras and colleagues from McMaster University, Hamilton, Ontario, published in the Annals of Internal Medicine, showing that undergoing bariatric surgery is associated with a significant reduction in overall mortality.

In this observational study, the researchers compared outcomes in over 13,000 patients who underwent bariatric surgery in Ontario, Canada (which has a public healthcare system), to over 13,000 non-surgical patients matched for index date, age, sex, BMI, diabetes status, and diabetes duration. 

As is typical for most bariatric patients, more than 80% were female, with a mean age of around 45 years and a baseline BMI of 47. Gastric bypass was the most common procedure (87%) with the rest receiving sleeve gastrectomies.

After a median follow-up of just 4.9 years, the overall mortality rate was 1.4% (n = 197) in the surgery group and 2.5% (n = 340) in the non-surgery group, with a lower adjusted hazard ratio (HR) of overall all-cause mortality (HR, 0.68 [95% CI, 0.57 to 0.81]). 

The risk reduction was even greater in patients aged 55 or older with a lower HR of mortality in the surgery group (HR, 0.53 [CI, 0.41 to 0.69]). 

Much of this reduced mortality risk was attributable to lower cardiovascular mortality (HR, 0.53 [CI, 0.34 to 0.84]) and lower cancer mortality (HR, 0.54 [CI, 0.36 to 0.80]).

Although the nature of observational studies is such that one should be cautious in jumping to conclusions regarding causality, the data do strongly support the notion that bariatric surgery may indeed save lives. 

This is not to say that bariatric surgery is entirely without risk – after all, it is still major surgery, where things can always go wrong. On the other hand, for people living with sever obesity, having bariatric surgery appears to be the less risky option, at least as far as mortality is concerned. 

While these data are both impressive and reassuring, one must keep in mind that bariatric surgery is not a cure for obesity. Rather, it is just one step in the management of a life-long chronic disease. 

Unfortunately, despite being offered in a public healthcare system, like virtually everywhere else, post-surgical follow-up and care in Ontario is haphazard and suboptimal, leaving considerable room for improvement. One could well imagine that improving follow-up care may further increase the long-term benefits of undergoing bariatric surgery. 

Nevertheless, it appears that failure to counsel patients with obesity regarding the potential benefits of undergoing bariatric surgery (with reduced mortality being just one of the benefits), can no longer be considered evidence-based practice.

@DrSharma
Berlin, D