Anyone familiar with the issue, would readily agree that the actual surgery involved in bariatric surgery is only a small (but undeniably important) technical piece in what is a rather complex treatment for a rather complex chronic disease. Clearly, this is not exactly how all bariatric surgeons approach or treat their bariatric patients. Since 2012, the US has a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program that designates bariatric surgery centers as Centres of Excellence if they meet specified requirements in 7 core standards that include case volume, commitment to quality, appropriate use of equipment and instruments, critical care support, continuum of care, data collection, and continuous quality improvement. However, as a recent paper by Andrew Ibrahim and colleagues, published in JAMA Surgery, elaborates, despite these quality criteria, there remains a substantial variability in outcomes across designated Bariatric Centres of Excellence. Based on their retrospective analysis of claims data from 145 527 patients who underwent bariatric procedures, there was a 17-fold variation (ranging from 0.6% to 10.3%) in rates of serious 30-day complications across accredited bariatric centers nationally and up to 9.5-fold variation across individual states. As the authors note, “this finding suggests that participation alone in the Center of Excellence Program did not ensure uniform high-quality care….Given that most bariatric procedures are now performed at accredited centers, wide variation among these centers suggests that accreditation alone does not discriminate enough to guide patients to the best centers for care.” Moreover, they found that poor performing centres were often located close to better performing centres (regression to the mean?). Interestingly, in contrast to what one may suspect, outcomes overall were not related to case volume (perhaps because in order to be a designated Centre of Excellence, all centres needed to have a minimum number of cases per year). Rather, the authors discuss that poorer outcomes may be largely attributable to varying technical skills of the surgeons as well as inconsistent adherence to accepted bariatric care pathways. Finally, the authors argue that there is need to make performance data available to the public, as simply trusting in the “Centre of Excellence” designation by no means guarantees excellent outcomes. As important as these data may be, it is also important to note that this paper only looked at complications within a 30-day time period following surgery. As anyone dealing with bariatric patients is well aware, successful outcomes of bariatric surgery(as well as its… Read More »
Liraglutide Effects on Upper Gastrointestinal Investigations: Implications Prior to Bariatric Surgery
With the considerable waits that patients in Canada often face prior to bariatric surgery, we generally recommend that patients, who have access to them, try anti-obesity medications while waiting. This not only prevents further wait gain, but also often helps them shed a significant amount of weight prior to surgery. The GLP-1 analogue liraglutide is now approved for long-term obesity treatment and is generally well tolerated. Nevertheless, we now present a series of patients in Obesity Surgery, who were treated with liraglutide 3.0 mg whilst waiting for bariatric surgery, and showed significant upper GI dismotility that was reversible on discontinuation of liraglutide. Although, investigations of upper GI motility are by no means part of routine assessment for bariatric surgery, tests may be ordered in patients who present with unclear upper GI symptoms, as the findings may guide the choice of surgical intervention. In this paper, we present six cases in which patients treated with liraglutie 3.0 mg presented with varying degrees of esophageal and/or gastric dysmotility demonstrated using a variety of investigative procedures including formal gastric emptying scintiography as well as less specific esophageal manometry, and upper endoscopy. In all cases normal motility was restored on discontinuation of liraglutide and all patients subsequently underwent or are continuing to wait for bariatric surgery. Based on our observations we discuss that, “Liraglutide is associated with decreased esophageal peristalsis and gastric emptying. These effects can result in abnormal upper GI investigations, leading to delays, increased testing, and questions of patient candidacy for surgery. If patients on liraglutide are noted to have abnormal esophageal manometry or gastric emptying studies, medication should be discontinued, with repeat studies done to look for reversibility. If this abnormal result is due to drug effect, this should not preclude patients from having bariatric surgery.” Just how long liraglutide needs to be stopped prior to performing upper GI investigations remains unclear. Furthermore, as the dysmotility often appears to be symptomless and well-tolerated, we do not recommend routine ordering of motility tests in patients treated with liraglutide. @DrSharms Edmonton, AB Disclaimer: I have served as a consultant and speaker for Novo Nordisk, the makers of liraglutide.
Obesity medicine, which I define as the medical care of someone living with obesity, should approach patients holistically with the aim of improving their overall health and well-being. Advice to lose weight may or may not be part of obesity management – much can be gained for someone living with obesity by promoting their health behaviours, getting them to feel better about themselves, improving their mental health, and helping them better managing their health issues. Much of this can be achieved with no or very little weight loss. Thus, we must consider the question of when weight loss would specifically need to be part of the treatment objectives. In my own practice, I approach this problem by considering the following three questions: Is this a problem unrelated to abnormal or excess body weight? Is this a problem aggravated by abnormal or excess body weight? Is this a problem caused by abnormal or excess body weight? From what I hear from my patients, the most common mistakes in medical practice fall into the first group – trying to address unrelated issues with weight loss recommendations. There are endless stories of patients going to see their health provider with problems clearly unrelated to their body fat (e.g. a broken arm, a sore throat, the flu, depression, migraines, etc.), who simply get told to lose weight. Indeed, there is evidence to suggest that patients with obesity are less likely to undergo diagnostic testing, most likely based on the assumption that their problems are simply related to their excess weight. This is not only where grave medical errors can be made (late or misdiagnosis), but also where the advice to lose weight is clearly wrong. If the presenting problem has nothing to do with excess weight, then no amount of weight loss will fix it. The second category deals with issues that are not causally related to abnormal or excess body fat but where the underlying problem either causes more symptoms or is more difficult to treat because of the patient’s size or fat distribution. There are countless medical problems that fall into this category. For e.g. a heart or respiratory problem entirely unrelated to excess weight (e.g. a valvular defect or asthma) can become worse, cause more symptoms, or be much more difficult to treat simply because of the patient’s size. This group also includes issues like neck or joint pain from a trauma… Read More »
In the same manner in that there is not one predisposing factor for the development of obesity, the phenotypic clinical presentation of obesity is likewise extraordinarily heterogenous. (This has some authors speaking of “obesities” rather than “obesity”). While it is now well established that BMI is a measure of size rather than health, it is perhaps less well recognised how the different types of body fat and their storage in various fat depots and organs can contribute to cardiometabolic disease (location, location, location!). Now, a comprehensive review by Ian Neeland from the University of Texas Southwestern Medical Center, Dallas, together with my colleagues Paul Poirier and JP Despres from Laval University in Quebec, published in Circulation discusses the cardiovascular and metabolic heterogeneity of obesity. As the authors point out, “Although the BMI has been a convenient and simple index to monitor the growth in obesity prevalence at the population level, many metabolic and clinical studies have revealed that obesity, when defined on the basis of the BMI alone, is a remarkably heterogeneous condition. For instance, patients with similar body weight or BMI values have been shown to display markedly different comorbidities and levels of health risk.” Not only has BMI never emerged as a significant component in risk engines such as the Framingham risk score, there are many individuals with obesity who never develop metabolic complications or heart disease during the course of their life. The paper offers a good review of what the author describe as adipose dysfunction or “adiposopathy” = “sick fat”. Thus, in some individuals, there is an accumulation of “unhealthy” fat (particularly visceral and ectopic fat), whereas in others, excess fat predominantly consists of “healthy” fat (predominantly in subcutaneous depots such as the hips and thighs). The authors thus emphasise the importance of measuring fat location with methods ranging from simple anthropometric measures (e.g. waist circumference) to comprehensive imaging techniques (e.g. MRI). The authors also provide a succinct overview of exactly how this “sick fat” contributes to cardiometabolic risk and briefly touches on the behavioural, medical, and surgical management of patients with obesity and elevated cardiometabolic risk. I, for one, was also happy to see the inclusion of the Edmonton Obesity Staging System in their reflections on this complex issue. This paper is certainly suggested reading for anyone interested in the link between obesity and cardiovascular disease. @DrSharma Edmonton, AB
In my experience, patients presenting with obesity tend to fall into three categories, each of which requires a distinct management approach. They are 1) Active Gainers, 2) Weight Stable, and 3) Post-Weight Loss. Active Gainers are patients currently at their lifetime maximum and continuing to gain significant amounts of weight – i.e. more than the usual 0.5 to 1 lb/year. Patients in this category require immediate attention – if nothing happens, their weight will most likely just continue to increase. The good news is that in almost every patient in this category, there is an identifiable reason for the ongoing weight gain – this can be psychosocial (e.g. depression, binge-eating disorder, etc.), due to a medical comorbidity (arthritis, chronic pain, etc.) or medications (e.g. atypical antipsychotics, hypoglycemic agents, etc.). From a management perspective, the sooner we identify and address the underlying problem, the sooner we can slow or even halt the rate of weight gain – in this patient – gaining less weight than before is the first sign of success. There is really no point trying to embark on losing weight as long as the underlying problem driving the weight gain has not been addressed, as this is likely to make sustained weight loss even more unlikely that it already is.. Weight Stable patients are those that present with excess weight but are relatively weight stable. Even though they may be at their lifetime maximum, they have been pretty much the same weight (perhaps a few lbs up or down but nothing drastic) for several years (sometimes even decades). By definition, a patient who is weight stable is in caloric balance, and thus, by definition is not eating too much. In fact, these patients are eating the exact number of calories needed to sustain their bodies, which is why they are weight stable. (Remember, even if you are weight-stable eating 4000 Cal a day, you are technically not “overeating”.) These patients of course have experienced significant weight gain in the past (historical weight gain), but whatever it was that caused them to gain weight is no longer an active problem (e.g. pregnancy, past depression, etc) – and therefore, probably doesn’t need to addressed (although, I always find it of interest to find out what caused the weight gain in the first place). With these patients, we can determine whether or not their weight is affecting their health, and if… Read More »