Benchmarking Best Practices in Weight Loss Surgery

Weight loss surgery (WLS) has had a tumultuous history. The initial operations performed 5 decades ago had questionable weight loss, carried unacceptably high risks, and had unknown long-term health benefits [1]. For many years, WLS was the option of last resort and only for the most extremely debilitated patients. But things have changed, and dramatically so. Unbridled growth in severe obesity has been matched by advances in surgical techniques and technologies available for its treatment. Soon it may not be unreasonable to consider WLS as the first line treatment for obesity and weight-related comorbidities like diabetes and sleep apnea. Indeed WLS offers much more than significant and sustained weight loss. Recent studies demonstrate its ability to cure diabetes [2], to improve outcomes from cardiovascular disease (CVD) in a large, matched cohort of patients [3], and to reduce the risk of death by approximately 35% over time [4,5]. Findings from the Longitudinal Assessment of Bariatric Surgery I (LABS-1) trial, a prospective, multicenter observational study in 4776 WLS patients, reported a 30-day overall death rate of 0.3%, with serious complications in 4.1% of patients—figures similar to those seen in other major operations [1,6–9] (Fig 1). Between 1998 and 2004, the number of weight loss procedures performed in the United States soared by 800% to 121,500 [10]. That number reached 171,000 in 2005 [1]. Despite this exponential growth, WLS still has the perception of being a risky procedure among the general public, insurance companies, and even other health care providers. The sheer number of cases performed annually has raised concerns among third party payers and government agencies about provider qualifications and patient safety. For its part, the obesity health care providers have gone through great lengths to ensure that the quality of WLS has kept pace with quantity. Fellowships devoted solely to bariatric surgery have been established [1], and more importantly, evidence-based standards for the care of WLS patients have been published [11]. Fig 1 Mortality after bariatric and other surgery after age 65. AAA, abdominal aortic aneurysm; CABG, coronary artery bypass grafting. (Reprinted with permission from Flum et al [84]. Adapted with permission from original in Goodney PP, Siewers AE, Stukel TA, ... The first such report came in the wake of a massive chemotherapy overdose that killed Boston Globe journalist Betsy Lehman [12] and led to the subsequent creation of the Betsy Lehman Center for Patient Safety and Medical Error Reduction (Lehman Center). This organization’s mission is to improve patient safety by developing evidence-based, best practice standards of care. In 2004, the Lehman Center and the Massachusetts Department of Public Health convened an Expert Panel [13] to assess weight loss procedures, identify issues related to patient safety, and develop evidence-based best practice recommendations. The Panel worked with more than 100 specialists in 9 separate task groups to examine every facet of care—from psychological evaluation and anesthetic perioperative procedures to multidisciplinary treatment and data collection (Table 1). Table 1 Task groups of the Lehman Center Report [13,14] The resulting document, published as a supplement to Obesity in 2005 [13], set the standard for WLS across the state and well beyond it. The Agency for Healthcare Research and Quality (AHRQ) abstracted the report for broad use and the American College of Surgeons (ACS) used it as the blueprint for its Bariatric Surgery Network Center accreditation program. Its recommendations influenced health care policy and medical practice in the United States and abroad [14]. Much has happened since 2005, including rapid growth in the literature, development of new procedures, shifting patient demographics, shorter lengths of hospital stay, and widespread use of laparoscopy. To address the impact of these changes on patient safety, the Lehman Center reconvened the Expert Panel in 2007 to update the earlier systematic literature review and evidence-based recommendations. The new report, published in Obesity 2009 [15], is even more comprehensive than the first. It covers every practice area in the original publication as well as 2 new topics: endoscopic interventions and policy and access. Recommendations were developed using an established evidence-based model. This approach was used to optimize patient safety in a high-risk specialty that continues to grow at a breakneck pace, fueled, in part, by the high failure rate of alternative therapies (eg, improved nutrition, behavior modification, increased exercise, and medications) [9,16]. In 2006, the number of weight loss procedures performed in the United States topped 200,000 [17]; in 2008, that figure reached an estimated 220,000 [18,19]. Weight loss operations will continue to grow at an accelerating pace as evidence on their safety and efficacy mounts and more insurers provide coverage [20]. Today, there are approximately 15 million people in the United States with a body mass index (BMI) greater than 40 kg/m2, but only 1% of the clinically eligible population receives surgical treatment for their obesity [18]. This situation is not limited to the United States. The World Health Organization (WHO) estimates that more than 400 million adults currently have class I obesity (BMI >30). By the year 2015, that number is expected to reach an estimated 700 million [21]. Without intervention, only 1 in 7 obese patients will reach their full life expectancy [22,23]. Bariatric surgery has taken on many forms since the first operations in the 1950s. Five decades later, no single “best” operation has emerged from the available options. But a lot of effort has been placed on determining the best way to treat obesity and to avoid the complications of WLS. Care starts with a multidisciplinary approach to surgical weight loss and ends with life-long follow-up for those who undergo WLS.