Bariatric surgery – not to be taken lightly
Authors: Shahrad Taheri, Harish Kumar, Sue Bridgwater, Anthony Barnett
Journal: Journal of the Royal Society of Medicine (2009)

We are currently facing an obesity epidemic: by 2010, 75% of men and 58% of women in England could be classified as overweight or obese.1 While preventive measures are desperately needed, a significant number of individuals will require specific treatment for obesity and its complications including diabetes, dyslipidaemia, hypertension, cardiovascular disease, fatty liver, arthritis, obstructive sleep apnoea, various cancers and psychological morbidity. In practice, lifestyle and pharmacological management of obesity has been minimally successful.

Bariatric (baros = weight, iatrikos = art of healing) surgery for extreme obesity is highly effective in reducing body weight and reversing co-morbidities. A meta-analysis of 22,094 patients revealed significant weight loss with bariatric surgery and resolution of diabetes in 76.8%, dyslipidaemia in 70% and hypertension in 61.7% of patients.2 Weight loss after surgery is more likely to be maintained in the long term. Importantly, recent data show a mortality reduction with weight loss after surgery.3

Bariatric surgery is a cost-effective approach that should be available to motivated patients who fulfil recommended criteria. The operative safety of bariatric surgery has improved with new technology and greater use of laparoscopic techniques. The National Institute of Health and Clinical Excellence (NICE) has recognized bariatric surgery's role and has provided guidance for patient selection for surgery.4 Previously, surgery was recommended for adults with BMI of 40kg/m2 or more, or 35kg/m2 with co-morbidities. NICE now also recommends surgery as a first-line option (instead of lifestyle interventions or drug treatment) for adults with BMI ≥50kg/m2 in whom surgery is considered appropriate.4

While it is important for bariatric surgery to be offered more widely,5attention needs to be paid to its conduct to ensure its success and development in the UK. Despite appropriateness of surgery for the right patient at the right time, there are worrying trends in both private and NHS sectors. Apart from bariatric operations being offered privately to some patients not fulfilling accepted criteria, increasingly, surgery is offered to patients abroad without appropriate patient selection and/or postoperative support. We are increasingly seeing patients who have received operations privately but have developed complications or have not been provided with the appropriate support and follow-up. Laparoscopic gastric banding is technically less challenging than other bariatric operations; unfortunately, this has resulted in some surgeons ‘dabbling’ in this operation without expertise in weight management. Within the NHS, patients may receive a bariatric operation based on general NICE guidance above, without attention to detail. NICE and other international guidance is very clear regarding the need for a multiprofessional approach, appropriate patient selection and long-term follow-up. This equally applies to patients who have BMI ≥50kg/m2;4 it is unethical to offer surgery to these patients without adequate prior multiprofessional assessment and support.

Successful bariatric surgery requires rigorous patient selection, support and follow-up with procedures being carried out at high-volume centres. These centres have significantly lower in-hospital deaths than low-volume centres and have benefits beyond the surgeon's skill or the annual number of operations carried out.6 Their success revolves around an expert multiprofessional team approach and well-developed cost-effective pathways which optimize patient safety; this has been recognized through several international guidelines.7 High-volume, multiprofessional centres are particularly needed for patients with malabsorptive operations such as gastric bypass and bilio-pancreatic diversion. These patients can suffer from serious, sometimes life-threatening, nutritional deficiencies needing lifelong support and follow-up.

The implementation of NICE guidance across the UK has been varied.8 Also, there are several continuing trends within the NHS that are worrying. First, there is the danger of proliferation of small units that do not have the appropriate expertise or infrastructure to provide the best care. Second, laparoscopic gastric banding is offered as the only operation in some centres where other operations are more appropriate; there is increasing evidence that other operations have better metabolic outcomes.9 Third, with increasing competition within the NHS, there is a tendency to cut corners and not provide the appropriate staffing for a successful bariatric practice. Finally, bariatric operations are prejudicially restricted to patients with very high BMI levels,5 thus excluding others who are likely to benefit. Greater patient education is also needed since many see surgery as a panacea to deleterious lifestyle behaviours. Behaviour and lifestyle changes have to combine with surgery to achieve the best outcomes long term. Bariatric surgery is not a cosmetic operation, as currently viewed in some private centres, since it involves major behaviour change that needs to be maintained on a daily basis.

Accumulating evidence supports the important role that surgery can play in alleviating extreme obesity and its complications. Current practices, however, need to be reviewed and corrected to ensure greater, equitable and safer availability of bariatric surgery, its provision by trained surgeons operating in high volume centres in a multiprofessional setting, and appropriate patient education, selection and preparation. Based on our observations, the current situation is likely to harm patients and tarnish a very effective treatment for a complex and serious condition.