Addressing challenges of weight loss surgery

A symposium hosted by Ethicon1 and Ethicon Endo Surgery2 on “massive weight loss body contouring”, held at the Royal Free Hospital in London, recently examined the challenges of weight loss surgery – from the provision of psychological support, improvements to the care pathway, optimal perioperative care, to staging complex cosmetic procedures, as well as the availability of funding on the NHS. David Floyd, a consultant plastic surgeon at the Royal Free in London, pointed out that obesity is a global problem and one that is expected to rise significantly. According to the World Health Organization (WHO), areas of particularly high incidence of obesity include North America, Saudi Arabia and the UK. The percentage level of people who are obese in this country is currently estimated to be 20% to 30% and hospital admissions for obesity related illnesses have increased dramatically. David Floyd pointed out: “The US is ahead of the game – they started collecting data on obesity trends in 1985. The data shows a significant increase in levels of obesity over a period of 15 years. In 1990, the average percentage of people considered obese in the US was 10% to 12% compared to around 30% in 2007. This is around a one per cent increase per year. Trends in demographics are also changing – obesity is now increasing at a higher rate for men than women in the UK. “The Department of Health has attempted to forecast levels of obesity in the UK and the growth is expected to be similar to the US – it is an increasing problem that is going to require more and more of our input.” In fact, the Health Survey for England estimated that 12 million adults will be classed as “obese”, along with one million children, by 2010. The World Health Organization defines obesity according to BMI – patients are categorised as obese if they have a BMI of over 30, severely obese when over 35, morbidly obese at 40.9 and above, and super obese when over 50. The majority of patients receiving bariatric surgery are currently in the super obese category. The NICE guidance sets out the indications for funding obesity surgery on the NHS – a BMI of over 40 is the criteria for surgery, but once a patient’s BMI reaches super obese (over 50), it is considered the “first line” treatment. Shaw Somers, consultant bariatric and upper GI surgeon, St Richard’s Hospital in Chichester and the London Clinic, pointed out that for morbidly obese patients with a BMI over 40, the standard non-surgical methods of weight loss “do not work durably” and, when BMI is over 50, they are “futile”. Nevertheless, bariatric surgery has experienced significant challenges – not least in terms of changing attitudes within the health service to the specialty. Shaw Somers recalled, when he first started performing bariatric procedures 12 years ago, it was a “dirty word” in general surgery. He explained that he had experienced “agonies” in setting up new services and had battled with PCTs, SHAs, public health leads, as well as fellow surgeons, over the provision and funding of bariatric services. He also cited examples where patients had faced delays in obtaining surgery as a result of their GPs’ attitudes – some refused to refer them and took the view that “we do not treat fat people; it is their fault”. This led to costly and tragic consequences in some cases – including stroke and long-term disability, which could have been avoided had bariatric treatment been provided earlier. “Obesity has historically been regarded as a ‘non-clinical issue’, but research has demonstrated that it is also an economic one,” he commented. “The attitude is ‘why should we bother?’ ‘It is selfinflicted; surgery is not essential and patients could lose weight if they tried’. But, if we applied this reasoning to many of treatments that we offer on the NHS, we would not offer a great deal – orthopaedics and trauma would be significantly reduced, and there would be no services available for alcohol, smoking or drug related illnesses. We have to get to grips with the fact that obesity is due to another type of addiction.” He pointed out that it is “much cheaper to perform bariatric surgery and subsequent body contouring, than to allow patients to remain obese and encounter the associated comorbidities and die,” adding that it costs around £100,000 per year to keep a patient in an armoured wheelchair – not to mention the huge cost of treating comorbidities and providing assistance with day-to-day living requirements and care. “Bariatric surgery is much more costeffective, costing just £15,000,” he argued. Furthermore, the reduction in comorbidities is significant: • Severe hypertension is reduced from 20% before surgery to 6% six months post-op. • Obstructive sleep apnoea is reduced from 40% to 2% six months post-op. • Incidence of osteo-arthritis is greatly improved. • Diabetes mellitus is reduced from 25% before surgery to 1% six months post op. In fact, for reasons not yet understood, diabetes “goes away” just days after surgery, as Shaw Somers pointed out: “One patient that I recently operated on previously required 500 units of insulin per day before their operation. She was able to reduce this to 10 units, just two days after surgery, and is expected to come off of the insulin altogether by the time she is discharged.” In light of such evidence, gastric bypass is now being investigated as a treatment for Type 2 diabetes, in adults, in the absence of obesity, he revealed.

Patient selection and assessment

There are various surgical approaches to weight loss surgery, including gastric banding and gastric bypass, but patient selection and assessment is crucial in deciding the most appropriate treatment to ensure the best outcome. During the selection process, evaluation of the risks vs benefits for an individual patient is extremely important, said Majid Hashemi. A consultant at the University College London, Majid Hashemi has been performing laparoscopic bariatric surgery since 2001 and led one of the first specialist multidisciplinary obesity surgery clinics in the UK – the North London Obesity Surgery Service. He pointed out that guidance states that patients with a BMI of over 40 can go straight to surgery, as a general rule. The procedure is also justified for patients who have a BMI of over 35, with established comorbidities, a family history of obesity-related comorbidities, and especially those who show signs of early onset of heart disease and diabetes. “The guidelines state that the age range for surgery is 18-55, but I have operated on patients aged 17 and up to 67 – colleagues have operated on patients even older than this. Age is not an absolute contraindication, therefore. However, patients must not be dependent on drugs or alcohol; they must agree to life-long follow up and they must show they are motivated,” he commented. “Matching the right procedure to the individual patient is crucial,” he continued. “In light of the effects of the bypass on metabolic syndrome, we would select this procedure for sweet eaters who have diabetes or other manifestations of metabolic syndrome as there is a massive and immediate response to insulin resistance after gastric bypass surgery. Furthermore, if patients consume a large amount of ‘meltable’ calories (for example chocolate) restrictive surgical approaches will be considered unsuitable.” He revealed that an examination of referrals between 2003 and 2005 showed that the primary driver for seeking help was psychological – such as self-esteem, depression and body image – followed by muskuloskeletal, then metabolic (such as diabetes) and lastly obstructive sleep apnoea. This has now changed. Today, if patients cite pain and reduction of mobility, as the primary drivers, as they are more likely to get funding. Although over 90% may have psychological issues, the primary driver stated tended to be muskuloskeletal. Metabolic syndrome is also now a key priority dealt with by gastric bypass and clinicians are now considering offering this to patients with a lower BMI with established metabolic syndrome.