Editorial
Surgical Treatment of Obesity — Weighing the Facts
N Engl J Med 2009; 361:520-521July 30, 2009DOI: 10.1056/NEJMe0904837
- Article
There has been an explosion in the number of bariatric surgical procedures performed worldwide. It is estimated that in 2005, the number of procedures performed in the United States was more than 10 times as great as the number performed in 1994, an increase from approximately 16,200 procedures to 171,000, and the number is still rising. This roaring growth has caused many observers to ask vital questions: Is bariatric surgery safe? Is it effective? Is it affordable?
In the past, now outdated bariatric procedures carried unacceptably high risks. The weight loss associated with the procedures was questionable, and the long-term health benefits were unproven. Bariatric surgery was used only as a last resort in patients who were substantially debilitated by their obesity. Things have changed: an obesity epidemic has erupted and continues unchecked. Current bariatric procedures more judiciously balance surgical risk and weight loss. Laparoscopic bariatric surgery is possible even in very obese patients, making hospital stays of 1 to 2 days routine. At present, bariatric surgery is recommended by the National Institutes of Health for obese patients with a body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) of at least 40 and for less obese patients with serious coexisting medical conditions and a BMI of at least 35.1
In this issue of the Journal, Flum and colleagues report the findings of the Longitudinal Assessment of Bariatric Surgery 1 (LABS-1) trial (ClinicalTrials.gov number, NCT00433810),2 a prospective, multicenter observational study that assessed 30-day complication rates in 4776 patients undergoing primary bariatric surgical procedures. The overall rate of death was 0.3%, and 4.1% of the patients had major complications — rates that are similar to those seen in other major operations. There was an increased rate of complications in patients who had a history of thrombotic disorders, poor functional status, or sleep apnea.
Of note, all the bariatric surgeons in this study were “LABS-certified” as being highly skilled. The operations were performed in high-volume bariatric centers. Hence, the LAB-1 data may represent a best-case scenario that may not be widely reproducible. However, as the number of bariatric surgeries has increased, so has the quality. This has been due in part to the establishment of bariatric-surgery fellowships and the publication of evidence-based standards for bariatric care. Some observers argue that bariatric outcomes are similar even in centers that are not certified as “centers of excellence” or high volume, suggesting that LABS-1 outcomes are generally achievable.3
The LABS-1 study also compared the safety of three procedures: the laparoscopic and open approaches to Roux-en-Y gastric bypass (in which a small stomach pouch is created, isolated from the remaining stomach, and attached to a loop of jejunum) and laparoscopic adjustable gastric banding (in which an adjustable band is wrapped around the upper stomach, creating a small pouch that empties into the remaining stomach through a narrow outlet). These three procedures account for 90% of bariatric procedures performed worldwide. The 30-day composite end point — death, serious complications, reintervention, or prolonged hospitalization — occurred in 1.0% of patients who underwent laparoscopic adjustable gastric banding, in 4.8% who underwent laparoscopic gastric bypass, and in 7.8% who underwent open gastric bypass.
Although it is tempting to choose the “best” bariatric procedure, such a conclusion cannot be based on the short-term LABS-1 data alone. Surgeons passionately debate which procedure is preferable. Some strongly prefer laparoscopic adjustable gastric banding over gastric bypass because of the former's safety advantage and the belief that long-term outcomes of the two procedures are similar.4 Others argue for gastric bypass because they believe long-term outcomes fall short in patients who undergo laparoscopic adjustable gastric banding and that there is an unacceptably high need to remove the band or convert to a bypass procedure.5
Similarly, the LABS-1 findings do not indicate whether laparoscopic versus open gastric bypass is preferable. Although the composite end point occurred more frequently in patients who underwent open gastric bypass than in those who underwent laparoscopic bypass, this difference was negated after adjustment for unfavorable factors that predominated in patients in the open-procedure group. Hence, proponents of both types of gastric bypass will be unmoved by the LABS-1 results and will point to data that support their opposing views.6,7 Until incontrovertible data are presented, the choice of bariatric procedure will continue to be dictated by the medical factors of individual patients and by the deep-seated preferences of both surgeons and patients.
Although the LABS-1 study addressed short-term safety, two landmark studies that were previously published in the Journal address the long-term efficacy of bariatric surgery. The Swedish Obese Subjects (SOS) study8 prospectively followed 2010 patients undergoing bariatric surgery and 2037 contemporaneously matched patients receiving conventional obesity treatments. After 10 to 15 years, the surgical patients had reduced development of and improved recovery from diabetes and cardiovascular risk factors and a 23.7% reduction in mortality, as compared with the control subjects. In a retrospective cohort study involving 7925 patients who underwent gastric bypass and matched controls, Adams and colleagues9 found that mortality was reduced by 40% in the patients who underwent gastric bypass.
Although safety and long-term efficacy data on bariatric surgery are encouraging, the financial implications of the surgical treatment of obesity must also be considered. Perioperative costs outstrip any nonsurgical treatment of obesity by far, and the expense of operating on the millions of potentially eligible obese adults could overwhelm an already financially stressed health care system. What makes surgery promising is that it reduces medication use, outpatient visits, and hospitalizations over time. This ultimately may make surgery less costly than the current, less effective nonsurgical treatments of obesity.10
In the future, we need to define how bariatric surgery works to develop even less invasive procedures. For example, initial work suggests that aside from restricting food intake, some bariatric procedures may alter gut peptide release in a manner that favors diabetes resolution and enhances weight loss.11 One can envision replicating this peptide milieu without surgery, by means of pharmacologic interventions.
In conclusion, it is a sobering fact that some obese young adults may lose up to 20 years of life expectancy if they do not reduce their weight.12 And the price tag for treating obesity and related conditions is daunting. One must treat obesity aggressively, though thoughtfully, and with an eye toward developing effective prevention and better therapies that ideally would eliminate the need for surgery altogether. But until we get to that point, the weight of the evidence indicates that bariatric surgery is safe, effective, and affordable.
Dr. Robinson reports receiving consulting fees from Storz and serving as an expert witness in legal cases regarding standards of care in bariatric surgery.
No other potential conflict of interest relevant to the article was reported.
Source Information
From the Department of Surgery, Harvard Medical School, Boston.
- References
References
1
Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin Nutr 1992;55:Suppl 2:615S-619S
Web of Science | Medline2
The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium
Free Full Text | Web of Science | Medline3
Livingston EH . Bariatric surgery outcomes at designated centers of excellence vs nondesignated programs. Arch Surg 2009;144:319-325
CrossRef | Web of Science | Medline4
Fielding GA ,Ren CJ . Laparoscopic adjustable gastric band. Surg Clin North Am 2005;85:129-140
CrossRef | Web of Science | Medline5
Cottam DR ,Atkinson J ,Anderson A ,Grace B ,Fisher B . A case-controlled match-pair cohort study of laparoscopic Roux-en Y gastric bypass and Lap-Band patients in a single US center with three-year follow-up. Obes Surg 2006;16:534-540
CrossRef | Web of Science | Medline6
Jones KB Jr ,Afram JD ,Benotti PN , et al. Open versus laparoscopic Roux-en-Y gastric bypass: a comparative study of over 25,000 open cases and the major laparoscopic bariatric reported series. Obes Surg 2006;16:721-727
CrossRef | Web of Science | Medline7
Weller WE ,Rosati C . Comparing outcomes of open versus laparoscopic bariatric surgery. Ann Surg 2008;248:10-15
CrossRef | Web of Science | Medline8
Sjostrom L ,Narbro K ,Sjostrom CD , et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357:741-752
Free Full Text | Web of Science | Medline9
Adams TD ,Gress RE ,Smith SC , et al. Long-term mortality after gastric bypass surgery. N Engl J Med 2007;357:753-761
Free Full Text | Web of Science | Medline10
Sampalis JS ,Liberman M ,Auger S ,Christou NV . The impact of weight reduction surgery on health-care costs in morbidly obese patients. Obes Surg 2004;14:939-947
CrossRef | Web of Science | Medline11
Vetter ML ,Cardillo S ,Rickels MR ,Iqbal M . Narrative review: effect of bariatric surgery on type 2 diabetes mellitus. Ann Intern Med 2009;150:94-103
Web of Science | Medline12
Fontaine KR ,Redden DT ,Wang C ,Westfall AO ,Allison DB . Years of life lost due to obesity. JAMA 2003;289:187-193
CrossRef | Web of Science | Medline
- Citing Articles (15)
Citing Articles
1
Michael H. Wood, Joshua J. Kroll, Beth Garretson. (2013) A comparison of outcomes between the traditional laparoscopic and totally robotic Roux-en-Y gastric bypass procedures. Journal of Robotic Surgery
2
J. Bikhchandani, R.A. Forse. Bariatric Surgery and Renal Disease. In: Nutritional Management of Renal Disease. Elsevier, 2013:473-483.
3
Antimo Gioiello, Emiliano Rosatelli, Roberto Nuti, Antonio Macchiarulo, Roberto Pellicciari. (2012) Patented TGR5 modulators: a review (2006 – present). Expert Opinion on Therapeutic Patents 22:12, 1399-1414
4
Davor timac, Sanja Klobucar Majanovic. (2012) Endoscopic Approaches to Obesity. Digestive Diseases 30:2, 187-195
5
Matt M. Kurrek, Chris Cobourn, Ziggy Wojtasik, Alexander Kiss, Steven L. Dain. (2011) Morbidity in Patients with or at High Risk for Obstructive Sleep Apnea after Ambulatory Laparoscopic Gastric Banding. Obesity Surgery 21:10, 1494-1498
6
Raj Padwal, Scott Klarenbach, Natasha Wiebe, Maureen Hazel, Daniel Birch, Shahzeer Karmali, Arya M. Sharma, Braden Manns, Marcello Tonelli. (2011) Bariatric Surgery: A Systematic Review of the Clinical and Economic Evidence. Journal of General Internal Medicine 26:10, 1183-1194
7
Yunfeng Cui, Dariush Elahi, Dana K. Andersen. (2011) Advances in the Etiology and Management of Hyperinsulinemic Hypoglycemia After Roux-en-Y Gastric Bypass. Journal of Gastrointestinal Surgery 15:10, 1879-1888
8
H. Ashrafian, T. Athanasiou, J. V. Li, M. Bueter, K. Ahmed, K. Nagpal, E. Holmes, A. Darzi, S. R. Bloom. (2011) Diabetes resolution and hyperinsulinaemia after metabolic Roux-en-Y gastric bypass. Obesity Reviews 12:5, e257-e272
9
Nestor Villamizar, Aurora D. Pryor. (2011) Safety, Effectiveness, and Cost Effectiveness of Metabolic Surgery in the Treatment of Type 2 Diabetes Mellitus. Journal of Obesity 2011, 1-6
10
Helen L Walls, Anna Peeters, Joseph Proietto, John J McNeil. (2011) Public health campaigns and obesity - a critique. BMC Public Health 11:1, 136
11
James V. Lewis. (2010) Bariatric Surgery. Southern Medical Journal 103:8, 725-726
12
Tiffany M. Powell, Amit Khera. (2010) Therapeutic Approaches to Obesity. Current Treatment Options in Cardiovascular Medicine 12:4, 381-395
13
Evangelos J. Papaevangelou. (2010) The “Changing face” of surgery. Hellenic Journal of Surgery 82:2, 90-94
14
Gary L. Davis, William L. Roberts. (2010) The Healthcare Burden Imposed by Liver Disease in Aging Baby Boomers. Current Gastroenterology Reports 12:1, 1-6
15
C. Ciangura, A. Basdevant. (2009) Bariatric surgery in young massively obese diabetic patients. Diabetes & Metabolism 35:6, 532-536
