Bariatric Surgery: Safe and Effective

Barry Greene, MD, FACS, FASMBS

Case

RW is a 66-year-old gentleman with a body mass index (BMI) of 54. He presented with poorly controlled diabetes, hypertension, gout, nonalcoholic steatohepatitis, lower-extremity edema, and osteoarthritis, which limited his ability to perform activities of daily living. He had tried many diets over the years and followed up regularly, but his weight continued to slowly rise. He used almost 100 units of insulin daily plus Actos, with poor diabetic control. Exercise was not possible because of immobility related to osteoarthritis and recurrent gout. After an extensive educational program that included support groups, nutritional counseling, psychological assessment, and therapeutic exercise, he underwent surgical therapy for his morbid obesity.

Following surgery, he noted a reduction in hunger. He maintained a low-carbohydrate diet and saw a rapid resolution of his diabetes. With continued weight loss, his exercise tolerance and quality of life dramatically improved. Now five years postoperative, he has a BMI of 29. His only remaining medical problem is mild hypertension, which is controlled with low-dose medications. His tophaceous gout has completely resolved, despite maintaining a diet with 70 grams of protein per day.

Discussion

The majority of obese people diet for years and lose some weight. However, studies show they usually regain their lost weight eventually.[1] Excess weight stops them from enjoying life, being productive citizens and fulfilling their dreams. Obesity causes or worsens diseases such as diabetes, hypertension, dyslipidemia, obstructive sleep apnea, gout, and osteoarthritis. Multiple studies show that associated diseases markedly improve or resolve with the resolution of obesity.[2],[3]

The “Look Ahead” trial, sponsored by the National Institutes of Health, studied in great detail the effects of intensive weight management in 5,000 patients over eight years and showed no decrease in cardiovascular events, and only slight improvement in diabetic control.[4] These results stand in stark comparison to the “Stampede” trial, in which patients with poorly controlled diabetes (hemoglobin A1c > 9%) were randomized to surgical versus medical management.

At three years of follow-up, glycemic control (hemoglobin A1c <7) was seen in more than 30% of surgical patients, with no major complications.[5] Hypertension and dyslipidemia have also been shown to resolve in more than 60% of patients following bariatric surgery. Gout medication was no longer needed in 72% of patients following weight-loss surgery.^2,3,6,7

The safety of bariatric surgery has improved dramatically over the past two decades. Accreditation of bariatric surgery centers has enhanced quality by requiring extensive training and preparation of staff and hospitals to perform surgery on these complicated patients. The result has been decreased perioperative complications and mortality, and decreased length of stay and readmission rates.

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) is a comprehensive program sponsored by The American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS). Accredited centers undergo periodic rigorous surveys and must submit independently verified, complete data on all patients undergoing bariatric surgery, including followup to a centralized database.

The HIPPA-compliant data is then compared to benchmarks and peers, identifying centers or surgeons that are outliers. Frequent collaboration between centers across the country raises the performance of all centers that participate.

The result has been a 0.11% 30-day mortality rate and 3% complication rate at accredited centers.[6] Tobias and Associates showed increased mortality in patients with all classes of obesity compared to normal and overweight patients.[7] A recent ASMBS consensus statement reviews in greater detail the outstanding advantages of surgical management for all classes of obesity, even those with a BMI of 30.[8]

Now that bariatric surgery has been overwhelmingly proven to be effective and safe when performed at an MBSAQIP-accredited center, we need to offer bariatric surgery to suitable patients who have not achieved and maintained significant weight and comorbidity improvement with nonsurgical treatment.

Barry Greene, MD, FACS, FASMBS is the medical director of Bariatric Surgery at Adventist HealthCare Shady Grove Medical Center, Rockville, Md., and a surveyor for the MBSAQIP. He can be reached at dr.barrygreene@gmail.com.

[1] Svelte LP, et al., Comparison of strategies for sustaining weight loss: the weight loss maintenance randomized controlled trial. JAMA. 2008 12;299(10):1139-48.

[2] Buchwald H, et al. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA. 2004;292(14):1724-1737. doi:10.1001/jama.292.14.1724

[3] Gloy, V.L. et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomized controlled trials. BMJ 2013;347:f5934

[4] The Look AHEAD Research Group. Cardiovascular Effects of Intensive Lifestyle Intervention in Type 2 Diabetes. N Engl J Med 2013; 369:145-154

[5] Schauer, PR, et al., Bariatric Surgery versus Intensive Medical Therapy for Diabetes — 3-Year Outcomes. NEJM 2012; 366:15 67-76

[6] Hutter, MM, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011 Sep;254(3):410-20

[7] Tobias, DK. et al. Body mass index and mortality among adults with incident type 2 diabetes. NEJM 2014 Jan; 233–244

[8] Breathauer, SA. et al. Bariatric Surgery and Class I Obesity (BMI 30–35 kg/m²). SOARD 2013 Sep:e1-e10

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