Bariatric Surgery – A Surgeon’s Perspective

In the first part of this series (published in Defence Update Winter 2014), a GP and a Physician provided their perspectives on bariatric surgery. In this final part, we have asked a Bariatric Surgeon and an Anaesthetist to discuss their views on this topic.

A Surgeon’s Perspective

The judgment in the NSW Supreme Court of Almario v Varipatis,¹ which was thankfully overturned, raised the prospect that a clinician may be found liable for failing to recommend appropriate treatment for a severely obese patient. This judgment would have created difficulty for clinicians, as real barriers exist in obtaining treatment for patients with obesity-related medical conditions. Despite the evident need, Australia lacks a framework within which obesity treatment can easily be offered. Obese patients visit their GPs frequently,² consume health resources frequently³ and are over-represented in the ranks of patients with chronic disease.⁴ Despite this, their treatment is predominantly managed by the dieting industry which offers treatments without clear benefits.⁵

Obesity is a chronic disease, but its management is not supported by Medicare. Also, while primary care streams for psychiatric, women’s health, paediatric and other common health conditions exist in General Practice, no such stream exists for obesity. Many National Health and Medical Research Council (NHMRC) recommendations such as those for asthma, diabetes and immunisations are routinely adhered to, but no discernible uptake of obesity management guidelines has occurred since NHMRC first published on the subject in 2004. Patients admitted into hospital with obesity-related diseases will be unlikely to receive inpatient or post-discharge treatments for their obesity condition. While bariatric surgery for public patients is provided in some Australian states, the services are poorly funded and oversubscribed or, as is the case in NSW and QLD, almost completely absent.

Bariatric surgery is a topic that generates conflicting emotions in clinicians, the media and the community. This is probably due to the dissonance experienced at the prospect of the broader community paying for what is, in its simplest consideration, a disease caused by overconsumption. This is reflected in the negative way in which both medical practitioners⁶ and the community⁷ can regard the obese person. Creating a framework for effectively treating obesity while managing valid concerns about the ethics of “rewarding” patients for poor health choices can occur in the Australian context – but firstly, the reasons for treatment need to be clearly articulated, and treatment needs to be managed in a way that is valid ethically⁸ and economically.

When considering treatment for obesity, the risks versus benefits of treatment need to be considered. Surgery in morbidly obese patients is known to improve health, quality of life and length of life.^9,10,11 However, it has also been shown to increase hospital costs^12,13 even while it decreases medication¹⁴ and probably food costs to the individual. Surgery creates abnormal anatomy and physiology in patients and creates a situation whereby illness can result from the procedure at any time from the early to late post-operative period.^15,16,17 In many chronic disease states, interventions are offered when the benefits are believed to outweigh risks, e.g. transplantation, dialysis, coronary revascularisation, major joint arthroplasty. However patients may seek obesity surgery before medical morbidities have occurred, or delay treatment until after organ injury has been sustained.

BMI is a crude determinant of the medical risk associated with obesity. Rating obesity according to its severity (see below) and making decisions to treat according to severity, rather than BMI, can make decisions easier for referring clinicians and alleviate concerns about resources and equity.

Proposed simple rating score for obesity

Stage I:  Obesity without discernible medical or physical disability.

Stage II:  Obesity with medical or physical conditions/disabilities for which non-surgical treatments are available.

Stage III:  Obesity with medical or physical conditions for which treatment is unlikely to result in return to reasonable health or where treatment slows but does not prevent further decline in health.

Stage IV:  Obesity with permanent organ dysfunction/failure where treatment may delay life or organ threatening disease, but return to normal health is not possible.

Perhaps we should target patients who are already active users of healthcare resources with an aim to returning them to a state of reduced healthcare consumption. This would have real potential to improve their health and also reduce their community-funded medical costs.

Selecting patients who have previously received and failed appropriate alternate treatments for their underlying conditions – e.g. a tablet-controlled diabetic in whom insulin treatment is now required – will improve the “bang-for-buck” of obesity surgery and improve the likelihood of health improvement. Surgery in inappropriately selected patients has the possibility of converting patients from “well but overweight” to “slim but unwell”. Stage III patients would be ideal candidates, and most appropriate in a public hospital setting, if public services were available. However some stage II and IV patients will also likely benefit from surgery if the risks were acceptable. Stage I patients may seek surgery as a “simple” treatment but are more likely to suffer harm than benefit from surgical therapies.

Obesity is a chronic disease, so chronic care is required. There are significant differences in outcomes between monitored¹⁸ and unmonitored¹⁹ patients after bariatric surgery. This means effort needs to be put in to preserve the investment made in performing the surgery in the first place. Long term follow-up is of paramount importance, not just in effectiveness but in safety. The issue of providing chronic care is a major stumbling block for surgery in many situations. Some clinics and clinicians may presume that patients may be okay to be discharged to their GP without long-term supervision, but this will likely lead to poor outcomes for many patients.

The data supporting obesity surgery in obese patients with medical morbidities is overwhelming. This is despite its controversy and barriers to providing long-term care to post-operative patients. Should the courts ever have cause to examine the reasons for patients being denied treatment in our public hospitals,²⁰ the outcomes could prove interesting.

Dr Michael Talbot, Bariatric Surgeon
MDA National Member

References
1. Almario v Varipatis (no. 2) [2012] NSWSC 1578. Available at: caselaw.nsw.gov.au/action/pjudg?jgmtid=162435. A detailed discussed of this case was published in our CaseBook section of Defence Update Summer 2013. Available at: defenceupdate.mdanational.com.au/varipatis-v-almario-an-exercise-in-futility/.
2. Frost GS, Lyons GF. Obesity impacts on general practice appointments. Obes Res 2005;13(8):1442–1429.
3. Counterweight Project Team. The impact of obesity on drug prescribing in primary care. Br J Gen Pract 2005;55(519):743–749.
4. Herrera-Valdes R, Almaguer M, Chipi J, Toirac X, Martinez O, Castellanos O, et al. Prevalence of Obesity and its Association with Chronic Kidney Disease, Hypertension and Diabetes Mellitus. Isle of Youth Study (ISYS), Cuba. MEDICC Review 2008;10(2):14–20.
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6. Foster GD, Wadden TA, Makris AP, Davidson D, Sanderson RS, Allison DB, Kessler A. Primary Care Physicians’ Attitudes About Obesity and its Treatment. Obesity Research 2003;11(10):1168–1177.
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8. NHMRC. Ethical Considerations Relating to Health Care Resource Allocation Decisions. Available at ncbi.nlm.nih.gov/pubmed/18317471.
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11. Karlsson J, Taf, C, Ryden A, Sjostrom L, Sullivan M. Ten-year Trends in Health-related Quality of Life After Surgical and Conventional Treatment for Severe Obesity: The SOS Intervention Study. International Journal of Obesity 2007;31(8):1248–1261.
12. Zingmond DS, McGory ML, Ko CY. (2005). Hospitalisation Before and After Gastric Bypass Surgery. JAMA : the Journal of the American Medical Association 2005;294(15):1918–1924.
13. Picot J, Jones J, Colquitt JL, Gospodarevskaya E, Loveman E, Baxter L, Clegg AJ. The Clinical Effectiveness and Cost-effectiveness of Bariatric (Weight Loss) Surgery for Obesity: A Systematic Review and Economic Evaluation. Health Technology Assessment (Winchester, England) 2009;13(41):1–190– 215–357– iii–iv.
14. Potteiger C E, Paragi PR, Inverso NA, Still C, Reed MJ, Strodel W, et al. Bariatric Surgery: Shedding the Monetary Weight of Prescription Costs in the Managed Care Arena. Obesity Surgery 2004;14(6):725–730.
15. Dixon J. Guidelines Fall Short on Bariatric Surgery. MJA 2014;2000(3):70.
16. Christoph Gasteyger et al, Nutritional Deficiencies After Roux-en-Y Gastric Bypass for Morbid Obesity Often Cannot Be Prevented by Standard Multivitamin Supplementation. Am J Clin Nutr 2008;87(5):1128–1133.
17. Hamdan K, Somers S, Chand M. Management of Late Postoperative Complications of Bariatric Surgery. Br J Surg 2011;98(10):1345–1355.
18. O’Brien PE, MacDonald L, Anderson M, Brennan L, Brown WA. Long-term Outcomes After Bariatric Surgery: Fifteen-year Follow-up of Adjustable Gastric Banding and a Systematic Review of the Bariatric Surgical Literature. Annals of Surgery 2013;257(1):87–94.
19. Higa K, Ho T, Tercero F, Yunus T, Boone KB. Laparoscopic Roux-en-Y Gastric Bypass: 10-year Follow-up. Surgery for Obesity and Related Diseases : Official Journal of the American Society for Bariatric Surgery 2011;7(4):516–525.
20. Talbot ML, Jorgensen JO, Loi KW. Difficulties in Provision of Bariatric Surgical Services to the Morbidly Obese. Med J Aust 2005;182(7):344–347.