Editorials

Obesity surgeryanother unmet need

It is effective but prejudice is preventing its use

Obesity, defined as having a body mass index >30 kg/m², is dramatically increasing in incidence in the Western world. For example, 20 years ago 5% of the population in the United Kingdom was obese; now 17% is.¹ The annual healthcare costs arising directly from obesity are at least £2bn ($3bn) in the United Kingdom and £45bn ($68bn) in the United States. ^{2 3} Data from several sources have identified the increased morbidity and mortality associated with obesity.⁴ Most patients who are obese are treated with a combination of advice on diet and lifestyle and in some cases with drugs. However, for patients who have morbid obesity (body mass index >40), this conservative approach is doomed to failure.

If left untreated patients who are morbidly obese (1-2% of the population in the United Kingdom) have only a 1 in 7 chance of reaching their normal life expectancy. A Cochrane review in 1997 noted that good results had been obtained from surgery for obesity in these patients.⁵ Over the past decade both the National Institutes of Health in the United States and the Scottish Intercollegiate Guidelines Network have suggested that surgery is the most effective treatment for selected patients who are morbidly obese; both organisations have recommended that surgery be carried out more frequently. ^{6 7} The selection criteria for surgery have been established by the International Federation for the Surgery of Obesity. The criteria are having a body mass index >40 or body mass index of 35-40 in patients with serious comorbid disease that is treatable by weight loss, being obese for a minimum of 5 years, having had conservative treatment that failed, having no history of alcohol misuse or major psychiatric illness, and being aged between 18 and 55 with acceptable operative risk as determined by preoperative assessment. Women must avoid becoming pregnant within two years of the operation. The surgery must be delivered in a multidisciplinary environment. There should be a dietician or specialist nurse to counsel the patient before and after surgery, a physician to assess fitness for surgery and to exclude patients who have endocrine causes of obesity, a psychologist to help the patient adjust to new eating habits after surgery, an anaesthetist who is experienced in anaesthetising obese patients, and a radiologist who can interpret special radiological investigations and carry out band adjustments if a gastric band has been inserted.

Preliminary data from the Swedish obese subjects study, a prospective matched cohort study of 2000 obese patients treated with drugs who are being compared with 2000 obese patients who have been treated with surgery, show that surgery is overwhelmingly better than conservative management in improving quality of life, curing type 2 diabetes, controlling high blood pressure, reducing atheroma, improving rates of employment, and in reducing costs to the health service.⁸ In addition, data from other sources confirm the efficacy of surgery for obesity in improving adverse lipid profiles, sleep apnoea, joint problems, gastro-oesophageal reflux, urinary incontinence, and asthma.⁹

If these data are so convincing why are fewer than 200 operations carried out each year in the United Kingdom and why are many of them funded privately? Firstly, there are few surgeons who are trained to treat obesity. Secondly, society is ignorant and prejudiced against patients with morbid obesity because there is a failure to understand that obesity needs treatment just like any other disease. There is also prejudice against surgeons who carry out this type of demanding surgery. Some doctors consider surgery for obesity to be a waste of resources, and others remember the poor results from earlier procedures such as the jejunoileal bypass. There is also a lack of robust data on the costs and benefits.

Since the advent of obesity surgery in the 1950s some procedures have been discarded and others validated for their good long term results. Data from over 14 000 patients on the international register of obesity surgery shows that at 12 months vertical banded gastroplasty and gastric bypass result in a mean loss of 53% and 72% of excess weight, respectively, with operative mortality of 0.17%.¹⁰ Moreover, 93% of patients have no morbidity.

New technology has increased the range of procedures available; the latest technique is the laparoscopic insertion of a gastric band, which results in patients losing about 50-60% of their excess weight and maintaining that loss for at least six years.¹¹ Regardless of which procedure is carried out by a competent surgeon, it usually results in patients losing more than 50% of their excess body weight during the first 1-2 years after surgery. If the patient is well motivated and given lifelong counselling the weight loss is usually permanent. However, attention should focus on the improvement of comorbid conditions rather than on actual weight loss, since there are good data to suggest that comorbidity decreases as a result of even modest weight loss.¹²

A medical cure for this disease is unlikely to emerge for some time because of the complexity of the disorder. Several surgical procedures that have been well validated are available if patients can find suitably trained surgeons with the necessary resources. Purchasers and providers are prejudiced against surgery for obesity and it is accorded a low priority, consequently it is being driven into the private sector where only the rich can benefit. Insurance companies will not pay for surgery because they do not understand that the procedures are cost effective. In 1991 a survey of all general surgeons in the United Kingdom showed there were only 38 obesity surgeons; most were doing only a small number of operations.¹³ A repeat survey two years ago showed that the number had dropped to 23.¹⁴ It is little wonder that in this area the United Kingdom is so far behind Europe, the United States, and Australasia.

An obesity surgeon should be available in all large hospitals together with the relevant multidisciplinary team. Doctors and the public will have to agitate for more resources to treat morbid obesity. When the Swedish obese subjects study finally reports the details of the advantages of surgery our profession will be under pressure to train more obesity surgeons to alleviate this often fatal disease.

John Baxter, professor of general surgery. 

Postgraduate Medical School, University of Wales, Swansea SA2 8PP

Footnotes

   Competing interests: JB is secretary of the British Obesity Surgery Society.

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