BMJ  2005;330:921 (23 April), doi:10.1136/bmj.330.7497.921-a

News

Bariatric surgery recommended for morbidly obese people

New York

New guidelines issued by the American College of Physicians recommend surgery as a "treatment option" for severely obese patients.

Opera singer Deborah Voight, who is renowned for her interpretation of the music of Wagner and Strauss, lost 45 kg after undergoing bariatric surgery in March Credit: GREGORY BULL/AP Credit: RICHARD DREW/AP

The guidelines, published in the Annals of Internal Medicine ( 2005;142: 525-31)[Abstract/Free Full Text], say that bariatric surgery, in which the stomach is reduced to a small pouch and, in some cases, joined to the small intestine to reduce food absorption, should be considered for patients with a body mass index of 40 and above who have obesity related illnesses, such as diabetes or high blood pressure. The patients should also have failed diet and exercise, with or without the use of adjunctive drug therapy.

The recommendations are based on a report by the US Department of Health's Agency for Healthcare Research and Quality that reviewed numerous studies of medical and surgical therapies for obesity.

The report's authors, citing the Swedish obese subjects study, stated, "We consider this study as providing conclusive evidence of the superiority of surgical treatment." The Swedish study compared 251 surgically treated patients with 232 medically treated patients and found that surgically treated patients had greater weight loss and greater reductions in hypertension, diabetes, and lipid abnormalities.

But critics say that the reductions in surrogate markers, such as cholesterol concentrations, do not necessarily translate into better health and mortality out-comes. In addition, the primary endpoint of the Swedish study, mortality, has not been reported despite a decade of accumulated data.

Paul Ernsberger, associate professor of medicine, pharmacology, and neuroscience at Case Western Reserve School of Medicine, told the BMJ that bariatric surgery is causing a resurgence of "diseases that were completely unheard of in the West" in recent times. He said that cases of beriberi, pernicious anaemia, and Wernicke-Korsakoff's psychosis are now being seen in the United States, problems that were not readily treated with vitamins since mal-absorption because of surgery often caused patients to pass the intact pills in their stools. These patients, said Dr Ernsberger, "have very nutritious stools."

The mortality risks of obesity have also been overplayed, according to Dr Ernsberger, who said that a widely quoted study showing a 12 times higher mortality in obese patients was flawed because the patients were rapidly regaining weight after being on a "zero calorie diet" for rapid weight loss.

The guidelines included the finding that one in every 50 patients (1.9%) dies within 30 days of surgery.

The number of patients having bariatric surgery has increased from 16 000 patients in 1992 to 141 000 in 2004.

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