Slimmed down surgeryBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5499 (Published 26 October 2010) Cite this as: BMJ 2010;341:c5499
Approaches to weight loss are subject to fad and fashion, but one measure looks set to stay. Thirty years ago bariatric surgery was treated as an oddity imported from the United States; now the procedures are recommended for certain patients by the UK’s National Institute for Health and Clinical Excellence (NICE).1
As the publicity surrounding the alleged obesity epidemic has taken hold, medical methods to try to combat it have drawn increased attention. Drug treatment for weight loss has not been very successful: ribonamant was withdrawn because of an increased risk of suicide and sibutramine, another centrally acting appetite suppressant, was banned early this year because of concerns about cardiac side effects. Orlistat, which prevents fat absorption, has unpleasant gastric side effects and compliance can be problematic. Patients who do manage to take it over six months are likely to lose an average of 2.3 kg in addition to 2.1 kg lost with lifestyle changes alone.2 Diet and exercise alone, although universally recommended in guidelines on the management of obesity, seem to have been unsuccessful in reducing the number of very obese patients presenting with complications.
NICE guidelines recommend bariatric surgery for people with a body mass index (BMI) ≥40 and those with a BMI of 35-40 who have obesity related disease, such as hypertension or diabetes, after other interventions have failed. A Cochrane review found that “surgery is more effective than conventional management,”3 and a health technology assessment published last year concluded that “bariatric surgery appears to be a clinically effective and cost effective intervention for moderately to severely obese people compared with non surgical interventions.”4
Several procedures fall under the bariatric umbrella including gastric bands, intragastric balloons, and gastric bypass. NICE recommends treatment by multidisciplinary teams that include psychological expertise and special expertise in bariatric surgery; teams should take part in national audit and provide adequate follow up. So can this be done, and is it a solution where others have failed?
David Haslam is a physician who deals with patients before and after bariatric surgery in Luton and Dunstable and is chairman of the National Obesity Forum. He is in no doubt about the benefits. “It’s valid as long as it’s done properly. And it’s cost effective to the extent that it pays for itself—in three and a half years for a gastric bypass and 18 months for a band. It’s the most effective treatment for type 2 diabetes, with resolution of diabetes in over 80%, sometimes up to 98% of patients. And it’s permanent, unlike diet.” He accepts that there are risks: “1 in 300 don’t wake up. But risks can be managed—for example, by doing procedures in centres with a high level of anaesthetic expertise.”
But should we be cautious about how useful bariatric surgery might be? “It’s fair enough to say that you should exhaust other options, except in people with BMIs of over 50, when NICE says you should proceed directly to surgery,” says Dr Haslam. “But realistically, these people do come to you having already tried, many times, dieting, more activity, sometimes pills. They usually have tried everything else. So sure, you have to make sure it’s done by the right people and as part of a multidisciplinary team where you’ve got adequate follow-up and you can manage patients properly—including things like the resolution of diabetes.”
Indeed, a recent report from the Office of Health Economics, commissioned by the Royal College of Surgeons of England, the National Obesity Forum, and Allergan and Covidien (who manufacture surgical devices used in laparoscopic gastric banding) insists that the economy is missing a massive trick in not supplying more bariatric surgery earlier, hence forgoing the opportunity to prevent later complications.5 By extrapolating from small studies, the report estimated that following NICE guidelines could produce direct healthcare savings of around £56m (€64m; $90m) a year.
The problem is that they aren’t. The report obtained freedom of information data showing that 65 of 118 primary care organisations were effectively rationing surgery, with some raising the BMI threshold above that in the NICE guidance. The report estimated that between 11 000 and 140 000 people in England qualify for bariatric surgery but that only 3607 such procedures took place in the English NHS during 2009-10. Additionally, practice varied widely, with one primary care trust (PCT) funding only one procedure and another funding 192; a tenth of PCTs ignore NICE guidance completely.
This situation is reflected in Bob Marshall’s experience: he is a consultant upper gastrointestinal surgeon at the Churchill Hospital, Oxford, with a catchment of around one million patients. He and two colleagues set up a bariatric surgery service two years ago and find it difficult to offer surgery on the NHS.
“The current situation is that the PCT will fund initial consultations and work up for patients with a BMI of 50 or more and who also have some comorbidity, such as sleep apnoea or diabetes. If we consider that these patients are suitable, then we have to reapply for PCT funding. Anyone with a BMI under 50 will not get funding on the NHS.” This is despite NICE recommending bariatric surgery for people with lower BMIs in specific circumstances. “If these other people want to pursue bariatric surgery,” says Mr Marshall, “then it has to be done privately. It’s disappointing that the PCT don’t fund it; there is lots of evidence that it helps people lose weight, that it is the best option for significant weight loss, and that it is cost effective.”
David Kerrigan, who was the Royal College of Surgeons’ representative on the NICE guidance group for obesity surgery, is also the founder of Gravitas, a network of private clinics providing bariatric surgery. Originating in Liverpool, it is now one of the country’s biggest providers. The catalyst for creating Gravitas, which takes equal numbers of NHS and private patients, was his wish to retain full consultant control of the service despite initial disinterest from his NHS trust. “At the outset, the trust actually sub-contracted the [bariatric] NHS work out to a local independent hospital because of a misperception that these patients would block beds and be a drain on resources. In a way, this negative approach proved to be an advantage, as it left us free to design an optimal patient focused service without many of the frustrations and disenchantment often associated with new service developments within the mainstream NHS.”
They went on to set up a service that now treats 500-600 patients a year and has been used as a model for services elsewhere in the country. They have arranged fellowships for training surgeons, are developing a diploma for general practitioners in tandem with the University of Chester, and are producing and publishing research regularly. “What we wanted to create was a specialist, academic, teaching unit in parallel with the NHS. Patients come in by two routes: the first, via the NHS presurgical weight loss clinic and, the second, private referrals. The NHS will not fund everyone—even those who fall within NICE guidelines.” Mr Kerrigan is clear, however, that there is no distinction made between NHS and non-NHS work. “The only difference between patients in the unit is who is paying. The package is identical for NHS and private patients.” He believes that having the unit effectively outside the NHS means that he is managing patients according to best practice and clinical need, and not because of administrative or political reasons.
Even so, Mr Haslam has concerns that the procedures are not being offered to the NHS patients who would most benefit from them. “Because [bariatric surgery] is effectively rationed, it means that a young diabetic man who is going blind isn’t a priority because his BMI is only 38. Whereas, someone older and without complications would get funding. Surgery isn’t being driven by clinical need.” Instead, primary care trusts are issuing commissioning policies that ration services locally and effectively ignore NICE guidelines.
This means that many people may choose to go outside the NHS, some going abroad. Does this ring alarm bells? “Medical tourism doesn’t do the job, no question. But there are other non-NHS enterprises which have all the follow up and are just as good as the NHS. And of course when the bad services fail, it’s the NHS that has to pick up the pieces,” says Mr Haslam. The briefest Google search reveals multiple opportunities for UK residents to pay for bariatric surgery, especially in eastern Europe. Follow-up after surgery abroad is a big problem. Celebrity Anne Diamond has publicly complained that her bariatric surgery failed after her follow-up in Belgium was inadequate; several UK surgeons have also voiced concern that standards of aftercare put the success of procedures done abroad at risk.6
Best we have
Does Mr Haslam think that the fact that bariatric surgery is so effective is, in itself, rather depressing? Isn’t there another way? “Well, we need to change the food we eat, the environment, school meals, breast feeding rates—we know that genetics play a role. Bariatric surgery is basically like speeding evolution up, giving us smaller stomachs and smaller intestines. It’s not perfect, but it’s a pretty good solution.”
Mr Marshall agrees, and says demand in both private and public sector is growing. “At first it was fairly slow, but since then demand has built up. Our NHS clinic is full, and, of course, these are the more difficult patients who are more suitable for the gastric band, which is more costly and takes more time. If demand continues as it is, we will struggle to cope.”
Surgery clearly comes with complications, not simply from anaesthesia but also from vitamin and mineral deficiencies after some procedures in the longer term; the rare phenomenon of gastric band slippage, which requires urgent care; and the adjustment of bands, which may have to be done repeatedly. Additionally, data are lacking on long term outcome. However, Mr Marshall believes that these operations work. “I’ve been enormously impressed by my initial experience. When patients have lost weight, it just transforms them.” Although he says that adverse outcomes are uncommon, he points to the need for a psychologist to help people who perhaps have dealt with stress by overeating and who no longer have that option after surgery. “But when you see patients come in with a big smile,” he says, “it’s worth it.”
Cite this as: BMJ 2010;341:c5499
Competing interests: The author has completed the unified competing interest form ww.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.