Surgery for obesity in adulthood
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3402 (Published 22 September 2009) Cite this as: BMJ 2009;339:b3402
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The authors of the article Surgery for Obesity in Adulthood would
like to acknowledge the contribution of the following individuals who
worked tirelessly to develop the North London Obesity Surgery Service and
who work hard to ensure its continuing success and to maximise patient
safety. More particularly, we wish to acknowledge their crucial role in
developing the algorithm describing the pathway through which patients
referred for bariatric surgery pass which was documented in the paper. The
“core members” of the team are as follows:- anaesthesia and intensive
care: A Badacsonyi, C Hargreaves , N Harper, M Kuper, S Makindie, H
Montgomery, K Rauf, A Ziyad; bariatric service co-ordination: E Spencer, L
Antoine; bariatric surgery: M Hashemi, P Sufi; cardiology: D Brull;
gastroenterology: D Suri, C Onnie; management: S Harrington, K Slemick, D
Sloman; metabolic and endocrine medicine: S Coppack, A Leeds, W May Kong;
obstetrics: H Morgan; physiotherapy: J Benton, J Ross; plastic surgery: S
Hamilton; psychiatry: C Gallagher, S Jacob, P Robinson; radiology: B
Timmis; respiratory medicine: L Restrick; specialist dietetics: L Jones, E
Segaran; specialist nurse practitioners: D Briner, K McDougall. We would
also like to thank all those who are not “core members” (such as
laboratory based, “out of hours” and support services) who have
contributed to the development and to the smooth running of the bariatric
service, who are too numerous to mention but whose contribution is greatly
appreciated.
Yours sincerely
Dugal Heath
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
The review article by Leff & Heath entitled ‘surgery for obesity
in adulthood’1 correctly identifies the need for a multi-disciplinary
approach in the surgical management of massive weight loss. Unfortunately,
the article fails to include the role of the Plastic and Reconstructive
Surgeon in this team. In many patients the skin envelope re-drapes and
tightens sufficiently to avoid body contouring surgery. Twenty to forty
percent2 of patients however will need plastic surgical correction of
excess and hanging tissues.
Weight loss gives rise to ‘deflation’ of tissues, analogous to an old
balloon that has lost its elasticity, and can leave folds of poor quality
skin hanging from the patient’s musculoskeletal frame. These folds of
tissue can interfere with function, develop fungal infections in the
recesses, and are unsightly. Surgical correction involves staged and
sometimes long operations. Patients embarking on Bariatric Surgery need to
be informed of all the possible outcomes. At St Georges Hospital in London
the Plastic Surgeon is integral to the MDT, and patients are given a
comprehensive information leaflet on Body Contouring after Massive Weight
Loss at the initial bariatric consultation. This ensures that expectations
are realistic and that patients understand that they may need plastic
surgery after weight loss.
Yours sincerely
Mr Christopher Abela SpR in Plastic Surgery
Mr Rishi Sharma CT1 in Plastic surgery
Mr Mark Soldin Consultant in Plastic surgery
St George’s hospital
London
References
1. Leff DR, Heath D. Surgery for obesity in adulthood. BMJ 2009 Sep
26; 339: 740-746
2. Gusenoff JA, Rubin, JP. Plastic Surgery after Weight Loss:
Current Concepts in Massive Weight Loss Surgery. Aesthetic Surgery
Journal, 2008, 28(4):452-455.
Competing interests:
None declared
Competing interests: No competing interests
Though of course the surgery for obesity described in this article
refers to the primary weight loss procedure many of these patients will
undergo multiple secondary surgical procedures. Massive weight loss often
results in an unsightly excess of lax skin.
As more patients are achieving massive weight loss the demand for
body contouring procedures to remove excess skin(apronectomies,
mastopexies, brachioplasties and thigh lifts) has also increased[1]. There
is literature to suggest that body contouring surgery after massive weight
loss improves quality of life and body image[2].
In the future it may be difficult for a primary care trust, which has
already funded a patient's bariatric surgery, to subsequently deny funding
for body contouring procedures made necessary by surgically induced weight
losses.
REFERENCES
1) Mitchell JE et al.The desire for body contouring surgery after
bariatric surgery. Obes Surg. 2008 Oct;18(10):1308-12.
2) Song AY et al. Body image and quality of life in post massive
weight loss body contouring patients. Obesity (Silver Spring). 2006
Sep;14(9):1626-36.
Competing interests:
None declared
Competing interests: No competing interests
Although the reduction of weight in obese patients who were underwent
to bariatric surgery is caused by the decrease in energy intake and/or
malabsorption; this surgery, bypass procedures specially, has several
endocrine consequences that could explain the substantial improvement of
obesity related conditions such as diabetes, hypertension, sleep apnea and
dyslipidemia. The metabolic changes include a significant decrease in
postoperative circulating insulin, leptin and insulin-like growth factor 1
(IGF-1) levels (1,2) and increase of gastric inhibitory peptide (GIP),
ghrelin and glucagon like peptide-1 (GLP-1) (3,4). These changes could
explain the early improvement in biochemical parameters in these patients
and suggest that the mechanism is far more complex than simply decreased
caloric intake. For this reason and its impact on mortality, bariatric
surgery might be considered as the best option in patients with metabolic
syndrome.
REFERENCES
1. Flatt PR. Effective surgical treatment of obesity may be mediated by
ablation of the lipogenic gut hormone gastric inhibitory peptide (GIP):
evidence and clinical opportunity for development of new obesity-related
drugs? Diab Vasc Dis Res 2007;4:150–152.
2. Wickremesekera K, Miller G, Naotunne T, et al. Loss of insulin
resistance after Rouxen-Y gastric bypass surgery: a time course study.
Obes Surg 2005;15:474–481.
3. Laferrere B, Heshka S, Wang K, et al. Incretin levels and effect are
markedly enhanced 1 month after Roux-en-Y gastric bypass surgery in obese
patients with type 2 diabetes. Diabetes Care 2007;30:1709–1716.
4. Korner J, Bessler M, Cirilo LJ, et al. Effects of laparoscopic Roux-en-
Y gastric bypass surgery on fasting and postprandial concentrations of
plasma ghrelin, PYY and insulin. J Clin Endocrinol Metab 2005;90:359–365.
Competing interests:
None declared
Competing interests: No competing interests
Dietary advic after bariatric surgery
Emanuele Cereda MD (1), Carlo Pedrolli MD (2).
(1) International Center for the Assessment of Nutritional Status
(ICANS) – Dipartimento di Scienze e Tecnologie Alimentari e
Microbiologiche (DISTAM), Università degli Studi di Milano, Italy.
(2) Dietetic and Clinical Nutrition Unit, Trento Hospital, Trento,
Italy.
It is very difficult, as in the article by Left and Heath [1], to say
many things in little space. Accordingly, with regard to dietary advice
to give patients after bariatric surgery, an effort was made to assure
that also nutritional aspects are considered, with the authors arguing for
basic principles similar for all procedures. However, this statement is
not to be intended as that “one way fits all”. As clearly highlighted by
the authors, also specific advice should be taken into account. These
have been recently provided by the American Association of Clinical
Endocrinologists, the Obesity Society, and the American Society for
Metabolic & Bariatric Surgery [2]. Few days after the surgical
procedure, generally 10-14 days, patients must be switched from common to
specific nutrition and meal-planning, particularly focused on fluids,
protein and micronutrients intake and depending on the type of procedure.
But there is even more.
Indeed, refeeding after surgery is a key task. General principles have
been reviewed and guidelines are available. However, also individual
treatment options do exist and these are the result of several issues
integration such as harms, benefits and quality of life [3,4]. After
surgery, an enhanced recovery may be the primary goal but with regard to
bariatric surgery we want to emphasize that several purposes lie behind
nutrition planning. Dietary advice is focused on education to achieve a
healthy diet, on how to achieve weight loss and, simultaneously, maintain
nutritional balance (micronutrients) best. Interest is also devoted to the
avoidance of complications, discomfort and side effects and, last but not
the least, to the long-term maintenance of weight loss results.
Refeeding after surgery is a great challenge [3], after bariatric surgery
probably even more.
References
1. Leff DR, Heath D. Surgery for obesity in adulthood. BMJ.
2009;339:b3402.
2. Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo
-Clavell ML, Spitz AF, et al. American Association of Clinical
Endocrinologists, The Obesity Society, and American Society for Metabolic
& Bariatric Surgery medical guidelines for clinical practice for the
perioperative nutritional, metabolic, and nonsurgical support of the
bariatric surgery patient. Obesity (Silver Spring) 2009;17(suppl 1):S1-70.
3. Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters
P; DGEM (German Society for Nutritional Medicine), Jauch KW, Kemen M,
Hiesmayr JM, Horbach T, Kuse ER, Vestweber KH; ESPEN (European Society for
Parenteral and Enteral Nutrition). ESPEN Guidelines on Enteral Nutrition:
Surgery including organ transplantation. Clin Nutr 2006 Apr;25(2):224-44.
4. Cereda E, Pedrolli C. A.S.P.E.N. Recommendations for Enteral
Nutrition: Practice Is the Result of Potential Benefits, Harms, Clinical
Judgment, and Ethical Issues. JPEN J Parenter Enteral Nutr 2009; IN PRESS
Corresponding author:
Emanuele Cereda MD,
International Center for the Assessment of Nutritional Status (ICANS) –
Dipartimento di Scienze e Tecnologie Alimentari e Microbiologiche
(DISTAM),
Università degli Studi di Milano,
via Botticelli 21, 20133 Milan, Italy.
E-mail: emanuele.cereda@virgilio.it
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
I read with interest your review of Surgical Treatments for obesity
in adulthood. I was interested to read that "In the United Kingdom,
funding for bariatric surgery must be applied for on an individual patient
basis from the primary care trust, which must apply the NICE guidelines in
its selection process". My experience is that this is not happening in
practice.
In my work as a General Practitioner I have been supporting a young
patient with morbid obesity and associated depression. With involvement of
secondary care psychiatry and specialised dietician services she is doing
a little better, but in spite of this intensive input her BMI remains very
high at 54+. We therefore discussed with the patient and her partner
referral for consideration of gastric banding or other bariatric surgery,
knowing that she met the NICE guidance for referral. She welcomed the
possibility of having bariatric surgery, and knowing that she met the NICE
criteria we did not foresee any problem referring her to our local
services. However, when I contacted the Local Health Board (LHB) to
inquire about the local referral process I was shocked and very upset to
then discover that the LHB is not honouring the criteria for bariatric
surgery that are stated by NICE. Several other criteria are added so that
my patient would not qualify, even if her BMI were to rise to 60 or 70
kg/m2; she would not qualify unless she had other conditions such as
hypertension uncontrollable by multiple medications by secondary care,
uncontrollable diabetes, etc. I was then left with the difficult task of
telling my patient this news. Perhaps I had been naive in assuming that
services were being offered in line with NICE guidance (though the authors
of the BMJ review stated themselves that bariatric surgery MUST be funded
in line the the NICE guidance), but I would never have offered the
possibility of referral to my already vulnerable patient had I realised
that the funding is NOT being offered as recommended by NICE.
Unfortunately I suspect that I am not alone in my inability to refer
patients for this cost-effective intervention in line with
recommendations.
Yours faithfully,
Dr Nicola Jones
Competing interests:
None declared
Editorial note
The patient whose case is described has given signed informed consent to publication.
Competing interests: No competing interests
Body Contouring Post-Bariatric surgery
Dear Sirs,
Your article on “Surgery for Obesity in adulthood” in September’s BMJ
although informative lacked any mention of a well recognised and important
factor of excess skin and soft tissue laxity after “bariatric surgery”.
Body contouring surgery is performed predominantly in the U.K by Plastic
Surgeons. The impact of a large increase in the numbers of patients
suitable for post bariatric revisional surgery may be enormous and has not
to our knowledge been highlighted by the government or health press.
Patients who lose a large amount of weight can be left with damaged,
stretched skin, which having lost its filling beneath, becomes loose and
hangs in festoons down the patient's body. Body areas typically affected
include the arms, breasts, abdomen, back, and thighs. This soft tissue
excess leads to interference with daily activities, chronic skin
infections, difficult hygiene and continued poor self-esteem. This
unintended result may not be addressed in preoperative counselling by the
bariatric surgery team.
Many centres in the USA recognise this problem and include plastic
surgeons in the MDT (1,2). As Mitchell et al. (3) point out, little
literature is available addressing how frequently patients who have
undergone bariatric surgery receive or desire body contouring surgery. In
this questionnaire study to patients who had undergone Roux-en-Y gastric
bypass surgery, over 50 % of patients had some form of subsequent body
contouring surgery. The most common procedures were abdominoplasty
(24.3%), breast lifts (8.6%), and thigh lifts (7.1%).
The National Bariatric Surgery and Massive Weight Loss Body
Contouring Survey (5) was sent to 500 members of the American Society for
Metabolic and Bariatric Surgery in order to better understand the
perspectives of bariatric surgeons toward body contouring procedures and
referral patterns to plastic surgeons. Sixty-four percent of surgeons
surveyed reported that patients ask about body contouring procedures
before bariatric procedures. Fifty-one percent of surgeons reported that
patients who have undergone body contouring procedures are overall more
satisfied with their decision to undergo bariatric surgery than those who
have not had body contouring.
The article by Daniel Leff and Dugal Heath (Surgery for obesity in
adulthood
BMJ 2009; 339: b3402) makes no mention of body contouring and it would
appear we are well behind the USA in recognising this matter. Even the
NICE guidance (4) mentions only once the “need for apronectomy” and quotes
this figure at 10% in 3 years however this is not referenced.
It is our experience that post bariatric surgical patients can be
nutritionally deficient, the surgical time and post operative stay longer
and risk of complications/co morbidities is higher. We are concerned that
the financial implications and capacity for caring for this patient group
in the NHS has not been sufficiently highlighted. Nationally there needs
to be more incorporation of Plastic Surgeons into the planning of
resources and multidisciplinary care for these patients
Yours,
Simon Filson MBBS MRCS
ST2 Plastics
Anna Barnard and Keith Allison
1.)Lockwood T. Lower body lift with superficial fascial system
suspension. Plast Recon Surg. 1993;92:1112–1122.
2) Taylor J, Shermak M. Body contouring following massive weight loss.
Obes Surg. 2004;14:1080–1085. [PubMed]
3.) MITCHELL James E. ; CROSBY Ross D. ; ERTELT Troy W. ; MARINO Joanna M.
; SARWER David B. The Desire for Body Contouring Surgery after Bariatric
Surgery. Obesity surgery ISSN 0960-8923
4.) Clegg AJ, Colquitt J, Sidhu MK, Royle P, Loveman E,Walker A. The
clinical effectiveness
and cost-effectiveness of surgery for people with morbid obesity: a
systematic review
and economic evaluation. Health Technol Assess 2002;6(12).
5.) Warner JP, Stacey DH, Sillah NM, Gould JC, Garren MJ, Gutowski KA.
National bariatric surgery and massive weight loss body contouring survey.
Plast Reconstr Surg. 2009 Sep;124(3):926-33.
Competing interests:
None declared
Competing interests: No competing interests