Re: Why the NHS should do more bariatric surgery; how much should we do?
Dear Editor
We welcome Welbourn and colleagues’ analysis of NHS provision for bariatric surgery (1). Bariatric surgery leads to improved outcomes for appropriately selected obese patients in a supportive environment.
We draw BMJ readers’ attention to the potential role of bariatric surgery in Prader-Willi Syndrome (PWS) for PWS awareness month in May. Since it was first eponymised 60 years ago, PWS has emerged as the most common genetic cause of life threatening obesity occurring in 1 in 13,000 to 1 in 30,000 births. PWS is typically characterised by neonatal hypotonia, lifelong hyperphagia, developmental delay, challenging behaviour and psychosocial disability. The neonatal period of early “failure-to-thrive” is followed by progressive hyperphagia and, if unchecked, morbid obesity.(2) Complications such as high blood pressure, diabetes, and obstructive sleep apnoea (OSA) are common to both PWS and non-genetic obesity, but PWS confers an additional constellation of health risks such as growth hormone deficiency, hypothalamic dysfunction, altered pain threshold and impaired vomiting reflex. Recent advances in early genetic diagnosis, growth hormone intervention, calorie restriction, educational and psychological support have markedly improved the prognosis for PWS patients and families alike, but safe and effective appetite control treatment remains elusive.
Historically, surgical outcomes were poor in PWS patients who underwent legacy bariatric surgery such as biliopancreatic diversion (BPD), intragastric balloon, jejuno-ileal bypass, gastroplasty, gastric bypass, or vagotomy. Complications included recurrent weight gain, revision surgery, post-operative bleeding and death.(3) However, Alqahtani et al (4) recently reported significantly improved long term outcomes in a contemporary series of obese PWS patients who had laparoscopic sleeve gastrectomy (LSG) for refractory weight control. In 24 PWS patients (aged 4.9 to 18 years, average BMI 46 kg/m2, all with obstructive sleep apnoea and none on growth hormone), BMI change at 1-, 2-, 3-, 4-, 5- years’ follow up was -14.7, -15, -12, -12.7, -10.7 kg/m2 with no reported re-operations or deaths, and improvement or remission of OSA, hypertension, diabetes, dyslipidaemia in 95% of cases.
Currently, NICE obesity guideline [CG189] 2014 makes no specific recommendation for bariatric surgery in the obese PWS patient. Modern LSG techniques may have a role in the weight management of carefully selected patients, provided in a multidisciplinary team environment with lifelong food access control and calorie restriction.
Yours faithfully
Dr Robin Chung
Chair, research working group
Prader-Willi Syndrome Association UK
Derby DE24 8AA www.pwsa.co.uk
References
(1) Welbourn R, le Roux C W, Owen-Smith A, Wordsworth S, Blazeby JM. Why the NHS should do more bariatric surgery: how much should we do? BMJ 2016; 353:i1472. doi: http://dx.doi.org/10.1136/bmj.i1472.
(2) Miller JL, Lynn CH, Driscoll DC, Goldstone AP, Gold JA, Kimonis V, Dykens E, Butler MG, Shuster JJ, Driscoll DJ. Nutritional phases in Prader-Willi Syndrome. Am J Med Genet A. 2011 May;155A(5):1040-9. doi: 10.1002/ajmg.a.33951. Epub 2011 Apr 4.
(3) Scheimann AO, Butler MG, Gourash L, Cuffari C and Klish W. Critical analysis of bariatric procedures in Prader-Willi syndrome. Journal of pediatric gastroenterology and nutrition. 2008;46:80-3.
(4) Alqahtani AR, Elahmedi MO, Al Qahtani AR, Lee J and Butler MG. Laparoscopic sleeve gastrectomy in children and adolescents with Prader-Willi syndrome: a matched-control study. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2016;12:100-10
Competing interests:
Parent of child with Prader-Willi Syndrome
17 May 2016
Robin Chung
NIHR BRC cardiology fellow UCL and Chair, research working group
Rapid Response:
Re: Why the NHS should do more bariatric surgery; how much should we do?
Dear Editor
We welcome Welbourn and colleagues’ analysis of NHS provision for bariatric surgery (1). Bariatric surgery leads to improved outcomes for appropriately selected obese patients in a supportive environment.
We draw BMJ readers’ attention to the potential role of bariatric surgery in Prader-Willi Syndrome (PWS) for PWS awareness month in May. Since it was first eponymised 60 years ago, PWS has emerged as the most common genetic cause of life threatening obesity occurring in 1 in 13,000 to 1 in 30,000 births. PWS is typically characterised by neonatal hypotonia, lifelong hyperphagia, developmental delay, challenging behaviour and psychosocial disability. The neonatal period of early “failure-to-thrive” is followed by progressive hyperphagia and, if unchecked, morbid obesity.(2) Complications such as high blood pressure, diabetes, and obstructive sleep apnoea (OSA) are common to both PWS and non-genetic obesity, but PWS confers an additional constellation of health risks such as growth hormone deficiency, hypothalamic dysfunction, altered pain threshold and impaired vomiting reflex. Recent advances in early genetic diagnosis, growth hormone intervention, calorie restriction, educational and psychological support have markedly improved the prognosis for PWS patients and families alike, but safe and effective appetite control treatment remains elusive.
Historically, surgical outcomes were poor in PWS patients who underwent legacy bariatric surgery such as biliopancreatic diversion (BPD), intragastric balloon, jejuno-ileal bypass, gastroplasty, gastric bypass, or vagotomy. Complications included recurrent weight gain, revision surgery, post-operative bleeding and death.(3) However, Alqahtani et al (4) recently reported significantly improved long term outcomes in a contemporary series of obese PWS patients who had laparoscopic sleeve gastrectomy (LSG) for refractory weight control. In 24 PWS patients (aged 4.9 to 18 years, average BMI 46 kg/m2, all with obstructive sleep apnoea and none on growth hormone), BMI change at 1-, 2-, 3-, 4-, 5- years’ follow up was -14.7, -15, -12, -12.7, -10.7 kg/m2 with no reported re-operations or deaths, and improvement or remission of OSA, hypertension, diabetes, dyslipidaemia in 95% of cases.
Currently, NICE obesity guideline [CG189] 2014 makes no specific recommendation for bariatric surgery in the obese PWS patient. Modern LSG techniques may have a role in the weight management of carefully selected patients, provided in a multidisciplinary team environment with lifelong food access control and calorie restriction.
Yours faithfully
Dr Robin Chung
Chair, research working group
Prader-Willi Syndrome Association UK
Derby DE24 8AA
www.pwsa.co.uk
References
(1) Welbourn R, le Roux C W, Owen-Smith A, Wordsworth S, Blazeby JM. Why the NHS should do more bariatric surgery: how much should we do? BMJ 2016; 353:i1472. doi: http://dx.doi.org/10.1136/bmj.i1472.
(2) Miller JL, Lynn CH, Driscoll DC, Goldstone AP, Gold JA, Kimonis V, Dykens E, Butler MG, Shuster JJ, Driscoll DJ. Nutritional phases in Prader-Willi Syndrome. Am J Med Genet A. 2011 May;155A(5):1040-9. doi: 10.1002/ajmg.a.33951. Epub 2011 Apr 4.
(3) Scheimann AO, Butler MG, Gourash L, Cuffari C and Klish W. Critical analysis of bariatric procedures in Prader-Willi syndrome. Journal of pediatric gastroenterology and nutrition. 2008;46:80-3.
(4) Alqahtani AR, Elahmedi MO, Al Qahtani AR, Lee J and Butler MG. Laparoscopic sleeve gastrectomy in children and adolescents with Prader-Willi syndrome: a matched-control study. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2016;12:100-10
Competing interests: Parent of child with Prader-Willi Syndrome