In a Surgery

When Will We Get Real About Bariatric Surgery?

Yesterday, JAMA published five articles about bariatric surgery. Two new research papers. Three editorials. Taken together they present a picture of the compelling benefits of bariatric surgery in patients with both obesity and diabetes. But they also point to the gap between the reality of bariatric surgery and how we’re dealing with it.

Cutting the Risk of Strokes and Heart Attacks

The biggest news comes from a study by David Fisher and colleagues. They did an observational study of matched cohorts – patients with both severe obesity and type 2 diabetes. Their focus was major vascular disease episodes: strokes, heart attacks, and related events. After five years, the rate of these events in people who had surgery was 2.1 percent. For carefully matched control patients without surgery, the rate was more than twice as high – 4.3 percent.

It’s also worth noting that deaths occurred in 1.3 percent of the surgery patients, compared to 4.5 percent of the controls.

Of course, this was an observational study. Randomized studies of surgery are possible, but they’re rare. It’s tough to get people to agree to leave a decision about surgery to chance. Especially when it’s a potentially life-changing surgery.

The study authors note this limitation. They say that confirming these results will require a randomized study.

Relying on High Cost, Low Benefit Care

In a JAMA editorial, Adam Sheka, Keith Wirth, and Sayeed Ikramuddin explain why the current constrained access to bariatric surgery for these patients makes no sense.

Intensive medical care for patients with severe obesity and diabetes is expensive and it has modest benefits. As the current data show, these patients suffer serious and expensive complications. Yet health plans persist in limiting access. For a growing number of patients, it’s so ridiculous that they leave the country to pay for the surgery themselves in places like Mexico.

Getting Real About Comprehensive Care

The second major study in JAMA tells an important story about setting expectations and managing long-term care. Obesity is a chronic disease. Surgery is a good treatment that can put it into remission. But it’s not a cure. Everyone knows that some weight regain is typical. However, this subject is difficult for both doctors and patients to discuss.

Wendy King and colleagues fill that gap with solid facts. After diving deep into data from the LABS study, they offer good advice on how to measure weight regain and what to expect. The best measure of regain is expressed as the percent of maximum weight lost, they found. That’s because it does the best job of predicting health outcomes.

How much weight can a patient expect to regain? King et al found that after five years, the median experience was to regain 27 percent of the total weight they lost. Of course, they found plenty of variation, too.

The bottom line is that surgery is an important element of obesity care, but it’s not the end of the line. The pathophysiology of obesity is still at work in a patient, even after surgery. Good care means setting realistic expectations and planning for follow-up care.

The best care in the future will come from medical and surgical obesity teams working together for complete, long-term care.

Click here for the study by Fisher et al and here for the study by King et al. For the companion editorials, click here, here, and here.

In a Surgery, pastel by István Nagy / WikiArt

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October 17, 2018

2 Responses to “When Will We Get Real About Bariatric Surgery?”

  1. October 18, 2018 at 8:21 pm, John dixoon said:

    Answer:
    When we stop the blame, shame and emphasis on personal responsibility.

    Yes, this applies to those that have had bariatric surgery. So many are blamed and shamed for weight regain!

    As nations we must change the conversation.

    My view is that we will not effectively prevent or treat obesity, and it’s COMPLICATIONS, until we can dispel the dominating myths about obesity, and get serious about addressing this serious relapsing disease.

    Our approach to all chronic disease needs to be consistent. To work with, and engage the individual to maximize health outcomes by using a full range of lifestyle, and additional evidence based therapies, as iare required and acceptable for that individual.

  2. October 18, 2018 at 8:37 pm, Ted said:

    Amen, John.