Experts dispute bariatric benefits

A DISPUTE has erupted between Australian experts over the use of bariatric surgery to treat obesity.

Professor Gary Wittert, an endocrinologist and obesity researcher, suggested that bariatric surgeons could not be trusted to provide the right procedure for individual patients with obesity, claiming lap band surgery should not be offered in the public health system because of its high failure rate.

Professor Wittert, who is also head of the Discipline of Medicine at the University of Adelaide, told MJA InSight the availability of publicly funded gastric banding in South Australia had led to a “rapidly increasing number of people, particularly with type 2 diabetes, whose clinical problems have been as a result of failed lap bands”.

However, Professor Paul O'Brien, emeritus director of the Centre for Obesity Research and Education at Melbourne’s Monash University, has strongly condemned Professor Wittert’s comments, saying they were based on “anecdotes from his hospital” rather than on the basis of randomised controlled trials.

Professor O’Brien said both gastric banding and gastric bypass required “competent operative technique and follow-up to get reasonable results”.

The debate was sparked by a longitudinal study published in this week’s MJA that suggested it would be feasible to expand public access to bariatric surgery in Australia. (1)

The study, which included obese patients aged 21–73 years with comorbid conditions who underwent publicly funded bariatric surgery, aimed to determine whether the benefits of bariatric surgery seen in the private hospital system could be replicated in the public system, for patients demonstrating commitment to postoperative lifestyle changes.

Among the 65 patientswho chose to receive either banding (n = 8) or sleeve gastrectomy (n = 57) through a publicly funded pilot, weight loss averaged 40 kg by 24 months after surgery.

At 6 months post-surgery, full resolution of comorbid conditions occurred in half of patients with diabetes at baseline, one-third of those with hypertension and almost half of those with obstructive sleep apnoea.

The authors wrote that if an obese person with type 2 diabetes mellitus had bariatric surgery, “the operation would pay for itself after about one year”.

“The health potential from bariatric surgery ranges from improved quality of life and amelioration of comorbid conditions to full resolution of complications and reduced mortality for all individuals, paying or not.”

They called for strategies to prioritise access to bariatric surgery for the poor, saying: “limited access to surgery discriminates against those who cannot afford the out-of-pocket costs, yet it is likely that this subgroup would benefit most”.

In an accompanying editorial, Professor Mark Harris, director of the Centre for Primary Health Care and Equity at the University of NSW, wrote that surgery should not be considered a last resort in managing patients with obesity, saying procedure choice should be individualised. (2)

Professor Harris said surgery was “most effective when it is part of a multidisciplinary approach that includes diet, physical activity and psychological support”.

Professor Wittert told MJA InSight the gold standard operation was Roux-en-Y gastric bypass, arguing that GPs had a “moral obligation to make sure they can advocate for their patients by informing them of the pluses and minuses of the different kinds of procedures and referring them to the surgeon who can do the procedure that will most benefit them”.

“It is reasonable for patients with type 2 diabetes to have a choice between a sleeve and a gastric bypass, but they should be counselled about the relative disadvantages of having a lap band.”

Professor Wittert cited a study he coauthored last year of patients undergoing gastric banding or bypass at the Royal Adelaide Hospital, which found 9% of the bands resulted in long-term complications requiring corrective procedures, compared with 2% of bypass operations. (3)

However, Professor O’Brien pointed to a systematic review he coauthored that showed no difference in weight loss between banding and bypass but significantly more deaths in the bypass group. (4)

He also cited two randomised controlled trials of gastric bypass and one of gastric banding that suggested both were highly effective in resolving diabetes, with up to 75% of patients experiencing remission. (5), (6), (7)

However, banding was a “gentle” outpatient procedure, which was “easily and fully reversible”, Professor O’Brien said.

Respected Sydney nutritionist and author, Dr Rosemary Stanton, said many obese patients “failed” at dieting because they expected a miracle.

“Realistically, even on strict supervised diets, weight loss of 1kg per month is the most that can be expected”, she told MJA InSight.

Dr Stanton urged GPs to lobby the government to make it possible for patients to visit an accredited dietitian on Medicare, urging doctors “not to give up on the patient whose lack of motivation is due to past [diet] failure”.

1.    MJA 2014; 201: 218-222
2.    MJA 2014; 201: 184-185
3.    World J Gastroenterol 2013; 19: 6035-6043
4.    Ann Surg 2013; 257: 87-94
5.    NEJM 2012; 366: 1577-1585
6.    JAMA 2013; 309: 2240-2249
7.    JAMA 2008; 299: 316-323

(Photo: Jim Varney / Science Photo Library)