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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)
I agree entirely with the comment from Belinda Cochrane. The serious conversation needs to take place about how to organise comprehensive and well coordinated multidisciplinary care that focuses on weight management for individuals who have significant health problems that compromise physical and psychological well-being, as a result of multi-comorbidity. But it is not only quality-of-life that is affected; the direct and indirect costs including the impact on workforce engagement are substantial. The benefits of just 5 to 7% weight loss are profound for the majority of patients, and in some cases enormous benefit can be obtained is so far as reducing chronic disease burden is concerned by optimising macronutrient intake, reducing sedentariness or increasing physical activity even if weight does not change much.
This topic raises issues far more important than which type(s) of bariatric surgery are effective. Obesity and nictoine dependence are the two issues most crucial to health outcomes in Australians. At present, many Australians do not have access to coordinated obesity services and our alcohol and drug services are not resourced to take on nicotine dependence. As a nation, until we recognise the need to invest sufficient funding towards achieving healthy weight and smoking cessation, we will not improve health outcomes. Moreover, if we could impact the obesity problem and reduce smoking rates, then we would reap the benefits (as savings on the cost of treating cardiovascular disease, diabetes, chronic lung disease and cancer).
Let’s put the patient up front for a few minutes and ask what their key to success was. Number one is being in the right “head space” and this is best achieved from being properly informed and prepared (both physically and psychologically) before bariatric surgery. This can only be done by initially talking to all involved, i.e. surgeon, GP, dietitian and psychologist as well as other patients who have had the procedure, both recently and many years ago. Many of us are psychological eaters and without a program of extended help from a psychologist, bariatric surgery for vast majority will NOT enjoy the longevity of true success and can sometimes leave patients in a worse off state.
Common extract I hear from obese patients: FEAR of isolation starting from my GP. Sends me, to see a dietitian (2 weeks) back to the GP (another week), sends me off to a Diabetic Educator (2 weeks) back to GP (another week) sends me to an endocrinologist (4 weeks) back to the GP, then finally to Bariatric Surgeon (4 weeks) ……… 7 visits over 4 months ….. I am sure you see where this is going. To have bariatric surgery after such ordeal and to expect that patient to have their head in the right space is not only ludicrous but dangerous. From the time they started their journey their condition is likely to have changed, meaning the original advice may no longer apply. All team members have to work together and simultaneously.
Therefore in our opinion, the essential components for all patients are a complete multidiscipline clinic, including psychological program which allows patients the time necessary to prepare both physically and psychologically for such a life changing experience. This is irrespective of whichever operation they have.
The vast majority of severely obese people have excess energy consumption which is not primarily driven by psychological reasons. It is true however, that many of these non-psychological eaters will also develop some “psychological eating” when other issues emerge as a result of their significant obesity.
People who are predominantly “psychological eaters” should not have bariatric surgery unless their psychological issues are being addressed by a clinical psychologist who believes that these issues can be overcome. Studies to date have not examined this issue in adequate detail and simply doing a validated psychological questionaire or having one standard clinical interview with a clinical psychologist is not enough, hence why there are only negative studies in this area.
People however who have non psychological eating related severe obesity, a significant obesity related co-morbidity and who have attempted a well supported and coordinated multidisciplinary weight loss program over a period of 12 months or more, should be offered publically funded bariatric surgery if they still have co-morbidities that will benefit from further weight loss. This is not only important from a longevity and quality of life perspective, but also is a more cost effective approach than simply medicating each illness which arises directly as a result of the obesity.
Long term follow up is now being addressed with the recent introduction of the National Bariatric Surgery Registry. I would recommend that patients only use surgeons who have enrolled in the registry.
Prof O’Brien comments are unfortunately somewhat disingenuous given that he’s out on a limb in relation to the majority of published studies almost all producing results considerably less optimistic than his own.
Taking a close look at his published work the majority, and possibly all of it, acknowledge support from manufacturers of the band. There is, accordingly, a conflict of interest.
An objective analysis of the literature shows quite clearly that the placement of a laparoscopic adjustable gastric band results in significantly less weight loss, a lower likelihood of resolution of comorbidities, a greater likelihood of disordered eating and a significant probability causing gastro-oesophageal reflux and significant oesophageal dysmotility. It is a procedure that the rest of the world has largely abandoned.
In our hospital well over 1000 Roux-en-Y gastric bypass procedures have been carried out with zero mortality and absolutely outstanding benefit in terms of weight loss and resolution of comorbidities. The procedure is reversible and the long term complications considerably less than what occurs after a band.
General practitioners have an obligation to provide their patients with objective information about the risks and benefits of each procedure particularly in relationship to their particular situation and risk profile. To simply send a patient to a surgeon who generally only performs one procedure which may or may not be in that particular patient’s best interests is a dereliction of duty and care.
Prof O’Brien’s condemnation of my comments and inferences about the competence of his colleagues is regrettable. A problem of idiosyncratic local anecdote or denial of the bleeding obvious.
The physical aspects of losing weight are hard. But a patient’s understanding of the psychological factors of weight gain should be at the forefront of weight reduction and that is the truly hard part. Unfortunately this aspect is vastly undervalued and under financed in our society where the population has been hoodwinked into instant results. If we were as a society more educationally and psychologically savvy we would not have the “epidemic” facing us. As Rosemary Stanton says we love comfort foods to offset our underlying discomfort. Come to grips with the discomfort and life becomes much more fulfilling in many other ways which do not involve a dependence on high calorfic foods especially the sugar laden ones.
The question here is to what extent surgery can be used to address what is essentially an emerging public health crisis in this country. Diabetes Australia estimates that some 1.7 million Australians currently have (mostly type II) diabetes of whom about 1 million are diagnosed. If we include pre-diabetes the number increases to 3.2 million. By 2031 Diabetes Australia estimates that there will be 3.3 million full blown cases of (mostly type II) diabetes. About 100,000 new type II diabetics are diagnosed in Australia annually and this is about how many weight loss surgical procedures as would be necessary each year just to keep diabetes from increasing.
See http://www.diabetesaustralia.com.au/Understanding-Diabetes/Diabetes-in-Australia/
Surgical waiting list in Australia have been an issue for long time and if we went down the surgical route for tackling diabetes, an increase in surgical capacity of around 100,000 weight loss procedures per year would be necessary to keep surgical wating lists from blowing out further.
It is at this point that enhanced lifestyle interventions and public education begin to look more attractive.
I think we need more care with proper follow-up to determine the kind of diet followed long-term after gastric banding. Some people may learn to simply eat small portions of normal foods – the aim of the procedure. Others, especially those who have previously used food as a ‘comfort’, gradually revert to a poor diet, but this is not picked up by those involved in the initial gastric banding. We see some people slowly regain weight and their eating habits reveal why – desserts and many soft junk foods ‘slip down’ easily. Where are the follow-up studies on what many people with gastric bands consume several years down the track? And who will help these people deal with the real cause of their problem which is using sweet and fatty foods as comfort? Should it not be part of the original team’s responsibility?
Clearly any new interventions need to be supported by the best evidence available and hopefully well conducted randomised controlled trials are available. It is interesting that is argued that only those trials where the “best” surgery is performed (either the best surgeons or best operation) should be considered and not those with poorer outcomes. It follows of course that these surgical interventions should also be compared with “best” non-surgical interventions.
More generally, any discussion of the issue is more properly a choice of policies of intervention. Furthermore, the best medical and surgical interventions need to be routine practice and not just the justification for the procedure. Also, patient selection considerations may also be at play. At the simplest level, the treating clinician needs to ask if their patient is the same as those in the trials.