The NHS should significantly increase rates of bariatric surgery to 50,000 a year, closer to the European average, to bring major health benefits for patients and help reduce healthcare costs in the long term, according to a paper published in The BMJ. The paper states that between 2011-12 and 2014-15, the number of bariatric operations performed on the NHS fell by 31% - from 8,794 to 6,032, and less than 1% of those who could benefit get treatment. This is in stark contrast to provision in many European Union countries, as the UK currently ranks 13th out of 17 for EU countries and sixth in the G8 countries for rates of bariatric surgery. This is despite the UK having the second highest rate of obesity in Europe, and sixth internationally.
In the paper, ‘Why the NHS should do more bariatric surgery; how much should we do?’, the authors examine the clinical and cost effectiveness of bariatric surgery and examine the barriers to access.
“Increasing surgery rates to 50 000 a year, which is closer to the European average, could have major benefits for patient health and reduce direct healthcare expenditure within two years.”
With regards to the effectiveness of surgery the cite the Swedish Obese Subjects study (SOS), which reported weight loss being maintained for 20 years, with glycaemic control improved for at least ten years after surgery. In addition, surgical patients were more likely to go into glycaemic remission of diabetes and fewer patients progressed from pre-diabetes to diabetes. This study also noted that the average weight loss was 25-35% of body weight (usually at least 15 kg) after one year for patients who are severely obese and 15-25% after 20 years. This is compared with an average 7% weight loss achieved by patients undergoing an intensive lifestyle weight management programme or weight loss drugs.
Furthermore, data from the UK National Bariatric Surgical Registry showed that over 3,000 patients with diabetes who had bariatric surgery (between 2011 and 2013), some 65% had acceptable glycaemic control without medication after surgery.
The authors also state that bariatric surgery is cost effective compared with non-surgical treatments and a UK health technology assessment concluded that bariatric surgery for patients with BMI≥40 results in an incremental cost effectiveness ratio for of between £2000 and £4000 per quality adjusted life year (QALY) gained over 20 years. In addition, the diabetic and patients with BMI 30-39 the incremental cost effective ratio was £1367 per QALY gained. This is substantially below the £20,000 per QALY threshold for cost effectiveness used by the National Institute for Health and Care Excellence (NICE). They also argue that the cost of surgery is justified as a diabetic will need prescriptions, this costs alone is recouped within three years of surgery
According to guidance from the National Institute for Health and Care Excellence, surgery should be considered for the “severe obesity in whom all non-surgical measures have been tried without achieving or maintaining adequate weight loss” – this equates to some 1.6 million people in the UK who have a BMI>40.14.
In addition, there are another half a million people with diabetes and other obesity related disease with BMI≥35. An extra 60,000 people a year reach a BMI40 and the number of people with type 2 diabetes has also increased by 60% over the past decade (to 3.3 million or 5% of the adult population), with 9.5% of adults predicted to have the condition by 2030 (190,000 new patients each year). Despite this, bariatric surgery procedures have reduced dramatically in the UK, with no NHS operations in Northern Ireland and few in Wales and Scotland.
“Given the severity of the problem, it seems urgent to consider the potential barriers to surgery,” the authors note.
They reported mean weight loss of 45.6kg (range 16.1–112.7), percentage body weight loss of 33.2% (range 11.4–55.4), and percentage excess body weight loss of 71.8% (range 23.2–138.3)
The outcomes showed that there were no deaths, although there were two (3.2%) 30 day and five (4.0%) late (>30 day) complications.
The procedure was also seen as a success by patients who, when asked, 96% of patients said that they would elect to have the operation again, with 82.4% of patients reporting a vast improvement in their quality of life
Wednesday, March 16, 2016 - 12:07
Owen Haskins - Editor in chief, Bariatric News
The first early outcomes from UK from centre in the UK on mini gastric bypass (MGB), ‘Mini Gastric Bypass: first report of 125 consecutive cases from United Kingdom’, published in the journal Clinical Obesity, has reported that the results are ‘encouraging’ with acceptable weight loss, comorbidity resolution rates and complication profile. Although the study authors, from Sunderland Royal Hospital, Sunderland, UK, acknowledge that longer term follow-up data with greater patient numbers are required to confirm these outcomes, the study nevertheless “demonstrates early safety and efficacy of MGB in a carefully selected British obese population in a high-volume centre.”
The study authors note that there are several apparent advantages of the MGB compared with the RYGB, including the single anastomosis, shorter learning curve, fewer internal defects for herniation and ease of revision or reversal. However, due to concerns the procedure can cause symptomatic biliary reflux and the risk of gastric/oesophageal cancer has so far limited general acceptance of the procedure.
They subsequently designed a retrospective cohort study to report their experience with an initial cohort of 125 consecutive MGB patients starting in October 2012 (ended November 2014), with the first three procedures were performed with the help of an experienced MGB surgeon from abroad. As the majority of the patients at the study centre currently undergo a gastric bypass (either RYGB or MGB), all patients were considered to be included in the study, although the presence of Gastro-Oesophageal Reflux Disease (GORD) and/or hiatus hernia was a contraindication to MGB. However, patients with perceived technical difficulty for RYGB (super-obese, male, apple shaped body habitus), were offered MGB.
The authors developed the following standardied technique for performing MGB: Closed pneumoperitoneum was established using optical insertion of 12mm port. This port was then used for camera insertion. Two further 12mm and one 5mm ports were used as working ports. A subxiphoid tract was created using 5mm port for insertion of Nathanson liver retractor. A long gastric pouch was created using Covidien TriStapler 45mm and 60mm Purple and Tan cartridges. Dissection was started at incisura and the first firing was carried out with stapler pointing towards the left iliac fossa.
A 36 French oro-gastric tube was used for pouch calibration in most cases (KM does not use it anymore). Omentum was not routinely divided. A loop of small bowel 200 cm from DJ flexure was then brought up to the gastric pouch in an ante colic, ante gastric fashion and anastomosed to it using Covidien Tristapler 45 mm Tan/Purple cartridge. Stapler entry site was then closed using 2/0 Vicryl in two layers. No attempt was made to close Petersen's defect and a leak test was performed using a dilute methylene blue solution. No drains were used.
From October 2012 to November 2014, 125 patients underwent MGB procedure a majority (68.8%) of these patients were female. The mean age of patients in this series was 45 (range 20–70) years, mean weight and BMI was 135.8 (range 85–244) kilograms and 48.1 (range 34.5–73.8), respectively. The mean operative time was 92.4 (range 45–150) minutes and the mean post-operative hospital stay was 2.2 (range 2–17) days (median 2.0 days). Fourteen patients had had previous bariatric intervention (13 balloon insertions, one sleeve gastrectomy).
The outcomes showed that there were no deaths, although there were two (3.2%) 30 day and five (4.0%) late (>30 day) complications.
The study authors noted 100% follow-up and the mean follow-up was 11.4 months. They reported mean weight loss of 45.6kg (range 16.1–112.7), percentage body weight loss of 33.2% (range 11.4–55.4), and percentage excess body weight loss of 71.8% (range 23.2–138.3). Figure 1 shows mean weight loss for the whole cohort at six, 12, 18 and 24 months with respective numbers available for follow-up at each time.
Figure 1: Weight loss after Mini Gastric Bypass. EWL, excess weight loss; TWL, total weight loss (Source: Clinical Obesity, John Wiley & Sons)
At the start of the study, 33 (26.4%) patients has T2DM and all noticed improvement/resolution of their diabetes; 16 of the 33 (48.4%) patients were on Insulin preoperatively; 13 of them were able to stop their Insulin and the remaining three have seen reduction in their insulin doses. Eight patients have gone into remission. In addition, from 45 hypertensive patients, 13 (29%) have stopped anti-hypertensive medications and 22 (49%) have reduced their medications.
The procedure was also seen as a success by patients who, when asked, 96% of patients said that they would elect to have the operation again, with 82.4% of patients reporting a vast improvement in their quality of life.
“It is worth noting that RYGB still accounts for approximately 75% of the surgical procedures performed within our unit and MGB accounts for an approximate 15%,” they write. “Over the years, we also seem to be recommending MGB for the patients, who in the past were offered sleeve gastrectomy for perceived technical difficulty.”
They also comment on the link between MGB and the risk of gastric and/or oesophageal cancer, and state that they cannot find any evidence that the MGB procedure puts patients at a higher risk of cancers in the long term. Despite the lack of data, they do acknowledge that MGB will continue to be ignored by some critics who claim a lack of long term, in spite of a similar lack of long term data for gastric banding and sleeve gastrectomy.
“Other surgeons are well advised to make themselves aware of all the technical and controversial aspects of this procedure before embarking on it,” they write. “As we have seen it in our practice, even in the hands of experienced bariatric surgeons, this operation has a definite learning curve. The authors believe time is now ripe for a well-designed, multicentre, adequately powered randomised controlled trial comparing MGB with RYGB and sleeve gastrectomy.”
Omega-loop gastric bypass (OLGB) or Mini gastric bypass results in better weight loss (WL) compared to Roux-en-Y gastric bypass (RYGB), according to a retrospective study by researchers from the Medical University of Vienna, the Karl Landsteiner Institute for Obesity and Metabolic Diseases, Vienna and the Special Institute for Preventive Cardiology And Nutrition (SIPCAN), Salzburg, Austria. The study, ‘The Effect of Roux-en-Y vs. Omega-Loop Gastric Bypass on Liver, Metabolic Parameters, and Weight Loss’, published in Obesity Surgery, also reported that OLGB resulted in an increase of liver parameters in the first year after surgery, whist deteriorating after RYGB.
“The impact of these results on hepatic outcomes such as non-alcoholic steatohepatitis and fibrosis progression requires further studies. In both groups, improved insulin resistance and sensitivity were correlated with higher WL and lower liver fat percentage, respectively,” the authors write. “It remains unclear what induces the bimodal alteration in liver transaminases and cholestatic parameters during the early postoperative phase and also after 12 months.”
Due to the lack of data, the aim of the study was to compare the development of hepatic and metabolic markers as well as WL between the two surgical procedures during the first postoperative year. It is known that bariatric surgery can adversely affect the liver with several case reports of patients with early hepatic failure after surgery.
Therefore, the aim of this evaluation was to provide data on the development of hepatic and metabolic markers as well as on WL in morbidly obese patients undergoing either Roux-en-Y gastric bypass or omega-loop gastric bypass during the first 12 postoperative months to facilitate the design of studies in larger populations.
The authors stated that all procedures were performed by the same surgical team using a laparoscopic approach. RYGB consists of a longitudinal 30ml gastric pouch which is anastomosed end-to-side with the jejunal limb and a latero-lateral jejuno-jejunal anastomosis resulting in a biliopancreatic limb of approximately 80cm and an alimentary limb of approximately 150cm . Omega-loop gastric bypass is a simplified procedure that consists of a unique gastrojejunal anastomosis between a 30–40ml sleeve gastric pouch and a jejunal omega loop of 200cm.
The researchers retrospectively evaluated the respective parameters in non-diabetic morbidly obese patients who underwent either RYGB (n=25) or OLGB (n=25). The baseline charactistics were as follows: RYGB (n=25, female=92 %, 44.6 ± 10.3a, 125 ± 18 kg, BMI 45.6 ± 4.1) and OLGB (n=25, male=88 %, 43.8 ± 13.1a, 128 ± 24 kg, BMI 45.3 ± 5.3).
The results revealed that WL (mean ± SD) was 30 ± 9 vs. 38 ± 7 % (%BMI loss), which equals a percentage excess WL (%EWL) of 94 ± 36 vs. 127 ± 31 % or percentage excess BMI loss (%EBMIL) of 67 ± 22 vs. 88 ± 16 % in RYGB vs. OLGB after 12 months (OR = 1.19; 95 % CI = 1.11–1.27; p<0.001).
With regards to liver function, aspartate transaminase (AST), a significant group and time difference could be found, whereas alanine transaminase (ALT) dropped in Roux-en-Y gastric bypass, while rising in omega-loop gastric bypass with a significant group and time difference. Moreover, a positive correlation could be found between ALT, surgical method (r = 0.406, p = 0.006) and De Ritis ratio >1 (r = 0.451, p = 0.002) at 12 months. There was no correlation observed between WL, ALT, and AST was observed.
Initially, Omega-loop gastric bypass group showed a significant higher count in platelets, this difference disappeared at three months. Nevertheless, a difference between the groups, as well as a negative correlation with WL (r = −0.346, p=0.002) was found.
A significant group and time interaction also could be found for prothrombin time, as well as a significant increasing proportion of low prothrombin time in omega-loop gastric bypass at three months (RYGB vs. OLGB; operative date: 8 vs. 0 %, n.s.; three months: 5 vs. 8 %, p<0.05). A negative correlation between prothrombin time and WL was found in omega-loop gastric bypass (r = −0.543, p<0.001).
No differences appeared in the course of albumin, while protein diminished significantly over time and group. A negative correlation between protein and WL in both groups (r = −0.428, p<0.001), as well as for albumin and hsCRP (r = −0.611, p<0.01) in omega-loop gastric bypass was found at six months.
The authors also report that in the RYGB group, gamma-glutamyltransferase (GGT) significantly decreased by nearly half of the initial value, while it remained stable in OLGB and a significant group and time difference was found. Younger patients (<50 years) had a greater chance of lower GGT quartiles over time (p<0.001; adjusted for initial BMI). A negative correlation between GGT and WL could be seen in Roux-en-Y gastric bypass (p<0.001).
“The superiority of omega-loop gastric bypass over Roux-en-Y gastric bypass in terms of WL was demonstrated in previous studies, as well as in our study. We did not observe any influence of gender, age, or preoperative BMI on WL regardless of the procedure…Importantly, we could not detect a correlation between liver transaminases and WL,” they write.
NAFLD liver fat score showed a significant higher proportion of NAFLD in RYGB until six months (13 vs. 5 %, n.s). Liver fat percentage showed a similar development with a significant difference over time, and a strong correlation could be found between liver fat percentage and HOMA2-IR (p<0.001); QUICKI (p<0.001); AST (p<0.001); ALT (p<0.001); and TG (p<0.001) in both groups.
Glucose significantly decreased in both groups until one year. Insulin was significantly higher in RYGB post-operatively, although no group and time interaction could be found.
“Given the potential for worsening fibrosis following bariatric surgery, patients should be monitored closely and continue to undergo through hepatological workup, including non-invasive testing for fibrosis or, even liver biopsy. More research in this field, including histopathological data, is needed to define clinical relevance of these findings on hepatic outcome in terms of deterioration of non-alcoholic steatohepatitis and fibrosis and to characterise patients at risk,” the authors conclude. “In both groups, improved outcome in terms of insulin resistance and sensitivity could be found in correlation to higher WL and lower liver fat percentage, respectively.”