Authors: A G N Robertson (Twitter: @robertson_a), T Wiggins (@TomWiggins23), F P Robertson, L Huppler (@LucyLucyHuppler), B Doleman, E M Harrison (@ewenharrison), M Hollyman (@misshollyman), R Welbourn
Obesity is the preventable and reversible disease of our lifetime. It is a worldwide health, economic and environmental problem in need of urgent and essential attention, and it has become clear that the world needs more than the traditional recommendations to survive this metabolic pandemic. The traditional advice has been acknowledged for centuries and even more so since the worldwide prevalence of obesity nearly tripled between 1975 and 20161. These lifestyle recommendations include physical exercise, less high calorific food content, balanced meals, optimising portion size, intermittent fasting and so on; we all know them. However, the human race is still falling short of tackling the major public health concern that this disease threatens to be.
Bariatric or weight loss surgery is a surgical sub-speciality which has been evolving since the first procedures of this type in the mid 20th century. Its development has led to the most effective method to achieve long-term weight loss, as well as the additional health benefits weight loss offers as a by-product. However, accessibility to this specialist treatment is limited with only 1% of eligible patients going on to receive bariatric surgery.2Reasons for this limited access are multifactorial, however a considerable factor is thought to be concerns regarding the perceived risks of weight-loss surgery from patients across all populations. We should therefore aim to give our patients the most up to date worldwide risk of mortality of these potentially life-saving procedures.
This month in the BJS, we’ve published the largest meta-analysis asking this question to date – and the findings are pivotal at providing a unanimous international statistic on this discussion. We’ve looked at perioperative mortality rates (inpatient, 30 day and 90 day mortality) of a range of bariatric procedures to include laparoscopic adjustable gastric band (LAGB), sleeve gastrectomy (SG), Laparoscopic Roux-en-Y gastric bypass (LRYGB), one-anastomosis gastric bypass (OAGB), biliopancreatic diversion/duodenal switch (BPD-DS) and other malabsorptive procedures. We’ve included 58 studies in our meta-analysis which has given us information on roughly 3.6 million patients over a 6-year period from worldwide practice. Multiple sources for data were used including administrative datasets, bariatric surgery registries, large scale case series as well as randomised controlled trials (RCTs).
The paper looks at mortality within each subgroup of operation. There are interesting findings within this showing significant differences in perioperative mortality between procedures (P<0.001) with biliopancreatic diversion/duodenal switch or other malabsorptive procedures having the highest perioperative mortality rates (0.41%) and laparoscopic adjustable gastric band (LAGB) followed by sleeve gastrectomy (SG) being the procedures with the lowest perioperative mortality rates (0.03% and 0.05% respectively). This naturally reflects the trend towards these latter procedures being offered more commonly in international practice. Although this paper looks closely at perioperative mortality it is noteworthy to mention that it doesn’t look at long term morbidity following these procedures or their potential complication rates.
Without a doubt, our most noteworthy finding has been the discovery that overall perioperative mortality following bariatric surgery is likely much lower than previously thought, with our pooled perioperative mortality rate at 0.08% (95% CI 0.06%-0.10%). It perhaps makes this statistic even more relatable when this is compared to other procedures we consider as ‘low-risk’ in our daily surgical practice. For example, laparoscopic cholecystectomy or fundoplication have comparable perioperative mortality rates reported at 0.1%. This new statistic is also lower than previously quoted in the literature from smaller scale studies. The mortality rate calculated in this meta-analysis puts bariatric surgery as a whole at lower risk of mortality as knee arthroplasty (0.3%)3. With this in mind, we hope that there can be a culture shift from avoidance of bariatric surgery due to risk, to giving patients the correct information to confidently weigh up the true risks and benefits of these procedures when indicated.
How should these findings shape the future of bariatric surgery in Europe and beyond? Certainly in the UK, the acceptability of bariatric surgery as a viable treatment option for obesity is limited. It is surprising how often we see patients who are eligible for bariatric surgery and who have met the criteria for some time yet to be offered this as a treatment option. There is a distinct barrier to accessing bariatric surgery for the wider population, perhaps due to taboo surrounding broaching the issue of weight in the primary care setting, and although many general practitioners do this very well, there remain limiting factors. Another stand-out factor includes lack of funding or commissioning within the public health service for referral for weight loss specialist services. Therefore, with the addition of this new internationally applicable statistic, our hope is that the most effective treatment option for sustained weight loss can now be available for all that require it. Bariatric surgery is safe.
- Welbourn R, le Roux CW, Owen-Smith A, Wordsworth S, Blazeby JM. Why the NHS should do more bariatric surgery; how much should we do? Bmj. 2016;353:i1472.
- Aminian A, Brethauer SA, Kirwan JP, Kashyap SR, Burguera B, Schauer PR. How safe is metabolic/diabetes surgery? Diabetes, Obes Metab. 2015; 17(2):198-201.
Image source: Eslam ibrahim66 2021 Creative Commons