Bariatric Surgery Not a Final Resort; Call for New Guidelines

Marlene Busko

February 05, 2014

Bariatric surgery is effective and safe and may reverse diabetes, prompting calls for the 1991 US National Institutes of Health (NIH) guidelines on the topic to be revised.

The procedure has changed greatly in the 20-plus years since the NIH advice was issued, yet it still directs practice worldwide and effectively confines bariatric surgery to a "last-chance" treatment, say doctors in a series of 4 review articles, 2 comments, and an editorial published February 3 in Lancet Diabetes & Endocrinology.

Bariatric surgery "offers a real opportunity for preventing comorbid diseases and complications of obesity. If it is only used as a final resort, this opportunity will be missed," says the editorial.

"It's time for the NIH to reconvene to update its perspective on [guidelines for bariatric surgery], recognizing that they still are executing incredible influence on the practice and payment of surgery vs nonsurgical methods worldwide," David E. Cummings, MD, from the Diabetes & Obesity Center of Excellence at the University of Washington, in Seattle, told Medscape Medical News.

NIH Advice Guides Insurance, Limits Coverage

Dr. Cummings, who reviews the need for new guidelines beyond body mass index (BMI), says the 1991 NIH position statement (Ann Intern Med. 1991;115:956–961) restricts surgery to patients with a BMI greater than 40 kg/m² or greater than 35 kg/m² with comorbidities such as diabetes. This has become "the gold standard for who gets surgery ever since, far outside just the United States," he explained.

"Importantly, insurance companies pin their decision about who gets paid even for classical operations like gastric bypass from these 1991 guidelines," he continued. "If you were faced with a patient with a BMI of 33 and rip-roaring diabetes, you might think it's a good idea to do gastric bypass, but insurances won't pay for it."

On the plus side, the guidelines have standardized care around the world and have led to a growing body of evidence about the long-term risks and benefits of this type of surgery.

However, they were developed when the procedure was done as open surgery — either gastroplasty (which is no longer done) or gastric bypass, which was in its infancy. Now, "almost all bariatric procedures are done laparoscopically…[and] sleeve gastrectomy is bursting onto the clinical scene worldwide," Dr. Cummings explained.

Weight-Loss Surgery Much Safer These Days

Consequently, weight-loss surgery is now much safer. Laparoscopic bariatric surgery "has the same safety profile as a hip replacement and one-tenth of the mortality of coronary artery bypass," Alfons Pomp, MD, from the department of surgery at Weill Cornell Medical College, in New York City, who commented about the safety of the procedure, pointed out to Medscape Medical News.

Others echoed this. "The risks are still there, but they are not as high as previously thought (ie, the risk of death is <0.3% for gastric bypass in experienced centers, [which is] similar to [that for] a cholecystectomy)," Alexander D. Miras, MRCP, of Imperial College London, United Kingdom, told Medscape Medical News in an email. Dr. Miras reviewed bariatric surgery and glycemia control, weight loss, and end-organ health in his article.

On the benefits side, there are improvements in beta-cell function and fertility, and a lower risk for cardiovascular disease and fatty-liver disease following bariatric surgery, which "can be substantial, and the magnitude is probably much greater than what can be achieved through lifestyle modification or pharmacotherapy," Dr. Miras noted.

Who Else Does Bariatric Surgery Benefit?

"The question now is whether the operation would benefit other people who fail to qualify based on their degree of obesity," Dr. Cummings said. Type 2 diabetes is a chronic, relentless, progressive disease, he noted, "but if you have a gastric bypass, you have an 80% chance of going into full remission, [and] it's clear now that [these procedures] are effective at getting rid of diabetes in thinner people who lose less weight."

Dr. Miras says there is currently a lack of evidence to help inform who is more or less suitable for bariatric surgery. "It appears that patients with high fasting insulin levels stand to benefit the most from bariatric surgery in terms of cardiovascular mortality and morbidity…[and] the shorter the duration of diabetes the better the longer-term outcome."

Nevertheless, he stresses that it's important that patients who are contemplating surgery "consider that their life and eating behavior will change dramatically after surgery, and [they] should be prepared for these changes."

Dr. Miras and Dr. Pomp have reported no financial conflicts of interest. Dr. Cummings is a principal investigator on the COSMID trial, which is funded by Johnson & Johnson; disclosures for his coauthor are listed in the paper.

Lancet Diabetes Endocrinol. 2014;2:91, 98-100, 141-151, 175-181. Editorial Pomp comment Miras article Cummings article


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