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WEDNESDAY, May 25th, 2011 (www.drsharma.ca) — So now, that we have extensively discussed the issue of risk in previous posts, let us turn our view to the benefits of bariatric surgery.
In this discussion let us be very clear about the following:
1) Bariatric surgery does not, nor is it intended to, address the many ‘root causes’ of obesity. Its only raison d’être is to help patients with weight-related health problems sustain a degree of weight loss that is, for the vast majority of people (i.e. 19 out of 20), simply impossible to sustain with diet and exercise alone.
2) To be honest, bariatric surgery is not even about weight loss! To put it bluntly, the real reason to even consider bariatric surgery is because of its positive impact on comorbid conditions (which is why I refuse to call it weight-loss surgery or WLS). While many patients appreciate the fact that bariatric surgery may help them attain and sustain a lower body weight – the real benefit, at least from a medical perspective, can only be measured in improvements in health and quality of life. In fact, if ‘bariatric’ surgery only improved health (with no weight loss), it would still be a worthwhile intervention.
3) I have already addressed the issue or surgical risk vs. the risk of not having surgery in previous posts. Thus, readers will recall that even the surprisingly small risk of undergoing laparoscopic bariatric surgery, may exceed the risk of not having surgery in obese people, who are otherwise healthy. These are NOT the folks who should be strongly considering surgery. On the other hand, the more obesity-related complications the patient has, the smaller the relative risk of undergoing surgery. So, I am by no means advocating for simply operating on anyone who is obese. In any obese patient without comorbidities or significant impairment of quality of life, even the rather small risk of surgery is clearly not worth taking.
4) Surgery is not for everyone. As pointed out in previous posts, we turn away many patients, who may meet both the BMI and medical criteria for surgery because we do not think that they will be able to make or sustain the considerable lifestyle changes that are required for surgery to ’succeed’. Some patients may slip through the ‘cracks’ because they manage to convince (I will not say intentionally mislead) us to think they will cope, when they clearly will not. But we certainly do our very best to try and identify such patients and turn them away from surgery.
5) Surgery is invasive and traumatic! It impacts dramatically on normal gut anatomy and function. Whether it just restricts normal passage of food through the gut (as in adjustable gastric banding), reduces the size of the stomach (as in sleeve gastrectomy), or additionally reroutes food through the gut (as in gastric bypass or biliopancreatic diversion), surgery has a profound, and in most cases, permanent impact on the anatomy and functioning of the digestive system. Tampering with an essentially ‘healthy’ gastro-intestinal system should never be considered trivial. This amazingly complex system has evolved through eons of human evolution to serve one of the most important biological functions – to digest and assimilate our food and drink – our only source of nutrients and calories. The expectation that this system can simply be surgically tampered with, without some very significant and sometimes dramatic consequences, is both naive and irresponsible. Of course bariatric surgery entails risk and there are very real consequences – the only question is whether or not these risks and consequences outweigh the risk and consequences of leaving things as they are – a question that I will address in the following.
With these caveats out of the way, let us look at the potential benefits of surgery (and, please remember, I AM NOT A SURGEON!).
I will limit my discussion to people who have higher BMIs and do have significant comorbidities, because this is the population that we see in our clinic.
One of the most common comorbidities (about 30% of patients) is diabetes mellitus.
Let us look at what it means for a 40 year old (the average age of our patients) to be told they are diabetic.
The diagnosis diabetes means, that this patient will now have to begin medical treatment, usually metformin, which she will hopefully tolerate without the often significant intestinal adverse effects (cramps and/or diarrhea) and will hopefully help lower her HBa1c levels to below 7, a level that should ward off the many complications of this disorder. She will also now need to regularly check her blood glucose levels and quite substantially change her diet and lifestyle to try and keep her diabetes under control. In addition, she will have to start seeing her doctor or nurse several times a year and perhaps go for annual checkups of her eyes and feet.
Unfortunately, given that diabetes is a chronic progressive condition, she may soon belong to the rather large number of patients where metformin alone is not enough to control their diabetes. The next step would be to consider sulphonylureas or even daily insulin injections, treatments that not only carry a small but important risk of hypoglycemia as well as an almost obligatory risk of further weight gain. Of course, these treatments also mean even more daily checking of blood glucose levels (perhaps even several times a day) and more visits to the nurse or doctor (I am not even mentioning cost here).
Although diabetes is a condition for which we have relatively good medical treatments, the annual risk of dying for a patient with diabetes is about 1 in 100. As none of these medical treatments are curative, treatment will continue over the next 10 to 15 years, by which time chances are that she will begin experiencing significant retinopathy, nephropathy, neuropathy and of course the almost obligatory atherosclerosis that accompanies this disorder.
Eventually, after about 20 years (remember that our patient is now still only in her 60s), she will have a substantial risk of losing her eyesight and/or kidney function, begin developing sores and ulcers on her feet that could lead to amputations, and of course, at any time, could experience a fatal heart attack or stroke.
This, unfortunately, is the natural course of type 2 diabetes, a condition that now affects 6 million Canadians and, in young people like this patient, is almost entirely accounted for by excess weight (or the lifestyles that leads to excess weight). There is no known medical treatment that can cure diabetes – once you are diabetic, treatment is for life.
Let us now consider the surgical alternative. Let us imagine, that this patient, at age 40 with her BMI of 47 meets a physician, who suggests she should perhaps consider the option of bariatric surgery. The doctor advises her that bariatric surgery, a relatively safe 45 to 90 min operation, offers an 80% chance of her diabetes going into complete remission for 5 to 10 years if not longer. During this time, she would still need to go for annual checkups, would need to follow a diet and take daily protein and vitamin supplements, but would be off her daily diabetes tablets and injections and, as one may expect, have virtually no risk of experiencing any diabetes-related complication for however long her diabetes remains in remission. In fact, there are studies showing an over 90% reduction in diabetes-related mortality upto 15 years following bariatric surgery. In addition, there is also a good chance that this operation would get her off her blood pressure pills, her CPAP machine, reduce her fatty liver disease, ease the pain in her hips and knees, improve her urinary incontinence and sex life, and reduce her risk of dying of cancer by 60%.
I am not making this scenario up or painting a too rosy picture because my surgical colleagues have somehow managed to brainwash me.
At least two highly credible non-surgical organisations have recently come out with positive recommendations on bariatric surgery – the American Heart Association and the International Diabetes Federation – no reasonable person would accuse either organisation to be involved in some secret conspiracy to drive more business to our surgical colleagues.
But these organisations are by no means alone. There are now countless position papers and detailed analyses from institutions like the UK National Institute for Health and Clinical Excellence (NICE) or the Canadian Agency for Drugs and Technologies in Health (CADTH) that have carefully evaluated the evidence – both the pros and cons – and come down heavily in favour of bariatric surgery as a treatment of choice for individuals with severe obesity, especially for those who also have significant comorbidities.
None of these reports depict bariatric surgery as being harmless or without risk. They all strongly recommend that patients are carefully selected, well prepared and receive long-term follow up for nutritional and other complications. Yet, they all recommend surgery as being a better alternative in terms of warding off complications, improving quality of life, and monetary savings compared to non-surgical treatment.
So unless, you want to believe in some major global ‘conspiracy theory’ that involves all of these government and non-government organisations, which for some unknown reason are now in cahoots with bariatric surgeons the world over, you would have to assume that modern bariatric surgery has some very strong evidence to support it.
Having myself worked closely with some of these organisations, I can assure you that these folks are not known to make rash recommendations or off-the-cuff decisions without carefully weighing the evidence.
So until someone comes up with a better or even equally effective (hopefully non-surgical) treatment for severe obesity, that delivers all of the same health benefits of surgery, I will have to continue discussing and, in most cases, recommending surgery to my patients.
But how exactly, does bariatric surgery deliver on this promise? How does it work? What are the real problems that any patient considering surgery must be aware of?
More on this in tomorrow’s post.