Bariatric surgery

The age of NHS austerity rumbles on and on with commissioners having to make increasingly difficult choices. Whilst an argument can be made for restricting some services and procedures, reducing the availability of others may be viewed as short sighted. One such example is bariatric surgery, a recent edition of PULSE reporting that some CCGs may be planning to reduce access to it. NICE guidance advises that bariatric surgery should be an option if a patient has a BMI of 40 or more, or between 35 and 40 and other significant disease such as diabetes and high blood pressure, as long as ‘all appropriate non-surgical measures’ have been tried and failed. Bariatric surgery is an umbrella term for three types of procedure commonly used in the UK. The laparoscopic adjustable gastric band is an adjustable silicone band is placed around the upper stomach, creating a small pouch above the band and a narrowing between the pouch and main part of the stomach below. This restricts the amount of food that can be eaten and reduces feelings of hunger by pressing on the surface of the stomach. The Laparoscopic or open Roux-en-Y gastric bypass (GBP) – a small pouch is created from the original stomach which remains attached to the oesophagus at one end, and at the other end is connected to a section of the small intestine, thus bypassing the remaining stomach and the initial loop of small intestine. The procedure can be performed as laparoscopic or open surgery. This anatomical change has an effect on intestinal absorption and as a result, patients are thus at risk of nutritional deficiencies and must take life-long supplements of vitamin B12, iron and calcium, and need to undergo lifelong monitoring and follow-up to avoid these problems.  Laparoscopic or open sleeve gastrectomy (SG) – this procedure probably has effects on appetite as well as some degree of restriction of eating. It involves division of the stomach vertically, reducing it in size by about 75%. The pyloric valve at the bottom of the stomach is left intact such that stomach function and digestion are unaltered. Other techniques including a silicon balloon can be used as a temporary measure pending a more definitive procedure. The speed of weight loss depends on the procedure but is usually rapid and it is important that patients receive medical input before (to determine suitability) and after surgery, the latter to avoid longer term complications such as vitamin and mineral deficiency. The benefits of bariatric surgery have been demonstrated in many studies with impacts on diabetes, hypertension, musculoskeletal conditions as well as quality of life. Indeed, data from the national bariatric surgery registry has shown that two thirds of patients with type 2 diabetes at the time of bariatric surgery showed no indication of diabetes two years later and were able to stop their treatment. Cost effectiveness depends on the initial BMI but for patients whose BMI>40, the procedures virtually pay for themselves within 2-3 years. Given the overwhelming evidence regarding the medical and financial benefits of bariatric surgery the proposal that this be restricted seems short sighted at the very least.

Dr Mark Freeman