Bariatric surgery found effective at lower weights
■ Conclusions from a data review fuel debate about when surgery should be considered.
By Victoria Stagg Elliott — Posted May 4, 2009
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Weight-loss surgery may help those with less-severe obesity shed pounds, but questions remain about long-term outcomes and whether some versions of the procedure are better than others. The conclusion was the result of a data review by researchers at the University of Southampton in England. Their findings were published April 15 in The Cochrane Library.
"[This paper] is not saying that we should be doing surgery for those with a BMI between 30 and 35. It's saying that, yes, surgery results in a greater weight loss, but is it worth it? We don't know," said Caroline Apovian, MD, director of the Nutrition and Weight Management Center at Boston Medical Center. She was not affiliated with the Cochrane review.
A National Institutes of Health 1991 consensus paper stated that bariatric surgery was appropriate for those with a body mass index higher than 40. It also noted those with a BMI between 35 and 40 who had serious weight-related illnesses could be considered. But the significant number of people who carry excess pounds combined with the development of safer, less-invasive procedures is leading some physicians to ask whether these recommendations should be adjusted.
"Eighteen years ago, procedures had a higher complication rate. The [gastric] band and sleeve didn't even exist. This should be studied," said Scott Shikora, MD, president of the American Society for Metabolic and Bariatric Surgery and director of the Weight and Wellness Center at Tufts Medical Center in Boston.
A 2004 consensus statement from the ASMBS suggested that bariatric surgery for patients with a BMI between 30 and 35 who have weight-related medical conditions may be indicated and needs study. A few research projects investigating the option as a treatment for people who have diabetes and a BMI as low as 30, including one project by Dr. Shikora, are either under way or being planned.
Some doctors say bariatric surgery for these patients could lower their chances of experiencing more severe weight-related adverse events.
"It means we're going to get to people earlier in the disease process," said Nick Nicholson, MD, medical director of the weight-loss surgery program at Baylor University Medical Center in Dallas and the Baylor Regional Medical Center in Plano, Texas. "[Surgery] is technically easier when they're at lower weights." On rare occasions, he has operated on patients with BMIs as low as 32 who had severe obesity-related complications.
But other physicians say unanswered questions remain on the longer-term effects. Some also feel the medical management used as a comparison in the reviewed studies was not as intensive as it could be -- giving the outcome advantage to surgery. And although the review found that surgery was more effective than medical management for weight loss, many would like to see analyses looking at differences in other factors, such as cost and adverse events.
"Surgery looks terribly promising, and I know it will play an important role. I don't think we know what the role is right now," said Tim Church, MD, MPH, PhD, director of preventive medicine research at Pennington Biomedical Research Center in Baton Rouge, La., who researches nonsurgical weight loss. "We spend 25 or 50 grand on bariatric surgery. We would never dream of committing even half that to a good behavioral intervention. Give me half that fee, and I will change someone's behavior and keep it changed."
Physicians who specialize in nonsurgical weight-loss strategies also say it is possible to lose large amounts of weight without an operation and expressed concern about patients having these kinds of procedures before exhausting other options.
"We can reverse many of the complications of obesity almost as effectively as bariatric surgery with a minimal rate of complications and cost," said Allen Rader, MD, secretary/treasurer of the American Society of Bariatric Physicians and the founder of Idaho Weight Loss in Boise. "We believe the treatment paradigm for obesity should be primary care physicians first, then referral to a bariatrician, then referral to the bariatric surgeon."