ARTICLE IN PRESS

Evidence-Based Healthcare & Public Health (2005) 9, 292–293

1744-2249/$ - sdoi:10.1016/j.e

www.elsevier.com/locate/ebhph

COMMENTARY

Bariatric surgery: an opinion from the front line

John Baxter

Consultant Surgeon, University of Wales Swansea, UK

The systematic review (pages 1–8) is a good reviewof the current situation with respect to surgery forobesity, although it has some shortcomings. Be-cause unrandomised studies were excluded, thereis no mention of the Swedish Obese Subjects (SOS)study, is the most influential matched cohort studyof obesity surgery. It recently reported its impress-ive 10 year results, confirming most of what isreported in the current review. The review alsogives the impression that obesity surgeons areseeking only one effective operation for alltheir patients. Gastric banding, vertical bandedgastroplasty and gastric bypass are all provenoperations but are indicated in different patients.For example, type II diabetes, which affects up to25% of morbidly obese patients, is substantiallyimproved by a gastric bypass. Many surgeons alsobelieve that patients who are superobese, with aBMI greater than 50, are best suited to gastricbypass because it produces greater weight lossand probably larger reductions in morbidity andmortality.

Biliopancreatic diversion, with or without aduodenal switch, is perhaps the most effectiveweight reducing operation of all. The duodenalswitch variation has much to recommend it and isincreasingly being carried out by many bariatricsurgeons.

There is no doubt that all bariatric surgery will belaparoscopic within 5 years and most bariatricsurgeons still performing open surgery are convert-ing to the laparoscopic approach. The reduction inaccess trauma, fewer wound complications andmuch earlier discharge from hospital and return to

ee front matter & 2005 Published by Elsevier Ltd.hbc.2005.05.011

normal activity make this approach mandatory.Indeed, patients are rightly insisting on it. Laparo-scopic bariatric surgery is one of the most complexlaparoscopic procedures that can be performed.Surgeons need intensive training and sufficientexperience to get good results. As a result trainingand accreditation of bariatric units is now animportant issue.

Like much of surgery today, bariatric surgery isinfluenced by developing technologies. For exam-ple, improved results may well come around fromuse of robotic assistance, improved gastric bandingdesign, remote control gastric band adjustmentdevices, and intragastric stimulators. All of thesewill need evaluating in well-designed clinicalstudies.

For patients, one of the most difficult issues isthe procedures’ relative effectiveness. Verticalbanded gastroplasty is now rarely performed,despite the evidence that it may be slightly moreeffective than gastric banding, because it istechnically difficult to perform laparoscopically.Gastric banding is relatively easy to do but has a10% revision rate, needs labour-intensive follow-upadjustments and patients must be cooperative toget good results. There is a risk of late weightregain although long-term results are always betterthan conservative treatment. Gastric bypass andbiliopancreatic diversion are both more destructiveprocedures, leading to greater weight loss and lessrisk of weight regain but slightly higher periopera-tive mortality. Both these procedures also needintensive long-term follow-up to avoid vitamin andmicronutrient deficiencies.

ARTICLE IN PRESS

Bariatric surgery: an opinion from the front line 293

In summary, bariatric surgery is effective inproducing weight reduction but at the cost ofrevisions and potential complications. On balance,most patients have a greatly improved quality oflife and in many cases complete resolution of theirco-morbidities. Surgery also leads to a reduction in

costs to the health service, including the manage-ment of complications. Bariatric surgery is thefastest growing area of gastrointestinal surgery inthe USA where obesity has reached epidemicproportions.