Bariatric surgery is cost-effective but has long-term complications

The majority of people who undergo bariatric weight-loss surgery benefit from the procedure, but long-term complications and further surgery are not uncommon, according to a UK paper on late postoperative complications in the October issue of BJS, the British Journal of Surgery.

However, a Finnish paper, published in the same issue, says that bariatric surgery is a more cost-effective way of tackling rising morbid obesity rates than non-operative care. Researchers state that it increases health-related quality of life and reduces the need for further treatment and total healthcare costs among patients who are very obese.

"In England, more than 30,000 deaths a year can be attributed to obesity alone, taking an average of nine years off a person's normal life expectancy" say the lead author of the UK paper, consultant surgeon Mr Khaled Hamdan, from the Digestive Diseases Unit at Brighton and Sussex University Hospitals.

"As a result of the current, largely ineffective, non-surgical options for treating obesity, the past decade has witnessed an exponential increase in the number of bariatric operations performed."

Mr Hamdan and colleagues reviewed the most recent research on late postoperative complications after bariatric surgery, including procedures involving laparoscopic adjustable gastric banding (LAGB) and Roux-en-Y gastric bypass (RYGB)

Their findings include:

• Long-term complications should be taken into consideration when deciding what type of surgery to undertake.

• The most common long-term complications are band slippage after LAGB, which affects 15% to 20% of patients, and erosion from pressure on the stomach wall, which can affect up to 4% of patients who have received LAGB.

• Megaoesophagus (dilation of the oesophagus) is a rare but well reported late complication, occurring in one in every 200 patients after LAGB.

• Between 13% and 36% of patients develop cholesterol gallstones after surgery, due to rapid weight loss, but only 10% develop symptoms requiring surgical intervention.

• Up to one-third of patients experience intermittent gastrointestinal disturbances, particularly if they don't adhere to the dietary advice and nutritional supplements they are given after surgery.

• 8% to 10% of patients developed incisional hernias after open bariatric surgery.

• Less than 5% to 10% of patients have chronic problems with dumping syndrome, which can cause facial flushing, lightheadedness and diarrhoea after eating carbohydrate-rich meals. Most patients find that reducing their intake of carbohydrates and avoiding drinking liquids half an hour before and after eating improves their symptoms.

The authors say that their review suggests three key pointers for clinical practice:

• Complications after bariatric surgery should be thoroughly assessed and investigated. It is important to consider that the patient's symptoms may not necessarily relate to their gastric surgery.
• The attending surgeon should be familiar with bariatric procedures and gastrointestinal alterations following surgery. Managing these patients can be challenging for a non-bariatric surgeon and timely liaison with a bariatric unit is advisable.   
• Functional problems affecting the gastrointestinal tract may pose a diagnostic conundrum, requiring specialist intervention and liaison with a gastroenterologist to spare patients unnecessary surgical interventions.

The study on cost-utility, led by Ms Suvi Mäklin from the Finnish Office for Health Technology Assessment, suggests that the average cost of treating an obese patient with bariatric surgery in Finland is €33,870, compared with €50,495 for non-operative treatment. These cost savings are due to reductions in other health conditions after surgery.  

The research team adds that bariatric surgery also increased the number of quality-adjusted life years - the extra time a patient can expect to live as the result of an intervention - by about half a year during the ten-year time frame they studied, when compared with non-surgical interventions.

"Our study compared bariatric surgery with the current practice in treating morbid obesity in Finland, which is ordinary treatment ranging from intensive conservative treatment to brief advice from a doctor to lose weight" says Ms Mäklin. "This was evaluated using data on healthcare resource use in patients with a body mass index of 35 kg/m2 or more from a large representative population survey.

"Surgery for morbid obesity improves health-related quality of life and reduces the need for further treatments and total healthcare costs. The present results suggest that, compared with surgical treatment, non-operative care will on average be more costly for the Finnish healthcare system five years after surgery. In Canada the corresponding time has been estimated to be three-and-a-half years."