Metabolic Surgery

This week we were reminded that almost 1 in 5 Canadian adults are obese. Readers of my blog will know why this is a challenge - once established, obesity becomes a chronic disease that requires lifelong management (irrespective of whether behavioural, medical or surgical - in all cases treatment is long-term or rezidivism is guaranteed!).

Clearly, for folks with severe obesity, surgery provides the best long-term results. Not only does it reduce mortality by 30-40%, it also leads to marked improvement in virtually all comorbidities while spectacularly improving quality of life.

That is, of course, when all goes well.

But even the safest surgery can result in problems when things go wrong. Recognizing and dealing with complications of obesity surgery is therefore a huge part of the program here at the 25th Annual Meeting of the American Society for Metabolic and Bariatric Surgery that I am currently attending at the Gaylord National on the Potomac River, on the outskirts of Washington D.C.

(My plenary "Keynote Lecture" on Friday morning is on the regulation of hunger and appetite)

No question, world wide obesity surgery is booming. As its value for severe obesity is now well beyond dispute, surgeons are turning to patients with ever lower BMIs - in some cases even below 30. The indication here is no longer weight loss, but rather type 2 diabetes, hence the term "metabolic surgery". Indeed, from everything I have seen and heard, surgery is probably the only known treatment for type 2 diabetes to result in extended remission - in short: highly effective, reasonably safe, and, given the high cost of diabetes complications, certainly cost-effective.

Obviously, the same contraindications apply to metabolic surgery as to obesity surgery, and yes, all patients need lifelong follow up to prevent nutritional deficiencies and ensure persistance with behavioural change (without which surgery does not work). And yes, surgery even at lower BMI's has complications (after all it is still surgery).

As evidenced by the many presentations here, the major determinants of complications are improper patients selection and preparation, low surgical volumes and lack of follow up. A clear warning to any policy makers and payers anxious to increase surgical volumes by simply throwing money at surgeons without providing resources to ensure competent lifelong follow-up.

As blogged previously, obesity surgery is not just about surgery - the actual surgery is simply a small (but important) technical part of a lifelong treatment plan.

AMS
National Harbor, Maryland