Bariatric Surgery – Is There Anything New? A Physician's Perspective

Whilst it would be the experience of most of us that bariatric surgery has become safer as it has become more widespread, this is an area that continues to offer practitioners an increased litigation risk as it does an increased risk of regulatory intervention. For that reason, even in the face (and perhaps because) of changes in practice, it is worth looking at some of the current issues.

Clinical issues

Physicians become involved in bariatric surgery for several reasons. These include being involved in the management of obese patients where a recommendation for surgery starts the long process towards surgery. Physicians will also become involved in pre-operative patient assessment. Here, there is an interesting almost circular debate around “how safe is safe” in the presence of BMIs > 35 if surgery will inevitably reduce that risk. There is a fundamental question as to whether pre-operative Physician assessment should be a matter of routine or not – a question made more complex because of the shortage of General Physicians in Australia. Given the real or potential co-morbidities these patients have, it is inevitable that Physicians from a number of sub-specialties become engaged in the post-operative care of bariatric patients – a commitment that may continue for considerable times on occasions. Clinical issues apart from obesity will include psychiatric disorders, cardiovascular and neurovascular conditions, obstructive sleep apnoea, diabetes and upper airway access difficulties.

Management questions

There are complex management matters to be resolved by Physicians no matter when they become part of the team. There remains a considerable difference of opinion regarding medical versus surgical management of obesity^1,4 – a debate that is more intense now as bariatric surgery,⁵ like other complex surgeries, has become safer with greater expertise. Even though most bariatric surgery will still be carried out in the private sector, we can anticipate a continuing trend to concentrate surgical and multidisciplinary management to ensure more is done by fewer surgical groups. However, all bariatric surgery carries its own risks which vary with the type of surgery performed. One of my Perth surgical colleagues⁶ indicated to me a year ago that a review of all patients operated on by his group of three showed that over 50% would have at least two surgeries – often further “cosmetic” procedures to deal with redundant tissue. However, there is also a significant incidence of re-operation for complications of bariatric surgery itself, and these surgeries may be necessary well after the primary procedure. Recognition and assessment of potential surgical complications may well not fall to the operating surgeon.

Future directions

The growth in demand for bariatric surgery is likely to continue for at least the next decade even if the direction that might be taken in private sector funding policies does not continue the current level of support. The difficulties for bariatric surgery to gain much traction in the public sector are likely to continue, as it is relatively resource-intensive. This means new strategies for management of the obese will be necessary, both in regards to prevention and non-surgical practices. Suggestions are emerging in the area of medical education⁷ – the idea that this epidemic might be met by a whole new strategy in teaching a new generation has attraction for this and a number of other chronic “diseases”. There is also a need for the profession to consider a fundamental truth⁸ in respect to its reluctance to discard management strategies. Scott and Elshaug advance a number of reasons for this, including concerns about litigation (defensive medicine), a tendency for intervention coupled with a “desire” to please referring clinicians particularly in the fee-for-service system that drives private practice.

In the complex field of obesity management, Physicians should play a major role in assessing and managing patients, particularly if bariatric surgery is involved. It is not safe to assume that patients are fully informed by “Dr Google”. Care and time should be taken to discuss all the material issues with each patient at each step along the way. Physicians have important roles in overseeing the indications for surgery, evaluating and correcting co-morbidities where possible and assisting in post-surgical management in hospital as well as for a period of time in the community. Detailed documentation is essential given the increased risk of dispute later on.

A/Prof David O Watson, Consultant Physician
MDA National Member

View a GP’s perspective – Bariatric surgery: The GP as Gatekeeper – provided in this edition of Defence Update. You can also read Anaesthetist’s and Bariatric Surgeon’s perspectives.

References
1. The Look AHEAD Research Group. Cardiovascular Effects of Intensive Lifestyle Intervention in Type 2 Diabetes. N Eng J Med 2013;369:145-54.
2. Block JP. A substantial tax on sugar sweetened drinks could help reduce obesity. Editorial, BMJ 2013;347:f5947.
3. Health behaviours and outcomes associated with fly-in fly-out and shift workers in Western Australia. Joyce S.J. et al, Int Med J 2013;43:440-44.
4. Gloy VL. et al. Bariatric surgery versus non-bariatric surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ 2013;347:f5934.
5. Birkmeyer JD. et al. Surgical Skill and Complication Rates after Bariatric Surgery. N Eng J Med 2013;369:1434-42.
6. Hamdorf J.M. Personal communication.
7. Colbert JA, Jangi S. Training Physicians to Manage Obesity—Back to the Drawing Board. Editorial. N Eng J Med 2013;369:1389-91.
8. Scott IA, Elshaug AG. Foregoing low-value care: how much evidence is needed to change beliefs? Editorial. Int Med J 2013;43:107-9.