We are all too aware that the obesity epidemic has arrived, and in the absence of any pharmacological breakthrough, it is undoubtedly here to stay for the foreseeable future. With one quarter of the UK adult population currently estimated to be obese, and predictions for this to rise to over 50% by 2050, the involvement of most healthcare professionals in some form of obesity management seems a certainty.
In the UK, we have seen a recent sharp increase in the numbers of obese patients presenting for bariatric surgery and an upsurge in the number of bariatric surgical centres. This phenomenon reflects patterns seen in the US over the past decade and has been encouraged by the advent of NICE guidelines and the NHS commitment to surgical treatment of obesity. The estimated cost for the overweight and obese population to the NHS is £4.2 billion, with projections for this to more than double by 2050. The immediate costs of bariatric surgery however, may well be offset by future costs of treating lifelong obesity-related disease.
Following obesity surgery, there exists compelling evidence for sustained long term weight loss, amelioration or complete resolution of co-morbidity, decreased risk of death and increased quality of life. Additionally, the increase in demand for surgery is not only linked to the increasing prevalence of obesity, but also to the growing body of evidence that bariatric surgery is safe in the short term whilst being effective in the long term. A recent large, prospective observational study of 4776 patients (LABS-1), reported 30 day mortality and adverse events risk of 0.3% and 4.3% respectively, following gastric bypass and adjustable gastric banding in 10 established centres in the US.1 These findings are in keeping with previous studies, and likely reflect realistic rates in the better performing centres.
Promoting and maintaining safety and best practice worldwide is recognized to be paramount in this field and relatively young organisations such as the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), the American Society for Metabolic and Bariatric Surgery (ASMBS) and the Surgical Review Corporation are working together to ensure this. Importantly, the Bariatric Surgery Centers of Excellence® (BSCOE®) programme aims to recognize good surgeons and centres with accreditation and optimize other more poorly performing centres. Indeed, following the first data analysis of over 50,000 patients in the Bariatric Outcomes Longitudinal Database™ (BOLD™) in the US, bariatric surgery was found to be significantly safer, when performed at BSCOEs, than other routine surgical procedures performed nationally. In the face of such high and increasing demand, these organizations aim to not limit bariatric surgery to a few highly specialized centres, but to enhance practice universally. Newer UK centres may thus be increasingly applying for such excellence accreditation and will benefit from the guidance and educational programmes offered.
An exciting recent development in the UK has been the implementation of a national bariatric surgery database, which, coupled with newly validated scoring systems to predict post-operative outcomes, will allow monitoring and comparison between centres. This will inject further competitive drive into the obesity surgery market and will help to differentiate individual centre strengths and weaknesses.
What must be recognized however, is that the decision for surgery in this patient population is often a complex process as obesity itself, alongwith the myriad of systemic diseases associated with it, place patients at higher risk of surgical and anaesthetic complications. As a result, the patient pathway often involves assessment, investigation and treatment by multiple medical disciplines inclusive of respiratory, sleep, cardiology and endocrinology, in addition to the psychological and dietetic services. The approach to surgery and follow-up must be fully tailored to the individual patient to maximize success.
As popularity for the surgical option to control obesity grows, our involvement as anaesthetists in such cases will in time, become commonplace. What therefore follows in this issue are 5 articles addressing the key areas related to the management of obese patients presenting for bariatric surgery.
A key role of the anaesthetist is to ensure patients are medically optimized prior to surgery to maximize successful post-operative outcomes. The article on “Anaesthetic considerations and management of the obese patient presenting for bariatric surgery” focuses on the assessment tools currently in use in the work-up process of obese individuals and covers intra-operative management of the bariatric patient. Additionally, the primary concern for many anaesthetists when faced with obese patients will be management of the airway. There is much published work on the obese airway and the article by Myatt & Haire reviews the evidence for difficult airway incidence, predictive markers and management options. Obstructive sleep apnoea has been shown to be a major contributor to mortality and morbidity rates following bariatric surgery, as highlighted in the recent LABS-1 study. It is thus important to establish a diagnosis in this group of patients and the article by Dakin & Margarson considers the sleep disorders, the risks they pose and their appropriate management in the peri-operative period.
Input from physicians is also crucial in many bariatric patients, as genetic and endocrine causes of obesity must be excluded in some cases and medical management of obesity related disease must be optimized in all cases. The article “Medical management of the patient considering bariatric surgery” focuses primarily on the proposed hormonal mechanisms in obesity and appropriate management strategies for diabetes and hypertension prior to surgery.
Lastly, it is fundamental that we understand the key surgical steps in the various, commonly performed bariatric procedures to allow intra-operative co-operation with our surgical colleagues. These are outlined by Kwhaja & Bonanomi and the article also includes reported surgical complications and post-operative outcomes.
In short, with regards to the obesity epidemic and obesity surgery, the future appears bright, but busy.
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