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Practicing Slow Medicine usually entails a conservative approach to invasive therapies. In most situations, we recommend elective procedures only after observation, lifestyle changes, and over-the-counter and prescription medications have failed. But this isn't always the case.
Is a cautious approach in which we painstakingly try every alternative approach before surgery the best approach in caring for patients who struggle with morbid obesity? Or is this one of those situations in which it might make sense to try an invasive therapy earlier?
Increasingly, we believe the evidence suggests we should consider bariatric surgery earlier rather than later, especially for patients with both obesity and diabetes.
Obesity underlies many chronic illnesses, and while dramatic dietary and exercise changes can sometimes reverse obesity, usually even aggressive lifestyle changes lead to only modest weight loss. (With an abundance of fast food joints, western societies do not make it easy for dieters.) And weight loss medications, given their lack of proven long-term efficacy and safety, are best avoided.
Bariatric surgery, unlike weight loss medications, has much evidence in its favor. The latest study that caught our attention, , compared long-term outcomes between 2,500 patients in the VA system who received bariatric surgery (74% received gastric bypass) with more than 7,000 matched controls. The average surgical patient in the study was 52 years of age with a body mass index of 47.
After 10 years, mortality rates among patients receiving surgery were 13.8% versus 23.9% among controls. This was not a randomized trial, and confounding factors may have influenced the results. For example, patients opting for surgery may have been more motivated than those who chose medical therapy.
Nevertheless, we find these mortality differences compelling, particularly when paired with the which also demonstrated an overall mortality benefit with surgery, albeit more modest (5% vs. 6.3% after 10 years) though most patients in this study received an outdated procedure -- vertical banded gastroplasty -- rather than gastric bypass.
Despite the positive findings with respect to mortality, there are plenty of reasons to be cautious. While bariatric surgery – and gastric bypass in particular – may provide a long-term mortality benefit, complications from the procedure abound and should give both patients and clinicians pause.
These complications include perioperative mortality (up to one in 250 in some series), cholelithiasis, hernias, alcoholism, dumping syndrome, and short bowel syndrome. A study also found a higher rate of small-for-gestational-age infants among women who had received bariatric surgery compared with matched controls, as well as a nonsignificant but concerning trend towards a higher rate of stillbirth or neonatal death.
Nonetheless, many patients who have undergone bariatric surgery report their lives are much improved after receiving the procedure as a result of weight loss, and there is some evidence that the overall effects are favorable in most patients. For example, the also demonstrated modest overall improvements in quality of life among patients undergoing surgery versus matched controls after 2 years, though again this was not a randomized trial and confounding factors may have influenced the results.
Still, even if quality of life improves following bariatric surgery on average, there is considerable variability. In the SOS study (which again involved an outdated procedure), among the minority of patients who lost less than 30 kg, improvements in quality of life were modest. And, not surprisingly, for patients who experienced substantial complications, quality of life took a serious dip even if substantial weight loss was achieved.
So how should Slow Medicine clinicians balance the pros, cons, and uncertainty of bariatric surgery? We focus on thoughtful shared decision making.
This does not involve placing a complex consent form in front of a confused patient and procuring his/her signature. Rather, we strive to understand our patient's health goals, engage in a discussion of the risks and benefits of surgery, and guide our patient to make a decision most in line with their goals.
We believe the evidence increasingly supports an important role for bariatric surgery early in the treatment of obesity for appropriate patients -- those with body mass index greater than 40 (or greater than 35 with diabetes) who are committed to the procedure, have made a concerted effort at lifestyle changes, and have an acceptable surgical risk. But the decision to pursue bariatric surgery should involve a thoughtful decision-making process to ensure that patients understand the risks and trade-offs, and whether (or not) surgery might help them achieve their goals.
In other words, we should be fast to discuss bariatric surgery with appropriate patients but slow and deliberate about deciding whether to proceed in each individual case.
"Updates in Slow Medicine" applies the latest medical research to support a thoughtful approach to clinical care. To learn more, . To receive all of our updates, contact Drs. Michael Hochman and Pieter Cohen at pcohen@challiance.org.