Anti-obesity drug sibutramine (Reductil) has had its licence suspended and GPs are being asked not to issue any new prescriptions for the drug. The suspension follows a review of the drug’s safety by the European Medicines Agency (EMEA) on the basis of data from the Sibutramine Cardiovascular Outcomes study.
This follows the suspension of the marketing authorisation for Accomplia (Rimonabant) in October 2008. The EMEA decided that the benefits of Acomplia, no longer outweighed its risks.

This leaves Orilstat (Xenical) which acts by reducing the body’s ability to absorb fats as the only major drug left in the GP’s armoury when attempting to manage obesity through conservative (non-surgical) means, although many patients find some of the side-effects of this drug unpleasant and/or embarrassing.

The review which brought about the suspension of Reductil concluded there was an increased risk of non-fatal heart attacks and strokes with sibutramine. The EMEA said that this risk outweighed the benefits of weight loss, which was modest and may not have been sustained in the long term after stopping treatment.
Prescribers are being advised by the MHRA not to issue any new prescriptions for sibutramine and to review the treatment of patients taking the drug. Pharmacists are asked to cease dispensing the medicine.
People who are currently taking sibutramine are advised to make a routine appointment with their doctor to discuss alternative measures to lose weight

Last year, 86,000 people were prescribed sibutramine on the NHS. The drug was licensed for as adjunctive therapy within a weight management programme. Its indication was limited to patients with either nutritional obesity and a BMI of at least 30 or nutritional excess weight and a BMI of at least 27 in those with obesity-related risk factors.

Surgical intervention for weight loss is, or should be, only considered for patients with a BMI of at least 40, or a BMI of at least 35 if they have other weight-related severe medical problems. For patients whose obesity is still a significant problem, but who do not qualify for surgery, the Intragastric Balloon is a procedure worth considering. It is designed to remain in the body for 6 months and enable the patient to lose (on average) between 10 and 30 KG, though careful management and long term dietary change must be part of the programme.
For further information on the Balloon and on Surgical solutions to Morbid Obesity please visit http://www.cosmeticbliss.co.uk/p/weight-loss-surgery

Sport & Health News.com, 21st January 2010

Access to NHS weight-loss operations is inconsistent, unethical and a postcode lottery, says Royal College of Surgeons
Obese patients are being “effectively encouraged� to pile on the pounds to qualify for weight-loss operations on the NHS, the Royal College of Surgeons warns today.

The college claims lives are being put at risk as some health trusts require patients to reach higher body mass index (BMI) levels than others before they receive surgical treatments.

The postcode lottery means that access to NHS weight-loss surgery is “inconsistent, unethical and completely dependent on geographical location�, according to the college.

Last year 4,300 operations to reduce body weight were carried out on the NHS, but as many as a million people could meet the National Institute for Health and Clinical Excellence (Nice) criteria for being classed as having severe obesity.

Bariatric, or weight-loss, surgery is carried out after diets, drugs and lifestyle-altering interventions are seen to have failed. It is not generally recommended for children or young people.

“Constraints on NHS funding mean that in some areas NHS decision-makers are opting to ignore professional guidelines and are denying patients’ access to surgery,� the college maintains. “In others, patients who already meet the [Nice] criteria are forced to wait until either they become more obese or develop life-threatening illness like diabetes or stroke.�

According to the Nice guidelines, bariatric surgery is recommended for adults with a BMI of more than 40, who have other significant diseases (for example, type 2 diabetes) that could be improved if they lost weight, and who have tried but failed to lose weight using non-surgical techniques.

The college, which is holding a conference on the issue today, says that hospitals are assessing patients referred from primary care trusts under different eligibility criteria, resulting in some patients with a BMI of 60 or greater being refused surgery while others with a BMI of 40 or less are undergoing operations.

“Nice guidelines are meant to signal the end of postcode lotteries yet local commissioning groups are choosing not to deliver on obesity surgery,� said the college’s director of education, Prof Mike Larvin. “In many regions the threshold criteria are being raised to save money in the short term, meaning patients are being denied life-saving and cost-effective treatments, and are effectively encouraged to eat more in order to gain a more risky operation further down the line.�

Another bariatric surgeon, Peter ­Sedman, said: “There is absolutely no doubt that some patients more needy of surgical treatment than others are being denied it. I will treat the patient, my hospital will offer the service, but unless the patient moves house they will not be referred and if they are the treatment is subsequently blocked.�

David Haslam, chair of the National Obesity Forum, added: “Bariatric surgery is amongst the most clinically effective and cost effective specialities in any field of medicine, preventing premature death and transforming lives, whilst saving vast amounts of money for the NHS and the economy.

“Even the most cynical taxpayer should support bariatric surgery, alongside clinicians, in opposing the unethical and immoral barriers to surgery imposed by NHS purse-string holders.�

The college is calling on the Department of Health to ensure all patients have equal access to treatment. It estimates that obesity problems cost the NHS £7.2bn a year.

Alberic Fiennes, president-elect of the British Obesity and Metabolic Surgery Society, said: “We recognise the difficulties faced in dealing with a ‘new’ disease of epidemic proportions, but to limit surgery to the most severely obese is unfair and short-sighted and against basic professional ethics. It is also contrary to strategies that are standard for diseases that overwhelm resources.�

Many healthcare companies are in the market offering to organise and assist patients who have decided to “go private� for their procedures – either as a first choice or because surgery is simply not available to them under the national health scheme.
Most prospective patients, certainly in the UK and Republic of Ireland, arrange their private treatment through commercial providers and/or facilitators, rather than attempting to deal direct with the surgeon, and many providers offer a range of procedures, from Cosmetic Surgery, Dental Treatment or Laser Eye Surgery to Obesity Surgery and General Surgery.
It can be quite bewildering for the prospective patient who must not only attempt to learn as much as possible about the procedure they wish to undergo, but also try to select a surgeon and medical team they are willing to put their trust in, and to choose a company which will inform and guide them honestly and put the patient’s best interests above their own desire to “make a sale�.
Michael Dermody and Deborah Darling of Cosmetic Bliss – a private healthcare company which arranges weight loss surgery and post-weight loss cosmetic surgery in the Czech Republic for English-speaking patients are calling for better standards of clear communication and improved support by healthcare facilitators for their patients – especially in the field of weight loss surgery , their own specialist area.
Michael Dermody is quoted as saying
“Our company’s high reputation on the various weight loss forums is founded on our being able to provide thorough and extensive information to our patients pre-operatively, ensuring that they are properly prepared for their surgery; supporting them whilst they make the visit for the surgical procedure and being available to them during the period of weight loss after their surgery.
I think what makes us special is the “hand-holding� service we give whilst the patient is with us for surgery. We make sure we are there – in the hospital – with them throughout their stay, and this is something our patients really value above everything else. Of course we couldn’t do it without the co-operation we get from our partner hospital and surgeon.
We realised a long time ago that taking patients through weight loss surgery was very different from arranging Cosmetic Surgery – it is much more demanding, and requires a much greater commitment by the provider
Firstly, there is the matter of assessing the patient’s suitability for surgery. Quite apart from fairly rigorous pre-operative preparation and testing, some of which should be done well before the surgery itself, there is the issue of making sure the patient is really ready for surgery and prepared to make the mental adjustments, in terms of relationship to food which are necessary if the surgery is to achieve long-term weight loss. Then there is the question of putting in place for the patient an adequate system of support and monitoring during the months and years after the surgery. Unless all these things are done, and done correctly, there’s every chance a patient is wasting their money in having the surgery, as the whole point of the exercise is for the patient to achieve sustained, long term weight loss, not merely a good safe operation with clean scars!
It disheartens and worries me when I see that there are still some companies out there that sell weight loss surgery in a way I would expect to see furniture sold, with “special offer� discounts, and “last minute deals�. It all seems to diminish the serious nature of the surgery and the commitment the patient has to make. More alarming, though, is the lack of quality information provided by some companies – and in some cases positively inaccurate and misleading information is openly advertised on websites. There are still providers of weight loss procedures who advertise a Gastric Bands as being “the same as Gastric Bypass�, and even one promoting Intragastric balloons (a non-surgical temporary endoscopic procedure) as “Lap Bands� .
That’s no different from selling someone a cat, and telling them it’s a dog, on the grounds that “it’s the same thing�!
I know that many companies do a good job, but it is not fair or right to expect the enquiring prospective patient to be able to distinguish between accurate and misleading or inadequate information – especially as they often come to the marketplace having done very little research before contacting providers.
I firmly believe that there is a crying need for Private Healthcare providers and Medical Tourism companies to get together – probably in the form of a trade organisation – to set agreed standards of care, support and accuracy of information, and devise a form of accreditation – not only for the sake of their own reputations but in the interests of true patient care.
Our own facilities in Breclav Hospital are specifically geared to Obesity Surgery, and there are emergency and ICU departments on hand at this modern major hospital to enable us to safely cater for those morbidly obese patients who have other serious health problems. We are working closely with the hospital and Dr Michal Cierny PhD, the Specialist Bariatric Surgeon in charge of the Bariatric and Metabolic Centre there in creating a European Centre of Excellence in Bariatric Surgery.
We are currently actively seeking to co-operate with other providers and facilitators of Private Healthcare – especially in the UK, Eire, and North America – who have a close and trusting relationship with their patients and who share our own commitment to the quality of information and pre- and post-operative care standards for Bariatric patients I have described.
We are willing to develop working relationships with companies who wish to take full advantage of our facilities for safe surgery, and who will value the round the clock support we will be able to provide to their patients when they are with us for surgery. This will enable the provider to focus on putting in place a solid system of pre-and post operative support, and we would welcome enquiries from other Private Healthcare companies working in this field who are interested in developing such a relationship, and promoting standards of excellence in the area of Obesity Surgery and care and support in managing weight loss post-surgery.
We would welcome enquiries from Healthcare Providers and Facilitators, initial contact can be made with us through our website: http://www.cosmeticbliss.co.uk/p/contact

Despite the yearly rise in the numbers classified as “Morbidly Obese” in the UK, and the drain on public health resources due to the costs of treating chronic illnesses which are caused by this epidemic of obesity, the provision of Surgery as an option for patients is still very scant in most areas of the UK. An article in the Scotsman on 27/12/2009 stated that only 0.8% of Scots eligible and willing to go ahead with Obesity Surgery receive it. In England the situation is marginally better – 1.2%!!
When NICE (The National Institute for Clinical Excellence) issued Guideline 43 in December 2006, it clearly stated who should be considered for surgery – patients with a BMI of over 40 (or over 35 with obesity-related “co-morbidities�) who have exhausted attempts to maintain weight loss through more conventional methods. The guidelines also recommend Surgery as a “first line option� for patients with a BMI of over 50.
In Jan 2008 BOSPA (the British Obesity Surgery Patients’ Association) published a survey of the attitude of PCTs – those bodies in the UK who are responsible for allocating funding for surgery. Many did not respond, but of those who did around half confirmed they applied much stricter criteria when approving funding of surgery than the NICE guidelines. There remains no clinical justification whatever for denying surgery to patients who meet the NICE guidelines – so the practice of insisting on much more severe criteria before allowing surgery is clearly based on limiting cost. Local PCTs clearly have a finite budget with many competing demands, and Obesity surgery is potentially a great drain on their resources. The NICE guidelines are, after all, only guidelines and are not legally enforceable – though some patients have sought legal redress for the failure of their PCTs to adequately deal with their health problem.
It seems a very short-sighted approach, in terms of the PCTs duty to provide adequate healthcare, condemning obese patients to become more ill as the obesity-related diseases develop, and even from the cost point of view studies have shown that Obesity Surgery pays for itself over approx. 3 years, as the cost burden of treating co-morbidities such as Type II Diabetes is reduced in patients who have lost significant weight. The government makes little provision for tackling this epidemic, and largely leaves PCTs to “get on with it as best they can�
So, what can someone who is classified as Morbidly Obese, and needs surgery do?
It is possible to attempt to put pressure on your local PCT through your GP to approve surgery, but it is a long uphill battle, with very little prospect of success.
You can look for surgery privately, which is the course most obese patients follow.
There are problems and pitfalls here, quite apart from the cost you will have to meet.
Firstly you have to be careful to choose a surgeon, hospital/clinic and company, (if you arrange your surgery through a Healthcare company as most do) who are not only experienced in the type of surgery which will be best for you, but also you must be sure that all the pre-operative health checks and tests are at least as extensive as in the NHS. It goes without saying that every effort should be made to ensure your surgery is as safe as possible. Psychological evaluation and some counselling to ensure a patient is at the right point to be able to succeed with weight loss following surgery is absolutely vital. NICE recommends that obesity should be managed by a multi-disciplinary team, and that post-operative support is essential
Post-operative support – whatever the surgery – is very important and you should be careful to chose a surgery provider who is willing to offer this, and not simply prepared to leave it to your GP to give advice and help after the surgery.
Cosmetic Bliss http://www.cosmeticbliss.co.uk/p/weight-loss-surgery is a weight loss surgery company who arrange safe Obesity Surgery for English-speaking patients at the Bariatric and Metabolic Centre – Breclav Hospital in the Czech Republic with Dr Michal Cierny PhD the Bariatric surgeon. They have a great deal of experience in preparing patients and giving them sufficient information to ensure safe surgery. The hospital is working to become a European Centre of Excellence in Bariatric Surgery, and the pre-operative health checks and tests for patients are very extensive. Cosmetic Bliss accompany all patients throughout their stay at the hospital and provide a full system of post operative support, nutrition diet and exercise advice. They encourage regular post-operative contact and follow up with patients for a minimum of 2 years after surgery, and monitor post-operative outcomes and weight loss following surgery on behalf of Dr Cierny. They are keen to work with UK GPs in providing post operative support to all patients. Although initially many patients are a little intimidated by the prospect of having surgery abroad, the quality of care, the system of safeguards Cosmetic Bliss and the Hospital have put in place, and the hand-holding service Cosmetic Bliss provide whilst the patient is in Hospital make it a very reassuring experience. Prices are fully inclusive and the cost is significantly lower than arranging for surgery in the UK also.

27 December 2009 – By Lyndsay Moss, The Scotsman
THOUSANDS of Scots are missing out on surgery that could transform their lives because not enough priority is being given to the treatment of obesity. Type 2 diabetes, which can lead to serious health complications, is one of the country’s fastest-growing conditions, largely because of poor diet and a lack of exercise.
But procedures such as gastric band and gastric bypass surgery that are proven to work are being denied to patients because health boards are not willing to finance them. Duff Bruce, an Aberdeen surgeon and chairman of the independent Severe and Complex Obesity Treatment Service (Scots), said that up to 25,000 Scots could be eligible and would be willing to have such surgery to improve their health.
If more patients were offered surgery, their health could be improved and the NHS would save money in the long term. But despite the growing problem, Scotland has one of the lowest rates of bariatric surgery in the world. In Scotland only 0.8 per cent of those eligible and willing to have weight-loss surgery receive treatment, compared with 1.2 per cent in England, 5.5 per cent in Sweden and 9 per cent in the United States.
Writing in the magazine of the Royal College of Surgeons of Edinburgh – published today – Bruce said patients with severe obesity, with complications such as diabetes and high blood pressure, are “one of Scotland’s fastest-growing and most difficult to manage populations”, taking up a disproportionately large share of the £171 million cost of treating weight-related problems.
But research has shown that obesity surgery can have a major effect on improving the health of obese patients.”With the data available to show that patients with Type 2 diabetes often go into remission following a (gastric) bypass, we are, as a nation, essentially withholding an intervention that could potentially cure not just sufferer’s obesity, but also much of their metabolic co-morbidities (conditions such as diabetes],” Bruce wrote.
He said: “There’s a significant percentage of patients who we know would be eligible and willing to have the operation who haven’t got access to the resource.”
Writing in the same issue, Dr Ingmar Naslund said Sweden has prioritised obesity surgery over other groups of surgery, such as gall bladder and hernia operations, and has reaped the benefits. “As we’ve helped more and more patients with obesity, it has become more obvious that these patients are the right ones to be prioritising,” he said. One in four men and women were classed as obese in 2008, and patients who are overweight are more likely to develop Type 2 diabetes. Severe obesity can also cause high blood pressure, heart disease, bone and joint problems, and sleep apnoea.

Almost 200,000 people north of the Border are estimated to have Type 2 diabetes, which is normally diagnosed in people over the age of 40.The number of bariatric procedures carried out in Scotland on the NHS each year is between 150 and 180, with a similar number carried out privately. A gastric band is an inflatable silicone device surgically placed around the top portion of the stomach. The device creates a small pouch at the top of the stomach that quickly fills with food, sending a message to the brain that the whole stomach is full. This sensation helps the person to be hungry less often, to feel sated for a longer period, to eat smaller portions and thus to lose weight. Gastric bypass surgery works in a similar way by also reducing the stomach’s volume.

One problem is the cost of the procedures compared with other surgical treatments. Obesity surgery and follow-up care costs the NHS between £3,500 and £5,500 per patient, so access to such operations in Scotland has so far been limited.
But Bruce said prioritising obesity surgery would save the NHS money over time, as it would spend less in the long term on weight-related conditions such as heart disease.
Research in Canada has suggested that bariatric surgery was “cost neutral” within three years because of the savings made on treating other complications.
Bruce said he hopes that with better and more clever use of resources, more patients could be given access to obesity surgery. He said: “In Scotland, we are starting from quite a low baseline. But Scotland is a small country, which means that everyone can work together well. We have good relationships with clinicians, health boards and government.”So hopefully, we have a chance of developing a national strategy that works well to deliver and develop this.”
A Scottish Government spokeswoman confirmed that obesity was one of the greatest health challenges facing Scotland. “That is why the Scottish Government is investing £56 million in our Healthy Eating, Active Living action plan which aims to improve diet, increase physical activity and tackle obesity,” she said. But she added it was a matter for individual health boards to decide what services to provide and how they allocated resources to meet needs.
• A £450,000 funding boost for the treatment of diabetes was announced yesterday by public health minister Shona Robison. The money will be invested in improving psychological support for people with the condition.
Case study
VICKI Simpson had to wait four years for surgery to treat her weight problems.
The 39-year-old from Aberdeen had a gastric band fitted in January 2007 and later a gastric bypass.
“It is the best thing I have ever done,” she says.
Before the surgery, Simpson weighed 21st 11lb.
She said she suffered from tiredness and sluggishness, and had problems sleeping. She was also told she was at risk of developing Type 2 diabetes.
With an active job as a hairdresser, she wanted to make sure she would continue to be able to do her job. She now weighs 12st 5lb.
“It has given me my life back. I was living in a shell, with no confidence. I was in a circle of eating for comfort and getting bigger and bigger. The problem gets bigger and it gets harder to get out of. The surgery has given me a new lease of life. I am not tired and it has been fantastic.”

On 1st November 2009 Cosmetic Bliss and Dr Michal Cierny PhD (Bariatric Surgeon) moved from the BMI Clinic in Brno where they had worked for over two years performing Gastric Band operations and Sleeve Gastrectomies, to Breclav Hospital near Brno.
The move was carried out to enable Dr Cierny to create a European Centre of Excellence in Bariatric Surgery. Dr Cierny plans to develop and extend his activities in the field of Bariatric Surgery by offering a wider range of procedures for Czech patients and also for patients from English-speaking countries who are brought to him and cared for by Cosmetic Bliss. The new centre, The Bariatric and Metabolic Centre, Breclav Hospital will fully integrate the disciplines of the dietitians, diabetologists, internal medicine specialists, anaesthetists and surgeon, and the comprehensive resuscitation, cardiac and ICU facilities of this large and well equipped hospital enable those patients with serious health problems to safely undergo surgery. Breclav Hospital is currently the only hospital in Europe to hold certificates for international standards ISO 9001. ISO 13001 and OHSAS 18001.
Dr Cierny said “I am more than ever convinced that it is vital to have a complete multi-disciplinary approach to the problems of obesity. Surgery is shown to be the long-term solution to morbid obesity, but surgery is only truly effective when the patients can receive the support and continuing encouragement and guidance of other professionals in the journey through their weight loss after their surgical procedure.”
Michael Dermody, one of the directors of Cosmetic Bliss, the UK company that arranges for English-speaking patients from UK, Eire and the USA to come for Weight Loss Surgery to Dr Cierny and Breclav Hospital welcomed this move, and suppported Dr Cierny’s comments. He added “I believe that psychological preparation for surgery, whether it is Banding, a Sleeve Gastrectomy, a Gastric Bypass or even a non-surgical intervention such as a stomach balloon is the most important factor in enabling the outcome of the procedure to be successful. I became even more aware of this during my own journey through weight loss after Dr Cierny performed a Sleeve Gastrectomy on me in September 2008. I have seen many cases of patients – both through the NHS and privately in the UK – going through weight loss surgery with inadequate preparation and information beforehand and little follow-up or counselling afterwards to enable them to understand the emotional changes and the changes in their relationship with food that weight loss after surgery brings about. We invest a great deal of our time and resources to ensure our patients are fully prepared for their procedure, and do our utmost to create a network of support, in terms of diet, nutrition and psychological assistance which our patients can call on in the months and years after their surgery. We really encourage our patients to maintain regular contact with us and with fellow patients. Quite honestly, Weight Loss Surgery is not a cheap nor an easy option, and it is wrong that people should make such a major investment, emotionally and financially, only to be left to fail because of inadequate preparation or poor support and follow up. In the UK, NICE (the National Institute for Clinical Excellence) has embraced the IFSO (International Federation of Surgeons in Obesity) criteria for acceptance of patients for surgical weight loss treatment, and part of those criteria involve careful psychological evaluation to ensure the patient is well placed to benefit from surgery. I know many UK PCTs set much tougher standards in terms of arbitrarily imposing higher BMI requirements on local candidates for surgery and this is clearly an attempt to limit the costs to the NHS of surgical procedures, but I believe they would be much better advised to concentrate on providing adequate support and counselling for those morbidly obese candidates for surgery they are able to afford to treat; in the long run this would prove a much more cost-effective option in terms of successful weight loss and the reduction of NHS costs in dealing with some of the co-morbidities associated with obesity such as Type II Diabetes and Hypertension”
Cosmetic Bliss is well placed to accept new patients for surgery with Dr Cierny in Breclav Hospital because of the new unit, though there is a waiting list of approximately 1 month.

Thu Dec 11, 2008 5:20am GMTLONDON (Reuters) – A third of all British adults — some 13 million people — will be obese by 2012 if current trends continue, jeopardising their health and straining healthcare budgets, researchers said on Thursday.

Over-eating and lack of exercise mean more and more Britons are seriously overweight, with 32.1 percent of men and 33.1 percent of women now expected to be clinically obese in four years’ time.

Almost half of them will be from low income and disadvantaged communities, widening the health gap between the haves and have-nots, according to Paola Zaninotto of University College London and colleagues.

Type 2 diabetes, heart disease and certain cancers are all directly linked to obesity, and the condition causes at least 9,000 premature deaths each year in England alone, the research team said.

It also costs the economy around 7.4 billion pounds a year, they reported in the Journal of Epidemiology and Community Health.

Their forecasts of future rates of obesity are based on data collected each year from 128,000 adults that provides a nationwide sample of Body Mass Index readings, which relate height to weight.

Previous research has shown a rapid rise in British obesity levels, with its prevalence almost doubling in men from 13.6 to 24 percent between 1993 and 2004 and rising nearly 50 percent among women, from 16.9 to 24.4 percent.

Obesity is a mounting concern for healthcare officials worldwide.

Drug companies have tried for years to develop a successful anti-obesity pill but the field is littered with failures, with Sanofi-Aventis’s Acomplia — withdrawn in October over links to mental disorders — the most recent casualty.

BBC News 17/10/08
Obesity and lack of fitness raise the risk of illness by impacting negatively on the body’s internal chemistry, research suggests.

A US team found levels of white blood cells were highest in men who were unfit and overweight.

White blood cells are key to fighting infection, but high levels can be a sign of inflammation, which is linked to coronary heart disease.

The study appears in the British Journal of Sports Medicine.

“There is nothing worse than a risk factor that an individual cannot modify, but here are two risk factors – obesity and fitness – which they can do something about
Professor Tim Church
Pennington Biomedical Research Center
A team from the Pennington Biomedical Research Center carried out tests on 452 healthy men who were taking part in a long-term study of fitness.

Blood tests were taken, and analysed for their content of various types of white blood cell.

After taking account of age, the researchers found that all groups of white blood cell were lowest in the men who were most physically fit.

The greater proportion of body fat a man had, the higher his white blood cell count was.

Total white cell count was highest in men who had a combination of higher body fat and lower levels of physical fitness.

Levels were also high among men with lower body weight but lower levels of fitness.

However, a high degree of physical fitness negated the effect of extra body fat.

Full article:http://news.bbc.co.uk/1/hi/health/7669966.stm

News Author: Jacquelyn K. Beals, PhD
CME Author: Désirée Lie, MD, MSEd
Medscape Today – Journal 15/10/08
Superobese patients who spend an average of 9 preoperative weeks on a very-low-calorie diet (VLCD) have reduced morbidity and mortality rates associated with bariatric surgery. The weight loss regimen appears to improve factors that influence technical aspects of surgery and reduces patient comorbidities.
George M. Eid, MD, FACS, from the Division of Minimally Invasive Surgery at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, presented the study here today at the American College of Surgeons 94th Annual Clinical Congress. The study reflected the literature on bariatric surgery that shows superobesity (body mass index [BMI] > 50 kg/m2) to be a major risk factor for adverse outcomes. Other risk factors are male sex, age, lower socioeconomic status, or smoking.
Dr. Eid noted in his presentation that the 30-day mortality rate reported for 575 bariatric surgery patients in the Veterans Administration system is 1.4%, with a 19.7% overall rate of complications. Superobese patients have a 2.3% mortality rate and a 29% morbidity rate.
The surgical risks associated with superobesity are both physiologic and technical. The physiology involves several comorbidities: diabetes mellitus, sleep apnea, congestive heart failure, hypertension, degenerative joint disease, and chronic obstructive pulmonary disease. Technical challenges include excess visceral fat, an enlarged liver (hepatomegaly), and a thickened abdominal wall.
The goal of the present study was to “evaluate changes in obesity-related comorbidities, liver size, and visceral and subcutaneous adipose tissue volumes following preoperative weight loss with a…VLCD program, and relate these changes with postoperative outcomes,” said Dr. Eid.
“The kind of medical weight loss we use in this study is called very-low-calorie diet. This is a mostly high-protein liquid diet with balanced electrolytes,” Dr. Eid told Medscape Surgery. “My understanding is it’s only FDA [US Food and Drug Administration] approved for a 3-month period.”
Even without the US Food and Drug Administration regulation, medical weight loss is rarely successful in the long-term.
“Medical weight loss has a high incidence of failure over the long period of time,” Dr. Eid told Medscape Surgery. “If you follow a patient at 6 and 12 months they regain their weight, and maybe gain more weight….Studies have been done showing over 1 to 2 periods of follow-up in a medical weight loss patient that you have a high percentage of weight regain and going back to square one.”
Data were collected prospectively from 30 consecutive patients (27 men and 3 women) with a BMI of more than 50 kg/m2 who were seen between August 2004 and April 2007 and were invited to take part in a supervised VLCD program. Participants received 5 servings of a high-protein liquid diet totaling 800 calories per day and were seen weekly for medical and behavioral follow-up. The targeted weight loss was 10% of body weight for patients with a BMI between 50 and 55 kg/m2. For patients with a BMI of more than 60 kg/m2, the goal was a BMI of less than 55 kg/m2.
Mean patient age was 53 years (age range, 34 – 65 years), mean baseline BMI was 56 kg/m2 (range, 51 – 69 kg/m2), and average period on the VLCD was 9 weeks (range, 4 – 13 weeks). To assess the physical changes that accompanied weight loss, computed tomographic scans of the abdomen were done at the beginning of the VLCD program and after its completion.
The scans determined liver volume in cubic centimeters, the depth of the abdominal wall in centimeters, and the subcutaneous adipose tissue and visceral adipose tissue in centimeters squared at locations 12 cm and 20 cm from the xiphoid process. The second scan showed significant improvements in BMI, liver volume, depth at 12 cm and 20 cm from the xiphoid process, total subcutaneous adipose tissue at 12 and 20 cm from the xiphoid process, and visceral adipose tissue (each P < .001).
Preoperative weight-loss with VLCD improved poorly controlled diabetes mellitus in 10 (62.5%) of 16 diabetic subjects. It also improved poorly controlled hypertension in 8 (40%) of 20 of affected patients, and improved degenerative joint disease with limited mobility in 12 (57%) of 21 of patients with this problem. “Some even stopped using their wheelchair and were able to do limited activity by walking,” observed Dr. Eid.
No deaths occurred in the patients who experienced weight loss with VLCD before their bariatric surgery, even with 1-year follow-up. There were 2 postoperative complications: a questionable pulmonary embolism that was examined and had a good outcome, and a minor bleeding episode. Historical data from the same institution report 0% mortality and 6.7% morbidity rates. National Veterans Administration data for superobese patients, as noted previously, show 2.3% mortality and 29% morbidity rates.
Dr. Eid and his colleagues conclude that “bariatric surgical outcomes in superobese patients are optimized through preoperative VLCD.” The significant reductions in liver volume, abdominal wall depth, and visceral adipose tissue and subcutaneous adipose tissue (technical factors) improve the surgical procedure. Improvements in diabetes, hypertension, and degenerative joint disease (physiologic factors) enhance the health of the patient.
“I had two factors. I had the technical factors and those had to do with decreasing the amount of fat and the size of the liver so we had better access to our organ and we can do a better job,” Dr. Eid told Medscape Surgery. “But also we had improvement in their medical condition with diabetes and everything, so it’s a two-pronged approach. On the one hand, you improve technical factors, but on the other hand you improve their comorbidities so you have less risk of complication and postoperative problems.”