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Complications and costs

Bariatric surgery worth the risks

New research shows complications not uncommon in bariatric surgery, but outweighed by benefits
30,000 deaths are caused by obesity every year in England, and non-surgical options are "ineffective"
Finnish study shows surgery reduces need for further treatment and total heatlhcare costs among very obese

According to two recently published papers in the October 2011 issue of the British Journal of Surgery, long-term complications and further surgery are not uncommon, but despite these disadvantages surgery is a more cost-effective way of tackling rising morbid obesity rates than non-operative care.

The first paper, ‘Management of late postoperative complications of bariatric surgery’, examined the increasing number of patients presenting to non-specialist units with complications following bariatric procedures and outlined the management of the most common late postoperative complications that are likely to present to the general surgeon.

“In England, there are more than 30,000 deaths a year attributed to obesity alone, taking an average of nine years off a person's normal life expectancy,” said the lead author of the paper, consultant surgeon Mr Khaled Hamdan, Digestive Diseases Unit at Brighton and Sussex University Hospitals. “As a result of the current, largely ineffective, non-surgical options for treating obesity, the past decade has witnessed an exponential increase in the number of bariatric operations performed.”

Therefore, the researchers undertook a literature search for late postoperative complications after bariatric surgery using PubMed, Embase, OVID and Google search engines, and combinations of the terms bariatric surgery, gastric bypass, gastric banding or sleeve gastrectomy, and late or delayed complications. Only studies with follow-up longer than six months were included.


The most common long-term complications after gastric banding include band slippage (which affects 15% to 20% of patients), erosion (which can affect up to 4% of patients). Deflation or removal of the band is often required.

Following gastric bypass, internal hernia (5% to 10%), adhesions and anastomotic stenosis are common causes of intestinal obstruction. Megaoesophagus (dilation of the esophagus) is a rare but well reported late complication, occurring in one in every 200 patients after LAGB. Hepatobiliary complications are another particular challenge because of the altered anatomy.

Functional disorders such as reflux and dumping, and nutritional deficiencies are common and should be differentiated from conditions that require urgent investigations and timely surgical intervention.

Up to one-third of patients experience intermittent gastrointestinal disturbances, particularly if they do not adhere to the dietary advice and nutritional supplements they are given after surgery.

Between 13% and 36% of patients develop cholesterol gallstones after surgery, due to rapid weight loss, but only 10% develop symptoms requiring surgical intervention. Less than 5% to 10% of patients have chronic problems with dumping syndrome, which can cause facial flushing, light-headedness and diarrhoea after eating carbohydrate-rich meals.

Most patients find that reducing their intake of carbohydrates and avoiding drinking liquids half an hour before and after eating improves their symptoms.

The authors note that complications after bariatric surgery should be thoroughly assessed and investigated. They highlight that the fact that a patient's symptoms may not necessarily relate to their gastric surgery. They also emphasise the importance that the attending surgeon should be familiar with bariatric procedures and gastrointestinal alterations following surgery.

Managing these patients can be challenging for a non-bariatric surgeon and timely liaison with a bariatric unit is advisable. In addition, functional problems affecting the gastrointestinal tract may pose a diagnostic conundrum, requiring specialist intervention and liaison with specialists in the field when necessary to spare patients unnecessary surgical interventions. The researchers stressed that long-term complications should be taken into consideration when deciding what type of surgery to undertake.


The second paper, ‘Cost-utility of bariatric surgery for morbid obesity in Finland.’ from the Finnish Office for Health Technology Assessment states that bariatric surgery is more cost-effective as it increases health-related quality of life and reduces the need for further treatment and total healthcare costs among patients who are very obese.

“Our study compared bariatric surgery with the current practice in treating morbid obesity in Finland, which is ordinary treatment ranging from intensive conservative treatment to brief advice from a doctor to lose weight,” said Ms Mäklin. "This was evaluated using data on healthcare resource use in patients with a body mass index of 35 or more from a large representative population survey.

“In the base-case analysis, bariatric surgery was both more effective and less costly than the ordinary treatment.”

The study evaluated the cost–utility of the following bariatric surgery procedures - gastric bypass, sleeve gastrectomy and gastric banding - compared with ordinary treatment.

Mäklin explained that an analysis was performed from a healthcare provider's perspective using a combination of a decision tree and a Markov model, with a time horizon of ten years. Health-related quality of life was estimated from a representative population survey, and other parameter values were based on registers, systematic reviews, controlled studies and expert opinion.

The results showed that In the base-case analysis, bariatric surgery was both more effective and less costly than the ordinary treatment. The mean costs of treating an obese patient with bariatric surgery in Finland was €33,870 compared with €50,495 for non-operative treatment. These cost savings are due to reductions in other health conditions after surgery. The research team also reported that bariatric surgery also increased the number of quality-adjusted life 7.63 vs. 7.05, for bariatric surgery and ordinary treatment, respectively, during the ten-year time frame they studied.

Uncertainty around the parameter values was tested comprehensively in sensitivity analyses, and the results were robust, said the researchers. "Surgery for morbid obesity improves health-related quality of life and reduces the need for further treatments and total healthcare costs,” the researchers concluded. “The present results suggest that, compared with surgical treatment, non-operative care will on average be more costly for the Finnish healthcare system five years after surgery.”

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