Due to concern about the growth of laparoscopy and adjustable gastric banding, which has been erroneously likened to cosmetic surgery, national social security systems have introduced regulations to reduce or even eliminate reimbursements for the procedure, depending on the individual country. In light of the public health problem represented by the current epidemic of obesity, the EU and its Member States have taken preventive measures to promote better nutrition and physical activity. However, the status of bariatric surgery remains a major problem, dominated by high costs.
Rationale for surgical treatment of morbid obesity
Defined as an excess weight of 40–45kg, morbid obesity was recognised as a distinct pathological entity in 1997 by the WHO. Contrary to popular belief, obesity is not due to lack of willpower. Instead, it is a polygenic disease that is facilitated by the toxic environment of our society, including sedentary lifestyles, stress and unstructured eating habits.(1)
Chronic and highly invalidating, morbid obesity is accompanied by numerous associated diseases such as high blood pressure, cardiovascular disease, sleep apnoea, diabetes, dyslipidaemia, osteoarthritis, depression and even certain cancers. This particularly serious disease shortens the life expectancy of affected individuals and is responsible for 220,000 deaths annually in Europe. This irreversible disease is practically incurable by standard medical treatments: diets of all types, behavioural treatments, physical activity or drugs. This was clearly demonstrated by the recent Swedish obese subjects study (SOS) that compared medical management with surgical treatment for 1,703 patients, which was followed up for 10 years. All medically treated patients had gained weight, while all of those who had undergone surgery showed significant weight loss.(2) In addition, after weight loss, 80% of all associated diseases had been improved or cured.(3)
Surgical treatment is based on two principles: diminishing intake by reducing stomach volume or reducing assimilation by creating intestinal malabsorption (see Figure 1). Gastroplasty is a restrictive procedure involving placement of an adjustable gastric band.(4) This particularly simple operation has an extremely low mortality rate (0.2%) and very low morbidity in the immediate postoperative period. However, late complications related to intolerance are reported in 40% of patients.
Gastric bypass is a combined restrictive and malabsorptive procedure with a mortality rate of 0.5% and morbidity of 5–10%. This is the current gold standard owing to its efficacy and comfort.(5)
Biliopancreatic diversion with a duodenal switch is a particularly complex malabsorptive technique characterised by mortality of 2% and morbidity of 20%. These rates can be reduced by performing the operation in two steps – sleeve gastrectomy, then diversion.(6) Today, sleeve gastrectomy is starting to be performed alone as a purely restrictive intervention.
Surgical indications are based on the recommendations of scientific societies and must be strictly respected: body mass index (BMI) = weight (kg)/height(2) (m(2)) greater than 40, or BMI between 35–40 when there is an associated pathology that may be improved by weight loss.(7) The indications of various procedures must be adapted to the patient’s personality, BMI and eating habits, particularly for sweet eaters or binge eaters.
Results depend on multidisciplinary follow-up, aimed at preventing digestive, nutritional and psychological complications. Weight loss is significant, corresponding to 50%, 75% or 85% of body weight respectively for gastric banding, gastric bypass and biliopancreatic diversion. After weight loss, associated pathologies are cured or improved and the resulting quality of life is excellent for most patients, even though nutritional restrictive procedures reduce nutritional comfort.(3,7,8)
The 21st century challenge for laparoscopic bariatric surgery
According to WHO, “obesity (BMI over 30) affects up to a third of the adult population in the European region”. This means that 135 million people are obese and that 20% of them (27 million) are morbidly obese. Of particular concern, “childhood obesity is an acute health crisis” characterised by an increasing incidence of type 2 diabetes and hypertension.(9)
In 1998, 40,000 bariatric operations had been performed worldwide – mainly in the US, but including several thousand in Europe. By 2003, these figures had risen to 146,301 operations worldwide, including 103,000 in North America and 30,021 in Europe. By 2005, some 150,000 operations had been performed in the US and 44,000 in Europe.(8,10)
This increase in bariatic surgery is related to the efficiency of results compared with the long-term failure observed with medical therapy, greater patient acceptance of laparoscopic techniques and, in Europe, widespread use of laparoscopic gastric banding (up to 90% of operations). Consequently, “in the future laparoscopic bariatric surgery will become the most common gastric intestinal procedure”.(9) However, only 1–2% of all morbidly obese patients in the US are treated by bariatric surgery; in Europe, this percentage is only around 0.2%.(10)
Possibilities for developing laparoscopic bariatric surgery are immense, especially because the prevalence of obesity is rising at an annual rate of 2%. “As the population of obese adults and children increases, there is an urgent need for solutions that can resolve the looming crisis”.(9) However, there is a financial barrier: no healthcare system in Europe appears capable of absorbing the expenses for the entire morbidly obese population.
Obesity represents a major economic burden due to both indirect and direct costs, and accounts for 2–8% of all healthcare spending. The largest percentage of costs corresponds to the treatment of co-morbidities – especially diabetes – and the expenses of disability pensions, missed days of work and lower productivity.
Consequently, bariatric surgery is often not covered by healthcare providers in Germany and the UK, and to a lesser extent in Belgium, France, Italy and Spain. This situation is reflected by the number of cases reported in 2003 (1,100 in Germany; 600 in the UK; 6,000 in Belgium; 12,000 in France; 3,000 in Italy; and 2,000 in Spain).(10)
However, as successful weight-loss surgery results in lower medical costs and fewer weight-related expenses, promotion of laparoscopic bariatric surgery appears essential.
Morbid obesity is currently incurable by standard medical therapies. Bariatric surgery is the only approach that achieves significant long-term weight loss, corrects associated pathologies and restores a satisfactory quality of life. Patients increasingly demand such surgery because the minimally invasive nature of laparoscopy limits perioperative morbidity, eliminates pain, shortens hospitalisation and permits faster recovery. However, the epidemic of obesity in Europe requires both an effective structured approach and considerable financial backing. The solution lies in achieving high-quality results through cooperation among all involved parties.
American Society for Bariatric Surgery (ASBS): 24th annual meeting June 11–16 2007; San Diego, CA, US
Society of American Gastrointestinal and Endoscopic Surgeons (SAGES): annual meeting April 19–22 2007; Las Vegas, Nevada, US
European Association for Endoscopic Surgery (EAES): 15th annual congress July 4–7 2007; Athens, Greece
International Federation for the Surgery of Obesity (IFSO): 12th world congress, September 5–8 2007; Porto, Portugal.
- National Institutes of Health. Consensus development conference panel. Gastro intestinal surgery for severe obesity. Ann Int Med 1991;115: 956-61.
- Sjöstrom L, Lindroos AK, Peltonen M, et al. Life style, diabetes and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351:2683 -93.
- Buchwald H, Avidor Y, Braunwald E et al. Bariatric surgery. A systematic review and meta-analysis. JAMA 2004;292:1724-37.
- Belachew M, Legrand MJ, Defechereux TH et al. Laparoscopic adjustable silicone gastric banding in the treatment of morbid obesity: a preliminary report. Surg Endosc 1994;8:1354-56.
- Wittgrove AC, Clark WG, Tremblay LJ. Laparoscopic gastric by pass Roux en Y. Preliminary report of five cases. Obes Surg 1994;4:353-7.
- Gagner M, Patterson E. Laparoscopic bilio pancreatic diversion with duodenal switch. Digest Surg 2000;17:547-66.
- Sauerland S, Angrisani L, Belachew M, et al. Obesity surgery: evidence based guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc 2005;19:200-21.
- Schirmer B.Laparoscopic bariatric surgery. Surg Endosc 2006;20:S450-5.
- Available from: www.euro.who.int/obesity
- Buchwald H, Williams SE. Bariatric surgery worldwide. Obes Surg 2003;14:1157-64.