Weight-loss surgery referral threshold lowered by NICE

28th July 2023

Patients should no longer have to attempt weight loss by non-surgical interventions before referral to bariatric surgery, under new NICE guidance.

They also no longer have to be ‘generally fit for anaesthesia and surgery’ before referral to a specialist weight management service, which will instead undertake this assessment.

A new update to the clinical guideline for obesity identification, assessment and management removes a number of barriers for GPs to refer patients to be assessed for weight-loss surgery.

The previous guidance, first published nine years ago, had stipulated that referral for bariatric surgery should only be considered once ‘all appropriate non-surgical measures have been tried but the person has not achieved or maintained adequate, clinically beneficial weight loss’.

But this has now been removed, alongside a requirement for the person to have gone through intensive weight management treatment in a Tier 3 service.

The new guideline instead uses the term ‘specialist weight management centre‘ – which requires the necessary expertise to assess patients but does not necessarily need to be tier 3.

Professor Alex Miras, professor of endocrinology at Ulster University, who participated in developing the new guidance, said: ‘If the team decide that the patient needs optimisation, this can take place before surgery is undertaken. If the team decide that there is no need for optimisation, then the patient can proceed to surgery much faster.’

The guidance also highlights that ‘drug treatments may be used to maintain or reduce weight before surgery for people who have been recommended surgery’.

And it further aims to clarify in which patents bariatric surgery interventions may be most beneficial.

Professor Miras said: ‘We have made it a bit more clear as to which obesity complications have a high level of evidence in terms of response to surgery (e.g. diabetes and fatty liver disease), while clarifying that the list is not exhaustive. In the previous guidance, the language used was more vague.’

GP referral criteria will also be subject to local commissioners, which may limit opportunities for bariatric surgery.

‘What we have done is make the patient’s journey towards bariatric surgery less cumbersome and removed some of the obstacles,’ said Professor Miras.

‘These changes may not necessarily increase the number of operations funded by the ICBs, but it will make the journey of the individual patient much more efficient.’

According to NICE, removing these barriers to referral will reduce variation in practice and increase uptake in previously overlooked groups.

‘This however does not mean more people will have bariatric surgery, because they may decide it is not right for them or they are not judged to be clinically suitable for surgery,’ a NICE spokesperson said.

Professor Azeem Majeed, a GP professor of primary care and public health at Imperial College London, said the new guideline ‘potentially has significant implications for general practices in England’.

He argued it will bring ‘additional work in discussing weight management with patients’ and that ‘suitable referral pathways would need to be in place with sufficient capacity to deal with an increase in patient numbers’.

This article was originally published by our sister publication Pulse.

Bariatric surgery weight loss decreases risk of obesity-related cancers

1st July 2022

Bariatric surgery has been shown to reduce the risk of subsequently developing obesity-related cancers and overall cancer mortality

Patient who have undergone bariatric surgery have a significantly lower risk of developing an obesity-related cancer as well as cancer-related mortality. This was the conclusion of a cohort study by a team of US researchers.

Individuals with a body mass index (BMI) above 25 are considered to be overweight but when the BMI exceeds 30, these individuals are deemed to be obese. Data from the World Health Organization suggest that in 2016, 1.9 billion adults across the world were classed as overweight and 650 million obese.

Although obesity increases the risk of cardiovascular disease, obesity has also been found to be associated with greater overall mortality in patients with cancer. 

Whilst dieting helps many people to lose weight, one of the most effective weight loss strategies is surgery and in one follow-up study after a Roux-en-Y gastric bypass, the mean weight loss change from baseline was 35 kg at 12 years.

Given the elevated risk of certain cancers in those who are obese, could weight loss reduce the risk of subsequently developing an obesity-related cancer?

Unfortunately, the evidence base supporting this premise is limited apart from one study in patients who underwent bariatric surgery and which found that after a mean follow-up of 12.5 years, total cancer incidence was significantly lower in the surgical group compared to controls. Nevertheless, a limitation of the study was the absence of a matched control group, particularly in relation to possible cancer risk factors such as smoking history.

Consequently, there remains some uncertainty over whether weight loss can reduce the risk of cancer and this was the basis for the current study. The US team undertook the Surgical Procedures and Long-term Effectiveness in Neoplastic Disease Incidence and Death (SPLENDID) trial, which was a retrospective, observational, matched, cohort study in adults with obesity who either underwent bariatric surgery or who received usual care (i.e., no surgery).

Participants were included if they had a BMI of between 35 and 80 and underwent either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). The primary endpoint of the study was the first occurrence of 1 of 13 types of obesity-associated cancers including oesophageal adenocarcinoma, renal cell carcinoma, colon, rectum, liver and pancreatic cancer.

As a secondary endpoint, the team considered the incidence of all types of cancer and cancer-related mortality.

Bariatric surgery and cancer development

A total of 30,318 patients with a median age of 46 years (77% female) including 5,053 who underwent bariatric surgery, (RYGB 66%) were included in the analysis. After 10 years, participants in the bariatric surgery group had lost 27.5 kg compared to 2.7 kg in the control group (p <0.001).

During the period of follow-up, 96 patients in the bariatric surgery group and 780 in the control group developed one of the obesity-related cancers, giving an incidence rate of 3 vs 4.6 events (surgery vs control) per 1000 person-years.

The cumulative incidence of the primary endpoint at 10 years was 2.9% in the surgery group and 4.9% in the non-surgical (control group) and which was statistically significant (hazard ratio, HR = 0.68, 95% CI 0.53 – 0.87, p = 0.02). In addition, the cumulative incidence of cancer-related mortality at 10 years was 0.8% in the surgical group compared to 1.4% in the control group and which again, as statistically significant (HR = 0.52, 95% CI 0.31 – 0.88, p = 0.01).

Based on these findings, the authors concluded that bariatric surgery is associated with a significantly lower incidence of obesity-associated cancer and cancer-related mortality.

Citation
Aminian A et al. Association of Bariatric Surgery With Cancer Risk and Mortality in Adults With Obesity JAMA 2022

Prior bariatric surgery associated with better outcomes in patients with COVID-19

30th November 2020

Obesity represents a risk factor associated with a worse prognosis in patients with COVID-19. Metabolic surgery for weight reduction leads to improvements in health and wellbeing and could therefore result in a better outcome among those who become infected with COVID-19.

The precise reasons why obesity enhances the risk of a more severe outcome in COVID-19 remains unclear. Nevertheless, obesity is associated with several other additional risk factors such as cardiometabolic, thromboembolic and pulmonary disease and it is likely that it is this combination of factors that raises the overall risk. For example, obese patients have higher levels of pro-inflammatory cytokines and oxidative stress which can impact on both the innate and adaptive immune system, all of which may contribute to a worse prognosis. Metabolic surgery in obese patients leads to improvements in cardiovascular risk factors and the amelioration of the pro-inflammatory state linked with obesity.

In a retrospective study of patients testing positive for COVID-19, researchers from the Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Ohio, US, set out to examine the relationship between prior metabolic surgery and the severity of COVID-19 in severely obese patients. A total of 33 individuals who had prior metabolic surgery (the surgical group) were identified and were matched 1:10 to non-surgical patients to create a cohort with a body mass index (BMI) greater than or equal to 40kg/m2 at the time of testing. The pre-specified endpoints examined were: admission to intensive care, need for mechanical ventilation, dialysis during their hospital stay and mortality.

Findings
Data on a total of 363 patients, including the 33 who had prior metabolic surgery were available for analysis. The surgical group had a mean age of 46.1 years (78% female) with a mean BMI of 37.2±7.1 compared to 46.7± 6.4kg/m2 in the control group. A subsequent univariate analysis showed that 18.2% of those in the surgery group and 42.1% in the control group were admitted to hospital because of their infection with COVID-19. A prior history of metabolic surgery was associated with a statistically lower odds of being admitted to hospital (odds ratio = 0.31, 95% CI 0.11 – 0.88, p = 0.028). Furthermore, none of the surgical group patients experienced one of the four pre-specified endpoints. In contrast, 13% of those in the control group were admitted to intensive care, 6.7% required mechanical ventilation, 1.5% dialysis and 2.4% died. The authors suggested that prior metabolic surgery was associated with a lower severity of COVID-19 infection but recognised that these observations were based on a small sample size and they were also unable to account for their findings.

They concluded by calling for more research to understand the mechanistic role of both obesity and intentional weight loss on COVID-19 infection.

Reference
Aminian A et al. Association of prior metabolic and bariatric surgery with severity of coronavirus disease 2019 (COVID-19) in patients with obesity. Surg Obes Relat Dis 2020. https://doi.org/10.1016/j.soard.2020.10.026