1. Lecture at Derby Bariatric Surgery Course
14-06-2012
Rationale for Bariatric Surgery:
Medical & Financial Arguments
Abeezar I. Sarela MSc MS MD FRCS
Consultant in Upper GI & Bariatric Surgery
Leeds Teaching Hospitals NHS Trust
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2. Why should we be paid to do
Bariatric Surgery?
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3. Rationale for Bariatric Surgery
Medical Financial
1. Efficacy
2. Efficiency
3. Safety
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4. Medical Rationale
For Bariatric Surgery
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5. Weight Loss with Bariatric Surgery
Sjostrom L et al. Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. N Engl J Med 2007;357:741-52.
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6. Bariatric Surgery:
What is the Evidence that it Works?
• 22,094 patients
• Excess weight loss
– Bypass: 60-75%
– Band: 55-65%
• Operative mortality
– Bypass: 0.5%
– Band: 0.1%
• Diabetes: Resolved in 77%
• Hypertension: Resolved in 62%
• Obstructive Sleep Apnea: Resolved in 86%
Bariatric Surgery. A Systematic Review and Meta-Analysis.
JAMA 2004;292:1724-1737
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7. Bariatric Surgery:
What is the Evidence that it Works?
• USA
• 1984-2002
• 7925 gastric bypass patients vs. 7925 weight
and risk matched controls
• Significantly ↓ mortality in bypass patients
– Overall mortality ↓ 40%
– Coronary disease related mortality ↓ 56%
– Diabetes related mortality ↓ 92%
– Cancer related mortality ↓ 60%
Long-Term Mortality After Gastric Bypass Surgery
NEJM 2007;357:753-61
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8. Bariatric Surgery:
What is the Evidence that it Works?
• 11 years follow-up
• Bariatric surgery 2010 patients vs.
Conventional treatment 2037 patients
• Weight loss
– Bypass: 2 years, 32%; 10 years, 25%
– Banding: 2 years, 20%; 10 years, 14%
• Risk adjusted hazard ratio for death: bariatric
surgery vs. conventional treatment – 0.70
Effects of Bariatric Surgery on Mortality in Swedish Obese Patients
NEJM 2007;357:741-752
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9. Effects of Bariatric Surgery on Type 2 DM
A Systematic Review and Meta-analysis
• 621 studies: 1990-2006
• 135, 246 patients
• Women: 80%
• Mean BMI 48 kg/m2
• Resolution of T2DM : 78%
• Resolution or improvement: 84%
Buchwald et al. Am J Med 2009;122:248-256
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10. Lexington
Stick or carrot?
When it comes to obesity, Michelle Obama
can teach Michael Bloomberg something
Jun 9th 2012 | from the print edition
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11. www.foregutsurgeon.com

12. Health Economics
Treating Obesity with Bariatric Surgery
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13. NIHR HTA
Southampton Health
Technology Assessments
Centre, University of
Southampton, UK.
Health Technology
Assessment Program was
established in 1993 as part
of the National Institute for
Health Research.
Research findings of HTA
directly influence decision-
making bodies such as
NICE and DoH.
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14. NIHR HTA of Bariatric Surgery
• Bariatric surgery was cost-effective in
comparison to non-surgical treatment in the
published estimates.
• Estimates are unlikely to be reliable and not
generalizable because of methodological
shortcoming and modeling assumptions.
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15. NIHR HTA of Bariatric Surgery
• Development of a new economic model
• Surgical management was more costly than
non-surgical management but gave improved
outcomes.
• Incremental cost-effectiveness ratios of
£2000-£4000 per QALY gained – within the
cost-effectiveness range for NHS decision-
making.
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16. Office of
Health
Economics
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17. Shedding The Pounds
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18. Shedding The Pounds
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19. Conclusion
• Bariatric Surgery is clinically effective and cost-
effective as compared to non-surgical
interventions.
• Uncertainties:
– QOL
– Impact of surgeon experience
– Late complications leading to re-operation
– Duration of co-morbidity remission
– Potential benefits of early intervention
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