REVIEW OF BARIATRIC SURGICAL SERVICES IN SCOTLAND. (Weight Loss Surgery for Adults who are Severely Obese)

Transcription

1 REVIEW OF BARIATRIC SURGICAL SERVICES IN SCOTLAND (Weight Loss Surgery for Adults who are Severely Obese) A Report by a Working Group of the Scottish Medical and Scientific Advisory Committee

2 REVIEW OF BARIATRIC SURGICAL SERVICES IN SCOTLAND (Weight Loss Surgery for Adults who are Severely Obese) A Report by a Working Group of the Scottish Medical and Scientific Advisory Committee

3 Crown copyright 2004 ISBN: Scottish Executive St Andrew s House Edinburgh EH1 3DG Produced for the Scottish Executive by Astron B /04 Published by the Scottish Executive, November, 2004 Further copies are available from Blackwell's Bookshop 53 South Bridge Edinburgh EH1 1YS The text pages of this document are produced from 100% elemental chlorine-free, environmentally-preferred material and are 100% recyclable.

4 SCOTTISH EXECUTIVE HEALTH DEPARTMENT REVIEW OF BARIATRIC SURGICAL SERVICES IN SCOTLAND (Weight Loss Surgery for Adults who are Severely Obese) A REPORT BY A WORKING GROUP OF THE SCOTTISH MEDICAL AND SCIENTIFIC ADVISORY COMMITTEE iii

5 TERMS OF REFERENCE The Group was set up to review services for the surgical management of patients with grade 3 obesity in NHSScotland and to make recommendations to the Chief Medical Officer on future delivery. Note Throughout this report, the term Grade 3 obesity is used to refer to adults who are morbidly obese. This is in line with terminology used by the World Health Organization (WHO) whose definitions, based on Body Mass Index (BMI) are as follows: Underweight Below 18.5 Healthy weight 18.5 to 24.9 Overweight (Grade 1 Obesity) 25.0 to 29.9 Obese (Grade 2 Obesity) 30.0 to 39.9 Morbid Obesity (Grade 3 Obesity) 40 or above (BMI = Weight kg / Height m 2 ) iv

6 EXECUTIVE SUMMARY Obesity is a global health issue. So much so that the World Health Organization has described it as the greatest health challenge of the 21 st century. Almost two-thirds of Scottish adults are overweight and more than one in five are classified as obese. By 2010 it is estimated that almost 30% of Scottish adults will be obese. Obesity is a major contributory factor for many of the potentially fatal diseases of the developed world and this has serious implications for the health of nations. In Scotland, it is a condition with important cost consequences that rank second only to smoking as a cause of burden upon the health service. Expressed in the most simplistic of terms, obesity occurs when an individual s intake of calories repeatedly exceeds the amount of energy expended. In reality, its aetiology is much more complex and is influenced by genetic, social, cultural, psychological, environmental and economic circumstances. This report, which has been prepared by a multidisciplinary Working Group of the Scottish Medical and Scientific Advisory Committee, (SMASAC), proposes a formal framework for the practice of bariatric surgery, [surgery for patients with grade 3 obesity] as a recognised treatment option within the overall management of obesity. For the most part, obesity should be managed within primary care. However, surgical interventions are sometimes used for severely obese patients when all other treatments have failed. These are major interventions that can only be undertaken in the context of a multidisciplinary team and with a strong emphasis on long-term supportive care. After full secondary care medical assessment, it is estimated that between 50 and 70 of these operations are currently performed each year in Scotland. The development of services for the surgical management of obesity have been largely unplanned. In general, they have developed through a combination of specialist interest, service demand, and creeping incrementalism. In addition, referral pathways for surgery are not well-defined. In some cases it is made at the suggestion or insistence of the patient, rather than as part of a practice-based on-going programme of attempted weight management. This report describes the main types of surgical intervention employed in weight loss surgery. Building on existing guidance both north and south of the border, it sets out the parameters v

7 within which this type of surgery should be conducted and places it within the overall context of weight management in NHSScotland. The report explores the subject from the patients perspective and places particular emphasis on the contribution of the multidisciplinary team and the need for long-term supportive care. A model care pathway is elaborated in Appendix III and a patient information leaflet, which sets out all the basic facts in a question and answer format, is given in Appendix IV. NHS Boards are encouraged to adapt this format to fit their local situation. The report concludes that weight loss surgery should be recognised as a component of general surgery and that expertise should be concentrated on a small number of centres to ensure critical mass and the further development of surgical skills. It suggests that these centres should be located in Glasgow, Aberdeen and Edinburgh but it will be up to NHS Boards to determine the extent to which these services can be developed and where they will be sited. ALISTAIR DORWARD Chairman of the Working Group vi

8 SUMMARY OF MAIN RECOMMENDATIONS Referral for Surgery NHS Boards, in conjunction with all relevant healthcare professionals, should establish a clear referral pathway for patients requiring bariatric surgery. This pathway should ensure that bariatric surgery is placed in its proper context and not delivered in isolation from other clinical and public health approaches to obesity. Information should be disseminated through NHS Boards to all referring clinicians. [A suggested model pathway is given in Appendix III]. Criteria for Surgery Surgery is recommended as a treatment option for people with grade 3 obesity providing all of the following criteria are met: Individuals should be between 18 and 60 years of age Individuals should have been in receipt of intensive management in a specialised obesity clinic There should be evidence that all appropriate and available non-surgical measures have been adequately tried but have failed to achieve and maintain appropriate weight loss There should be no specific clinical or psychological contraindications to this type of surgery Individuals should be generally fit for anaesthesia and surgery There should be a clear understanding by all concerned of the proposed procedure(s) and their effects Patients and staff should understand the need for long-term follow up. These criteria are based on those agreed by the National Institute for Clinical Excellence (NICE) which have been endorsed by the Health Technology Board for Scotland (HTBS). Surgical Management Bariatric surgery should be recognised as a component of general surgery. No surgeon should perform bariatric surgery without undertaking the appropriate training. Expertise should be concentrated on a small number of centres to ensure critical mass and the further development of surgical skills. vii

9 It is suggested that these centres could be located in Glasgow, Aberdeen and Edinburgh. It will be up to NHS Boards to determine the extent to which these services can be developed and where they will be sited. Availability of funding will be dependent upon demands from other competing priorities, including other aspects of weight management programmes, within each NHS Board. Bariatric surgery must only be practised in the context of a properly constituted and resourced team comprising a specialist dietitian, a clinical psychologist, a specialist nurse, a physician, anaesthetist, radiologist and surgeon. Decisions surrounding bariatric surgery must, wherever possible, be evidence-based, and surgery should be performed in accordance with national standards, guidelines and protocols. Centres undertaking bariatric surgery should regularly audit and compare all aspects of their care including the number of operations performed, complications and outcomes. Ideally, every bariatric surgeon should be able to perform a variety of procedures although it is recognised that most surgeons will settle on one or two procedures that work best in their hands. The choice of surgical intervention should be made jointly by the individual and the clinician after considering the best available evidence, the facilities and the equipment available, and the experience of the surgeon who would perform the operation. Centres offering bariatric surgery must have access to specialist endoscopy services. Specific OPCS codes should be assigned for each of the surgical procedures ( verticalbanded gastroplasty, gastric bypass and lap-band procedures) to enable a minimum dataset to be established for all in-patient episodes. These should be distinct from existing codes for more generalised procedures relating to operations on the stomach. Plastic Surgery for Patients who have Undergone Bariatric Surgery Criteria for patients undergoing plastic surgery to remove redundant skin and subcutaneous tissue must be clearly defined. Plastic surgery should not be carried out until the target weight has been achieved and maintained for one year. Psychological Support Arrangements should be made for appropriate healthcare professionals to provide preoperative and post-operative counselling and support to individuals being considered for surgery. A range of models of support should be provided post-operatively, e.g. patient support groups, telephone help-line, etc. in addition to routine clinical follow-up and monitoring. viii

10 Economic Considerations The cost-effectiveness of obesity-related interventions should continue to be addressed. Future research should be of good methodological quality, preferably using well controlled large studies with long-term follow up. Ten-year studies, involving long-term tracking of treated patients, may be necessary for the realistic comparison of medical and surgical therapies. ix

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12 CONTENTS Executive Summary Summary of Main Recommendations v vii 1. INTRODUCTION 1 -Introduction 1 -Background 1 -Remit 2 -Methodology 2 -Key Aims of the Report 3 2. BARIATRIC SURGICAL SERVICES IN SCOTLAND 4 -Introduction 4 -Profile of Current Service Provision 4 -Treatment Options 4 -Referral for Surgery 5 -Criteria for Selection 6 -Assessment for Surgery 6 -Types of Surgical Intervention 6 -Risk of Complications 7 -Volume of Surgery 7 -Conclusion 7 3. PLASTIC SURGERY 10 -Introduction 10 -Types of Surgical Intervention 10 -Pre-operative Considerations 10 -Per-operative Considerations 11 -Post-operative Considerations PRE- AND POST-OPERATIVE CARE AND CONTINUING PATIENT SUPPORT 12 -Introduction 12 -Pre-operative Support 12 -Support During Admission 12 -Immediate Post-operative Support 13 -Continuing Support 13 -Defining Success 14 -Conclusion 14 xi

13 5: ECONOMIC CONSIDERATIONS 15 -Introduction 15 -Selected UK Studies 15 -Economic Comparisons of Different Surgical Procedures 18 -Indirect Costs 19 -Conclusion 19 References 22 Glossary of Definitions, Acronyms and Abbreviations 26 APPENDICES 27 Appendix I: Membership of the Group 27 Appendix II: List of Contributors 29 Appendix III: Model Patient Flow Chart 30 Appendix IV: Model Patient Information Leaflet 33 Appendix V: Useful Contacts 39 xii

14 1: INTRODUCTION This chapter describes the background to the report, the Group s remit and its methodology. It also provides a summary of the key aims of the report. Introduction Confused by the title? 1. That well-worn phrase it s all Greek to me could not be more apt. Bariatric surgery (Greek baros weight, and iatrikos the art of healing) is a rapidly evolving branch of surgical science. In common parlance, it is referred to as surgery for morbid obesity. The aim is to secure substantial weight reduction in patients whose obesity poses a significant risk to health. 2. Different gradations of risk (overweight, obese and morbidly obese now referred to by the World Health Organization (WHO) as grade 3 obesity) are defined in terms of an individual s Body Mass Index (BMI) (body weight in kilograms divided by height in metres squared; kg/m 2 ). Overweight is defined by a BMI of over 25; obese by a BMI of over 30 and grade 3 obesity by a BMI that is greater than or equal to 40.[see footnote] 3. Bariatric surgery is a procedure of last resort that is to say, it is not something that is entered into lightly- and it is only considered as a treatment option for patients who are classified as being in grade 3 obesity. Background 4. Obesity is a global public health issue. The World Health Organization (WHO) has described it as the greatest health challenge of the 21 st century 1. It is estimated that around 250 million people worldwide are obese The USA has a particularly high prevalence of obesity. On average, over one third of the adult population are obese, increasing to more than a half in some ethnic sub-groups 3. Although the UK lags behind the USA, the rate of increase is very similar. 6. Almost two-thirds of Scottish adults are overweight and more than one in five are obese. By 2010 it is estimated that almost 30% of Scottish adults will be obese 4. Although BMI is a useful measure for the purposes of this report, it should be noted that it does not take into account factors such as body frame, proportion of lean mass, gender, and age. 5 In some instances, assessments such as girth-height ratio (GHR) (waist circumference divided by height) give a better predictor of cardiovascular risk than BMI 6,

15 7. The problem is not confined to adults. During the past two decades, the prevalence of obesity in children has risen greatly worldwide 8. This epidemic has affected a wide agerange, most ethnic groups and people of every socioeconomic status, though sometimes in disproportionate ways 9, In Scotland, almost 10% of primary school children and 17% of adolescents are obese. Two-thirds of obese teenagers are already carrying risk markers for future disease such as high blood pressure, raised cholesterol levels and impaired glucose tolerance as a result of their increased weight 3. We are now living in a generation in which parents will begin to outlive their children Obesity occurs when an individual s calorie intake repeatedly exceeds the amount of energy expended. Its multifactorial aetiology is largely as a result of genetic, social, cultural, psychological, environmental and economic influences. 10. Obesity reduces life expectancy because it increases the risk of other health disorders 11,12. It is a major contributory factor in many of the potentially fatal diseases of the developed world, including coronary heart disease 13,14, Type 2 diabetes 15,16,17 and certain types of cancer (for example, uterine cancer 1, colon cancer 18. ). There is also substantial comorbidity in relation to osteoarthritis 18, joint problems 18, reproductive disorders and complications during and after pregnancy 19, 20, 21,. Respiratory disorders, such as asthma and 22, 23 obstructive sleep apnoea are also associated with obesity. 11. Obesity is also a psychosocial and social burden, often resulting in social stigma, low self-esteem, reduced mobility and a generally poorer quality of life. The National Audit Office has estimated that 6% of all deaths can be attributed to obesity, and deaths linked to obesity shorten life by an average of nine years 24. Remit 12. This report examines one aspect of obesity management: surgery for adults who are severely obese. It is looked at in the context of the whole spectrum of the patient s journey of care. This surgical care pathway begins with referral and selection for surgery and ends with post-operative care and the continuous process of long-term patient support. 13. Recent policy initiatives in Scotland have concentrated on other aspects of obesity, in particular, its prevention. These initiatives include the appointment of a Scottish Food and Health Co-ordinator, based in the Scottish Executive Health Department, and the establishment of the Scottish Physical Activity Task Force. The Group acknowledges that these have an important role to play in promoting and co-ordinating efforts to prevent obesity. Methodology 14. The Group, which was multidisciplinary in composition, included representation from the medical, surgical and nursing professions as well as representatives from the allied health professions. A member of the public provided a valuable contribution from the patient s perspective. 2

16 15. Contributions were invited from a number of individuals in order to inform the work of the Group. A list of acknowledgments is given in Appendix II. Key Aims of the Report 16. The key aims of the report are as follows: To review the current organisation and management of bariatric surgical services in Scotland and to make recommendations for the future. To improve the patient s journey by placing an emphasis on pre-and post-operative care. To set in place an exemplary model for a bariatric surgical service in the context of both primary and secondary care. To place bariatric surgery in its proper context within NHSScotland and to establish it on a more formal basis as a recognised treatment option within the overall management of obesity. SUMMARY OF MAIN POINTS Obesity is a global public health issue. The World Health Organization (WHO) has described it as the greatest health challenge of the 21 st century. Obesity occurs when an individual s calorie intake repeatedly exceeds the amount of energy expended. Its multifactorial aetiology is largely as a result of genetic, social, cultural, psychological, environmental and economic influences. Obesity is a major contributory factor in many of the potentially fatal diseases of the developed world. 6% of all deaths can be attributed to obesity, and deaths linked to obesity shorten life by an average of nine years Almost two-thirds of Scottish adults are overweight and more than one in five are obese. By 2010 it is estimated that almost 30% of Scottish adults will be obese. 3

17 2: BARIATRIC SURGICAL SERVICES IN SCOTLAND This chapter provides a brief introduction to the development of bariatric surgery and goes on to describe the way in which bariatric surgical services are currently structured in Scotland in terms of referral, selection, types of surgical intervention, etc. Introduction 17. From an international perspective, bariatric surgery was pioneered in the 1950s. Early operations by-passed part of the small intestine to reduce absorption. Although effective for weight loss, operations such as the small bowel bypass procedure, also known as jejunoilial by-pass, were associated with an unacceptable number of significant long-term complications and mortality (liver failure and cirrhosis). 25,26.. In many cases, over half of all patients had to have their operations reversed or converted to gastric reduction procedures. In the 1970s, gastric stapling gained some prominence but it was very difficult to achieve the correct dimensions of the stomach for optimal weight loss and many patients experienced severe problems after surgery. By the early 1980s, bariatric surgery, in all its guises, was embraced as the most effective solution to severe weight gain in Europe and the USA but development in the UK has been more recent. 18. In the last five years there has been a significant change in laparoscopic approaches, especially laparoscopic gastric banding. Although this approach results in less weight loss than other bariatric surgical procedures, it is fast becoming the procedure of choice for many surgeons and their patients. Potential benefits from this approach include decreased perioperative morbidity, shorter recovery times and fewer long-term complications from incisional herniae and adhesions. Profile of Current and Projected Surgical Provision in NHSScotland 19. In Scotland, the development of services for the surgical management of grade 3 obesity have been largely unplanned. In general they have been developed through a combination of specialist interest, service demand and creeping incrementalism. For example, two separate hospital sites (initially three) offer services in Glasgow. Other centres operate from Lothian and Grampian. All of these centres accept referrals from outwith their area provided the funding follows the patient. A co-ordinated approach to weight management with clear referral guidelines through community dietetics and secondary care medical therapy has been established in Grampian and is currently being established in Glasgow. Treatment Options 20. In NHSScotland, obesity is managed mainly in general practice, with the most common approach being advice on weight control, diet, physical exercise and lifestyle provided by general practitioners, practice nurses and other members of the primary healthcare team. Other options, such as drug therapy, referral to specialist weight-loss clinics, behavioural therapy, etc., are also considered although decisions are currently 4

18 hampered by a general lack of information and resources within this sector to allow appropriate clinical care pathways to be established. Surgical interventions are sometimes used in severely obese patients when other treatments have failed. These are major interventions that can only be undertaken in the context of a multidisciplinary team and with a strong emphasis on long-term supportive care. 21. NICE has commissioned the National Collaborating Centre for Primary Care (NCC- PC) to work jointly with the Health Development Agency (HDA) to develop central guidance for England and Wales on the prevention, identification, assessment, treatment and weight maintenance of patients who are overweight and severely obese. The guidance will provide recommendations for good practice that are based on the best available evidence of effectiveness, including cost effectiveness. It will also identify interventions that could be delivered outside of the NHS through joint working with other potential partners. 22. Across the UK, the new GP contract has allocated substantial new resources to the Quality and Outcomes Framework and this will tend to focus time and other resources into the disease areas covered by the Framework. Dietitians in the community are a scarce resource, and find that they are increasingly focused on the vital work of dietary management in chronic disease. Referral for Surgery 23. The process of referral for surgery is not well-defined. At present, some patients are referred direct from primary care, while others are referred from other disciplines, mainly cardiovascular medicine, diabetes, endocrinology and metabolic medicine. Referring general practitioners comment that they can have difficulty in finding the appropriate referral path and seem to have been given contradictory or wrong information about availability. Furthermore, referral is often at the suggestion or insistence of the patient, rather than as part of a practice-based on-going programme of attempted weight management. Based on these findings, the immediate concern in this current review is to define a clear referral pathway for patients requiring bariatric surgery. 24. National guidelines, based on work undertaken by NICE 27 and agreed among bariatric surgeons, physicians, dietitians, patient representatives and general practitioners, on appropriate referrals to a bariatric surgical service should be subject to further development. These guidelines should be backed up with appropriate information for patients and primary care staff. NHS Boards should offer information on centres that offer bariatric surgery so that this could be disseminated to primary care teams. 25. There is likely to be substantial agreement within primary care that the management of motivated patients with grade 3 obesity, who make insufficient progress on diet and exercise programmes in the community, would be improved by having a single referral pathway to a multidisciplinary team for further specialist assessment and management at this stage. Such a team may be locality based, perhaps within a Community Health Partnership, with access to a physician and psychologist with a remit for obesity management, and would provide the opportunity for full assessment, possible appropriately supervised drug treatment or onward referral for consideration of surgery where appropriate. This would make a referral for surgery a tertiary referral. 5

19 26. A suggested model pathway is given in Appendix IV. Adherence to this pathway is likely to result in an increase in appropriate referrals to bariatric surgical services. Criteria for Selection 27. Criteria for selection has already been defined by NICE 27 and endorsed by the Health Technology Board for Scotland (HTBS) 28. The Group stand by this definition and see no reason as to why it should be changed at the present time. [The criteria are reproduced in full in the summary of the main recommendations at the front of this report]. Assessment for Surgery 28. All patients must undergo a full medical assessment, consultation and examination. Assessment is undertaken in a multidisciplinary context involving input from medical, surgical and dietetic colleagues. Wherever possible, a clinical psychologist should also be involved. The consultation should include a detailed discussion of the indications, risks, complications, success rates, process and outcomes relating to bariatric surgery. Types of Surgical Intervention 29. In general, there are three types of surgical intervention used in Scotland. These are as follows: a variant of vertical-banded gastroplasty laparoscopic gastric banding (laparoscopic lapband), and gastric by-pass In recent years there has been a change in trend from vertical-banded gastroplasty to laparoscopic gastric banding. 30. The first two types of surgery (gastroplasty and gastric banding) are referred to as a restrictive procedure and the last (gastric by-pass) as a malabsorptive procedure. 31. In the case of a restrictive procedure, the size of the stomach is restricted either by surgically stapling parts of the stomach together or by fitting a tight band to make a small pouch so that the patient experiences a feeling of fullness with less food. Early bands were non-adjustable, but those in current use incorporate an inflatable balloon within the lining which allows for changes to be made to the size of the stoma to regulate food intake. Adjustment is undertaken without the need for surgery by adding or removing an appropriate material (e.g. saline) through a subcutaneous access port. 32. In the case of a malabsorptive procedure, large parts of the nutrient absorptive gastrointestinal tract are by-passed so that the absorption of food is limited. Some procedures, such as the Roux-en-Y and resectional gastric bypass combine restriction and malabsorption techniques, creating both a small gastric pouch and a by-pass that prevents the patient from absorbing everything that they have eaten. 33. Traditionally, gastric by-pass surgery has been carried out as an open procedure but laparoscopic techniques are being used increasingly. 6

20 34. All three types of intervention are reversible but, of the three, gastric by-pass is the most difficult to reverse. Laparoscopic gastric banding allows for subsequent adjustment of the degree of restriction and easier reversal. It is also generally associated with lower operative morbidity and shorter hospital stays. 35. The British Obesity Surgery Society (BOSS) has accepted, with some modifications, guidelines prepared by the International Federation for the Surgery of Obesity (IFSO) on bariatric surgery. Risk of Complications 36. The surgery is technically demanding with potentially serious metabolic complications. Heart or lung complications can occur in a small number of patients following surgery. In the longer term, a hernia might develop at the site of the abdominal wound although this could be repaired by another operation. Volume of Surgery 37. Scottish hospital discharge records [SMR1 Forms] show that between 1981 and 1995 a total of 190 operations had been performed for grade 3 obesity. Nearly half of these had been performed at Dr Gray s Hospital, Elgin (NHS Grampian). In the absence of any specific codes for these types of procedure, more recent data are hard to track down but estimates suggest that between 50 and 70 operations are conducted in Scotland per annum at the present time. 38. Not all patients are treated within the NHS. Of those that are, some travel to have their surgery performed abroad [e.g. Lyons] but aftercare is undertaken within Scotland. Other patients will seek private treatment from the independent sector. Conclusion 39. The current level of service provision is largely unplanned and has been allowed to develop as a result of specialist interest, patient demand and creeping incrementalism. It is proposed that bariatric surgery should be recognised as a component of general surgery and that expertise should be concentrated on a small number of centres to ensure critical mass and the further development of surgical skills. 40. On the basis of current and projected demand, existing services, and having regard to considerations of geography, a commonsense approach would be to suggest that bariatric surgery should be undertaken in three centres in Scotland and that these centres could be located in Edinburgh, Glasgow and Aberdeen. It will be up to NHS Boards to determine the extent to which these services can be developed and where they will be sited. Availability of funding will be dependent upon demands from other competing priorities within each NHS Board. 29 7

21 The process for referral is not well-defined. SUMMARY OF MAIN POINTS There are three types of surgical intervention undertaken in Scotland: a variant of vertical-banded gastroplasty, laparoscopic gastric banding and gastric bypass. The surgery is technically demanding with potentially serious metabolic complications. There is no specific coding to inform a minimum dataset. At present, between surgical operations for grade 3 obesity are performed in NHSScotland per annum. Provision of bariatric surgical services is largely unplanned. Bariatric surgery should be formally recognised as a component of general surgery. Bariatric surgery should be concentrated within three centres of expertise in Scotland. Recommendations NHS Boards, in conjunction with all relevant healthcare professionals, should establish a clear referral pathway for patients requiring bariatric surgery. This pathway should ensure that bariatric surgery is placed in its proper context and not delivered in isolation from other clinical and public health approaches to obesity. Information should be disseminated through NHS Boards to all referring clinicians. [A suggested model pathway is given in Appendix III]. Bariatric surgery should be recognised as a component of general surgery. No surgeon should perform bariatric surgery without undertaking the appropriate training. Expertise should be concentrated on a small number of centres to ensure critical mass and the further development of surgical skills. It is suggested that these centres could be located in Glasgow, Aberdeen and Edinburgh. It will be up to NHS Boards to determine the extent to which these services can be developed and where they will be sited. Availability of funding will be dependent upon demands from other competing priorities, including other aspects of weight management programmes, within each NHS Board. 8

22 Bariatric surgery must only be practised in the context of a properly constituted team comprising a specialist dietitian, a specialist nurse, a clinical psychologist, a physician, anaesthetist, radiologist and surgeon. Decisions surrounding bariatric surgery must, wherever possible, be evidence-based, and surgery should be performed in accordance with national standards, guidelines and protocols. Centres undertaking bariatric surgery should regularly audit and compare all aspects of their care including the number of operations performed, complications and outcomes. Ideally, every bariatric surgeon should be able to perform a variety of procedures although it is recognised that most surgeons will settle on one or two procedures that work best in their hands. The choice of surgical intervention should be made jointly by the individual and the clinician after considering the best available evidence, the facilities and the equipment available, and the experience of the surgeon who would perform the operation. Centres offering bariatric surgery must have access to specialist endoscopy services. Specific OPCS codes should be assigned for each of the surgical procedures ( verticalbanded gastroplasty, gastric bypass and lap-band procedures) to enable a minimum dataset to be established for all in-patient episodes. These should be distinct from existing codes for more generalised procedures relating to operations on the stomach. 9

23 3: PLASTIC SURGERY This chapter describes the contribution of plastic surgery to the overall management of patients who have undergone bariatric surgery. It outlines the main types of procedures and emphasises the need for psychological support in the medium and longer term. Introduction 41. With the development of more sophisticated bariatric surgical techniques, an increasing number of patients with grade 3 obesity are undergoing surgical treatment and this number is likely to increase in the foreseeable future. Following significant weight loss the quality of life of many patients is hampered by large folds of redundant skin and subcutaneous tissue. In these cases plastic surgery is required at a later stage to remove the excess skin. The number of patients being referred for this type of surgery at present is small. It is likely to rise steadily in the foreseeable future and has implications for waiting lists. Types of Surgical Intervention 42. For patients undergoing plastic surgery following a bariatric procedure, the operations carried out include: dermolipectomy of the abdomen and flank dermolipectomy of the arms (above the elbow) breast reduction and breast mastopexy, and dermolipectomy of the thighs. 43. The most common procedure is dermolipectomy of the abdomen. All of the procedures involved are safe, without serious complication and with good functional and aesthetic results Obesity at the time of surgery can significantly increase complication rates 31. Pre-operative Considerations 45. Surgery should not be carried out until the target weight has been achieved and maintained for one year. 46. Great importance is attached to the role of support groups in maintaining weight loss. 47. Criteria for patients undergoing plastic surgery need to be clearly defined. Patients should have a realistic expectation of what can and cannot be achieved with a full 10

24 understanding of potential complications before they agree to surgery. An initial consultation of 30 minutes is recommended. The importance of a support group in the medium and longer term is paramount 32. Per-operative Considerations 48. The commonest procedure by far is dermolipectomy of the abdomen, also known as apronectomy. This involves making a large elliptical incision in the lower part of the abdomen. It usually needs to be extended into the flank area, and often circumferentially. Excision of the posterior section is often performed at a second operation. 49. There is debate as to whether multiple site operating at one procedure should be carried out. A recent paper 33 investigated this and concluded that combined dermolipectomy procedures could be advocated in patients who had reached their intended level of weight reduction and provided operative time and excessive blood loss were avoided. More specifically, the complication rate is significantly higher where patients are still obese (BMI >30), operating time is greater than three hours, the age of the patient is greater than 41 years and the blood loss is greater than one litre. Another paper 31 concluded that obesity at the time of surgery significantly increased the complication rate in abdominal dermolipectomy. Other factors likely to increase the complication rates include smoking, diabetes and coronary heart disease. Post-operative Considerations 50. An average of three post-operative visits is usually necessary for these patients. The importance of a support group in the medium and longer term is strongly emphasised 32. SUMMARY OF MAIN POINTS Plastic Surgery is an integral part of an overall Bariatric Surgical Service. The procedures involved are safe, without serious complication and with good aesthetic results. Criteria for patients undergoing plastic surgery must be clearly defined. The number of patients being referred for this type of surgery is small at present but is likely to increase in the foreseeable future. This will have implications for waiting lists. Recommendations: Criteria for patients undergoing plastic surgery must be clearly defined. Plastic surgery should not be carried out until the target weight has been achieved and maintained for one year. 11

25 4: PRE- AND POST-OPERATIVE CARE AND CONTINUING PATIENT SUPPORT This chapter describes the importance of psychological support and patient education at all stages of the patient s journey of care. Introduction 51. This chapter focuses on the importance of psychological support and patient education at all stages of the patient journey. The greatest need for patient support is in the post-operative phase, particularly in the weeks and months immediately following the operation. 52. Most of this work is shared in the initial stages between the patient and the clinical team and on a continuing basis between the patient and the primary care team including regular consultations with a specialist dietitian. 53. A description is given of the kind of support that is required at each stage in the process. Pre-Operative Support 54. Patients require to be assessed to ensure that they are suitable candidates for bariatric surgery. Patients should only be considered for surgery after other sustained but unsuccessful attempts at non-surgical treatments to lose weight. Multidisciplinary assessment should ensure compliance with criteria for surgery. This should include consideration of the patient s psychological and educational needs in addition to physical assessment for surgery. 55. Patients presenting for bariatric surgery are often deeply distressed and show a range of psychopathological states that must be managed within medical and surgical settings. 34 These problems will affect an individual s ability to make and sustain the behavioural changes that lead to weight loss. Such difficulties are frequently untreated and require to be managed, if only by appropriate referral. 56. It would appear that patients require a significant amount of education on what the procedure involves, the pre- and post-operative phases, the dietary treatment involved and the likely outcome, both in terms of weight loss and changes in family dynamics. Patients can be easily discouraged if the outcome of their operation does not come up to their expectation. For this reason, it is vitally important that expectations are discussed at the outset and salted with a sense of realism. Counselling is crucial at this stage, in particular, the need to convey to the patient that the change post-operatively will be experienced not just in medical terms but also in physical, emotional and social terms. Support During Admission 57. This phase is probably the most adequately resourced at present. It is important that patients receive support and education from the multidisciplinary team. In addition to 12

26 medical and surgical staff, this should include an input from a specialist dietitian, a physiotherapist, a specialist nurse and, where possible, a clinical psychologist. The support of family members is also important at this time. Immediate Post-Operative Support 58. Patients feel safe in hospital but have few options in terms of post-operative support once they return home. Most experts tend to be hospital-based and there is a need for ongoing support in the community to deal with the potential problems by patients including a limited understanding of the correct diet, vomiting, food sticking and causing obstruction, and symptom control. Some centres do have this support mechanism in place but resources are stretched. 59. There is clear evidence that behavioural interventions for obesity result in weight loss 35. It is also known that weight regain after successful loss occurs when behavioural changes slip 35. Psychological support (from a clinical psychologist or other member of the healthcare team) is important for the patient and close family who may experience first hand problems faced by patients in the weeks after discharge. Such support networks and professionals should ideally be attached to specialist centres. Continuing Support 60. It is not always appreciated or fully understood by healthcare professionals who are not directly involved in this specialty that these patients require continuing medical supervision to monitor potential complications and to reinforce dietary compliance 36. Some patients may also require long-term counselling or psychological support. In addition to the normal process of routine clinical review, a fast-track, telephone-based support service would be useful where patient queries can be quickly resolved. Clinicians providing this on-going support and review service would also be in a position to identify common problems and reassure patients that the problems that they experience are not unexpected. 61. Patients often feel that they have been left in a vacuum with no opportunity to share experiences with others. Social aspects, for example, are often overlooked. Obesity causes a great deal of personal anguish. Eating out can be problematic. Patients have to re-educate themselves to think in terms of portions that would fit on to saucers rather than plates and to accept the fact that one person s starter is another person s main course. Gaining the understanding of hosts without appearing to be ungrateful is another hurdle that has to be overcome. Cancelling family plans at the last minute because of sickness can induce feelings of guilt. All of these aspects, and others like them, need to be shared and discussed so that a common understanding and acceptance about these matters can be accommodated in daily life. 62. Self-help and motivation are vital to the success of the procedure. It is only very recently that patient support groups and telephone help-lines have begun to be formed to meet these needs. These groups are still in their infancy but they have already begun to fill a gap and to provide a comprehensive and much-valued service [see Appendix V for further details]. 13

27 Defining Success 63. It is important that patients consider their operations as having been successful. Patients who reach a plateau stage with their weight loss need to know that the importance of modest but sustained weight loss should not be underestimated. Attention should focus on the improvement of co-morbid conditions rather than on actual weight loss since there are good data to suggest that even a modest weight loss is capable of yielding significant reductions in the co-morbidity of obesity 37, 38. For this and other reasons, surgery should not necessarily aim to attain an ideal body weight. Conclusion 64. Each centre should provide an integrated programme of patient support and education that provides guidance on diet, physical activity and psychosocial concerns 36. Partnership for Care reinforces the need for multi-professional teams / local authorities to work together across primary and secondary care services and obesity management is an obvious example of where such networks are essential to achieving a successful outcome 39. SUMMARY OF MAIN POINTS Psychological support is important for patients and their carers and this support should be offered throughout the whole journey of care. The greatest need for patient support is in the post-operative phase, particularly in the weeks and months immediately following the operation. Patients require life-long medical supervision to monitor potential complications and to reinforce dietary compliance. A range of models of support should be provided post-operatively, e.g. patient support groups, telephone help-lines, etc. in addition to routine clinical follow-up and monitoring. Recommendations Arrangements should be made for appropriate healthcare professionals to provide preoperative and post-operative counselling and support to individuals being considered for surgery. A range of models of support should be provided post-operatively, e.g. patient support groups, telephone help-lines, etc. in addition to routine clinical follow-up and monitoring. 14

28 V: ECONOMIC CONSIDERATIONS This chapter provides an indication of the cost of obesity to the individual, the NHS and society. It highlights the work of some studies that have been undertaken in this field and offers some costing assumptions with reference to NHSScotland. Introduction 65. Most economic studies relating to obesity derive from overseas 27. In general, these studies concentrate on calculating the direct costs imposed on the health system arising from the current prevalence and treatment of obesity. The majority do not concern themselves in the strict sense with economic evaluation insofar as they do not attempt to make any comparison between specific treatment options from an economic standpoint In recent years a few studies relating to the total costs of obesity have been undertaken in the UK. These include studies by the National Audit Office 24, the University of Glasgow 41, NICE 27 and its Scottish equivalent, the HTBS 28, (now NHS QIS). Details from these studies are briefly outlined below. The study by the HTBS, which derives from NICE, offers some insight into the costs associated with undertaking bariatric surgery in Scotland. Selected UK Studies The National Audit Office 67. The Department of Health commissioned a cost-of-illness study to enable estimates to be prepared on the costs of obesity in England for the Westminster Parliament in order to provide a platform for further debate. The National Audit Office (NAO) report, Tackling Obesity in England, published in , was the result of this commission. The report looked at the human and financial costs of obesity and made recommendations to Government on the way overweight and obese patients are managed within the NHS and on cross-government work to prevent obesity. It became the subject of a Public Accounts Committee hearing and was followed by recommendations from the Committee to Government, and a published Government response. 68. The NAO report concluded that obesity accounted for 18 million lost working days due to associated illness and 30,000 deaths in 1998 for England. The direct cost of treatment of obesity and associated co-morbidities was conservatively estimated at 480m or 1.5% of the total NHS expenditure in England. Given that the report was unable to evaluate the costs of obesity-related back pain and several other conditions, the true costs may exceed the estimates. 15

29 University of Glasgow 69. A study from the University of Glasgow 41 has recently estimated that the annual cost to the NHS in Scotland for treating obesity and its consequences is 171m. This is more than three times higher than a simple pro rata analysis of the NAO figures, based on population size alone. Interestingly, only 2% of this total is due to treating obesity itself, 98% is consumed by the treatment of obesity co-morbidities such as high blood pressure, diabetes and heart disease. The study concludes that obesity carries important cost consequences that rank second only to smoking as a cause of burden upon the NHS. NICE 70. According to NICE 27, the number of people in England and Wales who have a BMI of 40kg/m 2 or more is about 600,000. The number having a BMI of between 35 and 40 kg/m 2 and a serious co-morbidity is not known but is assumed for their purposes also to be 600,000 giving an estimated target group of people with grade 3 obesity at 1.2 million. The rate of growth of this group is unknown but is assumed to be 5% per year. The number of deaths in the next year among the 1.2 million is assumed to be 30, The proportion of the target group who might take up obesity surgery is also not known but is assumed to be either 2% or 4%. The cost of each operation, over and above the cost of medical care, is assumed to be on average 5, The rate at which the number of operations can be increased over time is not known. It has been assumed that, as only 200 operations are performed each year at present, capacity could rise by 300 operations to 500 in the first year, and by an additional 500 operations in each year after that, up to a maximum of 4000 per year after 8 years. 73. On the basis of these assumptions, the estimated additional cost in the first year would be 1.7 million, rising to 4.4 million in year 2, and increasing by an additional 2.7 million each year up to an annual increase of 21 million after 8 years. The estimated annual steadystate cost would currently lie between 10 million per year (2% of all patients having surgery) and 20 million per year (4% of all patients having surgery) and it is assumed will increase by 5 % each year. HTBS 74. The HTBS calculate the budgetary impact of surgery for grade 3 obesity to NHSScotland by utilising the assumptions made by NICE and modifying them for Scotland. Thus the number of adults with grade 3 obesity in Scotland expected to receive surgery is estimated using the numbers expected to receive it in England and Wales multiplied by the population ratio of the year age group between Scotland and England and Wales (0.098). Consequently, the number of people within Scotland with a BMI of 40kg/m 2 or above is estimated to be 58,800. The number with a BMI between 35kg/m 2 and 40kg/m 2 and a significant co-morbidity is not known, but for the purposes of the HTBS assessment is also assumed to be 58,800. This gives an estimated total target group of 117,600 with grade 3 obesity. 75. Like NICE, the HTBS document assumes an annual increase of 5.0% in the number of people with grade 3 obesity. When coupled with an assumed death rate of 2.5% within 16