Bariatric Surgery – Improve Five-Year Outcomes

The short-term (2-3 year) outcomes of bariatric surgery have been extensively studied in RCTs, and the (mainly) positive outcomes documented. Now we can use unbiased information to look a little further into the future as longer-term outcomes of an RCT of bariatric surgery have been published.[1] Outcomes were assessed at the age of five years among 150 overweight, type 2 diabetic people randomised to intensive medical therapy alone versus such therapy accompanied by bariatric surgery (by-pass or gastric size reduction). At five years the differences in HbA1c were massive – 2.1 points vs. 0.3 points improvement over baseline. The surgical group were thinner, had improved blood fats and reported better quality of life.

So what are the service implications of this iconic study? We need to ‘industrialise’ surgery, so that more operations can be done at a given cost. That means teams of technicians operating under consultant (anaesthetist and surgeon) supervision. Here is an artist’s representation of such a ‘Taylorised’ process:

An Operations Director oversees a Surgeon and two Anaesthetists who oversee six technicians operating on six patients

Such a process was established to improve access to cataract surgery in Moscow over three decades ago.[2] Similar processes have been used with respect to open heart surgery in the US. I propose we should conduct simulations and then move gradually and incrementally to a safe, but efficient, method of implementing high-throughput bariatric surgery. Evaluation of the roll-out would be essential. Barriers will need to be overcome, but one or two effective demonstration sites will speak more than volumes of words. My only real concern is that some new ‘technology’ will come along and sweep away bariatric surgery and all its (protesting) practitioners.

— Richard Lilford, CLAHRC WM Director

References:

  1. Schaeur PR, Bhatt DL, Kirwan JP, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes – 5-Year Outcomes. New Engl J Med. 2017; 376: 641-51.
  2. Schmemann S. Moscow Eye Doctor Hails Assembly-Line Surgery at Clinic. The New York Times. 2 July 1985.
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