Cost-Utility Analysis of Bariatric Surgery (British Journal of Surgery)
Using a decision-analytic model, researchers compared the costs and outcomes of two treatment approaches for patients with severe obesity: bariatric surgery, which included gastric bypass, sleeve gastrectomy and adjustable gastric banding; and non-surgical usual care. Researchers found bariatric surgery was associated with reduced costs to health services by an average of about $3,200, and that surgery had the potential to reduce the lifetime risks of obesity-related cardiovascular diseases and diabetes. Compared with usual care, surgery was associated with a gain of 0.8 life-years and 4.0 quality-adjusted life-years (QALYs) over a lifetime. Delaying surgery for up to three years resulted in a reduction of
0.7 QALYs and a minor decrease of about $2,400, in related healthcare costs.
To determine if initial BMI influences weight loss and comorbidities improvement after bariatric surgery, 220 patients who underwent gastric bypass at a single institution were retrospectively classified based on initial BMI (obesity class I, II, and III). Diabetes remission and weight loss during the 12 months after surgery were compared, as well as metabolic profile (glucose, HbA1c%, C-peptide, insulin and diabetes medication), lipid profile (triglycerides, total cholesterol, HDL, LDL), and clinical data (systolic/diastolic blood pressure and cardiovascular risk). Of the patients in the study, 23 had class I obesity (group 1), 113 had class II (group 2), and 84 had class III (group 3). Initial weight, BMI and the number of patients with type 2 diabetes were statistically different in group 1; other parameters were homogenous. At 12 months, every group had similar improvement of the metabolic profile, excepting serum insulin. Diabetes remission was 57.9, 61.1, and 60% for group 1, 2, and 3. For weight loss, there were differences between groups when using BMI and percentage of excess weight loss, but not with percentage of total weight loss. The non-metabolic and clinical data improved without differences, except for total cholesterol and LDL. The metabolic, lipid, and clinical profiles associated with obesity present similar improvement one year after laparoscopic gastric bypass, despite different baseline BMI.
To determine if bariatric surgery and the resulting weight loss could reverse premature aging, researchers analyzed the markers of early aging including the SASP IL-6, CRP and PAI-1, 7 miRNAs, as well as telomere length and telomere oxidation in mononuclear cells in 58 patients with severe obesity undergoing bariatric surgery. Patients showed a significant drop in BMI from 43.98 to 28.02, and a significant reduction in SASP including a reduction of 55% of plasma IL-6 levels, 83% of CRP levels and 15% of plasma PAI-1 levels. Telomere length doubled in patients and was accompanied by a reduction in the telomere oxidation index by 70% and miR10a_5p, which is downregulated during aging, was upregulated after surgery. The data indicate a significant reduction of the pro-inflammatory SASP after bariatric surgery, and that, overall, bariatric surgery ameliorated premature aging.
Bariatric surgery is a safe and effective procedure to improve obesity-related co-morbidities in older patients suffering from super obesity. Researchers evaluated the safety and medium- to long-term outcomes of patients ages 60 and older who underwent sleeve gastrectomy, RYGB, or biliopancreatic diversion with duodenal switch between January 2006 and December 2014 and had at least two years of follow-up. Of the patients in this single-center retrospective study, 66 had super obesity (BMI >50 kg/m2). Of these patients, 74% had sleeve gastrectomy, 16% RYGB, and 8% underwent biliopancreatic diversion with duodenal switch. Mean age and BMI were 63.3 years and 51.7, respectively. At baseline, 78% had hypertension, 60% had type 2 diabetes, and 30% had obstructive sleep apnea. There was no 30-day mortality, and the complication rate was 14%. Mean percent excess weight loss at two years was 52.2 and remission rates of hypertension, type 2 diabetes, and obstructive sleep apnea were 26%, 44%, and 38%, respectively. Based on the results, age alone should not preclude older patients from getting bariatric surgery.
Researchers compared the 30-day postoperative morbidity and mortality between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-Y-gastric bypass (LRYGB) in a subset of patients with a model of end-stage liver disease (MELD) score of ≥8 using data extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database during 2012 and 2013. MELD score was calculated using serum creatinine, bilirubin, INR, and sodium. Out of 34,169 patients, 9.8% of cases had a MELD score of >=8. Thirty-day morbidity and mortality was significantly lower post-LSG (9.5%) compared to LRYGB (14.7%) [AOR=0.66]. In a subgroup analysis of patients with MELD scores of 15-19, morbidity and mortality post-LRYGB (30.6%) was significantly higher than LSG (15.7%). Superficial wound infection, prolonged hospital stay, and unplanned readmission were also more common in LRYGB. The findings suggest LRYGB is associated with a higher postoperative risk than LSG in patients with a MELD of ≥8 and that LSG might be a safer option for patients with severe obesity and high MELD scores.
The Cleveland Clinic Behavioral Rating Scale (CCBRS) completed before bariatric surgery predicted postoperative weight loss, quality of life, alcohol use, depression and anxiety in this observational study with two-year follow-up. Researchers concluded that the tool might prove useful in patient counseling and expectation management before surgery. Preoperative psychological clinical interviews were completed by 179 patients (113 RYGB and 66 sleeve gastrectomy), which included the Short Form 36 (SF-36) v.2 Health Survey and brief self-report questionnaires measuring depression (PHQ-9), anxiety (GAD-7), and alcohol use (AUDIT). At the conclusion of the pre-operative psychological evaluation, a psychologist completed the CCBRS. Generalized estimating equations were used to assess whether any CCBRS ratings predicted surgery outcomes. The SF-36 scores, PHQ-9 scores, and the AUDIT total scores improved significantly after surgery, while GAD-7 scores did not change much. The CCBRS Social Support rating predicted higher postoperative percentage of excess weight loss, while higher pre-operative CCBRS ratings predicted higher SF-36 scores, and lower PHQ-9, GAD-7 and AUDIT scores.