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 "This study further confirms the long-term durability of gastric
bypass surgery," chief author Dr. Ted Adams of Intermountain
Healthcare in Salt Lake City, Utah, told Reuters Health by phone.
"You have an intervention that, 12 years down the road, is helping
people maintain a 27 percent weight loss," said Dr. Jamy Ard,
co-director of the Weight Management Center at Wake Forest Baptist
Medical Center in Winston-Salem, North Carolina.
Because some insurance plans don't pay for the surgery, "we need to
rethink what we will cover from an insurance standpoint," said Ard,
who was not involved in the study.
On average, after 12 years, patients weighed 77 pounds (35 kg) less
than they did before the surgery, Adams and colleagues report in the
New England Journal of Medicine.
Half of those with type 2 diabetes at the time of surgery were free
of it 12 years later.
All of the patients underwent Roux-en-Y gastric bypass, where
surgeons close off all but an egg-size pouch of the stomach and then
bypass part of the small intestine. Gastric bypass typically costs
$20,000 to $30,000.
Researchers compared 387 patients who had surgery with 378
volunteers who decided against it, typically because insurance would
not cover it, and 303 other adults with severe obesity. The team had
previously reported benefits of the surgery at the 2- and 6-year
marks.
The average starting weight was 295 pounds (134 kg). People who
didn't undergo surgery typically lost just 6 pounds (2.9 kg).
"Despite a wide variation in change in body weight across the
sample, 360 of 387 patients (93 percent) in the surgery group
maintained at least a 10 percent weight loss from baseline to year
12; 271 (70 percent) maintained at least a 20 percent weight loss;
and 155 (40 percent) maintained at least a 30 percent weight loss,"
the researchers concluded. "Only 4 of 387 patients (1 percent) in
the surgery group had regained all their postsurgical weight loss."
While 26 percent of patients in the control groups had type 2
diabetes at the 12-year mark, the rate was a mere 3 percent with
surgery.
Remission was more likely when a diabetic was not taking insulin,
probably because those patients still had enough healthy pancreas
cells left to produce insulin.
"The more advanced the type 2 diabetes, the less the glycemic
benefit from Roux-en-Y gastric bypass," the Adams team concluded.
Blood markers for heart disease, such as bad cholesterol,
collectively improved more with the surgery. The reduction in high
blood pressure was significantly greater compared to one of the
control groups but not the other.
Most patients were female and white, so it's not certain if the
results apply as well to other groups.
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One troubling finding: there were five suicides in the surgery group
and two among people who were not in that group but had bypass
surgery outside the study. No people in the other control group took
their own lives.
"Whether the increase in suicides is attributable solely to
bariatric surgery itself or whether any large, sustained weight loss
would also be associated with an increased risk of suicide is
unknown," the researchers wrote.
"It is concerning," Adams said. "It doesn't occur very often, but it
has been enough that it raises a red flag. A number of groups are
looking for the underlying reasons." For example, rerouting the
digestive system might affect how alcohol or mental health
medications are metabolized.
Ard of Wake Forest told Reuters Health by phone that the suicide
question "highlights the need for comprehensive care" where a
behavioral specialist is part of the team that can look for warning
signs.
"What we can learn from this paper is that we have a very effective
treatment tool for severe obese patients with associated medical
problems," said Dr. Jaime Ponce, medical director for bariatric
surgery at CHI Memorial Hospital in Chattanooga, Tennessee.
"Also, it is important to see that patients that are not having
'access' to bariatric surgery, either because they don’t have
specific insurance coverage or have not been educated, will suffer
the consequences of remaining severely obese and deterioration of
health and quality of life," he told Reuters Health in an email.
Because people with diabetes typically cost the health system an
additional $7,000 per year, said Ard, "you don't have to do a lot of
surgeries to start saving money" if bypass prevents diabetes or puts
it in remission.
Fewer than 1 percent of eligible candidates get the surgery, said
Ponce, who is past president of the American Society for Metabolic
and Bariatric Surgery.
"We must change the thinking about obesity and begin to remove the
policy, social, medical, discriminatory, economic and perceptual
barriers that deny people appropriate treatment and support before
more people get sick or die," Ponce said. "This study supports that
treatment for obesity should be an essential health benefit that is
provided by all health plans."
SOURCE: http://bit.ly/2wkPnkx The New England Journal of Medicine,
online September 20, 2017.
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