Abstract
Keywords
There was a rapid worldwide increase in the number of bariatric procedures between the years 2003 and 2008 with annual operations raising from nearly 150,000 to more than 340,000 procedures, as can be seen in the review article by Lo Menzo, Szomstein, and Rosenthal in this issue. In Scandinavia, a 10-fold increase in annual operations was seen during approximately the same time period, with operations increasing from under 1000 operations per year to almost 9000 annual operations in Sweden (1) and in Finland from less than a hundred annual operations to more than 1000 operations per year (2). Between 2008 and 2011, the number of bariatric procedures seems to have plateaued and even slightly decreased worldwide. In accordance with the global trend, a similar plateau phase can also be seen in Scandinavia, and the number of annual operations is in fact decreasing. Bariatric surgery has demonstrated well-documented superior long-lasting results in the treatment of morbid obesity compared to other interventions. However, despite both the superior results and the magnitude of the obesity epidemic, only a minor fraction of the patients who could benefit from surgery actually have access to metabolic surgery. Why is that?
The reason cannot be the lack of evidence as the beneficial effects of metabolic surgery are widely recognized and reported. Several randomized, controlled trials comparing bariatric surgery with standard or intensified medical treatment in treating morbidly obese type 2 diabetes patients have demonstrated superior results for bariatric surgery as stated in the review by Maleckas et al. in this special issue. The Finnish Office for Health Technology Assessments (Finohta) concluded already in 2009 that bariatric surgery has provided level I evidence for successful surgical treatment of type 2 diabetes with a 2-year follow-up (3). The Swedish Obese Subjects (SOS) study can be considered one of the landmark studies in the field of bariatric surgery, and in this prospective nonrandomized study comparing surgery and conventional treatment for morbid obesity, the incidence of type 2 diabetes was significantly lower in the surgery group after 10 years. No medical treatment can achieve a 36% total type 2 diabetes remission rate lasting for 10 years. High insulin and/or high glucose at baseline predicted favorable treatment effect, whereas high baseline body mass index (BMI) did not, underlining the need for re-evaluating and redefining the current selection criteria for metabolic surgery (4). Metabolic surgery results in better glycemic control than active medical intervention and is effective in both treating and preventing microvascular complications of type 2 diabetes (5).
Other typical obesity-related comorbidities, such as hyperlipidemia, hypertension, sleep apnea, arthrosis, and infertility, have likewise shown good remission or improvement rates after surgery (6), and significant improvements in the quality of life have also been documented (7). The morbidly obese patients also have an increased cancer risk and a worsened cancer related prognosis compared to normal weight and also less obese cancer patients (8). It is self-evident that bariatric surgery, as any other major surgery, is not without adverse events. Surgical complications, the need for higher risk revisional surgery, insufficient weight loss, and vitamin deficiencies may develop stressing the importance of a meticulous selection and follow-up of operated patients laying a heavy responsibility on any health care system.
In 2009, it was estimated that over 2000 annual operations would be performed in Finland by the year 2013 (3), but only 888 operations were actually performed that year (2). Why is metabolic surgery worldwide decreasing? Is the obesity problem still stigmatized by our fellow physicians and by the public? Is the medical community afraid of the detrimental effects of possible surgical complications? Surgery is never without risks, but taken that these patients are selected and handled by multi-disciplinary teams, the operations performed in centers with sufficient volume and by experienced surgeons familiar with advanced laparoscopic techniques, the morbidity is lower compared with other common abdominal operations, such as laparoscopic cholecystectomy, hysterectomy, not to mention colonic resections (9). In such centers, patients are treated effectively by enhanced recovery pathways, operated by laparoscopy with durations <1 h, short hospital stay (1–2 days), low total morbidity rates (<10%), low major morbidity rates (<1%), and with a 30-day-mortality rate ranging from 0% to 0.3% (1, 9, 10). As may be seen in this issue, there are many different surgical treatment options available, and metabolic surgery is continually evolving aiming to refine the procedures more efficacious and safe. According to the latest news, sleeve gastrectomy has now surpassed gastric bypass as the most commonly performed bariatric operation worldwide (11), and sleeve gastrectomy is under active research; in the previous issue of The Scandinavian Journal of Surgery, the short-term results of the Finnish SLEEVEPASS randomized study (12) comparing sleeve gastrectomy and gastric bypass were presented. Gastric bypass surgery may still be considered “the golden standard” due to its well-documented long-term results, and new procedures need to be thoroughly evaluated with these results in mind; active research is essential in better defining the bariatric surgery field. The optimal surgical technique may vary, and future research hopefully enables us to define and select the best possible bariatric procedure for each patient. This selection of optimal bariatric surgery is further enhanced in the future by the growing understanding of the metabolic mechanisms of bariatric surgery.
We are thankful to all the authors for their contribution to this Special Issue of The Scandinavian Journal of Surgery. Bariatric surgery constitutes one small part in dealing with the global obesity epidemic, but for these eligible patients, this treatment option is evidence-based medicine. We hope that you find this issue inspiring and encouraging, adding both to the general awareness of the superior results of bariatric surgery within the surgical community and the need to enable access to this surgical treatment for the whole patient population, who would benefit from bariatric surgery.
Mikael Victorzon and Paulina Salminen
