Bariatric treatments for adult obesity - Institute of Health Economics

food, and a negative body image. As a direct consequence of successful surgery, 30% to 40% ofpatients require plastic surgery (known as body contouring surgery) to remove excess skin afterweight is lost. 39,40,46,53-55,57,67Outcomes vary by surgical procedure and depend on the intrinsic value of each procedure. 14,15,17,39,40,46,53-55,57,58,69,74,82,83,120,122,125Desired outcomes depend to a great extent on:the exclusion of candidates who are at risk for post-operative complications;the candidate’s pre-operative clinical and psychological preparation; the candidate’s acceptance of long-term, if not lifelong, follow-up.Long-term success after bariatric surgery depends on the candidate being well educated about howthe procedure will promote weight loss, and on the lifestyle and behavioural changes needed on theirpart to maintain that weight loss.Several factors may influence the choice of bariatric surgery procedure, including the patient’s andthe surgeon’s preference. 1,14,15,17,46,69,73,82,83,120 The choice also depends on:patient-related factors (including age, personality, eating patterns, BMI level, previousoperations, associated morbidities, contraindications, and personal understanding andcommitment);procedure-related factors (such as reversibility/non-reversibility and associated risks andcomplications); provider-related factors (learning curve, the availability of multidisciplinary care and support,accreditation of the center, and the training, credentials, and experience of the availablesurgical, medical, psychiatric, nursing, and other healthcare personnel).The number of competing surgical procedures and their utilization has increased during the past fewdecades. Both surgeon and institutional volumes have been shown in several large-population-basedstudies to affect outcomes. 1,14,15,17,120,125-130 As a result, facility and bariatric surgeon accreditation andcredentialing standards grounded in evidence-based best practice have been developed by variousbodies, including the American College of Surgeons (ACS), the American Society for Metabolic andBariatric Surgery (ASMBS), and others. 14,15,70,120,123,125,127,129,131-135According to best practice recommendations, effective and successful surgical programs requireappropriately accredited specialized facilities and multidisciplinary teams with experience in obesitymanagement and surgery (including dedicated and appropriately trained and credentialed physicians,nurses, dietitians, physiotherapists, psychologists/psychiatrists, counsellors, anestheticians, andsurgeons). 1,14,15,17,46,70,82,83,120,123,129-134 Substantial pre- and post-operative evaluation of patients, teaching,and monitoring are required to optimize the outcomes. Treated patients should be followed up forat least 5 years to ensure success and appropriate support. 1,15,120 Such specialized, multidisciplinary,long-term care is considered a valid indicator of quality in bariatric surgery programs, along with thedevelopment and use of care pathways and the prospective collection of data on thesafety andefficacy of all performed procedures. 70,123,129-134Best practice guidelines in bariatric surgery recommend the completion of formal residency trainingin general surgery and of formal training in open and laparoscopic approaches. 1,14,15,120,127,129-132 Toacquire the skills needed to perform laparoscopic bariatric surgery a surgeon must negotiate arelatively steep learning curve (between 75 and 100 cases). Ideal training would include theBariatric treatments for adult obesity 23