A career in bariatric surgery: the new metabolic surgery
Authors: Dimitrios Pournaras, Swethan Alagaratnam, Richard Welbourn
Publication date: 30 Apr 2008
Dimitrios Pournaras and colleagues explain why bariatric surgery can only get bigger
Why is the specialty important?
Obesity is the healthcare epidemic of the 21st century and is estimated to cost the NHS £500 million a year and the United Kingdom as a whole £7.4 billion per year. Bariatric surgery has been proved to be the only effective, long term treatment for morbid obesity. The effects of surgery are not simply restricted to substantial loss of excess weight, which is estimated to be in the region of 60%. Improvements in comorbidities associated with high body mass index, including hypertension, sleep apnoea, hyperlipidaemia, and type 2 diabetes, have been demonstrated. Of particular note is the resolution of type 2 diabetes, ie, the discontinuation of diabetic drugs and normal glycaemic control, in 80% of this patient group. Weight loss, reduced mortality, and type 2 diabetes have been demonstrated to be sustained for at least a 15 year period.
“If there would be one pill that keeps weight down and resolves type 2 diabetes mellitus (and other comorbidities) for at least 15-20 years, with low morbidity and mortality and impressive decrease in long term mortality, its inventor would probably deserve a Nobel prize,” Chilean surgeon Ricardo Cohen said at the Diabetes Surgery Summit in Rome in 2007 where the concept of “metabolic surgery” was borne. Indeed, in 2007 the American Society of Bariatric Surgery changed its name to the American Society of Metabolic and Bariatric Surgery to reflect the positive public health benefits of surgery. In the USA in 2006 there were more bariatric procedures than cholecystectomies, and the UK will see the same explosion of surgery in the next 10 years. It is predicted that metabolic surgery will play a key role in the treatment of diabetes in the near future.
What do bariatric surgeons do?
They make obese people well. The first bariatric procedure was the jejunoileal bypass developed in the 1950s. This extensive procedure led to unpleasant complications such as profound diarrhoea and is now obsolete. The Roux-en-Y gastric bypass was initially developed in the 1960s. It is the commonest bariatric procedure worldwide and was designed to combine a reduction in stomach volume and shorten the small intestine to produce a combination of a restrictive and malabsoptive state. Although it is now known that calorie malabsorption does not occur, the effects of bypass procedures are not entirely due to the reduced stomach volume. Recently it has been shown that the mechanism is partly due to profound loss of appetite in association with increased satiety gut hormone concentrations. The first laparoscopic bypass was reported in 1994 and since then it has been gaining popularity.
The laparoscopic adjustable gastric band is the commonest laparoscopic bariatric procedure in the UK. It is a purely restrictive procedure that is reversible. Other less common laparoscopic bariatric operations include the sleeve gastrectomy and the vertically banded gastroplasty, both the restrictive version and the biliopancreatic diversion, and the duodenal switch, both malabsorptive.
Laparoscopic bariatric surgery requires advanced laparoscopic skills. The learning curve is long and technically challenging but very rewarding to the surgeon. Bariatric surgery is life changing for the patients.
Box 1: A day in the life of a bariatric consultant surgeon
8-9 am—Post-take ward round after general surgical on call for the previous day
9-12 noon—Clinic seeing new patients as well as follow-up of patients already operated on
12-2 pm—Multidisciplinary meeting with endocrinologists, anaesthetists, dietitians, and managers discussing prospective patients
2-6 pm—Operating list: laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric band (three to four bypasses in an all day list)
Why is the specialty different?
Dedication to advanced laparoscopic skills with rapid patient throughput would suit those with highly developed hand-eye coordination and technical skills. All the surgery is elective, and there are few emergencies—although a wary eye has to be kept out for complications such as anastomotic leak. Few, if any, other interventions have such a dramatic effect on the patient population.
Training in bariatric surgery
Training is via the general surgical pathway and is summarised in box 2. Surgical trainees who declare an interest in benign upper gastrointestinal surgery can get exposure in centres that do bariatric surgery. Currently, most of the training opportunities exist at post-certificate of completion of specialist training level. This is likely to change in the future, however, with the increasing uptake of bariatric surgery. Laparoscopic bariatric surgery fellowships are offered in centres in the UK as well as abroad. The British Obesity Surgery Society and the Associations of Laparoscopic Surgeons offer support for such fellowships. In addition, courses offering live surgery or hands-on courses on live tissues are available in large academic centres. Some courses are organised by industry.
Box 2: Training
Basic surgical training, specialist training
Benign upper gastrointestinal interest
Bariatric fellowship post-certificate of completion of specialist training
Bariatric surgery is here to stay and is rapidly being recognised as a mainstream surgical specialty. There are few, if any, more cost effective therapeutic interventions (just consider the cost burden of type 2 diabetes to the NHS as the obesity epidemic continues to worsen). And the obesity of the population is expected to increase in the near future. It is well documented that surgeons performing laparoscopic bariatric surgery with increased frequency in high volume centres have far better results. Many more bariatric surgeons in more dedicated centres will be needed to undertake this workload. In addition there are ample opportunities for research because although there is no question regarding the effectiveness of this sort of surgery, some of the mechanisms through which it works have yet to be elucidated. Private practice opportunities do exist and currently a significant proportion of surgery is being carried out in the private sector. It is also important to note that the effect of obesity in today’s medicine will not be limited to surgeons. The provision of a bariatric service requires the expertise of anaesthetists, endocrinologists, dietitians, and specialist nurse practitioners with an obesity or bariatric interest.
Box 3: A career in laparoscopic bariatric surgery
Advanced laparoscopic skills
Satisfied and grateful patients
Ample research opportunities
Busy practice in the NHS and the private sector
Weekends usually free as patients have already gone home because recovery is so quick after laparoscopic bariatric surgery.
Long learning curve
This is a technically challenging specialty with fantastic results and extremely grateful patients. We are only scratching at the tip of the iceberg of the population who could benefit, and we are the most obese population in Europe.
- Department of Health. Health survey for England 2003. 2004. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_4098712.
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- Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724-37.
- Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg 2004;14:1157-64.
- Le Roux CW, Welbourn R, Werling M, Osborne A, Kokkinos A, Laurenius A, et al. Gut hormones as mediators of appetite and weight loss after Roux-en-Y gastric bypass. Ann Surg 2007;246:780-5.
Dimitrios Pournaras Royal College of Surgeons of England research fellow
Swethan Alagaratnam foundation year 2 doctor
Richard Welbourn consultant Department of Bariatric Surgery, Musgrove Park Hospital, Taunton TA1 5DA