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UK Registry data

UK bariatric registry demonstrates safety and effectiveness of surgery

Recorded in-hospital mortality rate was 0.07%
If 25% of eligible patients for bariatric surgery underwent surgery, the UK gross domestic product would increase by £1.3 billion due to increase in taxes paid, which would offset the costs of surgery within one year

Bariatric surgery leads to weight loss and substantial improvements in obesity-related co-morbidities, according to a paper reporting the outcomes from the National Bariatric Surgery Registry (NBSR) in the United Kingdom. Most notably, bariatric surgery noted to be safe despite the patients having more obesity-related disease over time. The paper, ‘Obesity surgery makes patients healthier and more functional: real world results from the United Kingdom National Bariatric Surgery Registry’, was published in SOARD.

The National Bariatric Surgery Registry (NBSR) was launched in January 2009 by the British Obesity and Metabolic Surgery Society in collaboration with the Association of Laparoscopic Surgeons of Great Britain and Ireland and the Association of Upper Gastrointestinal Surgeons and in partnership with Dendrite Clinical Systems (a clinical software company). This was the first time that bariatric surgery procedural, systematic data (patient demographic characteristics) and disease burden as part of the longitudinal database in the UK.

The paper’s authors sought to analyse NBSR data to determine whether the effects of obesity surgery on associated co-morbidities observed in small, randomised controlled clinical trials could be replicated in a ‘real life’ setting within UK healthcare. They subsequently extracted data entries from the NBSR to examine the disease burden of 50,782 patients and the effects of obesity surgery on related co-morbidities up to five years post-surgery. The first 3,756 entries were entered retrospectively and all entries from February 2008 to January 2015 were entered prospectively and analysed retrospectively.

Outcomes

The recorded postoperative cardiovascular complications, such as dysrhythmia or myocardial infarction, were recorded in 0.3% patients (total postoperative complications rate was reported as 3.1%,) and the recorded in-hospital mortality rate was 0.07%. The paper found that the commonest recorded co-morbidity was functional impairment (70%), followed by arthritis (54%) and hypertension (37%). Approximately one in three patients had type 2 diabetes and a gradual increase in the median number of reported preoperative co-morbidities was observed over 15 years. The distribution of Edmonton Obesity Staging System (EOSS) scores over 15 years is shown in Figure 1.

Figure 1: Edmonton Obesity Staging System score at baseline

Over the five-year follow-up, the authors found statistically significant reductions in the prevalence of type 2 diabetes, hypertension, dyslipidaemia, sleep apnoea, asthma, functional impairment, arthritis and gastroesophageal reflux disease. The ‘remission’ of these co-morbidities was evident 1 year postoperatively and reached a plateau two to five years after surgery. Bariatric surgery was particularly effective on functional impairment with the proportion of patients able to climb three flights of stairs almost doubling (compared with pre-operatively), as well as halving of the proportion of patients with type 2 diabetes-related hyperglycaemia (compared with pre-operatively). However, no significant change was found for Polycystic ovary syndrome and/or infertility.

Unsurprisingly, the most rapid weight loss took place during the first year after surgery and reached a nadir of 30±12% total weight loss at two years. This was followed by weight regain and 24±13% total weight loss at five years.

The most commonly performed operation was Roux-en-Y gastric bypass (RYGB; 51.4%), followed by vertical sleeve gastrectomy (VSG; 20.2%) and gastric banding (19.7%). Over the course of the observation period, there was a decrease in the percentage of gastric banding and an increase in the percentage of VSG operations performed (Figure 2), the remaining 8.7% of procedures were duodenal switch, biliopancreatic diversion, revisional gastric band, and intragastric balloon or were not specified. The vast majority of procedures were primary surgery (90%) and were performed laparoscopically (93%). Median postoperative length of stay was three days before 2006 and two days from 2007 onward.

Figure 2: Trends in the type of obesity surgery procedures performed

Interestingly, the authors note that obese patients have higher rates of unemployment compared with normal weight individuals and functional impairment is one of the major contributors. Previous UK and European studies have noted that 14 months after bariatric surgery patients’ paid working hours increased by 57% and state benefit claims decreased by 75%. Furthermore, the UK’s Office of Health Economics predicted that if 25% of eligible patients for bariatric surgery underwent surgery, the UK gross domestic product would increase by £1.3 billion due to increase in paid employment (taxes), which would offset the costs of surgery within one year.

The authors noted that the registry does not standardise definitions of specific diagnoses or include continuous data, imaging and other clinical investigation results or detailed medication usage – and entries were dependent on the judgment of the clinician submitting the data, not necessarily on robust disease diagnosis and remission criteria. In addition, they also acknowledge that the dataset does not record the number of medications, nutrient deficiencies, fractures, substance abuse etc . The data set was chosen as a balance between collecting too much data (risking poor engagement and incomplete records) and collecting too little data to generate meaningful analysis.

“These limitations could potentially be overcome in the future through consensus on clinical definitions, inclusion of patient identifiable information, and infrastructure to collect follow-up data from primary care,” the authors conclude. “…Appropriate support and funding will help improve the quality of the NBSR data set even further, thus potentially increasing its effect on healthcare policy.”

This paper was funded by Medical Research Council (UK), to access this paper please click here

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