Ledtter to the Editor: Bypassing Bariatric Surgery and Editorial Evidence
- John G Kral, Professor of Surgery and Medicine
SUNY Downstate Medical Center
The journal published a rarity: an ethical, scientific, randomized, trial of bariatric surgery (1) exhibiting equipoise: the two operations are similar, in contrast with randomizations between operations with different mechanisms and effects (2) or between any operation and “medical” care (3), although long-term data demonstrate superiority of the one operation. One might question equality of the two hospitals, equivalency of the teams’ learning curves, follow-up schedules lacking postoperative “dietitian and surgeon” visits during the important 12-24 months after bypass operations in superobese patients and drawing conclusions after only 2 years when slopes of the mean BMI diverge in groups with different follow-up rates, and particularly too early to evaluate the most valuable benefits of these operations. However, the accompanying Editorial (4) raises more serious questions:
Is it accurate or “evidence-based” to portray superobese patients as “metabolically normal”, “healthy” or “near -normal”?
Should all malabsorptive operations be branded as “inherently dangerous”? Gastrointestinal surgery is “dangerous” yet meets risk-benefit and cost-benefit criteria or else would not be allowed?
Can outcomes of treatments of superobese patients be evaluated after only 2 years? No 2-year evidence supports stating: “greater weight loss does not seem to change the anticipated long-term outcomes for bariatric surgery”. Predictions before weight and compensatory adaptive mechanisms have stabilized are unfounded. There is no evidence that “Many patients are well-adapted to their obesity”; neither superobese patients in general nor ‘bariatric surgery’ patients. The editorial criticizes the “low methodological quality” of studies of bariatric surgery and requests “good evidence”, yet describes a rare complication as “particularly worrisome for these young women” based on one case-report (5). Not to trivialize this, but the complication is rare and easily prevented by standard of care following authoritative guidelines (editorial refs 3 and 4).
“Complications are serious” and “may take years to manifest” but it is not accurate that “the true complication rate over the lifetime of these young patients can be expected to be formidable”. Both operations have been performed for 35 years with large series exceeding 15 years, including two with offspring of mothers with the potentially more “dangerous” of the operations followed for 2-24 years. The complications are known, germane to gastrointestinal surgery, but most important: They are easily preventable by competent follow-up care and are substantially easier to treat effectively than superobesity or less extreme forms of obesity. In the final analysis patients must decide whether effects of these operations, beneficial or adverse, outweigh their own suffering with their disease. Responsible physicians must provide the best available understandable evidence to lay patients.
1. Sovik TT et al. Weight loss, cardiovascular risk factors and quality of life after gastric bypass and duodenal switch. Ann Intern Med 2011;155: 281-91
2. Kral JG. Psychosurgery for obesity. Obes Facts 2009;2:339-41
3. Kral JG et al. Flaws in methods of evidence-based medicine may adversely affect public health directives. Surgery 2005;137:279-84
4. Livingston EH. Primum Non Nocere. Ann Intern Med 2011;155:329-330.
5. Huerta S, Rogers LM, Li Z, Heber D, Liu C, Livingston EH. Vitamin A deficiency an a newborn resulting from maternal hypovitaminosis A after biliopancreatic diversion for the treatment of morbid obesity. Am J Clin Nutr. 2002:76:426-9.
Conflict of Interest: