Experts Discuss the Bariatric Landscape in France
Editor’s Note: The following is an edited, translated transcript of a conversation taped in March 2015 between Boris Hansel, MD, endocrinologist/diabetologist and nutritionist, and Jean-Pierre Marmuse, MD, known as the pioneer of bariatric surgery in France.
Pr Jean-Pierre Marmuse
Chef de service Chirurgie digestive et viscérale
Hôpital Bichat – Claude Bernard Paris
A Global Perspective on a Rapidly Growing Treatment
Dr Hansel: Bariatric surgery is very much in the scientific news, with new data emerging on its benefits and risks. In France, bariatric surgeries increased from 15,000 in 2006 to 30,000 in 2011—in other words, the number doubled. And this trend has continued, with 42,000 such surgeries performed in 2013.
These figures are somewhat startling. Professor Marmuse, is this getting out of control? Is bariatric surgery as safe as an appendectomy or gallbladder surgery?
Dr Marmuse: As to your second question about safety, these procedures are much more complex and in theory carry a much greater risk than an appendectomy or a cholecystectomy. The risks are roughly equivalent to those associated with a gastrectomy. But once again, in France, bariatric surgery involves referral centers, and with experienced teams at these centers, the mortality rate is in the order of 1 in 1000, which is only slightly higher than that for appendectomies or cholecystectomies. These are, in fact, complex procedures, and—I want to emphasize this—patients should be careful to have surgery done only by experienced teams.
In France, bariatric surgeries are subject to prior agreement, so we can’t operate on a patient—or at least, the surgery won’t be covered—without the approval of medical experts. Therefore, in most cases, patients who undergo bariatric surgery in France meet the usual requirements for these procedures, which are based on body mass index (BMI) and associated comorbidities.
Which Patients Should Have Bariatric Surgery?
Dr Hansel: The guideline issued in France by the Haute Autorité de Santé (HAS; the French National Health Authority) is very similar to others in the rest of the world. For example, surgery is indicated in people with grade III obesity (BMI > 40 kg/m2), and in those with severe obesity (BMI > 35 kg/m2) who have comorbidities that could be improved with weight loss. As with any other surgical procedure, there are contraindications—in particular, uncontrolled and severe psychiatric problems, severe eating disorders (especially with vomiting), and certain addictions.
A lack of follow-up also is a contraindication, because patients must be monitored on a long-term basis. Do you automatically turn down people who tell you that a follow-up wouldn’t be possible?
Dr Marmuse: In general, yes, because these procedures potentially have harmful long-term side effects. On the other hand, it’s difficult to turn down someone with massive obesity that is making their life hellish. Patients really have to be evaluated on a case-by-case basis.
Dr Hansel: This is why it’s important to have a medical/surgical team that works collaboratively.
Dr Marmuse: And a multidisciplinary team—that is, a surgeon, a psychiatrist, an endocrinologist or a nutritionist—who will weigh the pros and cons, the risks and benefits, before establishing that the surgery is indicated.
Dr Hansel: The guidelines also mention a theoretical age limit. Is there an age above which you don’t operate?
Dr Marmuse: In my opinion, the recommendations are a bit outdated, because they haven’t been adjusted to reflect the current increase in life expectancy. The old recommendations, which came from the United States and which were copied almost everywhere else, set an upper age limit at 60 years. Frankly, today, at 60 to 65 years, people are far from the end of their lives.
For the lower age limit—18 years—I do think we need to be very careful. But over the age of 65 years, I think that if the patient is in good health, there are few reasons to turn them down, especially if their request concerns both weight and the impact on their joints. Orthopedic surgeons often refuse to do prostheses in very heavy people, so a solution has to be found where they can have surgery, in order to walk again.
Different Procedures, Different Risks and Benefits
Dr Hansel: Let’s take a quick look at the three procedures performed most often in France. The first one, which we will describe as « historical, » involves the placement of a gastric band around the upper part of the stomach. This creates a small gastric pouch that fills quickly and therefore leads to a feeling of blockage or, in any event, to the inability to eat any more as soon as it becomes full. This technique is reversible.
The second technique is called a « sleeve gastrectomy, » also known as a « vertical gastrectomy. » In very simple terms, the surgeon cuts away close to two thirds of the stomach, which is reduced to a tube. What’s important is that it’s not just a mechanical effect, because the cells that manufacture hunger hormones, such as ghrelin, also are removed. This is perhaps one of the reasons for the decreased appetite in people who have this surgery.
The third technique, gastric bypass, is a bit more complex because it creates a small stomach and results in malabsorption.
Dr Marmuse: The bypass does, in fact, create a small stomach, or gastric pouch, but it’s also a bit like removing the stomach. This technique was originally proposed in the United States by a surgeon named Edward Mason. At a time when the number of obese people in the United States already was large, Dr Mason noticed that when he performed gastrectomies for ulcers in obese patients, they lost weight and had a lot of difficulty gaining it back. So he said to himself, « Why not do the equivalent of a gastrectomy set-up, but not remove the stomach, to treat obesity? »
That is how the gastric bypass originated. Actually, it’s a virtual gastrectomy. Therefore, we remove, or rather exclude, two thirds of the stomach from the alimentary circuit and connect a very small gastric pouch to the proximal part of the small intestine. For anatomical reasons, we can’t do this without excluding from the alimentary circuit not only the stomach, but also the duodenum and about 40-50 cm of the small intestine. Therefore, food doesn’t go into this part of the gastrointestinal tract, where there is preferential absorption of certain vitamins. This is why, after undergoing this procedure, patients have to take supplements containing vitamins and trace elements (such as iron and vitamin B12) for the rest of their lives.
Dr Hansel: So, there’s a risk for deficiencies if patients don’t take these supplements, which is not associated with the other two techniques. Are there other bariatric procedures in addition to these three?
Dr Marmuse: Definitely. Owing to the growing prevalence of obesity in all countries and rising interest in bariatric surgery, a slew of techniques have been proposed. They are currently described in the literature, but none is currently approved at the international level. The only approved techniques are the three that we’ve talked about, plus another known as the « biliopancreatic bypass, » or the « duodenal switch. » However, that procedure carries an even greater risk for nutritional deficiency than the gastric bypass.
Current Trends in Bariatric Surgery
Dr Hansel: Let’s go back to the three commonly used, approved techniques. If we look at the history of these three procedures, we notice that there has been a considerable decrease in gastric banding in favor of bypasses and sleeve gastrectomies. This may seem surprising, given that the band is safer because it’s reversible. Why, then, has it practically been abandoned in France?
Dr Marmuse: It’s not just in France; it’s true in almost all countries. Why? First, let’s examine the reasons for its early, rapid growth. Originally, this technique worked very well because it was reversible, as you say (but even so, one has to reoperate to remove the band). Furthermore, it’s a technique with minimal risks, because it doesn’t involve any gastric sutures or removing any of the stomach. Therefore, it’s a really benign procedure. Second, it’s the technique with the fewest perioperative complications.
On the other hand, over time we realized that this technique was causing a huge number of long-term complications, in particular dilation of the stomach and band migration within the stomach. After 2-3 years, about one third of these patients had their band removed for such complications.
Finally, all of the long-term studies show that there’s a failure rate of about 90% if one adds up all the bands that have been removed and the procedures that were unsuccessful, in the sense that patients gradually gained back the weight. With this procedure, there is both a difficult lifestyle and, in the long term, a high failure rate.
Dr Hansel: We noticed the inefficacy of the band after 10 years. You’re not afraid that the same scenario will occur with the sleeve gastrectomy and the bypass?
Dr Marmuse: Bariatric surgeries, regardless of the technique, are not miracle solutions. If patients don’t make an effort both to structure and modify their eating habits, and to modify their lifestyle by doing sports and being physically active, these techniques will fail in the long term. Today, after a bypass or a sleeve gastrectomy, it is estimated that there will be a 10-year failure rate of about 30%.
Dr Hansel: So, we already have 10 years of experience.
Dr Marmuse: Yes, we have 10 years of experience with bypasses, with a 30%-35% failure rate. We don’t yet have 10 years of experience with the sleeve gastrectomy, at least with sufficient patient cohorts, but it’s very likely that in this case, too, we’ll see a failure rate of 30%-40%.
However, I’d like to talk about the difference in efficacy. The band is a purely mechanical technique that constricts the alimentary circuit. Food is blocked, which causes discomfort. The patients feel hungry; they want to eat, but they can’t.
With the other two techniques, patients don’t feel hungry. As you said earlier, part of the stomach that secretes a hunger hormone (ghrelin) is surgically removed. Therefore, patients don’t feel hungry, but rather satisfied—they have the feeling of having eaten a large meal.
Dr Hansel: Is there a consensus regarding the choice of one technique over another? We get the feeling that some teams only do sleeve gastrectomies, and they criticize those that do bypasses. I’m exaggerating a bit, but sometimes this is how it seems. And conversely, there are teams that are against sleeve gastrectomies and go straight to bypasses. What’s your approach to choosing the surgical technique?
Dr Marmuse: Before telling you my personal approach is, I would like to mention the overall results we have regarding sleeve gastrectomies. In terms of weight loss, the sleeve gastrectomy and the bypass yield fairly similar results in patients with a BMI < 50 kg/m2. As for the bypass, it gives significantly superior results in terms of weight loss in patients with a BMI > 50 kg/m2.
Therefore, when we see a patient, our reasoning could be as follows: « OK. He’s hugely overweight, so we’ll do a bypass. If he’s overweight, but not as much, we’ll do a sleeve gastrectomy. »
There’s another way to look at this. If we consider obesity as a chronic disease and we know that we’ll have a 10-year failure rate of 30%-40%, what will we do in 10 years when patients return because they’ve gained back the weight? What are we going to tell them? « You have already had your surgery. Tough luck. You shouldn’t have put the weight back on. »
Or, we can view the problem differently. We know that about 1 in 3 cases will result in failure because the patient, after a certain amount of time, forgets the advice they were given, forgets to go back to the nutritionist, and therefore goes back to their eating disorders. In such cases, we can say, « OK, we’re going to give you another chance. We’re going to convert a sleeve gastrectomy to a gastric bypass. »
That way, we’ll have a back-up in case of a failure, whereas if we start with a bypass…
Dr Hansel: …we’ll have no, or almost no, fallback.
So, we do as we do with any other chronic disease, saying that we’ll first put the patient in remission…
Dr Marmuse: Yes, that’s pretty much the way I see things nowadays.
The reason that failures are so common is that eating reflects two different things: hunger and the desire to eat. Hunger is hormonal, and we need to eat so that our bodies can function. And then there’s the desire to eat, which in general is emotional. We see this in people who snack when they’re happy or sad, or who eat to compensate for events in life. Actually, it’s an addiction, and surgery doesn’t prevent this addiction; hence the importance of a psychiatrist in helping these people.
Should the Guidelines Be Changed?
Dr Hansel: I’d like to talk about the people with a BMI < 35 kg/m2 who consult us directly, requesting surgery. You said earlier that the HAS recommendations are a bit outdated. With the data that we have now for people with a BMI < 35 kg/m2, which look fairly promising, do you think this cutoff should be lowered to 30 kg/m2? Or that people be operated on as soon as they become obese?
Dr Marmuse: Once again, my answer is going to be a bit more nuanced. A cutoff must be set, but what should it be? We could make it 30 kg/m2 because the definition of obesity is a BMI of 30 kg/m2. However, below 35 kg/m2, the risks associated with obesity (and I’m not talking about the psychological impact or the impact on everyday life, but rather the health risks) are fairly minor. There’s also the question of the risk/benefit ratio.
We know that the bypass and the sleeve gastrectomy result in lasting remissions in people with type 2 diabetes, even those who require insulin. I think the indications should probably be expanded to below 35 kg/m2 (that is, between 30 and 35 kg/m2) for patients with difficult-to-control type 2 diabetes.
Dr Hansel: Incidentally, this reminds me of the guidelines of the International Diabetes Federation, which mention bariatric surgery as a treatment option for obese persons with uncontrolled diabetes and a BMI between 30 and 35 kg/m2. But that’s another perspective.
If we have to focus on a single message, I think it would be for a patient to consult a medical/surgical team—with a physician, a surgeon, et cetera—before approaching surgery as the solution to an acute illness. Obesity is a chronic disease, and if people undergo surgery, they will live with a modified stomach and intestine for the rest of their lives. It is therefore imperative that their follow-up be coordinated.
Dr Marmuse: Yes, long-term follow-up is really essential for the success of the procedure and for maintaining its success.
[Editor’s note: In the United States, the 30-day mortality rates for sleeve gastrectomy, gastric bypass, and gastric banding are 0.08%, 0.14%, and 0.03%, respectively.[1-3] These rates are lower than those typically associated with gallbladder removal or hip replacement surgery.]
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