NCEPOD Launch Too Lean a Service NCEPOD Launch Too Lean a Service? London, October 2012 A review of patients who underwent bariatric surgery David Kerrigan Medical Director & Consultant Surgeon Phoenix Health

Some numbers Cost of obesity to the UK £7.9 Billion1 Predicted cost by 2050 £50 Billion 1 House of Commons Library, Statistics on Obesity Briefing Paper April 2011

Prevention is better than cure

Prevention is cheaper than cure

Prevention doesn’t help the one million people who already have BMI >40

Bariatric Surgery in a High Volume Unit Liverpool Audit 2007-2010 30 Day Mortality 1 death/ 1,334 ops = 0.07%

Fact ? Bariatric surgery is not dangerous

Deaths NCEPOD report

Deaths No deaths reported in 397 patients Almost half patients surveyed had gastric banding

Deaths RC Histopatholgists Audit n=29 A third of deaths (10/29) due to anastomotic leak 10% from bleeding

NCEPOD Hospital Volume Almost half of hospitals carrying out gastric banding do < 10 per year Main results is a lack of experience in out-patient care Poor weight loss Late recognition remediable complications

NCEPOD Hospital Volume 50% bypasses done in high volume units (>40/yr) 25% bypasses in units doing <10/yr

Hospital Infrastructure 23% (14/62) private hospitals fall outside new IHAS critical care guidance (level 1 only) Almost 10% (10/105) hospitals did not offer follow-up clinics

Critical Care 97% of patients do NOT require unexpected critical care admission

Unplanned Readmissions

Gastric Balloon 60% of all balloon patients are readmitted within 6 months Presumably not to have planned removal! Early vomiting very common

Gastric Band A Safe Operation ? 18% of bands require readmission Half of band readmissions (9% of all band patients) require reoperation

Gastric Band A Safe Operation ? Most reoperations (60%) for minor port problems But 3.5% of all bands require early reoperation for more serious complications

Gastric Bypass 25% of readmissions for symptoms suggestive of stomal ulcer/stricture A third of bypass readmissions required surgery

Audit Although only 57% entered on to NBSR…… 81% entered on to some audit/data registry

Surgery on low BMI patients (BMI 30-35) Balanced view taken regarding application NICE guidelines

Medical vs Surgical Treatment BMI 30-35 Randomised Trial Intensive Medical Treatment Orlistat + VLCD (Optifast) + Behavioural Therapy Bariatric Surgery Gastric banding vs

Medical vs Surgical Treatment BMI 30-35 Results after 2 years O’Brien P, Dixon J et al; Ann Int Med 2006 Medical 18% excess weight lost Surgery 68% excess weight lost vs

Conclusions Well written, balanced report Full of good suggestions for best practice (although a few recommendations a bit overly dogmatic)

Conclusions Overall standard of bariatric surgery in UK appears to be high Need to address low volume, poorly delivered services Need further study to investigate relationship between volume and outcome