This is the second comprehensive, nationwide analysis of outcomes from bariatric (obesity) and metabolic surgery in the United Kingdom & Ireland:
• 161 surgeons from 137 hospitals recorded 32,073 operations; 18,283 in the three financial years ending 2011, 2012 and 2013.
• In 2011-2013 76.2% operations were funded by the National Health Service; 22.6% were independently funded and a tiny proportion were paid for by private insurers.
• The majority of the analyses include data on operations carried out in the financial years 2011-2013 and include information on 9,526 gastric bypass procedures, 4,705 gastric band operations and 3,797 sleeve gastrectomy operations.
• 95.4% of all primary operations were performed laparoscopically over the last three financial years 2011, 2012 and 2013.
• The observed in-hospital mortality rate after primary surgery was 0.07% overall (and just 0.07% for gastric bypass), much lower than that for many other planned operations
• The recorded surgical complication rate overall for primary operations was 2.9%
• These figures compare to the best internationally available outcome benchmarks. Thus, surgery in the United Kingdom & Ireland, in the hands of the contributors, is safe.
• The average post-operative stay was 2.7 days, indicating efficient use of resources.
At the time of primary surgery:
• The average BMI was 48.8 kg m, which means that patients were almost twice their ideal weight
• 53.9% of men and 41.4% of women had a high level of co-existing disease (4 or more obesity related diseases)
• 44.6% of men and 25.9% of women had type 2 diabetes
• 39.9% of men and 15.8% of women were on treatment for sleep apnoea.
• 73.2% of men and 71.5% of women had some functional impairment, they could not manage to climb 3 flights of stairs without resting.
• Comparing the financial years 2009-2010 to 2011-2013, the average BMI has increased from 48.5 kg m to 48.8 kg; the average number of comorbidities has increased from 3.2 to 3.4; the average Obesity Surgery Mortality Risk Score has increased from 1.6 to 1.8; and average post-operative stay has fallen from 3.1 days to 2.7 days, even more remarkable given that the proportion of operations that were gastric banding decreased and the proportion of operations that were sleeve gastrectomy procedures (where patients stay 2-3 days typically) has increased.
Follow-up data derived from some 30,933 follow-up entries for the 2011-2012 patients show:
one year after primary surgery:
•On average, patients lost 58.4% of their excess weight (36.6% for gastric banding, 68.7% for gastric bypass & 58.9% for sleeve gastrectomy)
• Over half of patients (64.0%) with pre-operative functional impairment returned to a state of no impairment one year after surgery, meaning they could climb 3 flights of stairs without resting.
• 61.0% of patients with sleep apnoea were able to come off treatment.
two years after primary surgery:
• 65.1% of patients with type 2 diabetes returned to a state of no indication of diabetes, meaning, in practice, that they were able to stop their diabetic medications.
three years after primary surgery for the 2006-2011 cohort:
• On average, patients lost 59.6% of their excess weight (52.9% for gastric banding, n=453; 65.4% for gastric bypass, n=536; & 59.0% for sleeve gastrectomy, n=40).
Comment on mortality data:
• Two external sources have assessed mortality using independently-collected Hospital Episodes Statistics (HES) data:
• In an analysis conducted by the Quality Outcomes Research Unit in Birmingham presented on page 42 as part of the Surgeon-Level Outcomes Publication (2013) the estimated mortality for primary bariatric surgery for the 4 years April 2009 to February 2013 was 0.11% (25/23,760).
• In an earlier HES analysis of patients having bariatric surgery between 2000 and 2008, the 30-day mortality rate was 0.27% (19 / 6,953). When laparoscopic cases alone were considered, the mortality was much lower at 0.16% (7 / 4,436).
• Taking the evidence together, the NBSR Committee believes our results in the Second Report to be an accurate representation of the outcomes of those surgeons who submitted their data. We do not have 100% data submission yet, but this will come.
• Severe & Complex Obesity is a serious, life-long condition associated with many major medical conditions, the cost of which threatens to bankrupt the NHS. For severely obese people, medical therapy, lifestyle changes and attempts at dieting rarely succeed in maintaining long-term, clinically beneficial weight loss due to the hormonal effects of the obese state, dieting, and energy balance and metabolic rate.
• For all comparisons, the data show that there is great benefit from bariatric surgery for all the diseases studied, in particular the effect on diabetes has important implications for the NHS.
• By implication, bariatric surgery greatly and cost-effectively improves the health of obese patients, much more so than other treatments.
From the Chairman of the Database Committee and President of BOMSS
It is an honour and a privilege to present this Second Report of the National Bariatric Surgery Registry. Since the inaugural report in 2011 on data from over 8,000 operations, bariatric surgery in the United Kingdom has become more formalised, with NHS England publishing the Clinical Commissioning Policy for Complex and Specialised Obesity Surgery in April 2013. The Royal College of Physicians has also issued a call to action to ramp up medical obesity services and awareness of treating overweight and obese patients. Despite all this, the rate of surgery in the United Kingdom has fallen significantly, and this poses many challenges for clinicians trying to offer clinically- and cost-effective care for their patients. It is therefore timely to present data on a further 18,000 patients operated upon in the United Kingdom between 2010 and 2013, demonstrating some remarkable improvements in obesity-related disease after surgery, with up to 3 years of follow up data recorded.
When bariatric surgery for severe and complex obesity was first undertaken over 50 years ago, all surgery was undertaken using open surgical techniques. The scene has now changed dramatically, with nearly all surgery performed by laparoscopic techniques, which, together with protocols for enhanced recovery, mean that pain is much reduced for the patient and hospital stay is much shorter than before. The data presented in this report cover 3 main operations: gastric bypass, gastric banding and sleeve gastrectomy. We do not know which is the best bariatric surgery operation 1. Surgical techniques and trends change over time and with experience, but collecting a large amount of data on many thousands of patients means that important observations can be made that, in turn, lead onto and form the basis for research questions.
We urge those new to the field to look at the sections on diabetes control: the NHS is saving money because patients are coming off their diabetes medication(pages143-147 and 152-155) as a direct result of their bariatric surgery. Patients are also seeing vast improvement in their functional status, where even wheelchair users or housebound patients recover the ability to climb stairs (pages 143-151). These findings clearly show the efficacy of bariatric surgery for patients.
It is important to note that the NBSR was formed as a collaboration between three specialist surgical societies: the Association of Laparoscopic Surgeons, the Association of Upper Gastrointestinal Surgeons and the British Obesity and Metabolic Surgery Society (BOMSS), and their data management partner Dendrite Clinical Systems, and in large part to date has received no public funding. Bariatric surgery was one of the 10 specialties to participate in the publication of Surgeon-Level Consultant Outcomes in 2013 and anticipates receiving funding from the Healthcare Quality Improvement Partnership for the next round in October 2014. Aside from this, there has been no offer of public funding for the Registry whose day-to-day administration was taken over by BOMSS in January 2014. Publication of this report involved no public funding and the committee does not receive remuneration.
On a hospital level in the United Kingdom there is a distinct lack of administrative support to assist surgeons in assuring data quality; in particular there is no infrastructure to address the 3 problems of data quality, namely: missing records, incomplete records and erroneous data. There is also poorly-developed infrastructure, especially in capturing follow up beyond 2 years, in stark contrast to the processes deeply embedded within the NHS to collect data on, for example, cancer treatment and survival. This is a big challenge: how to improve the follow up of patients and record 5-year outcome data within the NHS. Even so, the complications and mortality data presented are comparable with the international literature, and there are many new findings that have not been observed before on the scale of a national registry on the outcomes following surgery for obesity-related disease.
This unique database provides clear evidence that bariatric surgery radically improves health for patients with severe and complex obesity. It demonstrates that the health benefits of bariatric surgery reported in the international literature apply equally to our patients in the United Kingdom. The challenges of raising awareness of the effects of bariatric surgery and increasing service provision are considerable. Many factors including deeply held societal prejudice and reorganisations within the NHS appear to be limiting the provision of surgery, which is much less than in other equivalent countries. For our part, those surgeons who submitted their data to the Registry in England have been open and transparent with their operative results, and to facilitate the pathway of patients from their GP to surgery BOMSS has developed multicollegiate commissioning guidance. The texts of both the 2013 Consultant Outcomes Publication and the 2014 Tier 3 Commissioning Guidance are reproduced in subsequent pages.
The NBSR Database Committee is grateful to all those surgeons who have voluntarily contributed their NHS and private patient data to the Registry in the time leading up to April 2013, when data submission became mandatory for units providing NHS surgery. There has been a substantial increase in the number of surgeons contributing since the first report from 84 to 150, and the number of contributing hospitals has increased from 86 to 129. We are also immensely grateful to Dr Peter Walton and Dr Robin Kinsman of Dendrite who have enthusiasticallypatiently and expertly put in many, many hours of time to project plan, analyse the data and help us deliver the report over the last 6 months. We are also indebted to Professors John Dixon, Paul O’Brien, Alberic Fiennes and Michel Gagner for contributing invited commentaries for the sections on gastric banding, gastric bypass and sleeve gastrectomy respectively. The NBSR Database Committee and bariatric surgeons are immensely grateful to Jenny Treglohan, who took on the considerable burden of being NBSR Administrator for the Surgeon-Level Outcomes Publication in 2013, and Sarvit Wunsch and Nichola Coates who took over as NBSR administrators this year.
President of the BOMSS and Chair of the NBSR Database Committee
The document is available as a free pdf download to AUGIS and BOMSS members via: www.e-dendrite.com/nbsr Additional copies may be purchased online from Dendrite’s e-bookshop: www.e-dendrite.com/publishing/reports