Increasing access to surgery and preventing post-op weight regain

Owen Haskins - Editor in chief, Bariatric News

In a wide-ranging interview, Bariatric News talked to Mr Shaw Somers, upper gastrointestinal and bariatric (metabolic) Consultant Surgeon with Streamline Surgical and President of the British Obesity & Metabolic Surgery Society (BOMSS), about the lack of access to surgery, the need to educate people on the causes of obesity and how to treat post-operative weight regain.

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Shaw Somers

“The problem we face in the UK is of a publicly-funded health system in which the government absolutely dictate what and who we can and can’t operate on, based on money,” Mr Somers began. “Unfortunately, we still have a disconnect in the UK between what the National Institute for Health and Care Excellence (NICE) guidance states and what politicians and the people within NHS England are prepared to accept as standards of care. We have NICE guidance which is very clear on how and what we should be spending money on in terms of treating obesity and yet it seems to be completely voluntary for commissioners to opt out of if they want. We now have less Tier 4 commissioned surgery than we did three years ago and only 44% of all commissioning groups procure bariatric services.”

He believes the lack of awareness about the causes of obesity and how to treat obesity comes down to a lack of education, as many people do not understand that obesity is a disease, and stated that it is up to obesity specialists including bariatric surgeons, researchers, nurses, dieticians etc to educate colleagues, politicians, policy-makers, commissioning groups, the media and the public that obesity is an illness - rather than a lifestyle choice.

Obesity is not a lifestyle choice

“I have met thousands of people with obesity and not one of them choose to be obese. Our great challenge will be to convince people that obesity is a disease and that there are treatments available that work,” said Mr Somers. “To ask people to eat less and exercise more is a ridiculous over simplification of the scientific evidence and is ignoring the fact that much of your weight is determined by genetics. I think we need to start exposing fat shaming for what it is - and that is the prejudice of ignorance - it does not work to help people lose weight, in fact it is counterproductive.”

He emphasised that BOMSS is still very busy behind the scenes lobbying the various stake-holders to raise awareness and try and improve access to all treatments for obesity, and will continue to work hard on behalf of the bariatric community to educate and demonstrate that bariatric procedures are safe, effective and have not only resulted in reducing the weight of tens of thousands of people over the years but have also improved their overall health and quality of life by reducing their co-morbidities, and improving quality of life.

"There is also evidence that shows sleeve and bypass procedure tend to fade with time, this ‘fatigue’ or loss of restriction means the restrictive and hormonal effects of the procedure diminish over time.”

He explained that people need to understand the nature of obesity as an illness and that obesity is about how our brain perceives food and satisfaction, and when that relationship becomes disordered, we start to eat more. Mr Somers added that is not because we are inherently greedy but because our brain does not respond in the way it should to food. The reason for this are multifactorial including the type of food we eat, the stresses of modern day life, mental illness - including anxiety and depression – all change the way the brain functions, and this includes the way the brain responds to food.

Bariatric and metabolic surgery

He explained that there is growing evidence that there is not one mechanism for bariatric surgery’s effects but many. He said that surgery’s effects are not just hormonal, not just restrictive and not just a change is the patient’s dietary habits and lifestyle – it is a combination of all three. He believes that there are three phrases to bariatric surgery’s effects:
1) There is an initial ‘shock and awe’ phase that changes a patient’s experience when the eat after the procedure, which includes a feeling of restriction.
2) A phase of hormonal effects where the actual physiology of the bariatric procedure changes how the patient feels and how they work with food, and;
3) The longer-term dietary rehabilitation and the longer-term effects of surgery that either help the patients maintain their habits or not - and it is here where weight regain occurs.

There are now many tens of thousands of people in the UK that have had successful bariatric procedures, unfortunately the human body adapts and changes over time, and these changes bring with it the possibility of weight regain.

According to Mr Somers, the first two phases work because of the restrictive effects of the procedure, depending on the procedure. If either the physical or hormonal effects are no longer present, this is when weight regain occurs. The question then becomes: How do you maintain the effects of the operation in the long-term? One solution is to maintain restriction.

“We know from long-term gastric band data that if the band is still in place and there have not been any complications then the outcomes are good, and there are several long-term gastric band studies that are at least as good as the long-term sleeve and bypass data. We know that once band patients are stable they don’t regain weight because the band is still working and is having an effect. There is also evidence that shows sleeve and bypass procedure tend to fade with time, this ‘fatigue’ or loss of restriction means the restrictive and hormonal effects of the procedure diminish over time.”

The ‘banded procedure’

One possible way to prevent ‘surgical fatigue’ and maintain restriction is to perform a ‘banded bypass’ or ‘banded sleeve’, in which a surgeon places a band or a MiniMizer Ring (Bariatric Solutions) around the gastric pouch to prevent pouch dilatation.

According to Mr Somers, patients who have a MiniMizer Ring find that the ‘fatigue’ effect does not occur as they still have an element of restriction and that stops weight regain in the long-term. Whilst the initial phases weight loss for ‘banded’ patients is generally the same as non-banded patients, it is the prevention of long-term weight regain that is the real benefit of using a device such as the MiniMizer Ring.

Mr Somers has been using the MiniMizer Ring for about three years and has performed about 40 - all private cases - as the MiniMizer Ring is not freely available on the NHS.

“I routinely offer the MiniMizer Ring to patients if they are undergoing a revision procedure from a band to a bypass, as the one thing they complain about is a loss of restriction and they don’t feel comfortable working with no restriction element,” he explained. “I believe that is one of the indications for a Ring – patients who have had a previous gastric band. I would also recommend a banded bypass in primary bypasses cases in superobese patients, as the procedure offers a much more durable restriction effect. When the bypass naturally fatigues - because all tissues soften and stretch with time – the added restriction of the MiniMizer Ring ‘protects’ the bypass and reduces the feeling that the restrictive effect has faded.”

He said that he particularly likes the MiniMizer Ring compared to a band as the Ring is easy to apply and calibrate, adding that he has had no complications using the MiniMizer Ring with regards to slippage or erosions, however using an inflatable band for a banded bypass he has had some complications.

“I think the adjustability aspect of bands means than you can over adjust the band and that is when patients will start to struggle this can lead to slippage, migration or dilatation of the pouch above the band which goes against the very reason you placed the band in the first place. The MiniMizer is easy to apply and is placed and fixed so it is ‘snug’ next to the pouch - but not tight - leaving enough space to allow the food to pass through. That is the beauty of the procedure – it is very simple and it seems to works!”

Feedback from patients who have received a Ring after revision surgery reveals that they are happy, because they have a restriction that they can work with. Patients without the Ring are not as happy as they notice the restriction waning as the procedure starts to fatigue.

Managing expectations

Mr Somers explained that another important aspect to surgery is managing patient’s expectations but also difficult because as a surgeon one does not want to put them off the procedure by mentioning weight regain otherwise they will think, ‘Well what’s the point?’

He said that ‘managing expectation’ is a discussion all surgeons should have with their patients, but it should be handled in an honest way and one should approach the conversation from the view that weight regain is a ‘probability’ rather than a ‘possibility’ in the longer term. He said that in discussions with patients, surgeons should be explicit that they are offering patients a tool that can provide a remission from their obesity, rather than a cure.

“I use the analogy of patients being given a new musical instrument. They will need to learn about it and be trained to use it if they are going to get any kind of music,” he concluded. “Furthermore, as the years go by they may need to renew their instrument, or even upgrade. The principle is the same for bariatric surgery.”