Open Access
Feature Article

Bariatric surgery: positive and negative effects

Open Access
Feature Article

Bariatric surgery: positive and negative effects

Eddy J. Tabet, Ian D. Caterson, Tania P. Markovic

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© BSIP RF/DIOMEDIA.COM
© BSIP RF/DIOMEDIA.COM
Dr Tabet is a Staff Specialist in the Department of Endocrinology at Royal Prince Alfred Hospital; and Clinical Associate Lecturer at The University of Sydney, Sydney. Professor Caterson is the Boden Professor of Human Nutrition and Director of The Boden Collaboration for Obesity, Nutrition, Exercise & Eating Disorders at The University of Sydney, Sydney; and an Endocrinologist at Royal Prince Alfred Hospital, Sydney. Dr Markovic is Director of Metabolism and Obesity Services at Royal Prince Alfred Hospital, Sydney; and Clinical Associate Professor, Boden Collaboration for Obesity, Nutrition, Exercise & Eating Disorders at The University of Sydney, Sydney, NSW.

Psychosocial consequences

Mental health problems are prevalent in patients with severe obesity (and vice versa). Poorly controlled depression, substance misuse and eating disorders can compromise surgical outcomes and are  frequently regarded as contraindications to bariatric surgery. Consequently, a preoperative psychological evaluation is recommended in most institutions. One systematic review showed the risk of suicide to be fourfold higher among patients after bariatric surgery compared with the background population.39 A cohort study of bariatric surgery, in which 98.5% of patients underwent RYGB, confirmed an increased rate of self-harm emergencies after surgery in patients older than 35 years, those with a low-income status, and those living in rural areas.40 Notably, 93% of the events occurred in patients with an existing mental health disorder that was diagnosed in the five years preceding surgery.40

The Western Australian study referred to previously examined the use of outpatient, emergency department and inpatient mental health services by the 24,766 patients who had bariatric surgery between January 2007 and December 2016. At least one mental health service was used by 16.1% of patients of whom 35.2% presented only before surgery, 25.8% both before and after surgery and 39% presenting only after surgery. There was a fivefold increase in presentations to the emergency department with deliberate self-harm and 25 (9.6%) of the 261 postoperative deaths were due to suicide. Complications after bariatric surgery requiring further surgery and a history of mental health service provision before surgery were the strongest associations with presentation to a mental health facility after bariatric surgery.41

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Conclusion

Knowledge of key long-term outcomes of bariatric surgery, such as durability of weight loss, remission of obesity-related comorbidities and surgical complications, has grown exponentially in recent years. Further insights into the physiological mechanisms underlying the outcomes will drive more effective and less invasive techniques that can be individualised to a patient’s needs. Once the appropriate procedure for a patient has been selected, the specific surgical referral pathway should be guided by the familiarity and experience of the surgeon with that procedure. Ultimately, bariatric surgery should be offered to motivated and well-informed patients, especially those with refractory complications of obesity. However, comprehensive medical and psychological evaluation should exclude patients who are at risk of nonadherence or self-harm in the postoperative period.    ET

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COMPETING INTERESTS: Dr Tabet has received support from MSD for registration at an Australian Diabetes Society meeting and an honoraria for speaking from Servier and Novo Nordisk. Professor Caterson has received funding for clinical trials from Novo Nordisk, Eli Lilly and Boerhingher Ingelheim and honoraria for chairing the ACTION IO Steering Committee and for speaking from Novo Nordisk. Dr Markovic is an advisory member to the Egg Nutrition Council and Nestle Health Science and has received honoraria for speaking from Novo Nordisk.