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Rapid Responses to:
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Electronic letters published:
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Harvey J Sugerman, MD Virginia Commonwealth University, John G. Kral, MD, PhD
Send rapid response to journal:
hsugerman{at}comcast.net Harvey J Sugerman, et al.
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To the editor: We appreciate the attention Annals has given to the management of obesity, in the form of Clinical Guidelines, a Meta-Analysis with Editors’ Notes, and a Summary for Patients [Ann Int Med 2005; 142(7)], although we have several concerns regarding the contents. The American College of Physicians (ACP) Clinical Guidelines for Pharmacologic and Surgical Management of Obesity are inappropriately confining, potentially leading to denial of effective treatment for severely obese patients. The guidelines do not provide a balanced assessment of the relative long-term efficacy of non-surgical treatments such as diets, behavior modification, exercise, drugs or combinations of these modalities, in patients with body mass index (BMI) 35 kg/m or greater with serious co-morbidities. More than 95% of severely obese patients fail such treatments after less than two years, and, on average, have made more than 5 unsuccessful attempts prior to referral for bariatric surgery. The Summary for Patients, regarding the benefits of a mean weight loss of 11 lbs during on-going non-surgical treatment (drugs, diets, etc), is misleading, if not disingenuous. Immediately after cessation of the 6-12 months of treatment, much of which is associated with alarmingly high drop-out rates, virtually 100% of patients return to their previous poor health. This rate of failure is extremely frustrating to both the patients and Primary Care physicians. The Guidelines list of co-morbidities of obesity requiring treatment is remarkably incomplete; asthma, gastroesophageal reflux, liver disease, obesity hypoventilation, pseudotumor cerebri, stress incontinence, polycystic ovary syndrome and venostasis disease, among others, are all serious and limit the quality and even length of life. There are numerous consistent confirmatory case-series in peer-reviewed publications demonstrating the long-term efficacy of surgical treatment. Three large studies revealed mortality reduction compared to medically treated cohorts (1-3), yet the published algorithm in your Guidelines doesn’t even mention a surgical treatment option! Your “Editors* Notes”, boldy displayed in “Meta-analysis: surgical treatment of obesity” (rather than on an editorial page), directly contradicts the preponderance of evidence regarding “..effectiveness of surgical therapy in the treatment of obesity..”. One meta-analysis4 and several “evidence-based” reports [stman J et al.(5), Sauerland S et al.(6), Clegg et al.(7), including the Meta-Analysis by Maggard et al. presented in this very issue of Annals], although flawed, concur with the 1991 National Institutes of Health Consensus panel (9) affirming the effectiveness and safety of surgery for obesity. Evidence based medicine criteria for assessment of strength of evidence mandating randomized controlled or cohort studies, are inappropriate for evaluating invasive treatments such as operations which have robust physiological and behavioral effects, are difficult to reverse and may have more serious and variable side-effects than the drug studies for which the criteria were developed. Ample data reveal the effect of surgeons’ case volumes on outcome in most types of operations, including anti-obesity surgery.(3,9) The American Society for Bariatric Surgery, recognizing an increasing number of adverse outcomes in step with the increasing demand for this surgery, has created a bariatric surgery accreditation program to assure physicians and patients alike that a high quality of care is being provided. Severe obesity is extremely difficult to manage in primary care. However, overly restrictive, incomplete treatment guidelines, such as those just published, are a disservice to all parties. Harvey J. Sugerman, MD President American Society for Bariatric Surgery Emeritus Professor of Surgery Virginia Commonwealth University Richmond, Virginia hsugerman@comcast.net John G. Kral, MD, PhD Professor of Surgery and Medicine SUNY Downstate Medical Center Brooklyn, New York References 1.MacDonald KG, Jr., Long SD, Swanson MS, Brown BM, Morris P, Dohm GL, Pories WJ. The gastric bypass operation reduces the progression and mortality of non-insulin dependent diabetes mellitus. J Gastrointest Surg 1997; 1:213-20. [PMID: 9834350] 2.Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long -term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg 2004;240:416-23; discussion 423-4. [PMID: 15319713] 3.Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: A population-based analysis. J Am Coll Surg 2004; 199:543-51. [PMID: 15454136] 4.Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery. A systemic review and meta-analysis. JAMA 2004; 292:1724-37. [PMID: 15479938] 5.*stman J, Britton M, Jonson E. Treating and preventing obesity: an evidence based review. WILEY-CVH verlag GmbH & Co Kga A, Weinhem, 2004. 6.Sauerland S, Angrisani L, Belachew M, Chevallier JM, Favretti F, Finer N, et al. Obesity surgery: evidence-based guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc 2004; Dec 2; [Epub ahead of print].[PMID 15580436] 7.Clegg A, Colquitt J, Sidhu M, Royle P, Walker A. Clinical and cost effectiveness of surgery for morbid obesity: a systematic review and economic evaluation. Int J Obes Relat Metab Disord 2003; 27:1167-77. [PMID:14513064] 8.NIH Conference: Gastrointestinal surgery for severe obesity: Consensus Development Conference Panel. Ann Intern Med 1991; 115:956-61. [PMID: 1952493] 9.Courcoulas A, Schuchert M, Gatti G, Luketich J. The relationship of surgeon and hospital volume to outcome after gastric bypass surgery in Pennsylvania: a 3-year summary. Surgery 2003; 134:613-21. [PMID: 14605622] Conflict of Interest:President, American Society for Bariatric Surgery |
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