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Bariatric Surgery—More Than Just an Operation

Bariatric Surgery—More Than Just an Operation Bariatric surgery is the most effective treatment of morbid obesity with a proven survival benefit.1,2 To view bariatric surgery as simply a weight loss procedure is misguided and can lead to inappropriate expectations and potentially dangerous consequences. The preoperative approval process is rigorous and, unfortunately, not fully evidence based. Payers have set forth many requirements without significant attention to the perceived benefits or risks of delayed treatment. These requirements may include participation in supervised weight loss; medical clearance through cardiac, pulmonary, and general medical testing; a sleep study; and a mental health evaluation to assess treatment of existing psychiatric diagnoses or to diagnose new mental health conditions. The 1991 National Institutes of Health Consensus Development Conference on Gastrointestinal Surgery for Severe Obesity3 established the mental health evaluation requirement. The American Society for Metabolic and Bariatric Surgery explains that its purpose is to “identify psychosocial risk factors and make recommendations to both the client and surgical group that are aimed at facilitating the best possible outcome for the patient.”4(p1) The mental health piece of this assessment remains difficult to standardize with common categories of assessment, including behavioral, cognitive or emotional, developmental, motivation, and expectations. Nonetheless, regardless of the type of surgery our patients undergo, there is an increasing appreciation of the cumulative effect of psychiatric disorders that influence long-term outcomes.5 In this issue of JAMA Surgery, Bhatti and colleagues6 present an intriguing self-matched longitudinal study assessing the risk of self-harm emergencies in patients who have undergone bariatric surgery. The study has excellent follow-up, with all patients having 3 years of preoperative and postoperative data. Instead of using case-matched controls, this study design helps alleviate concerns that surgical and nonsurgical obese patients may have different mental health characteristics and long-term outcomes. The study has 2 important findings. First, the preoperative incidence of self-harm emergencies in patients undergoing bariatric surgery is twice the population average and increases by an additional 50% in the postoperative period. The identification of patients with an increased risk of such adverse outcomes remains an elusive goal. Currently, there are multiple screening tools and surveillance recommendations based mostly on expert opinion. There remains significant room for improvement through adequately powered and controlled prospective trials to identify ideal screening tools, protocols, and follow-up. Second, most self-harm emergencies occur in the second and third postoperative years. There is currently no minimum standard for psychological follow-up. Although stringent criteria are in place for insurance and programmatic approval to undergo surgery, the postoperative follow-up rates in general have been poor. Furthermore, most programs focus on the first postoperative year when most weight loss occurs. However, this study provides data to support the call for long-term follow-up in bariatric surgery, especially for patients with a history of major depressive disorder and/or self-harm. The study by Bhatti and colleagues6 underscores the unique vulnerability of patients undergoing bariatric surgery and forces us to look closely at why suicide rates are more than 4 times higher in these patients than the general population.7 Bariatric surgery is more than just an operation—it is time we recognize and treat it as such. Back to top Article Information Corresponding Author: Amir A. Ghaferi, MD, MS, University of Michigan Center for Healthcare Outcomes and Policy, University of Michigan, 2800 Plymouth Rd, North Campus Research Complex B016, Room 167-C, Ann Arbor, MI 48109 (aghaferi@umich.edu). Published Online: October 7, 2015. doi:10.1001/jamasurg.2015.3396. Conflict of Interest Disclosures: Dr Ghaferi reported receiving salary support from Blue Cross Blue Shield of Michigan as the director of the Michigan Bariatric Surgery Collaborative. No other disclosures were reported. References 1. Arterburn DE, Olsen MK, Smith VA, et al. Association between bariatric surgery and long-term survival. JAMA. 2015;313(1):62-70.PubMedGoogle ScholarCrossref 2. Adams TD, Davidson LE, Litwin SE, et al. Health benefits of gastric bypass surgery after 6 years. JAMA. 2012;308(11):1122-1131.PubMedGoogle ScholarCrossref 3. Consensus Development Conference Panel. Gastrointestinal surgery for severe obesity. Ann Intern Med. 1991;115(12):956-961.PubMedGoogle ScholarCrossref 4. Pre-Surgical Psychological Assessment. 2004 . https://asmbs.org/resources/pre-surgical-psychological-assessment. Accessed July 22, 2015. 5. Rutledge T, Groesz LM, Savu M. Psychiatric factors and weight loss patterns following gastric bypass surgery in a veteran population. Obes Surg. 2011;21(1):29-35.PubMedGoogle ScholarCrossref 6. Bhatti JA, Nathens AB, Thiruchelvam D, Grantcharov T, Goldstein BI, Redelmeier DA. Self-harm emergencies after bariatric surgery: a population-based cohort study. JAMA Surg. doi:10.1001/jamasurg.2015.3414.Google Scholar 7. Peterhänsel C, Petroff D, Klinitzke G, Kersting A, Wagner B. Risk of completed suicide after bariatric surgery: a systematic review. Obes Rev. 2013;14(5):369-382.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

Bariatric Surgery—More Than Just an Operation

JAMA Surgery , Volume 151 (3) – Mar 1, 2016

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Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
2168-6254
eISSN
2168-6262
DOI
10.1001/jamasurg.2015.3396
Publisher site
See Article on Publisher Site

Abstract

Bariatric surgery is the most effective treatment of morbid obesity with a proven survival benefit.1,2 To view bariatric surgery as simply a weight loss procedure is misguided and can lead to inappropriate expectations and potentially dangerous consequences. The preoperative approval process is rigorous and, unfortunately, not fully evidence based. Payers have set forth many requirements without significant attention to the perceived benefits or risks of delayed treatment. These requirements may include participation in supervised weight loss; medical clearance through cardiac, pulmonary, and general medical testing; a sleep study; and a mental health evaluation to assess treatment of existing psychiatric diagnoses or to diagnose new mental health conditions. The 1991 National Institutes of Health Consensus Development Conference on Gastrointestinal Surgery for Severe Obesity3 established the mental health evaluation requirement. The American Society for Metabolic and Bariatric Surgery explains that its purpose is to “identify psychosocial risk factors and make recommendations to both the client and surgical group that are aimed at facilitating the best possible outcome for the patient.”4(p1) The mental health piece of this assessment remains difficult to standardize with common categories of assessment, including behavioral, cognitive or emotional, developmental, motivation, and expectations. Nonetheless, regardless of the type of surgery our patients undergo, there is an increasing appreciation of the cumulative effect of psychiatric disorders that influence long-term outcomes.5 In this issue of JAMA Surgery, Bhatti and colleagues6 present an intriguing self-matched longitudinal study assessing the risk of self-harm emergencies in patients who have undergone bariatric surgery. The study has excellent follow-up, with all patients having 3 years of preoperative and postoperative data. Instead of using case-matched controls, this study design helps alleviate concerns that surgical and nonsurgical obese patients may have different mental health characteristics and long-term outcomes. The study has 2 important findings. First, the preoperative incidence of self-harm emergencies in patients undergoing bariatric surgery is twice the population average and increases by an additional 50% in the postoperative period. The identification of patients with an increased risk of such adverse outcomes remains an elusive goal. Currently, there are multiple screening tools and surveillance recommendations based mostly on expert opinion. There remains significant room for improvement through adequately powered and controlled prospective trials to identify ideal screening tools, protocols, and follow-up. Second, most self-harm emergencies occur in the second and third postoperative years. There is currently no minimum standard for psychological follow-up. Although stringent criteria are in place for insurance and programmatic approval to undergo surgery, the postoperative follow-up rates in general have been poor. Furthermore, most programs focus on the first postoperative year when most weight loss occurs. However, this study provides data to support the call for long-term follow-up in bariatric surgery, especially for patients with a history of major depressive disorder and/or self-harm. The study by Bhatti and colleagues6 underscores the unique vulnerability of patients undergoing bariatric surgery and forces us to look closely at why suicide rates are more than 4 times higher in these patients than the general population.7 Bariatric surgery is more than just an operation—it is time we recognize and treat it as such. Back to top Article Information Corresponding Author: Amir A. Ghaferi, MD, MS, University of Michigan Center for Healthcare Outcomes and Policy, University of Michigan, 2800 Plymouth Rd, North Campus Research Complex B016, Room 167-C, Ann Arbor, MI 48109 (aghaferi@umich.edu). Published Online: October 7, 2015. doi:10.1001/jamasurg.2015.3396. Conflict of Interest Disclosures: Dr Ghaferi reported receiving salary support from Blue Cross Blue Shield of Michigan as the director of the Michigan Bariatric Surgery Collaborative. No other disclosures were reported. References 1. Arterburn DE, Olsen MK, Smith VA, et al. Association between bariatric surgery and long-term survival. JAMA. 2015;313(1):62-70.PubMedGoogle ScholarCrossref 2. Adams TD, Davidson LE, Litwin SE, et al. Health benefits of gastric bypass surgery after 6 years. JAMA. 2012;308(11):1122-1131.PubMedGoogle ScholarCrossref 3. Consensus Development Conference Panel. Gastrointestinal surgery for severe obesity. Ann Intern Med. 1991;115(12):956-961.PubMedGoogle ScholarCrossref 4. Pre-Surgical Psychological Assessment. 2004 . https://asmbs.org/resources/pre-surgical-psychological-assessment. Accessed July 22, 2015. 5. Rutledge T, Groesz LM, Savu M. Psychiatric factors and weight loss patterns following gastric bypass surgery in a veteran population. Obes Surg. 2011;21(1):29-35.PubMedGoogle ScholarCrossref 6. Bhatti JA, Nathens AB, Thiruchelvam D, Grantcharov T, Goldstein BI, Redelmeier DA. Self-harm emergencies after bariatric surgery: a population-based cohort study. JAMA Surg. doi:10.1001/jamasurg.2015.3414.Google Scholar 7. Peterhänsel C, Petroff D, Klinitzke G, Kersting A, Wagner B. Risk of completed suicide after bariatric surgery: a systematic review. Obes Rev. 2013;14(5):369-382.PubMedGoogle ScholarCrossref

Journal

JAMA SurgeryAmerican Medical Association

Published: Mar 1, 2016

Keywords: emergencies,follow-up,mental health services,obesity, morbid,postoperative care,postoperative period,preoperative care,self-injurious behavior,incidence,preoperative medical evaluation,psychiatric evaluation,psychiatric emergencies,bariatric surgery

References

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