Medical Matters: Suspension of surgery for obesity the worst type of HSE ‘slash and burn’ care

‘They have delivered a death sentence to my patients. They are playing with people’s lives.” It’s not often you will hear a hospital consultant utter words such as these.

Yet this was the reported response of Dr Donal O’Shea, consultant endocrinologist and obesity expert, last week when he learned by email that St Vincent’s hospital in Dublin had suspended bariatric (obesity) surgery for morbidly obese patients for the rest of the year.

There are two basic approaches to obesity surgery: restrictive operations aimed at reducing food intake; and malabsorptive surgery, which aims to reduce the capacity of the stomach and intestine to absorb nutrients from food.

For those who are morbidly obese, with a body mass index (BMI) greater than 40, gastric bypass surgery can literally be a lifesaver.

The sudden axing of the surgical programme at St Vincent’s hospital in Dublin – one of just two locations in the Republic that delivers this service to public patients, the other being University Hospital Galway – was announced in the same week that the results of the longest study to date comparing bariatric surgery with usual care in obese patients with diabetes were published.

Some 15 years after undergoing bariatric surgery, 30 per cent of patients in the study no longer had diabetes, but only 7 per cent of patients who received the usual care were in diabetes remission.

The Swedish Obese Subjects study enrolled 4,047 obese patients in Sweden between 1987 and 2001. Researchers analysed those who had diabetes at the beginning of the study: 260 patients then received the usual medical care and 343 patients underwent bariatric surgery. Patients had an average age of 50, a BMI of about 41 and had had diabetes for three years.

Complications

Of particular interest was the tracking of those in the study to look for complications of diabetes for an average of 17 years.

The researchers from Sahlgrenska University hospital in Gothenburg found significant reductions in what are termed microvascular complications affecting the eyes, kidneys and peripheral nerves. And macrovascular complications that cause stroke, heart attack and peripheral artery disease were also reduced in those who had bariatric surgery.

Published in the Journal of the American Medical Association, an accompanying editorial had this to say about the research: "Obese diabetics whose diabetes was of shorter duration or who had the greatest weight loss between the time of surgery and two years [later] were the most likely to have a sustained remission at 15 years.

“These patients likely had bariatric surgery before the failure of the insulin-producing cells of the pancreas was irreversible.”

While most of those operated on had a gastric bypass operation, others in the study had more old-fashioned procedures, leading the editorial writer to conclude that “additional follow-up of newer studies is required to answer the question of which bariatric procedure is best for inducing long-term remission of diabetes”.

Prior to the publication of the latest research, 13 smaller studies comparing surgery with medical treatment for both diabetes [and obesity] showed surgery to be superior to medical treatment. In some cases, patients’ insulin requirements drop off dramatically within hours of the surgery, leading to speculation that bariatric surgery rapidly induces some form of hormonal response in the body. There is evidence that gastric bypass operations reduce levels of gut hormones such as ghrelin and that sensitivity to insulin increases post-op.

What is no longer in doubt is how, in carefully chosen patients, bariatric surgery can resolve diabetes and move them from a situation where their multimorbidity is life-threatening to one where their longevity and quality of life is improved immeasurably.

And, as some 800 morbidly obese Irish people require surgery every year, the unilateral abrupt decision to stop funding at St Vincent’s is indefensible. It represents the worst kind of “slash and burn” healthcare rationing by an uncaring HSE, and must be reversed.

mhouston@irishtimes.com muirishouston.com