Common use of Bariatric Surgery Clause in Contracts

Bariatric Surgery. Surgical procedures to treat obesity have been performed since the 1950s265 and include truncal vagotomy266, jaw wiring267, intragastric balloons and liposuction. Bariatric (weight loss) surgery can be divided into purely restrictive procedures (vertical banded gastroplasty [VBG], laparoscopic adjustable silicone gastric banding [LASBG]) and combined restrictive and malabsorptive procedures (Roux-en-Y gastric bypass [GBP], biliopancreatic diversion [BPD])57,268. The latter induce larger weight losses and, hence, greater improvements in hy- pertension, dyslipidaemia, glucose metabolism and hyperinsulinaemia as compared to the purely restrictive techniques50,56. However, they are irreversible, sometimes leading to greater weight losses than necessary and also to nutritional deficiencies. Patients have to take vitamin supplements for the rest of their lives. LASBG is the most popular form of bariatric surgery in the Netherlands (and the rest of Europe), because it can be performed laparoscopic and therefore has fewer perioperative complications and it is reversible. In addition, some influ- ence as to the amount of food intake can be exerted via inflation/deflation of the saline-filled gastric ring57,268. This procedure also has disadvantages however, an estimated 7-17% of the patients has to be re-operated because of band erosion, dislocation or leakage or because of esophageal dilatation269,270. Bariatric surgery can induce large weight losses (20-50% of body weight) with a higher likelihood of maintaining weight loss (especially the combined restrictive and malabsorptive procedures) as compared to other weight loss interventions55,271. The Swedish Obese Subjects (SOS) study showed that surgically-treated obese subjects had about 25% percent greater weight loss at 10 years follow-up, along with a greater number of persons who no longer had diabetes (if present), hypertriglyceridaemia, low HDL-cholesterol concentrations, hypertension and hyperurikaemia as compared with conventionally treated obese subjects. The surgery group also had lower 2- and 10-year incidence rates of diabetes and hypertriglyceridaemia, but not hypercholesterolaemia43. Others have reported similar beneficial metabolic effects of bariatric surgery. Bariatric surgery has also been performed in patients with type 2 diabetes. Although in some studies the number of patients with diabetes were small52,55, the impressive results found were confirmed in larger studies51,53. A recent meta-analysis by ▇▇▇▇▇▇▇▇ et al. showed that 1417 out of 1846 patients (76.8%) completely recovered from their diabetes following bariatric surgery (in the studies that mentioned complete resolution). The mean reduction in BMI was 14 kg/m2 and a graded response with respect to diabetes resolution was noted with the greatest effect with BPD, whereas gastric banding was the least effective56. A recently published, retrospective chart review of 312 obese patients with type 2 diabetes that under- went biliopancreatic surgery (gastric bypass with biliopancreatic diversion), showed that the beneficial effects on glucose metabolism, dyslipidaemia and hypertension were maintained in most patients even after 10 years follow-up53. With respect to the underlying metabolic processes leading to the improvement in glucose metabolism following bariatric surgery, studies in morbidly obese patients have shown an improvement in insulin-stimulated glucose disposal, as assessed with the hyperinsulinaemic euglycaemic clamp technique47,50,272,273. Data on endogenous glucose production and whole- body lipolysis are not available. Moreover, in obese type 2 diabetic patients no studies using either of these sophisticated techniques have been performed to date.