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Obesity and the role of bariatric surgery in its management

Obesity is one of the most important public health issues facing Australia in the 21st century. It has proved difficult to prevent and according to the latest Australian Health Survey, 28.3% of Australians are now obese, up from 19% in 1995. Lifestyle interventions can be effective in the short term, however, are not really sustainable in the long term1,2. However, for those with severe obesity (BMI > 35kg/m2) there are several Randomised Controlled Trials (RCT)3-6 and multiple case series7 which suggest that Bariatric Surgery provides more predictable and sustainable weight loss than conservative regimes, and is generally very safe8,9.

Bariatric surgery is burgeoning in Australia. In 2014 there were expected to be more than 12,000 such procedures performed at a direct cost of $200 million. However there are no evidence based guidelines directing who should be offered this surgery, nor is there any long-term community data documenting the efficacy and safety of the procedures in Australia.

Recognising this need, a pilot Bariatric Surgery Registry (BSR) was established in 2009 with the support of Obesity Surgery Society of Australia and New Zealand (OSSANZ). The Bariatric Surgery Registry has the primary aim of measuring quality and safety. The Registry tracks the performance of hospitals, surgeons and devices.

The ability to track all persons undergoing bariatric procedures longitudinally offers an unprecedented opportunity to:

  1. Confirm the outcomes from clinical trials on bariatric surgery at a community level
  2. Measure the change in diabetes status over time in this population
  3. Translate these efficacy and health outcomes into practice guidelines
  4. Utilise the Registry as a resource for future research projects

Establishment of the bariatric surgery clinical quality registry

The primary aim of the Registry is to measure outcomes for patients undergoing bariatric surgery across surgical practices in Australia. It is predominantly a quality and safety registry.

The BSR has the support of the Obesity Surgery Society of Australia & New Zealand (OSSANZ) and the Royal Australasian College of Surgeons (RACS), who regards the registry establishment as an important step forward in monitoring and evaluating patient outcomes across Australia. The BSR is predominantly funded by the Commonwealth government.

The Registry collects information on patient weight loss, change in diabetes status and problems related to the surgery, both in the short and long term.

Data collection techniques and processes have been established and evaluated using a 2 year pilot study. Data collection has now been expanded to have national coverage.

Data collection will be standardised and of high quality. Outcomes will be risk adjusted to take into effect important factors not within the control of the treating surgeon, and data will be fed to stakeholders in an appropriate and timely manner to drive quality improvement.

This project is unique and important. It will provide us with an unprecedented tool for quality assurance. The outcomes of the Registry will provide hospitals, device manufacturers, government bodies and insurers with a greater understanding of the outcomes of bariatric surgery patients. It will provide a valuable resource to better understand and reduce factors associated with sub-optimal outcomes and improve surgical practices.

The stated aims of the Registry are to:

  1. Record the immediate safety of bariatric surgery in Australia
    • Surgical safety
    • Surgical quality
  2. Study longitudinally the safety and efficacy of bariatric surgery in Australia
    • Procedure
    • Devices
    • Complications
    • Re-operations
  3. Track key health changes following bariatric surgery in Australia
    • Weight change
    • Diabetes treatment

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References

  1. Wadden TA, Neiberg RH, Wing RR, et al. Four-year weight losses in the Look AHEAD study:
    factors associated with long-term success. Obesity 2011;19:1987-98.
  2. Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr 2005;82:222S-5S.
  3. Dixon J, O'Brien P, Playfair J, et al. Adjustable gastric banding and conventional therapy for
    type 2 diabetes: a randomized controlled trial. Jama 2008;299:316-23.
  4. Dixon JB, Schachter LM, O'Brien PE, et al. Surgical vs conventional therapy for weight loss
    treatment of obstructive sleep apnea: a randomized controlled trial. JAMA 2012;308:1142-9.
  5. O'Brien PE, Dixon JB, Laurie C, et al. Treatment of mild to moderate obesity with
    laparoscopic adjustable gastric banding or an intensive medical program: a randomized trial. Ann
    Intern Med 2006;144:625-33.
  6. O'Brien PE, Sawyer SM, Laurie C, et al. Laparoscopic adjustable gastric banding in severely
    obese adolescents: a randomized trial. JAMA 2010;303:519-26.
  7. Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery for obesity (Review). Cochrane Review
    2009.
  8. Flum D, Belle S, King W, et al. Perioperative safety in the longitudinal assessment of bariatric
    surgery. New England Journal of Medicine, The 2009;361:445-54.
  9. Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons
    Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness
    positioned between the band and the bypass. Ann Surg 2011;254:410-20.