NCEPOD Launch Too Lean a Service? London, October 2012 A review of - PowerPoint PPT Presentation

NCEPOD Launch Too Lean a Service? London, October 2012 A review of patients who underwent bariatric surgery David Kerrigan Medical Director & Consultant Surgeon Phoenix Health

Some numbers Cost of obesity to the UK £7.9 Billion 1 Predicted cost by 2050 £50 Billion 1 House of Commons Library, Statistics on Obesity Briefing Paper April 2011

Prevention is better than cure

Prevention is cheaper than cure

Prevention doesn ’ t help the one million people who already have BMI >40

Bariatric Surgery in a High Volume Unit Liverpool Audit 2007-2010 30 Day Mortality 1 death/ 1,334 ops = 0.07%

Fact ? Bariatric surgery is not dangerous

Deaths NCEPOD report

Deaths • No deaths reported in 397 patients • Almost half patients surveyed had gastric banding

Deaths RC Histopatholgists Audit n=29 • A third of deaths (10/29) due to anastomotic leak • 10% from bleeding

NCEPOD Hospital Volume • Almost half of hospitals carrying out gastric banding do < 10 per year • Main results is a lack of experience in out-patient care • Poor weight loss • Late recognition remediable complications

NCEPOD Hospital Volume • 50% bypasses done in high volume units (>40/yr) • 25% bypasses in units doing <10/yr

Hospital Infrastructure • 23% (14/62) private hospitals fall outside new IHAS critical care guidance (level 1 only) • Almost 10% (10/105) hospitals did not offer follow-up clinics

Critical Care • 97% of patients do NOT require unexpected critical care admission

Unplanned Readmissions

Gastric Balloon 60% of all balloon patients are readmitted within 6 months • Presumably not to have planned removal! • Early vomiting very common

Gastric Band A Safe Operation ? 18% of bands require readmission Half of band readmissions (9% of all band patients) require reoperation

Gastric Band A Safe Operation ? • Most reoperations (60%) for minor port problems • But 3.5% of all bands require early reoperation for more serious complications

Gastric Bypass • 25% of readmissions for symptoms suggestive of stomal ulcer/stricture • A third of bypass readmissions required surgery

Audit • Although only 57% entered on to NBSR…… • 81% entered on to some audit/data registry

Surgery on low BMI patients (BMI 30-35) • Balanced view taken regarding application NICE guidelines

Medical vs Surgical Treatment BMI 30-35 Randomised Trial Intensive Medical Bariatric Treatment Surgery vs Orlistat Gastric banding + VLCD (Optifast) + Behavioural Therapy

Medical vs Surgical Treatment BMI 30-35 Results after 2 years O ’ Brien P, Dixon J et al; Ann Int Med 2006 Surgery Medical vs 68% 18% excess weight lost excess weight lost

Conclusions • Well written, balanced report • Full of good suggestions for best practice (although a few recommendations a bit overly dogmatic)

Conclusions • Overall standard of bariatric surgery in UK appears to be high • Need to address low volume, poorly delivered services • Need further study to investigate relationship between volume and outcome