Bariatric Surgery in Australasia

The overwhelming obesity epidemic being faced by Health Care providers in Australasia is being met with the effective treatment that is Bariatric Surgery. In Australia nearly 60% of adults are overweight or obese – an increase of 250% since 1980. Bariatric surgery, also known as weight loss surgery, refers to the various surgical procedures performed to treat obesity by modification of the gastrointestinal tract to reduce nutrient intake and/or absorption. The term does not include procedures for surgical removal of body fat such as liposuction or abdominoplasty.

Far from a new concept, surgery for morbid obesity in one form or another has been performed for decades with varying degrees of success and complication. Procedures used in Bariatric surgery fall into three main categories and range from placing an inflatable plastic band around the first part of the stomach using keyhole surgery (Lap Banding) to cutting the stomach in two pieces and using a loop of the small intestine to help bypass the digestive juices in an open procedure. Current approaches generally either take the form of:

• Restrictive Procedures – where the size of the stomach (the storage pouch for meals) is reduced to give early feeling of satiety(or fullness). In Australia the majority of restrictive procedures involve Adjustable Laparoscopic Gastric Banding rather than Vertical Banded Gastroplasty [stomach stapling]. There are more than 8 band designs but in Australia the SAGB and Lap-Band® are the most commonly used.
  • Swedish Adjustable Band (SAGB) [Johnson&Johnson Medical P/L]
  • Lap-Band® System [Allergan Inc]
  • Watch a video of Adjustable Laparoscopic Gastric Banding
• Malabsorptive Procedures – where food and digestive juices are not allowed to mix in the usual way in an attempt to decrease the amount of energy absorbed from a meal. Biliopancreatic diversion or Jejunoileal bypass
• Mixed Procedure - combines both procedures simultaneously as Gastric Bypass Surgery [Roux-En-Y bypass] or the newer [Sleeve (tube) gastrectomy]

Swedish Adjustable Gastric Band (SAGB)

Lap-Band® System

Laparoscopic gastric banding surgery was first introduced to Australia in 1994. Since then, it has become the most widely used weight control surgery in the country. In 2008 alone, more than 12,000 laparoscopic gastric banding procedures were performed in Australia. However Gastric Bypass Surgery is the most commonly performed operation for weight loss in the United States.

There is no doubting the effectiveness of these procedures with reports of weight loss in the range of 50-60% of excess weight being lost in the first 1-2 year period and accompanied by this a reversal of metabolic type diseases such as diabetes and high blood pressure. Unfortunately all surgical procedures carry a risk and whilst most Bariatric Surgeons and patients are accepting of this risk, it can be difficult for patients to ascertain just how much experience the surgeon performing the procedure has.

Bariatric Surgery Training

Learning any task takes time and practice, and this is perhaps the most evident in the field of Surgery. Most surgical training programs have a duration of 4 to 5 years and take doctors from the post internship period to Fellowship. During this time they learn to perform the procedures they will be doing for the rest of their career. Traditionally in medicine it was thought that the ‘see one, do one, teach one’ dictum was sufficient. This may well be the case for simple procedures, however as expectations rise and operative complexity increases – training has been forced to adapt (somewhat sluggishly). Now, before performing a procedure on a patient solo, the trainee has often seen the procedure a hundred times; performed individual parts of the procedure under strict supervision just as many times, and finally… ‘graduated’ to perform the procedure on their own. It is no great surprise to learn that it takes a few attempts to get a procedure perfect, but where does this practice occur, and who does it occur on? This is one of the harrowing questions being posed to the world of Bariatric Surgery.

The Royal Australasian College of Surgeons (RACS) is responsible for maintaining standards for surgeons in Australia and their subspecialty colleges oversee training and supervision of doctors seeking to gain fellowship to the college. There is currently no college for Bariatric surgeons in Australia, so unlike Orthopaedic Surgeons who have acquired the skills needed to satisfy college requirements, Bariatric Surgeons are essentially self proclaimed and self regulated. This is not to say that they have not had enough training to perform a particular procedure, but that there is no formal body at present to check that they have, and more importantly to see that their work matched up to industry standards. The Obesity Surgery Society of Australia and New Zealand [OSSANZ] has been formed to encourage research, education and communication into bariatric surgery in Australasia.

In the USA, the American Society for Metabolic and Bariatric Surgery [ASMBS] developed in 2006 a curriculum of both skills and knowledge required for Bariatric surgeons. This encompasses the nature of the disease of morbid obesity, the operations to treat it and the complications and aftercare of these operations. They recommend that trainees are able to perform more than one type of bariatric surgery – this is defined as being the principal operating surgeon in at least 50 of 100 bariatric surgery cases. They also stipulate that as the type of operations in which the bowel is cut and or rejoined are more complicated then the workload as described above should have at least 50 of these cases in it. As a result of these guidelines, American Centres now offer training programs which enable trainees to meet the above requirements and be awarded Fellowship of their College. As previously mentioned, there is no formal training program for bariatrics in Australia and whilst some general surgical trainees will be exposed to bariatric surgery as part of their fellowship and some groups eg, Circle of Care, Monash University are offering courses ranging from 6 weeks to a year to give Surgeons a formal Bariatric Fellowship, it is still unclear exactly what allows a surgeon to offer bariatric services.

The startling reality of all of this for the consumer who is considering bariatric surgery is that the onus really is on them to make sure that their surgeon has had adequate training in the area and until the surgical college takes this task on, the questions will have to be asked by the patient themselves. So what do you ask a surgeon who is offering you bariatric or weight loss surgery?

1. Have you had any formal fellowship or post-fellowship training in Bariatric Surgery?
2. How many of the procedures have you performed as the chief operating surgeon?
3. Which procedures do you perform and why?
4. What are the possible complications of the surgery you offer and what are your rates of complication?

Simply asking these questions will give you much more information upon which to make your decision regarding what type of surgery to have and which surgeon you should choose. It will enable you to find out whether your surgeon has completed a fellowship in surgery, taken some special training in the field of bariatrics either in Australasia or abroad and importantly find out whether you will be patient 1 or 1001 on their books! It will also enable you to compare between surgeons with regard to complication rates as all surgeons are responsible for auditing their own work to see that their rates match up to industry standard.