Annals of the Royal College of Surgeons of England (1991) vol. 73, 36-38
Obesity surgery in the United Kingdom: survey of 970 general surgeons Eoghan R T C Owen
FRCS FRCSEd Surgical Registrar and Clinical Research Fellow
Melanie K Cooper
Allan E Kark
FRCS FACS Consultant Surgeon
RGN
Research Staff Nurse
MRC Clinical Research Centre, Northwick Park Hospital, Harrow, Middlesex
Key words: Morbid obesity,
surgery, survey
The results of a questionnaire survey on obesity surgery sent general surgeons working in the United Kingdom National Health Service are presented. The response rate was 37%. There were 38 surgeons actively practising this surgery. The majority were performing a gastric procedure, mostly gastroplasty, but some did gastric bypass or banding. Three were doing the biliopancreatic bypass. Most surgeons were doing less than 10 operations a year. A total of 109 expressed an interest in attending a UK symposium and 59 would participate in a UK Bariatric Register. This practice, though only a small part of UK surgery, is larger than expected. to 970 consultant
The surgical treatment of morbid obesity has developed into a subspecialty of general surgery and is known in the USA as bariatric surgery. There is no information on the prevalence of this surgery in the UK and the following survey was undertaken to establish this and identify those surgeons who would be interested in participating in a UK symposium, forming a national association, and setting up a national register.
Material and methods A short, two-page questionnaire consisting of 15 questions and accompanied by a covering letter and reply paid envelope, was sent to 970 surgeons practising as NHS consultants in general surgery. The questions were easily answered by simply encircling a response and a request was made to return the form even if not completed. A Correspondence to: Mr E R T C Owen, 44c Herga Court, Sudbury Hill, Harrow on the Hill, Middlesex HAI 3RT
period of 3 months returned.
was
allowed for all forms
to
be
Results A total of 362 (37%) questionnaires were returned. Fifty were not completed; a small number because the surgeon had retired or the respondent was in a specialty other than general surgery. Most of the respondents (272) had never undertaken a bariatric procedure (Table I) but 90 (25%) had done so at some time. Fifty-two of 90 (57%) had given up this practice (Table II). Thirty-eight
Table I. Some reasons for not doing bariatric surgery No time-already over committed Not justified on NHS
Too expensive Not interested Surgery inappropriate for a psychiatric problem Needs specialist centre Not trained or experienced enough Too old to start No demand for it Poor results Does not work
Table II. Reasons for giving up bariatric surgery Complications-metabolic/hepatic Difficult and dangerous Long-term benefits poor Bad use of resources No referrals Change of job/type of practice
Obesity surgery in the United Kingdom
50
37
has implications for surgical training and, with the decline oft gastric surgery for peptic ulcer and malignancy, it has been estimated that a general surgical resident in the USA is likely to obtain most of his training in gastric surgery with bariatric procedures (1). Obesity is the commonest form of malnutrition in the Western world and, presently, surgery is the only effective treatment for morbid obesity. It is likely that there wil be an increased demand for bariatric surgery in the UK over the next decade. Assuming that most surgeons interested in treating obesity were responders, this survey has demonstrated that a large number of UK surgeons (almost 10%) have practised such surgery at some stage. It would appear that because of the problems
40 30
20
S g/,/§z /g/ 1
relating to the jejunoileal bypass, many of these surgeons rzmmE W/zz/53 WzzzA/ >have abandoned their obesity practice rather than switch
1-5
6-10
11-30
3 1-50
>50
PROCEDURES ANNUALLY Figure 1. Bar cl bart of number of bariatric procedures per-
(numbersin formed annually surgeons). or on bars refer to actual number of surgeons).
boasedalonumberepls ofr
surgeons were still practising obesity surgery, and had been doing so for a mean of 8.6 years. Most surge(ons had referrals from consultant physicians (61%) anId general practitioners (53%), but 15% had some from ot;her sources, usually psychiatrists or oral surgeons. Of the 90 siurgeons who had some experience of this surgery, 56 (6,2%) had done the jejunoileal bypass and 42 (47%) had peirformed gastroplasty. The type of gastroplasty was specified by 13 surgeons; vertical banded (7), Silastic® ring vertical (3), and horizontal (3). Gastric banding had been done by 9 (10%) surgeons and gastric bypass also by 9. Three had done the biliopancreatic bypass. Forty-four (49%) did between one and five procedures annually. Only one did more than 30 procedures, and none did more than 50 (Fig. 1). In 46 (51%) of cases surgeons followed their patients indefinitely, whereas 10 (11%) did so for 2 years and seven (7.5%) for 5 years. Shared care with a physician was undertaken by 22 (24%) of surgeons, and two undertook no follow-up (Fig. 2). Of those surgeons who did not practise obesity surgery, 59 indicated they would consider it in the future. A total of 109 surgeons was interested in attending a UK symposium, and 59 would enter patient data into a
national bariatric register.
Discussion
procedure. Some of the reasons given by many surgeons for not performing or abandoning bariatric surgery (Tables I and II) highlight widespread prejudices and ignorance about obesity, its causes and therapy, yet many surgeons treat other diseases associated with abuse of such substances as achladtbco alcohol and tobacco. The need for some form of association or forum for surgeons in the UK interested in treating this disease is now apparent and will enable 'state of the art' therapy rather than the continuance of operations known to have poor long-term results (eg horizontal gastroplasty). A national bariatric register has been started in the USA (2). If the UK follows this lead, the results of all procedures will be scrutinised thoroughly, as will the effects of small changes in operative technique, which can have profound effects on the efficacy and complication rate of many of these operations. to another
z
0 U2
LI.
0
10
m//////m /////4M NO F.U
Bariatric surgery is widely practised in the developed world, particularly in the USA, Canada, Australia and Scandinavia. The American Society for Bariatric Surgery now has over 200 members, and the most frequent gastric operation in the USA is bariatric in nature. This
2YRS
//// M11A WE1101A -
5YRS
SHARED
INDEF
LENGTH OF FOLLOW UP F.U. = follow up; INDEF = indefinitely; YRS = years
Figure 2. Bar chart showing length of follow-up after bariatric operation (same format as Fig. 1).
38
ER TC Owen etal.
Although only small numbers of obesity operations are performed in the UK at present, a substantial number of surgeons are interested and it should be possible to form an association and national registry. The authors would like to thank Autosuture (UK) Ltd who generously supported this survey. Further information on the British Society of Obesity Surgery can be obtained from Mr Owen.
References I O'Leary JP. Promoting bariatric surgery. Lecture delivered to the 7th Annual Symposium on the Surgical Treatment of Obesity. Los Angeles, California, 1989. 2 Mason EE. The National Bariatric Surgery Registry. In: Deitel M ed. Surgery for the Morbidly Obese Patient. Philadelphia: Lea and Febiger, 1989:385-9.
Received 7 June 1990
Book review The Theory and Practice of Oncology by Ronald Raven. 366 pages, illustrated. The Parthenon Publishing Group, Carnforth, Lancs. 1990. £55. ISBN 1 85070 172 2 There must be few surgeons who do not know or know of Ronald Raven. The serious student or practitioner of oncology cannot escape him. So wide has been his influence, so fecund his writings, that for more than half a century he has grappled in what seems a heroic way with the problems of cancer. After a professional lifetime of achievement, the urge remains to further the cause. This volume is the latest, and it is hoped not the last, manifestation. The book is a compendium, a 'picking over' of the history, development and present principles of oncology. There is much here to whet the appetite. Virtually all aspects of the subject are covered, including chapters on voluntary cancer organisations, counselling services, education and training in oncology, as well as the more obvious topics such as classical oncological operations, chemotherapy, immunology and so on. There are twenty-two chapters in all. The style is terse, the references relevant, the illustrations fascinating and throughout the personality of the author can be discerned. Anyone interested in the subject of cancer should peruse this work, dip into and mull over it. In his preface the author states that "The task of searching, reading and abstracting the literature can be a full-time occupation for one person and really requires a team of experts." I am not sure that a team of experts could have produced this book. It requires the vision of one man and whilst the task is a daunting one, this is a brave effort. There are points at which one could cavil, for example the histopathological illustrations are, in the main, unhelpful, the index is incomplete in page references and the necessarily brief statements required to cover so vast a subject become almost banal unless taken in small doses.
There are numerous allusions to famous men of the past. We are informed, more than once, of the author's connection with a particular surgeon. Legendary names: William Ernest Miles ("the present author enjoyed his friendship for many years and was his junior colleague"); Sir Holburt Waring ("the present author was his House Surgeon at St Bartholomew's Hospital"); George Grey Turner ("the present author recalls watching him perform the operation [oesophagectomy] the 'pull-through' method at his clinic at Newcastle-upon-Tyne")-but no more is vouchsafed to us. Keynes, Gask and many others swam into his ken, but what were they like as men? How and what did they teach? How and under what conditions were the operations performed? To what surgical lengths were they prepared to go whilst reconciling morbidity and mortality with prognosis? Alas we are not told! The first page after the half-title is graced with the following from the Revelation of St John the Divine: Write all things which thou hasn't seen And the things which are And the things which shall be hereafter.
Perhaps should be added: Old men forget, yet all shall be forgot But he'll remember, with advantages, What feats he did that day.
It is to be hoped that Ronald Raven will write a further book and tell us more of the 'things which thou hasn't seen' and of what feats were done that day. J P BENNETT Consultant Plastic Surgeon Queen Victoria Hospital East Grinstead
Obesity surgery in the United Kingdom: survey of 970 general surgeons Eoghan R T C Owen
FRCS FRCSEd Surgical Registrar and Clinical Research Fellow
Melanie K Cooper
Allan E Kark
FRCS FACS Consultant Surgeon
RGN
Research Staff Nurse
MRC Clinical Research Centre, Northwick Park Hospital, Harrow, Middlesex
Key words: Morbid obesity,
surgery, survey
The results of a questionnaire survey on obesity surgery sent general surgeons working in the United Kingdom National Health Service are presented. The response rate was 37%. There were 38 surgeons actively practising this surgery. The majority were performing a gastric procedure, mostly gastroplasty, but some did gastric bypass or banding. Three were doing the biliopancreatic bypass. Most surgeons were doing less than 10 operations a year. A total of 109 expressed an interest in attending a UK symposium and 59 would participate in a UK Bariatric Register. This practice, though only a small part of UK surgery, is larger than expected. to 970 consultant
The surgical treatment of morbid obesity has developed into a subspecialty of general surgery and is known in the USA as bariatric surgery. There is no information on the prevalence of this surgery in the UK and the following survey was undertaken to establish this and identify those surgeons who would be interested in participating in a UK symposium, forming a national association, and setting up a national register.
Material and methods A short, two-page questionnaire consisting of 15 questions and accompanied by a covering letter and reply paid envelope, was sent to 970 surgeons practising as NHS consultants in general surgery. The questions were easily answered by simply encircling a response and a request was made to return the form even if not completed. A Correspondence to: Mr E R T C Owen, 44c Herga Court, Sudbury Hill, Harrow on the Hill, Middlesex HAI 3RT
period of 3 months returned.
was
allowed for all forms
to
be
Results A total of 362 (37%) questionnaires were returned. Fifty were not completed; a small number because the surgeon had retired or the respondent was in a specialty other than general surgery. Most of the respondents (272) had never undertaken a bariatric procedure (Table I) but 90 (25%) had done so at some time. Fifty-two of 90 (57%) had given up this practice (Table II). Thirty-eight
Table I. Some reasons for not doing bariatric surgery No time-already over committed Not justified on NHS
Too expensive Not interested Surgery inappropriate for a psychiatric problem Needs specialist centre Not trained or experienced enough Too old to start No demand for it Poor results Does not work
Table II. Reasons for giving up bariatric surgery Complications-metabolic/hepatic Difficult and dangerous Long-term benefits poor Bad use of resources No referrals Change of job/type of practice
Obesity surgery in the United Kingdom
50
37
has implications for surgical training and, with the decline oft gastric surgery for peptic ulcer and malignancy, it has been estimated that a general surgical resident in the USA is likely to obtain most of his training in gastric surgery with bariatric procedures (1). Obesity is the commonest form of malnutrition in the Western world and, presently, surgery is the only effective treatment for morbid obesity. It is likely that there wil be an increased demand for bariatric surgery in the UK over the next decade. Assuming that most surgeons interested in treating obesity were responders, this survey has demonstrated that a large number of UK surgeons (almost 10%) have practised such surgery at some stage. It would appear that because of the problems
40 30
20
S g/,/§z /g/ 1
relating to the jejunoileal bypass, many of these surgeons rzmmE W/zz/53 WzzzA/ >have abandoned their obesity practice rather than switch
1-5
6-10
11-30
3 1-50
>50
PROCEDURES ANNUALLY Figure 1. Bar cl bart of number of bariatric procedures per-
(numbersin formed annually surgeons). or on bars refer to actual number of surgeons).
boasedalonumberepls ofr
surgeons were still practising obesity surgery, and had been doing so for a mean of 8.6 years. Most surge(ons had referrals from consultant physicians (61%) anId general practitioners (53%), but 15% had some from ot;her sources, usually psychiatrists or oral surgeons. Of the 90 siurgeons who had some experience of this surgery, 56 (6,2%) had done the jejunoileal bypass and 42 (47%) had peirformed gastroplasty. The type of gastroplasty was specified by 13 surgeons; vertical banded (7), Silastic® ring vertical (3), and horizontal (3). Gastric banding had been done by 9 (10%) surgeons and gastric bypass also by 9. Three had done the biliopancreatic bypass. Forty-four (49%) did between one and five procedures annually. Only one did more than 30 procedures, and none did more than 50 (Fig. 1). In 46 (51%) of cases surgeons followed their patients indefinitely, whereas 10 (11%) did so for 2 years and seven (7.5%) for 5 years. Shared care with a physician was undertaken by 22 (24%) of surgeons, and two undertook no follow-up (Fig. 2). Of those surgeons who did not practise obesity surgery, 59 indicated they would consider it in the future. A total of 109 surgeons was interested in attending a UK symposium, and 59 would enter patient data into a
national bariatric register.
Discussion
procedure. Some of the reasons given by many surgeons for not performing or abandoning bariatric surgery (Tables I and II) highlight widespread prejudices and ignorance about obesity, its causes and therapy, yet many surgeons treat other diseases associated with abuse of such substances as achladtbco alcohol and tobacco. The need for some form of association or forum for surgeons in the UK interested in treating this disease is now apparent and will enable 'state of the art' therapy rather than the continuance of operations known to have poor long-term results (eg horizontal gastroplasty). A national bariatric register has been started in the USA (2). If the UK follows this lead, the results of all procedures will be scrutinised thoroughly, as will the effects of small changes in operative technique, which can have profound effects on the efficacy and complication rate of many of these operations. to another
z
0 U2
LI.
0
10
m//////m /////4M NO F.U
Bariatric surgery is widely practised in the developed world, particularly in the USA, Canada, Australia and Scandinavia. The American Society for Bariatric Surgery now has over 200 members, and the most frequent gastric operation in the USA is bariatric in nature. This
2YRS
//// M11A WE1101A -
5YRS
SHARED
INDEF
LENGTH OF FOLLOW UP F.U. = follow up; INDEF = indefinitely; YRS = years
Figure 2. Bar chart showing length of follow-up after bariatric operation (same format as Fig. 1).
38
ER TC Owen etal.
Although only small numbers of obesity operations are performed in the UK at present, a substantial number of surgeons are interested and it should be possible to form an association and national registry. The authors would like to thank Autosuture (UK) Ltd who generously supported this survey. Further information on the British Society of Obesity Surgery can be obtained from Mr Owen.
References I O'Leary JP. Promoting bariatric surgery. Lecture delivered to the 7th Annual Symposium on the Surgical Treatment of Obesity. Los Angeles, California, 1989. 2 Mason EE. The National Bariatric Surgery Registry. In: Deitel M ed. Surgery for the Morbidly Obese Patient. Philadelphia: Lea and Febiger, 1989:385-9.
Received 7 June 1990
Book review The Theory and Practice of Oncology by Ronald Raven. 366 pages, illustrated. The Parthenon Publishing Group, Carnforth, Lancs. 1990. £55. ISBN 1 85070 172 2 There must be few surgeons who do not know or know of Ronald Raven. The serious student or practitioner of oncology cannot escape him. So wide has been his influence, so fecund his writings, that for more than half a century he has grappled in what seems a heroic way with the problems of cancer. After a professional lifetime of achievement, the urge remains to further the cause. This volume is the latest, and it is hoped not the last, manifestation. The book is a compendium, a 'picking over' of the history, development and present principles of oncology. There is much here to whet the appetite. Virtually all aspects of the subject are covered, including chapters on voluntary cancer organisations, counselling services, education and training in oncology, as well as the more obvious topics such as classical oncological operations, chemotherapy, immunology and so on. There are twenty-two chapters in all. The style is terse, the references relevant, the illustrations fascinating and throughout the personality of the author can be discerned. Anyone interested in the subject of cancer should peruse this work, dip into and mull over it. In his preface the author states that "The task of searching, reading and abstracting the literature can be a full-time occupation for one person and really requires a team of experts." I am not sure that a team of experts could have produced this book. It requires the vision of one man and whilst the task is a daunting one, this is a brave effort. There are points at which one could cavil, for example the histopathological illustrations are, in the main, unhelpful, the index is incomplete in page references and the necessarily brief statements required to cover so vast a subject become almost banal unless taken in small doses.
There are numerous allusions to famous men of the past. We are informed, more than once, of the author's connection with a particular surgeon. Legendary names: William Ernest Miles ("the present author enjoyed his friendship for many years and was his junior colleague"); Sir Holburt Waring ("the present author was his House Surgeon at St Bartholomew's Hospital"); George Grey Turner ("the present author recalls watching him perform the operation [oesophagectomy] the 'pull-through' method at his clinic at Newcastle-upon-Tyne")-but no more is vouchsafed to us. Keynes, Gask and many others swam into his ken, but what were they like as men? How and what did they teach? How and under what conditions were the operations performed? To what surgical lengths were they prepared to go whilst reconciling morbidity and mortality with prognosis? Alas we are not told! The first page after the half-title is graced with the following from the Revelation of St John the Divine: Write all things which thou hasn't seen And the things which are And the things which shall be hereafter.
Perhaps should be added: Old men forget, yet all shall be forgot But he'll remember, with advantages, What feats he did that day.
It is to be hoped that Ronald Raven will write a further book and tell us more of the 'things which thou hasn't seen' and of what feats were done that day. J P BENNETT Consultant Plastic Surgeon Queen Victoria Hospital East Grinstead
