An updated National Institutes of Health consensus panel on bariatric surgery.

Abstract

The last time the National Institutes of Health (NIH) convenedaconsensuspanel onbariatric surgery,manyofour currentmedical studentswere still in diapers. At that time, fewer than 10 000 bariatric procedureswere done annually and the most commonly performed bariatric operations were the vertical banded gastroplasty and open Roux-en-Y gastric bypass. The landscape has changed dramatically since then. Bariatric surgery has become one of themost commonly performed general surgery procedures and it is almost exclusively performed laparoscopically, with a good safety profile. Verticalbandedgastroplastyhasbecomeobsoleteandthemost commonlyperformedbariatricprocedure is laparoscopicsleeve gastrectomy, whichwas not even on the radar screen in 1991. Despite all of these changes, decisions about who should receive bariatric surgery are still based on the 1991 NIH consensus panel. Although evidence on the effectiveness of bariatric surgery was limited at that time, the original NIH panel had a substantial impact on decisionmaking and opened the door for the dramatic growth in the field since then. In this issueof JAMASurgery, Courcoulas et al1 present the report from the second NIH consensus panel. It does not appear that the second consensus conference will have nearly the impact of the first. This appears tobebydesign, as thepanel’s chargewas largely to provide a review and summary of existing evidence. Consequently, the report by Courcoulas et al1 providesavery thoroughreviewof thesubstantialevidence insupportof theeffectivenessandefficacyofbariatric surgery,which may have the salutary effect of further legitimizing the field. This report can be used to support and inform coverage decisions to enhance access to bariatric procedures. However, the panel did not provide explicit recommendations on how coverage should change going forward. In particular, the time is ripe for lowering the body mass index (BMI, calculatedasweight inkilogramsdividedbyheight in meters squared) threshold for bariatric surgery. Evidence fromanumber of randomized clinical trials demonstrates the efficacyof bariatric surgery in the remissionof diabetesmellitusandother comorbidconditions forpatientswithclass Iobesity (BMI, 30-35).2-5 While long-term durability data are lacking for patients in this BMI range, the evidence supporting reducing the BMI threshold to 30 (with comorbidities) is substantially higher now than was the evidence for setting that threshold at 35 in 1991. Certainly, as thenewNIHpanel suggests, further studyof the long-termoutcomes of bariatric surgery, especially sleeve gastrectomy, is warranted. And such studies should include medically treatedpatients, particularlywhenexaminingquality of life and other patient-centered outcomes. But the evidence in support of bariatric surgeryvsmedical therapy in the treatmentofmorbidobesity andassociatedconditions is fairly overwhelming. However, we missed this opportunity to leverage the substantial expertise of this panel tomake recommendations about expanding coverage to these additional patients, who would very clearly benefit from it.