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Bariatric Therapy pp 491–508Cite as

Input of New Ways of Reasoning

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Abstract

It may well be that the input of other ways of reasoning could help to shape the identity and to direct the future of minimally invasive bariatric procedures. A more thorough analysis of weight trajectories, with or without any type of intervention, could have a significant input to our understanding of failure and success after these interventions. Weight cycling should also be revisited in this regard. All these considerations should be of help to improve our algorithms. Owing to systems biomedicine and adaptive trial design, paradigms could shift and redistribute current indications for weight loss treatments.

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Notes

  1. 1.

    The BMI question entails three discussions, with further consequences

    1. 1.

      Percentage of weight-loss

      • Surgeons often use EWL which will be high in less obese patients and low in super-morbidly obese patients with a similar weight loss in kilogram. Therefore this EWL measure should be abandoned. Indeed total weight loss in % is what counts. An obese patient, whatever his/her initial BMI, should lose 5–10% in order to improve his/her morbidities (real or potential), and his/her QOL. The assumption that a patient with a higher BMI needs to lose a higher % is essentially true, but may be discussed: lower BMI suffer from comorbidities too and need in this respect an intensive weight loss whereas those who do not have obvious comorbidities (whatever the BMI) may have hidden comorbidities (see also Chap. 1 on the discussion of the non-existence of a healthy obese). It has never been investigated if the absolute remaining BMI after weight loss or the relative reduction and speed of reduction will determine the life expectancy and fate of a person. Some allusion may be provided by the data of the SOS study where the life expectancy increased by weight loss but only after 10 years and mainly because of cancer-related mortality and that any role of the degree of weight loss by different operations and speed of weight loss could not be discerned (but probably due to insufficient numbers). In other words, and for many searchers/clinicians, there is no such thing as a “healthy obese patient.” Moreover, obesity per se is often presented as a morbidity by itself (although others argue that obesity is not necessarily a medical condition).

      • Nevertheless, let us take for granted that for patients with BMI > 40 or more, 25% TBWL is a sound objective (for the purpose of comorbidities’ improvement), and that this objective can be reasonably achieved only by surgical means. And further, endoscopic techniques have a shorter duration of efficient life, hence less expectations in terms of weight maintenance.

    2. 2.

      Atypical observations

      • Short-term and possibly repeated weight loss episodes represent nowadays the privilege of endoscopic techniques: this is not necessarily detrimental since weight cycling per se (if unrelated to medical conditions, such as cancer) has been proven mostly harmless, although this is a complex issue. Likewise, weight cycling does not prevent further weight loss, as shown in other studies.

      • When examining the way patients behave once a given technique has stopped to be active (the “on-off” effect), we observe erratic patterns of weight loss, and erratic trajectories. These trajectories may also be present with surgical methods (e.g. banding or neurostimulation), but to a lesser extent. It is important to go into the details of these trajectories, in terms of prevalence and consequences; for example, there is a centre effect, differing with commitments, as it seems very obvious that results are different in dedicated centres with all endoscopic and surgical modalities being available compared to centres where for instance endoscopic solutions are only a part of the options. Moreover, as patient-shared decision is a new paradigm, obesity centres should provide much of the conservative medical, endoscopic and surgical methods as possible.

    3. 3.

      Efficacy and cost/efficacy

      We may oppose the reasoning: “If a technique has few side-effects and risks, it may be less efficient or less cost/efficient, and less durable,” for two reasons:

      • Bariatric methods are weight loss methods that entail an intervention, more or less mediated by a device or several devices, with a risk/benefit ratio, a cost, etc. They belong to a sole armamentarium, regardless the way they are implemented, e.g. open surgery, laparoscopic surgery and endoscopic surgery (which could be similar for instance to a prostatectomy). Within this group, they compete, and represent alternative options that change over the time; sometimes a technique wins it all, and conquers 90% of the market: this is the case with the sleeve gastrectomy for the time being, and OverStitch might hypothetically be a major player in the next few years. This is why we can never be sure that a technique should or should not have less side effects or shortcomings than another one just because it belongs to a different category.

      • One never knows for sure especially not at the start which device is the least harmful.

  2. 2.

    To give a pregnant example: in the Netherlands there has been a discussion about the reimbursement of medication for very rare diseases such as Pompe and Fabry and in the past it was decided that 1 QUALY may cost a maximum of 80,000 euros. As 1 QUALY with Fabry’s disease costs 0.3–0.9 million euro and 1 QUALY of Pompe’s disease 3.3 million, it was decided not to reimburse their treatment. This evoked a lot of discussion and to set the discussions into medical perspective: 1 QUALY by breast cancer screening costs 4200 euro, by the national child vaccination programme 18,000 euro and by heart transplantation 38,000 euro, all well accepted by the Council of Health. In that same report, they also contrasted the healthcare costs for 1 QUALY against societal measures: 1 QUALY gained by the obligatory check-up of cars costs 80,000 euro, and 1 QUALY gained by the DELTA works to protect against floods costs two million and when the incomes from the DELTA works are subtracted it still costs 300,000 euro.

  3. 3.

    A critical note should be made here: most programmes are of short duration, not taking back patients who relapse and only addressing the short-term benefits, while it is a generally recognised fact that weight maintenance is even more difficult than losing weight and that weight maintenance requires a different approach than weight loss. Losing weight, but even more so maintenance of that reduced weight, is something that is almost incompatible with normal physiology. Moreover, there are only a few studies (not included in the graphs of Fig. 9.5) that give the optimal intensive lifestyle modification of supervised diet, exercise and behavioural therapy, the latter including coping and relapse prevention.

  4. 4.

    When one implements a technique that has an “on-off effect,” such as a gastric balloon, a gastric band with or without inflation, and a digestive neurostimulation with the device on or off, one assumes that when it is off, one may restart with whatever other technique without the interference of the previous one, at least theoretically. One may implement a new algorithm that is more or less influenced by the results of the previous one. This is influenced by the results because of the necessities of the trial (failure vs. success, etc.), but not in the sense that the previous technique had remnant effects.

Abbreviations

AUC:

Area under the curve

BMI:

Body mass index

DALYs:

Disease-adjusted life years

EBT:

Endoscopic bariatric therapy

IFSO:

International Federation for the Surgery of Obesity

PIVI:

Preservation and Incorporation of Valuable endoscopic Innovations

QUALY:

Quality-Adjusted Life Years

TBWL:

Total body weight loss

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Acknowledgments

The authors acknowledge the contribution of Lisbeth Mathus-Vliegen to this chapter.

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Authors and Affiliations

  1. Amsterdam UMC (University Medical Centres), Amsterdam, The Netherlands

    Elisabeth M. H. Mathus-Vliegen

  2. Polyclinique Lyon Nord, Lyon, France

    Jérôme Dargent

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  1. Elisabeth M. H. Mathus-Vliegen
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Mathus-Vliegen, E.M.H., Dargent, J. (2018). Input of New Ways of Reasoning. In: Bariatric Therapy. Springer, Cham. https://doi.org/10.1007/978-3-319-90074-2_9

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  • DOI: https://doi.org/10.1007/978-3-319-90074-2_9

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