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Referral for bariatric surgery

Referral for bariatric surgery

Best Practice Guidance

How up to date is this information?

Published May 2023 | Last reviewed September 2024

Using this guidance

The guidance set out here was reviewed extensively in the Autumn of 2024. There are no plans for any further reviews.

Medicine is constantly evolving and over time it is inevitable that the evidence base will change. Please use your own judgement and/or other sources of clinical guidance alongside the information set out here.

Please note this guidance is a recommendation and it should be used in the context of the overall care pathway and when all alternative interventions that may be available locally have been undertaken.

Summary

There are a variety of surgical options available for promoting weight loss. These bariatric procedures include Roux-en-Y gastric bypass, one anastomosis (mini) gastric bypass, vertical sleeve gastrectomy and adjustable gastric banding. The specific type of procedure should be decided as part of a shared decision making conversation between the patient and the surgeon, during which risks and possible outcomes are discussed.

Bariatric procedures aim to promote weight loss and improve other metabolic complications of obesity. This proposed guidance establishes criteria for referral of a patient to a bariatric surgical centre for consideration of performing a bariatric surgical procedure.

Recommendation

This guidance applies to those aged 18 years and over.

For patients with a BMI of 50 or more, surgery should be considered as a first-line treatment intervention.

Patients with a BMI less than 50 should be referred for consideration of bariatric surgery if they meet the following criteria:

  • The patient has a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m with significant obesity-related complications likely to improve with weight loss (for example, type 2 diabetes, sleep apnoea or hypertension)

OR

  • The patient has a BMI of 30 kg/m2 or more with type 2 diabetes of less than 10 years duration. This BMI threshold should be reduced to 27.5 kg/m2 if the patient is of Asian family origin.

All patients being considered for bariatric surgery must also meet the following criteria:

  • Appropriate non-surgical measures have been tried but the patient has not achieved or maintained adequate, clinically beneficial weight loss

AND

  • The patient has been receiving or will receive intensive management in a tier 3 service or equivalent. For more information on tier 3 services, please refer to NHS England’s report of the working group into joined up clinical pathways for obesity and The Royal College of Surgeon’s Weight Assessment and Management Tier Services Commissioning Guide.

AND

  • The patient is otherwise fit for anaesthesia and surgery

AND

  • The patient commits to long-term follow-up

AND

  • The patient and clinician have undertaken appropriate shared decision-making consultation regarding undergoing surgery including discussion of risks and benefits of surgical intervention.

After surgery, the host bariatric surgery unit should follow up with the patient for two years. Thereafter, responsibility for follow up should be handed over to the either the local nonsurgical Tier 3 service OR the patient’s GP, who should conduct yearly appointments. These appointments should include weight measurement and a request for nutritional blood tests. See British Obesity & Metabolic Surgery Society (BOMSS) guidance for more details.

Please note that this guidance is intended as a standard threshold for access. However, if you/ your patient falls outside of these criteria, the option to apply for an Individual Funding Request is still available to you.

Rationale for recommendation

According to NICE guideline CG189 surgery for the treatment of obesity is recommended if specific criteria are met, relating to the patient’s body mass index and the presence of obesity-related complications. This balances the risk of surgery with its potential positive long-term impact on the patient. When commissioned appropriately, obesity surgery is highly effective in promoting weight loss, and more importantly, reducing mortality and morbidity burden. It is also one of the most cost-effective treatments in the field of surgery. The penetrance of obesity surgery remains very low even though thousands of eligible patients stand to benefit from this life-saving intervention with the associated health benefits it provides.

Patient information

There are a variety of minimally invasive surgical options to help weight loss (bariatric surgery) and improve health. These include Roux-en-Y gastric bypass, one anastomosis (mini) gastric bypass, vertical sleeve gastrectomy and adjustable gastric banding. NICE guideline CG189 states that surgery for obesity is an option if specific criteria are met, balancing the risk of surgery with the long-term benefits of alleviating ill health caused by obesity.

Evidence shows that when commissioned as recommended, surgery is highly effective in causing weight loss, reduces the long-term impact of poor health and reduces the risk of premature death from obesity-related conditions. Despite this, the UK has one of the lowest rates of bariatric surgery in the developed world.

We recommend using the BRAN principles (Benfits, Risks, Alternatives and do Nothing) when speaking with patients about this.

Further information on patient involvement in EBI can be found on the EBI for patients section.

 

 

Make the most of your appointment using BRAN

2020

Coding

WHEN LEFT(Primary_Spell_Procedure,4) IN ('G281', 'G282', 'G283', 'G284', 'G285', 'G301', 'G302', 'G303', 'G304', 'G321', 'G328', 'G329', 'G331', 'G338', 'G339')
AND ( Any_Spell_Diagnosis LIKE '%E66[01289]%')
-- Only Elective Activity
AND APCS.Admission_Method NOT LIKE '2%'
-- Age between 18 and 120
AND isnull(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 18 AND 120
THEN '3F_Bariatric_Surgery'
Exclusions
WHERE 1=1
-- Cancer Diagnosis Exclusion
AND (Any_Spell_Diagnosis not like '%C[0-9][0-9]%' 
AND Any_Spell_Diagnosis not like '%D0%' 
AND Any_Spell_Diagnosis not like '%D3[789]%' 
AND Any_Spell_Diagnosis not like '%D4[012345678]%' 
OR Any_Spell_Diagnosis IS NULL)
-- Private Appointment Exclusion
AND apcs.Administrative_Category<>'02'

References

  1. Geltrude Mingrone, Simona Panunzi, Andrea De Gaetano, et al. Metabolic surgery versus conventional medical therapy in patients with type 2 diabetes: 10-year followup of an open-label, single-centre, randomised controlled trial. Lancet 2021; 397:293–304
  2. Chen G, Kusel J, Buguth B, Higgins A, Belarbi S. Cost effectiveness of surgery compared to conventional treatment from a societal perspective in Germany, France, Italy and the UK. Value in Health. 2017 20 A399-A811. PSY74
  3. Miras A, Kamocka A, Patel D, et al. Obesity surgery makes patients healthier and more fnctional: real world results from the United Kingdom National Bariatric Surgery Registry. 2018. Surgery for Obesity and Related Diseases 2018;14:1033-1040
  4. Picot J, Jones J, Colquitt J, Loveman E, Clegg A. Weight loss surgery for mild to moderate obesity: a systematic review and economic evaluation. Obes surg (2012) 22;1496-1506. DOI 10.1007/s11695-012-0679-z
  5. R. F. Pollock, J. Chilcott, G. Muduma & W. J. Valentine (2013) Laparoscopic adjustable gastric banding vs standard medical management in obese patients with type 2 diabetes: a budget impact analysis in the UK. Journal of Medical Economics, 16:2, 249-259, DOI:10.3111/13696998.2012.751388
  6. Qing Xia, Julie A. Campbell, Hasnat Ahmad, Lei Si1, Barbara de Graaff, Andrew J. Palmer. Bariatric surgery is a cost‐saving treatment for obesity — A comprehensive meta‐analysis and updated systematic review of health economic evaluations of bariatric surgery. Obesity Reviews. 2020;21:e12932
  7. Philip R. Schauer, M.D., Deepak L. Bhatt, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes — 5-Year Outcomes. N Engl J Med 2017;376:641-51.DOI:10.1056/NEJMoa1600869
  8. Richard Welbourn, Marianne Hollyman, Robin Kinsman, et al. Bariatric Surgery Worldwide: Baseline Demographic Description and One-Year Outcomes from the Fourth IFSO Global Registry Report 2018. Obesity Surgery (2019) 29:782–795. https://doi.org/10.1007/s11695-018-3593-1
  9. Francesco Rubino, David M. Nathan, Robert H. Eckel, et al. Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. Diabetes Care 2016; 39:861–877
  10. Picot J, Jones J, Colquitt JL, Gospodarevskaya E, Loveman E, Baxter L, Clegg AJ. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess. 2009 Sep;13(41):1-190, 215-357, iii-iv. doi: 10.3310/hta13410
  11. Borisenko O, Adam D, Funch-Jensen P, et al. Bariatric Surgery can Lead to Net Cost Savings to Health Care Systems: Results from a Comprehensive European Decision Analytic Model. Obes Surg. 2015;25(9):1559-1568. doi:10.1007/s11695-014-1567-5
  12. Ali Aminian, M.D. Alisan Fathalizadeh, M.D. Chao Tu, M.S. Raul J. Rosenthal, M.D. Bartolome Burguera, M.D. Steven E. Nissen, M.D. Association of prior metabolic and bariatric surgery with severity of coronavirus disease 2019 (COVID-19) in patients with obesity. SOARD 2021 17;1:P208-214
  13. NICE guidance and Bariatric Surgery in England. 2010. Shedding the pounds: obesity management. Office of Health Economics. ISBN: 978-1-899040-93-3
  14. The United Kingdom National Bariatric Surgery Registry. Second registry report. 2014
  15. NHS England. Guidance for Clinical Commissioning Groups (CCGs): Clinical Guidance: Surgery for Severe and Complex Obesity 2016. CCG Pack; Guidance for commissioning obesity surgery Appendix 7
  16. NHS England. Report of the working group into: Joined up clinical pathways for obesity. 2014
  17. NHS England. Appendix 9 Guidance for Clinical Commissioning Groups (CCGs): Service Specification Guidance for Obesity Surgery. 2016.
  18. The Royal College of Surgeons. Weight Assessment and Management Tier Services – Commissioning Guide. 2014.
  19. NHS England. Weight loss surgery Availability.
  20. NICE. Obesity: identification, assessment and management [CG189]. 2014
  21. NICE. BMI: preventing ill health and premature death in black, Asian and other minority ethnic groups.
  22. British Obesity & Metabolic Surgery Society. Guidelines on peri-operative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery. 2014.
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