Waiting for Riziv recognition of the bariatric care process (Dr. Dillemans)

“The obesity pandemic and the related medical problems are more topical than ever. Today we cannot open a newspaper or social media without finding articles or testimonials about yet another miracle diet, successful and unsuccessful gastric reductions and the pros and cons of promising medications .”

“Since the WHO recognized obesity as a formal disease, interest from science and the medical industry has also increased spectacularly. The approach to obesity is primarily conservative, with prevention taking precedence over treatment. Serious initiatives are now being launched worldwide to restrict excessive calorie intake (especially sugar) from a young age. However, the success of this must still translate into a decrease or at least stabilization of obesity prevalence.

New pharmacological treatments are gaining popularity and hype. The GLP-1 agonists can achieve a weight reduction of 15% with also a positive effect on metabolic morbidity. Even more high-performance medications, so-called dual and triple analogues, are in the pipeline. However, the long-term effects are not yet known, because most studies have a follow-up of less than 3 years. In addition, there are also questions about the appropriateness of long-term (lifelong?) supranormally dosed medication in often young patients, the high cost and the certain weight gain after stopping the medication.

The literature has unequivocally shown that surgical treatment of a morbidly obese patient is the most effective, both in terms of the amount and durability of weight loss, and is far more efficient than any conservative treatment. Moreover, several studies show an important positive impact of these interventions on the individual quality and quantity of life. Adams et al. calculated that after a gastric bypass the risk of cardiovascular mortality decreases by 50%, diabetes mortality by 95% and even cancer mortality by 60%. (1) This inspired eminent surgeon Walter Pories to make the famous statement in 1995: ‘Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus.’

Convincing evidence

Due to the very beneficial metabolic effect of bariatric procedures that goes beyond mere weight loss, we have expanded the professional organization Section of Obesity surgery Belgium (SOSB), founded in 2006, to the Belgian section of Obesity and Metabolic surgery (BeSOMS). Due to the convincing evidence, the Riziv included specific bariatric and metabolic interventions in the nomenclature in October 2007 for patients with a BMI ≥ 40 and after multidisciplinary evaluation. In 2008 and 2010, the criteria for this were refined to include patients with a BMI ≥ 35 with either diabetes mellitus, severe arterial hypertension or sleep apnea.

Over the last two decades, enormous steps forward have been made in the quality and results of surgical techniques, mainly due to the rise of laparoscopy. Postoperative discomfort, complication rate, hospital stay and disability have decreased enormously. A recent study at KU Leuven even calculated that 20.9% of disabled patients return to work afterwards! (2) Current techniques involve a combination of restrictive, malabsorptive and hormonal effects. Gastric bypass and sleeve gastrectomy make up the lion’s share of these procedures. Which procedure is most suitable for the individual patient depends on factors such as BMI, eating habits, comorbidities, etc. The choice should always be discussed in a multidisciplinary manner and assessed against the patient’s preferences.

Succession

Follow-up after bariatric surgery remains a challenge. Several retro- and prospective studies indicate gaps in aftercare and reduced patient compliance. During the first 3 years after surgery, close follow-up is recommended to monitor and coach behavioral changes, consolidate weight loss and counteract comorbidities.

To improve the screening and follow-up of bariatric patients, the KCE launched an optimized bariatric care process in 2020 after extensive consultation with relevant experts (including BeSOMS). For the time being, only a mandatory waiting period of 3 months between the first consultation and the intervention has been converted into a royal decree… Together with our colleagues from the BASO (Belgian Association for the Study of Obesity), the dieticians and the psychologists who are committed to the bariatric care process , we hope that the Riziv will still grant us the necessary recognition for this.

Dr. Bruno Dillemans, General and Bariatric Surgeon

Head of Department of General, Pediatric and Vascular Surgery

Chairman BeSOMS

1. Adams TD, Davidson LE, Litwin SE, et al. Weight and Metabolic Outcomes 12 Years after Gastric Bypass. N Engl J Med. 2017;377(12):1143-1155.

2. Van den Eynde, A., De Cock, D., Fabri, V. et al. Back to Work After Bariatric Surgery? A Belgian Population Study. Obes. Surg. 32, 2625–2631 (2022).

> Riziv inspection sensitizes bariatric surgeons to the indicator