Abstract
OBJECTIVE: To assess the clinical and cost effectiveness of surgery for people with morbid obesity.
DESIGN: A systematic review of randomised control trials (RCTs), prospective clinical trials and economic evaluations identified from 14 electronic databases (including Medline, Cochrane library and Embase from their inception to October 2001), bibliographies and consultation with experts and manufacturers was performed to assess the clinical and cost effectiveness of different surgical procedures and nonsurgical management for morbid obesity. An economic evaluation was undertaken to assess cost effectiveness in the UK.
SUBJECTS: People diagnosed as morbidly obese, defined as a body mass index (BMI) (weight in kilograms/height in metres2) >40 kg/m2, or with a BMI>35 kg/m2 with serious comorbid disease, in whom previous nonsurgical interventions had failed.
MEASUREMENTS: The outcomes assessed included weight change, quality of life, peri- and postoperative morbidity and mortality, revision rates and obesity comorbidities. Cost effectiveness was modelled from these data and presented as cost per quality-adjusted life year (QALY).
RESULTS: Included studies differed in methodological quality. Surgery resulted in a significantly greater loss of weight (23–37 kg more weight) than nonsurgical treatment, which was maintained to 8 years and led to improvements in quality of life and comorbidities. The economic evaluation of surgery compared with nonsurgical management suggested that surgery was cost effective at £11 000 per QALY. Comparisons of the different types of surgery were equivocal.
CONCLUSION: Surgery for morbid obesity appears to be clinically and cost effective. Because of the nature of the evidence, particularly the uncertainty in the clinical and economic evaluations, it is difficult to distinguish between the different surgical procedures.
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 print issues and online access
$259.00 per year
only $21.58 per issue
Buy this article
- Purchase on Springer Link
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
Similar content being viewed by others
References
Flegal KM, Carroll MD, Ogden CL, Johnson CL . Prevalence and trends in obesity among US adults, 1999–2000. JAMA 2002; 288: 1723–1727.
National Audit Office. Tackling obesity in England: report by the Comptroller and Auditor General. London: Stationery Office: 2001.
Ogden CL, Flegal KM, Carroll MD, Johnson CL . Prevalence and trends in overweight among US children and adolescents, 1999–2000. JAMA 2003; 288: 1728–1732.
National Institute for Clinical Excellence. Available from URL: http://www.nice.org.uk/. 2002.
Glenny AM, O’Meara S, Melville A, Sheldon TA, Wilson C . The treatment and prevention of obesity: a systematic review of the literature. Int J Obes Relat Metab Disord 1997; 21: 715–737.
NHS Centre for Reviews and Dissemination. Systematic review of interventions in the treatment and prevention of obesity. CRD Report 10. University of York: York; 1997.
Bryant J, Best L, Milne R . Gastroplasty for severe obesity. Southampton: Wessex Institute for Health Research and Development; 1997.Development and Evaluation Committee Report No. 68.
ASERNIP. Laparoscopic adjustable gastric banding for the treatment of obesity. Vol 9. Adelaide: ASERNIP; 2000.
Schneider WL . Laparoscopic adjustable gastric banding for clinically severe (morbid) obesity, Vol 7(b). Alberta: Alberta Heritage Foundation for Medical Research; 2000.
Robertson A, Douglas S, Waugh N . Gastric surgery for obesity. Aberdeen: SHPIC; 1998.
Clegg A, Sidhu MK, Colquitt J, Royle P, Loveman E, Walker A . Clinical and cost effectiveness of surgery for people with morbid obesity. Health Technol Assess 2002; 6: 1–153.
Drummond MF, Jefferson TO . Guidelines for authors and peer reviewers of economic submissions to the BMJ. BMJ 1996; 313: 275–283.
Spitzer WO, Lawrence V, Dales R, Hill G, Archer MC, Clark P et al. Links between passive smoking and disease: a best-evidence synthesis. Clin Invest Med 1990; 13: 17–42.
National Health Services in Scotland Information and Statistics Division. Scottish Health Service Costs 1999/2000. Available from URL: http://www.show.scot.nhs.uk/isd/Scottish_Health_Statistics/subject/Costs/2000/costs2000.pdf. 2000.
Netten A, Curtis L . Unit costs of health and social care. PSSRU: University of Kent, Canterbury; 2000.
Hakim Z, Wolf A, Garrison LP . Estimating the effect of changes in body mass index on health state preferences. Pharmacoeconomics 2002; 20: 393–404.
van Gemert WG, Adang EM, Kop M, Vos G, Greve JW, Soeters PB . A prospective cost-effectiveness analysis of vertical banded gastroplasty for the treatment of morbid obesity. Obes Surg 1999; 9: 484–491.
Andersen T, Stokholm KH, Backer OG, Quaade F . Long-term (5-year) results after either horizontal gastroplasty or very-low-calorie diet for morbid obesity. Int J Obes Relat Metab Disord 1988; 12: 277–284.
Andersen T, Backer OG, Stokholm KH, Quaade F . Randomized trial of diet and gastroplasty compared with diet alone in morbid obesity. N Engl J Med 1984; 310: 352–356.
Quaade F . Studies of operated and nonoperated obese patients. An interim report on the Scandinavian Obesity Project. Am J Clin Nutr 1977; 30: 16–20.
Stokholm KH, Nielsen PE, Quaade F . Correlation between initial blood pressure and blood pressure decrease after weight loss: a study in patients with jejunoileal bypass versus medical treatment for morbid obesity. Int J Obes Relat Metab Disord 1982; 6: 307–312.
Backer O, Gudmand-Hoyer E, Andersen B, Baden H, Martiny P, Juhl E and other members of Danish Obesity Project. Randomised trial of jejunoileal bypass versus medical treatment in morbid obesity. The Danish Obesity Project. Lancet 1979; 2: 1255–1258.
Karason K, Wallentin I, Larsson B, Sjostrom L . Effects of obesity and weight loss on left ventricular mass and relative wall thickness: survey and intervention study. Br Med J 1997; 315: 912–916.
Karason K, Wikstrand J, Sjostrom L, Wendelhag I . Weight loss and progression of early atherosclerosis in the carotid artery: a four-year controlled study of obese subjects. Int J Obes Relat Metab Disord 1999; 23: 948–956.
Karason K, Molgaard H, Wikstrand J, Sjostrom L . Heart rate variability in obesity and the effect of weight loss. Am J Cardiol 1999; 83: 1242–1247.
Karason K, Lindroos AK, Stenlof K, Sjostrom L . Relief of cardiorespiratory symptoms and increased physical activity after surgically induced weight loss: results from the Swedish Obese Subjects study. Arch Intern Med 2000; 160: 1797–1802.
Karlsson J, Sjostrom L, Sullivan M . Swedish obese subjects (SOS)—an intervention study of obesity. Two-year follow-up of health-related quality of life (HRQL) and eating behavior after gastric surgery for severe obesity. Int J Obes Relat Metab Disord 1998; 22: 113–126.
Narbro K, Agren G, Jonsson E, Larsson B, Naslund I, Wedel H, Sjostrom L . Sick leave and disability pension before and after treatment for obesity: a report from the Swedish Obese Subjects (SOS) study. Int J Obes Relat Metab Disord 1999; 23: 619–624.
Sjostrom CD, Lissner L, Wedel H, Sjostrom L . Reduction in incidence of diabetes, hypertension and lipid disturbances after intentional weight loss induced by bariatric surgery: the SOS Intervention Study. Obes Res 1999; 7: 477–484.
Sjostrom CD, Peltonen M, Wedel H, Sjostrom L . Differentiated long-term effects of intentional weight loss on diabetes and hypertension. Hypertension 2000; 36: 20–25.
Sjostrom CD, Peltonen M, Sjostrom L . Blood pressure and pulse pressure during long-term weight loss in the obese: the Swedish obese subjects (sos) intervention study. Obes Res 2001; 9: 188–195.
Griffen-WO J, Young VL, Stevenson CC . A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity. Ann Surg 1977; 186: 500–509.
Howard L, Malone M, Michalek A, Carter J, Alger S, Van Woert J . Gastric bypass and vertical banded gastroplasty — a prospective randomized comparison and 5-year follow-up. Obes Surg 1995; 5: 55–60.
Lechner GW, Callender AK . Subtotal gastric exclusion and gastric partitioning: a randomized prospective comparison of one hundred patients. Surgery 1981; 90: 637–644.
MacLean LD, Rhode BM, Sampalis J, Forse RA . Results of the surgical treatment of obesity. Am J Surg 1993; 165: 155–160.
MacLean LD, Rhode BM, Forse RA, Nohr C . Surgery for obesity — an update of a randomized trial. Obes Surg 1995; 5: 145–153.
Westling A, Gustavsson S . Laparoscopic vs open Roux-en-Y gastric bypass: a prospective, randomized trial. Obes Surg 2001; 11: 284–292.
Nilsell K, Thorne A, Sjostedt S, Apelman J, Pettersson N . Prospective randomised comparison of adjustable gastric banding and vertical banded gastroplasty for morbid obesity. Eur J Surg 2001; 167: 504–509.
Buckwalter JA . Clinical trial of surgery for morbid obesity. South Med J 1978; 71: 1370–1371.
Sugerman HJ, Starkey JV, Birkenhauer R . A randomized prospective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweets eaters. Ann Surg 1987; 205: 613–624.
Pories WJ, Flickinger EG, Meelheim D, Van Rij AM, Thomas FT . The effectiveness of gastric bypass over gastric partition in morbid obesity: consequence of distal gastric and duodenal exclusion. Ann Surg 1982; 196: 389–399.
de Wit LT, Mathus-Vliegen L, Hey C, Rademaker B, Gouma DJ, Obertop H . Open versus laparoscopic adjustable silicone gastric banding — A prospective randomized trial for treatment of morbid obesity. Ann Surg 1999; 230: 800–805.
Buckwalter JA . Clinical trial of jejunoileal and gastric bypass for the treatment of morbid obesity: four-year progress report. Am Surg 1980; 46: 377–381.
Buckwalter JA, Mason EE, Payne JH . A prospective comparison of the jejunoileal and gastric bypass operations for morbid obesity. World J Surg 1977; 1: 757–768.
Andersen T, Backer OG, Astrup A, Quaade F . Horizontal or vertical banded gastroplasty after pretreatment with very-low-calorie formula diet: a randomized trial. Int J Obes Relat Metab Disord 1987; 11: 295–304.
Laws HL, Piantadosi S . Superior gastric reduction procedure for morbid obesity: a prospective, randomized trial. Ann of Surg 1981; 193: 334–340.
Naslund I . The size of the gastric outlet and the outcome of surgery for obesity. Acta Chir Scand 1986; 152: 205–210.
Naslund I, Wickbom G, Christoffersson E, Agren G . A prospective randomized comparison of gastric bypass and gastroplasty. Complications and early results. Acta Chir Scand 1986; 152: 681–689.
Naslund I . Gastric bypass versus gastroplasty. A prospective study of differences in two surgical procedures for morbid obesity. Acta Chir Scand Suppl 1987; 536: 1–60.
Naslund I, Beckman KW . Gastric emptying rate after gastric bypass and gastroplasty. Scand J Gastroentero 1987; 22: 193–201.
Naslund I, Hallgren P, Sjostrom L . Fat cell weight and number before and after gastric surgery for morbid obesity in women. Int J Obes Relat Metab Disord 1988; 12: 191–197.
Naslund I, Jarnmark I, Andersson H . Dietary intake before and after gastric bypass and gastroplasty for morbid obesity in women. Int J Obes Relat Metab Disord 1988; 12: 503–513.
Hall JC, Watts JM, O'Brien PE, Dunstan RE, Walsh JF, Slavotinek AH, Elmslie RG . Gastric surgery for morbid obesity. The Adelaide Study. Ann Surg 1990; 211: 419–427.
Nguyen NT, Goldman C, Rosenquist CJ, Arango A, Cole CJ, Lee SJ, Wolfe BM . Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg 2001; 234: 279–289.
Sjostrom L, Narbro K, Sjostrom D . Costs and benefits when treating obesity. Int J Obes Relat Metab Disord 1995; 19: S9–S12.
Martin LF, Tan TL, Horn JR, Bixler EO, Kauffman GL, Becker DA, Hunter SM . Comparison of the costs associated with medical and surgical treatment of obesity. Surgery 1995; 118: 599–606.
Chua TY, Mendiola RM . Laparoscopic vertical banded gastroplasty: the Milwaukee experience. Obes Surg 1995; 5: 77–80.
Anonymous.Gastrointestinal Surgery for Severe Obesity. 9[1]. NIH Consens Dev Conf Consens Statement (March 25–27). 1991.
Jung RT, Cuschieri A . Obese patients. In: Cuschieri A, Steele RJC, Moosa AR (eds). Essential surgical practice–Vol 1, pp 227–240. Butterworth Heinemann: London: 2000. 4th edn.
NHS Centre for Reviews and Dissemination.Undertaking Systematic Reviews of Research on Effectiveness. CRD's Guidance for those Carrying Out or Commissioning Reviews. CRD Report Number, 42nd Edition. University of York: York; 2001.
MacLean LD, Rhode BM, Forse RA . A gastroplasty that avoids stapling in continuity. Surgery 1993; 113: 380–388.
Williams R, Van Gaal L, Lucioni C . Assessing the impact of complications on the costs of Type II diabetes. Diabetologia 2002; 45: S13–S17.
Acknowledgements
We thank the advisory group for advice and peer review of the research protocol and/or a draft of the original report for NICE, including Professor JN Baxter, Professor of Surgery, University of Wales; Sir Alfred Cuschieri, Professor of Surgery, University of Dundee; Professor Philip James, Chairman, International Obesity Task Force; Professor Roland Jung, Chief Scientist to Scottish Executive, Dundee; Dr AM Mir, Consultant Physician and Senior Lecturer, University of Wales College of Medicine, Cardiff; Mr JDB Miller, Consultant Surgeon, Dr Gray's Hospital, Elgin; Dr Ian Campbell, NOF Chairman, Nottingham; Dr JPH Wilding, Reader in Medicine, University Hospital Aintree, Liverpool; Mr Peter Sedman, Consultant Surgeon, Hull Royal Infirmary; Ms Mary O’Kane, Chief Dietitian, The General Infirmary, Leeds; Professor Bruce Campbell, Consultant General Surgeon, Royal Devon & Exeter Hospital, Exeter. We thank Ms Liz Hodson for support with obtaining information; Dr Norman Waugh and Dr Emma Loveman, SHTAC, University of Southampton; Dr Alison Avenell, University of Aberdeen Medical School, Aberdeen; Mr David Carson, Head of Financial Performance Management, Tayside Health Board, Dundee; Dr Janis Baird, Specialist Registrar in Public Health Medicine, University of Southampton. This work was funded by the NHS R&D HTA Programme. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NHS Executive.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Clegg, A., Colquitt, J., Sidhu, M. et al. Clinical and cost effectiveness of surgery for morbid obesity: a systematic review and economic evaluation. Int J Obes 27, 1167–1177 (2003). https://doi.org/10.1038/sj.ijo.0802394
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1038/sj.ijo.0802394
Keywords
This article is cited by
-
Economic Evaluations of Anti-obesity Interventions in Obese Adults: An Umbrella Review
Obesity Surgery (2024)
-
Pregnancy After Bariatric Surgery: What Are the Risks and Benefits?
Current Surgery Reports (2023)
-
Cost-effectiveness of metabolic surgery for the treatment of type 2 diabetes and obesity: a systematic review of economic evaluations
The European Journal of Health Economics (2023)
-
Implications of Bariatric Surgery on the Pharmacokinetics of Antiretrovirals in People Living with HIV
Clinical Pharmacokinetics (2022)
-
Oroxylum indicum (L.) Kurz extract inhibits adipogenesis and lipase activity in vitro
BMC Complementary and Alternative Medicine (2018)