Abstract
Purpose
This study aimed to investigate the current status of bariatric and metabolic surgery in Daejeon and Chungcheong province and to describe the early experiences after public medical insurance coverage in 2019.
Materials and Methods
Between January 2019 and August 2019, 64 cases of bariatric and metabolic surgery were performed in patients with morbid obesity or uncontrolled type 2 diabetes. We prospectively collected and analyzed data regarding the patients' demographics and comorbidities, surgical results, and early complications. The patient information before and after the insurance coverage was also compared.
Results
The number of surgeries in 9 years has been caught up only in the last 8 months after insurance coverage (58 vs. 64 patients). The mean body mass index was 37.7±5.8 kg/m2 (range, 22.7-52.1 kg/m2). The most frequently performed surgery was sleeve gastrectomy (53 cases, 82.8%), followed by Roux-en-Y gastric bypass (9 cases, 14.1%), and adjustable gastric banding (2 cases, 3.1%). Postoperative complications occurred in 6 patients (9.4%), and there was no mortality. The mean operation time (225.3±85.4 vs. 156.1±61.8 min, P<0.001) and postoperative stay (5.9±4.5 vs. 4.3±2.0 days, P=0.013) after the insurance coverage were significantly shorter than those before the insurance coverage.
Conclusion
We could assess the patients who had bariatric and metabolic surgery in Daejeon and Chungcheong province after public medical insurance coverage in 2019.
Keywords: Bariatric and metabolic surgery, Public medical insurance coverage, Early experiences
INTRODUCTION
Bariatric and metabolic surgery was finally included in the insurance coverage and was reimbursed through the national health insurance in January 2019 in Korea. Patients with body mass index (BMI) ≥35 kg/m2 or BMI ≥30 kg/m2 with comorbidities can benefit from the public medical insurance coverage, so the demand for bariatric and metabolic surgery is now increasing noticeably. The announcement of insurance coverage means two things. First, there have been enough evidences of bariatric and metabolic surgery. Despite consistent efforts, none of the conservative treatments, including medication, could successfully achieve long-lasting weight control [1,2]. However, the long-term effectiveness of bariatric and metabolic surgery in weight loss and remission of diabetes has been proven through well-designed studies [3,4,5,6]. Second, sufficient safety has been secured in bariatric and metabolic surgery. The safety of this surgery has been a sensitive issue, which caused social problems in Korea. The advances in the latest surgical instruments and anesthetic technology have played an important role in the establishment of safety of bariatric and metabolic surgery. Moreover, the Korean Society for Metabolic and Bariatric Surgery has introduced the accreditation system (for both surgeons and institutions) of bariatric and metabolic surgery for systematic supplementations of safety [7].
The Society of Chungcheong Obesity and Metabolic Surgery (SCOMS) was the first organized local research society in Korea, operating since 2015, and we have already reported our early experiences of bariatric and metabolic surgery before its inclusion in the insurance coverage [8]. This study aims to investigate the current status of bariatric and metabolic surgery in Daejeon and Chungcheong province after its inclusion in the public medical insurance coverage and describes the roles and necessity of a research society in our province.
MATERIALS AND METHODS
Between January 2019 and August 2019, 64 bariatric and metabolic surgeries were performed in patients with morbid obesity or uncontrolled type 2 diabetes at 7 institutions (9 surgeons) in Daejeon and Chungcheong province. All patients were suitably indicated for the surgery according to the national insurance coverage in Korea. We prospectively collected and analyzed data regarding the patients' demographics and comorbidities, surgical results, and early complications. Furthermore, patient demographics and surgical results as well as postoperative morbidity were compared according to the time of surgery. The patients who underwent surgery before the insurance coverage (from 2010 to 2018) were included in group A (n=58), whereas those who underwent the surgery after the insurance coverage were included in group B (n=64). Most of the patients in group A underwent surgery before the establishment of the research organization (45/58, 77.6%).
This study was approved by the Institutional Review Board (IRB) of each institution from where the data were collected (IRB Number 201911013 at the institution of the first author) and was conducted in line with the Declaration of Helsinki. Written informed consent was waived by the IRB. Categorical data were assessed using the χ2 test or Fisher's exact test. In addition, we used the t-test or the Mann-Whitney U test for continuous variables. A P<0.05 was considered statistically significant. All statistical analyses were performed using the SPSS software package for Windows, version 22.0 (IBM, Chicago, IL, USA).
RESULTS
1. Patient demographics and baseline characteristics
In total, 64 patients (14 men and 50 women; average age, 39.3±11.0 years) were included in this study. The baseline characteristics of the patients are summarized in Table 1. The mean body weight was 103.7±20.6 kg (54.3-145.0 kg), and the mean BMI was 37.7±5.8 kg/m2 (22.7-52.1 kg/m2). Fig. 1 shows the distribution of BMI. The patients with BMI>35 kg/m2 and<40 kg/m2 were most common (37.5%), and 3.1% of the patients were super morbidly obese with BMI>50. Most of the patients (62/64, 96.9%) had one or more comorbidities. The most common comorbidities were liver disease and hypertension followed by diabetes and dyslipidemia (Fig. 2).
Table 1. Patients demographics and baseline characteristics (n=64).
| Age (year) | 39.3±11.0 (21-68) | |
| Sex | ||
| Male | 14 (21.9%) | |
| Female | 50 (78.1%) | |
| Height (meter) | 1.65±0.09 (1.45-1.90) | |
| Weight (kilogram) | 103.7±20.6 (54.3-145.0) | |
| BMI (kg/m2) | 37.7±5.8 (22.7-52.1) | |
| ASA score | ||
| 1 | 35 (54.7%) | |
| 2 | 22 (34.4%) | |
| ≥3 | 7 (10.9%) | |
| Number of comorbidities | ||
| 0 | 2 (3.1%) | |
| 1 | 20 (31.2%) | |
| 2 | 9 (14.1%) | |
| ≥3 | 33 (51.6%) | |
| Diabetes control (n=23) | ||
| OHA | 14 (60.9%) | |
| OHA+insulin | 9 (39.1%) | |
| Smoking | ||
| Yes | 15 (23.4%) | |
| No | 49 (76.6%) | |
| Alcohol consumption | ||
| Yes | 41 (64.1%) | |
| No | 23 (35.9%) | |
| History of abdominal operation | ||
| Yes | 45 (70.3%) | |
| No | 19 (29.7%) | |
BMI = body mass index, ASA = American Society of Anesthesiologists, OHA = oral hypoglycemic agent.
Fig. 1. Distribution of patients' body mass index.
Fig. 2. Patients' comorbidities. GERD = gastroesophageal reflux disease, GB = gallbladder.
2. Surgical results
The most frequently performed surgery was sleeve gastrectomy (53 cases, 82.8%), followed by Roux-en-Y gastric bypass (9 cases, 14.1%), and adjustable gastric banding (2 cases, 3.1%). All the surgeries were performed with laparoscopic procedures. The mean operation time was 156.1±61.8 min, and mean postoperative stay was 4.3±2.0 days. Drainage was performed (38 cases, 59.4%) depending on the operators' preference and surgical situation (Table 2).
Table 2. Surgical result.
| Type of surgery | ||
| Laparoscopic adjustable gastric banding | 2 (3.1%) | |
| Laparoscopic sleeve gastrectomy | 53 (82.8%) | |
| Laparoscopic Roux-en-Y gastric bypass | 9 (14.1%) | |
| Operation time (minute) | 156.1±61.8 | |
| Postoperative stay (day) | 4.3±2.0 | |
| Estimated blood loss (mL) | 34.4±36.9 | |
| First SFD | 2.2±1.3 | |
| Drainage | ||
| Yes | 38 (59.4%) | |
| No | 26 (40.6%) | |
| Transfusion | ||
| Yes | 63 (98.4%) | |
| No | 1 (1.6%) | |
| Number of trocars | ||
| ≤3 | 8 (12.5%) | |
| 4 | 15 (23.4%) | |
| 5 | 19 (29.7%) | |
| ≥6 | 22 (34.4%) | |
SFD = semi-fluid diet.
3. Postoperative morbidity and mortality
Table 3 shows the postoperative morbidity and mortality. The surgical morbidities occurred in 6 patients (9.4%). Three patients developed a staple line leakage that was successfully managed with percutaneous drainage procedure (Clavien-Dindo grade IIIa). One patient corresponded to a Clavien-Dindo grade IIIb. This patient had distal esophageal injury, which was found on postoperative day 1. He was fully recovered after primary closure of perforation site. There was no mortality in this study.
Table 3. Postoperative morbidity and mortality (n=6, 9.4%).
| Number | Clavien-Dindo grade | ||
|---|---|---|---|
| Postoperative morbidity | |||
| #1. Intra-abdominal bleeding→transfusion | 1 | II | |
| #2. Staple line leakage→PCD insertion | 3 | IIIa | |
| #3. Wound complication→wound repair | 1 | I | |
| #4. Esophageal injury→re-operationa | 1 | IIIb | |
| #5. Medical complication | 0 | ||
| Postoperative mortality | 0 | ||
aPrimary closure of perforation site (distal esophagus).
PCD = percutaneous drainage.
4. Comparison before and after public medical insurance coverage
The patient information before and after the public medical insurance coverage was compared. The mean operation time (225.3±85.4 vs. 156.1±61.8, P<0.001) and postoperative stay duration (5.9±4.5 vs. 4.3±2.0, P=0.013) were significantly shorter in group B patients than in group A patients. However, no difference in the surgical morbidity rate (5.2% vs. 9.4%, P=0.375) was observed between both the groups (Table 4).
Table 4. Comparison of patients' information before and after insurance coverage.
| Group Aa (n=58) | Group Bb (n=64) | P-value | ||
|---|---|---|---|---|
| Age (year) | 36.9±11.4 | 39.3±11.0 | 0.247 | |
| Sex | 0.246 | |||
| Male | 8 (13.8%) | 14 (21.9%) | ||
| Female | 50 (86.2%) | 50 (78.1%) | ||
| Height (meter) | 1.64±0.08 | 1.65±0.09 | 0.320 | |
| Weight (kilogram) | 105.6±20.8 | 103.7±20.6 | 0.613 | |
| BMI (kg/m2) | 39.2±6.9 | 37.7±5.8 | 0.207 | |
| Comorbidities | <0.001 | |||
| Yes | 37 (63.8%) | 62 (96.1%) | ||
| No | 21 (36.2%) | 2 (3.9%) | ||
| Operation type | 0.018 | |||
| Adjustable gastric banding | 8 (13.8%) | 2 (3.1%) | ||
| Roux-en-Y gastric bypass | 2 (3.4%) | 9 (14.1%) | ||
| Sleeve gastrectomy | 48 (82.8%) | 53 (82.8%) | ||
| Operation time (minute) | 225.3±85.4 | 156.1±61.8 | <0.001 | |
| Postoperative stay (day) | 5.9±4.5 | 4.3±2.0 | 0.013 | |
| Postoperative morbidity | 3 (5.2%) | 6 (9.4%) | 0.375 | |
aOperations from 2010 to 2018, boperations in 2019 (after insurance coverage).
DISCUSSION
The demand for bariatric and metabolic surgery has considerably increased after its inclusion in the national insurance coverage in Korea. In Daejeon and Chungcheong province, only 58 patients underwent this surgery during 9 years before the insurance coverage, whereas 64 surgeries were performed after the insurance coverage. The number of surgeries in 9 years has been caught up only in the last 8 months. Although some patients who wanted surgery have flocked because of monetary benefits, this can be interpreted that the public perception of bariatric and metabolic surgery is gradually changing. Bariatric and metabolic surgery is now a well-established treatment, which is one of the best option for patients with morbid obesity and uncontrolled diabetes [3,4,5,6].
However, bariatric and metabolic surgery is not a simple procedure that any surgeon can easily access. Patients with morbid obesity who have considerable underlying diseases are usually at a high risk for general anesthesia, and this can be a significant burden on the designated surgeons. In addition, surgeons should be sufficiently accustomed to laparoscopic techniques with gastrointestinal anastomosis overcoming the resistance of thick abdominal wall and obstacles of visceral fat. Finally, patients undergoing bariatric and metabolic surgery tend to think that it is a cosmetic or plastic surgery; hence, when the results are not satisfactory, they complain more seriously. Is there any way to reduce this difficulty and burden of bariatric and metabolic surgery for surgeons with early experiences? There are several ways to solve this problem, but joining a local research society to discuss and learn from each other can be a good option. Through this study, we could show that bariatric and metabolic surgery was performed safely and efficiently in Daejeon and Chungcheong province. Although the postoperative morbidities did not decrease statistically, the mean operation time and postoperative stay were significantly shorter in cases after the public medical insurance coverage than in those before the insurance coverage (Table 4).
As reported earlier last year [8], the Society of Chungcheong Obesity and Metabolic Surgery (SCOMS) actively conducts academic and social activities in the province. First, we prospectively collected data of patients. Our committee selected academic members after discussion, and they revised the data form thoroughly. Subsequently, data collection, which was differently performed for each institution, was integrated into a multi-center data form where important information could be recorded without missing data. Second, we shared our initial experiences frankly. All of our members are general surgeons specialized in gastrointestinal or hepatobiliary division, so we have sufficient experience of basic laparoscopic technique. However, most are inexperienced in bariatric and metabolic surgery because they work at low-volume center in local hospitals. We discussed and shared tips for the surgery, including optimal position of trocars, position of patient, and selection of energy device or linear stapler. Occasionally, non-edited videos were shared to improve surgical techniques, and we often coped with postoperative complications together. Lectures and advices of experienced surgeons also made it easy for the beginners to get started for bariatric and metabolic surgery.
After experiencing early cases of bariatric and metabolic surgery, our society considered some discussion points for becoming advanced in this technique. First is the problem of patient consultation. Most of the morbidly obese patients were young women who had suffered socially or mentally because of their external appearance. They were quite a different patient group compared with common patients in general surgery. We think that the relationship and rapport with patients have a significant effect on the prognosis, including weight loss. Consequently, we should make time for in-depth consultation and to explain the questions one by one. A multidisciplinary approach was also an important factor for managing patients. We met patients who had several underlying diseases acquired secondarily rather than genetic diseases. For better treatment, various departments should collaborate with each other. For example, sophisticated diabetes control, management of sleep apnea, and postoperative medical management should be consulted to respective specialist at any time. As for the surgery, we should not dwell on the time of the surgery and the number of trocars. Accurate and safe procedure is essential for the beginners until overcoming the learning curve. We need to take time for the surgery with precision. In the same context, it will be better to use sufficient trocars until surgeons are accustomed to bariatric and metabolic surgery.
In conclusion, we could investigate the patients who had bariatric and metabolic surgery in Daejeon and Chungcheong province in 2019. The most noticeable changes was the significant increase in the number of surgery after public medical insurance coverage. Our research society will continue to work hard to ensure the safety of the surgery and management of morbidly obese and metabolic patients in our community.
ACKNOWLEDGMENTS
The authors wish to thank the members of our society for data collection and sharing in this study (Dankook University Hospital, Catholic University Daejeon St. Mary's Hospital, Soonchunhyang University Cheonan Hospital, Eulji University Hospital, Chungnam National University Hospital, Daejeon Sun Hospital, Konyang University Hospital).
Footnotes
CONFLICT OF INTEREST: None.
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