Bariatric surgery assessed by the Belgian Health Care Knowledge Center (KCE)

In June 2019, the Belgian Health Care Knowledge Center (KCE) published a report of the health technology assessment of bariatric surgery.

Reimbursement of bariatric surgery is currently restricted with inclusion criteria dating from 2010. Meanwhile, new scientific evidence has emerged, making these criteria potentially obsolete. The latest report provides an up-to-date evaluation of the clinical effectiveness, safety, and cost-effectiveness of bariatric surgery.

This HTA evaluates the most commonly used and best-documented techniques, which are the Roux-en-Y Gastric Bypass (RYGB), and the Sleeve Gastrectomy (SG), while some data and medical discussion also refer to a much lesser extent to laparoscopic adjustable gastric banding (LAGB), an intervention that was frequently performed until some time ago, and which now largely is being abandoned, mainly for safety and tolerance reasons.

The scope of the report does not include other historical bariatric interventions, RYGB options, more recent, but less established interventions, such as gastric bypass with a single anastomosis (OAGB, or so-called “mini-gastric bypass”). It also excludes the new, less known (gastroscopic) methods, such as balloons, endo-barrier, and transoral endoscopic gastroplasty.

Overall conclusion on clinical effectiveness and safety:

• MBS (metabolic and bariatric surgery) currently is the most effective durable treatment for morbid obesity (body mass index (BMI)  ≥40) and for severe obesity (BMI ≥35) associated with complications or significant co-morbidities, this in terms of successful weight reduction
• MBS can lead to better health status and outcomes overall
• When patients are screened and evaluated preoperatively well, the overall benefit-risk balance is positive. However, the benefit-risk balance will vary from patient to patient
• Based on the extensive safety review, it is clear that the decision to opt for MBS is not a decision that can be taken easily. MBS is not a miracle solution that will resolve everything or all aspects of obesity. The correct implementation of life-long lifestyle changes with regard to a correct adapted healthy diet and physical exercise remains crucial, as is the required compliance with lifelong medical follow-up
• Specific note on MBS in adolescents - the available evidence suggests that short-term effectiveness and safety outcomes of bariatric surgery in adolescents are comparable to those observed in adults. However, robust long-term data on the effectiveness and safety of bariatric surgery in adolescents are lacking

• Specific note on MBS in obese patients with type 2 diabetes and a BMI between 30-34.9 kg/m2:

• Randomized clinical trial evidence on diabetes remission in patients with a BMI of 35 kg/m². Bariatric surgery may improve the quality of life in diabetic patients with a BMI between 30 and 35 kg/m². (Low level of evidence). Direct evidence on long term survival specifically for diabetic patients with BMI between 30 and 35kg/ m² is not available

Results of economic evaluations:

• Results from the identified economic assessments show that bariatric surgery in the current reimbursement criteria can be considered a cost-effective intervention. In people with high BMI levels and/or diabetic patients, the intervention could even be dominant (i.e., better outcomes and fewer costs) if outcomes are modeled over a long-term horizon
• In relation to adolescents, the conclusions of the identified studies are in general positive. However, given the shortcomings of the economic evaluations, the studies are somewhat hypothetical and show the potential cost-effectiveness of bariatric surgery for adolescents with morbid obesity when a long-term horizon is modeled

See the full-text report in English here. The language can be changed to French or Dutch in the top-left corner.

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