The Second Nordic Bariatric Meeting

Uppsala, Sweden
March 20–21, 2014

by Magnus Sundbom, MD

Dr. Sundbom is from the Department of Surgery, University Hospital, Uppsala, Sweden.

FUNDING: No funding was provided.
DISCLOSURES: The author reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2014;11(5):24–26.

The Second Nordic Bariatric Meeting: The Highlights
More than 60 bariatric surgeons from the Nordic countries Norway, Sweden, Finland, Denmark, and Iceland had challenged a sudden massive snowfall and gathered outside Uppsala, Sweden, for the biannual Nordic Bariatric Meeting. The meeting was held at Krusenberg, a mansion dating back to 1802. Dr. Raul Rosenthal was the key-note speaker and international guest. The meeting focused on surgical treatment in super obesity, failed gastric bypass, and metabolic surgery, including a session on gastric sleeve, a rather infrequent procedure in the Nordic countries. Although the Nordic countries have much in common, including way of life, social structure, and public financed healthcare, the circumstances for bariatric surgery differ.

Bariatric Surgery In The Nordic Countries
Bariatric surgery has been performed since the 1950s in the Nordic countries, with pioneering work in jejuno-ileal bypass, laparoscopic VBG,[1] and a short, but intense, period of adjustable gastric banding, sometimes referred to as the Swedish Band.[2] Inspired by the United States, gastric bypass has dominated bariatric surgery during the last two decades, making this corner of the world true gastric bypass-land, as characterized by Dr. Raul Rosenthal. The five Nordic countries have 26 million inhabitants in total. In general, healthcare is publically financed and provided irrespectively of income or private insurances.

In Norway, as presented by Dr. Jon Kristinsson, the traditional The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) indications (BMI>40kg/m2 or 35kg/m2 with comorbidities) are used. Bariatric surgery been centralized by the health authorities to a few selected hospitals in each of the four health regions. In 2012, 2,948 bariatric procedures (73% gastric bypass, 27% sleeve, and a few duodenal switches) were performed, almost all by laparoscopy. Two-thirds of the procedures were performed in public care and the remaining part performed in private care. The proportion of sleeve was higher. Norway is about to join the Scandinavian Obesity Surgery Register (SOReg), which was started in Sweden in 2007.

The situation in Sweden was presented by the head of the national quality register, SOReg, Johan Ottoson. At present, the SOReg-material contains 39,000 bariatric procedures, 97 percent of all performed procedures, and covers all Swedish centers. In total, the number of procedures has increased 10-fold, from 700 to 7,500 in 2012, thus reaching almost 100 bariatric procedures per adult 100,000 inhabitants. Per capita, this puts Sweden in second place according to data from the world wide survey by Buchwald in 2011.[3–4] Laparoscopic gastric bypass dominates (95%), but a small increase in sleeve can be seen (5% of all procedures in 2013). Duodenal switch is performed in selected hospitals. Although 92 percent of all bariatric procedures had been financed by public care, a surprisingly large proportion, 43 percent, were performed at private clinics. The SOReg-data demonstrate low complication rates: leakage 1.5 percent, postoperative abscess 1.2 percent, and bleeding 2.2 percent, with a low 30-day morality of 0.04 percent.[5] Nationally, the lower BMI-limit has recently been set to 35kg/m2, irrespective of comorbidities.

In Finland, as presented by Mikael Victorzon, gastric bypass is most common (90%), followed by sleeve (7–8%), and duodenal switch together with other procedures (2–3%). Despite the 10-fold increase in the number of procedures, from 100 in 2003 to 1,054 in 2012, the total number of procedures is still low compared to the estimated need (5,000 procedures/year). This is probably due to low referral rates, despite presented benefits in health care and economy.[6] Bariatric surgery is performed at 12 public hospitals and five private clinics, with only two centers reaching 100 operations per year. Due to very strict laws concerning the Secrecy Act and official registries, it is not possible to create a national registry. The prospective randomized study, Sleevepass,[7] will, however, present good outcome data on sleeve and gastric bypass in the Finnish population.

In Denmark, a dramatic change in bariatric surgery was presented by Lars Naver. In 2005 to 2010, when standard IFSO-criteria were used, an expansion from 300 to almost 4,500 cases/year was seen. Specified requirements concerning quality (e.g. >100 annual procedures), high competence in laparoscopy, and close cooperation with anesthesiology and medical departments were set by the Danish Health and Medicines Authority, These requirement were most likley enforced due to high cost and loss of control, as an unusually large amount of procedures for a Nordic country (70%), was performed in private care. The new administrative indications set by the government in 2010 are as follows: 1) over 25 years of age, BMI above 50kg/m2 (or 35kg/m2 in combination with serious comorbidities [e.g., CPAP-demanding sleep apnea or type 2 diabetes, which is difficult to regulate]). This has resulted in a large decrease in the annual number of bariatric procedures, from almost 4,500 to 895 in 2013, as the private sector almost disappeared. On the national level this has been a very surprising development in a Nordic country.

Finally, the situations of two countries outside the Nordic region, having totally different maturity in bariatric surgery, Lithuania and the United States, were presented. In Lithuania, situated in the Baltic, bariatric surgery has just started, and about 250 procedures are performed annually in 3.25 million inhabitants, according to Almantas Maleckas. At present, patients have to pay for single-use instruments as the reimbursement for bariatric surgery is low. In 2013, this resulted in a large proportion of gastric plications (n=50), compared to the more expensive gastric bypass (n=110) and adjustable gastric band (n=80). Together with other national associations, the Lithuanian bariatric society has submitted a request for complete reimbursement of laparoscopic gastric bypass and adjustable gastric bands in patients with diabetes and BMI over 35kg/m2. Dr. Raul Rosenthal revealed that in the United States, a genuine high-volume country with 170,000 annual procedures, sleeve has now become the most frequent bariatric procedure. During the last years, a large rise in sleeve (18 to 42%) has been seen parallel to a corresponding decrease in the proportion of bands (35 to 14%), with a constant (35 percent) of gastric bypass. These figures surprised the audience and increased the interest for Dr. Rosenthal’s talk on sleeve the following day.

The Organizing Committee of the Second Nordic Bariatric meeting would like to thank all presenters and delegates for taking part in the vivid discussion during this memorable meeting. As the present and former Nordic meetings have been arranged on an individual basis, a Nordic Council was formed after an initiative by Dr. Raul Rosenthal. The appointed group, Drs. Jon Kristinsson, Norway; Magnus Sundbom, Sweden; Paulina Salminen, Finland;Lars Naver, Denmark; and Jakob Hedberg; Sweden has already started to work on improved Nordic collaboration and a new joint meeting in 2016.

References
1. Lönroth H, Dalenbäck J, Haglind E, et al. Vertical banded gastroplasty by laparoscopic technique in the treatment of morbid obesity. Surg Laparosc Endosc. 1996;6(2):102–107.
2. Forsell P, Hallberg D, Hellers G. Gastric banding for morbid obesity: Initial experience with a new adjustable band. Obes Surg. 1993;3(4):369–374.
3. Sundbom M, Hedberg J. Trends in use of upper abdominal procedures in Sweden 1998-2011: a population-based study. World J Surg. 2014;38(1):33–39.
4. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23(4):427–436.
5. Stenberg E, Szabo E, Agren G, et al; For the Scandinavian Obesity Surgery Registry Study Group. Early complications after laparoscopic gastric bypass surgery: Results from the Scandinavian Obesity Surgery Registry. Ann Surg. 2013 Dec 26. [Epub ahead of print].
6. Mäklin S, Malmivaara A, Linna M, et al. Cost-utility of bariatric surgery for morbid obesity in Finland. Br J Surg. 2011;98(10):1422–1429.
7. Helmiö M, Victorzon M, Ovaska J, et al. SLEEVEPASS: a randomized prospective multicenter study comparing laparoscopic sleeve gastrectomy and gastric bypass in the treatment of morbid obesity: preliminary results. Surg Endosc. 2012;26(9):2521–2526.

Tags: bariatric surgery

Category: Past Articles, Symposium Synopsis