Perioperative Care and Shared Decision Making (SDM)
Perioperative Medicine, which addresses the comprehensive care of patients from the time of surgical diagnosis to their best recovery, has as one of its tenets, shared decision making [SDM]. Armed with the best evidence and facts, patients can engage in decisions about their individual medical and surgical care. Long before the term SDM appeared, anesthesia clinicians have been thoughtful participants in this practical approach. By carefully reviewing options with health care providers, we empower patients to make decisions that are best for their individual goals/objectives, bearing in mind their risk profile.
A recent article in the October 15, 2020 issue of NEJM (New England Journal of Medicine), concerning bariatric surgery, provides a complex and sophisticated consideration of the SDM tenets. The Life Expectancy after Bariatric Surgery in the Swedish Obese Subjects Study [“SOS Study”] compared three cohorts of patients: i) control group: approximately 2,050 obese patients receiving usual obesity care; ii) surgery group: approximately 2,000 receiving bariatric surgery and iii) reference group: approximately 1,100 reference group: non-obese patients; with a mean follow-up for mortality of approximately 20, 22, and 24 years, respectively. Upon follow-up, 22.8% of surgical patients had died compared to 26.4% of controls [hazard ratio of 0.77]. For patients that underwent surgery, compared to patients in the reference group, the hazard ratio for death due to cardiovascular disease and cancer was 0.70 and 0.77, respectively.
The SOS study affirmed that being obese leads to shortened life expectancy and that bariatric surgery is not a panacea. As a cohort, the obese subjects lived an average of 5.5 years fewer than the SOS reference group. That said, for patients who have struggled with persistent weight loss, when compared to reference group, the SOS Study demonstrated that bariatric surgery may extend an obese patient’s life by 3 years.
Importantly, 5 patients within the surgery group died within 90-days following surgery compared to the reference group. Modern sophisticated approaches to perioperative care suggest that future studies may show a more substantial impact.
When talking with obese patients contemplating bariatric surgery and reviewing the above risks, the SOS Study may reassure and reenforce decisional confidence. Although the risk of morbidity and mortality should never be understated, it might be counterbalanced by the prospect of increasing longevity by about 3 years.