Bariatric Procedures for Severe Obesity
Operations for weight loss include a combination of volume-restrictive, intestinal hormone alteration, and nutrient-malabsorptive procedures that affect satiety, absorption, and insulin sensitivity in conjunction with behavior modification to achieve and sustain weight loss.
A consultation with a multidisciplinary bariatric team provides extensive education on nutrition, good psychological responses, and lifestyle modification needed for a patient to be successful with a surgical weight loss procedure. Proper bariatric care also includes lifelong surveillance. A reliable bariatric program will provide a comprehensive information session for potential surgical candidates that will detail realistic outcomes from weight loss surgery, including morbidities and mortalities.
This topic will review the contemporary, investigational, revisional, and obsolete bariatric procedures offered to patients with a surgical indication. The indications are a body mass index (BMI) of greater than or equal to 40 kg/m2, a BMI of 35 to 39.9 kg/m2 with an obesity-related comorbidity (eg, diabetes, hypertension, gastroesophageal reflux disease, osteoarthritis, among many others), or a BMI of >30 kg/m2 with difficult-to-control type II diabetes mellitus or dysmetabolic syndrome X.
Bariatric surgery is one of the fastest-growing operative procedures performed worldwide, with an estimated >579,000 operations performed in 2014 .In the United States, close to two million patients underwent bariatric surgery between 1993 and 2016, during which time the field has evolved from exclusively open surgery (gastric bypass or vertical banded gastroplasty) to 98 percent laparoscopic surgery (sleeve gastrectomy or gastric bypass) . Complication and mortality rates have decreased from 11.7 and 1 percent in 1998 to 1.4 and 0.04 percent in 2016. Despite that, only 0.5 percent of eligible patients actually underwent bariatric surgery in 2016 (compared with 0.07 percent in 1993 and 0.62 percent in 2004). This low percentage of utilization is likely the result of many factors.
The increase in the number of patients who need bariatric surgery has likely outpaced the increase in the volume of bariatric surgeries performed. Some patients can be managed without surgery, while others are not suitable surgical candidates because of behavioral or psychosocial issues. There continues to be referral bias from clinicians who still believe either that obesity is a behavior problem rather than a disease for which surgery can be therapeutic, or that bariatric surgery is too risky. Finally, there remains payer resistance to covering bariatric surgery despite its well-documented cost effectiveness.
