Current Trends in Bariatric Surgery
Morbid obesity is diagnosed when a patient has a body mass index (BMI) greater than 40 or a BMI between 35-40 in addition to an obesity-related comorbidity such as diabetes or hypertension. Nearly 18 million adults in the United States are morbidly obese. Multidisciplinary care for these patients is critical and often requires coordination between the primary care physician, nutritionist, health psychologist, bariatric surgeon and medical specialists, including endocrinologists, cardiologists and pulmonologists. The gold standard treatment for morbid obesity is bariatric surgery.
What are the patient benefits?
If your patient meets the BMI and comorbidity above, which were initially established by the National Institutes of Health in 1991, data from more than 30 randomized controlled trials and 125 observational studies involving more than 160,000 patients suggest that bariatric surgery would provide several benefits to your patient. For example, bariatric surgery:
Additionally, complication and mortality rates are low and comparable to other abdominal operations such as colon resection.
Are there any contraindications?
There are few absolute medical contraindications to bariatric surgery, as surgery is often the only evidence-based treatment which addresses many of the health issues that make these patients high-risk surgical candidates, such as coronary artery disease, diabetes and obstructive sleep apnea. The most common relative contraindications for bariatric surgery relate to the patient’s mental health status and comprehension of the lifestyle and dietary changes that are needed to be successful after bariatric surgery. Patients with a significant history of psychiatric disorders or substance abuse are carefully evaluated by each member of the multi-disciplinary team (bariatric surgeon, health psychologist and nutritionist) and their appropriateness for surgery is determined on a case-by-case basis.
Is poorly controlled diabetes a reason for bariatric surgery?
In 2012, two high-profile studies were published in The New England Journal of Medicine 1, 2 which indicated that bariatric surgery plus medical therapy resulted in better glycemic control than medical care alone for obese patients with poorly controlled diabetes. One recent editorial published in The Lancet Diabetes & Endocrinology 3 has advocated for significant expansion of bariatric surgery to include patients with poorly controlled diabetes. Bariatric surgeons in some countries are currently offering bariatric surgery to non-obese diabetic patients, although this is not currently common practice in the United States.
What bariatric operations are most commonly performed in 2014?
Nearly 95% of bariatric operations are performed laparoscopically as opposed to traditional open surgery. Three bariatric operations are commonly performed in the United States today:
At most medical centers across the country, gastric bypass is the most common bariatric operation performed, followed by gastric sleeve resection. Although effective for some patients, gastric banding is the least commonly performed at many institutions due to concerns regarding band erosion, slippage and infection.
Is one operation better than another for certain patients?
Although each bariatric operation will result in significant weight loss and resolution of obesity-related comorbidities, there are some cases in which one operation may be preferred over another. Diabetic patients often experience the best glycemic control with gastric bypass surgery. This is due to the anatomic and physiologic changes that accompany bypass surgery (in addition to the weight loss). Patients with significant gastroesophageal reflux disease are typically better candidates for gastric bypass surgery given that gastric sleeve resections can result in ongoing reflux symptoms. Patients who have undergone abdominal surgery previously and are expected to have significant abdominal adhesions — particularly in the pelvis — may be better candidates for gastric sleeve resection because manipulation of the small bowel is not required.
Does my patient’s insurance plan pay for bariatric surgery?
This is dependent on the specific insurance plans. Bariatric surgery is covered for Medicare patients, patients within the VA system and many state Medicaid plans. Bariatric surgery coverage of privately insured patients is variable. Most insurance plans available to Wisconsin residents do offer bariatric surgery coverage. Members of the bariatric surgery team can help patients and referring providers navigate questions and concerns related to insurance coverage.
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For More Information
For more information about bariatric surgery at UW Health, please visit our Medical & Surgical Weight Management Program.
1 Mingrone G, Panunzi S, De Gaetano A et al. Bariatric Surgery versus Conventional Medical Therapy for Type 2 Diabetes. The New England Journal of Medicine. 2012; 366:1577-1585.
2 Schauer PR, Kashyap SR, Wolski K et al. Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes. The New England Journal of Medicine. 2012; 366:1567-1576.
3 Cummings DE, Cohen RV. Beyond BMI: the need for new guidelines governing the use of bariatric and metabolic surgery. The Lancet Diabetes & Endocrinology. February 2014, 2:175-181.