The current state of bariatric surgery

By Luke Funk, MD

Dr. Luke Funk, Director of MIS Research in the Division of Minimally Invasive, Foregut and Bariatric Surgery, gives an update on the current state of batriatric surgery. Learn more about obesity management options, including baratric surgery and nutrition, at the inaugural University of Wisconsin Obesity Management Summit, May 18-19, 2018

Morbid obesity is diagnosed when a patient has a body mass index (BMI) of greater than 40 or a BMI between 35-39.9 in addition to an obesity-related comorbidity such as diabetes or hypertension. Nearly 18 million adults in the U.S. 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 benefits does bariatric surgery provide for my patients?

If your patient meets the BMI and comorbidity criteria above which were initially established by the National Institutes of Health in 1991, data from more than 40 randomized controlled trials and 125 observational studies involving more than 160,000 patients suggests that bariatric surgery provides several benefits to your patient. It reduces long term mortality, provides significant resolution of comorbidities like diabetes, obstructive sleep apnea, hypertension and hyperlipidemia, improves quality of life and decreases work absenteeism. Complication and mortality rates are comparable to other abdominal operations such as colon resection.

Are there any contraindications to bariatric surgery?

There are few absolute contra-indications 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 contra-indications 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 an indication for bariatric surgery?             

No. In fact the American Diabetes Association recently published guidelines (American Diabetes Association, Obesity Management for the Treatment of Type 2 Diabetes, Diabetes care. 2017;40(Suppl 1):S57-S63.) stating that “metabolic [bariatric] surgery should be recommended to treat type 2 diabetes in appropriate surgical candidates [with BMI >40 or 35-40] regardless of the level of glycemic control or complexity of glucose-lowering regimens.”

What bariatric operations are most commonly performed in 2017?

Nearly 95% of bariatric operations are performed laparoscopically as opposed to traditional open surgery. Nearly 90% of bariatric operations are laparoscopic vertical sleeve gastrectomy, Roux-en-Y gastric bypass, or adjustable gastric banding. Vertical sleeve gastrectomy is currently the most common bariatric procedure performed in the U.S. Although effective for some patients, gastric banding is the least commonly performed in the U.S. due to concerns regarding band erosion, slippage and infection.

Is one operation better than another one for certain patients?

Although each bariatric procedure will result in significant weight loss and resolution of obesity-related comorbidities, there are some cases where 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 for those patients. 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 depends 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. Coverage for state employees is limited to one plan. Members of the bariatric surgery team can help patients and referring providers navigate questions and concerns related to insurance coverage.

Learn more about obesity management

Mark your calendars for the inagural University of Wisconsin Obesity Management Summit, May 18-19, 2018, held in Madison, WI. The summit will be a chance for medical professionals to connect and discuss cutting edge obesity management approaches, including nutrition and bariatric surgery. Learn more about this event online.