Obesity is a chronic disease whose prevalence has increased to epidemic proportions in North America and across the world. Leading organisations in healthcare have compiled guidelines to help primary care practitioners screen, manage and treat patients with overweight and obesity. This review is the final part of our three-part series conducting an overview of the current clinical guidelines for obesity management. In this review, we provide an overview of the types of bariatric surgery, eligible populations, weight loss outcomes and future directions of surgical intervention for weight loss. Obesity is an important health issue that can lead to significant impacts on the heath. In severe cases, bariatric surgery is an appropriate intervention to help patients lose weight. This weight loss is associated with improved quality of life and comorbidity remission.
Background
Obesity is one of the most prevalent epidemics in North America.1 It is a chronic, multifactorial disease whose aetiology is multifaceted and still not completely understood. Clinical guidelines have been released by several organisations in an attempt to help primary care providers manage their obese and overweight patients.2 Thus far in our three-part series, we have explored the epidemiology, prevalence and causes of obesity as well as some first-line (diet and exercise) and second-line (pharmacotherapy) interventions to help obese patients lose weight. For patients with severe obesity, bariatric surgery is an appropriate weight management intervention to explore. In this paper, we provide an overview of the types of bariatric surgery available to patients as well as their effects on weight loss.
Prevalence of bariatric surgery
Because of the efficacy of bariatric surgery for weight loss in patients with severe obesity, the number bariatric surgeries performed in the USA has increased substantially from 2011 to 2020 (online supplemental table 1).3 In 2011, the total number of bariatric surgeries performed was just over 150 000. In 2019, this number increased to 256 000. Most of these procedures involve the sleeve gastrectomy and the Roux-en-Y gastric bypass or involve revisions of these surgical techniques. Globally, the number of bariatric surgeries being performed is also increasing. Growth is the most apparent in countries such as Belgium and France.4 However, despite 1.9 billion adults suffering from overweight and 650 million suffering from obesity, only 1%–2% of these individuals undergo surgical intervention for this disease. This is a testament to the underutilisation of this therapy for the management of obesity and metabolic disease.
Patient selection & pre-operative workup
In order to minimise postoperative complications, guidelines have stipulated a specific patient population eligible to receive surgical interventions for weight loss. Canadian guidelines suggest that bariatric surgery be considered for individuals with body mass indexes (BMIs) of >40 kg/m² or >35 kg/m² with one obesity-related disease.2 However, the 2022 American Society for Metabolic and Bariatric Surgery and International Federation for the Surgery of Obesity and Metabolic Disorders guidelines outline that bariatric surgery should be considered for patients whose BMI is≥35 kg/m2, regardless of presence, absence or severity of comorbidities.5 Importantly, patients with a BMI of 30–34.9 kg/m² and weight-related comorbidities may also benefit from bariatric surgery if previous unsuccessful weight loss attempts, either lifestyle modification or antiobesity medication, have not worked.6 Indications for bariatric surgery differ depending on race. According to guidelines, the Asian population is eligible for bariatric surgery at a BMI of ≥27.5 kg/m2 since clinical obesity is diagnosed at a BMI of >25 kg/m2.5 Predictors of successful postoperative weight loss include patients who implement lifestyle modifications such as diet and exercise in addition to their surgery as well as behavioural modifications like meditation or mindfulness.7 Other predictors include the presence of loss of control eating, sociodemographic factors, severity of eating disorder pathology and psychological comorbidity.8
Several screening tests must be performed before surgery can be performed on a patient. Guidelines suggest physicians perform cardiac and pulmonary evaluation as well as sleep apnoea screening on patients potentially undergoing bariatric surgery. Cardiovascular (CV) disease is a common comorbidity of obesity and could cause postoperative complications.9 Abnormal echocardiogram results are also associated with a higher risk of surgical complications. Patients with obesity are also susceptible to respiratory trouble. Restriction in lung volumes and abnormal respiratory mechanics can be detrimental during surgery.10 11 Lastly, sleep apnoea screening should be performed prior to surgery since this could cause problems with intubation and can lead to intensive care unit admissions.12 13
Bariatric surgery
The four major bariatric surgery procedures performed include the sleeve gastrectomy, gastric bypass (Roux-en-Y), adjustable gastric banding and biliopancreatic diversion (with or without duodenal switch).14 These procedures are mostly performed laparoscopically since laparoscopic procedures are considered safer than open surgery as less patients suffer from infection or hernia.15 The decision as to which type of bariatric surgery to perform should be approached by a multidisciplinary team of clinicians (bariatric nurse, dietitian, mental health specialist, social worker, internist and surgeon) and be based on the patient’s weight loss goals, medical history, comorbidities and side effects.6
Gastric banding
Gastric banding, more commonly known as the lap band, involves the installation of an adjustable band around the superior portion of the stomach (figure 1A). This band is tightened through the use of a subcutaneous pouch to restrict the amount of food let into the stomach. This type of surgery is associated with low risk of short-term complications, but a higher risk of long-term complications.6 These complications include band slippage, erosion and weight regain. For these reasons, other bariatric surgery procedures have been gradually replacing this procedure. Adjustable gastric banding is associated with a 45.5% excess weight loss (%EWL).16 %EWL is defined as the loss of excess weight in kg above the BMI of 25 kg/m² expressed as a percentage of initial weight. A randomised clinical trial (RCT) evaluating weight loss effects of gastric banding revealed that patients lost on average −27.4±14.5 kg.17 An excess weight loss of 14% was considered significant in this study. Over a follow-up period of 10 years, patients maintained a significant weight loss of −21.2%±11.9%. When compared with medical management in type II diabetes patients, patients with type II diabetes receiving gastric banding surgery lost more weight compared with patients receiving medical management (12.0±2.0 kg (95% CI −15.9 to −8.1) compared with 4.8±2.0 kg (95% CI −8.6 to −0.9), p=0.010).18 These patients also had greater EWL (−38.2%±7.0% vs −17.8%±7.0%, p=0.039).18 Therefore, compared with non-surgical weight loss approaches, gastric banding is superior at promoting weight loss and weight loss maintenance.
Visual representations of the four main kinds of bariatric surgery. (A) Sleeve gastrectomy, (B) Roux-en-Y gastric bypass, (C) adjustable gastric banding and (D) biliopancreatic diversion. Reproduced with permission from Philip R. Schauer https://doi.org/10.3949/ccjm.84.s1.06.
Sleeve gastrectomy
Sleeve gastrectomy is performed laparoscopically. The surgeon removes 80% of the stomach, leaving behind a banana-shaped organ (figure 1B).19 This procedure significantly reduces the size of the stomach, and therefore, limits the amount of food a patient can eat. Removing a portion of the stomach also reduces the amount of ghrelin it can produce and decreases appetite and cravings. Recently, this type of procedure has been performed the most in North America and worldwide (58.3% and 49.5%, respectively).6 Sleeve gastrectomy is associated with a 64% EWL.20 Over a follow-up period of 5 years, patients in the SLEEVEPASS RCT observed 49% EWL (95% CI 45% to 52%) compared with baseline.21 In the SM-BOSS RCT, patients in the sleeve gastrectomy arm lost 61.1% excess BMI after 5 years compared with 68.3% in the Roux-en-Y group (absolute difference, −7.18%; 95% CI −14.30% to −0.06%; p=0.22).22 In a prospective randomised study, patients with a baseline BMI of 47.3±6.58 kg/m2 had an average BMI of 27.42±4.47 kg/m2 after undergoing sleeve gastrectomy.23 Short-term complications (<30 days post operation) of this type of surgery include venous thromboembolism, gastrointestinal or intra-abdominal bleeding, staple line leak and wound infection while long-term complications (> 30 days postoperation) include sleeve stricture, gastro-oesophageal reflux disease, cholelithiasis, incisional hernia and nutritional and vitamin deficiencies.24 This procedure has significantly less complications compared with other types of procedures like gastric bypass. When compared with the gastric bypass and the biliopancreatic diversion, the sleeve gastrectomy is a less invasive and a lower-risk procedure which contributes to its increased frequency among patients with severe obesity. Although the gastric sleeve also has significant weight loss, the degree of weight loss is generally not as great as the percent initial weight loss associated with gastric bypass and the biliopancreatic diversion.
Roux-en-Y gastric bypass
During Roux-en-Y gastric bypasses, the surgeon reduces the stomach to a small pouch and connects it to the Roux limb of the duodenum (figure 1C). Like the sleeve gastrectomy, the stomach’s reduced size limits the amount of food the patient can consume, thus reducing their weight. Gastric bypass has been associated with an approximate 56.7% EWL.16 The Swedish Obese Subjects (SOS) RCT revealed that patients undergoing a Roux-en-Y bypass experienced a 27% maintenance loss of initial body weight 15 years after the operation.25 The Utah Obesity longitudinal study evaluated patients receiving gastric bypass surgery with two non-randomised matched control groups and determined that surgery patients lost on average 27.7% of their body weight at 11 years follow-up, similar to the SOS study which was at 15 years follow-up.26 Complications postoperation include bowel obstruction, venous thromboembolism, gastrointestinal or intra-abdominal bleeding, anastomotic leak, infection and internal hernia in the first 30 days of recovery.24 Past 30 days, the patient has been at risk for anastomotic stricture, bowel obstruction, marginal ulceration, cholelithiasis, incisional hernia, nutritional and vitamin deficiencies, dumping syndrome, malabsorption, gastrogastric fistula and internal hernia.
Biliopancreatic diversion
Biliopancreatic diversion is the most invasive type of procedure and is mostly used in extreme cases of obesity (BMI >50 kg/m2).27 It requires two steps (figure 1D). The first is a sleeve gastrectomy. The second is a bypass procedure where the end of the intestine is connected to the duodenum. This procedure restricts the amount of absorption that can occur in the intestine. Biliopancreatic diversion (with duodenal switch) has been associated with a 27% EWL16 in one systematic review while another systematic review reported a 72% (62%–75%) EWL%.28 At 2 years postoperation, patients undergoing this type of surgery reported an average loss of −33.82%±10.17% of their initial body weight compared with non-surgical intervention.29 The same study also evaluated changes in BMI (45.14±7.78– 29.19±4.90) and waist circumference (−20.7±8.34 cm). Since biliopancreatic diversion surgery is the most drastic and invasive of bariatric surgeries, its complications are more frequent and numerous. Seven per cent of patients receiving this procedure experience serious adverse events at <30 days postoperation.30 31 Thirty-day mortality is 1.1% and 90-day mortality is 1.3%. The most common short-term complications include gastric leak (1.5% of 1000 patients), duodenal leak (1.5% of 1000 patients), and anastomotic stenosis/small bowel obstruction (0.9% out of 1000 patients).32 Long-term complications include small bowel obstruction, malnutrition, incisional hernias, diarrhoea, abdominal bloating, malodorous flatus/stool and vitamin deficiency with 7.2% out of 1000 patients experiencing at least one of these events.32 This type of surgery is often associated with malabsorption, malnutrition and diarrhoea.33 Therefore, revision can be required to rectify significant long-term side effects including malnutrition, diarrhoea, perianal lesions, altered calcium metabolism and anaemia. Studies have shown that revisional surgeries can significantly improve side effects and interestingly, increase weight loss.33 Surgical revisions included elongating the common limb from 50 cm to 200 cm and reducing gastric pouch volume from 500 mL to 40 mL.34
Impact of bariatric surgery on morbidity and mortality
The significant weight loss patients experience postbariatric surgery has been proven to have implications for comorbidities and overall mortality. Table 1 outlines the four main bariatric surgery procedures and their effects on weight loss, comorbidity resolution and mortality rate. All bariatric surgery methods have similar mortality rates.35 Biliopancreatic diversion with duodenal switch is the most effective surgical technique, as it has the highest total weight loss and highest resolution rates of comorbidities such as diabetes, sleep apnoea and hypertension. However, compared with gastric banding, sleeve gastrectomy and Roux-en-Y, biliopancreatic surgery has slightly higher serious adverse events and long-term risks which can be linked to its complicated procedure. Further studies confirm the outcomes of bariatric surgery on patient’s health. A meta-analysis evaluating the effect of bariatric surgery on CV disease outcomes revealed that surgery had a positive effect on all-cause mortality (HR 0.55; 95% CI 0.49 to 0.62, p=0.001 vs controls) and CV mortality (HR 0.59, 95% CI 0.47 to 0.73, p=0.001).36 In addition, patients undergoing surgery had reduced occurrence of heart failure (HR 0.50, 95% CI 0.38 to 0.66, p=0.001), myocardial infarction (HR 0.58, 95% CI 0.43 to 0.76, p=0.001) and stroke (HR 0.64, 95% CI 0.53 to 0.77, p= 0.001) (figure 2). Interestingly, a non-significant association was observed between bariatric surgery and atrial fibrillation (HR 0.82, 95% CI 0.64 to 1.06, p=0.12). Bariatric surgery also reduces incidences of type II diabetes and microangiopathic and macroangiopathic diabetic complications.37–40 A controlled study in patients undergoing laparoscopic gastric banding revealed that compared with controls, patients receiving gastric banding had a reduced incidence of diabetes (15 vs 48 cases, p=0.035).39 Similar outcomes were observed in other procedures such as gastric bypass and sleeve gastrectomy where patients saw a reduction in cases of diabetes (p = 0.001), CV disease (p = 0.001), hyperlipidaemia (p = 0.001) and cancer (p = 0.001).40 The clear benefits of bariatric surgery in reducing morbidity and mortality make it a viable option for patients with severe obesity.
Forest plot of pooled HRs of atrial fibrillation, heart failure, myocardial infarction and stroke.36
Table 1
|
Comparison of bariatric surgery outcomes
The bariatric surgery field is rapidly evolving, and new methods are arising to better treat patients with severe obesity. Single anastomosis duodenal switch, a variation of the biliopancreatic duodenal switch procedure, was recently endorsed by the International Federation for the Surgery of Obesity and American Society for Metabolic and Bariatric Surgery.41 The basic method includes a sleeve gastrectomy and a duodenal transection. The simplified procedure helps reduce postoperative complications, increasing the accessibility of this procedure. Small studies have revealed that this procedure encourages weight loss of approximately 37%–38.9% in the first year to 34%–39%% in the second year.41 In addition, 88%, 60% and 40% of patients with type II diabetes, hypertension and dyslipidaemia experienced complete remission, respectively.
Gastric plication aims to duplicate the effects of sleeve gastrectomy while avoiding additional resection and stapling.42 This procedure is associated with significant gastric leak, food intolerances and nausea. At 1-year postoperation, BMI reduction went from 40.72±7 to 33.75±5 kg/m2 (p<0.001) and at 2 years BMI remained at 32.11±5 kg/m2 (p<0.001).43 Compared with the safer alternative, sleeve gastrectomy, it is unclear whether or not this procedure is beneficial in the long term.
As an alternative to the Roux-en-Y gastric bypass, single-anastomosis gastric bypass was developed to overcome the technical limitations of Roux-en-Y and sleeve gastrectomy.6 This procedure is mostly performed in Europe and Asia. Studies reveal that single-anastomosis gastric bypass encourages similar reductions in weight compared with sleeve gastrectomy and gastric bypass with %EWLs of 58% for single-anastomosis gastric bypass, 60.2% for Roux-en-Y gastric bypass and 49.7% for sleeve gastrectomy at 6 months follow-up.44 This procedure also has improved comorbidity remission rates compared with more common procedures at 2 years postsurgery (91.9% for type II diabetes in single-anastomosis gastric bypass vs 83.6% and 81.9% in Roux-en-Y gastric bypass and sleeve gastrectomy).44 Other analyses report similar or slightly lower remission values for type II diabetes (80.6% for single-anastomosis gastric bypass, 81.7% for Roux-en-Y gastric bypass and 77.1% for sleeve gastrectomy).45 Single-anastomosis gastric bypass has been associated with significant levels of bile acid reflux and increased risk of oesophageal and gastric cancer.46 Due to this, the long-term risks and benefits of this procedure remain to be examined.
Several endoscopic procedures can also be performed in lieu of metabolic surgery for patients who are not eligible for bariatric surgery and those who want to avoid postsurgical complications.47 A popular option is the intragastric balloon. The procedure involves the introduction of an inflatable gastric balloon in the stomach.48 This procedure is an option available for patients who are not suitable candidates for bariatric surgery.49 A study published in the Lancet in 2021 examines the use of an adjustable gastric balloon for the treatment of obesity.50 This is an open-label, multicentre, randomised controlled trial where 288 patients were randomised to the intragastric balloon procedure or a control. The mean total body weight lost at 32 weeks was 15% in the treatment group vs 3.3% in the control group. For patients who cannot receive bariatric surgery, intragastric balloons are a potential alternative for losing weight and maintaining weight loss.
A similar procedure to the RYGB called the endoscopic bypass involves placing a sleeve around the duodenum that is removed after 6 months.51 This intervention helps undigested food avoid bile acids and travel to the jejunum, thus reducing the amount of caloric absorption. Studies have shown that this procedure encourages a 32% EWL (−5.1 kg; 95% CI −7.3 to –3.0) compared with 16.4% EWL in control groups.52 53 Despite the apparent benefits of this procedure, a significant amount of patients (3%) experience serious adverse events such as acute pancreatitis, device migration and excess bleeding.54–56 Therefore, more research must be conducted on this procedure to determine its wide-spread viability.
Endoscopic sleeve gastroplasty, or the Pose procedure, reduces gastric volume using sutures in the fundus on the stomach.57 Compared with behavioural interventions, this procedure causes a 4.9%±7% vs 1.4%±5.6% (p<0.0001) weight loss in treatment versus control arm.58 Aspiration technology is another endoscopic procedure that can be used to aspire up to 30% of the calories from a meal. Patients undergoing this procedure have been shown to lose 12.1%±9.6% total body weight, compared with behavioural counselling (3.5%±6.0% total body weight (p<0.001)).59 Adverse events include nausea, vomiting, abdominal pain and infection. As with other endoscopic procedures, the long-term viability of this treatment is unknown.
Aspiration therapy, another type of endoscopic bariatric therapy, was approved by the FDA in 2016 for use in patients with a BMI of >35–55 kg/m2.60 Patients use a percutaneous gastrotomy tube to aspirate part of their meal and reduce the number of calories they intake. It is used in conjunction with lifestyle modifications in patients who have trouble losing weight or maintaining weight loss. Studies have shown that, compared with lifestyle therapy alone, aspiration therapy promotes a 18.6% body mass reduction at 1-year postinitiation.61 At 2 years, this loss rises to 20.1%. The PATHWAY study was a large multicentre randomised controlled trial evaluating the efficacy and safety of aspiration therapy for weight loss in patients with obesity.62 On follow-up from 1 to 4 years postinitiation of the therapy, participants were able to maintain a 14.2% total weight loss at 1 year, 15.3% total weight loss at 2 years, 16.6% total weight loss at 3 years and 18.7% total weight loss at 4 years follow-up.62 Therefore, for patients with class II and III obesity, aspiration therapy can be a useful option to encourage weight loss.
Comparison of bariatric surgery procedures
Different surgical options are more beneficial to patients depending on their BMI, medical history and comorbidities. When comparing weight loss, biliopancreatic diversion with duodenal switch is the most effective procedure, followed by Roux-en-Y gastric bypass, sleeve gastrectomy and gastric banding.63 However, when taking into account the patients’ health-related quality of life postsurgery, sleeve gastrectomy and Roux-en-Y gastric bypass are better options compared with duodenal switch.64 Furthermore, risk of complication increases with the complexity of the procedure. Therefore, patients who undergo biliopancreatic diversion have a higher risk of experiencing serious adverse events and mortality compared with those who undergo gastric bypass and sleeve gastrectomy.65 For patients with type II diabetes, sleeve gastrectomy and Roux-en-Y gastric bypasses have similar rates of remission while biliopancreatic diversion is superior to both.66 Biliopancreatic diversion without duodenal switch is the most effective procedure for patients with dyslipidaemia (remission rate of 99.1%), followed by gastric bypass (95%) and gastric banding (78.3%).28 Similar trends are observed in remission rates for obstructive sleep apnoea (biliopancreatic diversion with/without duodenal switch>sleeve gastrectomy>gastric bypass>gastric banding).67 Hence, there is no single procedure that is the most beneficial for all patients. Physicians and patients must decide which procedure to explore based on comorbidity profile, preferences and benefits versus risks of each surgery.
Pharmacotherapy postsurgery
There are no guidelines surrounding the perioperative use of antiobesity medications in bariatric surgery patients. However, data suggest that using pharmacotherapy after bariatric surgery could help patients maintain weight loss. These studies should be used to guide physicians who wish to prescribe medication postsurgery. Studies have shown that preoperative weight loss can be beneficial in patients undergoing gastric bypass but not sleeve gastrectomy.68 69 Patients with severe obesity administered phentermine/topiramate 7.5–46 mg daily experience greater postoperative weight loss at 2 years follow-up compared with non-medicated groups.70 A recent study evaluating the use of semaglutide and liraglutide postsurgery for maintenance of weight loss reports that, in patients with a postsurgical weight gain of 15%, use of GLP-1 receptor agonists promotes an 8.8% total weight loss after 6 months.71 Participants in a different study experienced a 12.9% wt loss 1 year after operation with the use of semaglutide.72 This reduction was more significant in the semaglutide treatment group compared with the liraglutide treatment group. In addition to available evidence, clinicians should consider the patient’s medical history and comorbidities, as certain medications are contraindicated for certain medical profiles. For instance, patients with poorly controlled gastro-oesophageal reflux disease (a concern for sleeve gastrectomy) or contraindications to GLP1-RAs should use topiramate or phentermine/topiramate whereas those with a contraindication to this medication (ie, nephrolithiasis or uncontrolled hypertension) could use bupropion or bupropion/naltrexone.73 Aside from these contraindications, using pharmacotherapy, especially GLP-1 receptor agonists, postbariatric surgery can be an efficacious way to curb weight regain.
Conclusion
As the obesity epidemic continues to grow, an increasing number of individuals require reliable, long-term interventions to help them maintain weight loss. For eligible patients with severe obesity, bariatric surgery is the most effective option to achieve this goal. Out of the four most common procedures, sleeve gastrectomy has overtaken Rou-en-Y gastric bypasses as the most popular option due to the sleeve gastrectomy’s reduced postoperative complications, less-invasive approach, and that it achieves a significant long-term weight loss that is similar to the gastric bypass. In addition to weight loss, bariatric surgery is the only proven weight management therapy that helps reduce CV outcomes and mortality. Significant levels of type II diabetes remission (above 90%) are also a benefit of bariatric surgery. To minimise complications and assure optimal safety, current guidelines recommend that physicians prepare their surgery candidates with a multidisciplinary team and screen them for CV, pulmonary and sleep apnoea complications before operation. Bariatric surgery is, therefore, a safe and viable long-term weight management interventions for patients with severe obesity. Therefore, there is not a singular procedure that universally benefits all patients. Physicians and patients must collaboratively determine the most suitable procedure to consider, taking into account factors such as comorbidity profile, individual preferences and weighing the benefits against the risks associated with each surgery.
Contributors: KP conducted the research and drafted the manuscript. ME designed and oversaw the project by providing comments and edits to the manuscript.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review: Not commissioned; externally peer reviewed.
Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
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