The Dynamic and Evolving Field of Metabolic and Bariatric Surgery: Current Perspective

| April 1, 2017

An Interview with:

Ninh T. Nguyen, MD, FACS, FASMBS
Professor of Surgery and Interim-Chair at University of California Irvine Medical Center, Orange, California

Esteban Varela, MD, FACS, FASMBS
Professor of Surgery at University of Central Florida and Chair of Surgery at HCA Medical Center, Orlando, Florida

In a recent article published in Nature Reviews Gastroenterology & Hepatology titled “Bariatric surgery for obesity and metabolic disorders: state of the art,” Drs. Ninh T. Nguyen and Esteban Varela provided an update on the current state of bariatric surgery, summarizing the epidemiology of obesity, history of bariatric surgery, and current state of procedure safety and efficacy. They reviewed procedure advantages and disadvantages and discussed the recent data comparing bariatric surgery to medical therapy for outcomes of weight loss and comorbidity improvement. The review also included a discussion on newly approved, minimally invasive and endoscopic procedures, including intra-gastric balloon systems and the vagal nerve blockade device. Bariatric Times interviewed Drs. Nguyen and Varela to learn what this paper means to the field of obesity treatment and the medical community.


Why was it important to provide a comprehensive update?

Drs. Nguyen & Varela: Bariatric surgery is a dynamic and evolving field. It is necessary that we update our medical colleagues on the current state of bariatric surgery as well as the latest level 1 evidence for the role of bariatric surgery compared to intensive medical therapy (Tables 1 and 2), as well as offer insight into the new endoscopic bariatric interventions that may bridge between medical therapy and bariatric surgery.

Table 1: Level 1 evidence: weight loss after bariatric surgery versus medical therapy for type 2 diabetes mellitus

Table 2: Randomized controlled trials: T2DM remission after bariatric surgery versus medical therapy

Why publish in Nature Reviews Gastroenterology & Hepatology, which encompasses a wide range of disorders and diseases—not solely obesity research and treatment?

Drs. Nguyen & Varela: It was important to publish this review article in a journal that reaches a broad audience of medical specialists that treat millions of patients with obesity and diabetes yearly.

In the article, you say that the landscape of bariatric surgery has changed dramatically since its introduction more than 50 years ago.

Drs. Nguyen & Varela: Yes, the most notable changes in bariatric surgery are the development and adoption of laparoscopic bariatric surgical techniques. Primary open bariatric operation, for the most part, has become obsolete. The laparoscopic approach offers improved surgical outcomes, including lower morbidity, reduced postoperative pain, and faster recovery, and has become the standard of care. Additionally, bariatric surgery as a field has evolved to be very safe with a mortality rate that is now similar to that that of common general surgical operations, such as cholecystectomy and antireflux surgery.

Your article includes a section on indications for bariatric surgery. Why is it important that bariatric surgery be included in medical guidelines, such as the American Diabetes Association and International Diabetes Federation? Why is it important to determine patient selection criteria for bariatric surgery?

Drs. Nguyen & Varela: The guidelines8–11 are commonly used by clinicians who treat obesity and T2DM. They provide important guidance on who would be appropriate candidates for bariatric surgery, and when to refer these patients to surgery.

What emerging trends are you seeing in the field?

Drs. Nguyen & Varela: Sleeve gastrectomy is now the preferred bariatric surgical option; however, emerging endoscopic devices and procedures will likely be developed to be more durable and effective and provide an alternative treatment option.

The number of metabolic and bariatric procedures performed in the United States and worldwide is currently less than one percent of the eligible population with severe obesity. How can healthcare professionals increase awareness among the healthcare community and public about the current state of bariatric surgery?

Drs. Nguyen & Varela: The number of patients who undergo bariatric surgery is still exceedingly low. Increasing obesity awareness and decreasing the barriers at all levels in the spectrum of care for the patients with obesity and diabetes is critical. A good start is to educate our patients and our medical colleagues regarding the available treatments. However, this is only a start! We need to do so much more, including improving coverage for obesity treatments and more extensive research that examines other obstacles to treatment.

Obesity remains a public health problem. How can we continue to progress in tackling the obesity epidemic?

Drs. Nguyen & Varela: There has been significant progress in both the prevention and medical and surgical treatments of obesity; however, a lot more work remains as only a small proportion of individuals with obesity obtain any type of the currently available therapy. Given the ample amount of scientific evidence, we must work as a team with our multidisciplinary obesity colleagues to educate patients on the available treatments, discuss any barriers to treatments, and refer these patients to appropriate providers for evaluation and treatments.

References
1.    Nguyen NT, Varela JE. Bariatric surgery for obesity and metabolic disorders: state of the art. Nat Rev Gastroenterol Hepatol. 2017;14(3):160–169. http://www.nature.com/nrgastro/journal/v14/n3/full/nrgastro.2016.170.html Accessed March 1, 2017.
2.    Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes—5-Year Outcomes. N Engl J Med. 2017;376(7):641–651.
3.    Cummings DE, Arterburn DE, Westbrook EO, et al. Gastric bypass surgery vs intensive lifestyle and medical intervention for type 2 diabetes: the CROSSROADS randomised controlled trial. Diabetologia. 2016;59(5):945–953. Epub 2016 Mar 17.
4.    Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial. Lancet. 2015;386(9997):964–973.
5.    Courcoulas AP1, Belle SH2, Neiberg RH, et al. Three-Year Outcomes of Bariatric Surgery vs Lifestyle Intervention for Type 2 Diabetes Mellitus Treatment: A Randomized Clinical Trial. JAMA Surg. 2015;150(10):931-40.
6.    Ikramuddin S, Korner J, Lee WJ, et al. Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA. 2013;309(21):2240–2249.
7.    Varela JE, Nguyen NT. Laparoscopic sleeve gastrectomy leads the U.S. utilization of bariatric surgery at academic medical centers. Surg Obes Relat Dis. 2015;11(5):987–990.
8.    Dixon JB, Zimmet P, Alberti KG, Rubino F. Bariatric surgery: an IDF statement for obese type 2 diabetes. Arq Bras Endocrinol Metabol. 2011; 55(6):367–382.
9.    Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society. Circulation. 2014 Jun 24;129(25 Suppl 2):S102–S138. Epub 2013 Nov 12.
10.    Handelsman Y, Bloomgarden ZT, Grunberger G, et al. American Association of Clinical Endocrinologists and American College of Endocrinology—clinical practice guidelines for developing a diabetes mellitus comprehensive care plan—2015. Endocr Pract. 2015;21 Suppl 1:1–87.
11.    American Diabetes Association. Standards of medical care in diabetes —2015: summary of revisions. Diabetes Care. 2015; 38 (Suppl. 1): S4.

Funding: No funding was provided in the preparation of this manuscript.

Financial disclosures: The authors report no conflicts of interest relevant to the content of this article.

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Category: Interviews, Past Articles

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