The Future of Bariatric Surgery? Three S’s

| August 1, 2021

by John M. Morton, MD, MPH, MHA, FACS, FASMBS, DABOM

Clinical Editor of Bariatric Times; Vice-Chair of Quality and Division Chief of Bariatric and Minimally Invasive Surgery in the Department of Surgery at Yale School of Medicine in New Haven, Connecticut.

Dear Friends and Readers,

I was recently giving a lecture and was relating that I have been performing bariatric surgery for over 20 years with 4,000 cases completed. I compared where our field was 20 years ago and where we are now. There is no doubt that we have been witness to tremendous improvements in safety, efficacy, and acceptance of our field. 

What has changed? Accreditation, access, acceptance, education, and therapeutic options. The patient safety revolution has touched bariatric surgery deeply with present-day mortality rates equivalent to hip/knee replacement and over 850 hospitals accredited nationally and internationally when we had none 20 years ago. Overwhelmingly, we lead all fields with almost universal adoption of laparoscopy, decreasing complications and resource utilization. While we have more work to do, access is clearly improved with all major insurance companies covering our procedures. Continued vigilance is the price of access. Additionally, we have well-established fellowship programs and are considered an essential service by general surgery residencies. We have multiple surgical procedures now, along with over 10 endoscopic devices and anti-obesity medications. The greatest change has been acceptance of our field in so many different ways, from recognition of obesity as a disease by the American Medical Association, to being a focused practice designation by the American Board of Surgery, to being a full quality partner with the American College of Surgeons.

So, now where do we go? How are we doing? Despite these enormous gains, more work needs to be done. First, we need to treat all in need—we treat one percent of the affected population. Second, patient preference needs to be taken into greater account along with providing assurance of long-term treatment effect. Third, we need to democratize bariatric surgery further so all patients undergoing bariatric surgery have access to all best practices.

I believe the future of bariatric surgery will be THREE S’s.

1. Sleeve: Patients have voted with their feet and have made sleeve gastrectomy (SG) a runaway leader in bariatric surgery procedures. There are Level 1 data indicating that for patients with a body mass index (BMI) less than 45kg/m2 there is equivalency in treatment effect for SG versus gastric bypass with safety data demonstrating a decided advantage for SG. There is no doubt that patients express a desire for less invasive rather than more invasive procedures. Despite American Society for Metabolic and Bariatric Surgery (ASMBS) approval of duodenal switch (DS)/ single anastomosis duodeno-ileostomy (SADI), we see more intra-gastric balloons (IGB) being placed than DS/SADI being performed, despite less efficacy and more out-of-pocket expense for IGB. Some have advocated for the SG to be the first port of arrival for a bariatric surgery patient. Unless there is malignant diabetes or documented gastroesophageal reflux disease (GERD), a SG can be a first-line treatment option for most patients. The issue with both the gastric bypass and DS is they are essentially terminal operations without good recourse in the event of lack of treatment effect/complications, which, though rare, can occur. What about larger patients or gastric reflux and/or weight gain following a SG? Standardization and semaglutide can help address these concerns.

2.Semaglutide: There have been three notable advances in obesity over the past generation; namely, laparoscopic bariatric surgery, understanding of the physiology of obesity, and now, United States Food and Drug Administration (FDA) approval of Wegovy® (semaglutide). Semaglutide is a game changer of high magnitude with a once-weekly injection of a drug providing 16 percent total body weight loss with minimal side-effects and 80 percent of patients having treatment response. Cost will be an issue as it was with bariatric surgery 20 years ago. What led the way for bariatric surgery coverage and will be the same for semaglutide is safety and effectiveness. If it works, the payors will come. And, there will likely be more similar anti-obesity medications in the future.

Where does semaglutide fit with bariatric surgery? Think of cancer surgery. We utilize both preoperative and postoperative chemotherapy to downstage the disease and safeguard results respectively. The same can be accomplished in bariatric surgery addressing the patients with late-stage disease (higher BMI) with chemotherapy (semaglutide) prior to surgery and utilizing the drug for patients at risk of recurrence (weight gain). For those of us worried about losing surgical cases, please remember we are here to care for patients by any means necessary. Would surgical oncologists bemoan a new effective chemotherapy? No, they would welcome it. Surgical oncologists would welcome the aid as cancer is a difficult foe and obesity for bariatric surgeons is no less an adversary. Also, there is a 20-percent nonresponse rate with semaglutide, and we have a 99-percent untreated population; so, there is ample opportunity for growth in all directions. 

3. Standardization: It is often repeated that, unlike other scientists, surgeons take pride in the fact that others might not be able to replicate their results. Now is a new time where we know what processes work for optimizing SG: routine preoperative endoscopy to rule out GERD; preoperative weight loss; intraoperative technical performance of a straight, 34–36 French, adequately mobilized SG without retained fundus; and postoperative surveillance for weight gain and/or GERD. Consistent pre- and postoperative endoscopy endorsed by the ASMBS and preoperative weight loss with anti-obesity medications such as semaglutide are attainable, reproducible, and available. Achieving technical standardization might be more difficult.

How do we achieve technical standardization? Fellowship training is now standard. For those in practice, continuing medical education (CME) courses and video coaching afford some opportunity, albeit they are difficult to scale for over 250,000 cases annually. Technical innovations can provide opportunities for standardization. One example is Standard Bariatrics®, which provides a clamp and a unique, single-fire 23cm staple load from the FDA-approved Titan® stapler to create a more consistent SG. Through innovations like this, weight loss can be optimized and complications like GERD can be potentially avoided. 

Though none of us can predict the future, I do believe the future of bariatric surgery will have the Three S’s and that we will be better when we work together. 



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