What Does the Future of Bariatric Surgery Look Like?

Article By: Rachel Ignomirello, MS, RDN, CSOWM, LDN

Rachel Ignomirello is a Bariatric Dietitian and Board-Certified Specialist in Obesity and Weight Management.

Metabolic and bariatric surgery (MBS) has been around since the 1960s. Since then, there have been amazing improvements in safety, success rates, and even community acceptance. For example, Roux-en- Y gastric bypass (RYGB) and sleeve gastrectomy (VSG) surgeries are now the most common while the adjustable gastric band (AGB) has mostly fallen by the wayside. It is also now a surgical standard to perform minimally invasive laparoscopic surgeries instead of open surgeries. These days, patients receive thorough preoperative education and long-term follow-up through accredited surgical centers. After the pandemic, many centers started offering virtual visits and even outpatient surgeries. As long as new research and improved access continues, so will the evolving field. I can’t predict the future, but I do know that these are four progressive areas in MBS.

1) Accessibility. The American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) just released a new position statement on MBS qualifiers. In this new release, they state that MBS is recommended for individuals with a body mass index (BMI) >35, regardless of presence, absence, or severity of co- morbidities. MBS should be considered for individuals with metabolic disease and BMI of 30- 34.9. BMI thresholds should be adjusted in the Asian population such that a BMI >25 kg/m2 suggests clinical obesity, and individuals with BMI >27.5 kg/m2 should be offered MBS. Appropriately selected children and adolescents should be considered for MBS. Right now, MBS is notably underused. According to the ASMBS, an estimated 256,000 procedures were performed in 2019, which represents less than 1% of the currently eligible surgical population based on BMI. If government and private insurance companies start to follow these new clinical guidelines, then accessibility to MBS is going to significantly increase.

2) Outcome focus. For years, bariatric surgery was called “weight loss surgery.” As techniques have advanced, so has the evidence that weight-loss and metabolic health improvements occur with these procedures. Hence, the name change to "metabolic and bariatric surgery.” Of course, weight is still decreased, but the focus seems to be more on outcomes now. People with obesity are more likely to have diseases like type 2 diabetes, high blood pressure, high cholesterol, sleep apnea, and more. These obesity-related diseases are significantly improved after MBS, so those patients have a lower risk of disability and death. With the new MBS name and outcome emphasis, I’m hopeful this will help reduce the stigma of MBS being the “easy way out” for weight loss.

3) Robotic surgeries. Many bariatric surgeons are moving toward robotic surgeries in the operating room. The robot consists of a cluster of arms and a camera. The arms can hold and manipulate tools with extreme accuracy. During surgeries, the surgeon sits at a console and controls the arms while having a 3D high-definition view. There are many benefits to using a robot: better perception with sharp views, better range of motion for precision, smaller incisions, faster recovery stay for patients, and more comfort for the surgeon who no longer has to stand during long procedures.

4) Medications. Even though MBS is the most durable and effective weight loss strategy, obesity is a chronic disease. Weight regain can happen. According to the ASMBS, 50% of patients regain 5% of their body weight within 2 years after surgery. As part of the long-term follow-up, patients who regain may be offered treatment with anti-obesity medications in addition to lifestyle changes. Studies have shown that anti-obesity medications halted weight regain in patients who underwent MBS. As of right now, there are five FDA-approved medications for long-term usage. They include: Orlistat (Xenical, Alli), Phentermine-topiramate (Qsymia), Naltrexone-bupropion (Contrave), Liraglutide (Saxenda), and Semaglutide (Wegovy). There are some short-term options, too, like Phentermine. With more medication options and promising research, medications usage may start to increase and may even help prevent or delay revisional surgery.

BariMelts provides general recommendations, not to be construed as medical advice. Please consult your doctor.

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