Metabolic and bariatric surgery (MBS) is surgery on the gastrointestinal tract aimed at weight loss and resolution of metabolic disease. These surgeries can result in remission of diabetes, hypertension, and sleep apnea in many patients, and can prolong life expectancy by 5 to 9 years. Because of the proven benefits, the American Society for Metabolic and Bariatric Surgery recommends surgery for all patients with a body mass index of 35 kg/m2 or higher, except for patients with diabetes whose threshold is 30 kg/m2 regardless of prior nonsurgical weight loss efforts. For children 13 years and older, MBS is recommended and has not been shown to negatively affect height or development. The MBS procedures have a very low risk of surgical complications but require careful preoperative counseling due to the major long-term effect expected on lifestyle. Family physicians are well suited to discuss MBS as an option for appropriate patients, refer to a qualified center, and monitor patients postoperatively. Attention must be given to effects on diet, fertility, and mental health, and adjustments must be made for long-term medications. These surgeries should not be viewed as a last resort for only patients with severe obesity but as an effective intervention to consider early in the treatment of obesity, especially when complicated by metabolic conditions.
Case 4. SD is a 39-year-old patient who underwent sleeve gastrectomy 3 years ago for severe obesity complicated by hypertension, polycystic ovary syndrome, and prediabetes. She comes to you with concerns about a 9-kg weight gain after losing 30 kg (67 lb) and reports feeling depressed and fatigued. She has not been taking any supplements.
Clinical Impact, Use, and Cost-Effectiveness of Surgery
Metabolic and bariatric surgery (MBS) is surgery on the gastrointestinal tract aimed at weight loss and reversal of metabolic disease. These surgeries lead to marked improvements or resolution of many conditions, including diabetes, dyslipidemia, hypertension, obesity, and reproductive health problems.1
In 2022, there were 280,000 MBS procedures performed in the United States representing only approximately 1% of eligible patients.2 The most commonly performed MBS procedures are vertical sleeve gastrectomy (58%) and Roux-en-Y gastric bypass (22%). Endoscopic sleeve gastrectomy and biliopancreatic diversion with duodenal switch are less common (2% each). Intragastric balloon placement also comprises approximately 2% of MBS procedures with moderate average weight loss of 6.9% and adverse effects that result in balloon removal 9.4% of the time.3 Gastric banding has fallen out of favor and now comprises less than 1% of procedures due to complications and less weight loss.4
Approximately 10% of MBS surgeries are revisions.2 The increased use of weight loss drugs has not affected the upward trend in surgical procedures over the past decade. MBS procedures and surgical approaches differ in effectiveness and risks. Of the two most common procedures, Roux-en-Y gastric bypass results in greater weight loss and reduction in metabolic conditions, but has higher complication rates.5 Vertical sleeve gastrectomy is overall better tolerated but can worsen symptoms of gastroesophageal reflux disease.5 Both procedures are effective, resulting in substantial weight loss and improvement of medical conditions, with a relatively low rate of complications.3
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