Obesity is a pandemic. Obesity (BMI > 30) is associated with diabetes, heart diseases, and cancer, and poses a negative impact on patients’ quality of life. According to the WHO, overweight kills more people than underweight. Weight loss is crucial for health improvement.
Prevention is ideal, but doctors and investigators have developed surgical and non-surgical strategies to promote weight loss and reduce mortality from the associated morbidities. For the last years, bariatric surgery has been the most used treatment aiming at weight loss. It has the most effective and durable results, with an expected weight loss of 20-30% total body weight loss (TBWL). Because bariatric surgery aims at improving a patient’s health and not just at weight loss, it is called metabolic surgery. Many patients seek a fast way of losing weight, most of them only because of aesthetic concerns, not because of metabolic disorders. This is because of the “dark” influence of the non-functional world society.
Bariatric surgery is not perfect, with up to 30% of patients needing a reoperation in 10 years because of weight regain. Additionally, complications and risks do exist in bariatric surgery, with potential nutritional deficits. According to Wendy Brown from the Department of Surgery and the Oesophago-Gastric and Bariatric Unit in Melbourne, Australia, we are living “winds of change”. Can patients lose weight without surgery and still improve their health? Can obesity comorbidities be controlled without surgery? Yes and no.
Wendy Brown is clear in her paper. Assuming health improvement is the aim of bariatric surgery, we must also assume that just 5% TBWL is associated with a significant health benefit, and that metabolic syndrome is solved with 12-15% TBWL. Do all patients need surgery? No. The drawback of non-surgical and non-pharmacological therapies is that only 3% of patients can maintain the weight loss beyond two years. But new tools are emerging. The indications for bariatric surgery were defined in 1992 (30 years ago). Medicine has evolved and new pharmacotherapies are now available with an impact on metabolism, hunger, and satiety. Medication such as phentermine can promote and maintain up to 10% TBWL. A combination of drugs can increase TBWL to 15%. Additionally, emerging endoscopic techniques can also help weight loss.
All these new armamentaria mean that personalized medicine is necessary to define who will benefit from bariatric surgery. The classic BMI-based criteria for bariatric surgery are out of date. TBWL percentage needed to achieve health benefits is becoming the cornerstone for treatment decisions. The author presents the following indications which are independent of the initial BMI:
The patient needs to lose 5% TBWL: caloric restriction and exercise
The patient needs to lose up to 15% TBWL: pharmacotherapies and endoscopic procedures
The patient needs to lose more than 15% TBWL: bariatric surgery
How to define which percentage of TBWL is adequate for health improvement in each patient is not clarified in the paper. This is crucial for a correct treatment decision, I think.
According to Wendy Brown, surgery is still the best treatment for 10-15% of the population who do not respond to pharmacotherapies, have side effects or contra-indications for it, or do not want to commit to a life-long medication. I believe many patients think surgery is easy and always goes well, is free of immediate or life-long complications, and that medications are toxic and something to avoid. World health systems should work on changing this widespread idea and make it clear to patients that all procedures (surgery included) can have catastrophic consequences. I believe a patient’s commitment to caloric restriction and exercise is paramount before invasive procedures. Are patients being operated on because they do not want to comply with a caloric restriction and exercise? Do patients want to lose weight while keep eating whatever they want? Are doctors choosing surgery because of income?
With the emergence of new pharmacotherapies, we can now combine non-surgical and surgical therapies in a way to avoid those procedures with a higher risk of complications. Nowadays, we can combine medications with surgical procedures with less weight loss but with lower risks (e.g. sleeve gastrectomy), and still promote a significant weight loss similar to more risky surgical procedures (e.g. gastric bypass, biliopancreatic diversion). With fewer risks, we can now promote a significant health improvement and increase the quality of life.
In conclusion, the author states that “bariatric surgeons should embrace all effective therapies as they bring with them opportunity to review our indications for surgery, design management plans based on health benefit, and, by combining therapies, not only improve weight loss and health outcomes but also potentially minimize surgical risk”. I believe with the improvement of medical therapies, and probably genetic therapies, bariatric surgery will see a decrease in indications. Is bariatric surgery the future? I have my doubts.
Link to PubMed:
Brown W. Has the tide turned on bariatric surgery? BJS 2022; 109: 395-396.
Dr. Carlos Eduardo Costa Almeida
General Surgery
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