Time to Seek a More Personalized Approach to Bariatric Surgery
TO THE EDITOR: Aside from several diversions in the surgical technique, three bariatric procedures are most commonly performed worldwide (1): sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with or without duodenal switch (BPD-DS). RYGB had been the gold standard among them for a long time until SG was recognized as a stand-alone procedure. SG quickly became popular because of its technical simplicity, good weight loss, and low complication rate (2). Many studies have demonstrated that the weight loss results of SG were similar to those of RYGB.
Bhandari et al. (3) compared 3-year outcomes of five different bariatric procedures for patients with super obesity. The article comes at a critical time to reevaluate the best procedure for patients with super obesity for two reasons. First, the prevalence of severe obesity (BMI ≥ 40 kg/m2) is on the rise (4). Consequently, a growing number of individuals with super obesity will need a bariatric procedure. Second, bariatric procedures are less effective for patients with super obesity compared with those without super obesity; patients with higher BMI tend to lose a lesser percentage of excess body weight than those with lower BMI after a bariatric procedure (5).
Bhandari et al. (3) found that 67.9% of patients with super obesity who had undergone SG failed to lose sufficient weight (defined as BMI ≥ 35) at 3 years. In comparison, only 29.2% of their patients who had undergone RYGB experienced weight loss failure during the same period. Because SG is technically the first step of BPD-DS, patients undergoing SG have an option to be converted to BPD-DS for additional weight loss. In this perspective, patients undergoing SG have a better choice for a revision than patients undergoing RYGB because they do not need a reversal of the procedure. Nevertheless, revisional procedures tend to be riskier and less effective than primary procedures; undergoing a single-stage BPD-DS in the first place would have resulted in better weight loss than converting a SG procedure to a BPD-DS procedure 3 years later. Furthermore, especially in the United States, getting insurance approval for the revisional procedure may be tricky, not to mention the overall health care cost for performing two procedures instead of one.
On a side note, Bhandari et al. (3) demonstrated that banded SG and RYGB procedures had the lowest failure rate at 3 years. Interpretation of these outcomes should be made with caution because banded procedures can have higher complication rates (6). The success of a bariatric procedure depends on not only weight loss but also low complication rates. Adjustable gastric banding became unpopular, in part, because of the high risk of stricture, slippage, and erosion (6). Although the authors claimed that they did not observe adverse effects related to the band itself, 3 years was not long enough to determine the long-term safety of a banded procedure. Furthermore, in this study, the number of patients who underwent a banded procedure might not have been large enough to detect adverse events.
In 2016, 69.8% of laparoscopic bariatric procedures in the United States were SG procedures (2). As with behavioral and medical approaches to obesity, the study by Bhandari et al. (3) suggests that no one procedure is best for all. As more patients with super obesity seek bariatric procedures, establishing a more personalized bariatric approach is imperative.
