GASTRIC SLEEVE It's estimated that 60% of U.S. bariatric patients opt for sleeve gastrectomy, 30% have gastric bypass and the remaining 10% choose from among other bariatric procedures.

Patients now have more surgical weight-loss options than ever: sleeve gastrectomy, laparoscopic gastric banding and intragastric balloon, as well as endoscopic gastric plication and stomach aspiration — all are considered safe and reliable outpatient bariatric procedures. Then there's gastric bypass, a major surgical procedure that reduces the size of the stomach and lets food bypass part of the small intestine. Although once considered inpatient only, this surgery has slowly made inroads into "avant-garde" outpatient settings, says Scott A. Cunneen, MD, FACS, FASMBS.

"Usually it's performed on lower-risk patients, with 23-hour outpatient monitoring or some other aftercare," says Dr. Cunneen, the director of metabolic and bariatric surgery at Cedars-Sinai Medical Center in Los Angeles, Calif. "It's primarily being done by people who are pushing the boundaries, and the patients tend to be young and relatively healthy."

The sleeve gastrectomy has become the figurative gold standard, according to Dimitrios Stefanidis, MD, PhD, the medical director of the bariatric program at Indiana University Health in Indianapolis. By his estimate, 60% of U.S. bariatric patients opt for sleeve gastrectomy; 30% have gastric bypass, and the remaining 10% choose from among the other bariatric procedures. The sleeve gastrectomy involves removing most of the stomach and shaping the remainder into a tubular pouch. He says patients like it because of its favorable safety profile as a means of predictable, long-term weight loss.

Intragastric balloon and endoscopic suturing also work well in the outpatient setting. Although these endoscopic procedures have less risk than surgery and often require only sedation, they are "still emerging" in the U.S. market, says Stacy Brethauer, MD, a bariatric surgeon with the Cleveland (Ohio) Clinic.

There's also stomach aspiration, a nonsurgical and reversible procedure that lets patients eat as they normally do and then lavage their stomach with saline to evacuate some of the stomach's contents through a port in the abdominal wall. One surgeon says the procedure could take off if patients can "get over the gross factor of flushing out the contents of their stomach, almost like medical bulimia."

Laparoscopic gastric banding remains a viable option, though it seems to have fallen out of favor in recent years, likely due to the meteoric rise of the sleeve gastrectomy.

"Most of my patients — I'd say 90% — want the sleeve gastrectomy," says Mustafa Ahmed, MD, FACS, a bariatric surgeon with Southern Nevada Bariatrics in Las Vegas. "Initially, nobody wants bypass because they know it's a more invasive procedure, but if someone has a contraindication for the sleeve, I try to help them see that bypass may be their best option."

If the patient has GERD or insulin-dependent diabetes, for example, bypass can essentially "cure" both conditions. Likewise, if the patient is severely obese, with a body mass index in the mid-50s or higher, Dr. Ahmed says gastric bypass may be more effective in helping the patient lose more of their excess weight than, say, the sleeve gastrectomy: 75% versus 55% to 65%.

Obese patients have unique risks related to anesthesia and potential airway complications. As Dr. Brethauer puts it, surgical facilities that offer these procedures must have several "safety nets" in place. This would include agreements to transfer patients to a hospital if they require a higher level of care after any bariatric procedure, says Dr. Brethauer.

Patient evaluation before any bariatric procedure must include a thorough medical assessment — including BMI analysis — to determine the risk for their procedure. The goal is to make the patient as "bulletproof" as possible, including identifying and addressing previously undiagnosed illnesses. For operations such as the sleeve gastrectomy, patients must also undergo nutritional and psychological evaluations. Regardless of the procedure, if there's a significant risk of airway compromise — especially if the patient has sleep apnea — Dr. Cunneen says it's best to have them monitored in a hospital.

BATTLE OF THE BANDS Laparoscopic gastric banding has fallen out of favor in recent years.

Aftercare + adjustments
Also, give careful consideration to the aftercare required for certain bariatric procedures, as follow-up appointments and adjustments will have an impact on surgeon and room scheduling. Laparoscopic banding in particular requires a good deal of aftercare, Dr. Cunneen says, as patients have to come back for adjustments as many as 5 times the first year and at least twice a year thereafter.

There's also the issue of post-operative support. If obesity is like alcoholism, as some suggest, a patient's ability to keep off the weight long term may hinge on the availability of ongoing peer support and nutritional education, both in person and through social media.

"Patients are going to need to be educated about what to expect, as well as how to change and maintain their eating habits after the surgery," says Dr. Cunneen. "We also have to make sure they have everything in place in terms of post-operative support groups. We build that into the cost of the procedure, because if we don't, they won't access it."

THE SKINNY ON BARIATRICS
Will Bands Expand And Balloons Take Off?

BAND PRACTICE Although its popularity has waned while other procedures have grown, laparoscopic adjustable gastric banding "has a place in bariatric surgery," says one surgeon.

After receiving FDA approval in 2001, laparoscopic adjustable gastric banding spent several years as the darling of bariatric surgery. But today surgeons are taking out or adjusting more gastric bands than they're putting in. The band's steady decline could be due to complications, to patients seeking more dramatic results or to the rise of other surgical weight-loss procedures, such as the laparoscopic sleeve gastrectomy. The sleeve accounted for more than half of all surgical weight-loss procedures performed in the United States in 2015, according to the American Society for Metabolic and Bariatric Surgery, up from just 17.8% in 2011. Comparatively, gastric banding accounted for just 5.7% of bariatric procedures in 2015, down from 35.4% in 2011.

Other bariatric procedures have recently made headlines for the wrong reasons. In August, the FDA issued a safety alert to healthcare providers regarding liquid-filled intragastric balloons — the second this year — in the aftermath of 5 patient deaths that occurred soon after the patients were implanted with the devices. In all 5 instances, death occurred within a month of balloon placement and, in 3 cases, within 3 days of placement.

The FDA says it doesn't yet know the root cause or incidence rate, and it hasn't been able to attribute the deaths specifically to the devices or the insertion procedures. The alert also cited 2 other balloon patients who died from complications: a gastric perforation in 1 case; and an esophageal perforation in the other.

Still, researchers and physicians tout the safety and effectiveness of intragastric balloons. A recent study (osmag.net/UkBmG8) shows that serious adverse events occur in only 1.3% of gastric balloon cases, with a mortality rate of 0.04%. By comparison, Roux-en-Y gastric bypass has a mortality rate of 0.2% to 1%.

"It's not for everybody, but the band is still a good procedure that has a place in bariatric surgery," says Scott A. Cunneen, MD, FACS, FASMBS, the director of metabolic and bariatric surgery at Cedars-Sinai Medical Center in Los Angeles, Calif.

— Bill Donahue

The payoff
So what do surgical facilities have to gain? A gastric bypass might bear a price tag of $27,000 to $40,000, while a gastric sleeve might run $12,000 to $14,000. Depending on the procedure, a hospital's facility and anesthesia fees could hit $10,000, says Dr. Ahmed, but the economics change in a surgery center. Public and private payers remain stingy on reimbursements in outpatient settings, meaning self-pay is the law of the land.

"The costs can be managed much better in an outpatient setting," adds Dr. Cunneen. "You're talking about a couple thousand dollars for equipment, a couple thousand dollars for other costs, so there's profit for all involved."

Considering the size of the patient population, bariatric surgeons believe they've hit only the tip of the iceberg. Right now, many patients rely solely on less invasive interventions that inevitably fail to give them the results they seek.

"People need to know all of their options and the risks of the individual procedures," says Dr. Stefanidis. "The success rate is less than 5% with exercise and dieting, but there's an 80% success rate with bariatric surgery, so there's an opportunity for some real transformation here." OSM