The Art of Metabolic and Bariatric Surgery for Obesity
By Alexander Knijnikov, D.O.

The “Pandemic”; a scary word. One we have all been living with for nearly two years. But given COVID-19 taking all the headlines daily, we oftentimes forget the quieter, less headline worthy pandemic of obesity. There are no flashy number trackers on news sites; there are no daily updates from world health agencies or leaders. It’s subtle and kills quietly and slowly, maiming millions over many years, until often inevitably early and preventable deaths ensue. Recent estimates of obesity related deaths range from 2.8 to 4 million annually worldwide.

     Obesity is a dire national and global health crisis, with most recent CDC numbers showing a 42.4% obesity prevalence rate in the U.S. Obesity is most commonly defined as a Body Mass Index, or BMI, of more than 30. Unfortunately, for people suffering from obesity, the consequences are severe with multiple malignancies that have been proven, in the literature beyond a reasonable doubt. The good news is that there is a cure for this morbid disease and its associated detrimental health effects.

     The art of metabolic and bariatric surgery has become a gold standard for curing this pandemic of obesity. Surgery has been proven to be both very effective and very safe, far better than any other attempt at durable weight-loss and co-morbidity resolution. The number of surgeries performed continues to grow dramatically, with a quarter million bariatric surgeries currently performed per year in the U.S. 

     The “sleeve”, or vertical sleeve gastrectomy, continues to far outpace any other bariatric surgery, with a growing trajectory over the last 10 years or so, mostly since gaining wider insurance coverage recently. The gastric bypass has generally fallen out of favor, with its numbers continuing to shrink nationwide. While the gastric bypass was a great operation, and has been performed since the 1960s, there are many factors driving the sleeve’s popularity.  As with many other things, it has a lot to do with Google. As one 63 year old patient told me recently, “Google told me to get the sleeve”. It’s generally the surgery that the patients are seeking and there are very few concrete contraindications. It is nearly as effective as, what most would call the gold standard, gastric bypass. However, it is simpler, quicker, and safer with nearly no chance of long term severe complications. It’s no surprise that it has become the new gold standard.

     The future of metabolic and bariatric surgery is also very promising. A recently approved operation, a modification of the classic duodenal switch, is making headway. It has been shown to both be a good primary option, as well as an excellent choice for revision – for those small chances a sleeve needs a revision.. While in the early days of bariatric surgery most people considered surgery a one stop shop, a cure for obesity, period. The newer thinking is that obesity is a lifelong disease and just as other lifelong diseases, say diabetes or hypertension, may require “adjustments” with treatment, so does surgical management of obesity, albeit for a small subset of patients.

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Lauby-Secretan B, Scoccianti C, Loomis D, Grosse Y, Bianchini F, Straif K. Body fatness and cancer—viewpoint of the IARC Working Group. New England Journal of Medicine. 2016 Aug 25;375(8):794-8.

GBD 2015 Obesity Collaborators. Health effects of overweight and obesity in 195 countries over 25 years. New England Journal of Medicine. 2017 Jul 6;377(1):13-27.

Osland E, Yunus RM, Khan S, Alodat T, Memon B, Memon MA. Postoperative early major and minor complications in laparoscopic vertical sleeve gastrectomy (LVSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures: a meta-analysis and systematic review. Obesity surgery. 2016 Oct;26(10):2273-84.

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