Successful bariatric surgery depends on pre-surgical selection and post-surgical follow-up

The devastating impact of obesity's rising prevalence is imminent, in terms of both the citizenry's health and the financial well-being of the health care industry. Major studies performed over the past few decades have found a clear correlation between obesity and the development of chronic metabolic conditions, such as type 2 diabetes mellitus, hypertension and hyperlipidemia.

New data regarding structural changes to the heart itself also are being obtained and have demonstrated a direct correlation between left ventricular (LV) mass and BMI and fat mass. A recent study revealed that the LV mass doubles at a body mass index (BMI) of 50 kg/m2 compared with a BMI of 20 kg/m2.

Other studies also have shown associations between obesity and dementia (including Alzheimer's disease), obstructive sleep apnea, osteoarthritis and overall mortality rate. In fact, today's physicians may be seeing the first generation of individuals with a lower life expectancy than their parents.

Despite aggressive research efforts, a novel weight management drug without notable adverse effects is not on the horizon. On the contrary, recent data have forced the Food and Drug Administration to remove from the market many long-standing weight management agents, such as sibutramine, because of their adverse-effect profile.

Bariatric surgery options

Bariatric surgery continues to be the most effective means of long-term weight management in people with medically complicated obesity, producing a resolution or improvement in many debilitating and life-threatening medical problems, as well as substantially improving quality of life. Not surprisingly, the number of bariatric procedures performed yearly has dramatically increased over the past decade. As of 2011, approximately 225,000 bariatric operations are performed annually in the United States, a nearly 500 percent increase since 2000.

Several operative procedures, including sleeve gastrectomy, Roux-en-Y gastric bypass and duodenal switch (also referred to as biliopancreatic diversion with duodenal switch), are offered at Mayo Clinic, with the Roux-en-Y gastric bypass being the most common (approximately 74 percent of all cases). Given its lackluster long-term performance, the laparoscopic gastric band procedure is no longer being offered at Mayo Clinic. A different type of restrictive procedure, the sleeve gastrectomy, has taken its place. Although long-term outcome data for the sleeve gastrectomy are lacking, early results show considerable promise in terms of weight loss and improvement or remission of weight-related comorbidities.

Despite the overwhelming benefits to patients, bariatric surgery is not without complications. As such, pre-surgical patient selection and post-surgical follow-up are critically important. To provide optimum patient care, Mayo staff has implemented an integrated, multidisciplinary approach to each patient seeking bariatric surgery. On referral, the patient meets with an endocrinologist specializing in nutrition, a psychologist specializing in behavior modification and a registered dietitian. A patient-specific, comprehensive medical weight management plan, centered on cognitive behavioral therapy, is then developed. When the behavior modification program is successfully completed, which on average takes three months, the patient is scheduled to meet with a surgeon to discuss which surgery may be best for him or her.

Mayo Clinic's multidisciplinary approach continues after surgery, with shared medical appointments that occur several times in the year following surgery and annually thereafter. This small group-based model allows for peer support among patients while controlling health care costs and limiting educational redundancy. Patients continue to be engaged as they incorporate lifestyle changes, with the hope of achieving greater weight loss that is sustained.

Despite these successes, continued efforts and research are needed to combat the obesity epidemic. An area of active investigation is the unfortunate phenomenon of weight regain after bariatric surgery. Mayo researchers aim to identify the factors contributing to weight regain and the potential interventions to prevent and manage it. Staff members are also exploring novel surgical treatment methods, including endoscopic procedures, that are targeted at weight maintenance after surgery.

Points to remember

  • The overall prevalence of obesity BMI ≥ 30 kg/m2 in the United States is 33 percent and is expected to rise to approximately 50 percent over the next 20 years.
  • Bariatric surgery continues to be the most effective means of long-term weight management in people with medically complicated obesity, resolving or improving many debilitating and life-threatening medical problems, as well as substantially improving quality of life.
  • Several operative procedures, including sleeve gastrectomy, Roux-en-Y gastric bypass and duodenal switch (also referred to as biliopancreatic diversion with duodenal switch), are offered at Mayo Clinic.

Before meeting with a surgeon, patients seeking bariatric surgery at Mayo Clinic consult with an endocrinologist specializing in nutrition, a psychologist specializing in behavior modification and a registered dietitian, as well as complete a behavior modification program.