September 2019, Volume XXXIII, No 6

Weight Control

Bariatric surgery

High ROI for severe forms of obesity

ariatric surgery within a multispecialty-supported program represents one of the biggest returns on investment (ROI) that health care providers can achieve today. Not only does weight loss improve the quality of a person’s life, but by preventing or curing life-threatening illnesses, it also can reduce or eliminate the need for medications to treat weight-related comorbid conditions.

Worldwide obesity rates continue to increase. While lower than the national average of 40%, obesity rates in Minnesota of 30% are rising, according to the Minnesota Department of Health.

Obesity was officially classified as a medical disease in 2013, with Class I defined as having a body mass index (BMI) of 30 or higher, Class II as a BMI of 35–40, and Class III as a BMI of 40 or more. The more severe forms of obesity are associated with increased risk of weight-related comorbidities, such as heart disease, hypertension, diabetes, gastroesophageal reflux disease, depression, obstructive sleep apnea, stroke, degenerative joint disease, and 13 different cancers. People with obesity have seven times the risk of type 2 diabetes and more than double the risk of developing heart failure, according to the American Heart Association.

The National Institutes of Health and the American Society for Metabolic and Bariatric Surgery (ASMBS) recommend considering surgical intervention for Class II patients with medical complications and all Class III patients. Despite the fact that the ASMBS estimates fewer than 1% of the 24 million U.S. adults who may qualify for bariatric surgery have the procedure each year, the number of operations has dramatically increased over the past two decades, from 10,000 weight-loss cases reported in the United States in 1996 to 235,000 cases in 2018. This growth is largely due to an increase in obesity rates and greater patient recognition of common threads between obesity and comorbidities.

Preparing a patient for bariatric surgery

The best time to discuss weight loss surgery with a patient is during a conversation about intervention to lessen or eliminate an associated medical condition, especially for Class II or III patients. For most people who need to lose 75 or more pounds, the ability to do so and keep the weight off permanently without anatomical support is nearly zero, even with coaching, medicine, trainers, and psychological support.

Worldwide obesity rates continue to increase.

Patients involved in multidisciplinary bariatric programs are more likely to achieve and maintain their weight and health goals. All of my bariatric surgery patients undergo a three-to-six-month in-person and online education and screening process, a comprehensive review of their medical history and patient-specific screenings, such as colonoscopy, upper endoscopy, or mammogram. Patients with obesity are less likely to seek screening or routine health visits to avoid the feeling of shame that can come with these appointments. They also meet with our program manager to discuss healthy habits, including diet and exercise, and they consult with a pharmacist to manage their medications.

If patients smoke, they need to stop several months prior to surgery. Nicotine induces vasospasm and decreases oxygen delivery to end vessels, hindering bowel anastomosis and wound healing after an operation. Wound infection is five times higher for smokers, the rate of ulcers after stomach surgery is higher, and staple line or anastomosis leak rates are higher.

All of our patients also undergo psychological evaluations, and introspection is encouraged. The development and maintenance of a good support system among family and friends is critical, as depression and anxiety are common among this population.

Current bariatric surgery options

Today, there are several options for bariatric surgery. We use shared decision making when choosing an operation, taking into consideration a person’s eating habits and medical history. Options include:

  • Sleeve gastrectomy is the most common bariatric surgery in the United States, representing 60% of all weight-loss surgeries. With this procedure, the stomach is divided and stapled vertically, removing approximately 85% of the tissue and leaving a smaller, banana-shaped pouch. Patients with significant reflux should avoid this option, as it can exacerbate heartburn.
  •  Roux-en-Y gastric bypass represents 18% of U.S. weight-loss surgeries. Here, we reduce the stomach to the size of a shot glass and attach it to the middle of the small intestine, bypassing several feet of intestine. At Specialists in General Surgery, 100% of bypass patients control their diabetes with less medication or even stop all diabetes medications entirely, compared to a national average of 85% who achieve such control. Roux-en-Y also cures reflux nearly 100% of the time. This surgery may not be a good option for patients with alcohol overuse or abuse history, as the smaller stomach pouch enables alcohol to pass quickly to the small intestine and be absorbed much faster. Our multidisciplinary teams screen for alcohol overuse, and recommend that patients who do have this procedure refrain from alcohol for one year after surgery.
  •  Adjustable gastric banding refers to a silicone band filled with saline wrapped around the upper part of the stomach to restrict food intake. It is performed in fewer than 3% of the surgeries. It is not as robust as the sleeve or Roux-en-Y, and it has the highest reoperation rate. The band can wear out over time and leak, erode through the stomach, slip out of place, or cause bowel obstructions.
  • Biliopancreatic diversion with duodenal switch permanently removes the majority of the stomach and bypasses as much as three-fourths of the small intestines. It is for patients who need to lose hundreds of pounds.
  • Intragastric balloons represent a newer procedure involving a saline-filled silicone balloon temporarily placed in the stomach to limit the amount of food that can be eaten. This procedure is only appropriate in patients with much less weight to lose or as a six-month bridge to surgery and is performed in less than 3% of the surgeries. When the balloon is removed, most patients regain the lost weight.

Benefits and risks of bariatric surgery

For most patients, the risks of severe obesity outweigh any risks associated with bariatric surgery, and the resolution or improvement in certain conditions following bariatric surgery is significant. According to ASMBS, type 2 diabetes is resolved in 77% of the cases, hypertension is resolved in 62%, obstructive sleep apnea goes away for 84% of patients, and hyperlipidemia is resolved in 62%.

Bariatric surgery reduces a patient’s risk of premature  death by 30%.

Patients also typically realize a reduced risk of cardiovascular disease and cancer, improved fertility and lower-risk pregnancies in women, and a higher chance of having a healthy baby. Bariatric surgery is also performed as a weight management option prior to orthopedic surgery on weight-bearing joints.

Following bariatric surgery, most patients experience an improved quality of life and a greater ability to perform daily activities. Studies reported in the New England Journal of Medicine also reveal bariatric surgery reduces a patient’s risk of premature death by 30%. Specifically, deaths from obesity-related diabetes decrease by 92%, coronary artery disease by 59%, and cancer by 60%, with the greatest reduction in breast and colon cancers.

While all surgeries carry risks, bariatric surgery carries a few unique risks, such as leaks in the gastrointestinal system and dehydration. Longer-term risks include a 12% to 15% risk of bowel obstruction and as much as a 30% risk of developing symptomatic gallstones. Patients also may experience dumping syndrome—in which food and sugar move too quickly from the stomach into the small bowel—causing diarrhea, nausea, or vomiting, more likely with the Roux-en-Y procedure. This, however, is less likely if the patient follows the prescribed diet. In the long term, it is important for patients to participate in regular weight-bearing exercises and take daily vitamin D and calcium supplements to prevent bone loss.

Growth of robotic bariatric surgery

Today, 90% of my bariatric surgeries are performed robotically. Robotic bariatric surgery is especially useful for deeper or taller patients, revisional bariatric operations, or with patients who have had previous abdominal procedures.

Instruments used in robotic surgery are longer and stronger than those used in laparoscopic cases and have better reach. The two-lens camera enables accurate 3D imaging, resulting in improved visibility. When I dissect the gastric pouch or perform a gastrojejunal anastomosis deep in the upper abdomen, I can see better and have more instrument maneuverability compared to the laparoscopic approach. I believe the robotic Roux-en-Y is as good as or better than a laparoscopic approach, due, in part, to the greater precision and articulation of instruments. Over time, I believe we will continue to see the post-surgical leak rate trend toward zero.

With robotic procedures, patients report less pain and less nausea, leading to faster recoveries and better overall outcomes. Typically, my patients can start drinking liquids as soon as they wake up. It has improved the length of stay for our patients, especially those who have a sleeve gastrectomy. While most stay one night, some patients are able to go home the day of surgery.

Value of multidisciplinary approach

Patients considering bariatric surgery should look for surgeons at facilities that have been accredited by the ASMBS, have excellent outcomes, and offer a multidisciplinary approach to care. At Specialists in General Surgery, our team can include the primary care provider, bariatric program nurse manager, surgeon, nurse practitioner, dietician, psychologist, sleep medicine provider, pharmacist, athletic trainer, and home visits with someone from North Memorial Health’s Community Paramedic Program.

One of the most common reasons for seeking medical help in the first 30 days after surgery is dehydration. That’s why we arrange for a paramedic to visit within 48 hours of discharge, reducing unscheduled clinic and emergency department visits.

Statistics show better overall results with frequent interactions, especially in the year following surgery. We schedule a clinic visit at one week, another paramedic visit at two weeks, a second clinic visit at one month, and a visit with the dietician around five weeks after surgery, around the time a patient starts to eat solid food. Additional visits occur at three, six, nine, 12, 18, and 24 months, followed by yearly visits for life.

Bariatric surgery as a return on investment

In the current cost-conscious health care environment, it is not just surgical risk and health reward that we need to consider. We also need to study the financial costs and benefits to the surgical treatment of obesity. A significant number of patients resist bariatric surgery because of insurance denials or prerequisites. The average national cost of bariatric surgery is between $17,000 and $26,000, according to ASMBS.

Yet, bariatric surgery provides a significant ROI. We can prevent or cure life-threatening illnesses in our patients, many of whom say the surgery is transformative, especially in regard to quality of life. Unhealthy dietary and lifestyle behaviors are addressed early, and healthy changes are supported at subsequent visits. Medications are often reduced or eliminated.

The Centers for Disease Control and Prevention reports the medical cost of obesity in the United States to be $147 billion. Within five years of bariatric surgery, however, the average health care cost for patients is reduced by 29%. In addition, after surgical treatment of severe obesity, an individual’s work productivity increases $2,765 per year in the United States. As insurance companies begin to recognize this ROI, more and more are covering bariatric surgeries, resulting in improved total cost of care for this health population—and improved quality of life for patients diagnosed with obesity.

Jonathan C. Gipson, MD, FACS, is a surgeon with Specialists in General Surgery. He also is Medical Director of Metabolic and Bariatric Surgery at North Memorial Health Hospital, which partners with Specialists in General Surgery to provide comprehensive care, management, and planning for surgical weight loss in qualified patients. 

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Jonathan C. Gipson, MD, FACS, is a surgeon with Specialists in General Surgery. He also is Medical Director of Metabolic and Bariatric Surgery at North Memorial Health Hospital, which partners with Specialists in General Surgery to provide comprehensive care, management, and planning for surgical weight loss in qualified patients.