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Benefits and Risks of Bariatric Surgery in AdultsA Review

Educational Objective
To review the benefits and risks of bariatric surgery.
1 Credit CME
Abstract

Importance  Severe obesity and its related diseases, such as type 2 diabetes, hypertension, dyslipidemia, and sleep apnea, are very common in the United States, but currently very few patients with these conditions choose to undergo bariatric surgery. Summaries of the expanding evidence for both the benefits and risks of bariatric surgery are needed to better guide shared decision-making conversations.

Observations  There are approximately 252 000 bariatric procedures (per 2018 numbers) performed each year in the US, of which an estimated 15% are revisions. The 1991 National Institutes of Health guidelines recommended consideration of bariatric surgery in patients with a body mass index (calculated as weight in kilograms divided by height in meters squared) of 40 or higher or 35 or higher with serious obesity-related comorbidities. These guidelines are still widely used; however, there is increasing evidence that bariatric procedures should also be considered for patients with type 2 diabetes and a body mass index of 30 to 35 if hyperglycemia is inadequately controlled despite optimal medical treatment for type 2 diabetes. Substantial evidence indicates that surgery results in greater improvements in weight loss and type 2 diabetes outcomes, compared with nonsurgical interventions, regardless of the type of procedures used. The 2 most common procedures used currently, the sleeve gastrectomy and gastric bypass, have similar effects on weight loss and diabetes outcomes and similar safety through at least 5-year follow-up. However, emerging evidence suggests that the sleeve procedure is associated with fewer reoperations, and the bypass procedure may lead to more durable weight loss and glycemic control. Although safety is a concern, current data indicate that the perioperative mortality rates range from 0.03% to 0.2%, which has substantially improved since early 2000s. More long-term randomized studies are needed to assess the effect of bariatric procedures on cardiovascular disease, cancer, and other health outcomes and to evaluate emerging newer procedures.

Conclusions and Relevance  Modern bariatric procedures have strong evidence of efficacy and safety. All patients with severe obesity—and especially those with type 2 diabetes—should be engaged in a shared decision-making conversation about the risks and benefits of surgery compared with continuing usual medical and lifestyle treatment, and the decision about surgery should be driven primarily by informed patient preferences.

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Article Information

Accepted for Publication: June 26, 2020.

Corresponding Author: David Arterburn, MD, MPH, Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA 98101 (david.e.arterburn@kp.org).

Author Contributions: Dr Arterburn had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Arterburn.

Acquisition, analysis, or interpretation of data: Telem, Kushner, Courcoulas.

Drafting of the manuscript: Arterburn, Telem, Kushner.

Critical revision of the manuscript for important intellectual content: Telem, Courcoulas.

Administrative, technical, or material support: Courcoulas.

Supervision: Arterburn, Telem.

Conflict of Interest Disclosures: Dr Arterburn reported grants from the National Institutes of Health during the conduct of the study; and grants from the Patient-Centered Outcomes Research Institute and nonfinancial support from International Federation for the Surgery of Obesity and Metabolic Disorders Latin American Chapter outside the submitted work. Dr Telem reported grants from the National Institutes of Health during the conduct of the study; and grants from the Agency for Healthcare Research and Quality and from Medtronic outside the submitted work. Dr Courcoulas reported grants from Allurion and Covidien/Ethicon outside the submitted work. No other disclosures were reported.

Funding/Support: Drs Arterburn and Courcoulas were funded by a grant from the National Institute for Diabetes and Digestive and Kidney Diseases (R01 DK105960). Drs Telem and Arterburn were funded by a grant from the National Institute for Diabetes and Digestive and Kidney Diseases (R01 DK115408).

Role of the Funder/Sponsor: The National Institute for Diabetes and Digestive and Kidney Diseases had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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