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The Future of Weight Loss Surgery

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by Kent C. Sasse, M.D., MPH, FACS

With the obesity epidemic showing very few signs of waning, weight-loss surgery and related medical treatments for obesity will become increasingly important in the years to come.  Close to 200,000 weight loss surgical procedures are being performed annually in the United States.  Yet there are many factors that will likely lead to a dramatic increase in the number of weight loss operations performed in the future. 

Chief among these factors that will drive more overweight and obese individuals to seek surgery is the fact that weight-loss surgery is moving to the outpatient arena. In the past a limited number of people were willing to consider an invasive procedure that involved a significant hospital stay, but today a much larger percentage of overweight individuals would undergo an outpatient weight loss procedure.  Outpatient surgery implies that the procedure is less invasive, less risky, and requires much less recovery time.  For many people, it also means better protection of their privacy, and less time away from work and family responsibilities. 

Ba riatric surgery has in fact become much less invasive, less risky, and more demonstrably effective in the past two decades. Increasingly sophisticated procedures are performed with minimally-invasive laparoscopic technique involving four to six small (less than a half-inch) incisions. Long term studies show weight loss of 55-85% of excess body weight and dramatic gains in health and longevity after weight-loss surgery. Coverage of bariatric surgery by businesses is now shown to result in net cost savings by improving worker productivity and decreasing medical absenteeism.

Outpatient weight loss surgery is likely to grow at a much faster rate than other types of weight loss surgery and probably faster than many other types of outpatient surgical procedures including orthopedic and gynecologic procedures.  The shift toward outpatient surgery involves a shift towards less invasive procedures, and predominantly toward the laparoscopic adjustable gastric band (LAGB).  But in some centers, an increasing fraction of people is also undergoing outpatient laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) with a minimally-invasive technique and very short hospital stay. 

The definition of ?outpatient? varies from state to state, but in the most general terms as used by the federal government, the term ?outpatient? means that the total stay at the surgery center or hospital lasts less than 24 hours.  So, while most people can undergo a laparoscopic adjustable gastric band procedure and be home in a matter of four to six hours, some people may also undergo laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass and be home in less than 24 hours.  An even higher percentage of people can be home in less than 48 hours.

So with less invasive laparoscopic surgery requiring little to no hospital stay, some of the fears about the invasiveness and risk of bariatric surgery will continue to dissipate in the minds of both overweight patients and their referring physicians. This is likely to lead to increased acceptance of weight loss surgery, more people attending informational seminars about it, and more people choosing the procedure.

Another very potent factor leading to the increase in performance of weight loss surgery in the future is the robust competition and marketing capabilities of the two large medical device companies that manufacture and sell adjustable gastric bands.  Ethicon Endosurgery recently won approval of the REALIZE? band that now competes with the Lap-Band® from Allergan Corporation.  Both companies produce very effective and persuasive direct-to-consumer marketing of the adjustable gastric bands.  And as ads for outpatient LAGB weight-loss surgery appear increasingly on common shows and sites, acceptance of these procedures among the more than 100 million seriously overweight Americans will continue to rise.

The current economic climate may limit the growth of weight-loss surgery in several ways. As unemployment rises and benefits are tightened, fewer people will have coverage for bariatric surgery through insurance. And others who might have paid for the service out of pocket will now find that resources must be conserved or spent elsewhere.

Nonetheless, obesity continues to be the most important and widespread health problem in the U.S. And bariatric surgery is increasingly recognized as the only effective treatment with proven, durable results. If the number of procedures being performed annually rises significantly and we soon have 300,000 to 400,000 of these procedures being performed annually (a number that still represents a small percentage of the population that qualifies every year by having a Body Mass Index over 35, the current widely accepted criterion), then there may be a need for more surgeons to become skilled at providing the procedure.  There may be a role for more general surgeons to perform bariatric surgery and more centers to become equipped to do so. 

Surgeons and centers entering into this field will likely encounter resistance, as there is currently a strong push to maintain specialization and high-quality, focused bariatric services. The accreditation of selected centers, hospitals and20surgeons as Centers of Excellence through the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery has created emphasis on high volume centers with highly trained and experienced surgeons and staff with specialized equipment including high weight-limit beds, tables and chairs.  Whether these criteria and the expense of offering such specialized care will serve as barriers to entry and limit the new surgeons and centers that perform bariatric procedures will become clear in the coming years.

Strongly credentialed, experienced surgeons will maintain a competitive advantage, as will centers that invest in all of the specialized capital equipment and training necessary to compete as a Center of Excellence.

Bariatric surgery is poised to grow significantly as more people choose the minimally-invasive procedures. Recognition of its effectiveness and the shift to20the outpatient environment will likely create a rising demand. And the obesity epidemic, already the #1 health problem in the country, shows very few signs of diminishing.

Kent C. Sasse, MD, MPH, FACS is the Medical Director of Western Bariatric Institute and the author of Outpatient Weight Loss Surgery, Safe and Effective Weight Loss with Modern Bariatric Surgery.  For further information please visit www.SasseGuide.com.