Latest developments in bariatric surgery

Attendees at the Joint Irish-UK Endocrine Meeting 2024 received a tour de force presentation on the latest advances, findings, and outcomes in bariatric surgery from Prof Helen Heneghan, Consultant Bariatric Surgeon, St Vincent’s University Hospital, Dublin. Her talk was titled: ‘Metabolic surgery: Which to choose and new developments’.

In terms of trends, Prof Heneghan said the gastric band is “becoming a redundant procedure” and has the highest rates of long-term complications. The approach is also the least effective in terms of weight loss and comorbidity resolution, when compared to the commonest operations performed – sleeve gastrectomy and gastric bypass.

Delegates received a detailed overview of each procedure, noting that bypassing the foregut (duodenum and proximal jejunum) leads to “a lot of the gut hormone benefits responsible for metabolic improvements”. Prof Heneghan also stated that sleeve gastrectomy “leads the way in terms of volume”, accounting for over 60 per cent of bariatric surgeries performed worldwide.

Describing her own practice and experiences, Prof Heneghan talked about the value of “enhanced recovery after surgery”. She described this process as a “bundle” of measures implemented before, during, and after surgery to enhance safety, facilitate early discharge, and reduce risks. The measures include a simple laparoscopic approach and early resumption of mobility post-operatively. Prof Heneghan told the conference that bariatric surgery carried a mortality rate equal to cholecystectomy, which is less than one-in-1,000. Major complications arise in 1-2 per cent of cases, while one-in-10 patients will experience mild-to-moderate problems, she said.

Moving to the benefits of bariatric surgery, Prof Heneghan noted that “every organ affected by obesity can be improved”. She described an array of positive outcomes, which also extend to mental health benefits and a reduced risk of cancer (excluding lung cancer).

The superiority debate: Choosing a procedure

Prof Heneghan explained that if patients do not have a preference regarding sleeve gastrectomy or bypass, “it’s not an easy decision”. Only around half of patients will have a preference and many may be misinformed, particularly due to social media. “There are pros and cons to both procedures,” she said. The benefits of sleeve gastrectomy include the fact it is technically a straightforward procedure, relatively safe, and is effective for weight loss and obesity complications. On the other hand it is not reversible and weight regain occurs in up to 70 per cent of patients. Gastro-oesophageal reflux disease occurs in 20-30 per cent of patients, with one-in-five developing non-dysplastic Barrett’s oesophagus, the conference heard.

Gastric bypass is reversible, slightly more effective than sleeve gastrectomy, and reduces obesity complications. “There is a risk of ulcers and strictures at the first anastomosis,” said Prof Heneghan, who also noted the surgery carried a slightly higher risk of iron deficiency.

“There is some new data to help decide which procedure to choose,” according to Prof Heneghan. She presented the latest published and some unpublished findings to summarise current understanding that “bypass outperforms a sleeve, which outperforms a band”, and that gastric bypass achieved a better quality-of-life.

“Bypass is more clinically effective than a sleeve and a band in the short- and medium-term. We need data beyond three years, particularly beyond five years. I think based on experience and non-randomised data, the bypass will outperform the sleeve…. The bypass is now as safe as a sleeve and as cost-effective, but that data has yet to be published.”

Novel therapies

A range of novel approaches are emerging in bariatric treatment, delegates heard. These included the intragastric balloon. This involves an endoscopic procedure that is “very safe for temporary weight loss or patients unsuitable for surgery”. However, the weight goes back on when the balloon is removed.

“The most novel endoscopic device coming to market is the magnet anastomotic system,” stated Prof Heneghan. She said it “involves placing a magnet in the proximal jejunum using endoscopy and one in the terminal ileum using colonoscopy, let them meet each other, and compression will form an anastomosis in a really safe way”. Prof Heneghan also discussed selecting patients for the duodenal mucosal resurfacing procedure, which involves endoscopic ablation to resurface the mucosa. It takes “less than one hour to perform, is really safe, and is associated with an improved A1C and weight loss of around 7 per cent at one year”.

Concluding with a summary of current knowledge, Prof Heneghan said: “Bariatric surgery is clinically- and cost-effective for the treatment of obesity. A gastric bypass is more effective and as safe as a sleeve gastrectomy. Patient choice is also important in determining which procedure people have. They have to be informed on the likely procedure outcomes. There are really exciting novel metabolic procedures on the way that I think, combined with medications, will transform the treatment of obesity in future.”