"Which Procedure is Best for My Patient?"

We were at a "meet and greet" lunch meeting for one of our referring Primary Care offices in the area yesterday, and an excellent, fundamental question came up by one of the MDs.

"Which procedure is best for my patient?"

If you scan through this Blog, you will find the answer to that question, and a whole bunch more, but I thought I would draw up a shorter answer here that may cut to the chase.

First off, when your patient comes in to see us, they will see their Surgeon twice before surgery.  That enables the patient to be able to go over their thoughts and concerns about their procedure of choice, should they have any, as the Surgeon reviews each procedure and their inherent risks and benefits. And again, we don't generally force a patient into any procedure, we just inform them and guide them into making the best decision for them on their weight loss "tool"/surgery.

Here's my attempt at an encapsulated view.

Gastric Band

*Probably best for lower BMIs, in the range of (30-35 with DM2*) 35 to 45 or so.  That being said, we have many successful patients that have started with much higher BMIs, although those with less to lose often do better, as the weight loss expected with the Band is slower (1-2#/week). 

The FDA has approved the Band for DM2 and a BMI of 30 -35, although insurance companies have been sluggish to adopt this standard. As you probably know, NIH, and generally insurance standards, dictate a BMI of 35-40 with comorbidites to be an acceptable candiate for surgery, and a BMI of >40 even in the absence of comorbidities.

*As far as Diabetes goes as a comorbidity, the weight loss is the driver for the resolution in this process, rather than the immediate benefit from Gastric transection as with the other 2 procedures.  If a patient is "mildly" Diabetic (diet-controlled, just on PO meds with decent control /glyco's, onset of DM < 5 years) they may do fine, and a Band is certainly better than no tool at all, if they won't even consider any other procedure type.

Sleeve Gastrectomy

Long term Data is in the process of being gathered, and substantiated by increasing numbers of sleeves being done since the recent past.  data thus far shows a little less  % Excess Weight Loss (EWL) than the Gastric Bypass, and perhaps a little less weight loss long term.  So,

*Perhaps more beneficial in patients with mid to lower range BMIs (<50) due to above reasons.

*Diabetics do nearly just as well for the immediately beneficial metabolic effect on Glucose regulation than do the Bypass patients, so a big benefit there over a Band.

*May be relatively contraindicated inpatients with severe GERD or Barretts, due to higher likelihood of GERD after surgery in some.

*Potentially more favorable in patients on a lot of meds, especially NSAIDS, which we generally like to have patients discontinue after surgery.  With the Sleeve, they should generally fare better than the Bypass with ulcer risk.

Gastric Bypass

*Bypass still is the gold standard Bariatric procedure, with the best success, and has the most data to support its long term impact on weight  loss and comorbidities.  So, correspondingly, any range of BMIs is acceptable, and certainly with Diabetes, slightly better DM2 resolution and remission rates (than Sleeve Gastrectomy) have been documented, as well as generally more weight loss with both its restrictive and malabsorptive effects..


I hereby fully admit my bias- Any surgery type for the right candidate is better than no surgery at all for weight loss. 

Optimizing which patient type for which procedure can be done to a degree, but again, surgery beats medical weight loss hands down.  That being said, there are some subtleties that are good to be aware of, and hopefully this brief guide will help you as you guide patients to a surgical "tool" that will work the best for them.

Please feel free to post a comment or question at any time on this blog entry, or any other one you see, as it may be helpful to others who are following along and may have the same issue.