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MsJacquiiC · #1

Bariatric specialists have been on the forefront of new and revolutionary surgical treatment modalities for obesity and related comorbidities.

A questionnaire was distributed to members of the American Society for Metabolic and Bariatric Surgery, asking which specific bariatric surgery the physicians would personally choose for themselves.

On a regular basis, patients are educated, counseled, and evaluated to determine the most appropriate surgical procedure based on the severity of their obesity and their related comorbidities. However, evidence-based guidelines for the selection of bariatric procedures are still evolving. In the absence of such guidelines, specialists rely on their own experience and the preferences of their patients to decide the type of operation that is best for their patients. But if given the same surgical options, what operation would bariatric specialists choose for themselves?

Study
In an attempt to understand this decision-making process, a 16-item online questionnaire, approved by the institutional review board (IRB) at Johns Hopkins Medical Institution, was distributed to members of the American Society for Metabolic and Bariatric Surgery (ASMBS). Responders were then asked to choose the most appropriate bariatric procedure for themselves given several body mass index (BMI) categories. In addition, we asked how their decisions would be influenced by the concurrent diagnosis of type 2 diabetes. The surgical options included laparoscopic Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric band (LAGB), laparoscopic sleeve gastrectomy (SG), and laparoscopic duodenal switch with biliopancreatic diversion (DS-BPD).

A random sample of 200 members of the ASMBS was surveyed. One hundred and eight questionnaires were returned, for a response rate of 54 percent. Sixty-three responders were surgeons and 45 were allied health members. Sixty responders were men, with a mean age of 46.7, and 48 responders were women, with a mean age of 42.4.

Findings
When asked which procedure they would choose for themselves if they had diabetes and a BMI of 35 to 44.9, most (58.3%) chose a RYGB. Without diabetes for the same BMI category, the responders chose the LAGB (45.4%) most frequently, followed by the RYGB (27.8%) and SG (25.9%).

For a higher BMI of 45 to 54.9 with diabetes, the RYGB seems to be most popular, with 72.2 percent of our responders preferring this procedure over the other options, the breakdown for which was LAGB (13.9%), SG (9.3%), and BPD-DS (4.6%). For the same BMI category without diabetes, the preferences did not change significantly: the RYGB was still most popular (61.1%) followed by LAGB (25.9%), SG (10.2%), and BPD-DS (2.8%).

In superobese individuals with BMIs greater than 55, the response was also similar regardless of the diagnosis of diabetes. Almost sixty-nine percent (68.5%) of responders prefer the RYGB for themselves in the setting of diabetes, while 66.7 percent chose the same procedure even if they did not have diabetes. The next most popular choice was the BPD-DS at 16.7 percent with diabetes and 13 percent without diabetes. Other bariatric procedures were not as popular options for the superobese weight category (LAGB 8.3% and SG 6.5%).

Conclusion
It seems clear that, among bariatric specialists and allied health professionals, the laparoscopic Roux-en-Y gastric bypass is the preferred procedure under most circumstances, and is chosen most often when there is a concurrent diagnosis of diabetes. The adjustable gastric band was preferred when there was a lower BMI of 35 to 44.9 without the diagnosis of diabetes, followed by gastric bypass and sleeve gastrectomy.

According to the most recent report from the Centers for Disease Control (CDC), the rate of adult obesity continues to rise in the United States.[1] In 2007, 25.6 percent of adults reported being obese, an increase from 23.9 percent in 2005. The percentage of adults who are obese varies by state and region, with obesity being most prevalent in the South. States most affected are Alabama, Mississippi, and Tennessee, with a recorded 30-percent obesity rate among residents.[2] This formidable challenge of rising obesity motivates the continuation of medical research that will allow us to provide our patients with the knowledge and ability to choose the best operation that will hopefully prevent, reduce, and reverse the comorbidities of obesity.

by Hien Nguyen, MD; Kimberley Steele, MD; Anne Lidor, MD; and Michael Schweitzer, MD
All from the Johns Hopkins Medical Institutions.
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