Weight loss surgery has increased significantly in France: the number of bariatric procedures quadrupled in the last decade to reach 50,000 in 2015. The number of facilities providing weight loss surgery has also increased, nearing 500. The trend has been seen around the world: some 468,000 procedures were carried out globally in 2013, led by the U.S. and Brazil.
Weight loss surgery has also developed in other European countries: in the UK, the number of procedures has increased tenfold since 2000. The type of procedure has changed: sleeve gastrectomy has been the most common bariatric surgery procedure in France since 2011, representing 60.7% of procedures in 2014, whilst gastric banding now accounts for just 9.3%. Gastric bypass accounts for 29.8% of procedures (1).
There are several factors that could explain the increase in bariatric surgery procedures:
Firstly, it is the only effective treatment for morbid obesity and the associated metabolic complications, with medical treatments having little effect (2).
In addition, the prevalence of type 3 obesity has quadrupled in fifteen years, according to the Obépi survey (3).
Perioperative mortality has fallen due to the introduction of laparoscopy and the creation of centres of excellence. In France, postoperative mortality at three months is approximately 1 per 1000.
The improvement in postoperative metabolic complications and obesity-related excess mortality is now clearly demonstrated (4).
The indications for weight loss surgery were defined by France's National Authority for Health (HAS) in 2009: patients with a Body Mass Index (BMI) greater than 40 kg/m2 or greater than 35 kg/m2 associated with comorbidities (diabetes, HT, etc.) in second intention when six months of appropriate medical treatment have failed. It is also essential that patients are fully informed and understand the need for long-term follow-up. The boom in bariatric surgery in France requires the country's surgical centres to be assessed and organized.
Around 20% of patients regain weight following a gastric bypass. The figure is 30% for gastric sleeves and 40% for gastric bands. That leads many patients to request a second or third procedure. Beyond the technical complications, further surgery should only be provided following another comprehensive workup, particularly nutritional and psychiatric (5).
Follow-up is important, not only to reiterate the nutritional advice and importance of physical activity, but also to identify nutritional or vitamin-related complications. However, it is poorly defined in terms of intention and frequency. A recent CNAM survey found that two thirds of surgical patients are monitored only by their general practitioner in the first two years postoperatively.
In conclusion, under pressure from patients, weight loss surgery has increased significantly, largely due to the reduction in postoperative mortality and good midterm results (five years). However, the surgery's long-term success is dependent on proper preparation for the procedure and regular follow-up thereafter. The organization of obesity centres with multidisciplinary specialist teams, the concentration of procedures in centres with high volumes of activity and the involvement of general practitioners in obese patients' treatment pathways have become essential.
Pr Jean GUGENHEIM