A New Take on an Old Problem

The less radical solution to one of society’s greatest problems

Gruppo Ospedaliero San Donato (GSD)

Bariatric surgery has evolved a great deal from its origins as a primarily cosmetic procedure. As health systems have attempted to come to grips with the obesity crisis and the burdens it puts on them from increasing rates of diabetes to cardiovascular disease, bariatric surgery is increasingly seen as a means of combating the root causes of a variety of conditions. Far from a cosmetic procedure, bariatric surgery may well hold the key to reducing strain on global health systems as well as significantly improving patient outcomes and quality of life. 

Group San Donato’s Prof Andrea Formiga, MD, head of the Interdisciplinary Center for Obesity and Bariatics, explains that when talking about obesity in a medical context, one is really speaking about a whole host of diseases such as hypertension, type 2 diabetes, other respiratory diseases and orthopedic problems. All of these conditions, he says, can be improved by reducing the patient’s weight. 

As its potential as means of treating and preventing serious health conditions has come to the fore, so too are the means and technologies behind bariatric procedures. Often seen as a radical method of treatment reserved only for the worst cases, Formiga explains that bariatric surgery is undergoing a sea change. Far from the radical gastric bypasses, device makers are not pioneering gentler solutions. Endoluminal solutions are, says Formiga, “changing the way we approach surgery.” He cites a relatively new technology, the endobarrier, a sleeve that covers the first 60cm of the small bowel so that what the patient eats isn’t absorbed by that part of the bowel, much like a bypass. Other endoluminal solutions employed by Formiga and his team are the inter-gastric balloon whereby the surgical team performs an endoscopy and inserts the balloon in the stomach to reduce the gastric volume, reducing the amount the patient can eat. In addition, the team have also begun offering a new device, overstitch, that clips the stomach to reduce its volume. 

These methods of performing bariatric surgery are less invasive and present significantly reduced risks to the patient as a result as well as allowing for shorter hospital stays and faster procedures, freeing up valuable operating theatre time for the hospital. However, Formiga stresses the fact that while there are many advantages to these less radical approaches, they cannot be compared to the more extreme forms of bariatric surgery such as sleeve gastrectomy. “The results are different and also the indications are different. When you treat a patient you have a multi disciplinary team composed of the surgeon, dietician, psychologist and of course, endocrinologist, and all together, we examine the patient and decide which treatment is best for the patient.” 

The key, he continues, is to have a complete understanding of the specific patient’s situation and their dietary behaviour as each patient’s case is unique. Once Formiga’s multidisciplinary team has fully assessed the patient, they can recommend the optimal form of bariatric surgery for their case as each procedure has different outcomes. True surgical interventions are, he explains, “more powerful than endoluminal approaches.” However, endoluminal procedures are ideal for patients with lower BMI. “You can’t do a sleeve gastrectomy on a patient with a BMI of 35 for example. The patient has to lose only 20 kilos, if you do a sleeve gastrectomy they’ll lose 50-60. It’s not correct for them.”

For example, Formiga explains that the endobarrier is often used in cases where patients suffer from type 2 diabetes “because when you avoid contact with the food in the small bowel it improves insulin response.” He cites the example of a patient from Saudi Arabia he treated at his practice outside Milan. During one year of treatment with the endobarrier system, the patient experienced a two point reduction of glycated hemoglobin, something he cites as being one of the positive outcomes such treatments can have on diabetes. Indeed, he explained that the patient wants to return to have the procedure again as it allowed him to reduce his medication, with his condition improving to the point he was able to stop taking daily insulin injections. It is, he says, “a great result with a low risk endoluminal solution.”

Asked whether such treatments are suited to medical travel, Formiga highlights the importance of post operative followup care. Each patient, he explains, requires specific and detailed followup. “If you do the surgery and don’t follow up, it can fail.” Without the involvement of the surgeon, dietician, psychologist and endocrinologist to monitor the patient, he explains that there are many ways that the procedures can fail, especially those such as the sleeve gastrectomy. “We see a lot of places that see a lot of patients but don’t follow up. Indeed, failure of these procedures is a common problem because of that.” Therefore, he says, “multidisciplinary followup is mandatory” to ensure the success of the procedure. 

Despite the followup requirement however, Formiga sees no reason why patients cannot travel to have the procedure and return home for their followup. He explains that his team can implement a system to confer with the patient’s local doctors to ensure that the post operative followup is adhered to. The less invasive procedures such as the endobarrier and balloons are, he says, even more suited to medical travel as they require much shorter stays in the hospital with a two-day stay for the endobarrier and just one night for the balloon. The more serious procedures, however, require a weeklong stay to ensure there are no complications and that the patient recovers properly. 

 “The whole world is looking to these solutions,” says Formiga when asked if bariatric surgery is the best method to cope with the global obesity crisis. As rates of diabetes and heart disease in the Middle East skyrocket, he warns that gastric bypass and sleeve gastrectomy failure rates are too high, citing them as being “a great problem.” However, he sees endoluminal procedures as being the ideal method of dealing with the crisis as they are of much lower risk and much lower cost thanks to less time in the hospital and operating theatre. Formiga warns that while there is certainly a place for more radical surgeries - sleeve gastrectomy is still the most common form of bariatric surgery - the medical community is waking up to the failures as after a few years, the tube made in the patient gets bigger and the patient regains weight. “Therefore, you need something more about 10 years later - either endoluminal solution or you convert it to a gastric bypass. This is how you manage the situation.”

Far from simply being a means of coping with the obesity crisis, Formiga sees endoluminal solutions as being the wave of the future for general surgery “because they minimise the instruments, and the possibility to treat cancer or lesions inside from the endoluminal part is something a lot of companies are researching” as it is less invasive with comparable results.