Bariatric Surgery: Is It the Right Choice for My Patient?

“Have you ever considered bariatric surgery for weight loss?”

“Oh, I would never do that.”

“Why’s that?”

“Surgery is too scary. ”

Mr. S was motivated to lose weight.  He had spent most of his adult life working as a long-haul truck driver.  Although he said he was able to provide for his family, the work had taken its toll on his body.  His BMI was in the 40s, and he had diabetes and peripheral neuropathy.  He was worried about cardiovascular disease that had affected some of his colleagues.  He was retiring and wanted to spend the rest of his years in better health.  He came to me to discuss weight loss.  When I brought up bariatric surgery, he said, “never.”

This is a conversation I have had many times with many patients in my diabetes clinic. I was reminded of them when I read the Annals article “Comparative Effectiveness and Safety of Bariatric Procedures for Weight Loss: A PCORnet Cohort Study.”  The article compared types of bariatric surgeries. The authors determined that not only were different procedures associated with more weight loss or more short-term adverse events, but certain patient populations had more success than others. Specifically, they found that patients aged 65 years or older, those with diabetes, those with a preoperative BMI less than 50 kg/m², and racial minority patients generally lost less weight with Roux-En-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) than younger, nondiabetic, more severely obese, and non-Hispanic white patients.  With this information, I would be able to provide clearer guidance to Mr. S more tailored to him.

Data like these help me inform my patients. When patients tell me they don’t want to consider surgery, I move on.  I wonder if I should not be moving on so quickly. I could answer my patient’s questions, but I couldn’t dispel the fear. Surgery can be a daunting prospect for patients.  It can also be daunting as an internist to recommend something like elective surgery. 

The picture my patient had of bariatric surgery was indeed scary.  He knew of friends who suffered from complications.  He had seen surgery depicted on fictional TV shows.  To him, RYGB felt “scarier” than other bariatric options.   As someone who is not a surgeon, I can empathize with that fear.  A band or a sleeve just sounds less intimidating than a bypass.  It is helpful to have facts behind me, but facts do not allay fear.  Surgery, any surgery, is scary.  Committing to something that feels so permanent is scary. 

With Mr. S and my other patients, I find that when I acknowledge that their fear is real and is justified, we can have a relationship that allows me to have honest discussions on recommendations.  The article mentions needing to “tailor” to patient’s clinical situation.  When it comes to weight loss, decisions must be tailored as much to what is physiologically beneficial but what is emotionally acceptable to them, too.  Ultimately, our goal is for our patients to have the best health outcomes possible.  In doing so, we need to acknowledge our patients' concerns but also use evidence to help alleviate them.

Reference

1. Arterburn D, Wellman R, Emiliano A, Smith SR, Odegaard AO, Murali S, et al. Comparative effectiveness and safety of bariatric procedures for weight loss: a PCORnet cohort study. Ann Intern Med. [Epub ahead of print 30 October 2018]. doi:10.7326/M17-2786