- Email: [email protected]
American Society for Metabolic and Bariatric Surgery 2018 estimate of metabolic and bariatric procedures performed in the United States
Journal Pre-proof “American Society for Metabolic and Bariatric Surgery 2018 estimate of metabolic and bariatric procedures performed in the United States” Wayne J. English, MD, FACS, E.J. DeMaria, M.M. Hutter, S.N. Kothari, S.G. Mattar, S.A. Brethauer, J.M. Morton PII:
S1550-7289(19)31160-8
DOI:
https://doi.org/10.1016/j.soard.2019.12.022
Reference:
SOARD 4012
To appear in:
Surgery for Obesity and Related Diseases
Received Date: 23 December 2019 Accepted Date: 24 December 2019
Please cite this article as: English WJ, DeMaria E, Hutter M, Kothari S, Mattar S, Brethauer S, Morton J, “American Society for Metabolic and Bariatric Surgery 2018 estimate of metabolic and bariatric procedures performed in the United States”, Surgery for Obesity and Related Diseases (2020), doi: https://doi.org/10.1016/j.soard.2019.12.022. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc. on behalf of American Society for Bariatric Surgery.
“American Society for Metabolic and Bariatric Surgery 2018 estimate of metabolic and bariatric procedures performed in the United States” Short Title: “2018 bariatric surgery numbers estimate” Corresponding Author Wayne J English, MD, FACS
Affiliation Vanderbilt University Medical Center 1161 21st Avenue South Room D5203 MCN Nashville, TN 37232-2577 Email: [email protected] Office Phone: (615) 322-7555 Mobile Phone: (615) 840-2644 Fax: (615) 343-9485
Contributing Authors DeMaria EJ
Affiliation East Carolina University Brody School of Medicine 600 Moye Blvd Greenville, NC 27834 Email: [email protected]
Hutter MM
Harvard University Massachusetts General Hospital 15 Parkman Street Boston, MA 02114 Email: [email protected]
Kothari SN
University of South Carolina Greenville Prisma Health - Greenville Memorial Medical Campus 701 Grove Road Greenville, SC 29605 Email: [email protected]
Mattar SG
Swedish Medical Center 1124 Columbia Street, Suite 400 Seattle, WA 98104 Email: [email protected]
Brethauer SA
The Ohio State University Wexner Medical Center 2050 Kenny Road Pavilion, 2nd Floor, Suite 2500 Columbus, OH 43221 Email: [email protected]
Morton JM
Yale School of Medicine Orchard Medical Center 330 Orchard Street 2nd Floor, Suite MOB 2 New Haven, CT 06511 Email: [email protected]
Background: Metabolic and bariatric surgery, despite being the only effective durable treatment for obesity, remains underutilized as approximately 1% of all patients who qualify actually undergo surgery. The American Society for Metabolic and Bariatric Surgery created a Numbers Taskforce to specify annual rate of utilization for obesity treatment interventions and to determine if patients in need are receiving appropriate therapy.
Objectives: The objective of this study was to provide the best estimated number of metabolic and bariatric procedure performed in the United States in 2018.
Setting: United States
Methods: We reviewed data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), National Surgical Quality Improvement Program (NSQIP), Bariatric Outcomes Longitudinal Database (BOLD) and Nationwide Inpatient Sample (NIS). In
addition, data from industry and outpatient centers were used to estimate outpatient center activity. Data from 2018 was compared mainly to data from the previous two years.
Results: Compared to 2017, the total number of metabolic and bariatric procedures performed in 2018 increased from approximately 228,000 to 252,000. The sleeve gastrectomy continues to be the most common procedure. The gastric bypass procedure trend remained relatively stable and the gastric band procedure trend continued to decline. The percentage of revision procedures and biliopancreatic diversion with duodenal switch (BPD-DS) procedures increased slightly. Finally, intragastric balloons placement continues as a significant contributor to the cumulative total number of procedures performed but declined from the previous year.
Conclusions: There was a 10.8% increase in the number of metabolic and bariatric procedures performed in 2018, compared to 2017, with an overall increase of approximately 60% since 2011. When taking into account primary procedures only, approximately 1.1% of patients who qualified for metabolic and bariatric surgery were treated with surgery in 2018.
Keywords: Bariatric surgery; Procedure trends; Bariatric surgery procedure trends; Numbers task force; Estimated numbers; 2018
Introduction
The adult obesity rate in the United States (US) increased from 13.4% in 1962 to 39.8% in 2016, an increase of approximately 200%, and currently affects over 93.3 million adults age 20 and older in the US. The percentage of patients with a body mass 5
index of greater than 40 kg/m2 is approximately 7.7%, or approximately 18 million adults age 20 and older. (1, 2) As a result, the economic impact of treating comorbidities associated with obesity has risen significantly. It has been demonstrated that patients with obesity, compared to patients who are not obese, experience increases in annual healthcare costs of 36% and medication costs of 77%. (3) Obesity as a risk factor is by far
10
the greatest contributor to the burden of chronic diseases in the US, accounting for 47.1 percent of the total cost of chronic diseases nationwide. Subsequently, the overall economic burden of obesity is calculated to be $1.72 trillion, which is equivalent to 9.3% of the US gross domestic product. (4)
Metabolic and bariatric surgery, the only effective and durable treatment for 15
obesity, remains underutilized in treating the obesity epidemic in the US. Based on the previous estimates, surgery as a treatment option is used by approximately 1% of all patients who qualify as candidates for metabolic and bariatric surgery. (5) To determine if patients in need are receiving appropriate therapy, the American Society for Metabolic and Bariatric Surgery created a Numbers Taskforce to specify annual rate of utilization
20
for obesity treatment interventions.
Here, the American Society for Metabolic and Bariatric Surgery Numbers Taskforce is reporting the 2018 estimate of the number of metabolic and bariatric surgery
1
procedures performed in the US. This report provides the best approximation using the methodology described below.
25
Methodology
A comprehensive review of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was completed. This included 100% of the primary and revisional metabolic and bariatric procedures performed within the 847 metabolic and bariatric surgery centers accredited by MBSAQIP in 2018.
30
In addition, a review of the National Surgical Quality Improvement Program (NSQIP) database was also performed which included primary metabolic and bariatric procedures performed within non-MBSAQIP accredited metabolic and bariatric surgery centers. A major limitation of using NSQIP data is that participating centers are only required to report a minimum of 20% of surgical cases, a portion of which are metabolic
35
and bariatric procedures. Underreporting at these centers is expected, however some centers may report up to 100% of all metabolic and bariatric surgery procedures.
Additionally, a review of other national registries was undertaken including the Bariatric Outcomes Longitudinal Database (BOLD) and Nationwide Inpatient Sample (NIS). A limitation of utilizing the NIS database is that it does not record outpatient 40
metabolic and bariatric procedures or track patients longitudinally.
To capture outpatient procedures performed at centers that do not submit data to MBSAQIP, NSQIP or BOLD, relevant medical device companies were surveyed to obtain the total number of gastric bands and intragastric balloons sold in 2018. However,
2
estimates were made to determine devices purchased, but not used. Furthermore, as the 45
only known comprehensive state outpatient database in the US, data from the State of Texas was applied to the estimate for outpatient procedures being performed outside of MBSAQIP.
MBSAQIP and BOLD data were considered to originate from accredited centers for purposes of this assessment. Data from NIS and NSQIP were used to estimate non50
accredited inpatient center activity. Data from industry and outpatient centers were used to estimate outpatient center activity. A 5% reduction in the overall number was applied to account for devices purchased but not used, in keeping with supply chain industry standards.
Primary surgical procedure categories were sleeve gastrectomy, Roux-en-Y 55
gastric bypass, gastric banding, biliopancreatic diversion with duodenal switch (BPDDS), and gastric balloons. Revisions and conversions included procedures in which primary procedures were previously performed, including gastric band removal, gastric bypass reversal, perforated marginal ulcer repair and internal hernia correction. The “Other” procedure category included, but was not limited to, gastric plication, single-
60
anastomosis gastric bypass and duodenal switch, vertical-banded gastroplasty, vagal blockade, endoscopic therapies (not including gastric balloons), unlisted procedures and other investigational procedures.
Results
3
In 2018, compared to 2017, the total number of bariatric procedures increased 65
almost 10.8% from approximately 228,000 to 252,000. The overall estimated number of metabolic and bariatric procedures for 2018, as well as the trend and procedure breakdown from 2011 to 2018 is listed in Figure 1, and Tables 1 and 2.
The sleeve gastrectomy continues to be the most common procedure, comprising 61.4% of all procedures in 2018. A 23.7% increase was noted since 2016 (125,318 to 70
154,976), but even more striking was the observed growth trend of 451% since 2011.
The number of gastric bypass procedures comprised 17.0% of all procedures in 2018. Although the gastric bypass trend shows a decline of 25.9% since 2011, the numbers from 2016 to 2017 were relatively stable (40,316 to 40,574 respectively). However, a trend reversal was noted from 2017 to 2018 as the number of gastric bypasses 75
performed increased 5.8%, from 40,574 in 2017 to 42,945 in 2018.
The gastric banding trend continues to decline as seen in previous years. The number of gastric band procedures was only 1.1% of all procedures performed in 2018, declining 57.9% from 6,318 in 2017 to 2,660 in 2018. A 95.2% decrease was observed since 2011, further reinforcing the fact that gastric banding has lost its appeal in the US.
80
The percentage of revision procedures increased slightly, from 14.4% to 15.4%. The number of revision procedures performed increased 19.7% from 32,238 in 2017 to 38,971 in 2018, with an observed 311% increase since 2011. Gastric band removal only comprised of 27.6% of all revision procedures.
4
The percentage of BPD/DS procedures only minimally increased from 0.7% to 85
0.8%.
However, the number of procedures increased 33.7%, with 2,123 in 2018
compared to 1,588 in 2017. When compared to 2016, a 71.8% increase was noted.
Gastric balloons continue to contribute to the aggregate procedure number, but a 19.7% decline was seen from the previous year. An estimated 5,042 patients received balloons, representing 2.0% of all procedures.
90
When taking into account the four primary procedures only, sleeve gastrectomy was performed 76.5%, Roux-en-Y gastric bypass, gastric banding and BPD-DS was performed 21.2%, 1.3% and 1.0% respectively. [Table 3]
Procedures performed at accredited centers
MBSAQIP: In 2018, 202,451 procedures, or approximately 80% of all 95
procedures, were performed at MBSAQIP-accredited centers. This is an increase of 8.9% compared to 185,890 procedures in 2016, and a 2.1% increase from 198,229 procedures in 2017. [Table 4]
During the 2018 calendar year, 847 centers reported data in the MBSAQIP registry, a 6.5% increase from 795 centers in 2016. Canadian and International centers 100
also participate in MBSAQIP but were not included in this analysis.
The number of adolescent patients undergoing metabolic and bariatric surgery comprised of only 0.17% of the total volume of procedures reported in the MBSAQIP data registry. However, the number of adolescent procedures performed increased by
5
117% since 2014, with laparoscopic sleeve gastrectomy being the most commonly 105
performed procedure. [Tables 5, 6]
BOLD: A total of 18 centers were contributing data to BOLD at the time of this assessment. Seven centers were dual entry programs, entering data into MBSAQIP and BOLD, and were not included in the BOLD number estimate. The remaining 11 centers were included in the estimate as BOLD-only programs. A total of 3,529 procedures were 110
performed at BOLD centers in 2018, but only 2,156 procedure were applied to the estimate given 61% of BOLD centers were not participating in MBSAQIP.
Procedures performed at non-accredited centers
NSQIP: Data from NSQIP centers not participating in MBSAQIP (NSQIP/NONMBSAQIP) was obtained from the American College of Surgeons (ACS). A total of 115
3,266 procedures were reported, with the sleeve gastrectomy representing 67% of all cases being reported at these centers.
Of the 84 NSQIP/NON-MBSAQIP centers performing metabolic and bariatric surgery, only 37 (44%) reported at least 25 procedures, 31 centers (37%) reported fewer than 10 cases, while 16 centers (19%) reported only one procedure in 2018 (range 1-296). 120
Notably, there was a 51.7% decrease in the number of NSQIP/NON-MBSAQIP centers since 2016, possibly accounting for some of the newly accredited MBSAQIP centers. The lower volume per NSQIP/NON-MBSAQIP centers may be due to centers not meeting MBASQIP volume standards. The procedure number provided by the ACS was used as a conservative estimate for the NSQIP data, which was not extrapolated to
6
125
account for the potential reporting differences. Therefore, the true number of procedures performed at NSQIP/NON-MBSAQIP centers may be significantly higher than estimated in this report.
Nationwide Inpatient Sample (NIS): Review of NIS data determined that 8% of inpatient centers performing metabolic and bariatric surgery were non-accredited. This 130
would account for approximately 16,196 procedures performed at non-accredited inpatient centers. However, MBSAQIP added 52 newly accredited centers in 2017 & 2018, accounting for 6,240 procedures. Subtracting these procedures from previous estimates results in a decreased number of cases performed at inpatient non-accredited facilities by approximately 40% (8% to 4.9%) in 2018. When taking into account the
135
aggregate numbers, an estimate of 9,920 procedures were performed in non-accredited inpatient centers in 2018.
NSQIP/NON-MBSAQIP data already demonstrated 3,266
procedures and was subtracted from the NIS non-accredited estimate. Therefore, an estimated 6,654 procedures were performed at non-accredited inpatient centers.
Outpatient Procedure Estimate
140
Gastric Bands and Balloons: Industry estimates determined approximately 2,800 gastric bands were sold in the US in 2018. Using supply chain industry standards, a 5% reduction in the overall number was applied to account for devices purchased, but not used. Therefore, 2,660 gastric bands were performed with approximately 51.9% of the gastric band procedures being performed at accredited centers.
7
145
Industry estimates for gastric balloons inserted were approximately 5,042 for 2018. Accredited centers performed balloon insertion in 1,107 patients. Therefore, it was estimated that 3,935 patients underwent balloon insertion in non-accredited centers.
Stapling Procedures: An accurate number of stapling procedures performed in outpatient centers is difficult to obtain, as many centers do not participate in MBSAQIP 150
and do not enter data into a registry. The outpatient estimate was based on analysis of 2017 outpatient data from the State of Texas. (6) Of the 26 ambulatory surgery centers in which outpatient data was obtained, none entered data into the MBSAQIP data registry.
The State of Texas outpatient data registry revealed that 4,649 sleeve gastrectomy, 257 Roux-en-Y gastric bypass, 5 biliopancreatic diversion, 115 gastric 155
bands and 822 revision procedures were performed in an outpatient setting.
Sleeve gastrectomy was the primary stapling procedure performed at Texas outpatient centers, accounting for approximately 80% of the outpatient procedures performed. Roux-en-Y gastric bypass comprised of approximately 4%, and revision procedures approximately 14%.
160
When analyzing the inpatient and outpatient data registries in Texas, only 73% of the data was captured in the MBSAQIP database. Estimating that 27% of the procedures were not captured in the State of Texas, a conservative estimate of 18% was used for outpatient procedures not captured in the MBSAQIP registry throughout all other states. Therefore, the task force members feel that a very conservative estimated number of
8
165
36,415 outpatient procedures is appropriate for the purpose of this analysis, of which 717 procedures were designated as gastric band procedures.
Discussion
This paper represents the best estimate of metabolic and bariatric procedures performed in the US in the year 2018. Trends over time, continue to demonstrate a 170
significant increase in the number of procedures with another notable increase in the past year. One factor contributing to the increased number of procedures includes the first time use of an outpatient database in estimating procedures in nonaccredited centers, accounting for a greater increase than what was seen in previous years.
A major
limitation exists in assuming data from one state is generalizable and can be extrapolated 175
to determine outpatient procedure numbers for the rest of the US, but the task force members feel this data provides a better reflection of outpatient procedure activity throughout the US and that previously published reports were likely significantly underestimated. Other factors that potentially contributed to the increase include the continued growth of supporting Level I evidence, specialty society outreach, improved
180
access to care, and messaging through media platforms. (7-10)
Although adolescent patients represent only 0.17% of all procedures performed in the US, substantial evidence supports the safety and effectiveness of surgical weight loss for children and adolescents, and robust best practice guidelines supporting these procedures were recently developed and endorsed by the American Academy of 185
Pediatrics. (11,12) As a result, it is feasible that the number of adolescent patients
9
undergoing metabolic and bariatric surgery may significantly increase in the upcoming annual estimates.
An additional factor that may play a role in increasing utilization of metabolic and bariatric surgery includes a recent announcement made by the American Board of 190
Surgery, indicating that metabolic and bariatric surgery will become its first surgical specialty participating in the focused practice designation recognized by the American Board of Medical Specialties, thus providing an opportunity for increasing awareness of, and further legitimizing, metabolic and bariatric surgery as a surgical specialty. As a result, it is possible that a significant increase in patients undergoing metabolic and
195
bariatric surgery may be realized in the near future. (13)
There continues to be steady growth in revision procedures emphasizing the fact that obesity is a chronic disease with variable treatment outcomes. Gastric band removal as a standalone procedure comprised 27.6% of all revision procedures at MBSAQIP centers and there is an increasing number of conversions from gastric banding to sleeve 200
gastrectomy or Roux-en-Y gastric bypass being performed concurrently. It has been demonstrated that, on average, gastric band patients experience 3.8 procedures following surgery and approximately 77% of insurance payments related to gastric banding were for reoperations related to the gastric band complications or weight loss failure. (14) The trend for reoperative metabolic and bariatric surgery is difficult to predict but a plateau,
205
or even a decline, may be seen in future years as the number of gastric band removals decrease over time. Furthermore, the most common procedure performed today,
10
laparoscopic sleeve gastrectomy, is associated with a lower reoperation rate over 10 years compared to gastric banding (9.8% vs. 26%, respectively). (15)
Lastly, ambulatory surgery and intragastric device procedures are likely 210
underestimated due to the lack of reporting requirements for these interventions in nonaccredited centers where surgeon and non-surgeon proceduralists are performing these procedures. Given that data is difficult to obtain in these settings, it is important to appreciate the significant benefit of MBSAQIP as a clinical registry.
Regarding the breakdown of BPD/DS procedures, the MBSAQIP database cannot 215
distinguish between BPD with or without DS, or how many single anastomosis DS procedures were performed in 2018. However, a breakdown is anticipated for upcoming annual procedure estimates as future revisions of the MBSAQIP data registry are completed.
Conclusions
220
There has been a 10.8% increase in the number of metabolic and bariatric procedures performed in 2018, compared to 2017, with an overall increase of approximately 60% since 2011.
It must be noted, however, that for the year 2018, an
additional reporting mechanism was applied to include a portion of outpatient procedures in non-accredited centers, resulting in the potential for a surreptitious increase in total 225
numbers, when compared to the preceding year. The sleeve gastrectomy continues to be the most commonly performed procedure in the US. The number of gastric bypass procedures increased for the first year since 2012, but the overall percentage continues to
11
decline. The number of gastric banding procedures performed annually continues to decline precipitously. The trend for gastric balloon appears to be declining and its future 230
activity remains to be seen. The number of revision procedures continues to grow, and evidence-based treatment options are currently being developed to match patients with the most appropriate procedure to optimize outcomes.
Metabolic and bariatric surgery is a proven safe and effective obesity treatment alternative, but it remains underutilized. When taking into account primary procedures 235
only, approximately 1.1% of patients who qualified for metabolic and bariatric surgery were treated with surgery in 2018.
References 1. Hales CM, Fryar CD, Carroll MD, Freedman DS, Ogden CL. Trends in Obesity and Severe Obesity Prevalence in US Youth and Adults by Sex and Age, 2007-2008 to 240
2015-2016. JAMA. Vol 319. United States2018:1723-1725. 2. Fryar C, Carroll M, Ogden C. Prevalence of Overweight, Obesity, and Extreme Obesity Among Adults Aged 20 and Over: United States, 1960–1962 Through 2013– 2014. NCHS Health E-Stats, CDC. Published July 2016. Accessed July 31, 2019. 3. Sturm R. The effects of obesity, smoking, and drinking on medical problems and
245
costs. Health Aff (Millwood). 2002;21(2):245-253. 4. Waters H, Graf M. America's Obesity Crisis: The Health and Economic Costs of Excess Weight. https://milkeninstitute.org/sites/default/files/reports-pdf/MiAmericas-Obesity-Crisis-WEB.pdf. Published October 2018. Accessed August 3, 2019.
12
250
5. English WJ, DeMaria EJ, Brethauer SA, Mattar SG, Rosenthal RJ, Morton JM. American Society for Metabolic and Bariatric Surgery estimation of metabolic and bariatric procedures performed in the United States in 2016. Surg Obes Relat Dis. 2018;14(3):259-263. 6. Clapp B, Wicker E, Jones R, et al. Where are sleeves performed? An analysis of
255
inpatient versus outpatient databases in a large state. Surg Obes Relat Dis. 2019;15(7):1066-1074. 7. Kim DD, Arterburn DE, Sullivan SD, Basu A. Association Between the Publication of Clinical Evidence and the Use of Bariatric Surgery. Obes Surg. 2018;28(5):13211328.
260
8. Obesity Summit. ASMBS. https://asmbs.org/obesity-summit. Accessed August 3, 2019. 9. English W, Williams B, Scott J, Morton J. Covering bariatric surgery has minimal effect on insurance premium costs within the Affordable Care Act. Surg Obes Relat Dis. 2016;12(5):1045-1050.
265
10. Bariatric Surgery Changes Lives. " It Starts Today" video. ASMBS. https://asmbs.org/bariatric-surgery-changes-lives?/video-it-starts-today-obesitysurgery-helps-people-reclaim-their-lives. Accessed August 3, 2019. 11. Bolling CF, Armstrong SC, Reichard KW, Michalsky MP, SECTION ON OBESITY SECTOS. Metabolic and Bariatric Surgery for Pediatric Patients With Severe
270
Obesity. Pediatrics. 2019.
13
12. Armstrong SC, Bolling CF, Michalsky MP, Reichard KW, SECTION ON OBESITY SECTOS. Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices. Pediatrics. 2019. 13. ABS E-News - Spring/Summer 2019. 275
http://www.absurgery.org/quicklink/absnews/absupdate0619.html#fpd. Accessed November 15, 2019. 14. Ibrahim AM, Thumma JR, Dimick JB. Reoperation and Medicare Expenditures After Laparoscopic Gastric Band Surgery. JAMA Surg. 2017;152(9):835-842. 15. Altieri MS, Yang J, Nie L, Blackstone R, Spaniolas K, Pryor A. Rate of revisions or
280
conversion after bariatric surgery over 10 years in the state of New York. Surg Obes Relat Dis. 2018;14(4):500-507.
285
290
14
Table 1
2011
2012
2013
2014
2015
2016
2017
2018
Sleeve
17.8%
33.0%
42.1%
51.7%
53.6%
58.11%
59.39%
61.4%
RYGBP
36.7%
37.5%
34.2%
26.8%
23.02%
18.69%
17.80%
17.0%
Band
35.4%
20.2%
14.0%
9.5%
5.68%
3.39%
2.77%
1.1%
BPD-DS
0.9%
1.0%
1.0%
0.4%
0.60%
0.57%
0.70%
0.8%
Revision
6.00%
6.00%
6.00%
11.50%
13.55%
13.95%
14.14%
15.4%
Other
3.20%
2.30%
2.70%
0.10%
3.19%
2.63%
2.46%
2.3%
0.36%
2.66%
2.75%
2.0%
Balloons
Table 1. Percentage breakdown of all metabolic and bariatric procedures, 2011-2018. RYGB: Roux-en-Y gastric bypass BPD-DS: Biliopancreatic diversion-duodenal switch
Table 2
2011
2012
2013
2014
2015
2016
2017
2018*
Sleeve
28,124
57,090
75,359
99,781
105,448
125,318
135,401
154,976
RYGB
57,986
64,875
61,218
51,724
45,276
40,316
40,574
42,945
Band
55,932
34,946
25,060
18,335
11,172
7,310
6,318
2,660
BPD-DS
1,422
1,730
1,790
772
1,176
1,236
1,588
2,123
Revision
9,480
10,380
10,740
22,195
26,656
30,077
32,238
38,971
Other
5,056
3,979
4,833
193
6,272
5,665
5,606
5,847
700
5,744
6,280
5,042
196,700
215,666
228,005
252,565
Balloons Total
158,000
173,000
179,000
193,000
Table 2. Number of metabolic and bariatric procedures, 2011-18. RYGB: Roux-en-Y gastric bypass BPD-DS: Biliopancreatic diversion-duodenal switch)
*Enhanced methodology; Assumptions for outpatient procedures based on Texas database from 2016-17.
Table 3
Primary Procedures
# of procedures
% of Primary Procedures
Sleeve
154,976
76.5%
RYGB
42,945
21.2%
Band
2,660
1.3%
BPD/DS
2,123
1.0%
Total
202,704
100%
Table 3. Number of primary metabolic and bariatric procedures performed with percentage breakdown, 2018. RYGB: Roux-en-Y gastric bypass BPD-DS: Biliopancreatic diversion-duodenal switch
Table 4
2016
2017
2018
Sleeve
107,343
117,404
120,791
RYGB
39,375
39,633
40,026
Band
2,866
1,874
1,339
BPD-DS
1,187
1,539
2,007
Revision
29,003
31,164
32,268
Other
5,113
5,076
4,926
Balloons
1,003
1,539
1,094
Total
185,890
198,229
202,451
Table 4. Number of metabolic and bariatric procedures performed at MBSAQIP centers, 2016-18. RYGB: Roux-en-Y gastric bypass BPD-DS: Biliopancreatic diversion-duodenal switch
Table 5
Year
# Adolescent procedures in MBSAQIP
# Total procedures in MBSAQIP
Adolescent Volume (% of Total)
2014
157
155554
0.10%
2016
257
186772
0.14%
2018
342
202451
0.17%
Table 5. Number of adolescent metabolic and bariatric procedures performed at MBSAQIP centers (2014, 2016 and 2018).
Table 6 Frequency
Percent
Sleeve
284
83.04
RYGB
28
8.19
Other Experimental
7
2.05
Other Revision
7
2.05
Band
6
1.75
Balloons
3
0.88
Endoscopic
3
0.88
BPD-DS
1
0.29
Band to Sleeve
1
0.29
Other
1
0.29
Unlisted
1
0.29
TOTAL
342
100
Table 6. Breakdown of adolescent metabolic and bariatric procedures at MBSAQIP centers, 2018. RYGB: Roux-en-Y gastric bypass BPD-DS: Biliopancreatic diversion-duodenal switch
Figure 1
Figure 1. Metabolic and bariatric procedure trend, 2011-2018 RYGB: Roux-en-Y gastric bypass BPD-DS: Biliopancreatic diversion-duodenal switch
Highlights
Within the United States in 2018: •
Metabolic and bariatric surgery is underutilized as an obesity treatment option
•
The number of procedures being performed increased from the previous year
•
The sleeve gastrectomy is the most popular procedure performed
•
The number of revision procedures have increased slightly
S1550-7289(19)31160-8
DOI:
https://doi.org/10.1016/j.soard.2019.12.022
Reference:
SOARD 4012
To appear in:
Surgery for Obesity and Related Diseases
Received Date: 23 December 2019 Accepted Date: 24 December 2019
Please cite this article as: English WJ, DeMaria E, Hutter M, Kothari S, Mattar S, Brethauer S, Morton J, “American Society for Metabolic and Bariatric Surgery 2018 estimate of metabolic and bariatric procedures performed in the United States”, Surgery for Obesity and Related Diseases (2020), doi: https://doi.org/10.1016/j.soard.2019.12.022. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc. on behalf of American Society for Bariatric Surgery.
“American Society for Metabolic and Bariatric Surgery 2018 estimate of metabolic and bariatric procedures performed in the United States” Short Title: “2018 bariatric surgery numbers estimate” Corresponding Author Wayne J English, MD, FACS
Affiliation Vanderbilt University Medical Center 1161 21st Avenue South Room D5203 MCN Nashville, TN 37232-2577 Email: [email protected] Office Phone: (615) 322-7555 Mobile Phone: (615) 840-2644 Fax: (615) 343-9485
Contributing Authors DeMaria EJ
Affiliation East Carolina University Brody School of Medicine 600 Moye Blvd Greenville, NC 27834 Email: [email protected]
Hutter MM
Harvard University Massachusetts General Hospital 15 Parkman Street Boston, MA 02114 Email: [email protected]
Kothari SN
University of South Carolina Greenville Prisma Health - Greenville Memorial Medical Campus 701 Grove Road Greenville, SC 29605 Email: [email protected]
Mattar SG
Swedish Medical Center 1124 Columbia Street, Suite 400 Seattle, WA 98104 Email: [email protected]
Brethauer SA
The Ohio State University Wexner Medical Center 2050 Kenny Road Pavilion, 2nd Floor, Suite 2500 Columbus, OH 43221 Email: [email protected]
Morton JM
Yale School of Medicine Orchard Medical Center 330 Orchard Street 2nd Floor, Suite MOB 2 New Haven, CT 06511 Email: [email protected]
Background: Metabolic and bariatric surgery, despite being the only effective durable treatment for obesity, remains underutilized as approximately 1% of all patients who qualify actually undergo surgery. The American Society for Metabolic and Bariatric Surgery created a Numbers Taskforce to specify annual rate of utilization for obesity treatment interventions and to determine if patients in need are receiving appropriate therapy.
Objectives: The objective of this study was to provide the best estimated number of metabolic and bariatric procedure performed in the United States in 2018.
Setting: United States
Methods: We reviewed data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), National Surgical Quality Improvement Program (NSQIP), Bariatric Outcomes Longitudinal Database (BOLD) and Nationwide Inpatient Sample (NIS). In
addition, data from industry and outpatient centers were used to estimate outpatient center activity. Data from 2018 was compared mainly to data from the previous two years.
Results: Compared to 2017, the total number of metabolic and bariatric procedures performed in 2018 increased from approximately 228,000 to 252,000. The sleeve gastrectomy continues to be the most common procedure. The gastric bypass procedure trend remained relatively stable and the gastric band procedure trend continued to decline. The percentage of revision procedures and biliopancreatic diversion with duodenal switch (BPD-DS) procedures increased slightly. Finally, intragastric balloons placement continues as a significant contributor to the cumulative total number of procedures performed but declined from the previous year.
Conclusions: There was a 10.8% increase in the number of metabolic and bariatric procedures performed in 2018, compared to 2017, with an overall increase of approximately 60% since 2011. When taking into account primary procedures only, approximately 1.1% of patients who qualified for metabolic and bariatric surgery were treated with surgery in 2018.
Keywords: Bariatric surgery; Procedure trends; Bariatric surgery procedure trends; Numbers task force; Estimated numbers; 2018
Introduction
The adult obesity rate in the United States (US) increased from 13.4% in 1962 to 39.8% in 2016, an increase of approximately 200%, and currently affects over 93.3 million adults age 20 and older in the US. The percentage of patients with a body mass 5
index of greater than 40 kg/m2 is approximately 7.7%, or approximately 18 million adults age 20 and older. (1, 2) As a result, the economic impact of treating comorbidities associated with obesity has risen significantly. It has been demonstrated that patients with obesity, compared to patients who are not obese, experience increases in annual healthcare costs of 36% and medication costs of 77%. (3) Obesity as a risk factor is by far
10
the greatest contributor to the burden of chronic diseases in the US, accounting for 47.1 percent of the total cost of chronic diseases nationwide. Subsequently, the overall economic burden of obesity is calculated to be $1.72 trillion, which is equivalent to 9.3% of the US gross domestic product. (4)
Metabolic and bariatric surgery, the only effective and durable treatment for 15
obesity, remains underutilized in treating the obesity epidemic in the US. Based on the previous estimates, surgery as a treatment option is used by approximately 1% of all patients who qualify as candidates for metabolic and bariatric surgery. (5) To determine if patients in need are receiving appropriate therapy, the American Society for Metabolic and Bariatric Surgery created a Numbers Taskforce to specify annual rate of utilization
20
for obesity treatment interventions.
Here, the American Society for Metabolic and Bariatric Surgery Numbers Taskforce is reporting the 2018 estimate of the number of metabolic and bariatric surgery
1
procedures performed in the US. This report provides the best approximation using the methodology described below.
25
Methodology
A comprehensive review of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was completed. This included 100% of the primary and revisional metabolic and bariatric procedures performed within the 847 metabolic and bariatric surgery centers accredited by MBSAQIP in 2018.
30
In addition, a review of the National Surgical Quality Improvement Program (NSQIP) database was also performed which included primary metabolic and bariatric procedures performed within non-MBSAQIP accredited metabolic and bariatric surgery centers. A major limitation of using NSQIP data is that participating centers are only required to report a minimum of 20% of surgical cases, a portion of which are metabolic
35
and bariatric procedures. Underreporting at these centers is expected, however some centers may report up to 100% of all metabolic and bariatric surgery procedures.
Additionally, a review of other national registries was undertaken including the Bariatric Outcomes Longitudinal Database (BOLD) and Nationwide Inpatient Sample (NIS). A limitation of utilizing the NIS database is that it does not record outpatient 40
metabolic and bariatric procedures or track patients longitudinally.
To capture outpatient procedures performed at centers that do not submit data to MBSAQIP, NSQIP or BOLD, relevant medical device companies were surveyed to obtain the total number of gastric bands and intragastric balloons sold in 2018. However,
2
estimates were made to determine devices purchased, but not used. Furthermore, as the 45
only known comprehensive state outpatient database in the US, data from the State of Texas was applied to the estimate for outpatient procedures being performed outside of MBSAQIP.
MBSAQIP and BOLD data were considered to originate from accredited centers for purposes of this assessment. Data from NIS and NSQIP were used to estimate non50
accredited inpatient center activity. Data from industry and outpatient centers were used to estimate outpatient center activity. A 5% reduction in the overall number was applied to account for devices purchased but not used, in keeping with supply chain industry standards.
Primary surgical procedure categories were sleeve gastrectomy, Roux-en-Y 55
gastric bypass, gastric banding, biliopancreatic diversion with duodenal switch (BPDDS), and gastric balloons. Revisions and conversions included procedures in which primary procedures were previously performed, including gastric band removal, gastric bypass reversal, perforated marginal ulcer repair and internal hernia correction. The “Other” procedure category included, but was not limited to, gastric plication, single-
60
anastomosis gastric bypass and duodenal switch, vertical-banded gastroplasty, vagal blockade, endoscopic therapies (not including gastric balloons), unlisted procedures and other investigational procedures.
Results
3
In 2018, compared to 2017, the total number of bariatric procedures increased 65
almost 10.8% from approximately 228,000 to 252,000. The overall estimated number of metabolic and bariatric procedures for 2018, as well as the trend and procedure breakdown from 2011 to 2018 is listed in Figure 1, and Tables 1 and 2.
The sleeve gastrectomy continues to be the most common procedure, comprising 61.4% of all procedures in 2018. A 23.7% increase was noted since 2016 (125,318 to 70
154,976), but even more striking was the observed growth trend of 451% since 2011.
The number of gastric bypass procedures comprised 17.0% of all procedures in 2018. Although the gastric bypass trend shows a decline of 25.9% since 2011, the numbers from 2016 to 2017 were relatively stable (40,316 to 40,574 respectively). However, a trend reversal was noted from 2017 to 2018 as the number of gastric bypasses 75
performed increased 5.8%, from 40,574 in 2017 to 42,945 in 2018.
The gastric banding trend continues to decline as seen in previous years. The number of gastric band procedures was only 1.1% of all procedures performed in 2018, declining 57.9% from 6,318 in 2017 to 2,660 in 2018. A 95.2% decrease was observed since 2011, further reinforcing the fact that gastric banding has lost its appeal in the US.
80
The percentage of revision procedures increased slightly, from 14.4% to 15.4%. The number of revision procedures performed increased 19.7% from 32,238 in 2017 to 38,971 in 2018, with an observed 311% increase since 2011. Gastric band removal only comprised of 27.6% of all revision procedures.
4
The percentage of BPD/DS procedures only minimally increased from 0.7% to 85
0.8%.
However, the number of procedures increased 33.7%, with 2,123 in 2018
compared to 1,588 in 2017. When compared to 2016, a 71.8% increase was noted.
Gastric balloons continue to contribute to the aggregate procedure number, but a 19.7% decline was seen from the previous year. An estimated 5,042 patients received balloons, representing 2.0% of all procedures.
90
When taking into account the four primary procedures only, sleeve gastrectomy was performed 76.5%, Roux-en-Y gastric bypass, gastric banding and BPD-DS was performed 21.2%, 1.3% and 1.0% respectively. [Table 3]
Procedures performed at accredited centers
MBSAQIP: In 2018, 202,451 procedures, or approximately 80% of all 95
procedures, were performed at MBSAQIP-accredited centers. This is an increase of 8.9% compared to 185,890 procedures in 2016, and a 2.1% increase from 198,229 procedures in 2017. [Table 4]
During the 2018 calendar year, 847 centers reported data in the MBSAQIP registry, a 6.5% increase from 795 centers in 2016. Canadian and International centers 100
also participate in MBSAQIP but were not included in this analysis.
The number of adolescent patients undergoing metabolic and bariatric surgery comprised of only 0.17% of the total volume of procedures reported in the MBSAQIP data registry. However, the number of adolescent procedures performed increased by
5
117% since 2014, with laparoscopic sleeve gastrectomy being the most commonly 105
performed procedure. [Tables 5, 6]
BOLD: A total of 18 centers were contributing data to BOLD at the time of this assessment. Seven centers were dual entry programs, entering data into MBSAQIP and BOLD, and were not included in the BOLD number estimate. The remaining 11 centers were included in the estimate as BOLD-only programs. A total of 3,529 procedures were 110
performed at BOLD centers in 2018, but only 2,156 procedure were applied to the estimate given 61% of BOLD centers were not participating in MBSAQIP.
Procedures performed at non-accredited centers
NSQIP: Data from NSQIP centers not participating in MBSAQIP (NSQIP/NONMBSAQIP) was obtained from the American College of Surgeons (ACS). A total of 115
3,266 procedures were reported, with the sleeve gastrectomy representing 67% of all cases being reported at these centers.
Of the 84 NSQIP/NON-MBSAQIP centers performing metabolic and bariatric surgery, only 37 (44%) reported at least 25 procedures, 31 centers (37%) reported fewer than 10 cases, while 16 centers (19%) reported only one procedure in 2018 (range 1-296). 120
Notably, there was a 51.7% decrease in the number of NSQIP/NON-MBSAQIP centers since 2016, possibly accounting for some of the newly accredited MBSAQIP centers. The lower volume per NSQIP/NON-MBSAQIP centers may be due to centers not meeting MBASQIP volume standards. The procedure number provided by the ACS was used as a conservative estimate for the NSQIP data, which was not extrapolated to
6
125
account for the potential reporting differences. Therefore, the true number of procedures performed at NSQIP/NON-MBSAQIP centers may be significantly higher than estimated in this report.
Nationwide Inpatient Sample (NIS): Review of NIS data determined that 8% of inpatient centers performing metabolic and bariatric surgery were non-accredited. This 130
would account for approximately 16,196 procedures performed at non-accredited inpatient centers. However, MBSAQIP added 52 newly accredited centers in 2017 & 2018, accounting for 6,240 procedures. Subtracting these procedures from previous estimates results in a decreased number of cases performed at inpatient non-accredited facilities by approximately 40% (8% to 4.9%) in 2018. When taking into account the
135
aggregate numbers, an estimate of 9,920 procedures were performed in non-accredited inpatient centers in 2018.
NSQIP/NON-MBSAQIP data already demonstrated 3,266
procedures and was subtracted from the NIS non-accredited estimate. Therefore, an estimated 6,654 procedures were performed at non-accredited inpatient centers.
Outpatient Procedure Estimate
140
Gastric Bands and Balloons: Industry estimates determined approximately 2,800 gastric bands were sold in the US in 2018. Using supply chain industry standards, a 5% reduction in the overall number was applied to account for devices purchased, but not used. Therefore, 2,660 gastric bands were performed with approximately 51.9% of the gastric band procedures being performed at accredited centers.
7
145
Industry estimates for gastric balloons inserted were approximately 5,042 for 2018. Accredited centers performed balloon insertion in 1,107 patients. Therefore, it was estimated that 3,935 patients underwent balloon insertion in non-accredited centers.
Stapling Procedures: An accurate number of stapling procedures performed in outpatient centers is difficult to obtain, as many centers do not participate in MBSAQIP 150
and do not enter data into a registry. The outpatient estimate was based on analysis of 2017 outpatient data from the State of Texas. (6) Of the 26 ambulatory surgery centers in which outpatient data was obtained, none entered data into the MBSAQIP data registry.
The State of Texas outpatient data registry revealed that 4,649 sleeve gastrectomy, 257 Roux-en-Y gastric bypass, 5 biliopancreatic diversion, 115 gastric 155
bands and 822 revision procedures were performed in an outpatient setting.
Sleeve gastrectomy was the primary stapling procedure performed at Texas outpatient centers, accounting for approximately 80% of the outpatient procedures performed. Roux-en-Y gastric bypass comprised of approximately 4%, and revision procedures approximately 14%.
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When analyzing the inpatient and outpatient data registries in Texas, only 73% of the data was captured in the MBSAQIP database. Estimating that 27% of the procedures were not captured in the State of Texas, a conservative estimate of 18% was used for outpatient procedures not captured in the MBSAQIP registry throughout all other states. Therefore, the task force members feel that a very conservative estimated number of
8
165
36,415 outpatient procedures is appropriate for the purpose of this analysis, of which 717 procedures were designated as gastric band procedures.
Discussion
This paper represents the best estimate of metabolic and bariatric procedures performed in the US in the year 2018. Trends over time, continue to demonstrate a 170
significant increase in the number of procedures with another notable increase in the past year. One factor contributing to the increased number of procedures includes the first time use of an outpatient database in estimating procedures in nonaccredited centers, accounting for a greater increase than what was seen in previous years.
A major
limitation exists in assuming data from one state is generalizable and can be extrapolated 175
to determine outpatient procedure numbers for the rest of the US, but the task force members feel this data provides a better reflection of outpatient procedure activity throughout the US and that previously published reports were likely significantly underestimated. Other factors that potentially contributed to the increase include the continued growth of supporting Level I evidence, specialty society outreach, improved
180
access to care, and messaging through media platforms. (7-10)
Although adolescent patients represent only 0.17% of all procedures performed in the US, substantial evidence supports the safety and effectiveness of surgical weight loss for children and adolescents, and robust best practice guidelines supporting these procedures were recently developed and endorsed by the American Academy of 185
Pediatrics. (11,12) As a result, it is feasible that the number of adolescent patients
9
undergoing metabolic and bariatric surgery may significantly increase in the upcoming annual estimates.
An additional factor that may play a role in increasing utilization of metabolic and bariatric surgery includes a recent announcement made by the American Board of 190
Surgery, indicating that metabolic and bariatric surgery will become its first surgical specialty participating in the focused practice designation recognized by the American Board of Medical Specialties, thus providing an opportunity for increasing awareness of, and further legitimizing, metabolic and bariatric surgery as a surgical specialty. As a result, it is possible that a significant increase in patients undergoing metabolic and
195
bariatric surgery may be realized in the near future. (13)
There continues to be steady growth in revision procedures emphasizing the fact that obesity is a chronic disease with variable treatment outcomes. Gastric band removal as a standalone procedure comprised 27.6% of all revision procedures at MBSAQIP centers and there is an increasing number of conversions from gastric banding to sleeve 200
gastrectomy or Roux-en-Y gastric bypass being performed concurrently. It has been demonstrated that, on average, gastric band patients experience 3.8 procedures following surgery and approximately 77% of insurance payments related to gastric banding were for reoperations related to the gastric band complications or weight loss failure. (14) The trend for reoperative metabolic and bariatric surgery is difficult to predict but a plateau,
205
or even a decline, may be seen in future years as the number of gastric band removals decrease over time. Furthermore, the most common procedure performed today,
10
laparoscopic sleeve gastrectomy, is associated with a lower reoperation rate over 10 years compared to gastric banding (9.8% vs. 26%, respectively). (15)
Lastly, ambulatory surgery and intragastric device procedures are likely 210
underestimated due to the lack of reporting requirements for these interventions in nonaccredited centers where surgeon and non-surgeon proceduralists are performing these procedures. Given that data is difficult to obtain in these settings, it is important to appreciate the significant benefit of MBSAQIP as a clinical registry.
Regarding the breakdown of BPD/DS procedures, the MBSAQIP database cannot 215
distinguish between BPD with or without DS, or how many single anastomosis DS procedures were performed in 2018. However, a breakdown is anticipated for upcoming annual procedure estimates as future revisions of the MBSAQIP data registry are completed.
Conclusions
220
There has been a 10.8% increase in the number of metabolic and bariatric procedures performed in 2018, compared to 2017, with an overall increase of approximately 60% since 2011.
It must be noted, however, that for the year 2018, an
additional reporting mechanism was applied to include a portion of outpatient procedures in non-accredited centers, resulting in the potential for a surreptitious increase in total 225
numbers, when compared to the preceding year. The sleeve gastrectomy continues to be the most commonly performed procedure in the US. The number of gastric bypass procedures increased for the first year since 2012, but the overall percentage continues to
11
decline. The number of gastric banding procedures performed annually continues to decline precipitously. The trend for gastric balloon appears to be declining and its future 230
activity remains to be seen. The number of revision procedures continues to grow, and evidence-based treatment options are currently being developed to match patients with the most appropriate procedure to optimize outcomes.
Metabolic and bariatric surgery is a proven safe and effective obesity treatment alternative, but it remains underutilized. When taking into account primary procedures 235
only, approximately 1.1% of patients who qualified for metabolic and bariatric surgery were treated with surgery in 2018.
References 1. Hales CM, Fryar CD, Carroll MD, Freedman DS, Ogden CL. Trends in Obesity and Severe Obesity Prevalence in US Youth and Adults by Sex and Age, 2007-2008 to 240
2015-2016. JAMA. Vol 319. United States2018:1723-1725. 2. Fryar C, Carroll M, Ogden C. Prevalence of Overweight, Obesity, and Extreme Obesity Among Adults Aged 20 and Over: United States, 1960–1962 Through 2013– 2014. NCHS Health E-Stats, CDC. Published July 2016. Accessed July 31, 2019. 3. Sturm R. The effects of obesity, smoking, and drinking on medical problems and
245
costs. Health Aff (Millwood). 2002;21(2):245-253. 4. Waters H, Graf M. America's Obesity Crisis: The Health and Economic Costs of Excess Weight. https://milkeninstitute.org/sites/default/files/reports-pdf/MiAmericas-Obesity-Crisis-WEB.pdf. Published October 2018. Accessed August 3, 2019.
12
250
5. English WJ, DeMaria EJ, Brethauer SA, Mattar SG, Rosenthal RJ, Morton JM. American Society for Metabolic and Bariatric Surgery estimation of metabolic and bariatric procedures performed in the United States in 2016. Surg Obes Relat Dis. 2018;14(3):259-263. 6. Clapp B, Wicker E, Jones R, et al. Where are sleeves performed? An analysis of
255
inpatient versus outpatient databases in a large state. Surg Obes Relat Dis. 2019;15(7):1066-1074. 7. Kim DD, Arterburn DE, Sullivan SD, Basu A. Association Between the Publication of Clinical Evidence and the Use of Bariatric Surgery. Obes Surg. 2018;28(5):13211328.
260
8. Obesity Summit. ASMBS. https://asmbs.org/obesity-summit. Accessed August 3, 2019. 9. English W, Williams B, Scott J, Morton J. Covering bariatric surgery has minimal effect on insurance premium costs within the Affordable Care Act. Surg Obes Relat Dis. 2016;12(5):1045-1050.
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10. Bariatric Surgery Changes Lives. " It Starts Today" video. ASMBS. https://asmbs.org/bariatric-surgery-changes-lives?/video-it-starts-today-obesitysurgery-helps-people-reclaim-their-lives. Accessed August 3, 2019. 11. Bolling CF, Armstrong SC, Reichard KW, Michalsky MP, SECTION ON OBESITY SECTOS. Metabolic and Bariatric Surgery for Pediatric Patients With Severe
270
Obesity. Pediatrics. 2019.
13
12. Armstrong SC, Bolling CF, Michalsky MP, Reichard KW, SECTION ON OBESITY SECTOS. Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices. Pediatrics. 2019. 13. ABS E-News - Spring/Summer 2019. 275
http://www.absurgery.org/quicklink/absnews/absupdate0619.html#fpd. Accessed November 15, 2019. 14. Ibrahim AM, Thumma JR, Dimick JB. Reoperation and Medicare Expenditures After Laparoscopic Gastric Band Surgery. JAMA Surg. 2017;152(9):835-842. 15. Altieri MS, Yang J, Nie L, Blackstone R, Spaniolas K, Pryor A. Rate of revisions or
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conversion after bariatric surgery over 10 years in the state of New York. Surg Obes Relat Dis. 2018;14(4):500-507.
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290
14
Table 1
2011
2012
2013
2014
2015
2016
2017
2018
Sleeve
17.8%
33.0%
42.1%
51.7%
53.6%
58.11%
59.39%
61.4%
RYGBP
36.7%
37.5%
34.2%
26.8%
23.02%
18.69%
17.80%
17.0%
Band
35.4%
20.2%
14.0%
9.5%
5.68%
3.39%
2.77%
1.1%
BPD-DS
0.9%
1.0%
1.0%
0.4%
0.60%
0.57%
0.70%
0.8%
Revision
6.00%
6.00%
6.00%
11.50%
13.55%
13.95%
14.14%
15.4%
Other
3.20%
2.30%
2.70%
0.10%
3.19%
2.63%
2.46%
2.3%
0.36%
2.66%
2.75%
2.0%
Balloons
Table 1. Percentage breakdown of all metabolic and bariatric procedures, 2011-2018. RYGB: Roux-en-Y gastric bypass BPD-DS: Biliopancreatic diversion-duodenal switch
Table 2
2011
2012
2013
2014
2015
2016
2017
2018*
Sleeve
28,124
57,090
75,359
99,781
105,448
125,318
135,401
154,976
RYGB
57,986
64,875
61,218
51,724
45,276
40,316
40,574
42,945
Band
55,932
34,946
25,060
18,335
11,172
7,310
6,318
2,660
BPD-DS
1,422
1,730
1,790
772
1,176
1,236
1,588
2,123
Revision
9,480
10,380
10,740
22,195
26,656
30,077
32,238
38,971
Other
5,056
3,979
4,833
193
6,272
5,665
5,606
5,847
700
5,744
6,280
5,042
196,700
215,666
228,005
252,565
Balloons Total
158,000
173,000
179,000
193,000
Table 2. Number of metabolic and bariatric procedures, 2011-18. RYGB: Roux-en-Y gastric bypass BPD-DS: Biliopancreatic diversion-duodenal switch)
*Enhanced methodology; Assumptions for outpatient procedures based on Texas database from 2016-17.
Table 3
Primary Procedures
# of procedures
% of Primary Procedures
Sleeve
154,976
76.5%
RYGB
42,945
21.2%
Band
2,660
1.3%
BPD/DS
2,123
1.0%
Total
202,704
100%
Table 3. Number of primary metabolic and bariatric procedures performed with percentage breakdown, 2018. RYGB: Roux-en-Y gastric bypass BPD-DS: Biliopancreatic diversion-duodenal switch
Table 4
2016
2017
2018
Sleeve
107,343
117,404
120,791
RYGB
39,375
39,633
40,026
Band
2,866
1,874
1,339
BPD-DS
1,187
1,539
2,007
Revision
29,003
31,164
32,268
Other
5,113
5,076
4,926
Balloons
1,003
1,539
1,094
Total
185,890
198,229
202,451
Table 4. Number of metabolic and bariatric procedures performed at MBSAQIP centers, 2016-18. RYGB: Roux-en-Y gastric bypass BPD-DS: Biliopancreatic diversion-duodenal switch
Table 5
Year
# Adolescent procedures in MBSAQIP
# Total procedures in MBSAQIP
Adolescent Volume (% of Total)
2014
157
155554
0.10%
2016
257
186772
0.14%
2018
342
202451
0.17%
Table 5. Number of adolescent metabolic and bariatric procedures performed at MBSAQIP centers (2014, 2016 and 2018).
Table 6 Frequency
Percent
Sleeve
284
83.04
RYGB
28
8.19
Other Experimental
7
2.05
Other Revision
7
2.05
Band
6
1.75
Balloons
3
0.88
Endoscopic
3
0.88
BPD-DS
1
0.29
Band to Sleeve
1
0.29
Other
1
0.29
Unlisted
1
0.29
TOTAL
342
100
Table 6. Breakdown of adolescent metabolic and bariatric procedures at MBSAQIP centers, 2018. RYGB: Roux-en-Y gastric bypass BPD-DS: Biliopancreatic diversion-duodenal switch
Figure 1
Figure 1. Metabolic and bariatric procedure trend, 2011-2018 RYGB: Roux-en-Y gastric bypass BPD-DS: Biliopancreatic diversion-duodenal switch
Highlights
Within the United States in 2018: •
Metabolic and bariatric surgery is underutilized as an obesity treatment option
•
The number of procedures being performed increased from the previous year
•
The sleeve gastrectomy is the most popular procedure performed
•
The number of revision procedures have increased slightly