PLENTY OF OPTIONS Stacy Brethauer, MD, seen here performing a gastric bypass at the Cleveland Clinic, says less invasive weight-loss procedures bridge the gap between medical treatments and complex surgery.

The bariatric surgery boom? It's pretty much gone belly-up. Even as the nation's obesity problem continues to expand, surgical weight-loss procedures have remained flat. Over the past 4 years, annual case volumes have increased by just 5%, a barely perceptible rise. Surgeons perform about 200,000 weight-loss procedures each year — that's only 1% to 2% of obese patients who are eligible for surgery. But where some see a sagging market, others see a renaissance. The reason for their optimism? Their excitement over these 5 relatively new and promising treatment options.

1 Sleeve gastrectomy
This safe and effective laparoscopic procedure involves removing 80% of the stomach and turning it into a tubular banana-shaped pouch. The procedure does not involve intestinal bypass. After surgery, patients have very good hunger control, feel full after eating small portions and typically experience 80 to 100 pounds of weight loss within a year. Most patients keep the weight off long term, although some struggle with chronic progressive disease and will regain some weight over time.

Sleeve gastrectomy has evolved into today's most popular weight-loss surgery, mostly because patients easily understand the concept, the procedure has an excellent safety profile with very few long-term associated complications, and it results in predictable and relatively fast weight loss. The majority of patients who undergo sleeve gastrectomy want to manage their weight and metabolic disease, but the procedure can also prepare patients for other needed procedures. For that reason, it's a great bridge to additional treatment for patients who are too heavy to undergo, for example, large hernia repair or joint replacement surgery. It's also ideally suited for patients who are ineligible for gastric bypass due to prior surgery or other conditions that would make the bypass unsafe. With this procedure, surgeons have been able to help patients who otherwise wouldn't be able to effectively treat their obesity.

Patients who are severely obese are at increased risk of respiratory issues and the surgery itself can be challenging to perform because of patients' increased body mass. For those reasons, most procedures are done in the inpatient setting with an overnight stay. However, there are some surgeons who perform it in the ambulatory setting at accredited Bariatric Centers of Excellence, which must meet several national safety standards in order to perform the procedures.

2 Laparoscopic gastric banding
The procedure involves placement of an adjustable band around the upper part of the stomach to restrict the amount of food the stomach can comfortably hold. Surgeons can make the band tighter or looser after implantation, depending on the patient's comfort level and weight-loss progress. It was the procedure of choice several years ago, but has decreased in use nationally because of unpredictable weight-loss results and inappropriate patient selection. Banding was perceived as a very safe treatment option, so surgeons performed the procedure on a variety of patients who did not respond well after the band was implanted. Approximately 30% of patients who received the band experienced some sort of mechanical failure, and another 30% had it removed and converted to another treatment option when they didn't experience optimal weight loss.

Gastric banding's popularity and safety profile was part of its undoing as many facilities implanted the devices in patients who probably should have received another treatment option. Another potential issue: The band does not produce the same metabolic benefit that other weight-loss procedures provide. For example, patients who undergo sleeve gastrectomy experience improvements in diabetes or hypertension, so even with below-average weight loss, they still derive metabolic benefits from the procedure. The band, though, can still provide excellent therapy for patients with lower BMIs who are active and can exercise regularly. There are still many centers that perform the procedure and have great results, because they're devoted to the success of the therapy.

3 Gastric balloons
Surgeons use a catheter to insert a gastric balloon into the stomach endoscopically, fill the balloon with saline solution and remove the catheter. The filled balloon serves as a space-occupying device that forces patients to practice better portion control during meals. Implanted balloons are removed after 6 months, so they offer temporary therapy to a chronic disease for individuals with mild obesity who have been unsuccessful with medical management alone. Ultimately, the procedure lets patients with lower BMIs achieve modest weight-loss goals in the 30- to 40-pound range.

Gastric balloons provide weight-loss help for patients who aren't getting good results with medical therapy or lifestyle changes, but who also aren't interested in undergoing more invasive stomach-altering surgery. The bottom line is that intragastric balloons help to fill the treatment gap between medication and surgery, and this option appeals to many patients who aren't ready for more invasive treatments.

EXPERT OPINION Surgeons must consider a patient's weight-loss goals, medical history and lifestyle choices to determine the safest, most effective procedure, says Dr. Brethauer.

4 Endoscopic gastric plication
This approach involves using an endoscopic suturing device that resembles a sewing machine to create several folds in the stomach. The result, which is somewhat similar to the surgical anatomy created with sleeve gastrectomy, limits the amount of food patients can eat comfortably. The suturing devices developed several years ago for this purpose weren't robust enough and the sutures placed to create the stomach folds simply didn't hold, which made the technique largely ineffective. Current technologies allow for surgical-like closure of the stomach tissue, so we're seeing better results. It's too early to tell if outcomes will be durable enough for the FDA to approve the technique for a weight-loss indication. (The technology is currently approved for general tissue acquisition and repair along the intestinal tract.) There are several ongoing trials to find out.

5 Stomach aspiration
Unlike many other weight-loss procedures, stomach aspiration is non-surgical and reversible. A gastrostomy tube is implanted in the stomach. The tube is then attached to a button on the outside of the abdomen. The basic concept is that patients are allowed to eat regular meals before lavaging their stomach with saline and evacuating about 30% of the stomach's contents through the port that's been created in the abdomen wall.

Once the tube is implanted, patients must improve their diet and chew their food very well, so the procedure does force patients to change unhealthy eating habits to some degree. Patients typically keep the device implanted for a year, but have the option of keeping it in longer. Some patients who like having control over their caloric intake do opt to keep the device in place for longer periods.

At first glance this is a concept that's disturbing to some people, because it doesn't fit with the typical treatment paradigms for weight loss. It's true that the solution is far different than conventional treatment options and will likely be accepted, at least initially, by a unique set of patients who find it to be the right answer to achieving their weight-loss goals. The procedure has shown excellent weight-loss results in international trials and has demonstrated superiority over medical treatment options in FDA trials. Some type of treatment is certainly better than no treatment or ineffective treatment, so this device may find a place in our armamentarium. It will take time to find out, though, and until we have more data in the U.S. with its use, I don't think it will be widely adopted. OSM