Metabolic Surgery in the Mediterranean Area
Obesity is considered nowadays a pandemic and its incidence increases year after year. Multiple treatments have been proposed but current literature data suggest that surgery is the most effective of them. Studies such as STAMPEDE concluded that, at five years, bariatric surgery plus intensive medical therapy is more effective than intensive medical therapy alone in decreasing hyperglycemia in obese patients with uncontrolled type II diabetes. Mediterranean surveys reported in 2014 a 15.1% of patients with obesity among the population aged 18 to 74 years (15.2% men, 15.1% women). This health survey reflects a relationship between excess weight and social class of educational level. This is reflected by the fact that 7.3% of the population with university studies was obese compared with 22.9% of the population with primary education. In the case of women, this relationship was more intense, being those women without studies or with primary education four times more likely to present obesity than women with university studies. Laparoscopic surgery has become the gold standard approach for the surgical treatment of obesity, due to enhanced recovery. This easier recovery from surgery has popularized bariatric surgery, with increasing numbers of patients treated each year worldwide. Data from Catalonia reflect 10,872 patients with morbid obesity surgically treated between 2012 and 2016. These outcomes can be compared with those reported from the 2016 International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), which represent a Federation of 62 national societies. The total number of bariatric procedures performed in 2016 was 685,874, including both surgical (96%) and interventional (4%). The most common surgical procedure in primary indication was sleeve gastrectomy (53.6%), followed by Roux-en-Y gastric bypass (30.1%). As in Mediterranean registries, there was a significant fluctuation of the type of bariatric procedures over the time, being sleeve gastrectomy the most commonly performed surgical intervention after 2013. Mediterranean data on surgical outcomes report a length of hospital stay of 5 days (range 0-180) with 4.6% of the patients requiring Intensive Care Unit. It is clear that the number of bariatric procedures (both surgical and endoluminal) continues to increase. Moreover, since 2013, the most commonly performed surgical intervention is sleeve gastrectomy. Experience from pancreatic and esophageal surgery suggest that regionalizing patients in high volume centers may decrease complications, this has also been shown in metabolic surgery. In conclusion, obesity is a pandemic that affects nearly 1/6 of the population. Its incidence is higher among patients with low education, especially in women. Bariatric surgery associated with intensive medical therapy is the most effective treatment for obesity and its comorbidities such as hyperglycemia. The surgical procedures have been changing over the years, with an important increase of sleeve gastrectomy procedures after 2013 on the Mediterranean area, reflecting the global tendency showed by the IFSO survey. Bariatric surgery is safe, with a low rate of complications and mortality, and on Mediterranean patients is associated with a fast recovery (LOS < 5 days). The regionalization of bariatric and metabolic surgery in high experienced centers is desirable.
