Is Bariatric Surgery at Risk of Becoming Obsolete?

The availability of second-generation obesity drugs (glucagon-like peptide 1 [GLP-1] analogues) has raised questions about the role of bariatric surgery. During its 40th annual congress in October 2024, the French Society of Endocrinology held a debate on this topic. Emmanuel Disse, MD, PhD, an endocrinologist at Lyon University Hospital, Lyon, argued in favor of bariatric surgery, while François Pattou, MD, a surgeon from Lille University Hospital, Lille, France, highlighted its shortcomings.

Effective, Safe, and Cost-Effective Surgery

Disse emphasized that weight loss, specifically the percentage of weight reduction, should serve as a biomarker for evaluating obesity treatments. In fact, the intensity of weight loss is positively correlated with benefits in terms of preventing complications. He noted that significant weight loss correlates with reduced risks for complications.

Disse explained that bariatric surgery most often results in weight loss exceeding 25% of initial weight, and in some cases (such as biliopancreatic diversion), the loss can reach up to 40%. This weight loss is typically maintained 5-10 years later. This level of effectiveness surpasses that of GLP-1 analogs, which lead to weight loss ranging from 5% to 10% (Saxenda), 15% to 17% (Wegovy), or 15% to 22.5% (Mounjaro), based on clinical studies.

Weight loss outcomes from medications also vary widely, following a Gaussian curve. For example, weight loss with 2.4 mg semaglutide (Wegovy) achieves an average reduction of 14.9%, but around one quarter of patients do not respond to treatment. While bariatric surgery also shows variability, the Swedish Obese Subjects trial, a non-randomized follow-up study, showed that weight loss is sustained for up to 30 years. Furthermore, surgery reduced overall mortality and cardiovascular mortality by 30% and cancer mortality by 23%. GLP-1 analogs have yet to demonstrate similar long-term benefits.

Surgery has demonstrated good tolerance over time, whereas the long-term safety of new obesity drugs remains uncertain. Past experiences with similar treatments, many of which were withdrawn from the market, should encourage caution.

Finally, surgery is less expensive than medications. While its first-year cost ranges from €3000 to €4500, compared with €2400 to €3600 for medications, the 5-year total costs, including follow-up care, range from €4250 to €6000. For medications, the costs range from €12,000 to €18,000 over the same period.

In conclusion, Disse argued that even with 50,000 procedures performed annually in France, bariatric surgery is underutilized, with many eligible patients not seeking treatment.

Unstoppable Rise for New Therapeutics

Pattou presented a less optimistic opinion on bariatric surgery. He noted that France is one of the “most active countries in the world for surgery,” with 1% of the total population having already undergone surgery. However, he pointed out two significant flaws in studies supporting surgery. First, there is a selection bias, as not all patients are willing to undergo surgery. Second, no well-designed randomized trials have compared surgery with medications.

Studies showing a reduction of more than 50% in mortality following surgery compared with medications are based on older drugs. The effectiveness of GLP-1 analogs, however, is now approaching that of surgery. Additionally, the weight loss achieved through surgery is not constant, as patients tend to regain some of the lost weight. This weight regain, along with surgical complications, leads to 13% of procedures being reoperations.

While surgery has a low risk for complications, when they do occur, they are serious. This may explain why only 5%-10% of patients who could benefit from surgery, according to the recommendations of the French National Authority for Health (Haute Autorité de Santé), choose to undergo it.

Toward Personalized Medicine

Both speakers agreed on one important point: Surgery and medications are complementary, with each approach potentially playing a role at different stages of patient management. However, clear decision-making trees are currently lacking to guide clinicians in determining the appropriate intervention based on the patient’s situation. The future likely lies in personalized medicine, where bariatric surgery will likely diminish. A growing demand for obesity treatment, driven by substantial investments from pharmaceutical companies, is expected to advance knowledge and treatment options significantly.

This story was translated from Univadis France using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.