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BACKGROUND: Surgery remains the most effective intervention for obesity and its comorbidities. However, the long-term efficacy of bariatric procedures is rarely reported. This study addresses operative trends, efficiency, and long-term outcomes from a large bariatric program. STUDY DESIGN: Data were prospectively collected on 3,460 patients undergoing 3,503 operations from January 2004 to March 2013. Primary procedures included Roux-en-Y gastric bypass (RY; n = 2,966), adjustable band (AB; n = 352), and sleeve gastrectomy (SG; n = 118). There were 67 revisional procedures (RP). Mean operative time, hospital length of stay, major 30-day morbidity/mortality, follow-up compliance, and weight loss per procedure at follow-up were recorded. RESULTS: Mean operative times decreased to the following: RY, 53 minutes; AB, 35 minutes; SG, 46 minutes; and RP, 71 minutes. Mean length of stay was reduced to the following: RY, 1.53 days; AB, 0.97 days; SG, 2.12 days; and RP, 2.68 days. Major complications were mortality, 0.09%; leak, 0.51%; bleed, 2.37%; pneumonia, 0.63%; venous thromboembolism, 0.40%; and reoperation, 2.34%. The complication rate was lowest for AB and highest for SG (p < 0.05). Adjustable band was the initial procedure in 73% of cases requiring RP. Follow-up compliance was 93% at 1 year, 79% at 3 years, 71% at 5 years, and 33% at 9 years. Adjustable band offered significant weight loss at 1 and 3 years (p < 0.0001), but less than RY or SG (p < 0.0001). Excess weight loss was not significantly different between RY and SG at 1 year. Significant weight loss with RY persisted at 7 to 9 years (p < 0.0001). CONCLUSIONS: Our bariatric program experienced an increase in SG and RP and a decrease in AB. Optimization of care reduced operative time and length of stay. All procedures achieved significant weight loss in the first year. Adjusted band had the lowest morbidity, but inferior weight loss and greater need for revision. Long-term weight-loss data are only available for RY.

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Rapid shifts in the demographics and techniques of weight loss surgery (WLS) have led to new issues, new data, new concerns, and new challenges. In 2004, this journal published comprehensive evidence-based guidelines on WLS. In this issue, we've updated those guidelines to assure patient safety in this fast-changing field. WLS involves a uniquely vulnerable population in need of specialized resources and ongoing multidisciplinary care. Timely best-practice updates are required to identify new risks, develop strategies to address them, and optimize treatment. Findings in these reports are based on a comprehensive review of the most current literature on WLS; they directly link patient safety to methods for setting evidence-based guidelines developed from peer-reviewed scientific publications. Among other outcomes, these reports show that WLS reduces chronic disease risk factors, improves health, and confers a survival benefit on those who undergo it. The literature also shows that laparoscopy has displaced open surgery as the predominant approach; that government agencies and insurers only reimburse procedures performed at accredited WLS centers; that best practice care requires close collaboration between members of a multidisciplinary team; and that new and existing facilities require wide-ranging changes to accommodate growing numbers of severely obese patients. More than 100 specialists from across the state of Massachusetts and across the many disciplines involved in WLS came together to develop these new standards. We expect them to have far-reaching effects of the development of health care policy and the practice of WLS.

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To update evidence-based best practice guidelines for coding and reimbursement and establish policy and access standards for weight loss surgery (WLS). Systematic search of English-language literature on WLS and health-care policy, access, insurance reimbursement, coding, private payers, public policy, and mandated benefits published between April 2004 and May 2007 in MEDLINE, EMBASE, and the Cochrane Library. Use of key words to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. We identified 51 publications in our literature search; the 20 most relevant were examined in detail. These included reviews, cost-benefit analyses, and trend and cost studies from administrative databases. Literature on policy issues surrounding WLS are very sparse and largely focused on economic analyses. Reports on policy initiatives in the public and private arenas are primarily limited to narrative reviews of nonsurgical efforts to fight obesity. A substantial body of work shows that WLS improves or reverses most obesity-related comorbidities. Mounting evidence also indicates that WLS confers a significant survival advantage for those who undergo it. WLS is a viable and cost-effective treatment for an increasingly common disease, and policy decisions are more frequently being linked to incentives for national health-care goals. However, access to WLS often varies by payer and region. Currently, there are no uniform criteria for determining patient appropriateness for surgery.

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