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Obesity Surgery

, Volume 27, Issue 9, pp 2279–2289 | Cite as

Bariatric Surgery and Endoluminal Procedures: IFSO Worldwide Survey 2014

  • L. Angrisani
  • A. Santonicola
  • P. Iovino
  • A. Vitiello
  • N. Zundel
  • H. Buchwald
  • N. Scopinaro
Open Access
Original Contributions

Abstract

Background and aim

Several bariatric surgery worldwide surveys have been previously published to illustrate the evolution of bariatric surgery in the last decades. The aim of this survey is to report an updated overview of all bariatric procedures performed in 2014.For the first time, a special section on endoluminal techniques was added.

Methods

The 2014 International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) survey form evaluating the number and the type of surgical and endoluminal bariatric procedures was emailed to all IFSO societies. Trend analyses from 2011 to 2014 were also performed.

Results

There were 56/60 (93.3%) responders. The total number of bariatric/metabolic procedures performed in 2014 consisted of 579,517 (97.6%) surgical operations and 14,725 (2.4%) endoluminal procedures. The most commonly performed procedure in the world was sleeve gastrectomy (SG) that reached 45.9%, followed by Roux-en-Y gastric bypass (RYGB) (39.6%), and adjustable gastric banding (AGB) (7.4%). The annual percentage changes from 2013 revealed the increase of SG and decrease of RYGB in all the IFSO regions (USA/Canada, Europe, and Asia/Pacific) with the exception of Latin/South America, where SG decreased and RYGB represented the most frequent procedure.

Conclusions

There was a further increase in the total number of bariatric/metabolic procedures in 2014 and SG is currently the most frequent surgical procedure in the world. This is the first survey that describes the endoluminal procedures, but the accuracy of provided data should be hopefully improved in the next future. We encourage the creation of further national registries and their continuous updates taking into account all new bariatric procedures including the endoscopic procedures that will obtain increasing importance in the near future.

Keywords

Bariatric/metabolic surgery Endoluminal procedures IFSO survey Sleeve gastrectomy 

Introduction

All bariatric procedures currently available are actually considered effective in the treatment of morbid obesity and its related comorbidities compared to non-surgical interventions [1, 2]. The choice of one bariatric procedure over another is generally influenced by a number of factors such as literature results, specific local conditions, and the experience of the surgical staff in each country. Several bariatric surgery worldwide surveys have been previously published [3, 4, 5, 6] to illustrate the evolution of bariatric surgery around the world in the last decades. Recently, we have published a global overview describing the number and type of each performed procedure of worldwide bariatric surgery in 2013 [7], together with the trends for the most important procedures during the 2003–2013 decade. Our data showed that sleeve gastrectomy (SG) had a steep increase all around the world, although Roux-en-Y gastric bypass (RYGB) still represented the most performed procedure, while adjustable gastric banding (AGB) declined.

During the last years, different endoluminal procedures (Orbera/BIB, Obalon, Spatz adjustable balloon system, heliosphere bag, primary obesity surgery endolumenal (POSE), stomaphix, Apollo, overstiches, endobarrier) have gained popularity among bariatric surgeons in the attempt to fill the gap between medical and surgical treatment for borderline patients [8].

Our aim in this survey is to report an updated overview of all bariatric procedures performed in the nations of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) in 2014. For the first time, in the 2014 IFSO survey, a special section on endoluminal techniques was added. Moreover, we chose the definition “mini-gastric bypass/one anastomosis gastric bypass (MGB/OAGB)”, as suggested by other authors [9, 10], in an attempt to reduce the heterogeneity in definitions that could generate a loss of accuracy in the reported data.

Methods

Survey

The IFSO Secretariat asked the national societies to provide data on the surgical techniques utilized by filling-out the 2014 survey form (Table 1). Each national society returned the data collected from its members, in some cases asking for information from each member of the society, and, in other cases, providing the information directly from a national registry.
Table 1

Questionnaire

Data Analysis

The relative prevalence of specific procedures is provided as weighted averages to account for the wide ranges in the number of procedures performed by the different IFSO member nations or national groupings. These data were used to estimate the annual percentage changes from 2013 [7].

Results

Response Rate

Sixty national bariatric societies or groups were contacted; among them 56 (93.3%) answered and provided a response form. Twenty had a national registry. Figure 1 depicts the completeness of data that each responding society declared, expressed as percentages.
Fig. 1

Completeness of data from each responding society

Number and Type of Procedures

The total number of bariatric/metabolic procedures performed in 2014 consisted of 579,517 (97.6%) surgical operations and 14,725 (2.4%) endoluminal procedures. Tables 2 and 3 show the total number of each bariatric/metabolic surgical procedure together with the percentage of the most commonly performed such as sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB), mini-gastric bypass/one anastomosis gastric bypass (MGB/OAGB), biliopancreatic diversion/ duodenal switch (BPD/DS), and the total number of each endoluminal procedure.
Table 2

Total number and percentage of bariatric/metabolic surgical procedures performed worldwide in 2014

Procedures

Number

Percentage

Sleeve gastrectomy (SG)

265,898

45.9

Roux-en-Y gastric bypass (RYGB)

229,455

39.6

Adjustable gastric banding (AGB)

42,388

7.4

Mini-gastric bypass/one anastomosis gastric bypass (MGB/OAGB)

10,403

1.8

Biliopancreatic diversion/ duodenal switch (BPD/DS)

6123

1.1

Miscellanea

25,250

4.3

Total

579,517

100

Table 3

Total number and percentage of endoluminal procedures performed worldwide in 2014

Procedures

Number

Percentage

Orbera/BIB

1664

11.6

Obalon

741

5.2

Spatz adjustable balloon system

62

0.4

Heliosphere bag

7

0.05

POSE

25

0.2

Apollo

6

0.04

Endobarrier

112

0.8

Not specified

11,658

81.6

Total

14,275

100

Overall total population of the 56 IFSO nations or national groupings in 2014 was estimated as 3,264,082,824 [11], so the 579,517-bariatric/metabolic surgical procedures performed account for 0.02% of the total population.

Table 4 showed the bariatric/metabolic surgical procedures and the endoluminal procedures performed in the four IFSO regions of the world: USA/Canada, Europe, Latin/South America, and Asia/Pacific.
Table 4

The bariatric/metabolic surgical procedures and the endoluminal procedures performed in the four IFSO regions of the world: USA/Canada, Europe, Latin/South America, and Asia/Pacific

Country

Total

AGB

RYGB

SG

BPD/DS

GP

MGB/OAGB

Other

Endoluminal procedures

North America

 Canada

6.522

702

3.158

2.362

300

0

0

0

0

 U.S.A.

191.920

18.500

59.124

113.381

886

29

0

0

0

Total per area

198.442

19.202

62.282

115.743

1.186

29

0

0

0

Europe

 Austria

2.553

91

1.418

521

4

496

0

23

18

 Azerbaijan

16

0

1

14

0

1

0

0

 

 Belgium

12.000

1.000

5.500

4.000

0

1.500

0

0

 

 Czech Republic

1.448

280

90

150

50

8

670

200

220

 Egypt

10.340

180

1.500

3.100

40

800

200

4.520

1200

 Finland

839

0

694

139

4

0

0

2

 

 France

46.960

4.364

14.015

28.581

0

0

0

0

 

 Germany

7.298

133

3.332

3.681

9

131

9

3

 

 Greece

1.327

110

85

756

8

275

65

28

10

 Iceland

163

108

52

3

0

0

0

0

 

 Israel

8881

659

877

7262

65

 

0

18

 

 Italy

8867

2182

1628

3799

124

477

268

389

 

 Lebanon*

         

 Lithuania

252

63

103

6

0

0

68

12

12

 Netherlands

8350

77

6757

1158

10

44

0

304

80

 Norway

3002

 

1653

1316

30

3

0

0

 

 Poland

2531

318

492

1334

1

207

0

179

179

 Portugal

2892

94

1290

986

54

260

9

199

 

 Romania

1380

27

99

1128

11

22

39

54

17

 Russian Federation

1621

419

118

861

71

29

7

116

77

 Serbia*

         

 Slovenia

200

3

31

26

0

115

0

25

 

 South Africa

566

0

423

63

68

0

0

12

 

 Spain

4030

126

1562

1839

142

34

27

300

 

 Sweden

6607

2

5386

1090

47

0

4

78

39

 Switzerland

4167

17

3173

646

41

17

0

273

 

 Turkey

6347

200

1350

3520

125

818

60

274

100

 Ukraine

251

2

30

91

47

13

27

41

18

 United Kingdom

6391

823

3011

2012

13

0

0

532

198

Total per area

149.279

11.278

54.670

68.082

964

5.250

1.453

7.582

2.168

Latin America

 Argentina

36.668

0

25.520

8.754

2.227

35

0

132

132

 Bolivia

314

0

92

174

0

2

36

10

 

 Brazil

97.480

450

66.000

20.200

1.050

600

30

9.150

8600

 Chile

5.311

3

1.133

3.814

0

0

3

358

196

 Colombia

12.700

4.800

7.200

0

50

150

0

500

500

 Costa Rica

1.448

280

90

150

50

8

670

200

220

 Dominican Republic

1.117

0

29

981

7

38

20

42

8

 Ecuador

626

0

80

150

3

40

10

343

30

 Guatemala

200

2

68

112

0

0

8

10

10

 Mexico*

         

 Panama*

         

 Paraguay

300

0

300

0

0

0

0

0

 

 Perù*

         

 Venezuela

4.472

11

2.880

1.498

3

0

0

80

 

Total per area

160.636

5.546

103.392

35.833

3.390

873

777

10.825

9.696

Asia/Pacific

 Australia—New Zeland

15.136

3.604

1.019

10.227

31

  

255

 

 China

4.195

50

1.866

2.229

0

0

20

30

 

 Hong Kong

144

2

4

116

1

1

1

19

17

 India

11.336

12

1.833

7.638

28

1.537

12

276

22

 Japan

222

4

20

144

54

0

0

0

 

 Korea

889

439

134

166

0

0

43

107

 

 Kuwait

5.498

244

61

3.803

4

22

0

1.364

1356

 Saudi Arabia

15.571

1.215

3.033

8.649

500

1.580

300

294

294

 Singapore

299

2

103

193

0

0

0

1

1

 Taiwan

2.421

31

119

1.484

0

194

21

572

34

 UEA

4033

170

262

3223

0

230

0

148

87

Total per area

59.744

5.773

8.454

37.872

618

3.564

397

3.066

1.811

*Not received

Nine nations or national grouping reported more than 10,000 bariatric/metabolic surgical procedures: USA (n = 191.920), Brazil (n = 97.480), France (n = 46.960), Argentina (n = 36.668), Saudi Arabia (n = 15.571), Australia—New Zeeland (n = 14.966), Colombia (n = 12.700), Belgium (n = 12.000) and India (n = 11.336). Kuwait’s total population has the world’s highest rate of bariatric/metabolic surgical procedures (0.28%) (Table 5). Kuwait also reported the highest number of endoluminal procedures of the Asia/Pacific Chapter (n = 1356). Among the nations of the European Chapter, the highest number of endoluminal interventions was performed in Egypt (n = 1200), while in Latin/South America, the largest number was reported by Brazil (n = 8600). USA/Canada did not report any endoluminal procedures (Table 4).

Trends

Worldwide

The annual percentage changes from 2013 of the worldwide bariatric/metabolic surgical procedures revealed that SG had the largest average annual percentage increase of approximately 9%; RYGB and AGB decreased, approximately 5 and 2.6%, respectively. MGB/OAGB and BPD/DS plateaued. Figure 2 presents the short-term trend in the world’s main bariatric/metabolic surgical procedures (SG, RYGB, AGB, MGB/OAGB, and BPD/DS) expressed as the relative proportion at the fixed intervals 2011–2013–2014.
Fig. 2

Short-term trend in the world’s main bariatric/metabolic surgical procedures

Previous surveys did not report any data on endoluminal procedures, so the annual percentage changes or the time trend for these procedures were not calculated.

USA/Canada

The annual percentage changes from 2013 in USA/Canada revealed a further increase in the number of SG (+15.3%) that was consistent with the previous survey [7] and the slight decrease of RYGB (−3.9%). AGB and BPD/DS plateaued. Data on MGB/OAGB were not reported. Figure 3 shows the short-term trend of the main bariatric/metabolic surgical procedures (SG, RYGB, AGB, and BPD/DS) in USA/Canada expressed as the relative proportion at the fixed intervals 2011–2013–2014.
Fig. 3

Short-term trend in the USA/Canada of bariatric/metabolic surgical procedures

Europe

The annual percentage changes from 2013 in Europe revealed a steep increase in SG (+10.7%) and a slight decrease of RYGB (−3%). Also AGB, MGB/OAGB, and BPD/DS decreased (−7.5, −1.8, and −0.7%, respectively). Figure 4 shows the short-term trend of the main bariatric/metabolic surgical procedures (SG, RYGB, AGB, MGB/OAGB, and BPD/DS) in Europe expressed as the relative proportion at the fixed intervals 2011–2013–2014.
Fig. 4

Short-term trend in Europe of bariatric/metabolic surgical procedures

Latin/South America

The annual percentage changes from 2013 in Latin/South America revealed that the RYGB plateaued and represented the most frequently performed procedure; SG decreased, approximately 2.9%. AGB, MGB/OAGB and BPD/DS showed a plateauing. Figure 5 shows the short-term trend of the main bariatric/metabolic surgical procedures (SG, RYGB, AGB, MGB/OAGB, and BPD/DS) in Latin/South America expressed as the relative proportion at the fixed intervals 2011–2013–2014.
Fig. 5

Short-term trend in Latin/South American of bariatric/metabolic surgical procedures

Asia/Pacific

The annual percentage changes from 2013 in Asia/Pacific revealed an increase of SG and MGB/OAGB, approximately 11 and 2.7%, respectively; RYGB and AGB decreased (−11.2 and 4.7%, respectively). BPD/DS plateaued. Figure 6 shows the short-term trend of the main bariatric/metabolic surgical procedures (SG, RYGB, AGB, MGB/OAGB, and BPD/DS) in Asia/Pacific expressed as the relative proportion at the fixed intervals 2011–2013–2014.
Fig. 6

Short-term trend in Asia/Pacific of bariatric/metabolic surgical procedures

Discussion

This survey gives an updated description of bariatric procedures performed worldwide in 2014 and, for the first time, shows the worldwide incidence of endoluminal procedures such as Orbera/BIB, Obalon, Spatz adjustable balloon system, heliosphere bag, POSE, stomaphix, Apollo overstiches, and endobarrier.

This collected data reveal a further worldwide increase in the total number of bariatric/metabolic procedures in 2014 and demonstrate that SG in 2014 became the commonest bariatric procedure performed in the world. The strength of this survey compared to the previous one performed in 2013 was the higher response rate (93.3 vs 90.7%) that demonstrated a further increase of the bariatric/metabolic procedures declared in 2014 (+23%) [7]. Even more interestingly, SG has become the most frequently performed procedure in the world and has overtaken RYGB, which remains the most performed bariatric/metabolic procedure only in Latin/South America. As we have already hypothesized in our previous survey [7] the simpler surgical technique of SG compared to RYGB, together with the promising long-term weight loss outcomes [12, 13], could explain this result.

This survey also shows the short-term trend, from 2011 to 2014, of MGB/OAGB. Rutledge published the first experience on MGB/OAGB in 2001 [14]; it was subsequently performed around the world and several studies supported its efficacy and safety [15]. However, the worldwide MGB/OAGB trend reveals plateauing, with the exception of Asia/Pacific, the only region where MGB/OAGB increased. The current report on the number of MGB/OAGB could be underestimated considering that USA/Canada did not provide any data. Remarkably, the MGB/OAGB prevalence has not been reported not even in the last published estimation of bariatric procedures in the USA carried out by the American Society for Metabolic and Bariatric Surgery (ASMBS) [16].

Another strength of this survey is that we describe for the first time the endoluminal procedures performed in the world. The endoluminal interventions have gained popularity among bariatric surgeons and may be an appealing alternative to a wide group of patients who refuse bariatric surgery because of concerns about potential risks and complications or who were not eligible for bariatric surgery according to the current guidelines. On the other hand, for most of these new technologies, there are currently limited literature data, often based on small series [8] and there are no clinical guidelines. According to our data collection, 14,275 endoluminal procedures have been performed during 2014, but the real number is probably higher. Unfortunately many national databases are still lacking with information on endoluminal procedures. Therefore, we strongly recommend each society to endeavor to report as accurate data as possible.

In an attempt to improve the accuracy of our data, we contacted the manufacturers of the endoluminal devices. They declared a higher number of utilized devices compared to that reported by the IFSO nations. In fact, during 2014, Allergan BioEnterics stated that they have sold 25,043 Orbera/BIB, 953 Apollo endosurgery overstitch, 2935 medical implant helioscopie heliosphere, 5500 POSE, respectively. GI dynamics was not able to provide any data, however, they answered that 2900 endobarriers have been distributed since 2009. Obalon was removed from the market in 2014. Thus, the number of endoluminal procedures performed in 2014 is higher compared to those reported by IFSO nations and we believe that also the number of total bariatric procedures actually performed in the world is greater. Furthermore, the endoscopic and surgical procedures executed in private healthcare were not usually reported.
Table 5

Total population and number of procedures per country

Country

Total population

Total procedures per country

% of procedures for total population

North America

 USA—Canada

234,333,465

198.442

0.08

Total per area

234,333,465

198.442

0.08

EUROPE

 Austria

5,525,965

2.553

0.05

 Azerbaijan

6,881,963

16

0.00

 Belgium

6,836,150

12.000

0.18

 Czech Republic

7,181,452

1.448

0.02

 Egypt

54,652,669

8.140

0.01

 Finland

3,393,294

839

0.02

 France

41,728,824

46.960

0.11

 Germany

53,375,007

7.296

0.01

 Greece

7,077,088

1.315

0.02

 Iceland

212,047

163

0.08

 Israel

4,886,589

8.869

0.18

 Italy

40,232,892

8.787

0.02

 Jordan

4,780,143

7.407

0.15

 Kazakhstan

12,195,673

114

0.00

 Lithuania

2,435,496

252

0.01

 Netherlands

11,059,026

8.350

0.08

 Norway

3,381,831

3.002

0.09

 Poland

27,015,538

2.531

0.01

 Portugal

7,083,260

2.892

0.04

 Romania

15,224,032

1380

0.01

 Russian Federation

100,255,437

1.621

0.00

 Slovenia

1,365,999

200

0.01

 South Africa

31,673,647

566

0.00

 Spain

31,954,884

4.030

0.01

 Sweden

6,148,142

6.607

0.11

 Switzerland

5,427,608

4.167

0.08

 Turkey

55,288,903

6.347

0.01

 Ukraine

30,041,037

251

0.00

 United Kingdom

34,124,066

6.391

0.02

Total per area

611,438,662

154,494,00

0.03

Latin America

 Argentina

27,396,887

36.668

0.13

 Bolivia

13,125,128

314

0.00

 Brazil

139,204,011

97.480

0.07

 Chile

12,043,383

5.311

0.04

 Colombia

31,427,165

12.700

0.04

 Costa Rica

3,305,826

400

0.01

 Dominican Republic

6,722,618

1.117

0.02

 Ecuador

10,117,590

626

0.01

 Guatemala

8,735,638

200

0.00

 Mexico

78,705,142

2.500

0.00

 Paraguay

4,507,926

300

0.01

 Venezuela

19,024,145

4472

0.02

Total per area

354,315,459

162,088,00

0.05

Asia/Pacific

 Australia—New Zeland

17,957,192

14.966

0.08

 China

993,331,831

4.195

0.00

 Hong Kong

5,205,526

144

0.00

 India

812,335,761

11.336

0.00

 Iran

57,467,376

4.919

0.01

 Japan

77,538,543

222

0.00

 Korea

35,897,893

889

0.00

 Kuwait

1,983,536

5498

0.28

 Saudi Arabia

18,929,961

15.571

0.08

 Singapore

4,348,692

299

0.01

 Taiwan

34,593,332

2.421

0.01

 UAE

4,405,595

4.033

0.09

Total per area

2,063,995,238

64,493,00

0.00

Total

3,264,082,824

579,517,00

0.02

The significance of the value is specified in the first line of the table: it represents the percentage of bariatric procedures/total population (i.e. Among the Austrian population (5,525,965 people) were performed 2553 procedures that represents the 0.05%)

Therefore the accuracy of provided data is the major point of weakness of this survey. Only 35% of national societies had a national registry and most of the data were estimated. This flaw regards the entire database but may be more critical for the endoluminal therapies.

There have been five previous reports of the status of bariatric surgery worldwide [3, 4, 5, 6, 7]. All of them, as well as the current survey, were limited by the management and report of the data by the IFSO nations. The analysis of these data can never reach the accuracy and precision of a planned experiment or a clinical trial. However, this is the best achievable analysis of worldwide reported data. Despite these limits, worldwide surveys have always been a scientific landmark. The bariatric surgery community could not progress without a periodic collection and report of worldwide data. Results regarding the techniques of endoluminal bariatric surgery are extremely useful in the current scenario of modern bariatric armamentarium. The reported lack of response aims to be provocative. Data should absolutely be collected at national level by the IFSO societies.

In conclusion, national and international registries should be implemented and regularly updated taking into account all new endoscopic procedures that are continually evolving and will gain increasing importance in the near future. Moreover, further studies on large series of patients are mandatory to increase our knowledge of endoluminal procedures and to encourage the creation of specific international guidelines.

Notes

Acknowledgments

We thank Francesco Carignani and Manuela Mazzarella of IFSO Secretariat for their support.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

Statement of Informed Consent

This is a survey in which we do not directly involve human subjects; it is limited to an analysis of bariatric procedures performed around the world.

Statement of Human and Animal Rights

This is a survey in which we do not directly involve human subjects or animals; it is limited to an analysis of bariatric procedures performed around the world.

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© The Author(s) 2017

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  1. 1.General and Endoscopic Surgery UnitS. Giovanni Bosco HospitalNaplesItaly
  2. 2.Gastrointestinal Unit, Department of Medicine and SurgeryUniversity of SalernoSalernoItaly
  3. 3.Minimally Invasive and Bariatric SurgeryFSFBBogataColombia
  4. 4.Departments of Surgery and Biomedical EngineeringUniversity of MinnesotaMinneapolisUSA
  5. 5.Department of Surgery, School of MedicineUniversity of GenoaGenoaItaly

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