Department of Internal Medicine, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY (Dr. Barenbaum); Comprehensive Weight Control Center, Division of Endocrinology, Diabetes and Metabolism, Weill Cornell Medicine, New York, NY (Drs. Saunders, Igel, Shukla, and Aronne) srb9023@nyp.org
Dr. Aronne serves as a consultant to Eisai Co., Gelesis, GI Dynamics, Jamieson Laboratories, Janssen, Novo Nordisk, Pfizer, Real Appeal, Inc., and UnitedHealth Group Ventures; receives grant/research support from Aspire Bariatrics, AstraZeneca, and Eisai Co.; has an equity interest in BMIQ, Gelesis, Jamieson Laboratories, MYOS RENS Technology Inc., and Zafgen, Inc.; and serves on the board of directors of BMIQ, Jamieson Laboratories, and MYOS RENS Technology Inc.
Drs. Barenbaum, Saunders, Igel, and Shukla reported no potential conflict of interest relevant to this article.
Anne P, a 42-year-old woman with class-III obesity (5’6”; 290 lb; BMI, 46.8 kg/m2), presents to discuss bariatric surgery. Comorbidities include T2D, for which she takes metformin, a glucagon-like peptide-1 (GLP-1) receptor agonist, and a sodium–glucose cotransporter-2 (SGLT-2) inhibitor; GERD; hypertension, for which she takes an angiotensin-converting enzyme inhibitor and a calcium-channel blocker; hyperlipidemia, for which she takes a statin; and osteoarthritis.
Roux-en-Y gastric bypass is effective for weight loss because patients eat smaller portions and cannot absorb all they eat.
Ms. P lost 30 pounds—reducing her BMI from 51.6—when the sulfonylurea and thiazolidinedione she was taking were switched to the GLP-1 receptor agonist and the SGLT2 inhibitor. She also made behavioral modifications, including 30 minutes a day of physical activity and a reduced-calorie meal plan under the guidance of a dietitian.
However, Ms. P has been unable to lose more weight or reduce her hemoglobin A1c (HbA1c) level below 8%. Her goal is to avoid the need to take insulin (which several members of her family take), lower her HbA1c level, and decrease her medication requirement.
Ms. P does not have cardiac or respiratory disease or psychiatric diagnoses. Which surgical intervention would you recommend for her?
Good option for Ms. P: Roux-en-Y gastric bypass
RYGB is a reasonable option for a patient with class-III obesity and multiple comorbidities, including poorly controlled T2D and GERD, who has failed conservative measures but wants to lose more weight, reduce her HbA1c, reduce her medication requirement, and avoid the need for insulin.
