Severe obesity with comorbidity
By The Treatment Registry editors
Patients with BMI ≥40, or ≥35 with significant comorbidity (type 2 diabetes, sleep apnoea, hypertension), may be candidates for bariatric (weight-loss) surgery. The treatment ladder runs through medical management, modern weight-loss pharmacotherapy, endoscopic procedures, and definitive surgery. Surgical options have different mechanisms and trade-offs around weight loss, reflux, and reversibility.
Treatment ladder
Conservative options are first-line where appropriate; surgical options are typically reserved for cases where lower-tier options are unsuitable or have failed. Decisions are individual and depend on clinical assessment.
Conservative
- Multidisciplinary medical weight management
Coordinated dietetic, behavioural, and exercise support. Effective in some patients but historically modest long-term outcomes for severe obesity.
- GLP-1 receptor agonist therapy
Semaglutide, tirzepatide, and related agents producing 15-25% body-weight reduction in many patients. Continuing evidence base; weight typically regained on cessation.
Procedural
- Endoscopic gastric balloon
Saline- or air-filled balloon placed endoscopically for 6 months. Modest weight loss; suitable as a bridge therapy or for patients ineligible for surgery.
- Endoscopic sleeve gastroplasty
Endoscopic suturing to reduce stomach volume without surgical resection. Less established evidence than surgical alternatives.
Surgical
- Sleeve gastrectomy · View procedure page
Resection of approximately 75% of the stomach to create a tubular gastric remnant. The most commonly performed bariatric operation worldwide; durable weight loss but elevated reflux risk in some patients.
- Roux-en-Y gastric bypass
Creation of a small gastric pouch and a Roux limb of small bowel, bypassing most of the stomach and proximal small bowel. Greater weight loss than sleeve in many series; better resolution of reflux and type 2 diabetes; technically more demanding.
- Mini gastric bypass (one-anastomosis)
Single-anastomosis variant of bypass. Shorter operating time; concerns about long-term bile reflux remain debated.