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.
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 [3‐6] 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].
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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
×
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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
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.
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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 [3‐7]. 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.
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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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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.
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