Q&A with Penn Medicine bariatric surgeon Maria Altieri, MD, MS, FACS

I spent two years as a research fellow during my training with a surgeon who specialized in metabolic and bariatric surgery.

I was impressed by the technical proficiency and surgical outcomes of the procedures, which are performed through small incisions and equally as safe as other common general surgical procedures. I was particularly impressed by the benefits this surgery offers patients in terms of the “non-scale victories” (i.e., unrelated to weight on the scale) that positively affect their entire body.

Patients described the impact of small victories, including resolution or improvement of obesity related comorbidities (type 2 diabetes, hypertension, obstructive sleep apnea) and discontinuing medications or treatments. They also reported increased energy, improved lifestyle benefits (less joint pain, better sleep quality, travel, enjoying time with children, and lack of embarrassment in public). Several patients shared their happiness with seeing their toes, which was something that hadn’t happened in decades.

Beyond weight loss and improvement of comorbidities, happiness centered on how surgery had transformed their quality of life. Providing such a positive impact was something that I strived to achieve, and having the opportunity to deliver that level of happiness remains inspiring.

Our program focuses on a patient-centered approach that starts at our first meeting with them. This visit is critical to determining and establishing their expectations and goals. These often focus on a better quality of life that includes fewer medications, improved longevity, and enhancing the quality of the time they spend with loved ones.

The most common questions we have during these conversations include:

• What goals are they trying to achieve?
• What options do they have for their specific condition (medications, endoscopic procedures, surgery)?
• What are the risks, benefits, and alternatives associated with each choice?
• What does the data show regarding long-term success with each option?

The conversation begins with establishing what the patient wants and continues with education on what each approach can deliver.

It’s had an overall positive effect. Historically, weight has been a difficult topic for patients and providers. However, the emergence of these medications has motivated patients to be proactive about discussions with providers about obesity and obesity related comorbidities.

This has introduced more opportunities for us as health care providers to communicate the potential benefits of different approaches (medical, endoscopic, or surgical weight loss). It also allows us to emphasize that each requires a long-term commitment by the patient to lifestyle changes supporting healthy habits enabling them to both meet their goals and sustain them.

In my experience, there is no one-size-fits-all approach to how or when medication might benefit a given patient. I’ve used it as a first-line treatment for morbidly obese patients (BMI > 50 kg/m²) as a means of weight loss to significantly decrease their surgical risk. I’ve also used it in place of revision surgery to address postsurgical weight regain.

For patients unsure whether they’re ready for surgery or a revisional procedure, medication might be the right answer depending on their goals and commitment to lifestyle changes. Similarly, some patients start on medication but either see limited success or have to stop due to complications or side effects. For those patients, surgery or an endoscopic procedure may now be a great option after having gained some experience and perspective.

For morbidly obese patients with no disqualifying factors, I would recommend surgery as the best option, because it’s the gold standard in terms of safety and patient outcomes. However, I’m also a proponent of combining surgery and medication to help achieve better weight loss and resolution of comorbidities. Having more tools at our disposal simply allows us to treat patients in a multidisciplinary way in order to achieve the best outcomes.

Although no surgery is 100 percent risk-free, bariatric surgery is safe and has a comparable risk profile with common general surgical procedures, such as appendectomies, gallbladder surgery, and hernia procedures. Because these procedures are mostly (>98 percent) minimally invasive (with incisions ≤1.2 cm), this translates to faster recovery, less pain, and fewer complications.

Surgery’s benefits can also be viewed in terms of the risks posed by obesity to many patients. Patients that undergo bariatric surgery have a longer life expectancy (at least 5 years) relative to those who don’t undergo surgery. These patients also present a lower risk of weight-related cardiovascular events, such as stroke and heart attack, as well as developing diabetes and/or high blood pressure.

The earlier the referral, the sooner we can help address misconceptions regarding surgery, the potential roles of medication, and realistic weight loss expectations.

It’s critically important that patients understand all of their options prior to entering a treatment pathway. Specifically, what are the benefits and limitations of each approach, and what other options are available if one pathway fails?

Also, referrals shouldn’t be limited only to patients considered candidates for bariatric surgery. For example, a specialist can determine whether certain disqualifying conditions (e.g., hernia, gastroesophageal reflux disease, etc.) can be appropriately addressed so that bariatric surgery is an option. Early referral in such cases can potentially allow surgeons to address multiple conditions in a relatively short time period.

Patients should arrive with insight into their goals and expectations. The truth is that there is no miracle cure for their condition, regardless of the route they choose (diet and exercise, medications, or surgery). The process involves hard work, and a patient has to show the determination necessary to achieve their goal.

One of my former patients began her weight loss journey at 540 pounds and with a goal of improving both her quality of life and that of her family. After surgery, she made all the required lifestyle modifications and maintained them. As she continued losing weight, her health and chronic pain improved, which allowed her to start exercising five to six days a week. These successes led to further weight loss and the increased energy required to keep up with her child.

Better quality of life translated into gratitude for each small victory and the opportunity to take advantage of it. At one-year post-surgery, she weighed 200 pounds and was living her best life.

The moral of the story is that surgery and medication are just tools. What makes patients successful is how they use them, which relies on hard work and refusing to take small victories for granted.

Clinical consult with a Penn Medicine weight management specialist

For clinical consult with a provider from the Penn Bariatric Surgery Program, or to refer a patient, call 877-937-7366 or submit a referral request online.