Safe Care for Life: How Metabolic Bariatric Surgery is Changing

The landscape of metabolic bariatric surgery has changed considerably during my training.

I still remember, as a core surgical trainee, pacing around the hospital trying to locate the apparently mythical stash of Huber needles needed to decompress a slipped gastric band. At the time, this felt like an essential piece of surgical knowledge. Today, conversations around treatments for obesity are increasingly about sleeve gastrectomy, gastric bypass and, more recently, the rapidly expanding role of GLP-1-receptor agonists.

That evolution reflects real progress, but it also raises an important patient-safety question: what does safe care for patients with obesity actually look like over a lifetime?

This feels particularly relevant for World Patient Safety Day 2026, with its theme of “Safe care for noncommunicable diseases”.

Metabolic and bariatric surgery remains one of the most effective established treatments for severe obesity. Importantly, we now have long-term experience that allows us to look well beyond peri-operative outcomes.

Our unit at the Royal Infirmary of Edinburgh recently reported outcomes following sleeve gastrectomy and Roux-en-Y gastric bypass extending to 19 years after surgery. Among respondents, the median follow-up was 10 years and median total weight loss was 23.7%. Almost 88% were satisfied with their surgical outcome, 91% said they would undergo surgery again and nearly 90% reported an improvement in quality of life.

These findings are encouraging, but they also highlight something fundamental: success cannot be judged at 30 days, or even at one or two years.

Metabolic bariatric surgery is an intervention for a chronic disease. Patients may develop nutritional deficiencies, weight regain, reflux, gallstones or other problems many years later. Their requirements for treatment of diabetes, hypertension and other comorbidities may change substantially. Safe surgery therefore means more than performing a technically successful operation. It requires continuity of care long after the patient has left the operating theatre.

The arrival of GLP-1 receptor agonists and related therapies has added another dimension to this changing landscape. These drugs have transformed expectations around pharmacological weight loss and are increasingly encountered by surgical teams.

GLP-1 therapy has provided a seismic change for obesity management and has been beneficial for many. However, for some there can be side effects.

In a prospective audit within our Surgical Observation Unit in 2025, we identified 91 patients taking GLP-1-based treatment who presented to the acute surgical service. Almost all presented with abdominal pain and biliary colic was the most frequent diagnosis. More than 70% reported obtaining their medication through online pharmacies.

These observations cannot establish that GLP-1 therapy caused each presentation, but the follow-up findings raised important questions about continuity and responsibility for care. Of 57 patients followed up, 61% had stopped their medication following presentation. Almost half of those subsequently reported weight gain, while only one third recalled receiving support or safety-netting from the provider prescribing their medication.

Again, the lesson is not that one treatment is safer or better than another. It is that obesity treatment cannot safely exist as a single prescription, procedure or episode of care and should be led by dedicated obesity specialists.

This was reinforced during a recent panel discussion at the Roux training congress, which this year took place in Newcastle. Nicola Carruthers, a specialist dietitian working in adult weight management services, described a pilot approach in which GLP-1-based therapy was used to help selected patients reach a target weight before surgery. What struck me was that the emphasis was not simply on reaching a number on the scales, but on embedding treatment within appropriate multidisciplinary care, including nutritional and psychological support.

That feels increasingly important. GLP-1 therapies may complement surgery, help optimise patients before an operation or offer an alternative treatment pathway altogether. But whichever route is chosen, patients still need education, monitoring, nutritional support and clear access to clinicians when problems arise.

Even apparent success deserves careful interpretation. As was also highlighted during the congress discussion, weight loss alone does not necessarily tell us what has been lost. A falling number on the scales may represent loss of fat, lean muscle mass, or both. It is another reminder that good care for obesity requires us to look beyond kilograms alone.

For surgical trainees, patient safety is often taught through the prevention and management of immediate complications: bleeding, leaks, infection and deterioration. Specialist obesity management broadens that definition.

Safe care may mean recognising an acute complication, but it also means ensuring nutritional surveillance years after metabolic bariatric surgery, providing psychological support, managing medication safely and creating pathways that join together primary care, specialist obesity services, private providers and acute surgical teams.

The tools we use to treat obesity will continue to change. The principle should not.

For obesity, “Safe care for life” cannot simply mean a safe operation or a safe prescription. It must mean safe, coordinated and multidisciplinary care for life.