Bariatric surgery is a specialized treatment for obesity involving intentional changes to the digestive system to promote weight loss. Gastroenterology is the medical specialty focusing on the diagnosis and treatment of conditions affecting the entire gastrointestinal tract, including the esophagus, stomach, and intestines. Since both disciplines deal with the digestive system, confusion exists about which specialist performs these complex weight loss procedures. A clear distinction exists between the surgical interventions performed by surgeons and the medical or minimally invasive endoscopic treatments provided by gastroenterologists.
Defining the Medical Specialties
A gastroenterologist is a physician specializing in the medical management of digestive diseases. They complete extensive internal medicine training followed by a fellowship in gastroenterology. This specialist uses non-surgical methods, diagnostic testing, and advanced endoscopy to treat conditions like inflammatory bowel disease, acid reflux, or ulcers. Their expertise focuses on the diagnosis and medical treatment of the digestive tract, not surgical alteration.
A bariatric surgeon is a highly specialized general surgeon. They complete a General Surgery residency followed by a dedicated fellowship in metabolic and bariatric surgery. This extensive training allows them to perform complex, open, or minimally invasive operations. The surgeon physically changes the anatomy of the stomach and intestines, performing the permanent, anatomical modifications that define traditional bariatric operations.
The Role of the Bariatric Surgeon
Bariatric surgeons are the only specialists who perform the major, irreversible surgical procedures traditionally referred to as bariatric surgery. These operations involve cutting, stapling, and rerouting digestive organs to achieve weight loss and metabolic improvement. The two most common procedures are the Roux-en-Y Gastric Bypass and the Sleeve Gastrectomy.
During a Sleeve Gastrectomy, the surgeon permanently removes 75% to 80% of the stomach, leaving a narrow, tube-like pouch that restricts food intake. The Roux-en-Y Gastric Bypass is a more complex operation where the surgeon creates a small stomach pouch and reroutes the small intestine to bypass a significant portion of the digestive tract. Both procedures permanently alter the patient’s anatomy, typically via a laparoscopic approach, to limit food consumption and nutrient absorption.
Gastroenterology’s Role in Weight Management
While they do not perform major surgical operations, gastroenterologists are integral members of the multidisciplinary team managing bariatric patients. Their involvement begins with the pre-operative assessment, often performing an upper gastrointestinal endoscopy to evaluate the stomach and esophagus. This evaluation identifies conditions, such as a large hiatal hernia or Barrett’s esophagus, which may influence the choice of surgical procedure or contraindicate certain operations like the Sleeve Gastrectomy.
Post-operatively, the gastroenterologist manages long-term gastrointestinal complications arising from surgical alteration. They monitor patients for nutritional deficiencies, malabsorption, marginal ulcers, and strictures that develop at surgical connection points. Using advanced endoscopic skills, they can diagnose and sometimes treat these complications without requiring a second major surgery.
Endoscopic Procedures for Weight Loss
The most significant source of confusion regarding the roles of these specialists is the advent of bariatric endoscopy, which is performed by gastroenterologists with advanced training. These procedures are non-surgical, meaning they do not involve external incisions or permanent removal of stomach tissue. Instead, a thin, flexible tube called an endoscope is inserted through the mouth to access the stomach.
Endoscopic Sleeve Gastroplasty (ESG)
One prominent procedure is the Endoscopic Sleeve Gastroplasty (ESG). The gastroenterologist places sutures in the stomach lining to reduce its volume by creating accordion-like folds. This technique shrinks the stomach’s capacity by about 70%, helping the patient feel fuller faster without requiring cutting or stapling.
Intragastric Balloons and Revisions
Gastroenterologists also perform the placement of intragastric balloons. These are saline-filled devices temporarily placed in the stomach for six months to occupy space and reduce appetite. Furthermore, for patients who regain weight after a surgical bypass, a gastroenterologist can perform an endoscopic revision like Transoral Outlet Reduction (TORe). TORe tightens the stretched connection between the stomach pouch and the small intestine without requiring abdominal surgery.