Declining Bariatric Surgery Volumes and Shifting Practice Patterns: A Five-Year Analysis of Over One Million Procedures

Bariatric surgery volumes are declining despite rising obesity prevalence. Practice patterns have shifted toward more complex conversion procedures and away from sleeve gastrectomy. Quality improvements at accredited centers have maintained low complication rates despite increasing patient complexity, but falling volumes threaten training capacity and access. OBJECTIVE: To characterize trends in bariatric surgery volumes, patient complexity, procedure selection, and outcomes from 2020 to 2024. Bariatric surgery remains the most effective obesity treatment, yet fewer than 1% of eligible patients undergo surgery. The COVID-19 pandemic and glucagon-like peptide-1 receptor agonists have disrupted surgical volumes. Understanding current practice patterns is critical for resource planning, fellowship training, and maintaining surgical access as obesity prevalence rises. METHODS: Retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database (2020 to 2024). Demographics, comorbidities, procedure types, and 30-day outcomes were analyzed. Trends were evaluated using chi-square and linear regression. RESULTS: Among 1,006,270 procedures, volumes declined 23% from the 2022 peak (230,707 to 177,789 in 2024). Primary procedures decreased from 90.2% to 83.9% of total cases, while conversions increased from 8.9% to 11.0%. Sleeve gastrectomy declined from 73.4% to 70.6% of primary procedures; Roux-en-Y gastric bypass increased from 26.6% to 29.4% (all p