High-Volume Public Bariatric Surgery
in Brazil With State Cofinancing:
2,200 Laparoscopic Cases

Authors:
Herbert Motta de Almeida, MD, MSc; Rodrigo Igansi, MD; Patrícia Souto Maior, MD; Ivys Marinho, MD

 

Institution: Hospital Carvalho Beltrão – Coruripe, Alagoas, Brazil (private hospital accredited by SUS)

 

 

Background

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Obesity is a major global health problem, strongly linked to diabetes, cardiovascular disease, disability, and premature death. Bariatric surgery is the most effective treatment for severe obesity, with proven safety and cost-effectiveness [1–3].

In Brazil, although bariatric surgery is covered by the Unified Health System (SUS), long waiting lists and lack of specialized centers limit access. To address this, the Government of Alagoas created a state cofinancing program that made it possible to deliver high-volume bariatric surgery in a SUS-accredited private hospital, with no out-of-pocket costs for patients’ surgeries.

This study reports the first 2,200 laparoscopic cases, using a structured pathway based on the Adjusted 5A Framework Protocol, adapted to the SUS context with state cofinancing [4].

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Methods

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Setting and Financing

Retrospective review of 2,200 consecutive cases (December 2020 – June 2024).
Hospital Carvalho Beltrão, Coruripe (private SUS-accredited hospital).
Funding: 100% SUS + state cofinancing of R$ 22,000 (~US$ 4,400) per case.
No out-of-pocket costs for patients’ surgeries.

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Adjusted 5A Framework Protocol (table 1)

1. Ask – All patients on the waiting list were systematically invited for triage consultation. BMI, comorbidities, and history were recorded.

2. Assess – Eligibility followed CFM Resolution nº 2.429/2025 [5] and international guidelines [1–3]. Mandatory exams included hemogram, coagulogram, renal function, fasting glucose, HbA1c, bilirubin, protein fractions, iron metabolism, lipid profile, electrolytes, thyroid hormones (TSH, T3, T4), parathormone (PTH), dexamethasone suppression test with morning cortisol, and vitamins A, D, B1, B6, B12. Imaging: abdominal ultrasound, upper GI endoscopy, chest X-ray, ECG. Specialist consults: cardiology, endocrinology, psychology, nutrition, nutrology. All patients also underwent bioelectrical impedance analysis (BIA).

3. Advise – Counseling on risks, benefits, expectations, and lifestyle. Weight loss required: 6–8% of excess weight, or reduction to BMI ≤55 for super-obese.

4. Agree – Surgery authorized only after full compliance with exams, weight loss, and agreement between patient, team, and health authorities.

5. Assist – Perioperative care followed ERAS guidelines [1,2]. Structured follow-up included nutrition, endocrinology, psychology, and surgical review.

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Surgical Approach

All procedures were laparoscopic.
Distribution: 90.2% sleeve gastrectomy; 9.8% Roux-en-Y gastric bypass.
Bypass indications: refractory severe esophagitis, Barrett’s esophagus, technical impossibility of performing sleeve, or massive hepatomegaly.

 

 

Results

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Demographics: 82.1% women; 17.9% men.
Mean BMI: 46.17 kg/m² (range 35–66).
Mean age: 38.1 ± 10.3 years.
Procedures: 90.2% sleeve; 9.8% bypass.
Mortality: 0.22% (n=5).
Comorbidities: >70% with obesity-related diseases.
Backlog: reduced from >1,800 to <350 patients.

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Costs

The SUS–state program cost was approximately US$ 4,400 per surgery, fully covered by public funding, with no out-of-pocket costs for patients’ surgeries.

In the Brazilian private sector, commercial packages for bariatric surgery range between R$ 20,000 and R$ 50,000 (US$ 4,000–10,000).

Pajecki et al. (Clinics) reported a mean private cost of ~US$ 3,227.16 in Brazil (vs ~US$ 1,380.74 in SUS for open procedures) [6], though likely underestimating laparoscopic costs including OPME and multidisciplinary care.

International benchmarks: ~US$ 10,900 for sleeve and ~US$ 13,600 for bypass (Böger et al., 2024) [7]; systematic review mean ~US$ 14,389, range US$ 7,423–33,541 (Doble et al., 2017) [8].

Thus, the SUS–state program delivered surgery at significantly lower costs than both Brazilian private prices and international benchmarks.

 

 

Conclusion

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The Adjusted 5A Framework Protocol, applied under SUS with state cofinancing, enabled delivery of safe, effective, and cost-efficient bariatric surgery in a resource-limited setting.

By following the 5A steps (Ask, Assess, Advise, Agree, Assist), the program structured the entire pathway, from triage and evaluation to counseling, decision-making, and follow-up.

This demonstrates that bariatric surgery can be scaled in universal health systems with high efficiency and low cost, offering a replicable strategy for other regions and countries.

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Conflict of Interest

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The authors declare no conflicts of interest. The program was financed entirely by SUS and the Government of Alagoas. The hospital is a private SUS-accredited institution.

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Keywords

Bariatric Surgery; 5A Framework; Unified Health System; Public–Private Partnership; Cost-Effectiveness; Multidisciplinary Team

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Table 1 – Adjusted 5A Framework Protocol (Applied in Alagoas)

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References

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1. Stenberg E, dos Reis Falcão LF, O’Kane M, Liem R, Pournaras DJ, Salminen P, et al. Guidelines for Perioperative Care in Bariatric Surgery: ERAS Society Recommendations: A 2021 Update. World J Surg. 2022;46(4):729–751. doi:10.1007/s00268-021-06394-9.

2. Thorell A, MacCormick AD, Awad S, Reynolds N, Roulin D, Demartines N, et al. Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg. 2016;40(9):2065–2083. doi:10.1007/s00268-016-3492-3.

3. Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, et al. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures—2019 Update. Obesity (Silver Spring). 2020;28(4):O1–O58. doi:10.1002/oby.22719.

4. Vallis M, Piccinini-Vallis H, Sharma AM, Freedhoff Y. Modified 5As: Minimal intervention for obesity counseling in primary care. Can Fam Physician. 2013;59(1):27–31.

5. Conselho Federal de Medicina. Resolução CFM nº 2.429/2025, de 25 de abril de 2025. Diário Oficial da União. 2025 mai 20; Seção 1:170.

6. Pajecki D, Kawamoto F, Dantas ACB, Andrade PC, Brasil NC, Junqueira SM, et al. Real-world evidence of health outcomes and medication use 24 months after bariatric surgery in the public healthcare system in Brazil: a retrospective, single-center study. Clinics (Sao Paulo). 2020;75:e1588. doi:10.6061/clinics/2020/e1588.

7. Böger B, Cardoso N, Oliveira W, et al. Evaluation of the cost and care outcomes by group related to the diagnosis of bariatric surgery. BMC Surg. 2024;24. doi:10.1186/s12893-024-02682-y.

8. Doble B, Wordsworth S, Rogers CA, Welbourn R, Byrne J, Blazeby JM; By-Band-Sleeve Trial Management Group. What Are the Real Procedural Costs of Bariatric Surgery? A Systematic Literature Review of Published Cost Analyses. Obes Surg. 2017;27(8):2179–2192. doi:10.1007/s11695-017-2749-8.

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