Obesity: When to consider surgery
Bariatric surgery is underutilized despite an obesity epidemic. Here, 3 patients pursue a surgical option when they can't reach their target weight and optimal health by nonsurgical means.
PRACTICE RECOMMENDATIONS
Among adult patients with body mass index* ≥40, or ≥35 with obesity-related comorbid conditions:
› Consider bariatric surgery in those who are motivated to lose weight but who have not responded to lifestyle modification with or without pharmacotherapy in order to achieve sufficient and sustained weight loss. A
› Consider bariatric surgery to help patients achieve target health goals and reduce/improve obesity-related comorbidities. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
*Calculated as weight in kilograms divided by height in meters squared.
How does the procedure work? SG removes a large portion of the stomach along the greater curvature, reducing the organ to approximately 15% to 25% of its original size.18 The procedure leaves the pyloric valve intact and does not involve removal or bypass of the intestines.
How appealing and successful is it? The majority of patients who undergo SG experience significant weight loss; studies report approximately 25% total body weight loss after 1 to 2 years.14 Furthermore, most patients with T2D experience resolution of, or improvement in, disease markers.19 Because SG leaves the pylorus intact, there are fewer restrictions on what a patient can eat after surgery, compared with RYGB. With further weight loss, Ms. W may experience improvement in, or resolution of, hypertension, hyperlipidemia, and OSA.
The SG procedure itself is simpler than some other bariatric procedures and presents less risk of malabsorption because the intestines are left intact. Patients who undergo SG report feeling less hungry because the fundus of the stomach, which secretes ghrelin (the so-called hunger hormone), is removed.18,20
What are special considerations, including candidacy? Patients with GERD are not ideal candidates for this procedure because exacerbation of the disease is a potential associated adverse event. SG is a reasonable surgical option for Ms. W because the procedure is less likely to exacerbate her nutritional deficiency (iron-deficiency anemia), compared to RYGB, and she does not have a history of GERD.
What are the complications? Complications of SG occur at a lower rate than they do with RYGB, which is associated with a greater risk of nutritional deficiency.18 Common early complications of SG include leaking, bleeding, stenosis, GERD, and vomiting due to excessive eating. Late complications include stomach expansion by 12 months, leading to decreased restriction.15 Unlike RYGB and LAGB, SG is not reversible.
Continue to: CASE 2
