ADVERTISEMENT

Obesity: When to consider surgery

The Journal of Family Practice. 2018 October;67(10):614-616,618-620
October 1, 2018|Family Medicine
Sarah R. Barenbaum, MD;Katherine H. Saunders, MD, DABOM;Leon I. Igel, MD, FACP, DABOM;Alpana P. Shukla, MD, MRCP;Louis J. Aronne, MD, FACP, FTOS, DABOM
Author and Disclosure Information

Department of Internal Medicine, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY (Dr. Barenbaum); Comprehensive Weight Control Center, Division of Endocrinology, Diabetes and Metabolism, Weill Cornell Medicine, New York, NY (Drs. Saunders, Igel, Shukla, and Aronne)
srb9023@nyp.org

Dr. Aronne serves as a consultant to Eisai Co., Gelesis, GI Dynamics, Jamieson Laboratories, Janssen, Novo Nordisk, Pfizer, Real Appeal, Inc., and UnitedHealth Group Ventures; receives grant/research support from Aspire Bariatrics, AstraZeneca, and Eisai Co.; has an equity interest in BMIQ, Gelesis, Jamieson Laboratories, MYOS RENS Technology Inc., and Zafgen, Inc.; and serves on the board of directors of BMIQ, Jamieson Laboratories, and MYOS RENS Technology Inc.

Drs. Barenbaum, Saunders, Igel, and Shukla reported no potential conflict of interest relevant to this article.

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.

CASE 2

Severe obesity, polypharmacy for type 2 diabetes

Anne P, a 42-year-old woman with class-III obesity (5’6”; 290 lb; BMI, 46.8 kg/m2), presents to discuss bariatric surgery. Comorbidities include T2D, for which she takes metformin, a glucagon-like peptide-1 (GLP-1) receptor agonist, and a sodium–glucose cotransporter-2 (SGLT-2) inhibitor; GERD; hypertension, for which she takes an angiotensin-converting enzyme inhibitor and a calcium-channel blocker; hyperlipidemia, for which she takes a statin; and osteoarthritis.

Roux-en-Y gastric bypass is effective for weight loss because patients eat smaller portions and cannot absorb all they eat.

Ms. P lost 30 pounds—reducing her BMI from 51.6—when the sulfonylurea and thiazolidinedione she was taking were switched to the GLP-1 receptor agonist and the SGLT2 inhibitor. She also made behavioral modifications, including 30 minutes a day of physical activity and a reduced-calorie meal plan under the guidance of a dietitian.

However, Ms. P has been unable to lose more weight or reduce her hemoglobin A1c (HbA1c) level below 8%. Her goal is to avoid the need to take insulin (which several members of her family take), lower her HbA1c level, and decrease her medication requirement.

Ms. P does not have cardiac or respiratory disease or psychiatric diagnoses. Which surgical intervention would you recommend for her?

Good option for Ms. P: Roux-en-Y gastric bypass

RYGB is a reasonable option for a patient with class-III obesity and multiple comorbidities, including poorly controlled T2D and GERD, who has failed conservative measures but wants to lose more weight, reduce her HbA1c, reduce her medication requirement, and avoid the need for insulin.

Continue to: How does the procedure work?

ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT