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? RYGB constructs a small pouch from the proximal portion of the stomach and attaches it directly to the jejunum, thus bypassing part of the stomach and duodenum. The procedure is effective for weight loss because it is both restrictive and malabsorptive: patients not only eat smaller portions, but cannot absorb all they eat. Other mechanisms attributed to RYGB that are hypothesized to promote weight loss include21:
- alteration of endogenous gut hormones, which promotes postprandial satiety
- increased levels of bile acids, which promotes alteration of the gut microbiome
- intestinal hypertrophy.
How successful is it? RYGB is associated with significant total body weight loss of approximately 35% at 2 years.9 The procedure has been shown to produce superior outcomes in reducing comorbid disease compared to other bariatric procedures or medical therapy alone. Of the procedures discussed in this article, RYGB is associated with the greatest reduction in triglycerides, HbA1c, and use of diabetes medications, including insulin.22
What are special considerations, including candidacy? For patients with mild or moderate T2D (calculated using the Individualized Metabolic Surgery Score [https://riskcalc.org/Metabolic_Surgery_Score/], which categorizes patients by number of diabetes medications, insulin use, duration of diabetes before surgery, and HbA1c), RYGB is recommended over SG because it leads to greater long-term remission of T2D.
RYGB is associated with a lower rate of GERD than SG and can even alleviate GERD in patients who have the disease. Furthermore, for patients with limited pancreatic beta cell reserve, RYBG and SG have similarly low efficacy for T2D remission; SG is therefore recommended over RYGB in this specific circumstance, given its slightly lower risk profile.23
What are the complications? Patients who undergo any bariatric surgical procedure require long-term follow-up and vitamin supplementation, but those who undergo RYGB require stricter dietary adherence after the procedure; lifelong vitamin (D, B12, folic acid, and thiamine), iron, and calcium supplementation; and long-term follow-up to reduce the risk and severity of complications and to monitor for nutritional deficiencies.7 As such, patients who have shown poor adherence to medical treatment are not good candidates for the procedure.
Continue to: Early complications include...
