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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.

Early complications include leak, stricture, obstruction, and failure of the staple partition of the upper stomach. Late complications include nutritional deficiencies, as noted, and ulceration of the anastomosis. Dumping syndrome (overly rapid transit of food from the stomach into the small intestine) can develop early or late; early dumping leads to osmotic diarrhea and abdominal cramping, and late dumping leads to reactive hypoglycemia.15

Most patients with T2D who undergo sleeve gastrectomy see resolution of, or improvement in, markers of diabetes.

Technically, RYGB is a reversible procedure, although generally it is reversed only in extreme circumstances.

CASE 3

Fatty liver disease, hesitation to undergo surgery

Walt Z, a 35 year-old-man with class-II obesity (5’10”; 265 lb; BMI, 38 kg/m2), T2D, and hepatic steatosis, presents for weight management. He has been able to lose modest weight over the years with behavioral modifications, but has been unsuccessful in maintaining that loss. He requests referral to a bariatric surgeon but is concerned about the permanence and invasiveness of most bariatric procedures.

 

Which surgical intervention would you recommend for this patient?

Good option for Mr. Z: Laparoscopic adjustable gastric band

Given that Mr. Z is a candidate for a surgical intervention but does not want a permanent or invasive procedure, LAGB is a reasonable option.

Continue to: How does the procedure work?

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