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? LAGB is a reversible procedure in which an inflatable band is placed around the fundus of the stomach to create a small pouch. The band can be adjusted to regulate food intake by adding or removing saline through a subcutaneous access port.
How appealing and successful is it? LAGB results in approximately 15% total body weight loss at 2 years.13 Because the procedure is purely restrictive, it carries a reduced risk of nutritional deficiency associated more commonly with malabsorptive procedures.
What are special considerations, including candidacy? As noted, Mr. Z expressed concern about the permanence and invasiveness of most bariatric procedures, and therefore wants to undergo a reversible procedure; LAGB can be a reasonable option for such a patient. Patients who want a reversible or minimally invasive procedure should also be made aware that endoscopic bariatric therapies and other devices are being developed to fill the treatment gap in the management of obesity.
What are the complications? Although LAGB is the least invasive procedure discussed here, it is associated with the highest rate of complications—most commonly, complications associated with the band itself (eg, nausea, vomiting, obstruction, band erosion or migration, esophageal dysmotility leading to acid reflux) and failure to lose weight.7 LAGB also requires more postoperative visits than other procedures, to optimize band tightness. A high number of bands are removed eventually because of complications or inadequate weight loss, or both.13,24
Shared decision-making and dialogue are essential to overcome obstacles
Despite the known benefits of bariatric surgery, including greater reduction in the risk and severity of obesity-related comorbid conditions than seen with other interventions and a long-term reduction in overall mortality when compared with usual care, fewer than 1% of eligible patients undergo a weight-loss procedure.25 Likely, this is due to:
- limited patient knowledge of the health benefits of surgery
- limited provider comfort recommending surgery
- inadequate insurance coverage, which might, in part, be due to a lack of prospective studies comparing various bariatric procedures.18
Continue to: Ultimately, the decision whether to undergo a bariatric procedure...
