Bariatric surgery sequelae

Excess weight is responsible for an estimated 500,000 deaths per year in the US.​[1]Ward ZJ, Willett WC, Hu FB, et al. Excess mortality associated with elevated body weight in the USA by state and demographic subgroup: a modelling study. EClinicalMedicine. 2022 Jun;48:101429. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(22)00159-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/35516446?tool=bestpractice.com In England and Scotland, an estimated 23% of all deaths are attributed to overweight or obesity.[2]Ho FK, Celis-Morales C, Petermann-Rocha F, et al. Changes over 15 years in the contribution of adiposity and smoking to deaths in England and Scotland. BMC Public Health. 2021 Feb 11;21(1):169. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-10167-3 http://www.ncbi.nlm.nih.gov/pubmed/33568116?tool=bestpractice.com ​​ The incidence of class III obesity (body mass index [BMI] of 40 or above) is increasing at a rapid rate, and this has resulted in an increase in bariatric operations worldwide. Bariatric surgery (also referred to as metabolic surgery) has been shown to substantially lower all-cause mortality rates among adults with obesity, compared with nonsurgical obesity management.[3]Syn NL, Cummings DE, Wang LZ, et al. Association of metabolic-bariatric surgery with long-term survival in adults with and without diabetes: a one-stage meta-analysis of matched cohort and prospective controlled studies with 174 772 participants. Lancet. 2021 May 15;397(10287):1830-41. http://www.ncbi.nlm.nih.gov/pubmed/33965067?tool=bestpractice.com ​​​ Studies demonstrate that children and adolescents with class III obesity benefit from weight loss surgery.[4]NHS England. Clinical Commissioning Policy: Obesity surgery for children with severe complex obesity. April 2017. https://www.england.nhs.uk https://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-e/e02 ​ The mechanism of action of bariatric surgery for obesity is not fully understood but is believed to include gastric volume restriction, malabsorption, and hormonal changes.[5]Beckman LM, Beckman TR, Earthman CP. Changes in gastrointestinal hormones and leptin after Roux-en-Y gastric bypass procedure: a review. J Am Diet Assoc. 2010 Apr;110(4):571-84. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4284064 http://www.ncbi.nlm.nih.gov/pubmed/20338283?tool=bestpractice.com ​​[6]Balsiger BM, Poggio JL, Mai J, et al. Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity. J Gastrointest Surg. 2000 Nov-Dec;4(6):598-605. http://www.ncbi.nlm.nih.gov/pubmed/11307094?tool=bestpractice.com

Recommendations for the BMI threshold for bariatric surgery differ among guidelines.[7]National Institute for Health and Care Excellence (NICE). Obesity: identification, assessment and management. Jul 2023​ [internet publication]. https://www.nice.org.uk/guidance/cg189 [8]Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) indications for metabolic and bariatric surgery. Obes Surg. 2023 Jan;33(1):3-14. https://link.springer.com/article/10.1007/s11695-022-06332-1 http://www.ncbi.nlm.nih.gov/pubmed/36336720?tool=bestpractice.com [9]Welbourn R, Hopkins J, Dixon JB, et al. Commissioning guidance for weight assessment and management in adults and children with severe complex obesity. Obes Rev. 2018 Jan;19(1):14-27. https://onlinelibrary.wiley.com/doi/10.1111/obr.12601 http://www.ncbi.nlm.nih.gov/pubmed/29024367?tool=bestpractice.com [10]Di Lorenzo N, Antoniou SA, Batterham RL, et al. Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP. Surg Endosc. 2020 Jun;34(6):2332-58. https://link.springer.com/article/10.1007/s00464-020-07555-y http://www.ncbi.nlm.nih.gov/pubmed/32328827?tool=bestpractice.com ​​​​​​ The American Society of Metabolic and Bariatric Surgery and the International Federation for the Surgery of Obesity and Metabolic Disorders recommend bariatric surgery for individuals who have a BMI of ≥35 kg/m², regardless of comorbidities, or for individuals with a BMI between 30.0 and 34.9 kg/m² who do not achieve durable weight loss and management of comorbidities despite optimal nonsurgical therapy.[8]Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) indications for metabolic and bariatric surgery. Obes Surg. 2023 Jan;33(1):3-14. https://link.springer.com/article/10.1007/s11695-022-06332-1 http://www.ncbi.nlm.nih.gov/pubmed/36336720?tool=bestpractice.com ​ Bariatric surgery is also a treatment option for patients with type 2 diabetes and a BMI >30 kg/m² who do not achieve durable weight loss and management of comorbidities despite optimal nonsurgical therapy.[8]Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) indications for metabolic and bariatric surgery. Obes Surg. 2023 Jan;33(1):3-14. https://link.springer.com/article/10.1007/s11695-022-06332-1 http://www.ncbi.nlm.nih.gov/pubmed/36336720?tool=bestpractice.com [11]ElSayed NA, Aleppo G, Aroda VR, et al. 8. Obesity and weight management for the prevention and treatment of type 2 diabetes: standards of care in diabetes-2023. Diabetes Care. 2023 Jan 1;46(1 suppl):S128-39. https://diabetesjournals.org/care/article/46/Supplement_1/S128/148043/8-Obesity-and-Weight-Management-for-the-Prevention http://www.ncbi.nlm.nih.gov/pubmed/36507637?tool=bestpractice.com ​ In Asian individuals the BMI threshold is lower due to differences in body composition and cardiometabolic risk.[11]ElSayed NA, Aleppo G, Aroda VR, et al. 8. Obesity and weight management for the prevention and treatment of type 2 diabetes: standards of care in diabetes-2023. Diabetes Care. 2023 Jan 1;46(1 suppl):S128-39. https://diabetesjournals.org/care/article/46/Supplement_1/S128/148043/8-Obesity-and-Weight-Management-for-the-Prevention http://www.ncbi.nlm.nih.gov/pubmed/36507637?tool=bestpractice.com

After bariatric surgery, patients may present to clinics, emergency departments, or a hospital other than the one where they had the operation. Thus, knowledge of common complications is necessary.[12]Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery. American Society for Metabolic and Bariatric Surgery position statement on emergency care of patients with complications related to bariatric surgery. Surg Obes Relat Dis. 2010 Mar 4;6(2):115-7. http://www.ncbi.nlm.nih.gov/pubmed/20189469?tool=bestpractice.com ​ The abdomen with central adiposity may be difficult to examine and can mask typical signs of sepsis. Careful attention to vital signs, examination findings, and any deviation from expected postoperative course is essential.