Obesity and inactivity are responsible for 365,000 deaths per year in the US.[1]Mokdad AH, Marks JS, Stroup DF, et al. Actual causes of death in the United States, 2000. JAMA. 2004;291:1238-1245.
http://www.ncbi.nlm.nih.gov/pubmed/15010446?tool=bestpractice.com
[2]Mokdad AH, Marks JS, Stroup DF, et al. Correction: actual causes of death in the United States, 2000. JAMA. 2005;293:293-294.
http://www.ncbi.nlm.nih.gov/pubmed/15657315?tool=bestpractice.com
[3]Scottish Intercollegiate Guidelines Network (SIGN). Management of obesity: a national clinical guideline. February 2010. https://www.sign.ac.uk/our-guidelines.html
https://www.sign.ac.uk/sign-115-management-of-obesity.html
The incidence of class III obesity (body mass index of 40 or above) is increasing at a rapid rate, and this has resulted in an increase in bariatric operations worldwide. In large-scale prospective trials, obesity surgery has been shown to result in improved quality of life and a decreased risk of death for people of all ages with class III obesity.[4]Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741-52.
http://www.nejm.org/doi/full/10.1056/NEJMoa066254#t=article
http://www.ncbi.nlm.nih.gov/pubmed/17715408?tool=bestpractice.com
[5]Inabnet WB 3rd, Belle SH, Bessler M, et al. Comparison of 30-day outcomes after non-LapBand primary and revisional bariatric surgical procedures from the Longitudinal Assessment of Bariatric Surgery study. Surg Obes Relat Dis. 2010;6:22-30.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2836857/pdf/nihms174958.pdf
http://www.ncbi.nlm.nih.gov/pubmed/20129303?tool=bestpractice.com
[6]Healthcare Improvement Scotland (NHS QIS). Bariatric surgery in adults: Evidence Note 28. June 2010. http://www.healthcareimprovementscotland.org
http://www.healthcareimprovementscotland.org/programmes/clinical__cost_effectiveness/shtg_-_evidence_notes/evidence_note_28.aspx
[7]Pontiroli AE, Morabito A. Long-term prevention of mortality in morbid obesity through bariatric surgery. A systematic review and meta-analysis of trials performed with gastric banding and gastric bypass. Ann Surg. 2011;253:484-487. [Erratum in Ann Surg. 2011;253:1056.]
http://www.ncbi.nlm.nih.gov/pubmed/21245741?tool=bestpractice.com
[8]Tayyem R, Ali A, Atkinson J, et al. Analysis of health-related quality-of-life instruments measuring the impact of bariatric surgery: systematic review of the instruments used and their content validity. Patient. 2011;4:73-87.
http://www.ncbi.nlm.nih.gov/pubmed/21766897?tool=bestpractice.com
[9]Flum DR, Belle SH, King WC, et al; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361:445-454.
http://www.nejm.org/doi/full/10.1056/NEJMoa0901836
http://www.ncbi.nlm.nih.gov/pubmed/19641201?tool=bestpractice.com
[10]Inge TH, Courcoulas AP, Jenkins TM, et al; Teen-LABS Consortium. Weight loss and health status 3 years after bariatric surgery in adolescents. N Engl J Med. 2016;374:113-123.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4810437
http://www.ncbi.nlm.nih.gov/pubmed/26544725?tool=bestpractice.com
Studies demonstrate that children and adolescents with class III obesity benefit from weight loss surgery.[11]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
Patients with class II (body mass index of 35 to 39.9) to class III obesity should undergo a comprehensive assessment and receive care in the immediate and distant postoperative course from weight loss surgery.[12]British Obesity & Metabolic Surgery Society, Royal College of Surgeons. Commissioning guide: Weight assessment and management clinics. March 2014. http://www.bomss.org.uk
http://www.bomss.org.uk/commissioning-guide-weight-assessment-and-management-clinics-tier-3
Bariatric surgery (also referred to as metabolic surgery) is also being investigated as a possible primary therapy for type 2 diabetes. Results from randomized controlled trials and systematic reviews with meta-analyses have shown superior glycemic control with bariatric surgery compared with conventional medical therapy alone in people with obesity and type 2 diabetes.[13]Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. 2009;122:248-256.e5.
http://www.ncbi.nlm.nih.gov/pubmed/19272486?tool=bestpractice.com
[14]Yan Y, Sha Y, Yao G, et al. Roux-en-Y gastric bypass versus medical treatment for type 2 diabetes Mellitus in obese patients: a systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore). 2016;95:e3462.
http://www.ncbi.nlm.nih.gov/pubmed/27124041?tool=bestpractice.com
[15]Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes - 5-year outcomes. N Engl J Med. 2017;376:641-651.
http://www.nejm.org/doi/full/10.1056/NEJMoa1600869
http://www.ncbi.nlm.nih.gov/pubmed/24679060?tool=bestpractice.com
[16]Müller-Stich BP, Senft JD, Warschkow R, et al. Surgical versus medical treatment of type 2 diabetes mellitus in nonseverely obese patients: a systematic review and meta-analysis. Ann Surg. 2015;261:421-429.
http://www.ncbi.nlm.nih.gov/pubmed/25405560?tool=bestpractice.com
[17]Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial. Lancet. 2015;386:964-973.
http://www.ncbi.nlm.nih.gov/pubmed/26369473?tool=bestpractice.com
Furthermore, guidelines from the American Diabetes Association, the UK-based National Institute for Health and Care Excellence, and the International Diabetes Foundation, recommend the use of bariatric surgery in people with obesity and type 2 diabetes who have inadequate glycemic control on optimal medical therapy alone.[18]American Diabetes Association. Standards of medical care in diabetes - 2022. Diabetes care. 2022 Jan;45(1 suppl):S1-2.
https://diabetesjournals.org/care/issue/45/Supplement_1
[19]National Institute for Health and Care Excellence (NICE). Obesity: identification, assessment and
management. November 2014. http://www.nice.org.uk
https://www.nice.org.uk/guidance/cg189/resources/obesity-identification-assessment-and-management-35109821097925
[20]International Diabetes Federation. Bariatric surgical and procedural interventions in the treatment of obese patients with type 2 diabetes. A position statement from the International Diabetes Federation Taskforce on Epidemiology and Prevention. 2011. http://www.idf.org
http://www.idf.org/webdata/docs/IDF-Position-Statement-Bariatric-Surgery.pdf
[21]Dixon JB, Zimmet P, Alberti KG, et al; International Diabetes Federation Taskforce on Epidemiology and Prevention. Bariatric surgery: an IDF statement for obese Type 2 diabetes. Diabet Med. 2011;28:628-642.
http://onlinelibrary.wiley.com/doi/10.1111/j.1464-5491.2011.03306.x/full
http://www.ncbi.nlm.nih.gov/pubmed/21480973?tool=bestpractice.com
In one small randomized trial, bariatric surgery reduced the number of antihypertensive medications (≥30%) required to maintain blood pressure control in people with obesity and hypertension compared with medical therapy alone.[22]Schiavon CA, Bersch-Ferreira AC, Santucci EV, et al. Effects of bariatric surgery in obese patients with hypertension: The GATEWAY Randomized Trial (Gastric Bypass to Treat Obese Patients With Steady Hypertension). Circulation. 2018;137:1132-1142.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5865494
http://www.ncbi.nlm.nih.gov/pubmed/29133606?tool=bestpractice.com
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.[23]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;110:571-584.
http://www.ncbi.nlm.nih.gov/pubmed/20338283?tool=bestpractice.com
[24]Balsiger BM, Poggio JL, Mai J, et al. Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity. Gastrointest Surg. 2000;4:598-605.
http://www.ncbi.nlm.nih.gov/pubmed/11307094?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.[25]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;6:115-117.
http://s3.amazonaws.com/publicASMBS/GuidelinesStatements/PositionStatement/ASMBS_Position_Statement_on_Emergency_Care_of_Ptients_with_Complications_Related_to_Bariatric_Surgery_Mar_2010.pdf
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.
In order to help patients sustain weight loss after bariatric surgery, regular self-monitoring and frequent postoperative follow-up visits may be required.[26]Odom J, Zalesin KC, Washington TL, et al. Behavioral predictors of weight regain after bariatric surgery. Obes Surg. 2010;20:349-356.
http://www.ncbi.nlm.nih.gov/pubmed/19554382?tool=bestpractice.com