A obesidade e a inatividade são responsáveis por 30,000 mortes por ano na Inglaterra e 365,000 mortes por ano nos EUA.[1]National Audit Office. Tackling obesity in England. February 2001. http://www.nao.org.uk
http://www.nao.org.uk/wp-content/uploads/2001/02/0001220.pdf
[2]Mokdad AH, Marks JS, Stroup DF, et al. Actual causes of death in the United States, 2000. JAMA. 2004 Mar 10;291(10):1238-45.
http://www.ncbi.nlm.nih.gov/pubmed/15010446?tool=bestpractice.com
[3]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
[4]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
A incidência de obesidade classe III (índice de massa corporal de 40 ou mais) está crescendo rapidamente e isso resultou em um aumento drástico das cirurgias bariátricas no mundo inteiro. Ensaios prospectivos de larga escala demonstraram que a cirurgia de obesidade resulta em melhora da qualidade de vida e diminuição do risco de morte em indivíduos com obesidade classe III.[5]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
[6]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
[7]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
[8]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
[9]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
[10]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
[11]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;374:113-23.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4810437
http://www.ncbi.nlm.nih.gov/pubmed/26544725?tool=bestpractice.com
Estudos demonstraram que crianças e adolescentes com obesidade classe III beneficiam da cirurgia para perda de peso.[12]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
Os pacientes com obesidade classe II (índice de massa corporal de 35 a 39.9) a classe III devem passar por uma avaliação abrangente e receber atendimento no ciclo pós-operatório imediato e distante da cirurgia para perda de peso.[13]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
A cirurgia bariátrica (também referida como cirurgia metabólica) está sendo investigada como uma terapia primária possível para o diabetes do tipo 2. Resultados de ensaios clínicos randomizados e controlados e revisões sistemáticas com metanálises mostraram controle superior da glicemia com cirurgia bariátrica em comparação com a terapia medicamentosa convencional isoladamente em pessoas com obesidade e diabetes do tipo 2.[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;376:641-51.
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
[18]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
Além disso, as diretrizes da American Diabetes Association, do National Institute for Health and Care Excellence sediado no Reino Unido e da International Diabetes Foundation recomendam o uso de cirurgia bariátrica em pessoas com obesidade e diabetes do tipo 2 com controle inadequado da glicemia apenas com terapia medicamentosa otimizada.[19]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
[20]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
[21]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
[22]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
Em um pequeno ensaio randomizado, a cirurgia bariátrica reduziu o número de medicações anti-hipertensivas (≥30%) necessárias para manter o controle da pressão arterial em pessoas com obesidade e hipertensão, comparada com a terapia medicamentosa isolada.[23]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
O mecanismo de ação da cirurgia bariátrica para obesidade não é completamente compreendido atualmente, mas parece incluir restrição do volume gástrico, má absorção e alterações hormonais.[24]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
[25]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
Após a cirurgia bariátrica, é possível que os pacientes compareçam a clínicas, prontos-socorros ou hospitais diferentes daqueles onde foram operados. Assim, torna-se necessário o conhecimento das complicações comuns.[26]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
O abdome com adiposidade central pode ser difícil de examinar, podendo mascarar sinais típicos de sepse. É essencial prestar muita atenção aos sinais vitais, aos achados do exame físico e a qualquer mudança em relação à evolução pós-operatória esperada.
Para ajudar os pacientes a manter a perda de peso após a cirurgia bariátrica, o automonitoramento regular e consultas frequentes de acompanhamento pós-operatório podem ser necessários.[27]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
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