Review articleManagement of the bariatric surgery patient☆
Section snippets
Prevalence of morbid obesity
The prevalence of overweight and obesity has increased to epidemic proportions throughout the Western world, now afflicting most adults in the United States. The prevalence of obesity, defined as a body mass index (BMI) greater than 30, has increased from 12% in 1991 to 18% in 1998 [1]. The rate of morbid obesity, defined as more than 100 pounds or 100% above ideal body weight (IBW), is as high as 2% to 5% of men and 6% to 7% of women [2], [3]. This degree of obesity carries with it a marked
Patient selection
The generally accepted criteria for gastrointestinal surgery for weight-reduction were established by the 1991 NIH Consensus Development Conference Panel [9]. Criteria include patients with BMI greater than 40 or BMI greater than 35 complicated by obesity-associated life-threatening cardiopulmonary complications or severe diabetes mellitus. Because of the intractability of obesity even at lower weights, patients with BMI levels of less than 35 are being accepted as surgical candidates [10].
Managing comorbidities
There are several obesity-related comorbidities that must be considered by the clinician before referral for bariatric surgery. These disorders not only serve to make the patient a stronger candidate for surgery, but also must be evaluated and optimized to reduce perioperative morbidity and mortality. Those medical complications that must be considered include the following: [7], [23]
Degenerative joint disease
Type 2 diabetes mellitus
Hypertension
Hyperlipidemia
Coronary artery disease
Hypertrophic
Necessity for support staff and special facilities
Given the unique challenges presented by the morbidly obese, bariatric surgery requires an extraordinary commitment on the part of the operating facility. A multidisciplinary team in required, consisting of a physician with a special interest in obesity, a dietician, a psychologist or psychiatrist interested in behavior modification and eating disorders, and a surgeon with experience in bariatric procedures [7], [36]. In addition, specialized equipment and medical support staff are needed to
Long-term management
Because of complications related to bariatric surgery, patients require life-long follow up [21], [62]. For a variety of reasons however, patients are not followed as closely as recommended following surgery. The International Bariatric Surgery Registry reported a follow-up rate of only 5.1% at 5 years of 1359 eligible for that time interval [63]. Clearly several patients and their complications are being managed by clinicians not involved with the initial surgery and likely without any
Improvements in comorbidities
The effective long-term weight loss achieved by bariatric surgery is extremely effective in alleviating or curing many of the weight-related medical problems afflicting the morbidly obese. Bariatric surgery leads to improvements in blood pressure, cardiac chamber size, wall thickness, left ventricular function, hyperlipidemia, respiratory insufficiency, and diabetes [25]. The cure rates 2 years following bariatric surgery are: 85% of diabetes, 66% of hypertension, and 85% for hyperlipidemia
Summary
Morbid obesity has reached epidemic proportions in the United States. Unfortunately, medical interventions have been largely ineffective in this growing population. Currently bariatric surgery is the most effective intervention in managing morbid obesity and its comorbidities. As more patients become eligible for and pursue weight reduction surgery, it becomes important for the clinician to possess a thorough understanding of the different procedures available and the management of patients
References (78)
Management of the problem patient after bariatric surgery
Gastroenterol Clin N Am
(1994)- et al.
Bariatric surgery. Surgery for weight control in patients with morbid obesity
Med Clin N Am
(2000) - et al.
Gastric bypass surgery in adolescents with morbid obesity
J Pediatr
(2001) - et al.
Psychosocial aspects of obesity and obesity surgery
Surg Clin N Am
(2001) Gastric bypass
Surg Clin N Am
(2001)- et al.
Laparoscopic surgery for morbid obesity
Surg Clin N Am
(2001) Complications of surgery for obesity
Surg Clin N Am
(2001)- et al.
Bariatric surgery in morbidly obese sleep-apnea patients: short- and long-term follow-up
Am J Clin Nutr
(1992) Surgery for obesity
Endocrinol Metab Clin North Am
(1996)- et al.
Malabsorptive obesity surgery
Surg Clin North Am
(2001)
Results of the surgical treatment of obesity
Am J Surg
Nutritional outcomes of gastric operations
Gastroenterol Clin N Am
Prospective evaluation of vertical banded gastroplasty as the primary operation for morbid obesity
Mayo Clin Proc
Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity
Mayo Clin Proc
Lipid risk profile and weight stability after gastric restrictive operations for morbid obesity
J Gastrointest Surg
Resectional gastric bypass is a new alternative in morbid obesity
Am J Surg
A multicenter, placebo-controlled, randomized, double blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric bypass-induced rapid weight loss
Am J Surg
Gastric bypass surgery as maternal risk factor for neural tube defects
Lancet
Postgastrectomy syndromes: dumping and diarrhea
Gastroenterol Clin N Am
Are vitamin B12 and folate deficiency clinically important after roux-en-Y gastric bypass?
J Gastrointest Surg
The spread of the obesity epidemic in the United States, 1991–1998
JAMA
Severe obesity: expensive to society, frustrating to treat, but important to confront
South Med J
Excessive mortality and causes of death in morbidly obese men
JAMA
Late outcome of isolated gastric bypass
Ann Surg
Bariatric surgery programs growing quickly nationwide
Health Care Strateg Manage
Methods for voluntary weight loss and control
Ann Intern Med
National Institutes of Health consensus development conference statement, March 1991
Am J Clin Nutr
Selection of patients for anti-obesity surgery
Int J Obes Relat Metab Disord
Adolescents having obesity surgery: a 6-year follow-up
South Med J
Bariatric Surgery
Surg Clin N Am
Gastric bypass for morbid obesity in patients more than fifty years of age
Surg Gynecol Obstet
Results of bariatric surgery for morbid obesity in patients older than 50 years
Obes Surg
Gastric surgery for morbid obesity. The Adelaide study
Ann Surg
Gastric surgery in morbid obesity. Outcome in patients aged 55 years and older
Arch Surg
Starting a successful bariatric surgical practice in the community hospital setting
Obes Surg
Surgery for morbid obesity: a continuing challenge
Henry Ford Hosp Med J
Gastric bypass in morbidly obese kidney transplant recipients
Clin Transplant
Health implications of obesity
Consens Dev Conf Consens Statement
Nonsurgical factors that influence the outcome of bariatric surgery: a review
Psychosom Med
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The opinions expressed in this article reflect the personal views of the author and not the official views of the United States Army or the Department of Defense.