Review article
Management of the bariatric surgery patient

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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

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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.

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