Guidelines updated for bariatric surgery

Significant new scientific evidence published over the last four years has prompted three major medical societies to change their guidance on who should receive metabolic and bariatric surgery and which methods should be used.

The new guidelines from the American Society for Metabolic and Bariatric Surgery (ASMBS), the American Association of Clinical Endocrinologists (AACE), and The Obesity Society (TOS) were published in the latest issues of “Surgery for Obesity and Related Diseases,” “Endocrine Practice,” and “Obesity,” the official peer-reviewed journals of each of the societies. The original clinical guidelines from the three organizations first appeared in 2008.

“Bariatric or metabolic surgery is among the most studied surgical interventions in medicine, and this ever-increasing mountain of evidence continues to show that these procedures are the most successful and durable treatment for obesity and several related diseases,” said Daniel B. Jones, MD, MS, FACS, professor of surgery at Harvard Medical School in Boston and one of a 12-member panel that developed the guidelines. “However, we’ve gleaned important new insights, cautions, and best practices based on the thousands of studies that were published in medical journals in just the last four years alone, and these are reflected in the new guidelines.”

Among the 74 evidence-based recommendations is the reclassification of sleeve gastrectomy, a restrictive surgical weight loss procedure that limits the amount of food patients can eat, as a proven weight loss surgical option, rather than an investigational one; that surgical eligibility be expanded to include patients with mild to moderate obesity and diabetes or metabolic syndrome; that women should avoid pregnancy before surgery and for 12 to 18 months after surgery; and a team approach to perioperative care “is mandatory with special attention to nutritional and metabolic issues.” The guidelines also provide recommendations on patient screening and selection, preoperative and postoperative management, selection of surgical method, and criteria for hospital readmission after surgery.

Sleeve gastrectomy isn’t ‘investigational’

Laparoscopic sleeve gastrectomy joins laparoscopic adjustable gastric banding, laparoscopic Roux-en-Y gastric bypass, and laparoscopic biliopancreatic diversion BPD, BPD/duodenal switch as primary bariatric and metabolic procedures for patients requiring weight loss and/or metabolic control. Research demonstrates sleeve gastrectomy has benefits comparable to these other procedures in terms of weight loss, resolution of obesity-related conditions, and rate of complications.

The guidelines do not recommend one primary procedure over another as each procedure poses different risks and benefits. It is recommended that the surgical method chosen should be based on specific patient goals and motivations, and surgeon and institutional expertise and experience. However, laparoscopic procedures are preferred over open procedures due to lower early postoperative morbidity and mortality.

Data have emerged on other procedures including gastric plication, electrical neuromodulation, and endoscopic sleeves, but the guidelines continue to classify them as investigational because of a lack of sufficient outcomes evidence.

Surgery for mild to moderate obesity and metabolic disease

According to the guidelines, patients with body mass index (BMI) of 30-34.9 kg/m2 with diabetes or metabolic syndrome may be offered a bariatric procedure, “although current evidence is limited by the number of subjects studied and lack of long term data demonstrating net benefit.” It is further noted that there is insufficient evidence for recommending a bariatric surgical procedure specifically for glycemic control alone, lipid lowering alone, or cardiovascular disease risk reduction alone, independent of BMI criteria. (Editor’s note: Type 2 diabetes is one of the co-morbidities the Centers for Medicare and Medicaid Services considers in determining whether bariatric surgery will be covered for a Medicare beneficiary who is morbidly obese, as long as the surgery is furnished at a Medicare-approved facility.)

Jaime Ponce, MD, ASMBS president, said, “These clinical guidelines provide evidence-based recommendations and information to help surgeons, primary care doctors and other health professionals make the most informed decisions for the benefit of patients.”

The guidelines are available at http://bit.ly/YAJHtW.