What are the criteria for bariatric surgery?

Criteria for Bariatric Surgery

Bariatric surgery should be considered for individuals with a BMI ≥40 kg/m² or BMI ≥35 kg/m² with at least one obesity-related comorbidity, and for those with BMI ≥30 kg/m² and type 2 diabetes that could potentially go into remission. 1

Primary Eligibility Criteria

• BMI ≥40 kg/m² without comorbidities 1
• BMI ≥35 kg/m² with at least one severe obesity-related comorbidity, such as:
  • Type 2 diabetes 1
  • Hypertension 1
  • Hyperlipidemia 1
  • Obstructive sleep apnea 1
  • Non-alcoholic fatty liver disease 1
• BMI ≥30 kg/m² with type 2 diabetes that could potentially achieve remission (metabolic surgery) 1
• Lower BMI thresholds should be applied for Asian populations 1

Additional Considerations

• Failure of conventional weight loss methods 1
  • Diet, exercise, behavioral therapy, and pharmacotherapy have been attempted 1
  • For patients with BMI <35 kg/m², a trial of nonsurgical therapy is recommended prior to surgical referral 1
• Ability to comply with long-term treatment and follow-up 1
• Acceptable operative risk 1, 2
• Psychological stability and understanding of the required lifestyle changes 1

Pre-Surgical Evaluation Requirements

• Comprehensive nutritional evaluation 1
• Mental health evaluation 1
• For patients with type 2 diabetes being considered for metabolic surgery:
  • Assessment of pancreatic insulin secretory reserve 1
  • Tests to distinguish type 1 from type 2 diabetes (fasting C-peptide, anti-GAD antibodies) 1
  • Evaluation using prediction scales (DiaRem, Ad-DiaRem, ABCD, DRS) to identify potential beneficiaries 1

Procedure Selection Considerations

• Patient BMI (higher BMI may indicate more aggressive procedures) 1
• Presence and severity of comorbidities 1
• Surgeon expertise and preference 1
• Patient preference 1
• Procedural contraindications (e.g., hiatal hernia, gastric ulcers) 1

Post-Surgical Requirements

• Long-term multidisciplinary follow-up for at least 2 years, sometimes lifelong 1
• Regular appointments with physicians familiar with obesity treatment and bariatric surgery (at least annually) 1
• Nutritional monitoring and supplementation 1
• Psychological support 1

Common Pitfalls and Caveats

• Bariatric surgery is not a standalone solution but requires comprehensive lifestyle changes 1
• 20-30% of patients may experience suboptimal clinical response or weight regain despite surgery 1
• Potential complications include surgical complications and nutritional deficiencies 1
• Careful patient selection is crucial to minimize risks and maximize benefits 2
• Surgery should be performed by specialized surgeons in hospitals with dedicated multidisciplinary teams 1

The most recent guidelines emphasize that bariatric surgery should be considered earlier in the treatment algorithm for eligible patients, as it provides the most effective and durable weight loss compared to non-surgical interventions, with significant improvements in obesity-related comorbidities and mortality 1, 2.