Indications for Bariatric Surgery
Bariatric surgery is indicated for individuals with a BMI ≥40 kg/m² regardless of comorbidities, or BMI ≥35 kg/m² with at least one obesity-related comorbidity, or BMI ≥30 kg/m² with type 2 diabetes that could potentially go into remission. 1, 2
Primary Eligibility Criteria
- BMI ≥40 kg/m² (severe obesity) regardless of comorbidities 1, 2
- BMI ≥35 kg/m² with at least one obesity-related comorbidity such as:
- BMI ≥30 kg/m² with type 2 diabetes that could potentially go into remission (metabolic surgery) 1, 2
- Lower BMI thresholds should be applied for Asian populations 2
Additional Eligibility Considerations
- Failure of non-surgical weight loss methods, including:
- Patient motivation and ability to comply with long-term treatment and follow-up 2
- Acceptable operative risk 2
- Psychological stability and understanding of required lifestyle changes 2
Pre-Surgical Evaluation Requirements
- Comprehensive medical evaluation to assess obesity-related comorbidities 1, 2
- Nutritional evaluation 2
- Mental health evaluation 2
- For patients with type 2 diabetes:
Types of Bariatric Procedures
- Gastric bypass (Roux-en-Y anastomosis) - 25-30% weight loss, 50-65% excess weight loss 1, 3
- Sleeve gastrectomy - 20-35% weight loss, 35-70% excess weight loss 1, 3
- Gastric banding (LAP-BAND) - 20-35% weight loss, 35-70% excess weight loss 1
- Biliopancreatic diversion with or without duodenal switch - 35-40% weight loss, 70-80% excess weight loss 1, 4
Procedure Selection Considerations
- Patient BMI and severity of obesity 2
- Presence and severity of comorbidities 2
- Surgeon expertise and preference 2
- Patient preference 2
- Procedural contraindications 2
Post-Surgical Requirements
- Long-term multidisciplinary follow-up for at least 2 years, sometimes lifelong 1, 2
- Regular appointments with physicians familiar with obesity treatment and bariatric surgery 1, 2
- Nutritional monitoring and supplementation 1, 2
- Psychological support 1, 2
Expected Benefits
- Significant and sustained weight loss 1, 3
- Improvement or resolution of obesity-related comorbidities:
- Reduced risk of some malignant tumors 1
- Reduced risk of acute cerebrovascular events 1
- Reduced all-cause mortality 1, 3
- Enhanced quality of life 1
- Increased longevity 1
Potential Risks and Complications
- Surgical complications 1, 3
- Nutritional deficiencies 1, 2
- Suboptimal clinical response (20-30% of patients) 1, 2
- Recurrent weight gain (20-30% of patients) 1, 2
Important Considerations and Caveats
- Bariatric surgery should be performed by specialized surgeons in hospitals with dedicated multidisciplinary teams 1, 2
- Surgery is not a standalone solution but requires comprehensive lifestyle changes 1, 2
- Perioperative mortality rates have improved substantially and now range from 0.03% to 0.2% 3
- For patients with obesity and decompensated cirrhosis with BMI >35, bariatric surgery should only be considered at the time of liver transplantation or thereafter 1
- For patients with compensated cirrhosis and BMI >35 without clinically significant portal hypertension, bariatric surgery may be considered in centers with experience in both liver transplantation and bariatric surgery 1
- Sleeve gastrectomy is the technique of choice for selected patients with obesity and well-compensated cirrhosis 1