A focus on surgical preoperative evaluation of the bariatric patient--the Cleveland Clinic protocol and review of the literature

Point-Counterpoint Debate: Surgery vs Medical Treatment for the Management of Obesity

Obesity is a chronic, relapsing condition with severe health risks and a huge economic burden. Effective interventions for severe obesity include bariatric or metabolic surgery and high-intensity medical management involving lifestyle changes and pharmacotherapy. This article summarizes the debate between Drs. Schauer and Rothberg at the June 2024 Endocrine Society meeting regarding the optimal approach to managing obesity, exploring mechanisms, outcomes, safety, quality-of-life, and cost-effectiveness. Metabolic surgery results in substantial and sustained weight loss, improvements in comorbidities such as type 2 diabetes, and reduced mortality, and it is cost-effective. However, it carries risks associated with surgery and long-term complications, and its high upfront costs limit its scalability. Conversely, high-intensity medical management, which includes comprehensive lifestyle interventions and pharmacotherapy, leads to meaningful, though sometimes less substantial, weight loss and health improvements. The latter approach prioritizes behavioral changes and is cost-effective but requires patient adherence and faces challenges with medication side effects and costs. Both interventions offer substantial health benefits; the choice between them should consider individual patient needs, health status, target weight loss, and personal preferences. Metabolic surgery may be more suitable for individuals with severe obesity or when comorbidities are inadequately controlled, whereas medical management may be more suited to patients with less severe obesity and those preferring nonsurgical options. Future research should investigate the combined effects of surgery and medical management and enhance access to and affordability of these treatments. A multidisciplinary, personalized approach will likely yield the best outcomes in managing this complex health issue.

Metabolic surgery in treatment of obese Japanese patients with type 2 diabetes: a joint consensus statement from the Japanese Society for Treatment of Obesity, the Japan Diabetes Society, and the Japan Society for the Study of Obesity

Bariatric surgery has been shown to have a variety of metabolically beneficial effects for patients with type 2 diabetes (T2D), and is now also called metabolic surgery. At the 2nd Diabetes Surgery Summit held in 2015 in London, the indication for bariatric and metabolic surgery was included in the “algorithm for patients with type T2D”. With this background, the Japanese Society for Treatment of Obesity (JSTO), the Japan Diabetes Society (JDS) and the Japan Society for the Study of Obesity (JASSO) have formed a joint committee to develop a consensus statement regarding bariatric and metabolic surgery for the treatment of Japanese patients with T2D. Eventually, the consensus statement was announced at the joint meeting of the 38th Annual Meeting of JSTO and the 41st Annual Meeting of JASSO convened in Toyama on March 21, 2021. In preparing the consensus statement, we used Japanese data as much as possible as scientific evidence to consider the indication criteria, and set two types of recommendation grades, “recommendation” and “consideration”, for items for which recommendations are possible. We hope that this statement will be helpful in providing evidence-based high-quality care through bariatric and metabolic surgery for the treatment of obese Japanese patients with T2D.

Preoperative Endoscopic and Radiologic Evaluation of Bariatric Patients: What Do They Add?

BACKGROUND

Preoperative esophagogastroduodenoscopy (EGD) and barium swallow (BS) are commonly performed for evaluation in bariatric surgery patients. The routine use of these modalities has been controversial.

METHODS

A retrospective review of a prospectively maintained database was performed to include primary bariatric surgery patients between March 2013 and August 2016.

RESULTS

Two hundred nine patients were included. All the patients underwent preoperative EGD and BS. The mean age was 43.12 years and BMI 46.4 kg/m². Reflux symptoms were present in 58.5% of patients. Preoperative EGD revealed abnormalities in 87.5% of patients: esophagitis (54.5%), Barrett's esophagus (5.3%), dysplasia (1%), and gastritis (51%). Endoscopic evidence of HH was documented in 52.2% of patients while only 34% of patients had evidence of HH in their BS. Of the asymptomatic patients, 80.2% had abnormal EGD. Helicobacter pylori on biopsy was found in 17.2% patients, out of which 47.2% were asymptomatic. Based on EGD findings, the choice of surgical procedure was changed in 3.34% of patients. Repair of HH was performed in 107 patients, with 68.2% (n = 73) symptomatic patients and 31.8% (n = 34) asymptomatic patients. On ROC analysis, EGD was better predictive of the presence of HH (AUC = 0.802, OR 5.20, p  =   < 0.0001) and symptoms were a poor indicator for GERD.

CONCLUSIONS

Preoperative EGD is abnormal in the majority of patients regardless of their symptoms. EGD is the only modality that can provide tissue sample, which can potentially determine the type of bariatric surgery. Given the low diagnostic accuracy of BS, its routine use can be eliminated.

The Outcome of Bariatric Surgery in Patients Aged 75 years and Older

BACKGROUND

Bariatric surgery has been shown to be safe and effective in patients aged 60-75 years; however, outcomes in patients aged 75 or older are undocumented.

METHODS

Patients aged 75 years and older who underwent bariatric procedures in two academic centers between 2006 and 2015 were studied.

RESULTS

A total of 19 patients aged 75 years and above were identified. Eleven (58%) were male, the median age was 76 years old (range 75-81), and the median preoperative body mass index (BMI) was 41.4 kg/m² (range 35.8-57.5). All of the bariatric procedures were primary procedures and performed laparoscopically: sleeve gastrectomy (SG) (n = 11, 58%), adjustable gastric band (AGB) (n = 4, 21%), Roux-en-Y gastric bypass (RYGB) (n = 2, 11%), banded gastric plication (n = 1, 5%), and gastric plication (n = 1, 5%). The median operative time was 120 min (range 75-240), and the median length of stay was 2 days (range 1-7). Three patients (16%) developed postoperative atrial fibrillation which completely resolved at discharge. At 1 year, the median percentage of total weight loss (%TWL) was 18.4% (range 7.4-22.0). The 1-year %TWL varied among the bariatric procedures performed: SG (21%), RYGB (22%), AGB (7%), and gastric plication (8%). There were no 30-day readmissions, reoperations, or mortalities.

CONCLUSION

Our experience suggests that bariatric surgery in selected patients aged 75 years and older would be safe and effective despite being higher risk. Age alone should not be the limiting factor for selecting patients for bariatric surgery.

Preoperative Evaluation in Bariatric Surgery

An adequate preoperative workup is critical for the success of bariatric surgery. A key component of the preoperative evaluation involves a comprehensive patient education about surgical outcomes and the postoperative behavioral regimen required. A complete medical evaluation should include the study of the cardiovascular, pulmonary, and gastrointestinal systems as well as a metabolic status assessment. The nutrition professional should be in charge of the nutritional assessment, preoperative weight loss efforts, and diet education regarding postoperative eating behaviors. A psychological evaluation is also needed because psychosocial factors have a significant impact on the long-term outcomes of bariatric surgery, including adherence to recommended postoperative lifestyle regimen, emotional adjustment, and weight loss outcomes. We recommend preoperative abdominal ultrasound to assess for biliary tract pathology, steatosis, fibrosis, and presence of nonalcoholic steatohepatitis. A routine preoperative esophagogastroduodenoscopy is also recommended to evaluate common gastrointestinal disorders associated with obesity. Preoperative weight loss should be strongly encouraged.

Influence of psychological variables in morbidly obese patients undergoing bariatric surgery after 24 months of evolution

BACKGROUND

Bariatric surgery is considered a more effective means of achieving weight loss than non-surgical options in morbid obesity. Rates of failure or relapse range from 20 to 30%. The study aims to analyse the influence of psychological variables (self-esteem, social support, coping strategies and personality) in the maintenance of weight loss after bariatric surgery.

METHODS

A cohort study was conducted involving 64 patients undergoing bariatric surgery for 24 months. At the end of the follow-up period, patients were divided into 2sub-cohorts classified as successes or failures. Success or favorable development was considered when the value of percent excess weight loss was 50 or higher.

RESULTS

No statistically significant differences were observed between the 2groups in any variable studied. All patients had high self-esteem (87,3 those who failed and 88,1 those who are successful) and social support (90,2 and 90,9). Patients who succeed presented higher scores for cognitive restructuring (57,1) and were more introverted (47,1), while those who failed scored more highly in desiderative thinking (65,7) and were more prone to aggression (50,7) and neuroticism (51,7).

CONCLUSIONS

High self-esteem and social support does not guarantee successful treatment. The groups differed in how they coped with obesity but the data obtained do not justify the weight evolution. In the absence of psychopathology, personality trait variability between patients is insufficient to predict the results.

Active Mental Illnesses Adversely Affect Surgical Outcomes

Depression, anxiety, posttraumatic stress disorder (PTSD), and substance abuse are linked to higher rates of morbidity and mortality after various surgical procedures. Comparable data in general surgery are lacking. Records from 183 consecutive patients undergoing elective general surgery procedures at a single tertiary hospital were reviewed. Patients with depression, anxiety, PTSD, and substance abuse or any combination of these at the time of surgery were classified as having “active mental illness” (AMI). Thirty-day complications, readmissions, and emergency room (ER) visits were identified. Univariate analysis was performed followed by creation of multivariate regression models. 41.5 per cent (n = 76) met criteria for the AMI group and 58.5 per cent (n = 107) were without a mental illness (WAMI). The two groups had similar incidence of medical comorbidities and similar mean values of serum albumin and creatinine. The AMI group had higher rates of readmissions (14.5 vs 3.7 %, P = 0.009) and ER (19.7 vs 8.4 %, P = 0.025) visits compared with the WAMI group. Differences in length of stay and 30-day complications did not reach statistical significance. In patients undergoing elective general surgery, depression, anxiety, PTSD, and substance abuse are associated with higher rates of readmission and ER visits. These results suggest a need for further research on the impact of specific mental illnesses on postoperative complications.

The Role of the Multidisciplinary Conference in the Evaluation of Bariatric Surgery Candidates with a High-Risk Psychiatric Profile

Background: Implementation of a multidisciplinary conference (MC) attended by medical, surgical, nutrition, bioethics, and psychology specialists may help identify treatment plans for bariatric surgery candidates with a high-risk psychiatric profile. Methods: Data were assessed for all bariatric candidates evaluated by the MC in an academic center between January 2009 and December 2010. Results: A total of 134 patients of 2798 patients assessed by four different psychologists were subsequently evaluated by the MC. The most frequent psychiatric diagnoses were mood disorders (n = 37, 27.6%), anxiety disorders (n = 24, 17.9%), and binge eating disorder (n = 19, 14.1%). More than one psychiatric diagnosis was observed in 95.6% of the cohort. Substance abuse issues were present in 25% patients. Fifteen patients (11.2%) were eventually cleared and underwent surgery, 35 (26.1%) left the program before completing their requirements, and 84 patients (62.7%) were still working toward their individualized goals in the program. For those who underwent surgery, mean preoperative management duration was 221 days (range, 111-366) with an average of 11 preoperative psychiatric visits (range, 9-15). Conclusions: Patients with a high-risk psychosocial profile seeking bariatric surgery require multiple visits and resources to determine their candidacy. The majority of these patients are either deemed ineligible for surgery or require prolonged preoperative evaluation.

Is Laparoscopic Bariatric Surgery a Safe Option in Extremely High-Risk Morbidly Obese Patients?

INTRODUCTION

Age, superobesity, and cardiopulmonary comorbidities define patients as high risk for bariatric surgery. We evaluated the outcomes following bariatric surgery in extremely high-risk patients.

MATERIALS AND METHODS

Among 3240 patients who underwent laparoscopic bariatric surgery at a single academic center from January 2006 through June 2012, extremely high-risk patients were identified using the following criteria: age ≥ 65 years, body mass index (BMI) ≥ 50 kg/m(2), and presence of at least two of six cardiopulmonary comorbidities, including hypertension, ischemic heart disease, congestive heart failure, chronic obstructive pulmonary disease, obstructive sleep apnea, and history of venous thromboembolism. Perioperative and intermediate-term outcomes were assessed.

RESULTS

Forty-four extremely high-risk patients underwent laparoscopic Roux-en-Y gastric bypass (n = 23), adjustable gastric banding (n = 11), or sleeve gastrectomy (n = 10). Patients had a mean age of 67.9 ± 2.7 years, a mean BMI of 54.8 ± 5.5 kg/m(2), and a median of two (range, two to five) cardiopulmonary comorbidities. There was no conversion to laparotomy. Thirteen (29.5%) 30-day postoperative complications occurred; only six were major complications. Thirty-day postoperative re-admission, re-operation, and mortality rates were 15.9%, 2.3%, and 0%, respectively. Within a mean follow-up time of 24.0 ± 18.4 months, late morbidity and mortality rates were 18.2% and 2.3%, respectively. The mean percentage total weight and excess weight losses after at least 1 year of follow-up were 26.7 ± 12.0% and 44.1 ± 20.6%, respectively.

CONCLUSIONS

Laparoscopic bariatric surgery is safe and can be performed with acceptable perioperative outcomes in extremely high-risk patients. Advanced age, BMI, and severe cardiopulmonary comorbidities should not exclude patients from consideration for bariatric surgery.

Revisional bariatric surgery for unsuccessful weight loss and complications

BACKGROUND

There are growing numbers of patients who require revisional bariatric surgery due to the undesirable results of their primary procedures. The aim of this study was to review our experience with bariatric patients undergoing revisional surgery.

METHODS

We conducted a retrospective analysis to review the indications for revisional bariatric procedures and assess their postoperative outcomes.

RESULTS

From 04/04 to 01/11, 2,918 patients underwent bariatric surgery at our institution. A total of 154 patients (5.3%) of these cases were coded as revisional procedures. The mean age at revision was 49.1 ± 11.3 and the mean BMI was 44.0 ± 13.7 kg/m2. Revisional surgery was performed laparoscopically in 121 patients (78.6%). Laparoscopic revisions had less blood loss, shorter length of hospital stay, and fewer complications compared to open revisions. Two groups (A and B) were defined by the indication for revision: patients with unsuccessful weight loss (group A, n = 106) and patients with complications of their primary procedures (group B, n = 48). In group A, 74.5% of the patients were revised to a bypass procedure and 25.5% to a restrictive procedure. Mean excess weight loss was 53.7 ± 29.3% after revision of primary restrictive procedures and 37.6 ± 35.1% after revision of bypass procedures at >1-year follow-up (p < 0.05). In group B, the complications prompting revision were effectively treated by revisional surgery.

CONCLUSIONS

Revisional bariatric surgery effectively treated the undesirable results from primary bariatric surgery. Laparoscopic revisional surgery can be performed after both failed open and laparoscopic bariatric procedures without a prohibitive complication rate. Carefully selected patients undergoing revision for weight regain have satisfactory additional weight loss.

Bariatric surgery: severity, level of control, and time required for preoperative asthma control

BACKGROUND

There is an increased prevalence of asthmatic, obese patients undergoing bariatric surgery. The objective of our study is to evaluate the severity, level of control, respiratory medication use, and time required for prebariatric surgery asthma control.

METHODS

This is a prospective study in which 88 obese asthmatics were evaluated by a pulmonologist in two steps, prebariatric surgery. In the first step, patients were evaluated for severity, level of control, and respiratory medication in use, categorized as bronchodilators and corticosteroids. In the second step, the time required for asthma control between steps and appropriate respiratory medication was determined.

RESULTS

Thirty-eight obese patients (43.2%) had intermittent asthma, 22 had mildly persistent (25.0%), 24 moderately persistent (27.3%), and 4 severely persistent (4.5%). There were 43 patients with controlled asthma (48.9%), 31 partly controlled (35.2%), and 14 uncontrolled (15.9%). The study sample showed a significant increase in bronchodilators in the first step and corticosteroids in the second step (p ≤ 0.0001). Comparisons between steps showed significant differences with a reduction of bronchodilators and increase in corticosteroids in the second step (p ≤ 0.0001). The mean time (days) required for asthma control between steps was 28.98 ± 33.40 days, with significant differences between groups (p ≤ 0.001).

CONCLUSIONS

In prebariatric surgery, there was a higher proportion of intermittent asthma and uncontrolled asthma, with asthma severity influencing the achievement of asthma control and the time required for surgical release.

Lifestyle modifications and surgical options in the treatment of patients with obesity and type 2 diabetes mellitus

This article reviews recent developments in the behavioral and surgical treatment of obesity and type 2 diabetes mellitus (T2DM). Randomized controlled trials of comprehensive lifestyle-modification programs, which include dietary interventions, physical activity, and behavioral therapy, have shown weight losses of 7% to 10% of initial body weight within 4 to 6 months after treatment. These programs also reduce the likelihood of developing T2DM by 58% for individuals with impaired glucose tolerance. Long-term maintenance of these improvements requires continued implementation of the program diet, physical activity, and self-regulatory behaviors. This can be successfully facilitated by continued patient-provider contact, which is frequently delivered by phone, mail, email, or online. However, these benefits may have less impact on those with extreme obesity or more significant health problems. For these individuals, bariatric surgery may be a more appropriate treatment. Bariatric surgical procedures induce mean weight losses of 15% to 30% of initial body weight (depending on the procedure) within 2 years after surgery, as well as a 45% to 95% rate of diabetes remission. Familiarity with these developments can help physicians and patients to determine which combinations of behavioral, medical, and surgical interventions are appropriate for the treatment of obesity and T2DM.

Bariatric surgery versus intensive medical therapy in obese patients with diabetes

BACKGROUND

Observational studies have shown improvement in patients with type 2 diabetes mellitus after bariatric surgery.

METHODS

In this randomized, nonblinded, single-center trial, we evaluated the efficacy of intensive medical therapy alone versus medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy in 150 obese patients with uncontrolled type 2 diabetes. The mean (±SD) age of the patients was 49±8 years, and 66% were women. The average glycated hemoglobin level was 9.2±1.5%. The primary end point was the proportion of patients with a glycated hemoglobin level of 6.0% or less 12 months after treatment.

RESULTS

Of the 150 patients, 93% completed 12 months of follow-up. The proportion of patients with the primary end point was 12% (5 of 41 patients) in the medical-therapy group versus 42% (21 of 50 patients) in the gastric-bypass group (P=0.002) and 37% (18 of 49 patients) in the sleeve-gastrectomy group (P=0.008). Glycemic control improved in all three groups, with a mean glycated hemoglobin level of 7.5±1.8% in the medical-therapy group, 6.4±0.9% in the gastric-bypass group (P<0.001), and 6.6±1.0% in the sleeve-gastrectomy group (P=0.003). Weight loss was greater in the gastric-bypass group and sleeve-gastrectomy group (-29.4±9.0 kg and -25.1±8.5 kg, respectively) than in the medical-therapy group (-5.4±8.0 kg) (P<0.001 for both comparisons). The use of drugs to lower glucose, lipid, and blood-pressure levels decreased significantly after both surgical procedures but increased in patients receiving medical therapy only. The index for homeostasis model assessment of insulin resistance (HOMA-IR) improved significantly after bariatric surgery. Four patients underwent reoperation. There were no deaths or life-threatening complications.

CONCLUSIONS

In obese patients with uncontrolled type 2 diabetes, 12 months of medical therapy plus bariatric surgery achieved glycemic control in significantly more patients than medical therapy alone. Further study will be necessary to assess the durability of these results. (Funded by Ethicon Endo-Surgery and others; ClinicalTrials.gov number, NCT00432809.).