Bariatric surgery: indications

National data indicate that more than 5 million Americans have a BMI >35. Thus the implications of recommending bariatric surgery are enormous. Patients who have undergone surgical treatment for Obesity require lifelong monitoring and often nutritional supplementation, and the lifelong severe dietary restriction that follows bariatric surgery can be psychologically devastating. Psychological and behavioral factors must be carefully considered in presurgical evaluation. No standardized protocol exists for this assessment and few empiric data specify which factors predict successful surgical outcomes.

Great progress has been made in developing safer and more effective surgical procedures for promoting weight loss, yet the possibility of significant adverse effects remain. Assessing both perioperative risk and long-term complications is critical and requires a risk/benefit analysis in each case.

Consensus guidelines suggest that the surgical treatment of Obesity should be reserved for patients with a body-mass index (BMI) >40 kg/m2 or with BMI >35 kg/m2 and 1 or more significant comorbid conditions, when less invasive methods of weight loss have failed and the patient is at high risk for Obesity-associated morbidity and mortality (strength of recommendation: C, based on consensus guidelines).

Because of the nature of major surgery, there are practical and ethical barriers to true randomized controlled trials (RCTs) comparing bariatric surgery with placebo or to no intervention. However, multiple RCTs have compared the weight-reducing effects of different bariatric surgical techniques against each other. All studies included patients who had a BMI >40 kg/m2, or a BMI >35 kg/m2 with at least 1 comorbidity, such as cardiovascular disease, sleep apnea, uncontrolled type 2 diabetes, or weight-induced physical problems interfering with performance of daily life activities. It is these study inclusion criteria that, by default, have become widely accepted indications for bariatric surgery. Weight loss in all RCTs was substantial, ranging from 50 to 100 kg over 6 months to 1 year. Comorbid factors associated with Obesity showed either resolution or improvement after surgery in 91% of patients.

Patients with a BMI >40 have substantially more serious health consequences and a reduced life expectancy. Obesity significantly impairs quality of life, and the risk of morbidity and mortality increases with the degree of . Those who are extremely obese often do not have sustained benefit from more conservative treatment. The benefits of nonsurgical treatment are significantly limited by the failure to maintain reduced body weight.