INNOVATIONS IN OBESITY SURGERY
2022 AMERICAN METABOLIC AND BARIATRIC SURGERY ASSOCIATION (ASMBS)
AND INTERNATIONAL FEDERATION FOR OBESITY AND METABOLIC DISORDERS SURGERY(IFSO):
INDICATIONS FOR METABOLIC AND BARIATRIC SURGERY(BMS)
The concept of pandemic has entered in our lives with the coronavirus epidemic, which has emerged in the recent past and whose effects still continue. Pandemic, by definition, is the general name given to epidemics that spread over very large areas in more than one country or continent in the world. Obesity can also be considered as a pandemic because it is a disease that affects the whole world and spreads to a wide area.
Obesity is not a cosmetic problem and is a serious disease. Each of them contains serious diseases that shorten the life span. Today, although bariatric & metabolic surgeries (BMS) come to the fore with their cosmetic results on social media platforms and other platforms;
As physicians, our main aim is to treat diseases that accompany obesity by providing weight loss. This distinction is important and deontologically open to debate.
As physicians, we have been fighting obesity for many years. With our current knowledge, the most effective treatment known in the treatment of obesity is surgery. 30 years ago, the United States National Institutes of Health (NIH) published a consensus statement on the fight against obesity. Despite all efforts in the last 30 years, the obesity pandemic could not be prevented. In the 30-year period, has been observed an increase in the number of obese patients around the world.
30 years later, the American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) have published their international guideline recommendations.
This guideline includes changes in bariatric & metabolic surgery indications and many other issues, unlike the consensus statement of the National Institutes of Health.
CRITERIA FOR THE SURGERY:
BMI (Body mass index) kg/m²:
It is the most appropriate and widely used criterion to identify and classify patients with overweight or obesity. BMSs are currently the most effective evidence-based treatment for obesity in all BMI classes.
In the National Institutes of Health (NIH) consensus statement, those with BMI>35kg/m2 and obesity-related diseases;
recommended surgery for patients with BMI>40kg/m2, regardless of the presence of concomitant disease.
In the new guideline;
- It is recommended to try non-surgical treatment in class 1 obesity patients with a BMI between 30-35kg/m2.
- BMS is recommended in eligible individuals with: obesity and Type 2 DM, hypertension, dyslipidemia, obstructive sleep apnea, cardiovascular disease (eg, coronary artery disease, heart attack, atrial fibrillation), asthma, hepatic steatosis, and nonalcoholic steatohepatitis , chronic kidney diseases. polycystic ovary syndrome (PCOS), infertility, gastroesophageal reflux, pseudotumor cerebri, bone and joint disease.
- BMS is strongly recommended in patients with BMI >35kg/m2, with or without concomitant obesity-related disease.
- Surgery should be considered when a BMI is 27.5kg/m2 in the Asian population.
AGE:
Advanced age: There is not enough data to determine the age limit. The decision should be made by considering the accompanying diseases and the general condition of the patient. There is evidence that suitable patients benefit from BMSs, albeit at an advanced age, and that they can be performed safely.
Pediatric patients and adolescents: BMSs are safe in the adolescent group under 18 years of age. Contrary to popular belief, BMSs do not have a negative effect on growth and pubertal development.
In the pediatric group, it recommends evaluating BMSs in children/adolescents with a BMI >120% of the 95th percentile (class II obesity) and major comorbidity or BMI >140% of the 95th percentile (class III obesity). No lower age limit is specified.
AS A BRIDGE TO OTHER TREATMENTS:
Arthroplasty: It is recommended to have a BMI below 40 in patients who will undergo major joint surgeries. Complication rates decrease and the success rate of treatment increases in patients operated with low BMI. Therefore, BMSs can be considered as transitional surgery prior to major joint surgery.
Abdominal wall hernias: Obesity is a risk factor for the formation of abdominal wall hernia due to increased intra-abdominal pressure. Hernia repair performed in obese individuals may predispose to wound infection, recurrence and other complications. In obese patients with large abdominal wall hernia, weight loss before hernia repair will reduce the complication and recurrence rate. Therefore, BMSs should be considered before hernia repair in obese patients with large abdominal wall hernias.
Organ transplantation: Obesity is a risk factor for end-stage organ failure (liver failure, kidney failure…). Obesity may constitute a contraindication for organ transplantation from a metabolic and technical point of view. For this reason, the access of obese individuals to organ transplantation may be restricted. BMSs have been identified as a way to improve candidacy for transplantation in patients with end-stage organ disease. Patients with end-stage organ disease can achieve significant weight loss and increase their eligibility for organ transplant.
BMS in high-risk patients: Since patients with high BMI have more comorbidities, they are considered high-risk for surgery. However, studies have shown that BMSs can be performed safely even in patients with BMI>70kg/m2. Therefore, BMSs should be considered as a preferred method in patients with excessive BMI.
In addition, BMSs have been shown to improve early stage liver cirrhosis and heart function following weight loss. In order to stop the progression of such diseases and to provide recovery, BMS can be recommended in appropriate patients.
The 1991 NIH Consensus Statement recommended that patients with BMS be evaluated by a multidisciplinary team. This view is still valid today. Studies have shown that preoperative evaluation of the patient by a multidisciplinary team can reduce complication rates. There is no scientific data on the necessity or first attempt of weight loss before surgery. This process may cause delay in treatment in an obese patient due to comorbidities. Preoperative multidisciplinary evaluation may reduce preventable risk factors and complication rates, but the decision to prepare for surgery should be determined by the surgeon.
Nutrition after surgery is very important. It is recommended to have an experienced dietitian in the multidisciplinary team who will evaluate the patient before the surgery and follow up afterwards. Again, psychological support is recommended to cope with the changing body image and lifestyle changes after weight loss.
As a result;
• BMSs are effective and safe surgeries in the treatment of severe obesity and accompanying diseases. Compared to non-surgical treatment methods, mortality rates due to diseases accompanying obesity are reduced.
• For patients with BMI>35kg/m2 with or without concomitant disease
• In patients with BMI>30kg/m2 and type 2 diabetes
• BMA should be considered in patients with a BMI of 30-35kg/m2 and who cannot achieve permanent weight loss or improvement in comorbidities with non-surgical methods.
• In the Asian Population, the obesity limit should be accepted as 25kg/m2 and BMA should be considered in patients with BMI>27.5kg/m2.
• There is no upper age limit for BMSs. BMSs can be performed in suitable patients by considering the accompanying diseases and risk status of the patient.
• BMSs can be performed safely in pediatric and adolescent age groups. Surgery can be recommended to patients who are evaluated by an experienced center and a multidisciplinary team and deemed appropriate.
• In patients with severe obesity; It can be considered as a bridge treatment for special surgeries such as major joint surgeries, abdominal wall hernia or organ transplantation.
• The decision to operate should be determined by the surgeon. Preoperative multidisciplinary evaluation can help manage preventable risk factors and reduce complication rates.
REFERENCE:
2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation of Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery
