Seung Ho Choi and Kazunori Kasama (eds.)Bariatric and Metabolic Surgery201410.1007/978-3-642-35591-2_4
© Springer-Verlag Berlin Heidelberg 2014
4. Current Indication
(1)
Head of Obesity and Diabetes Research Unit, Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
Abstract
The National Institutes of Health (NIH) criteria for patient selection for gastrointestinal surgery for severe obesity were developed in 1991 at a consensus conference involving expert surgeons, gastroenterologists, endocrinologists, psychiatrists, nutritionists and other health-care professionals, as well as the public. After weighing the evidence, the panel made the following recommendations:
4.1 NIH Criteria
The National Institutes of Health (NIH) criteria for patient selection for gastrointestinal surgery for severe obesity were developed in 1991 at a consensus conference involving expert surgeons, gastroenterologists, endocrinologists, psychiatrists, nutritionists and other health-care professionals, as well as the public [1]. After weighing the evidence, the panel made the following recommendations:
1.
Patients seeking therapy for severe obesity for the first time should be considered for treatment in a nonsurgical program with integrated components of a dietary regimen, appropriate exercise, and behavioral modification and support.
2.
Gastric restrictive or bypass procedures could be considered for well-informed and motivated patients with acceptable operative risks.
3.
Patients who are candidates for surgical procedures should be selected carefully after evaluation by a multidisciplinary team with medical, surgical, psychiatric, and nutritional expertise.
4.
The operation should be performed by a surgeon substantially experienced with the appropriate procedures and working in a clinical setting with adequate support for all aspects of management and assessment.
5.
Lifelong medical surveillance after surgical therapy is necessary to monitor for complications and lifestyle adjustments.
In short, the patient selection criteria recommendations were that surgery is an option for well-informed and motivated patients who have “clinically severe obesity,” indicated by a body mass index (BMI) 40 kg/m2, or a BMI 35 kg/m2, and serious comorbid conditions.
Although these criteria were established more than 20 years ago, they continue to be the most quoted and used. Many surgical societies, health-care service providers, and third-party payers around the world have adopted very similar, or at times more restrictive, eligibility criteria for bariatric surgery.
4.2 ASMBS Statements/Guidelines in Class I Obesity
Since the NIH consensus conference of 1991, new procedures have been introduced, the laparoscopic approach has largely replaced open surgery, and higher levels of scientific evidence are available regarding the health hazards of obesity and the risks and benefits of bariatric surgery. In response to this, the ASMBS (American Society for Metabolic and Bariatric Surgery) Clinical Issues Committee has most recently issued the following position statements regarding bariatric surgery in Class I obesity (BMI 30–35 kg/m2) based on current knowledge, expert opinion, and published peer-reviewed scientific evidence [2]:
1.
Class I obesity is a well-defined disease that causes or exacerbates multiple other diseases, decreases lifespan, and decreases quality of life. A patient with Class I obesity should be recognized as deserving treatment for this disease.
2.
Current options of nonsurgical treatment for Class I obesity are not generally effective in achieving substantial and durable weight reduction.
3.
For patients with BMI 30–35 kg/m2 who do not achieve substantial and durable weight and comorbidity improvement with nonsurgical methods, bariatric surgery should be an available option for suitable individuals. The existing cutoff of BMI, which excludes those with Class I obesity, was established arbitrarily nearly 20 years ago. There is no current justification on grounds of evidence of clinical effectiveness, cost-effectiveness, ethics, or equity that this group should be excluded from life-saving treatment.
4.
Gastric banding, sleeve gastrectomy, and gastric bypass have been shown in randomized controlled trials to be well-tolerated and effective treatment for patients with BMI 30–35 kg/m2 in the short and medium term.
4.3 Contraindication to Bariatric Surgery
There are no absolute contraindications to bariatric surgery. Relative contraindications to surgery may include severe heart failure, unstable coronary artery disease, end-stage lung disease, active cancer diagnosis/treatment, cirrhosis with portal hypertension, uncontrolled drug or alcohol dependency, and severely impaired intellectual capacity. Crohn’s disease may be a relative contraindication to Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) and is listed by the manufacturer as a contraindication to adjustable gastric banding (AGB).
4.3.1 Age
Traditionally, surgeons offered bariatric surgery to patients aged 18–60 years. However, in the current era of refined anesthesiology, effective critical care, and high-quality surgical outcomes, age restrictions are less rigidly employed. Laparoscopic bariatric surgery has been performed in patients older than 55–60 years [3–5], but with less weight loss, longer length of hospitalization, higher morbidity and mortality, and less complete resolution of comorbidities compared with younger patients. Still, the reduction in comorbidities supports use of laparoscopic RYGB or laparoscopic AGB in well-selected older patients [6–13].
On the other hand, bariatric surgery for morbidly obese children and adolescents was not advised because of insufficient data at the NIH consensus conference in 1991. However, with pediatric obesity increasing in prevalence and severity, interest in adolescent bariatric surgery is growing [14]. RYGB is well tolerated and produces excellent weight loss in patients younger than 18 years with a 10-year follow-up [15–21
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