© Springer Science+Business Media New York 2015
Ninh T. Nguyen, Robin P. Blackstone, John M. Morton, Jaime Ponce and Raul J. Rosenthal (eds.)The ASMBS Textbook of Bariatric Surgery10.1007/978-1-4939-1206-3_66. Indications and Contraindications for Bariatric Surgery
(1)
Department of Surgery, Texas Health Presbyterian Hospital, 2501 Scripture St, Suite 303, Denton, TX 76227, USA
Chapter Objectives
1.
To assess the risk-benefit of bariatric surgery
2.
To discuss contraindications to bariatric surgery
Introduction
Metabolic and bariatric surgery is a proven therapy for the treatment of obesity and obesity-related comorbidities. Available evidence, as detailed elsewhere in the text, strongly suggests that metabolic and bariatric surgery produces weight loss that is significantly greater and more durable than that achieved with best nonsurgical therapies. Resolution or improvement of associated diseases or conditions including, but not limited to, diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, gastroesophageal reflux, and pseudotumor cerebri occurs. Reductions in the development of cancers, particularly breast and colon cancers, have been demonstrated. Several case-controlled studies have demonstrated improvements in long-term survival. A major benefit of metabolic and bariatric surgery, though not often considered when defining the indications for surgery, is the improvement in overall quality of life. When selecting appropriate candidates for surgery, these benefits must be carefully weighed against the potential perioperative and long-term risks of the procedures.
Indications for Metabolic and Bariatric Surgery
Although more than 20 years old, the 1991 National Institutes of Health (NIH) Consensus Development Conference Statement on Gastrointestinal Surgery for Severe Obesity [1] continues to be the most frequently referenced guideline when determining the body mass index (BMI) indications for metabolic and bariatric surgery. The statement notes that patients must be acceptable of the operative risks, motivated, well informed, and able to participate in treatment and follow-up. Patients judged to have a low probability of success with nonsurgical methods of weight loss may be considered for surgery. Assessment of risk-benefit should be performed for each case. Potential candidates include:
Patients whose body mass index (BMI) exceeds 40
Patients with BMIs between 35 and 40 with high-risk comorbid conditions or lifestyle-limiting obesity-induced physical conditions
Examples of associated comorbid conditions to be considered in patients with a BMI less than 40 include life-threatening cardiopulmonary problems such as sleep apnea, obesity hypoventilation, obesity-related cardiomyopathy, and diabetes. Physical conditions to be considered include joint disease treatable but for obesity and body size problems interfering with employment, family function, or ambulation. The conditions listed were examples and not meant to be all inclusive. Other obesity-related comorbidities often considered when determining the appropriateness of surgery in patients with a BMI less than 40 include hypertension, hyperlipidemia, nonalcoholic fatty liver disease, gastroesophageal reflux, pseudotumor cerebri, asthma, venous stasis disease, and urinary incontinence [2].
The NIH Consensus Conference Statement noted that surgical candidates should be evaluated by a “multidisciplinary team with access to medical, surgical, psychiatric, and nutritional expertise” [1]. The pros and cons of various treatment options, both surgical and nonsurgical, should be discussed with the patient. Metabolic and bariatric surgery should be performed by a surgeon experienced with the appropriate procedure, working in a program with adequate support for all aspects of perioperative and postoperative care. Postoperative surveillance should continue for an indefinitely long period.
No upper age limit for bariatric surgery was recommended by the consensus panel. At the time of publication, it was felt that insufficient data was available to make a recommendation for or against surgery in the adolescent population.
Defining the indications for metabolic and bariatric surgery begins with an assessment of the risk-benefit of a given procedure. Significant advances in surgical techniques, reductions in operative risk, and greater knowledge of the potential risk of untreated obesity have greatly altered the risk-benefit of surgery since 1991. Many of these changes were summarized in the 2004 American Society for Bariatric Surgery (ASBS) Consensus Conference Statement on Bariatric Surgery for Morbid Obesity [3] and include:
1.
The marked increase in the incidence of obesity
2.
Expansion of available operative procedures (e.g., vertical sleeve gastrectomy and laparoscopic adjustable gastric banding)
3.
Significant reductions in perioperative mortality and morbidity
4.
The introduction of laparoscopic techniques
5.
Increased experience with a team management approach
6.
Increased experience with metabolic and bariatric surgery in adolescents and the elderly
7.
Greater demonstration of the effect of surgery in improving or reversing obesity-related comorbidities
8.
Demonstration that metabolic and bariatric surgery improves life expectancy
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