Indications for Bariatric Surgery

© Springer International Publishing Switzerland 2015
Marcello Lucchese and Nicola Scopinaro (eds.)Minimally Invasive Bariatric and Metabolic Surgery10.1007/978-3-319-15356-8_13

13. Indications for Bariatric Surgery

Marcello Lucchese , Giovanni Quartararo , Lucia Godini2, Alessandro Sturiale  and Enrico Facchiano 

Department of Surgery, Bariatric and Metabolic Surgery Unit, Azienda Sanitaria Firenze, Santa Maria Nuova Hospital, Piazza Santa Maria Nuova, 1, Florence, 50122, Italy

Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, Largo Brambilla, 3, Florence, 50134, Italy



Marcello Lucchese (Corresponding author)


Giovanni Quartararo


Alessandro Sturiale


Enrico Facchiano

13.1 Introduction

Early bariatric surgeries took place in the 1950s and initially consisted of the intestinal bypass procedure, aimed to induce an iatrogenic malabsorption resulting in weight loss.

In 1991 the National Institute of Health proposed the first guidelines for the practice of bariatric surgery, eventually creating new guidelines expanding indications and procedures [1].

Indications for bariatric surgery have been analysed and accepted by different scientific societies over years, including the last revision published by the European Chapter of International Federation for the Surgery of Obesity in 2014 [2].

On the other hand, there are no precise recommendations concerning the type of procedure based on patient characteristics. This choice seems to be related to surgeon experience more than anything else, since there is a wide disparity in the proportions of different types of operations performed between centres and countries [3].

13.2 Actual Indications

Bariatric surgery is indicated in patient in the age from 18 to 60 years having:


BMI ≥40 kg/m2



BMI ≥35 kg/m2 with co-morbidities that can improve with weight loss (diabetes, hypertension, OSAS, severe joint disease, severe psychological problems secondary to obesity, etc.) [2]


13.3 Type 2 Diabetes

Bariatric surgery in these years took an important role in diabetes treatment. Medical therapeutic options targeting primarily glucose control, in fact, have very limited success in controlling blood glucose levels amongst the severely obese, with many of these patients not achieving targets [4].

Bariatric surgery has demonstrated to be effective in long-term control of type 2 diabetes.

RYGBP seems to be the best operation when obesity is associated with type 2 diabetes, even though some studies have shown that even pure restrictive procedures can be effective [5].

The problem of long-term recovery from type 2 diabetes after bariatric surgery has been extensively treated elsewhere in this volume.

13.4 Young Obese

Bariatric surgery in adolescents and child can be actually considered only in specialised centres and after a careful multidisciplinary evaluation [2].

According to the recent update of the ASMBS paediatric committee best practice guidelines, the selection criteria for adolescents being considered for a bariatric procedure should include a BMI of >35 kg/m2 with major co-morbidities (i.e. type 2 diabetes mellitus, moderate-to-severe sleep apnoea, pseudotumour cerebri or severe NASH) or a BMI >40 kg/m2 with other co-morbidities (e.g. hypertension, insulin resistance, glucose intolerance, substantially impaired quality of life or activities of daily living, dyslipidemia, sleep apnoea with apnoea–hypopnea index >5) [6, 7].

For what concerns European guidelines, recently the Interdisciplinary European Guidelines on Metabolic and Bariatric Surgery have been published on behalf of IFSO-EC and EASO [2], and we report their considerations:

An adolescent with severe obesity bariatric surgery can be considered if he/she:


Has a BMI >40 kg/m2 (or 99.5th percentile for respective age) and at least one co-morbidity



Has followed at least 6 months of organised weight-reducing attempts in a specialised centre



Shows skeletal and developmental maturity



Is capable to commit to comprehensive medical and psychological follow-up



Is willing to participate in a post-operative multidisciplinary treatment programme in a unit with specialist paediatric support (nursing, anaesthesia, psychology, post-operative care)


It is also underlined that bariatric surgery can be considered in genetic syndromes, such as Prader–Willi syndrome, only after careful consideration of an expert medical, paediatric and surgical team [2, 8, 9].

In adolescent patients, the RYGB ensures the best weight maintenance but it requires an adherence to the follow-up, such a commitment is not always guaranteed in such subjects [10]. On the other hand, SG procedure seems to prove to be a viable option for the treatment of adolescent obesity, achieving both weight loss variations and resolution of co-morbidities comparable to the RYGB procedure without malabsorptive risks [2].

Despite single differences in recommendations guidelines, we can conclude that bariatric surgery in adolescents and children should be performed only in centres of excellence with extensive experience in bariatric surgery for adults. A multidisciplinary approach to these patients, including paediatric specialists, is mandatory.

13.5 Elderly Obese

In the elderly obese (>65yy), bariatric surgery did not necessarily show to be effective in significantly prolonging the average mean of life [2, 11].

Benefits of bariatric surgery in the senior obese patient are still being evaluated. Even if postoperative risks in the over 60 obese are potentially higher, the advantages of recovered mobility, the increased independence and the improved control of co-morbidity may lead to a better quality of life [12, 13].

The proof of favourable risk–benefit of bariatric surgery in elderly is lacking so far. Several recent studies proposed sleeve gastrectomy as the procedure of choice in elderly obese since it could obtain advantage in terms of quality of life from weight loss for the low complication rate and the absence of malabsorptive component [14].

Age seems to be a prognostic factor for weight loss and co-morbidities remission as well the degree of obesity, patient motivation and the presence of uncompensated binge-eating disorder. Further studies are needed to identify predictive factors of outcome after bariatric surgery, in particular regarding physical activity and psychiatric disorders [15, 16]. The identification of predictive factors of success will help to develop interventions targeting specific needs of patients.

As for young obese, in the elderly obese patients, an accurate multidisciplinary evaluation is mandatory in order to evaluate the risk–benefit ratio before possible bariatric surgery.

13.6 Novel Indications

In the last decade, we are assisting to a novel dynamic revaluation of the historical selection criteria for bariatric surgery. This is not just for the higher incidence of obesity worldwide but for the evidence of new obesity-related pathological conditions and co-morbidities.

The necessity of evaluating new obesity-related metabolic disorders that may potentially beneficiate of a surgically induced weight loss is getting evidence in literature.

13.6.1 Hypogonadism

Hypogonadism and sub-fertility can be frequently associated to obesity and metabolic syndrome. Hypogonadal state has demonstrated to induce a worsening of co-morbidities such as cardiovascular disorders and type II diabetes [17]. In particular the correlation between testosterone low level and peripheral insulin resistance could lead to presume an important role of testosterone on the glycaemic metabolic improvement after bariatric surgery [18, 19]. As recently reported in literature, alterations in sex hormones, testosterone in male obese patients, can improve drastically after weight [15, 18, 20, 21]. Obviously, treatment of impaired fertility and poor sexual life in obese patients will result in implementation of overall health and quality of life.

In a recent meta-analysis, it has been demonstrated that body weight loss significantly increases testosterone levels in obese patients. Moreover, testosterone recovery seems to be directly correlated with the weight loss. Testosterone rise induced by lifestyle interventions was only modest, probably reflecting the relatively modest results of the targeted diet and physical activity on body weight loss. The testosterone increase would be more important after surgical-induced weight loss (9.8 % with diet vs. 32 % with surgery) [20].

As a matter of fact, male hypogonadism could represent a new co-morbidity to consider when evaluating patients for bariatric surgery, and so it could become a new possible criterion for patients with BMI ≥35 [19].

More studies, based on randomised trials, are needed to confirm the role of testosterone of glycaemic metabolic control after bariatric surgery.

13.6.2 NALFD

Morbid obesity is strongly associated with nonalcoholic fatty liver disease (NAFLD), which is one of the most common causes of chronic liver disease worldwide [22].

NAFLD includes a broad spectrum of liver tissue alterations, which range from steatosis (pure fatty liver) through nonalcoholic steatohepatitis (NASH) to fibrosis, cirrhosis and liver failure. In the severely obese, the fatty liver and its stages often have progressed to NASH or cirrhosis even before contemplating therapy [23].

Weight loss should be a primary therapy for NAFLD. However, evidence supporting intentional weight loss as a therapy for NAFLD is limited [24].

Since insulin resistance causes abnormal deposition of triglycerides in the liver, the link between metabolic syndrome and NALFD is clear. By the way bariatric surgery could improve NALFD, ameliorating also other factors like weight loss, inflammation, dyslipidaemia and intestinal hormones. These are the reasons bariatric surgery has to be considered a potential treatment of NALFD [22, 25].

The NAFLD guideline does not formally recommend bariatric surgery for the treatment of NASH because beyond potential benefits, there is an important lack of scientific evidence that could demonstrate any recommendation to support or reject bariatric surgery to treat NASH patients [26, 27].

On the other hand, it is important to note that bariatric surgery is not contraindicated in NASH patients without cirrhosis [28, 29].

The promising results in literature about metabolic surgical treatment of liver steatosis should encourage to design new randomised clinical trials in order to assess the therapeutic effect of bariatric surgery with long follow-up periods.

13.6.3 Class I Obesity

Class I obesity (BMI >30 < 35 kg/m2) has been demonstrated to have a co-morbidity burden, in particular type II diabetes, similar than class II or III obesity; even class I obesity is associated with lower mortality rate than higher obesity class [30].

In the Consensus Conference Statement on Bariatric Surgery for morbid obesity published 10 years ago, Buchwald already proposed the possibility in extending the benefits of bariatric surgery to patients with class I obesity who have a condition that can be cured or markedly improved by substantial and sustained weight loss [31]. Since 2004 a considerable number of trials, meta-analysis and observational studies have been published about possible extension of the NIH recommendation of 1991 [1, 3234].

In 2009 the American Diabetes Association considered the current evidence insufficient to recommend surgery to BMI >30 with type II diabetes. Recently the International Diabetes Federation suggested that patients with type II diabetes with class I obesity could be candidate to surgery if they fall in the same metabolic and clinical conditions warranting prioritisation in the 35–40 BMI class [4].

Recently ASMBS stated that the BMI alone is a poor index of adiposity and risk. Underlining the limitation of the 35 BMI cut-off, the ASMBS concluded that bariatric surgery shouldn’t be denied to patient with BMI >30 < 35 kg/m2 or >27.5 kg/m2 for at-risk ethnicities who do not achieve substantial and durable weight and co-morbidity improvement [35, 36].

In conclusion, as clearly stated in the recent position statement of IFSO, the access to bariatric surgery should not be denied to patient with class I obesity associated with significant obesity-related co-morbidities simply on the basis of BMI level [37].

13.7 Contraindications for Bariatric Surgery

Mean contraindications are regarding psychiatric (not stabilised) disorders, behavioural eating disorders (such as bulimia and binge-eating disorder), addictions (alcoholism, toxicomania) and uncontrolled progressive severe chronic disease (cancer, cirrhosis, inflammatory bowel disease, etc.).

Here we report the schematic contraindications to bariatric surgery of the Interdisciplinary European Guidelines on Metabolic and Bariatric Surgery [2].


Absence of a period of identifiable medical management



Patient who is unable to participate in prolonged medical follow-up



Non-stabilised psychotic disorders, severe depression and personality and eating disorders, unless specifically advised by a psychiatrist experienced in obesity



Alcohol abuse and/or drug dependencies



Diseases threatening life in the short term



Patients who are unable to care for themselves and have no long-term family or social support that will warrant such care


Specific exclusion criteria for bariatric surgery in the treatment of T2DM are as follows:


Secondary diabetes



Antibodies positive (anti-GAD or ICA) or C-peptide <1 ng/ml or unresponsive to mixed meal challenge


Fried et al. [2]

13.8 Co-morbidities That Could Influence the Choice of Bariatric Procedure

13.8.1 GERD

Gastroesophageal reflux disease (GERD) is one most common disease worldwide. Obesity has demonstrated to increase the severity and the incidence of GERD due to several factors such as augmented intra-abdominal pressure, increased hiatal hernia incidence, oesophageal dismotility disorders and lower oesophageal sphincter decreased pressure [38, 39]. Roux-en-Y gastric bypass (RYGB) is considered an anti-reflux system, and there is accordance in literature about GERD remission after RYGB. In fact RYGB has been proposed by many authors as a good choice for redo surgery in case of failed anti-reflux operations [4042].

Studies in literature are inconsisted regarding the possible effect of laparoscopic adjustable gastric banding (LAGB) or laparoscopic sleeve gastrectomy (LSG) on patients with preoperative existing GERD. There is not a clear evidence of worsening of GERD after LAGB because of the difficulty of distinguishing recurrent GERD and symptoms indicating a complication of the banding [43, 44].

Some series demonstrated an initial GERD remission after surgery probably due to the weight loss, reduced intra-gastric pressure and reduced number of transient lower oesophageal relaxation (TLESR) after LAGB. However, a significant worsening of reflux symptoms and de novo esophagitis has been demonstrated during long-term follow-up [38, 45]. Outcomes in terms of GERD after LSG are contradictory [46].

Symptomatic GERD complicates sleeve gastrectomy up to 25 % of cases according to the literature [47, 48].

In fact despite the initial high incidence of de novo GERD symptoms or worsening of GERD after LSG, many studies demonstrate a decrease of GERD on long-term follow-up. Possible causes are the weight loss and the “Angle of His” restorations [38, 49, 50].

Some technical precautions could avoid the worsening of GERD or creation of de novo GERD symptoms after LSG: avoiding large pouch, strictures that could decreased the acid clearance, the lesion of lower oesophageal sphincter and antrum narrowing [38, 49, 50].

The presence of GERD symptoms could be actually considered only a relative contraindication to sleeve gastrectomy and gastric banding in morbidly obese patients [51, 52].

Even in the absence of large RCT, RYGBP could be the procedure of choice in case of symptomatic GERD [14, 43] As suggested by many authors, a preoperative oesophageal manometry and pH-metry should be performed in patients candidate to LSG [38, 39].

Further prospective studies are needed to clarify the role of GERD in the selection for bariatric operations.

13.8.2 Osteoporosis

Several studies demonstrate a significant worsening of bone density after bariatric surgery, in particular in postmenopausal women.

As calcium absorption happens in the duodenum and proximal jejunum, performing procedures with the bypass of duodenum or with a malabsorptive component in patients with pre-existing osteoporosis could not be recommended [53, 54].

13.8.3 Familiarity for Upper GI Cancer

In these cases, preoperative endoscopy is mandatory. In case of direct familiarity with upper GI cancer, procedures that consist of the exclusion of part of the stomach are not recommended. If LAGB or SG is not suitable for a patient with upper GI cancer familiarity, it is possible to perform RYGBP with subtotal gastrectomy [55, 56].

13.8.4 Suspected Low Adherence to the Follow-Up

In case of high suspicion of low adherence to the follow-up after bariatric surgery, a SG should be recommended, avoiding the procedures that can require a strict follow-up (malabsorptive or LAGB) [14, 57, 58]. However, the exclusion of these patients from bariatric surgery programmes should be evaluated.

13.8.5 Systemic Disease Requiring Chronic Drug Somministration (IBD, Neurological Syndromes, Transplant Patient, IRC)

When a morbid obese patient is affected by systemic diseases, it should be recommended to perform a pure restrictive procedure [3, 59, 60].

13.8.6 Type I Diabetes

There isn’t too much literature about obesity surgery and type I diabetes. After bariatric surgery, patients with type I diabetes demonstrate a significant improvement in terms of quality of life, with an improvement of glycaemic control and reduction of overall doses of insulin.

In case of malabsorptive procedure, there are risks of impaired or inadequate drugs absorption; this is why a restrictive procedure should be performed. On the other hand, it should be considered that the bypass of duodenum and proximal part of jejunum represents weight-independent factor of insulin sensibilisation [14, 61, 62].

13.9 Psychological and Psychiatric Aspects in the Choice of the Type of Bariatric Surgery

Patients candidate for bariatric surgery show frequently high rates of current and lifetime psychiatric axis I pathologies, with rates of up to 70 %. Mood disorders, anxiety disorders and binge-eating disorder (BED) are the most prevalent psychiatric diseases found in these patients [63]. Pre-bariatric surgery individuals display also several other bad eating habits such as sweet eating, snack eating, food craving and nighttime eating and have significantly increased odds of alcohol use and personality disorders [64] and lower levels of self-esteem and quality of life [65].

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Mar 31, 2016 | Posted by in General Surgery | Comments Off on Indications for Bariatric Surgery

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