Treatment of Adult Obesity with Bariatric Surgery

 


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Am Fam Physician. 2016 Jan 1;93(1):31-37.

  Related Close-ups: Making Lifestyle Changes After Gastric Bypass

  Patient information: See related handout on weight loss surgery, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

In 2013, approximately 179,000 bariatric surgery procedures were performed in the United States, including the laparoscopic sleeve gastrectomy (42.1%), Roux-en-Y gastric bypass (34.2%), and laparoscopic adjustable gastric banding (14.0%). Choice of procedure depends on the medical conditions of the patient, patient preference, and expertise of the surgeon. On average, weight loss of 60% to 70% of excess body weight is achieved in the short term, and up to 50% at 10 years. Remission of type 2 diabetes mellitus occurs in 60% to 80% of patients two years after surgery and persists in about 30% of patients 15 years after Roux-en-Y gastric bypass. Other obesity-related comorbidities are greatly reduced, and health-related quality of life improves. The Roux-en-Y procedure carries an increased risk of malabsorption sequelae, which can be minimized with nutritional supplementation and surveillance. Overall, these procedures have a mortality risk of less than 0.5%. Cohort studies show that bariatric surgery reduces all-cause mortality by 30% to 50% at seven to 15 years postsurgery compared with patients with obesity who did not have surgery. Dietary changes, such as consuming protein first at every meal, and regular physical activity are critical for patient success after bariatric surgery. The family physician is well positioned to counsel patients about bariatric surgical options, the risks and benefits of surgery, and to provide long-term support and medical management postsurgery.

Obesity is a disease that has serious physical, psychological, and economic implications for patients, and poses major challenges for the physicians caring for them.1 Approximately 35% of the U.S. adult population is obese.2  Obesity affects every organ system (Table 11,35); the related pathologic processes create a health burden for patients and an economic burden for the health care system. The U.S. Preventive Services Task Force recommends screening all adults for obesity. Patients with a body mass index (BMI) of 30 kg per m2 or higher should be offered or referred to intensive, multicomponent behavioral interventions.6 These interventions can result in clinically significant weight loss (5% or greater) in patients with obesity and can be initiated by the family physician.6 Surgical treatment of obesity results in greater weight loss, greater reduction in comorbidities, and prolonged survival compared with nonsurgical interventions.3,79 Recent emphasis has shifted from weight loss outcomes to the metabolic effects of these surgical procedures.10 Family physicians are well positioned to counsel patients about bariatric surgical options, as well as provide long-term support and medical management postsurgery.

WHAT IS NEW ON THIS TOPIC: BARIATRIC SURGERY

Remission of diabetes mellitus occurs in 60% to 80% of patients 1 to 2 years after Roux-en-Y gastric bypass surgery, and remission is retained in approximately 30% of patients at 15 years.

In multiple cohort studies, bariatric surgery is associated with relative reductions in all-cause mortality of 30% to 50% after 7 to 15 years.

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Bariatric surgery results in greater weight loss than nonsurgical weight loss interventions.

A

1, 3, 16, 22

Bariatric surgery is highly effective in treating obesity-related comorbidities, particularly diabetes mellitus.

A

1, 16, 18, 19, 22, 24

Bariatric surgery reduces obesity-related mortality.

B

1, 79, 16, 27


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Bariatric surgery results in greater weight loss than nonsurgical weight loss interventions.

A

1, 3, 16, 22

Bariatric surgery is highly effective in treating obesity-related comorbidities, particularly diabetes mellitus.

A

1, 16, 18, 19, 22, 24

Bariatric surgery reduces obesity-related mortality.

B

1, 79, 16, 27


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

View/Print Table

Table 1.

Conditions with Higher Prevalence in Adults with Obesity

CardiovascularEndocrineGastrointestinalGenitourinaryMusculoskeletalOther

Atrial fibrillation

Hypoandrogenism

Colorectal cancer

Breast cancer

Chronic low back pain

Dementia

Cardiomyopathy

Hypothyroidism

Esophageal cancer

Chronic kidney disease

Immobility

Leukemia

Dyslipidemia

Infertility

Gallbladder cancer

Endometrial cancer

Osteoarthritis

Malignant melanoma

Hypertension

Metabolic syndrome

Gastroesophageal reflux

Kidney stones

Long QT

The Authors

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ROBIN SCHROEDER, MD, is an associate professor in the department of Family Medicine at the Morsani School of Medicine, University of South Florida, and is the medical director of the Weight Management Center at Lehigh Valley Health Network, Allentown, Penn....

T. DANIEL HARRISON, DO, is a bariatric surgeon at Lehigh Valley Health Network.

SHANIQUA L. McGRAW, MD, is a resident in the Department of Family Medicine at Lehigh Valley Health Network.

Address correspondence to Robin Schroeder, MD, 1243 S. Cedar Crest Blvd., Ste. 2200, Allentown, PA 18103 (e-mail: Robin.Schroeder@lvhn.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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1. Colquitt JL, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014;(8):CD003641....

2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA. 2014;311(8):806–814.

3. Gloy VL, Briel M, Bhatt DL, et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:f5934.

4. Dynamed [Internet]. Ipswich (MA): EBSCO Publishing. 2015, Bariatric Surgery. http://www.dynamed.com/home (registration and login required). Accessed November 2, 2015.

5. Essential Evidence Plus. Obesity and weight loss (bariatric surgery). 2015. http://www.essentialevidenceplus.com (subscription required). Accessed October 27, 2015.

6. U.S. Preventive Services Task Force. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(5):373–378.

7. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753–761.

8. Sjöström L, Narbro K, Sjöström CD, et al.; Swedish Obese Subjects Study. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357(8):741–752.

9. Sjöström L, Peltonen M, Jacobson P, et al. Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications. JAMA. 2014;311(22):2297–2304.

10. Mechanick JI, Youdim A, Jones DB, et al.; American Association of Clinical Endocrinologists; Obesity Society; American Society for Metabolic & Bariatric Surgery. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring). 2013;21(suppl 1):S1–S27.

11. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23(4):427–436.

12. American Society for Metabolic and Bariatric Surgery (ASMBS). New procedure estimates for bariatric surgery: what the numbers reveal. Connect. May 2014. http://connect.asmbs.org/may-2014-bariatric-surgery-growth.html. Accessed July 18, 2015.

13. National Institutes of Health. NIH Consensus Statement. Gastrointestinal surgery for severe obesity. http://consensus.nih.gov/1991/1991gisurgeryobesity084html.htm. Accessed February 12, 2015.

14. Banka G, Woodard G, Hernandez-Boussard T, Morton JM. Laparoscopic vs open gastric bypass surgery: differences in patient demographics, safety, and outcomes. Arch Surg. 2012;147(6):550–556.

15. Schroeder R, Garrison JM Jr, Johnson MS. Treatment of adult obesity with bariatric surgery. Am Fam Physician. 2011;84(7):805–814.

16. Chang SH, Stoll CR, Song J, Varela JE, Eagon CJ, Colditz GA. The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003–2012. JAMA Surg. 2014;149(3):275–287.

17. Nguyen NT, Nguyen B, Gebhart A, Hohmann S. Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy. J Am Coll Surg. 2013;216(2):252–257.

18. Schauer PR, Bhatt DL, Kirwan JP, et al.; STAMPEDE Investigators. Bariatric surgery versus intensive medical therapy for diabetes—3-year outcomes. N Engl J Med. 2014;370(21):2002–2013.

19. Davies SW, Efird JT, Guidry CA, et al. Long-term diabetic response to gastric bypass. J Surg Res. 2014;190(2):498–503.

20. Cho YM. A gut feeling to cure diabetes: potential mechanisms of diabetes remission after bariatric surgery [published correction appears in Diabetes Metab J. 2015;39(2):175]. Diabetes Metab J. 2014;38(6):406–415.

21. Puzziferri N, Roshek TB III, Mayo HG, Gallagher R, Belle SH, Livingston EH. Long-term follow-up after bariatric surgery: a systematic review. JAMA. 2014;312(9):934–942.

22. Courcoulas AP, Christian NJ, Belle SH, et al.; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013;310(22):2416–2425.

23. Yip S, Plank LD, Murphy R. Gastric bypass and sleeve gastrectomy for type 2 diabetes: a systematic review and meta-analysis of outcomes. Obes Surg. 2013;23(12):1994–2003.

24. Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366(17):1577–1585.

25. Courcoulas AP, Goodpaster BH, Eagleton JK, et al. Surgical vs medical treatments for type 2 diabetes mellitus: a randomized clinical trial. JAMA Surg. 2014;149(7):707–715.

26. Müller-Stich BP, Senft JD, Warschkow R, et al. Surgical versus medical treatment of type 2 diabetes mellitus in nonseverely obese patients: a systematic review and meta-analysis. Ann Surg. 2015;261(3):421–429.

27. Arterburn DE, Olsen MK, Smith VA, et al. Association between bariatric surgery and long-term survival. JAMA. 2015;313(1):62–70.

28. Coblijn UK, Verveld CJ, van Wagensveld BA, Lagarde SM. Laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy as revisional procedure after adjustable gastric band—a systematic review. Obes Surg. 2013;23(11):1899–1914.

29. Karmali S, Brar B, Shi X, Sharma AM, de Gara C, Birch DW. Weight recidivism post-bariatric surgery: a systematic review. Obes Surg. 2013;23(11):1922–1933.

30. Cooper TC, Simmons EB, Webb K, Burns JL, Kushner RF. Trends in weight regain following Roux-en-Y gastric bypass (RYGB) bariatric surgery. Obes Surg. 2015;25(8):1474–1481.

31. Weiner JP, Goodwin SM, Chang HY, et al. Impact of bariatric surgery on health care costs of obese persons: a 6-year follow-up of surgical and comparison cohorts using health plan data. JAMA Surg. 2013;148(6):555–562.

32. Maciejewski ML, Arterburn DE. Cost-effectiveness of bariatric surgery. JAMA. 2013;310(7):742–743.

33. Wang BC, Furnback W. Modelling the long-term outcomes of bariatric surgery: a review of cost-effectiveness studies. Best Pract Res Clin Gastroenterol. 2013;27(6):987–995.



 

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