AACE/TOS/ASMBS Guidelines
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,☆☆

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Abstract

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Introduction

Obesity continues to be a major public health problem in the United States, with more than one third of adults considered obese in 2009–2010, as defined by a body mass index (BMI)≥30 kg/m2 (1 [EL 3, SS]). Obesity has been associated with an increased hazard ratio for all-cause mortality (2 [EL 3, SS]), as well as significant medical and psychological co-morbidity. Indeed, obesity is not only a chronic medical condition but should be regarded as a bona fide disease state (3 [EL 4, NE]). Nonsurgical management can effectively induce 5%–10% weight loss and improve health in severely obese individuals (4 [EL 1, RCT]) resulting in cardiometabolic benefit. Bariatric surgery procedures are indicated for patients with clinically severe obesity. Currently, these procedures are the most successful and durable treatment for obesity. Furthermore, although overall obesity rates and bariatric surgery procedures have plateaued in the United States, rates of severe obesity are still increasing and now there are approximately 15 million people in the United States with a BMI≥40 kg/m2 ([1], [5]). Only 1% of the clinically eligible population receives surgical treatment for obesity (6 [EL 3, SS]). Given the potentially increased need for bariatric surgery as a treatment for obesity, it is apparent that clinical practice guidelines (CPG) on the subject keep pace and are kept current.

Since the 2008 TOS/ASMBS/AACE CPG for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient (7 [EL 4; CPG]), significant data have emerged regarding a broader range of available surgeries for the treatment of obesity. A PubMed computerized literature search (performed on December 15, 2012) using the search term “bariatric surgery” reveals a total of 14,287 publications with approximately 6800 citations from 2008 to 2012. Updated CPG are therefore needed to guide clinicians in the care of the bariatric surgery patient.

What are the salient advances in bariatric surgery since 2008? The sleeve gastrectomy (SG; laparoscopic SG [LSG]) has demonstrated benefits comparable to other bariatric procedures and is no longer considered investigational (8 [EL 4, NE]). A national risk-adjusted database positions SG between the laparoscopic adjustable gastric band (LAGB) and laparoscopic Roux-en-Y gastric bypass (RYGB) in terms of weight loss, co-morbidity resolution, and complications (9 [EL 2, PCS]). The number of SG procedures has increased with greater third-party payor coverage (9 [EL 2, PCS]). Other unique procedures are gaining attention, such as gastric plication, electrical neuromodulation, and endoscopic sleeves, but these procedures lack sufficient outcome evidence and therefore remain investigational and outside the scope of this CPG update.

There is also emerging data on bariatric surgery in specific patient populations, including those with mild to moderate obesity, type 2 diabetes (T2D) with class I obesity (BMI 30–34.9 kg/m2), and patients at the extremes of age. Clinical studies have demonstrated short-term efficacy of LAGB in mild to moderate obesity ([10], [11], [12], [13]), leading the Food and Drug Administration (FDA) to approve the use of LAGB for patients with a BMI of 30 to 35 kg/m2 with T2D or other obesity-related co-morbidities (14 [EL 4, NE]). Although controversial, this position was incorporated by the International Diabetes Federation, which proposed eligibility for bariatric procedures in a subset of patients with T2D and a BMI of 30 kg/m2 with suboptimal glycemic control despite optimal medical management (15 [EL 4, NE]). Thus, the term metabolic surgery has emerged to describe procedures intended to treat T2D as well as reduce cardiometabolic risk factors. In 1 study, metabolic surgery was shown to induce T2D remission in up to 72% of subjects at 2 years; however, this number was reduced to 36% at 10 years (16 [EL 2, PCS]). In a more recent study, patients who underwent RYGB sustained diabetes remission rates of 62% at 6 years (17 [EL 2, PCS]). The overall long-term effect of bariatric surgery on T2D remission rates is currently not well studied. Additionally, for patients who have T2D recurrence several years after surgery, the legacy effects of a remission period on their long-term cardiovascular risk is not known. The mechanism of T2D remission has not been completely elucidated but appears to include an incretin effect (SG and RYGB procedures) in addition to caloric restriction and weight loss. These findings potentially expand the eligible population for bariatric and metabolic surgery.

Another area of recent interest is the use of bariatric surgery at the extremes of age. Historically, the 1991 National Institutes of Health (NIH) consensus criteria stipulated that treatment of obesity with bariatric surgery is limited to adults (18 [EL 4, NE]). Until 2003,<.7% of bariatric procedures were performed in adolescents (age<20 years) (19 [EL 3, SS]). However, in academic centers alone, the number of bariatric procedures in adolescents nearly doubled from 2002–2006 to>100 cases per year in 2007–2009 (20 [EL 3, SS]). Morbidity and mortality in this 2007–2009 cohort were 2.9% and 0%, respectively (20 [EL 3, SS]).

Advanced age >45 years has also been cited as a risk factor for bariatric surgery in some series; however, the data have been conflicting. Prospective data collected from a single academic center demonstrated that patients age≥55 years had a 3-fold mortality compared with younger patients (21 [EL 3, SS]). However, recent American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data of 48,378 patients failed to reveal advanced age to be associated with statistically significant mortality compared with controls (22 [EL 3, SS]). Although many bariatric programs have established arbitrary cutoff levels for age at 65–70 years, other programs primarily consider overall health risks and physiological status.

The Obesity Surgery Mortality Risk Score (OS-MRS) by DeMaria et al. [23], [24] identified 5 preoperative risk factors that predicted increased risk of 30-day morbidity and mortality after RYGB. These included advanced age (≥45 years), “super-obesity” (BMI≥50 kg/m2), hypertension, male gender, and pulmonary embolism (PE) or surrogate ([23], [24]). However, a more recent multicenter study of 4776 patients who underwent bariatric surgery failed to replicate the OS-MRS (25 [EL 2, PCS]). The Longitudinal Assessment of Bariatric Surgery (LABS) data did find that a history of thrombophilia (deep venous thrombosis [DVT] and PE), obstructive sleep apnea (OSA), or functional status to be independently predictive of 30-day adverse outcomes, including death (25 [EL 2, PCS]). Age and gender, however, were not predictors of death in the LABS analysis (25 [EL 2, PCS]). Moreover, 30-day mortality for RYGB and LAGB occurred in only .3% of procedures, less than had been reported previously (25 [EL 2, PCS]).

Despite the known complications of bariatric surgery, overall mortality has improved since 2008. Data reported from the Swedish Obese Subjects (SOS) study, a large prospective observational study of>2000 patients who underwent bariatric surgery, demonstrated a mortality hazard ratio (HR) of .71, 10 years following bariatric surgery compared with matched obese controls (17 [EL 2, PCS]). More recent data from this cohort followed for up to 20 years demonstrated a HR of .47 in cardiovascular death (including stroke and myocardial infarction) among surgical subjects compared with obese controls (26 [EL 2, PCS]). In another cohort, all-cause mortality was reduced by 40% 7 years after RYGB, compared with the control group, and cause-specific mortality in the surgery group decreased by 56% for coronary artery disease, by 92% for T2D, and by 60% for cancer (27 [EL 2, RCCS]).

As the prevalence of obesity has grown in the United States, so too has the number of bariatric operations for the surgical treatment of obesity. Promising pharmacological (including biological) treatments are on the horizon, but at present, bariatric surgery remains superior to nonsurgical treatments in terms of short-term benefits in surrogate markers of metabolic disease. Durability of benefit in terms of pertinent clinical outcomes will be the endpoints of current prospective trials. An enriched evidence base, expanding eligible patient populations, and safer, innovative surgical treatments for obesity will likely result in a greater number of obese patients undergoing surgery. This CPG update aims to keep pace with the evidenced based literature, and along with the accompanying checklist (28 [EL 4]), assist physicians and allied health professionals with both routine and difficult clinical decision making.

Section snippets

Methods

The Boards of Directors for the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), and the American Society for Metabolic & Bariatric Surgery (ASMBS) approved this update of the 2008 AACE, TOS, and ASMBS Medical Guidelines for Clinical Practice for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient (2008 AACE-TOS-ASMBS CPG; 7). These CPG expired in 2011 per the National Guideline Clearinghouse (//www.guideline.gov/content.aspx?id=13022&search=bariatric+aace

Executive summary

There are 74 recommendations in this 2013 update, compared with 164 original recommendations in 2008. There are 56 revised recommendations and 2 new recommendations (R30 and R59) in this 2013 update. Consensus among primary writers was obtained for each of the recommendations.

Evidence base

This evidence base pertains to the updated recommendations and contains 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG (7 [EL 4, CPG]). The evidence base, supporting tables, and unrevised recommendations for general information may be found in the 2008 AACE-TOS-ASMBS CPG (7 [EL 4, CPG]).

Disclosures

Jeffrey I Mechanick, M.D.: Abbott Nutrition, honoraria for lectures and program development. Daniel B. Jones, M.D., M.S.: Allurion, consultant. W. Timothy Garvey, M.D.: Merck, speakers list; Daiichi-Sanyo, Vivus, Alkermes, Liposcience, Tethys Bioscience, advisory boards; Merck, Amylin, Weight Watchers, research. Scott Shikora, M.D.: Baxter Healthcare, consultant; EnteroMedics, consultant; GI Dynamics, stock options for previous consultant work. John B. Dixon, M.B.B.S., Ph.D.: Consultant for

Acknowledgements

Reviewers: Robin Blackstone, M.D.: Immediate Past President, ASMBS; George Blackburn, M.D., Ph.D.: Co-Chair, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA; Alan Garber, M.D.: Departments of Medicine, Biochemistry and Molecular Medicine and Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX; David B. Sarwer, Ph.D.: Professor of Psychology, Departments of Psychiatry and Surgery and Director, Clinical Services, Center for Weight and Eating Disorders,

References (403)

  • J. Choi et al.

    Outcomes of laparoscopic adjustable gastric banding in patients with low body mass index

    Surg Obes Relat Dis

    (2010)
  • F.J. Serrot et al.

    Comparative effectiveness of bariatric surgery and nonsurgical therapy in adults with type 2 diabetes mellitus and body mass index<35 kg/m2

    Surgery

    (2011)
  • W.J. Lee et al.

    Laparoscopic sleeve gastrectomy for diabetes treatment in nonmorbidly obese patients: efficacy and change of insulin secretion

    Surgery

    (2010)
  • S.S. Shah et al.

    Diabetes remission and reduced cardiovascular risk after gastric bypass in Asian Indians with body mass index<35 kg/m2

    Surg Obes Relat Dis

    (2010)
  • A.P. Schulman et al.

    “Metabolic” surgery for treatment of type 2 diabetes mellitus

    Endocr Pract

    (2009)
  • B. Laferrere

    Effect of gastric bypass surgery on the incretins

    Diabetes Metab

    (2009)
  • G. Mingrone et al.

    Mechanisms of early improvement/resolution of type 2 diabetes after bariatric surgery

    Diabetes Metab

    (2009)
  • W.J. Lee et al.

    Changes in postprandial gut hormones after metabolic surgery: a comparison of gastric bypass and sleeve gastrectomy

    Surg Obes Relat Dis

    (2011)
  • C.L. Ogden et al.

    Prevalence of obesity in the United States, 2009–2020

    NCHS Data Brief

    (2012)
  • A. Berrington de Gonzalez et al.

    Body-mass index and mortality among 1.46 million white adults

    N Engl J Med

    (2010)
  • D.H. Ryan et al.

    Nonsurgical weight loss for extreme obesity in primary care settings: results of the Louisiana Obese Subjects Study

    Arch Intern Med

    (2010)
  • Fact Sheet. Metabolic & Bariatric Surgery. American Society for Metabolic & Bariatric Surgery. Available at:...
  • American Society for Metabolic & Bariatric Surgery. Updated position statement on sleeve gastrectomy as a bariatric...
  • M.M. Hutter et al.

    First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass

    Ann Surg

    (2011)
  • P.E. O’Brien et al.

    Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: a randomized trial

    Ann Intern Med

    (2006)
  • S. Sultan et al.

    Early U.S. outcomes after laparoscopic adjustable gastric banding in patients with a body mass index less than 35kg/m2

    Surg Endosc

    (2009)
  • L. Angrisani et al.

    Italian group for Lap-Band system: results of multicenter study on patients with BMI≤35kg/m2

    Obes Surg

    (2004)
  • U.S. Food and Drug Administration. FDA expands use of banding system for weight loss. Available at:...
  • J.B. Dixon et al.

    Bariatric surgery: an IDF statement for obese Type 2 diabetes

    Diabet Med

    (2011)
  • L. Sjöström et al.

    Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery

    N Engl J Med

    (2004)
  • T.D. Adams et al.

    Health benefits of gastric bypass surgery after 6 years

    JAMA

    (2012)
  • NIH conference

    Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel

    Ann Intern Med

    (1991)
  • W.S. Tsai

    Bariatric Surgery in Adolescents: recent national trends in use and in-hospital outcome

    Arch Pediatr Adolesc Med

    (2007)
  • N.T. Nguyen et al.

    Increasing utilization of laparoscopic gastric banding in the adolescent: data from academic medical centers, 2002–2009

    Am Surg

    (2011)
  • E.H. Livingston et al.

    Male gender is a predictor of morbidity and age a predictor of mortality for patients undergoing gastric bypass surgery

    Ann Surg

    (2002)
  • E.J. DeMaria et al.

    Validation of the obesity surgery mortality risk score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity

    Ann Surg

    (2007)
  • The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium

    Perioperative Safety in the Longitudinal Assessment of Bariatric Surgery

    N Engl J Med

    (2009)
  • L. Sjöström et al.

    Bariatric surgery and long-term cardiovascular events

    JAMA

    (2012)
  • T.D. Adams et al.

    Long-term mortality after gastric bypass surgery

    N Engl J Med

    (2007)
  • B.D. Winters et al.

    Clinical review: checklists—translating evidence into practice

    Crit Care

    (2009)
  • Agency for Healthcare research and Quality (AHRQ). National Guideline Clearinghouse. Available at:...
  • A.E.W. Pontiroli et al.

    Long-term prevention of mortality in morbid obesity through bariatric surgery. A systematic review and meta-analysis of trials performed with gastric banding and gastric bypass

    Ann Surg

    (2011)
  • H. Buchwald et al.

    Overall mortality, incremental life expectancy, and cause of death at 25 years in the program on the surgical control of the hyperlipidemias

    Ann Surg

    (2010)
  • R. Padwal et al.

    Bariatric surgery: a systematic review and network meta-analysis of randomized trials

    Obes Rev

    (2011)
  • J. Garb et al.

    Bariatric surgery for the treatment of morbid obesity: a meta-analysis of weight loss outcomes for laparoscopic adjustable gastric banding and laparoscopic gastric bypass

    Obes Surg

    (2009)
  • A.C. Valezi et al.

    Weight loss outcome after silastic ring Roux-en Y gastric by-pass: 8 years of follow-up

    Obes Surg

    (2010)
  • H. Buchwald et al.

    Weight and type 2 diabetes after bariatric surgery: systemic review and meta-analysis

    Am J Med

    (2009)
  • D. Hofsø et al.

    Obesity-related cardiovascular risk factors after weight loss: a clinical trial comparing gastric bypass surgery and intensive lifestyle intervention

    Eur J Endocrinol

    (2010)
  • P.R. Schauer et al.

    Bariatric surgery versus intensive medical therapy in obese diabetic patients

    N Engl J Med

    (2012)
  • G. Mingrone et al.

    Bariatric surgery versus conventional medical therapy for type 2 diabetes

    N Engl J Med

    (2012)
  • Cited by (0)

    These Guidelines are endorsed by the European Association for the Study of Obesity (EASO), International Association for the Study of Obesity (IASO), International Society for the Perioperative Care of the Obese Patient (ISPCOP), Society American Gastrointestinal Endoscopic Surgeons (SAGES), American College of Surgery (ACS), and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO).

    ☆☆

    By mutual agreement among the authors and editors of their respective journals, this work is being published jointly in Surgery for Obesity and Related Diseases 2013, http://dx.doi.org/10.1016/j.soard.2012.12.010; Obesity 2013, http://dx.doi.org/10.1002/oby.20461; and Endocrine Practice 2013, http://dx.doi.org/10.4158/EP12437.GL.

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