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New IFSO Recommendations For Obesity Surgery



sharma-obesity-surgerySurgery is no doubt the most effective treatment for severe obesity (defined here as the presence of excess body fat that impairs health).

Now, the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), has published a new Position Statement on indications for surgery for obesity and weight-related diseases, published in Obesity Surgery.

Recommendations are graded based on the strength of the current evidence.

Recommendations with the highest strength of evidence include the following:

  • Surgery for obesity and weight-related diseases is a codified discipline that has proven to be effective in the treatment of obesity resulting in long-term weight loss, improvement in or resolution of comorbidities, and the lengthening of life expectancy. (Level of evidence 1, grade of recommendation A)
  • Surgery for obesity and weight-related diseases is a safe and effective therapeutic option for the management of T2DM in patients with obesity. Along with optimal medical treatment and lifestyle adjustment, it has been demon- strated that surgery for obesity and weight-related diseases can achieve a better glycemic control, lower glyco- sylated hemoglobin, and reduction of diabetes medications than optimal medical and lifestyle treatment alone. (Level of evidence 1, grade of recommendation A)
  • Surgery for obesity and weight-related diseases demonstrated an excellent short- and midterm risk/benefit ratio in patients with class I obesity (BMI 30–35 kg/m2) suffering from T2DM and/or other comorbidities.
    (Level of evidence 1, grade of recommendation A)
  • Obesity, and visceral obesity in particular, is a major modifiable risk factor for cardiovascular diseases (CVD). Weight loss induced by surgery has been shown to reduce CVD risk, with the most relevant reductions in risk ob- served in the group of patients having the higher CVD risk before surgery. These patients obtain the most significant metabolic improvements thereafter. (Level of evidence 1, grade of recommendation A)
  • Weight loss induced by surgery for obesity and weight- related diseases is associated to a reduction in the inci- dence of major cardiovascular events in patients with obesity, including myocardial infarction and stroke. Event reductions are more relevant in patients with a high cardiovascular risk before surgery. (Level of evidence 1, grade of recommendation A)
  • Surgery for obesity and weight-related diseases may result in resolution/improvement of obstructive sleep apnea syndrome (OSAS). (Level of evidence 1, grade of recommendation A)
  • In patients undergoing surgery for obesity and weight- related diseases, weight loss results in a substantial im- provement in pain and a reduction of disability derived from joint disease. (Level of evidence 1, grade of recommendation A)
  • Surgery for obesity and weight-related diseases has proven to be effective in determining the overall improvement of the quality of life of patients suffering from obesity. (Level of evidence 1, grade of recommendation A)
  • The improvement in the quality of life of the patient with obesity treated by surgery for obesity and weight-related diseases is independent from the type of performed procedure. (Level of evidence 1, grade of recommendation A)
  • Surgery for obesity and weight-related diseases is effective in patients with class I obesity (BMI 30–35 kg/m2) and comorbidity. (Level of evidence 1, grade of recommendation A)

In addition, there are numerous recommendations, for which the evidence is perhaps less robust but nevertheless promising.

These recommendations cover a wide range of health issues including gastroesophageal reflux disease (GERD), hepatobiliary diseases, mental health, endocrinopathies and fertility, cancer and organ transplantation, pseudotumor cerebri, chronic inflammation, urinary tract and renal function, functional status, and quality of life.

I was particularly pleased to see the statement include recommendations regarding the limitations of BMI and an extensive discussion of the Edmonton Obesity Staging System as a potential guide to better defining indications for surgery.

@DrSharma
Frankfurt, Germany

1 Comment

  1. Hello Arya,
    Thank you for highlighting this report. I agree with many of the recommendations of the panel given the strong evidence, however it seems that nutritional issues were not given much consideration. It is well known that individuals who are severely obese have a high risk for malnutrition in essential vitamins and minerals including iron, zinc and calcium and vitamins D and A. Unfortunately weight loss surgery exacerbates the risk of malnutrition due to decreased dietary intake and malabsorption of nutrients. The evidence for the adverse impact of surgery on nutritional status is clear, some from high quality studies including randomized clinical trials. The clinical and functional consequences of malnutrition are also well documented, including anemia, fatigue, bone fractures, impaired vision, and defects in musculoskeletal function that can be debilitating. Patients dealing with these health issues would have difficulty complying with recommendations for diet and exercise to maintain their weight loss and this could account for the high incidence of weight regain. Moreover it is possible that fetal development may be impaired by malnutrition in women who conceive after bariatric surgery given reports of increased neonatal mortality and babies born too small for gestational weight. Such poor nutritional outcomes may overtime negate the positive benefits of surgery. The good news is that many of these adverse events can be prevented and treated especially if practitioners are vigilant about educating patients, screening for deficiencies and providing evidence-based nutritional support. This report scarcely mentions the issue of nutrition complications even in special populations such as adolescents and the elderly. Ignoring the problem won’t make it go away! Let’s instead find ways to improve the risk benefit ratio, so that patients truly benefit from this lifesaving surgery.

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