Bariatric and metabolic surgery: a shift in eligibility and success criteria

• Published in: Nature reviews. Endocrinology Vol. 11; no. 8; pp. 465 - 477
• Main Author: Fruhbeck, Gema
• Format: Journal Article
• Language: English
• Published: London Nature Publishing Group UK 01.08.2015; Nature Publishing Group
• Subjects: 692/163/2743/137/773; 692/163/2743/393; 692/700/2817; 692/700/565/545/2098; Bariatric Surgery - methods; Bariatric Surgery - standards; Care and treatment; Diabetes; Diabetes Mellitus, Type 1 - surgery; Endocrinology; Gastrointestinal surgery; Humans; Hypertension; Medicine & Public Health; Metabolic Diseases - surgery; Metabolism; Mortality; Obesity; Obesity - surgery; Patients; Public health; review-article; Semantics; Success; Surgery; Treatment Outcome; Weight control
• ISSN: 1759-5029; 1759-5037; 1759-5037
• DOI: 10.1038/nrendo.2015.84

Key Points Bariatric surgery has a proven role in achieving sustained weight loss, improving obesity-related comorbidities and reducing mortality Bariatric surgery is considered to address mainly weight loss, whereas metabolic surgery focuses mainly on improving type 2 diabetes mellitus Bariatric and metabolic surgery cannot be viewed as dichotomic procedures, as most of the clinical benefits of both approaches have a multifactorial origin derived from a combination of effects Detailed patient phenotyping shows that the BMI cut-off points for determining eligibility for surgery are blurred when considering total adiposity and fat distribution, as BMI often does not tally with these factors Changes in eligibility and follow-up criteria that move away from a merely BMI-centric view for indicating bariatric or metabolic surgery should be pursued A more functional, individualized and holistic approach with extensive evaluation of comorbidities will yield improved patient selection that does not have a 'weight-centric' focus Bariatric and metabolic surgeries are increasingly being used to treat patients with obesity, which is a major public health challenge. In this Review, Gema Frühbeck discusses the current body of evidence related to the outcomes of bariatric and metabolic surgery. Frühbeck suggests that a paradigm shift in eligibility and success criteria is required. She proposes that patient selection and follow-up should no longer focus solely on weight and BMI. The obesity epidemic, combined with the lack of available and effective treatments for morbid obesity, is a scientific and public health priority. Worldwide, bariatric and metabolic surgeries are increasingly being performed to effectively aid weight loss in patients with severe obesity, as well as because of the favourable metabolic effects of the procedures. The positive effects of bariatric surgery, especially with respect to improvements in type 2 diabetes mellitus, have expanded the eligibility criteria for metabolic surgery to patients with diabetes mellitus and a BMI of 30–35 kg/m 2 . However, the limitations of BMI, both in the diagnosis and follow-up of patients, need to be considered, particularly for determining the actual adiposity and fat distribution of the patients following weight loss. Understanding the characteristics shared by bariatric and metabolic surgeries, as well as their differential aspects and outcomes, is required to enhance patient benefits and operative achievements. For a holistic approach that focuses on the multifactorial effects of bariatric and metabolic surgery to be possible, a paradigm shift that goes beyond the pure semantics is needed. Such a shift could lead to profound clinical implications for eligibility criteria and the definition of success of the surgical approach.