A focus on surgical preoperative evaluation of the bariatric patient – The Cleveland Clinic protocol and review of the literature

Bariatric surgery is well established as a safe and effective treatment for morbid obesity and related metabolic diseases. As an elective procedure, it is critical that individuals considering bariatric surgery should be carefully selected, extensively evaluated, and optimized in order to achieve optimal outcomes. This patient population has unique and challenging issues, including an extensive range of potential medical, psychiatric, and psychological comorbidities, and often patients have unrealistic expectations of the surgery. Therefore, a multidisciplinary, comprehensive and timely assessment preoperatively is of great importance. Individual bariatric units utilise different preoperative patient evaluation protocols. There is at present no uniformly accepted or recommended practice. In this article we describe what we believe are the essential components of a preoperative bariatric surgery evaluation, with supporting evidence for each recommendation. We also present a protocol currently in practice at a high volume bariatric center of excellence; the Bariatric and Metabolic Institute in the Cleveland Clinic, Ohio.     

青少年肥胖病人行减重手术适应证及手术方式探讨

我国青少年肥胖发病率逐年升高，越来越受到全社会的重视。青少年重度肥胖保守治疗效果有限，但由于青少年生理、心理尚不成熟，行减重手术治疗青少年肥胖尚未获得广泛接受。有限的临床证据表明，行减重手术治疗青少年肥胖安全有效，并发症发生率较低，主要适用于BMI≥32.5且有合并症的青少年肥胖病人，手术方式推荐胃袖状切除术和胃旁路术，其中胃袖状切除术为首选术式。术前须仔细评估病人的生理及心理成熟度，术后须配合生活方式矫正，并随访治疗手术并发症及营养并发症。虽然减重手术治疗青少年肥胖开展少，接受度低，但随着越来越多高质量临床研究的开展，减重手术必将成为治疗青少年肥胖最有效的手段。     

Psychiatric considerations of the massive weight loss patient

As bariatric surgery for extreme obesity continues to grow in popularity, so does interest in postbariatric surgery body-contouring surgery. There is an extensive literature on the psychological characteristics of persons with extreme obesity who undergo bariatric surgery and the psychological changes that typically occur postoperatively. Far less, however, is known about the psychological aspects of body contouring following massive weight loss. This article reviews the psychosocial characteristics of individuals with extreme obesity who undergo bariatric surgery, as well as the changes in these traits that typically occur postoperatively. Because there have been few studies of the psychological aspects of patients who have lost massive amounts of weight, we use related literatures on the relationship between body image dissatisfaction and other plastic surgical procedures to identify the most relevant research and clinical issues for this unique patient population. Appropriate psychiatric screening and management of these patients is believed to play an important role in successful postoperative outcomes.     

Natural history of morbid obesity without surgical intervention.

BACKGROUND: To study the mortality among morbidly obese patients qualifying for bariatric surgery. Mortality from bariatric surgery for morbid obesity has been widely reported; however, little is known about the mortality in morbidly obese patients who defer surgery. METHODS: Consecutive patients evaluated for bariatric surgery with an initial encounter between 1997 and 2004 were identified. The Social Security Death Index and office records were used to identify mortality through 2006. We conducted telephone interviews to determine whether the 305 patients who did not undergo bariatric surgery at our institution had undergone the surgery elsewhere. Using Cox proportional hazards models, we compared the mortality in patients undergoing surgery with that of those who did not. To evaluate bias resulting from missing data, we conducted analyses assuming that all patients with missing data had (1) undergone surgery and (2) not undergone surgery. RESULTS: A total of 908 patients underwent bariatric surgery (880 patients at our institution and 28 patients elsewhere). A total of 112 patients did not undergo surgery. Data regarding surgery on 165 patients could not be obtained. The mortality in those patients who did not undergo surgery was 14.3% compared with 2.9% for those who did undergo surgery. Adjusting for age, gender, and body mass index, patients who had undergone surgery had an 82% reduction in mortality (hazard ratio 0.18, 95% confidence interval 0.09-0.35, P <.0001). Sensitivity analysis, assuming that all patients with missing data received surgery resulted in an 85% mortality reduction (P <.001) and assuming that patients did not receive surgery resulted in a 50% mortality reduction (P = .04). CONCLUSIONS: Mortality among morbidly obese patients without surgery was 14.3% during the study period. Surgical intervention offered a 50%-85% mortality reduction benefit.     

围手术期外科之家在减重代谢外科的应用

围手术期外科之家（PSH）是对病人从术前准备到术后随访进行重新设计的临床新理念,强调从评估手术指征到围手术期并发症预防的长程管理模式。PSH涵盖了以往围手术期医学和加速康复理念。PSH理念更适合针对接受减重代谢手术的重度肥胖病人院前和围手术期管理以及长期随访,即在院前对于病人的伴发疾病进行干预,包括术前减重,心肺功能改善,血糖血压治疗等;住院以后针对病人的心理问题以及维生素缺乏、肝肾功能障碍、心肺功能进行评估,在术后施行加速康复措施,全程优化病人术式选择以及术后康复指导等。针对减重手术的特殊性,倡导终身随访,多学科团队干预,特别是内分泌科营养科以及心理医师进行术后的随访指导等。PSH理念可以为重度肥胖病人提供多学科全程围手术期管理,提高安全性。     

Psychological classification as a communication and management tool in obese patients undergoing bariatric surgery

BackgroundPsychological evaluations are used to ascertain patient suitability for bariatric surgery and to challenge their ability to comply with therapy. The modern paradigm of obesity includes a neurobiologic component working in parallel with the limbic system of appetite and reward. To achieve the goals of surgery, an evaluation of the psychological fitness of the patient is often included in the clinical pathway. We present a psychological classification system with the goal of integrating the psychological factors into patient treatment.MethodsAll patients (Roux-en-Y gastric bypass, n = 1814; laparoscopic adjustable gastric banding, n = 589) were evaluated using psychological testing/interview and assigned to groups 1–4 before surgery. The group 1 patients (n = 788; 32.8%) did not necessitate intervention, group 2 (n = 1110; 46.2%) were requested to attend the support group, groups 3A (n = 394; 16.4%) and 3B (n = 111; 4.6%) required intervention to continue to surgery, and group 4 patients were not recommended for surgery. The main outcome measures, including complication, readmission, and reoperation rates, were analyzed for differences among the psychological groups.ResultsAfter comparing the outcome measures between each classification, no significant differences were found in the major complication rates, readmissions, reoperations, or length of stay among the groups. Groups 3A and 3B were able to achieve similar rates of success, despite their psychosocial impairment at the initial evaluation.ConclusionThe assignment of a psychological classification can facilitate bariatric team recognition of the unique psychological factors that affect the success of surgery. Assessing the patient's psychological composition and addressing potential psychosocial barriers before surgery can increase the positive long-term outcomes and reduce the incidence of complications after bariatric surgery.     

Bariatric surgery and work-up of the massive weight loss patient

Bariatric surgery remains the treatment of choice for the extremely obese patient, with an exponential growth in the number of procedures performed in response to the obesity epidemic. There are a variety of bariatric procedures available, which differ according to the method in which they achieve sustained weight loss. Plastic surgeons are beginning to see large numbers of patients who have undergone bariatric surgery and who have sustained massive weight loss (MWL) for evaluation of complex and lengthy-body contouring procedures. Proper evaluation of the patient who has sustained MWL requires an understanding of the physiologic impact of different bariatric procedures with particular knowledge of potential long-term nutritional complications.     

Bariatric surgery in adolescence

Background/purpose: Surgical treatment for morbid obesity is relatively contraindicated in patients less than 18 years of age. However, on some occasions, there is extreme obesity in this age group that does not respond to nonsurgical treatment. The aim of this study was to evaluate the surgical management of severe morbid obesity in adolescents.Methods: During a 4-year period, the authors assessed 11 adolescent patients with severe morbid obesity. All patients underwent extensive preoperative evaluation including thorough psychological evaluation together with their families. Laparoscopic adjustable gastric banding (LAGB) was performed in all patients. Patients underwent follow-up for a mean of 23 months.Results: The mean age of the 11 children in this study was 15.7 years (range, 11 to 17 years). Associated conditions included heart failure and pulmonary hypertension in one patient, amenorrhea in 2 patients, and gallstones in 1 patient. Mean preoperative body mass index (BMI) was 46.4 kg/m² (range, 38 to 56.6). There were no operative complications. Over a mean follow-up period of 23 months (range, 6 to 36 months), the mean BMI dropped from 46.6 to 32.1 kg/m² with marked improvement in medical conditions and general psychologic well being. No late complications developed in any patient.Conclusions: Children are routinely excluded from bariatric surgery programs because of the difficulties involved in psychologically and cognitively preparing this population for surgery. However, extreme morbid obesity rarely responds to nonsurgical therapy for any extended period. This select population will benefit from bariatric surgery if an effort is made to properly prepare patients, together with their families, for the postoperative change in lifestyle and body image.     

A Review of Unmet Needs in Obesity Management

The prevalence of obesity continues to escalate in the USA; however, there is no consensus regarding the optimal therapy for obesity. For the vast majority of severely obese patients, conventional medical therapies (i.e., diet, exercise, behavioral counseling) often fail over the long term. Existing pharmacotherapy adjunctive to behavioral therapy has limited effectiveness and an imperfect safety record. In contrast, bariatric surgery has a high degree of weight loss efficacy, yet only a small fraction of the qualifying obese population undergoes these procedures because of the associated perioperative risks and potential late complications. In addition, the role of bariatric surgery is unclear in certain patient populations, such as patients with lower body mass index (BMI, 30-35 kg/m(2)), the high-risk super-super obese patients (BMI > 60), the morbidly obese adolescent, and obese patients requiring weight reduction in preparation for other procedures, such as orthopedic, transplant, or vascular surgeries. In these circumstances, there is a need for an effective but less invasive treatment to bridge the gap between medical and surgical therapy. This review examines current treatment outcomes, identifies prominent areas of unmet clinical needs, and provides an overview of two minimally invasive "temporary procedures for weight loss" that may eventually address some of the unmet needs in obesity management.