Reproductive implications of bariatric surgery: Pre- and postoperative considerations for extremely obese women of childbearing age

Extreme obesity remains a frustrating and formidable disease, with most sufferers requiring surgical intervention in order to achieve long-term, sustained weight loss. Most bariatric procedures today are performed on women, many of whom are of reproductive age; yet minimal evidence exists to guide clinicians in the care of such women before, during, and after pregnancy. This review outlines the fundamental nutritional and surgical alterations of the most commonly performed bariatric procedures with the aim to elucidate a physiologically sound approach to counseling and management of extremely obese women of childbearing age who are either contemplating or have already undergone bariatric surgery. Preconception, pregnancy, and lactation guidelines are offered based on available evidence. Outstanding questions are highlighted for further investigation.     

A role for exercise after bariatric surgery?

Obesity predisposes an individual to develop numerous comorbidities, including type 2 diabetes, and represents a major healthcare issue in many countries worldwide. Bariatric surgery can be an effective treatment option, resulting in profound weight loss and improvements in metabolic health; however, not all patients achieve similar weight loss or metabolic improvements. Exercise is an excellent way to improve health, with well‐characterized physiological and psychological benefits. In the present paper we review the evidence to determine whether there may be a role for exercise as a complementary adjunct therapy to bariatric surgery. Objectively measured physical activity data indicate that most patients who undergo bariatric surgery do not exercise enough to reap the health benefits of exercise. While there is a dearth of data on the effects of exercise on weight loss and weight loss maintenance after surgery, evidence from studies of caloric restriction and exercise suggest that similar adjunctive benefits may be extended to patients who perform exercise after bariatric surgery. Recent evidence from exercise interventions after bariatric surgery suggests that exercise may provide further improvements in metabolic health compared with surgery‐induced weight loss alone. Additional randomized controlled exercise trials are now needed as the next step to more clearly define the potential for exercise to provide additional health benefits after bariatric surgery. This valuable evidence will inform clinical practice regarding much‐needed guidelines for exercise after bariatric surgery.     

Oral drug therapy following bariatric surgery: an overview of fundamentals,literature and clinical recommendations

Bariatric surgery is the most effective solution for severe obesity and obesity with comorbidities, and the number of patients going through bariatric surgery is rapidly and constantly growing. The modified gastrointestinal anatomy of the patient may lead to significant pharmacokinetic alterations in the oral absorption of drugs after the surgery; however, because of insufficient available literature and inadequate awareness of the medical team, bariatric surgery patients may be discharged from the hospital with insufficient instructions regarding their medication therapy. In this article, we aim to present the various mechanisms by which bariatric surgery may influence oral drug absorption, to provide an overview of the currently available literature on the subject, and to draw guidelines for the recommendations bariatric surgery patients should be instructed before leaving the hospital. To date, and until more robust data are published, it is essential to follow and monitor patients closely for safety and efficacy of their medication therapies, both in the immediate and distant time post‐surgery.     

The complexity of body image following bariatric surgery: a systematic review of the literature

Poor body image is common among individuals seeking bariatric surgery and is associated with adverse psychosocial sequelae. Following massive weight loss secondary to bariatric surgery, many individuals experience excess skin and associated concerns, leading to subsequent body contouring procedures. Little is known, however, about body image changes and associated features from pre‐to post‐bariatric surgery and subsequent body contouring. The objective of the present study was to conduct a comprehensive literature review of body image following bariatric surgery to help inform future clinical research and care. The articles for the current review were identified by searching PubMed and SCOPUS and references from relevant articles. A total of 60 articles examining body image post‐bariatric surgery were identified, and 45 did not include body contouring surgery. Overall, there was great variation in standards of reporting sample characteristics and body image terms. When examining broad levels of body image dissatisfaction, the literature suggests general improvements in certain aspects of body image following bariatric surgery; however, few studies have systematically examined various body image domains from pre‐to post‐bariatric surgery and subsequent body contouring surgery. In conclusion, there is a paucity of research that examines the multidimensional elements of body image following bariatric surgery.     

Guidelines for the management of pregnant women with obesity: A systematic review

Multiple clinical practice guidelines (CPGs) have been established for pregnant women with obesity. The quality and consistency of recommendations remain unknown. The objective of this study is to conduct a systematic review to synthesize and appraise evidence from CPGs, available worldwide, for pregnant women affected by obesity. An experienced information specialist performed a rigorous search of the literature, searching MEDLINE, Embase, grey literature, and guideline registries to locate CPGs that reported on pregnancy care relating to obesity. CPGs related to antenatal care of pregnant women with obesity (pre‐pregnancy body mass index [BMI] ≥ 30 kg/m²) in low‐risk (eg, care provider = family physician or midwife) or high‐risk settings (eg, obstetrician or maternal fetal medicine) were included. CPGs were appraised for quality with independent data collection by two raters. Information was categorized into five domains: preconception care. care during pregnancy, diet and exercise during pregnancy, care immediately before, during, and after delivery, and postpartum care. The literature search yielded 2614 unique citations. Following screening of abstracts and full texts, 32 CPGs were included, with quality ranging between 0 and 100 on the AGREE II tool. The strongest evidence related to nutritional advice, exercise, and pregnancy risk counselling. Guidance was limited for timing of screening tests, antenatal visits and delivery, ideal postpartum care, and management of adverse pregnancy outcomes. Most guidelines in this population are not evidence based. Research is needed to bridge knowledge gaps pertaining to fetal antenatal surveillance, management of adverse outcomes and postpartum care, and enhance consistency across CPGs.     

减重与代谢外科加速康复外科原则中国专家共识（2021版）

目的近年加速康复外科（ERAS）在外科领域得以广泛应用,减重与代谢外科有其特殊性,建立适合中国国情的减重与代谢外科ERAS原则专家共识十分必要。 方法参照改良Delphi方法建立《减重与代谢外科加速康复外科原则中国专家共识（2021版）》。由20位从事减重与代谢外科的专家组成专家组,提出、审核EARS原则条目,由专家组邀请56位有经验的减重与代谢外科医师,共76位专家对42项ERAS原则条目进行投票,经两轮投票赞成率≥70%的条目为达成共识。 结果经第一轮投票,42项ERAS原则条目中,14项赞成率<80%;经第二轮投票,最终36项ERAS原则条目达成共识,6项条目未达成共识。 结论结合文献证据及中国减重与代谢外科具体情况,建立《减重与代谢外科加速康复原则中国专家共识（2021版）》,供减重与代谢外科医师临床实践中参考。     

Post‐operative behavioural management in bariatric surgery: a systematic review and meta‐analysis of randomized controlled trials

Recent research has provided evidence that bariatric surgery maximizes long‐term weight loss in patients with severe obesity. However, a substantial number of patients experience poor weight loss outcome and weight regain over time. Post‐operative behavioural management may facilitate long‐term weight control in bariatric surgery population. The objective of this systematic review and meta‐analysis was to determine the effects of post‐operative behavioural management on weight loss following bariatric surgery. Eligible articles were systematically searched in electronic databases. Among the 414 citations, five randomized controlled trials, two prospective and eight retrospective cohort trials analysing behavioural lifestyle interventions and support groups fulfilled the inclusion criteria. The main finding is that behavioural management had a positive effect on weight loss following surgery. In 13 studies, patients receiving behavioural management had greater weight loss than patients receiving usual care or no treatment. A meta‐analysis of five randomized controlled trials suggests greater weight loss in patients with behavioural lifestyle interventions compared with control groups. Post‐operative behavioural management has the potential to facilitate optimal weight loss following bariatric surgery, but conclusions were limited by the small and heterogeneous samples of studies. A more rigorous empirical evaluation on its clinical significance is warranted to improve effectiveness of bariatric surgery.     

减重代谢外科多学科随访模式构建实证研究

目的探讨多学科随访模式在减重代谢外科质量控制中的实证研究。 方法回顾性分析2016年1月至2016年12月在南京医科大学第一附属医院减重代谢外科接受手术的110例肥胖症患者的临床资料。2016年1月至2016年6月入院的患者由外科医生主导随访,作为传统减重管理组（对照组）;2016年7月至2016年12月入院的患者,其术后随访由多学科团队共同完成,作为多学科随访管理组（研究组）。其中研究组57例,男16例,女41例,年龄（46.1±10.9）岁;对照组53例,男14例,女39例,年龄（42.2±8.3）岁。多学科随访管理组由减重外科医生、减重管理师、内分泌科医生、营养科医生组成;传统减重管理随访组由外科医生和减重管理师构成。比较两组患者的术后随访率、医疗服务满意率和术后营养并发症的发生率、术后胃肠道并发症的发生率、多余体重减少率。 结果研究组术后1年随访率为82.5%,明显高于对照组（χ2=14.907,P<0.05）;研究组患者的多余体重减少率为（83.1±16.1）%,明显高于对照组（t=3.959,P<0.05）;研究组患者对手术效果的满意率为93.0%（53/57）,明显高于对照组的73.6%（39/53）（χ2=4.410,P<0.05）;研究组患者营养并发症发生率为5.3%（3/57）,明显低于对照组的22.6%（12/53）（χ2=4.961,P<0.05）。 结论多学科随访模式能适应代谢外科多学科综合治疗的需要,在提高患者随访率、降低术后并发症的发生、增加患者术后多余体重减少率、提高患者满意度方面,较传统减重管理模式有明显优势。     

International workshop on immune tolerance induction: consensus recommendations1

Summary. Although immune tolerance induction (ITI) has been used for 30 years to eliminate inhibitors and restore normal factor pharmacokinetics in patients with hemophilia, there is a paucity of scientific evidence to guide therapeutic decision‐making. In an effort to provide direction for physicians and hemophilia treatment center staff members, an international panel of hemophilia opinion leaders met to develop consensus recommendations for ITI in patients with severe and mild hemophilia A and hemophilia B. These recommendations draw on the available published literature and the collective clinical experience of the group and are rated based on the level of supporting evidence .     

肥胖代谢外科个案管理中国专家共识（2022版）

目的制订《肥胖代谢外科个案管理中国专家共识（2022版）》,推动我国肥胖代谢外科个案管理规范化发展。 方法在全面回顾个案管理来源、国外个案管理模式、国际肥胖代谢外科专科护士考核内容、肥胖代谢外科围手术期管理指南与共识基础上,对7位具有5年以上肥胖代谢外科个案管理经验的专家进行访谈,形成《肥胖代谢外科个案管理中国专家共识（2022版）》初稿,并完成第一轮专家论证。根据专家意见修改后,邀请37位相关领域专家,完成第二轮专家论证,经修订后形成《肥胖代谢外科个案管理中国专家共识（2022版）》。 结果《肥胖代谢外科个案管理中国专家共识（2022版）》包括肥胖代谢外科个案管理定义、个案管理师管理内容、个案管理管案模式、个案管理成效指标四个方面。 结论《肥胖代谢外科个案管理中国专家共识（2022版）》具有科学性和实用性,可为肥胖代谢外科开展临床个案管理提供专业指引与参考依据。     

Psychological outcomes following surgical and endoscopic bariatric procedures: A systematic review

Obesity is a leading global epidemic. Bariatric surgery is the only treatment demonstrating substantial long‐term weight loss and medical benefits. However, there is limited research on the psychological outcomes following surgery. Therefore, the primary aim of this study was to systematically review depression, anxiety, and binge eating outcomes at different time points following bariatric surgery and identify whether bariatric surgery significantly reduces psychological symptoms over time. These outcomes were also examined among endoscopic bariatric procedures as a secondary aim. Forty‐eight studies met inclusion criteria. Findings suggested that most patients experience a short‐term reduction in anxiety and depression symptoms from pre‐surgery. Over time, however, these symptoms increase and may even return to pre‐surgery levels. Furthermore, while binge eating was uncommon after surgery, other disordered eating patterns may emerge. Binge eating may also restart over time as the stomach enlarges again. Overall, the complex psychological difficulties faced by individuals with obesity continue after surgery and may contribute to longer‐term weight recidivism. More comprehensive and standardised psychological assessment procedures, including clinical interviews and longer‐term follow‐up, may provide insight into the psychological mechanisms maintaining weight management issues, and may serve as a starting point for improving the long‐term success of patients with obesity.     

Bariatric surgery for diabetes: the International Diabetes Federation takes a position

Type 2 diabetes (T2D) and obesity are both complex and chronic medical disorders, each with an escalating worldwide prevalence. When obesity is severe, and/or available medical therapies fail to control the diabetes, bariatric surgery becomes a cost-effective therapy for T2D. When there are other major comorbidities and cardiovascular risk, the option of bariatric surgery becomes even more worthy of consideration. National guidelines for bariatric surgery need to be developed and implemented for people with T2D. With this in mind, the International Diabetes Federation convened a multidisciplinary working group to develop a position statement. The key recommendations cover describing those eligible for surgery and who should be prioritized, incorporating bariatric surgery into T2D treatment algorithms, performing surgery in centers with multidisciplinary teams that are experienced in the management of both obesity and diabetes, and developing bariatric surgery registries and reporting standards.     

Nutritional follow‐up of patients after obesity surgery: best practice

Obesity surgery is an appropriate treatment option for patients with severe and complex obesity and helps in the improvement of comorbidities. In the first 2 years following surgery, follow‐up is provided by the obesity surgery centre. Ongoing care is then usually returned to the general practitioner. Patients need access to ongoing support and monitoring otherwise may be at risk of developing nutritional deficiencies such as anaemia or protein malnutrition. The British Obesity and Metabolic Surgery Society have developed guidelines on nutritional monitoring and nutritional supplements to support both bariatric centres and general practitioners. The Royal College of General Practitioners and BOMSS have worked collaboratively to develop Ten Top Tips for the management of obesity surgery patients to aid with the long‐term management in primary care. Women, planning to get pregnant, need access to preconception advice and additional monitoring during pregnancy. It is essential that long‐term data are collected and inputted into the National Bariatric Surgery Register. Obesity surgery improves comorbidities; however, patients must have access to long‐term nutritional monitoring.     

Does weight loss in overweight or obese women improve fertility treatment outcomes? A systematic review

This systematic review assessed the effect of weight loss in overweight and/or obese women undergoing assisted reproductive technology (ART) on their subsequent pregnancy outcome. Weight losses achieved by diet and lifestyle changes, very‐low‐energy diets, non‐surgical medical interventions and bariatric surgery translated into significantly increased pregnancy rates and/or live birth in overweight and/or obese women undergoing ART in 8 of the 11 studies reviewed. In addition, regularization of the menstrual pattern, a decrease in cancellation rates, an increase in the number of embryos available for transfer, a reduction in the number of ART cycles required to achieve pregnancy and a decrease in miscarriage rates were reported. There were also a number of natural conceptions in five of the six studies that reported this outcome. Non‐surgical medical weight loss procedures and bariatric surgery induced the greatest weight losses, but their use, as well as that of very‐low‐energy diets, for weight loss prior to ART requires careful consideration. While the overall quality of the studies included in this review was poor, these results support the clinical recommendation of advising overweight and/or obese women to lose weight prior to ART. Prospective randomized controlled trials are required to establish efficacious evidence‐based guidelines for weight loss interventions in overweight and/or obese women prior to ART treatment.     

Food addiction and bariatric surgery: a systematic review of the literature

Emerging research suggests that rates of food addiction are high among individuals seeking bariatric surgery, but little is known about associated features and the prognostic significance of pre‐operative food addiction. Thus, this article provides a systematic review and synthesis of the literature on food addiction and bariatric surgery. Articles were identified through PubMed and SCOPUS databases, resulting in a total of 19 studies which assessed food addiction among pre‐bariatric and/or post‐bariatric surgery patients using the Yale Food Addiction Scale. Most studies were cross‐sectional, and only two studies prospectively measured food addiction both pre‐operatively and post‐operatively. The presence of pre‐surgical food addiction was not associated with pre‐surgical weight or post‐surgical weight outcomes, yet pre‐surgical food addiction was related to broad levels of psychopathology. The relationship between food addiction and substance misuse among individuals undergoing bariatric surgery is mixed. In addition, very few studies have attempted to validate the construct of food addiction among bariatric surgery patients. Results should be interpreted with caution due to the methodological limitations and small sample sizes reported in most studies. Future rigorous research with larger and more diverse samples should prospectively examine the clinical utility and validity of the food addiction construct following bariatric surgery.     

Metabolic surgery for the treatment of type 2 diabetes in patients with BMI lower than 35 kg/m2: Why caution is still needed

Bariatric surgery has shifted from being a risky procedure to an evidence‐based one, with proven benefits on all‐cause mortality, cardiovascular disease, cancer, and diabetes control. The procedure has an overall positive result on type 2 diabetes mellitus (T2DM), with a substantial number of patients achieving disease remission. This has resulted in several studies assessing possible weight‐independent effects of bariatric surgery on glycemic improvement, in addition to recommendation of the procedure to patients with class 1 obesity and T2DM, for whom the procedure was classically not indicated, and adoption of a new term, “metabolic surgery,” to highlight the overall metabolic benefit of the procedure beyond weight loss. Recently, the Diabetes Surgery Summit (DSS) has included metabolic surgery in its T2DM treatment algorithm. Although the discussion brought by this consensus is highly relevant, the recommendation of metabolic surgery for patients with uncontrolled T2DM and a body mass index of 30 to 35 kg/m² still lacks enough evidence. This article provides an overall view of the metabolic benefits of bariatric/metabolic surgery in patients with class 1 obesity, compares the procedure against clinical treatment, and presents our rationale for defending caution on recommending the procedure to less obese individuals.     

The role of parents in pre‐adolescent and adolescent overweight and obesity treatment: a systematic review of clinical recommendations

The study aims to describe clinical recommendations (i) on the role of parents in both pre‐adolescent and adolescent overweight and obesity treatment; (ii) to health professionals on how to involve parents in paediatric overweight and obesity treatment and (iii) to identify deficiencies in the associated literature. A systematic literature review was conducted in March 2010 to identify clinical practice guidelines, position or consensus statements on clinical management of paediatric overweight or obesity, developed by a national or international health professional association or government agency, and endorsed for current use. Relevant clinical recommendations in these documents were identified via a screen for the words ‘parent’, ‘family’ and synonyms. Twenty documents were included. Most documents emphasized the importance of involving parents or the family in paediatric overweight and obesity treatment with approximately a third of documents providing separate recommendations on the role of parents/family for pre‐adolescents and adolescents. The documents varied markedly with regard to the presence of recommendations on parent/family involvement in the various components of lifestyle interventions or bariatric surgery. Almost half of the documents contained recommendations to health professionals regarding interactions with parents. High‐quality research is needed on age‐specific techniques to optimize the involvement of parents and family members in paediatric overweight and obesity treatment.     

Pharmacokinetic changes post–bariatric surgery: A scoping review

Bariatric surgeries induce structural changes that can alter the absorption of drugs in patients already at risk of polypharmacy. This scoping review aimed to explore pharmacokinetic changes of orally administered drugs in patients post‐bariatric surgery, and assess the quality and level of bias. Electronic databases were searched for articles relating to bariatric surgery and pharmacokinetics published between 1998 and 2019. Pre‐post studies reporting on pharmacokinetic parameters were included, and the Newcastle‐Ottawa Scale was used to assess risk‐of‐bias. A total of 21 studies were included in this review, and changes in absorption were reported in all included studies across 29 drugs. In 11 studies, this change was reported as statistically significant (p<.05), while six reported a nonsignificant change. More drugs exhibited a shorter Tmax and higher Cmax after surgery than otherwise, however changes in AUC were variable. Four studies were assessed as having fair quality while the remainder of the included studies were of good quality and low risk‐of‐bias. Bariatric surgery alters the absorption of drugs and several mechanisms are implicated to be responsible. Short and long‐term monitoring is recommended in patients post‐surgery for clinical changes in response to medications. Future research with a higher number of participants and greater control of variables, such as concurrent medications, malabsorptive disorders, and body composition should be considered.     

Influences of Obesity and Bariatric Surgery on the Clinical and Pharmacologic Profile of Rivaroxaban

The health implications of obesity are myriad and multifaceted. Physiologic changes associated with obesity can affect the absorption, distribution, metabolism, and excretion of administered drugs, thereby altering their pharmacologic profiles. In 2016, the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis published recommendations about the use of direct oral anticoagulants (DOACs) in obese patients. This guidance provides uniform recommendations for all DOACs, yet data suggest that individual agents may be affected to different degrees by obesity. Moreover, there are no recommendations currently available to guide DOAC use in bariatric surgery patients, in whom anatomic and physiologic changes to the digestive system can influence drug pharmacokinetics. Our review of the available literature indicates that the clinical profile of the DOAC rivaroxaban is not affected by high weight or bariatric surgery; hence, it does not appear that rivaroxaban dosing needs to be altered in these patient populations.     

Binge Eating,Binge Eating Disorder and Loss of Control Eating: Effects on Weight Outcomes after Bariatric Surgery

There is increasing evidence that patients who have problems with binge eating (BE) or BE disorder (BED) are quite common among the severely obese, including bariatric surgery candidates. The literature suggests that in many cases such eating behaviours improve after bariatric surgery, although this is not uniformly true. The current paper reviews the data on the development of BE, BED and loss of control (LOC) eating after bariatric surgery and the impact of these problems on long‐term weight outcome. A search was made of various databases regarding evidence of BE, BED and LOC eating post‐operatively in bariatric surgery patients. The data extracted from the literature suggests that 15 research studies have now examined this question. Fourteen of the available 15 studies suggest that the development of problems with BE, BED or LOC eating post‐bariatric surgery is associated with less weight loss and/or more weight regain post‐bariatric surgery. These data suggests that it is important to identify individuals at high risk for these problems, to follow them post‐operatively, and, if appropriate interventions can be developed if such behaviours occur in order to maximize weight loss outcomes. Copyright © 2013 John Wiley & Sons, Ltd and Eating Disorders Association.