Bariatric surgery advancement spurs guideline update
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Bariatric surgery advancement spurs guideline update

Weight loss surgery patients should get routine copper supplements along with other vitamins and minerals, according to newly updated bariatric surgery guidelines from the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery.

The groups call for 2 mg/day to offset the potential for surgery to cause a deficiency. Although routine copper screening isn’t necessary after the procedure, copper levels should be assessed and treated as needed in patients with anemia, neutropenia, myeloneuropathy, and impaired wound healing.

The copper recommendations are new since the guidelines were last published in 2008. Other recommendations – there are 74 in all – have been revised to incorporate new advances in weight loss surgery and an improved evidence base. Changes are pointed out where they’ve been made, and the level of evidence cited for each assertion. Pre- and postoperative bariatric surgery checklists have been added as well, to help avoid errors.

"This is actually a very unique collaboration among the internists represented by the endocrinologists and the obesity people and the surgeons. We actually agreed on all these things. The main intent is to assist with clinical decision making," including selecting patients and procedures and perioperative management, said lead author Dr. Jeffrey Mechanick, president-elect of the American Association of Clinical Endocrinologists and director of metabolic support at the Mt. Sinai School of Medicine in New York.

"We scrutinized every recommendation one by one in the context of the new data. In many cases the recommendations changed," he said in an interview.

Another new recommendation is for patients to be followed by their primary care physicians and screened for cancer prior to surgery, as appropriate for age and risk. Dr. Mechanick and his colleagues have also given more attention to consent, behavioral, and psychiatric issues as well as weight loss surgery in patients with type 2 diabetes.

There’s more information on sleeve gastrectomy, as well. Considered experimental in 2008, it’s now "approved and being done more widely. There are some very nice data about its metabolic effects, independent from just the weight loss effect, effects on glycemic control, and cardiovascular risk. It was very important to devote a fair amount of time" to the procedure, he said.

The guidelines note that "sleeve gastrectomy has demonstrated benefits comparable to other bariatric procedures. ... A national risk-adjusted database positions [it] between the laparoscopic adjustable gastric band and laparoscopic Roux-en-Y gastric bypass in terms of weight loss, co-morbidity resolution, and complications."

"We [also] addressed two issues which were quite controversial, and are still rather unsettled. The first is the use of the lap band for mild obesity. The second is the use of these weight loss procedures specifically for patients with type 2 diabetes for glycemic control. Since 2008, there’ve been a lot more data" about the issues, he said, just as there’ve been more data about the need for copper supplementation.

As in 2008, the guidelines do not recommend bariatric surgery solely for glycemic control. "We still don’t have an absolute indication for ‘diabetes surgery,’ but we do recognize the existence of the salutary effects on glycemic control when these procedures are done for weight loss. It was important for the reader to be exposed to this information," Dr. Mechanick said.

Regarding surgery in the mildly obese, the guidelines note that patients with a body mass index of 30-34.9 kg/m2 with diabetes or metabolic syndrome "may also be offered a bariatric procedure, although current evidence is limited by the number of subjects studied and lack of long-term data demonstrating net benefit."

The guidelines will be published in the March/April 2013 issue of Endocrine Practice and March 2013 issue of Surgery for Obesity and Related Diseases.

Dr. Mechanick disclosed compensation from Abbott Nutrition for lectures and program development.

aotto@frontlinemedcom.com

Body

From preoperative evaluation through bariatric

surgery and onward through long-term postoperative health management, weight

loss surgery and the medical care associated with it is, obligatorily, a

thoroughly interdisciplinary effort. Endocrinologists and internists on the

bariatrics team spearhead lifestyle management, medical weight loss, and

long-term postoperative care and efforts to maintain durable weight loss.

Surgeons, endocrinologists, and internists work together to select patients

appropriate for bariatric surgery, to choose the weight-loss surgery best

suited to each individual patient, and to provide the proper preoperative

evaluation. Surgeons perform the appropriate bariatric operation and oversee

immediate postoperative and short-term perioperative care, and, frequently in

concert with gastroenterologists, internists, and endocrinologists, manage

complications that can result from bariatric surgery. Finally, long-term

continuity of medical care and durable maintenance of weight loss is again

directed by the endocrinologist and internist.

Thus, given that the entire bariatric care schema is

such an interdisciplinary effort, clinical practice guidelines for the

management of bariatric surgical patients must also be the product of an

analogous interdisciplinary effort. It is with this aim and in this spirit that

the American Association of Clinical Endocrinologists (AACE), The Obesity

Society (TOS), and American Society for Metabolic and Bariatric Surgery (AAMBS)

published their initial Medical Guidelines for Clinical Practice for the Perioperative

Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery

Patient in 2008. The same cooperating societies have just published their

sequel with numerous substantive additions, changes, and refinements. The

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 was published jointly in

the March issue of Surgery for Obesity and Related Disease, and in the

March/April issue of Endocrine Practice.

Clearly, much has changed in the bariatric landscape

in the intervening half-decade. Laparoscopic gastric band surgery has declined,

while sleeve gastrectomy has gained traction as a restrictive bariatric

operation with more robust weight loss and glycemic effects.  The

increasingly recognized impact of Roux-en-Y gastric bypass surgery not only on

weight loss, but also on glycemic control and other endocrinologic endpoints

has prompted studies to determine if such benefits might also result from

restrictive-only bariatric surgeries such as sleeve gastrectomy, and initial

results appear encouraging. The arrival of more and higher-quality data with

longer-term follow up of a greater variety of endpoints has led to the ability

of these updated guidelines to provide an increasing number of more specific,

data-driven recommendations related to the broader spectrum of bariatric

surgical procedures and anatomies managed by clinicians today. They cover every

aspect of the bariatric surgical patient, from preoperative evaluation through

surgery, to postoperative management, all with more solidly outcomes-based

recommendations from over 400 references, with user-friendly and more

error-proof preoperative and postoperative care checklists, while still

arriving at such expert guidelines through interdisciplinary study and

agreement in this timely update.

 

John A. Martin, M.D., is associate

professor of medicine and surgery and director of endoscopy, Northwestern

University Feinberg School of Medicine, Chicago.

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Body

From preoperative evaluation through bariatric

surgery and onward through long-term postoperative health management, weight

loss surgery and the medical care associated with it is, obligatorily, a

thoroughly interdisciplinary effort. Endocrinologists and internists on the

bariatrics team spearhead lifestyle management, medical weight loss, and

long-term postoperative care and efforts to maintain durable weight loss.

Surgeons, endocrinologists, and internists work together to select patients

appropriate for bariatric surgery, to choose the weight-loss surgery best

suited to each individual patient, and to provide the proper preoperative

evaluation. Surgeons perform the appropriate bariatric operation and oversee

immediate postoperative and short-term perioperative care, and, frequently in

concert with gastroenterologists, internists, and endocrinologists, manage

complications that can result from bariatric surgery. Finally, long-term

continuity of medical care and durable maintenance of weight loss is again

directed by the endocrinologist and internist.

Thus, given that the entire bariatric care schema is

such an interdisciplinary effort, clinical practice guidelines for the

management of bariatric surgical patients must also be the product of an

analogous interdisciplinary effort. It is with this aim and in this spirit that

the American Association of Clinical Endocrinologists (AACE), The Obesity

Society (TOS), and American Society for Metabolic and Bariatric Surgery (AAMBS)

published their initial Medical Guidelines for Clinical Practice for the Perioperative

Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery

Patient in 2008. The same cooperating societies have just published their

sequel with numerous substantive additions, changes, and refinements. The

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 was published jointly in

the March issue of Surgery for Obesity and Related Disease, and in the

March/April issue of Endocrine Practice.

Clearly, much has changed in the bariatric landscape

in the intervening half-decade. Laparoscopic gastric band surgery has declined,

while sleeve gastrectomy has gained traction as a restrictive bariatric

operation with more robust weight loss and glycemic effects.  The

increasingly recognized impact of Roux-en-Y gastric bypass surgery not only on

weight loss, but also on glycemic control and other endocrinologic endpoints

has prompted studies to determine if such benefits might also result from

restrictive-only bariatric surgeries such as sleeve gastrectomy, and initial

results appear encouraging. The arrival of more and higher-quality data with

longer-term follow up of a greater variety of endpoints has led to the ability

of these updated guidelines to provide an increasing number of more specific,

data-driven recommendations related to the broader spectrum of bariatric

surgical procedures and anatomies managed by clinicians today. They cover every

aspect of the bariatric surgical patient, from preoperative evaluation through

surgery, to postoperative management, all with more solidly outcomes-based

recommendations from over 400 references, with user-friendly and more

error-proof preoperative and postoperative care checklists, while still

arriving at such expert guidelines through interdisciplinary study and

agreement in this timely update.

 

John A. Martin, M.D., is associate

professor of medicine and surgery and director of endoscopy, Northwestern

University Feinberg School of Medicine, Chicago.

Body

From preoperative evaluation through bariatric

surgery and onward through long-term postoperative health management, weight

loss surgery and the medical care associated with it is, obligatorily, a

thoroughly interdisciplinary effort. Endocrinologists and internists on the

bariatrics team spearhead lifestyle management, medical weight loss, and

long-term postoperative care and efforts to maintain durable weight loss.

Surgeons, endocrinologists, and internists work together to select patients

appropriate for bariatric surgery, to choose the weight-loss surgery best

suited to each individual patient, and to provide the proper preoperative

evaluation. Surgeons perform the appropriate bariatric operation and oversee

immediate postoperative and short-term perioperative care, and, frequently in

concert with gastroenterologists, internists, and endocrinologists, manage

complications that can result from bariatric surgery. Finally, long-term

continuity of medical care and durable maintenance of weight loss is again

directed by the endocrinologist and internist.

Thus, given that the entire bariatric care schema is

such an interdisciplinary effort, clinical practice guidelines for the

management of bariatric surgical patients must also be the product of an

analogous interdisciplinary effort. It is with this aim and in this spirit that

the American Association of Clinical Endocrinologists (AACE), The Obesity

Society (TOS), and American Society for Metabolic and Bariatric Surgery (AAMBS)

published their initial Medical Guidelines for Clinical Practice for the Perioperative

Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery

Patient in 2008. The same cooperating societies have just published their

sequel with numerous substantive additions, changes, and refinements. The

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 was published jointly in

the March issue of Surgery for Obesity and Related Disease, and in the

March/April issue of Endocrine Practice.

Clearly, much has changed in the bariatric landscape

in the intervening half-decade. Laparoscopic gastric band surgery has declined,

while sleeve gastrectomy has gained traction as a restrictive bariatric

operation with more robust weight loss and glycemic effects.  The

increasingly recognized impact of Roux-en-Y gastric bypass surgery not only on

weight loss, but also on glycemic control and other endocrinologic endpoints

has prompted studies to determine if such benefits might also result from

restrictive-only bariatric surgeries such as sleeve gastrectomy, and initial

results appear encouraging. The arrival of more and higher-quality data with

longer-term follow up of a greater variety of endpoints has led to the ability

of these updated guidelines to provide an increasing number of more specific,

data-driven recommendations related to the broader spectrum of bariatric

surgical procedures and anatomies managed by clinicians today. They cover every

aspect of the bariatric surgical patient, from preoperative evaluation through

surgery, to postoperative management, all with more solidly outcomes-based

recommendations from over 400 references, with user-friendly and more

error-proof preoperative and postoperative care checklists, while still

arriving at such expert guidelines through interdisciplinary study and

agreement in this timely update.

 

John A. Martin, M.D., is associate

professor of medicine and surgery and director of endoscopy, Northwestern

University Feinberg School of Medicine, Chicago.

Title
Bariatric surgery advancement spurs guideline update
Bariatric surgery advancement spurs guideline update

Weight loss surgery patients should get routine copper supplements along with other vitamins and minerals, according to newly updated bariatric surgery guidelines from the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery.

The groups call for 2 mg/day to offset the potential for surgery to cause a deficiency. Although routine copper screening isn’t necessary after the procedure, copper levels should be assessed and treated as needed in patients with anemia, neutropenia, myeloneuropathy, and impaired wound healing.

The copper recommendations are new since the guidelines were last published in 2008. Other recommendations – there are 74 in all – have been revised to incorporate new advances in weight loss surgery and an improved evidence base. Changes are pointed out where they’ve been made, and the level of evidence cited for each assertion. Pre- and postoperative bariatric surgery checklists have been added as well, to help avoid errors.

"This is actually a very unique collaboration among the internists represented by the endocrinologists and the obesity people and the surgeons. We actually agreed on all these things. The main intent is to assist with clinical decision making," including selecting patients and procedures and perioperative management, said lead author Dr. Jeffrey Mechanick, president-elect of the American Association of Clinical Endocrinologists and director of metabolic support at the Mt. Sinai School of Medicine in New York.

"We scrutinized every recommendation one by one in the context of the new data. In many cases the recommendations changed," he said in an interview.

Another new recommendation is for patients to be followed by their primary care physicians and screened for cancer prior to surgery, as appropriate for age and risk. Dr. Mechanick and his colleagues have also given more attention to consent, behavioral, and psychiatric issues as well as weight loss surgery in patients with type 2 diabetes.

There’s more information on sleeve gastrectomy, as well. Considered experimental in 2008, it’s now "approved and being done more widely. There are some very nice data about its metabolic effects, independent from just the weight loss effect, effects on glycemic control, and cardiovascular risk. It was very important to devote a fair amount of time" to the procedure, he said.

The guidelines note that "sleeve gastrectomy has demonstrated benefits comparable to other bariatric procedures. ... A national risk-adjusted database positions [it] between the laparoscopic adjustable gastric band and laparoscopic Roux-en-Y gastric bypass in terms of weight loss, co-morbidity resolution, and complications."

"We [also] addressed two issues which were quite controversial, and are still rather unsettled. The first is the use of the lap band for mild obesity. The second is the use of these weight loss procedures specifically for patients with type 2 diabetes for glycemic control. Since 2008, there’ve been a lot more data" about the issues, he said, just as there’ve been more data about the need for copper supplementation.

As in 2008, the guidelines do not recommend bariatric surgery solely for glycemic control. "We still don’t have an absolute indication for ‘diabetes surgery,’ but we do recognize the existence of the salutary effects on glycemic control when these procedures are done for weight loss. It was important for the reader to be exposed to this information," Dr. Mechanick said.

Regarding surgery in the mildly obese, the guidelines note that patients with a body mass index of 30-34.9 kg/m2 with diabetes or metabolic syndrome "may also be offered a bariatric procedure, although current evidence is limited by the number of subjects studied and lack of long-term data demonstrating net benefit."

The guidelines will be published in the March/April 2013 issue of Endocrine Practice and March 2013 issue of Surgery for Obesity and Related Diseases.

Dr. Mechanick disclosed compensation from Abbott Nutrition for lectures and program development.

aotto@frontlinemedcom.com

Weight loss surgery patients should get routine copper supplements along with other vitamins and minerals, according to newly updated bariatric surgery guidelines from the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery.

The groups call for 2 mg/day to offset the potential for surgery to cause a deficiency. Although routine copper screening isn’t necessary after the procedure, copper levels should be assessed and treated as needed in patients with anemia, neutropenia, myeloneuropathy, and impaired wound healing.

The copper recommendations are new since the guidelines were last published in 2008. Other recommendations – there are 74 in all – have been revised to incorporate new advances in weight loss surgery and an improved evidence base. Changes are pointed out where they’ve been made, and the level of evidence cited for each assertion. Pre- and postoperative bariatric surgery checklists have been added as well, to help avoid errors.

"This is actually a very unique collaboration among the internists represented by the endocrinologists and the obesity people and the surgeons. We actually agreed on all these things. The main intent is to assist with clinical decision making," including selecting patients and procedures and perioperative management, said lead author Dr. Jeffrey Mechanick, president-elect of the American Association of Clinical Endocrinologists and director of metabolic support at the Mt. Sinai School of Medicine in New York.

"We scrutinized every recommendation one by one in the context of the new data. In many cases the recommendations changed," he said in an interview.

Another new recommendation is for patients to be followed by their primary care physicians and screened for cancer prior to surgery, as appropriate for age and risk. Dr. Mechanick and his colleagues have also given more attention to consent, behavioral, and psychiatric issues as well as weight loss surgery in patients with type 2 diabetes.

There’s more information on sleeve gastrectomy, as well. Considered experimental in 2008, it’s now "approved and being done more widely. There are some very nice data about its metabolic effects, independent from just the weight loss effect, effects on glycemic control, and cardiovascular risk. It was very important to devote a fair amount of time" to the procedure, he said.

The guidelines note that "sleeve gastrectomy has demonstrated benefits comparable to other bariatric procedures. ... A national risk-adjusted database positions [it] between the laparoscopic adjustable gastric band and laparoscopic Roux-en-Y gastric bypass in terms of weight loss, co-morbidity resolution, and complications."

"We [also] addressed two issues which were quite controversial, and are still rather unsettled. The first is the use of the lap band for mild obesity. The second is the use of these weight loss procedures specifically for patients with type 2 diabetes for glycemic control. Since 2008, there’ve been a lot more data" about the issues, he said, just as there’ve been more data about the need for copper supplementation.

As in 2008, the guidelines do not recommend bariatric surgery solely for glycemic control. "We still don’t have an absolute indication for ‘diabetes surgery,’ but we do recognize the existence of the salutary effects on glycemic control when these procedures are done for weight loss. It was important for the reader to be exposed to this information," Dr. Mechanick said.

Regarding surgery in the mildly obese, the guidelines note that patients with a body mass index of 30-34.9 kg/m2 with diabetes or metabolic syndrome "may also be offered a bariatric procedure, although current evidence is limited by the number of subjects studied and lack of long-term data demonstrating net benefit."

The guidelines will be published in the March/April 2013 issue of Endocrine Practice and March 2013 issue of Surgery for Obesity and Related Diseases.

Dr. Mechanick disclosed compensation from Abbott Nutrition for lectures and program development.

aotto@frontlinemedcom.com

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