Bariatric Surgery is rapidly gaining popularity. Knowing the right Indications and Contra Indications is paramount for Surgeons starting their career in Bariatric Surgery.
3. Bariatric Surgery
Indications & Contraindications
Morbid obesity is a chronic, lifelong,
multifactorial, genetically related disease
of excessive fat storage with highly
significant medical, psychological,
social, physical and economic co-
morbidities
IFSO Sept, 1996
4. Bariatric Surgery
Indications & Contraindications
Quantification of obesity
BMI = Body Mass Index
= Body weight (Kg)
Height (in m2)
5. Bariatric Surgery
Indications & Contraindications
BARIATRIC RECOMMENDATIONS
WHO CRITERIA RECOMMENDATION
FOR ASIANS
BMI (kg per m2)
Normal < 25.0 < 23.0
Overweight > 25.0 > 23.0
Obese > 30.0 > 27.5
Severe Obesity > 35.0 > 32.5
Morbid Obesity > 40.0 > 37.5
6. Bariatric Surgery
Indications & Contraindications
Bariatric Surgery: Multiple Health Benefits
~77 % Excess weight loss
~ 85 % resolution of OSA
~ 52 to 92 % resolution of HTN
~ 73 – 83% resolution of type 2 diabetes
> 80 % resolution of Metabolic Syndrome
Sjostrom et al New Engl J Med 2004
Sjostrom et al, N Engl J Med 2007
8. Bariatric Surgery
Indications & Contraindications
NIH Consensus Conference Criteria(1991)
BMI > 40 or > 35 kg/m2 with co-morbidity
Failure of non-operative Rx
Absence of contraindications
Well informed, compliant, motivated patient
9. Bariatric Surgery
Indications & Contraindications
Controversies
Surgery for Adolescents & Elderly
( Age < 18 / > 65 yrs )
Surgery for BMI < 35
Surgery for Metabolic indications only
10. Bariatric Surgery
Indications & Contraindications
? Surgery for Adolescents
Adolescent bariatric surgery (<18 yrs) has proven
effective but should be performed only in a
specialty centre
Selection criteria similar
to adults
SAGES Guidelines for Clinical Application of Laparoscopic
Bariatric Surgery, 2008; Level II, Grade B,C evidence.
11. Bariatric Surgery
Indications & Contraindications
Panel of experts on Adolescent Obesity
BMI > 40 with comorbidities
Skeletal / physiologic maturity
Failure of > 6 mths of structured wt loss attempts
Commitment, ability to follow post-op instructions
Decision making capacity
Commitment to avoid pregnancy x 1 year
Curr Opin Paediatr 2005.
12. Bariatric Surgery
Indications & Contraindications
? Surgery for Age > 65
Patients > 65 yrs at risk of death (early & late)
after WLS
Should have life expectancy > 5 yrs
Should be evaluated & treated in
an established Center of Excellence
JAMA 2005
Annals of Surgery 2004
SAGES Guidelines for Clinical Application of Laparoscopic
Bariatric Surgery, 2008; Level II, Grade B evidence.
13. Bariatric Surgery
Indications & Contraindications
? Surgery for BMI < 35
“Individuals with BMI 30-35 kg/m2 may
benefit from Lap. bariatric surgery given
the poor results of non-surgical Rx”
SAGES Guidelines for Clinical Application of Laparoscopic Bariatric Surgery,
2008; Level I, Grade B evidence.
14. Bariatric Surgery
Indications & Contraindications
Surgery for Diabetes / Metabolic Syndrome
?
Risks vs Benefits?
Choice of procedure?
Economic Considerations?
When to intervene?
? BMI < 35
16. Bariatric Surgery
Indications & Contraindications
Medical
Severe co-morbidities / unacceptable risk
Uncontrolled coagulopathy
Incurable disease (cancer,AIDS, cirrhosis)
? Certain GI diseases (Crohns, dysmotilities)
V.Poor QOL not expected to improve with WLS
17. Bariatric Surgery
Indications & Contraindications
Unacceptable risk of Anaesthesia
Uncontrolled severe OSA + Pulmonary HTN
(Pulm. Syst. Pressure > 50mm Hg)
Severe COPD (Gold Spirometric Criteria)
- FEV1 / FVC < 0.7
- FEV1 < 30% predicted, or
- FEV1 < 50% predicted + chr. resp. failure
CHF, unstable angina
? Complete prolonged immobility
18. Bariatric Surgery
Indications & Contraindications
Surgical (Relative)
Multiple previous surgeries
Abdominal irradiation / Liver transplant
Very large incisional hernia
Previous int. resection for GBP / BPD-DS
Severe GERD / Barrets for LAGB
Need for surveillance endoscopy for GBP
19. Bariatric Surgery
Indications & Contraindications
Behavioral / Psychosocial
Significant psychatric dis./ major depression
Severe mental retardation
Self destructive tendency
Active bullimia, drug or alcohol abuse
Inability to comprehend behavioral changes
Inability to integrate basic lifestyle adjustments
20. Bariatric Surgery
Indications & Contraindications
Indications for Retreat / Change of surgical plan
Extreme hepatomegaly / cirrhosis with large
varices
Profuse visceral fat
Poor exposure
Extensive adhesions
Cardiopulmonary instability