AACE/TOS/ASMBS guidelines
American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient

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American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied.

These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances.

The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

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Section snippets

Preface

Surgical therapy for obesity, or “bariatric surgery,” is indicated for certain high-risk patients, termed by the National Institutes of Health (NIH) as having “clinically severe obesity.” These clinical practice guidelines (CPG) are cosponsored by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), and the American Society for Metabolic & Bariatric Surgery (ASMBS). These guidelines represent an extension of the AACE/American College of Endocrinology Obesity

History of bariatric surgery

The original bariatric surgical procedure was the jejunocolic bypass, followed shortly thereafter by the jejunoileal bypass. This approach was introduced in 1954 and consisted of 14 inches (35.6 cm) of jejunum connected to 4 inches (10.2 cm) of ileum as either an end-to-end or an end-to-side anastomosis, which bypassed most of the small intestine [4[EL 4], 5[EL 3]]. This procedure resulted in substantial weight loss but with an unacceptably high risk of unanticipated early and late

Indications for bariatric surgery

Overweight and obesity are at epidemic proportions in the United States, affecting nearly 65% (or approximately 130 million) of the adult population [13[EL 3]]. Obesity is defined as a body mass index (BMI; weight in kg/[height in meters]2) ≥30 kg/m2, in an overall classification in which the healthy range of weight is 18.5 to 24.9 kg/m2, overweight is 25 to 29.9 kg/m2, class 1 obesity is 30 to 34.9 kg/m2, class 2 obesity is 35 to 39.9 kg/m2, and class 3 obesity is ≥40 kg/m2. Some groups

Types of bariatric surgery

Various bariatric procedures are available for management of high-risk obese patients (Table 1 and Fig. 1). Minimal scientific data exist for establishing which procedure should be performed for which patient. Currently, most bariatric procedures are being performed laparoscopically. This approach has the advantages of fewer wound complications, less postoperative pain, a briefer hospital stay, and more rapid postoperative recovery with comparable efficacy [[55], [56], [57], [58], [59][EL 2-4]

Mortality from bariatric procedures

Considerable concern has been raised regarding the mortality associated with bariatric surgical procedures. One study using statewide outcome data for bariatric surgery found a 1.9% risk of death in the state of Washington; however, procedures performed by more experienced surgeons were associated with a much lower risk of death [40[EL 3]]. Another study that used similar methods found that the risk of intraoperative death was 0.18% and the 30-day mortality was 0.33% for gastric bypass surgery

Benefits of bariatric surgery

The purpose of bariatric surgery is to induce substantial, clinically important weight loss that is sufficient to reduce obesity-related medical complications to acceptable levels [[103], [104], [105], [106], [107][EL 3]] (Table 2). The loss of fat mass, particularly visceral fat, is associated with improved insulin sensitivity and glucose disposal, reduced flux of free fatty acids, increased adiponectin levels, and decreased interleukin-6, tumor necrosis factor-α, and highly sensitive

Methods for development of AACE-TOS-ASMBS CPG

In 2004, the AACE Protocol for Standardized Production of Clinical Practice Guidelines was published in Endocrine Practice [219[EL 4]]. These CPG for perioperative nonsurgical management of the bariatric surgery patient are in strict accordance with the AACE Task Force CPG protocols and have been approved by TOS and ASMBS. Important production attributes unique to these CPG are described in the subsequent material.

Executive summary of recommendations

The following recommendations (labeled “R”) are evidence-based (Grades A, B, and C) or based on expert opinion because of a lack of conclusive clinical evidence (Grade D). The “best evidence” rating level (BEL), which corresponds to the best conclusive evidence found, accompanies the recommendation grade in this Executive Summary. Details regarding the mapping of clinical evidence ratings to these recommendation grades are provided in the Appendix (Section 9, “Discussion of the Clinical

Effectiveness of bariatric surgery for obesity comorbidities

The comorbidities of severe obesity affect all the major organ systems of the body. Surgically induced weight loss will substantially improve or reverse the vast majority of these adverse effects from severe obesity.

Physician resources

Interested physicians may refer to several key textbooks, journals, Web sites, and guidelines for information regarding various aspects in the care of bariatric surgical patients (Table 21). In general, the textbooks provide basic concepts, whereas certain journals are replete with pertinent and specific reports. Many of the journal articles contain sound experimental design and valid conclusions, although careful scrutiny is advised before extrapolation of their results to a specific clinical

Cochairmen

Dr. Jeffrey I. Mechanick reports that he does not have any relevant financial relationships with any commercial interests.

Dr. Robert F. Kushner reports that he has received Advisory Board honoraria from GI Dynamics, Merck & Co., Inc., and Orexigen Therapeutics, Inc. and speaker honoraria from sanofi-aventis U.S. LLC.

Dr. Harvey J. Sugerman reports that he has received speaker honoraria from Ethicon Endo-Surgery, Inc., consultant fees from EnteroMedics, salary for his role as Editor from Surgery

Cochairmen

Jeffrey I. Mechanick, M.D., F.A.C.P., F.A.C.E., F.A.C.N.

Robert F. Kushner, M.D.

Harvey J. Sugerman, M.D.

American Association of Clinical Endocrinologists Bariatric Surgery Task Force Primary Writers

J. Michael Gonzalez-Campoy, M.D., Ph.D., F.A.C.E.

Maria L. Collazo-Clavell, M.D., F.A.C.E.

Safak Guven, M.D., F.A.C.P., F.A.C.E.

Adam F. Spitz, M.D., F.A.C.E.

The Obesity Society Bariatric Surgery Task Force Primary Writers

Caroline M. Apovian, M.D.

Edward H. Livingston, M.D., FACS

Robert Brolin, M.D.

David B. Sarwer, Ph.D.

Wendy A. Anderson, M.S., R.D., L.D.N.

American Society for Metabolic & Bariatric Surgery Primary Writer

John Dixon, M.D.

American Association of Clinical Endocrinologists Nutrition Committee Reviewers

Elise M. Brett, M.D., F.A.C.E., C.N.S.P.

Osama Hamdy, M.D., Ph.D.

M. Molly McMahon, M.D., F.A.C.E.

Yi-Hao Yu, M.D., F.A.C.E.

The Obesity Society Reviewers

Ken Fujioka, M.D.

Susan Cummings, M.S., R.D.

Stephanie Sogg, Ph.D.

American Society for Metabolic & Bariatric Surgery Reviewers

Philip R. Schauer, M.D.

Scott A. Shikora, M.D.

Jaime Ponce, M.D.

Michael Sarr, M.D.

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