Bariatric Surgery in Adults With Extreme (Not Morbid) Obesity

© 2006 Mayo Foundation for Medical Education and Research The pandemic of obesity has received widespread publicity. Only recently has the increase in obesity showed signs of slowing in some segments of the US population, with stable prevalence estimates from 1999 through 2004 reported in women with obesity and in white men and black women with extreme (class III) obesity. Generally, the treatment of obesity results in modest shortterm success followed by recidivism. An exception to this trend is bariatric surgery, which is associated with the greatest success but also the greatest risks and costs. The increasing popularity of this treatment suggests that many patients and third-party payers are accepting the risks and costs to achieve successful weight loss in most cases. The fact that overweight in pediatric groups has nearly tripled in the past 30 years suggests that the demand for bariatric surgery will continue. This supplement focuses on extreme obesity (body mass index [calculated as weight in kilograms divided by the square of height in meters] >40 kg/m) and specifically on bariatric surgery in adults. The number of people with overweight, obesity, and medically complicated obesity is staggering (Figure 1). More than 9 million people in the United States are extremely obese. In addition, up to 15 million people have a body mass index between 35.0 and 39.9 kg/m and at least 1 obesity-related complication, which may potentially qualify them for bariatric surgery. This is the tip of the iceberg in view of the more than 60 million people who are obese and the estimated 130 million people who are overweight or obese. Extreme obesity can potentially affect all organ systems and psychological health, and increasing numbers of people are undergoing bariatric surgical procedures. Therefore, primary care practitioners, subspecialists, dietitians, nurses, physical therapists, and other health care professionals may be involved in the care of bariatric patients. Communication and collaboration among these caregivers is essential. It is important that health care professionals involved in caring for these patients be familiar with the many facets of bariatric surgery, from the initial assessment process to longitudinal follow-up. These and other topics are covered in this supplement, which is based primarily on information available in the medical literature and our clinical experience involving more than 1800 weight-loss surgeries managed by an integrated, multidisciplinary treatment team. The article by Hensrud and Klein presents background information on the epidemiology of extreme obesity and bariatric surgery. Changing lifestyle patterns related to weight management is extremely difficult. Collazo-Clavell et al address this problem and outline an approach for the medical and psychological assessment of patients considering bariatric surgery, emphasizing careful patient selection, adequate patient preparation, emotional support, and advocacy. Kendrick and Dakin review the various surgical approaches used in bariatric surgery, including the most common procedure, the Roux-en-Y gastric bypass, along with a laparoscopic approach to this procedure, which is increasing in popularity. McGlinch et al cover perioperative care and the prevention and treatment of complications. Lack of consistent follow-up after bariatric surgery carries the potential for serious nutritional deficiencies as well as missed opportunities for continued emphasis on lifestyle behavioral changes needed to achieve optimal outcomes. McMahon et al describe important aspects of ongoing care that will help improve health long after the bariatric procedure. Finally, Kushner and Noble cover the long-term results that can be expected after bariatric surgery. The epidemic of obesity affects certain ethnic groups disproportionately, such as African Americans, Hispanic Americans, and other minorities. Findings from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project suggest that the use of bariatric surgery is greater in female patients, privately paying patients, and patients with the highest annual incomes. Racial disparities could not be determined from the data set. With up to 1 in 10 US adults being a potential candidate for bariatric surgery, evaluation should continue into the cost-benefit ratio of this treatment, who is having it done, and how the surgery is allocated in society.