Two of the world’s leading
authorities on bariatric and metabolic surgery have issued new evidence-based
clinical guidelines for patients with type 2 diabetes beginning at a body mass
index (BMI) of 30. The
ASMBS/IFSO Guidelines on Indications for Metabolic and Bariatric Surgery – 2022, published online in the journals, Surgery for Obesity and Related
Diseases (SOARD) and Obesity Surgery, are meant to replace a consensus statement developed by
National Institutes of Health (NIH) more than 30 years ago that set
standards most insurers and doctors still rely upon to make decisions about who
should get weight-loss surgery, what kind they should get, and when they should
get it.

In the 1991 consensus
statement, bariatric surgery was confined to patients with a BMI of at least 40
or a BMI of 35 or more and at least one obesity-related condition such as
hypertension or heart disease. There were no references to metabolic surgery
for diabetes or references to the emerging laparoscopic techniques and
procedures that would become mainstay and make weight-loss surgery as safe or
safer than common operations including
gallbladder surgery, appendectomy, and knee replacement. The
statement also recommended against surgery in children and adolescents even
with BMIs over 40 because it had not been sufficiently studied.

The ASMBS/IFSO Guidelines now recommend
metabolic and bariatric surgery for individuals with a BMI of 35 or more “regardless of presence, absence, or
severity of obesity-related conditions” and that it be considered for
people with a BMI 30-34.9 and metabolic disease and in “appropriately selected children and adolescents.”

But even without metabolic
disease, the guidelines say weight-loss surgery should be considered starting
at BMI 30 for people who do not achieve substantial or durable weight loss or
obesity disease-related improvement using nonsurgical methods. It was also recommended that obesity definitions using standard BMI
thresholds be adjusted by population and that Asian individuals consider
weight-loss surgery beginning at BMI 27.5.

The new guidelines further state “metabolic and bariatric surgery is
currently the most effective evidence-based treatment for obesity across all
BMI classes” and that “studies with
long-term follow up, published in the decades following the 1991 NIH Consensus
Statement, have consistently demonstrated that metabolic and bariatric surgery
produces superior weight loss outcomes compared with non-operative treatments.”

It is also noted that multiple studies have
shown significant improvement of metabolic disease and a decrease in overall
mortality after surgery and that “older
surgical operations have been replaced with safer and more effective
operations.” Two laparoscopic procedures, 6sleeve
gastrectomy and 7Roux-en-Y Gastric Bypass
(RYGB), now account for about 90% of all operations performed worldwide.


Teresa LaMasters et al,2022 American
Society for Metabolic and Bariatric Surgery (ASMBS) and International
Federation for the Surgery of Obesity and Metabolic Disorders (IFSO):
Indications for Metabolic and Bariatric Surgery,Surgery for Obesity and Related

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