Bariatric surgery – An update for the endocrinologist

Abstract

Obesity is a major public health problem, is associated with increased rates of mortality risk and of developing several comorbidities, and lessens life expectancy. Bariatric surgery is the most effective treatment for morbidly obese patients, reducing risk of developing new comorbidities, health care utilization and mortality. The establishment of centers of excellence with interdisciplinary staff in bariatric surgery has been reducing operative mortality in the course of time, improving surgical safety and quality. The endocrinologist is part of the interdisciplinary team. The aim of this review is to provide endocrinologists, physicians and health care providers crucial elements of good clinical practice in the management of morbidly obese bariatric surgical candidates. This information includes formal indications and contraindications for bariatric operations, description of usual bariatric and metabolic operations as well as endoscopic treatments, preoperative assessments including psychological, metabolic and cardiorespiratory evaluation and postoperative dietary staged meal progression and nutritional supplementation follow-up with micronutrient deficiencies monitoring, surgical complications, suspension of medications in type 2 diabetic patients, dumping syndrome and hypoglycemia. Arq Bras Endocrinol Metab. 2014;58(9):875-88 Keywords Bariatric surgery; Roux-en-Y gastric bypass; biliopancreatic diversions; obesity; weight loss RESUMO A obesidade é um problema de saúde pública, está associada com aumento do risco de mortalidade e de desenvolver diversas comorbidades e diminui a expectativa de vida. A cirurgia bariátrica é o tratamento mais eficaz para pacientes com obesidade mórbida, reduzindo o desenvolvimento de novas comorbidades, a utilização dos cuidados de saúde e a mortalidade. A criação de centros de excelência com equipes interdisciplinares em cirurgia bariátrica vem reduzindo a mortalidade operatória no decorrer do tempo, melhorando a segurança e a qualidade cirúrgica. O endocrinologista faz parte da equipe interdisciplinar. O objetivo desta revisão é fornecer aos endocrinologistas, médicos e prestadores de cuidados de saúde elementos cruciais de boas práticas clínicas no tratamento de pacientes com obesidade mórbida candidatos à cirurgia bariátrica. Essas informações incluem indicações formais e contraindicações para as operações bariátricas, descrição das operações bariátricas e metabólicas habituais, bem como tratamentos endoscópicos, avaliação pré-operatória, incluindo avaliação cardiorrespiratória psicológica, metabólica e no pós-operatório, dieta com refeições progressivamente estagiadas e seguimento com suplementação nutricional e monitoramento de deficiências de micronutrientes, complicações cirúrgicas, suspensão de medicamentos em pacientes diabéticos tipo 2, síndrome de dumping e hipoglicemia. Arq Bras Endocrinol Metab. 2014;58(9):875-88 Descritores Cirurgia bariátrica; bypass gástrico em Y de Roux; desvios biliopancreáticos; obesidade; perda de peso

Application of BAROS’ questionnaire in obese patients undergoing bariatric surgery with 2 years of evolution

“…Overweight and obesity have significantly increased morbidity and mortality around the world due to its associated medical conditions (12) .…”

Dealing with diabetes and pregnancy following bariatric surgery: a double-edged sword?

“…Recently, some cardiovascular safety trials with diabetes medications have demonstrated that these drugs offer cardiovascular protection (2); more data on hard outcomes are required to better assess not only the efficacy, but mainly the safety in very large series before endorsing the widespread indication of bariatric surgery in the subpopulation of type 2 diabetics with a BMI below 35 kg/m 2 . A significant proportion of individuals undergoing bariatric surgery experiment weight regain, residual diabetes or diabetes relapse (i.e., around one third of initial remitters over five years do not achieve remission or have diabetes recurrence), requiring to cope with the residual diabetes and emerging obesity (2,3) and also to deal with lifelong nutritional deficiencies and other potential long-term complications, such as vomiting, adhesions, strictures, gallstones, hernias, drinking problems, and small-bowel obstruction (4,5). In the scope under discussion, it is essential that the diagnosis of diabetes in patients undergoing bariatric surgery be reliable and safe.…”

“…In recent years, episodes of severe late postprandial hypoglycemia have been increasingly reported in gastric bypass patients. In the evaluation of these most frequently asymptomatic hypoglycemic events, fasting and post-prandial self-monitoring reflectance meter glucose determinations in the home setting, or fasting and post-prandial blood glucose concentration measurements can be requested occasionally and, if symptoms of hypoglycemia occur likewise (5,7,8). These patients could also be evaluated by ambulatory continuous measuring of interstitial fluid glucose systems (5,8) or a mixed meal test, preferably liquid (7).…”

“…The same approach has been considered valid in the evaluation of remission and relapse of type 2 diabetes mellitus, as well as measurement of glycated hemoglobin levels (5,8). Over the years, many different criteria of diabetes remission have been proposed based on maintaining fasting glucose and glycated hemoglobin levels below stricter or less strict thresholds for shorter or longer periods of time (e.g.…”

“…Even if significant weight loss reduces the risk of gestational diabetes mellitus (GDM), most women remain overweight after bariatric surgery, and, thus, should be screened for GDM. The assessment can be accomplished between 24 and 28 weeks of gestation by fasting and post-prandial reflectance meter glucose determinations or blood glucose concentrations or also be evaluated by ambulatory continuous measuring of interstitial fluid glucose systems (5,8). Many women who were unable to get pregnant before surgery conceive after bariatric procedures, suggesting a beneficial influence on fertility outcomes.…”