November 05, 2019
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Updated guideline highlights nonsurgical options, perioperative care for bariatric procedures

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Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity, and clinical decision-making should be evidence-based within the context of a chronic disease, according to an updated clinical practice guideline published in Endocrine Practice.

Jeffery Mechanick
Jeffrey I. Mechanick

The new clinical practice guideline is based on an increased number and quality of available scientific studies available since the last update in 2013. The recommendations guide health care providers in the clinical care of patients with obesity who undergo surgical and nonsurgical bariatric procedures, according to the authors. The guideline identifies candidates for bariatric procedures, discusses which types of procedures should be offered, outlines management of patients before procedures, and recommends how to optimize patient care during and after procedures.

“This is an updated methodology,” Jeffrey I. Mechanick, MD, FACP, MACE, FACN, ECNU, professor of medicine at the Icahn School of Medicine at Mount Sinai and a past president of AACE and the American College of Endocrinology (ACE), told Endocrine Today. “We have much more granularity in terms of the type of papers we put in and the weight of evidence. We look forward to the implementation of these guidelines.”

The guideline has 85 numbered recommendations of which 61 are revised and 12 are new.

Disease context

The guideline reflects a 2017 position paper published by the American Association of Clinical Endocrinologists and the American College of Endocrinology advocating for a new diagnostic term “adiposity-based chronic disease,” or ABCD. The term is intended to more accurately represent obesity as a true health threat, and account for the distribution of fat and the abnormal function of fat in addition to BMI alone. The ABCD terminology has also been adopted by the European Association for the Study of Obesity.

“All prior bariatric surgery guidelines, including every obesity guideline that is out there, is in the context of obesity itself as a disease with just the narrow perspective of looking at increased BMI,” Mechanick said. “At AACE, we redefined it and restructured the framework to look at any chronic disease where adiposity is the main driver. With these diseases, you want as early and as sustainable a prevention as possible. So where do bariatric procedures fit in? Even though it is later, you are still preventing complications from getting worse and preventing further morbidity within the context of obesity.”

The guideline notes that the role for surgical and nonsurgical bariatric procedures has been reexamined in a complications-centric framework of ABCD and dysglycemia-based chronic disease, or DBCD, providing “the potential for greater precision for clinical decision-making based on biological correlates, clinical relevance, cardiometabolic risk assessment and ethnicity-related differences in anthropometrics.”

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“For example, someone from South Asia may not meet BMI criteria, but has increased waist circumference and uncontrolled type 2 diabetes with significant cardiovascular risk,” Mechanick said. “For that person, you may want to start thinking about a bariatric procedure sooner rather than later.”

Nonsurgical therapies

The guideline includes an expanded section on procedure selection, Mechanick said, with a special focus on nonsurgical therapies that reflect numerous updates in the space during the past 6 years.

“We changed the title of this guideline from bariatric surgery to bariatric procedures, and that is because there has been an advent of new, nonsurgical bariatric procedures that are not only approved, but are becoming more popular,” Mechanick said. “We still haven’t figured out exactly where these procedures fit into the strategy, but we take great pains to have a nuance-based table to assist the reader more with decision-making, something we have avoided in the past. Now, because we have more data, we are able to create that kind of table and be more inclusive.”

There are many bariatric surgical and nonsurgical procedures that are reimbursed by third-party payers, use FDA-approved devices, or remain available through clinical investigative protocols. Advancements in nonsurgical approaches to obesity include development of endoscopic bariatric therapies, approval of newer anti-obesity medications, and even development of more successful structured lifestyle interventions.

The guideline highlights three endoscopic bariatric therapies designed to reduce gastric volume: intragastric balloons, which reduce the stomach’s capacity via a space-occupying device; endoscopic sleeve gastrectomy, which remodels the stomach utilizing endoscopic suturing/plication devices; and aspiration therapy, which diverts excess calories away from the stomach.

“Other nonsurgical resources for treatment of obesity are anti-obesity medications, which are well defined in guidelines for obesity treatment based on demonstrable weight-loss efficacy and associated metabolic improvements,” the researchers wrote. “Four medications have been approved by the FDA since 2012: phentermine/topiramate ER, lorcaserin [Belviq, Eisai], naltrexone/bupropion ER [Contrave, Nalpropion Pharmaceuticals], and liraglutide 3 mg [Saxenda, Novo Nordisk].”

Perioperative protocols

The authors outlined interventions to improve postoperative outcomes with an emphasis on perioperative enhanced recovery after bariatric surgery, or ERABS, via clinical pathways, Mechanick said.

For the first time, the guideline authors recommend that a “lifestyle medicine checklist” be completed as part of a formal medical clearance process for all patients considered for any bariatric procedure. Additionally, the guideline now advises that comprehensive preoperative optimization, or “prehabilitation,” should be implemented before surgery, including deep breathing exercises, continuous positive airway pressure as appropriate, incentive spirometry, leg exercises, continued oral nutrition with carbohydrates, opioid-sparing multimodal analgesia and thromboprophylaxis.

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As part of ERABS protocol, clinicians should perform routine pulmonary recruitment maneuvers intraoperatively as needed, according to the guideline. Intraoperative use of dexmedetomidine may be considered to decrease perioperative opioid use, and intraoperative protocols to detect possible silent bleeding sites should be followed.

“There is a lot of data on this, and we incorporated as much as we could into the recommendations for perioperative care,” Mechanick said. “It took years to put this together, and we are playing catch up. While we were writing it, we had new data coming in, and we tried to synchronize as best we could.”

The guideline is co-sponsored by The Obesity Society, the American Society for Metabolic and Bariatric Surgery and, for the first time, by the Obesity Medicine Association and the American Society of Anesthesiologists. The guideline is also endorsed by the American Society of Nutrition, the Obesity Action Coalition and the American Society for Parenteral and Enteral Nutrition. – by Regina Schaffer

Disclosures: Mechanick reports he has received honoraria from Abbott Nutrition for lectures and program development. Please see the guideline for all other authors’ relevant financial disclosures.