Section 5: Specialty Consultation—What the Consulting Hospitalist Needs to Know

Surgical Management of Obesity

INTRODUCTION

Obesity is a global problem and a major contributor to morbidity and mortality in the United States. The World Health Organization (WHO) estimates that 1.9 billion adults worldwide are overweight (BMI > 25 kg/m²) and 600 million are obese (BMI > 30 kg/m²). In the United States, 67% of adults are overweight, 35% of adults are considered obese, and 6.4% are morbidly obese (BMI > 40 kg/m²). While there is increasing knowledge about obesity and efforts to reduce the epidemic in the United States, the prevalence of obesity has remained largely unchanged over the past 10 years. In addition, the number of obese children has more than doubled over the past 3 decades to 17%. The more than 50 million obese Americans are at risk of developing numerous obesity-related health problems, including hypertension, diabetes, and coronary artery disease (Table 63-1).

Currently, the annual cost for treating obesity and its related comorbid conditions are estimated at $147 billion and those who are obese have approximately $1400 more in annual medical costs. Obesity accounts for more than 100,000 premature deaths annually and is considered the second most preventable cause of death after cigarette smoking.

To date, surgery is the most effective means of achieving and maintaining long-term weight loss in obese patients. It is also consistently found to be more effective than medical weight loss alone for the improvement or remission of type 2 diabetes and other major comorbid illnesses. In a 2014 Cochrane Review of randomized controlled trials, all seven included trials comparing outcomes of bariatric surgery to nonsurgical interventions found significantly more weight loss in the surgical groups (weight loss is often measured as percentage of excess body weight loss, EBWL, calculated as weight loss/excess weight × 100). Another meta-analysis including more recent trials showed that the mean decrease in BMI for all bariatric surgical procedures was 13.4 kg/m² with 55% of EBWL, and 65% of patients experienced remission of diabetes. These outcomes are far superior to medical interventions for obesity and its associated comorbid conditions as long-term maintenance of more than 10% EBWL is uncommon with diet, exercise and other medical interventions alone.

INDICATIONS FOR REFERRAL FOR BARIATRIC SURGERY

Based on the 1991 consensus statement on bariatric surgery for morbid obesity issued by the NIH, it is ...