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Mechanick 2020 AACE TOS ASMBS Guidelines

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Mechanick 2020 AACE TOS ASMBS Guidelines

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Cláudia Neves

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Surgery for Obesity and Related Diseases 16 (2020) 175–247

Guidelines

Clinical practice guidelines for the perioperative nutrition, metabolic,

and nonsurgical support of patients undergoing bariatric procedures –
2019 update: cosponsored by American Association of Clinical
Endocrinologists/American College of Endocrinology, The Obesity
Society, American Society for Metabolic & Bariatric Surgery, Obesity
Medicine Association, and American Society of Anesthesiologists
Jeffrey I. Mechanick, M.D., F.A.C.P., F.A.C.N., M.A.C.E.a,b,*, Caroline Apovian, M.D.c,
Stacy Brethauer, M.D.d, W. Timothy Garvey, M.D., F.A.C.E.e,f,
Aaron M. Joffe, D.O., F.C.C.M.g, Julie Kim, M.D.h, Robert F. Kushner, M.D.i,
Richard Lindquist, M.D., F.A.A.S.P.j, Rachel Pessah-Pollack, M.D., F.A.C.E.k,
Jennifer Seger, M.D.l, Richard D. Urman, M.B.A., M.D., C.P.E.m, Stephanie Adams, Ph.D.n,
John B. Cleek, M.D.e, Riccardo Correa, M.D., F.A.C.E.o,
M. Kathleen Figaro, M.S., M.D., F.A.C.E.p, Karen Flanders, M.S.N., C.N.P., C.B.N.q,
Jayleen Grams, M.D., Ph.D.r,s, Daniel L. Hurley, M.D., F.A.C.E.t,
Shanu Kothari, M.D., F.A.C.S., F.A.S.M.B.S.u,
Michael V. Seger, M.D., F.A.C.S., F.A.S.M.B.S.v,
Christopher D. Still, D.O., F.A.C.N., F.A.C.P.w,x
a
Marie-Josee and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, New York, New York
b
Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai,
New York, New York
c
Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
d
Ohio State University, Columbus, Ohio
e
Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama
f
UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
g
University of Washington, Harborview Medical Center, Seattle, Washington
h
Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
i
Northwestern University Feinberg School of Medicine, Chicago, Illinois
j
Providence Health Services, Seattle, Washington
k
Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
l
Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
m
Brigham and Women’s Hospital, Boston, Massachusetts
n
American Association of Clinical Endocrinologists, Jacksonville, Florida
o
University of Arizona College of Medicine, Phoenix, Arizona

These Guidelines are endorsed by The American Society for Nutrition * Correspondence: Jeffrey I. Mechanick, M.D., F.A.C.P., M.A.C.E.,
(ASN), the Obesity Action Coalition (OAC), International Federation for F.A.C.N., Divisions of Cardiology and Endocrinology, Diabetes, and
the Surgery of Obesity and Metabolic Disorders (IFSO), International Soci- Bone Disease, Icahn School of Medicine at Mount Sinai, Box 1030, New
ety for the Perioperative Care of the Obese Patient (ISPCOP), and the Amer- York, NY 10029.
ican Society for Parenteral and Enteral Nutrition (ASPEN). E-mail address: [email protected] (J.I. Mechanick).

https://doi.org/10.1016/j.soard.2019.10.025
1550-7289/Ó 2019 Published by Elsevier Inc. on behalf of American Society for Bariatric Surgery.

p
Heartland Endocrine Group, Davenport, Iowa
q
Massachusetts General Hospital Weight Center, Boston, Massachusetts
r
Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
s
Birmingham VA Medical Center, Birmingham, Alabama
t
Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
u
Gundersen Health System, La Crosse, Wisconsin
v
Bariatric Medical Institute of Texas, San Antonio, Texas, University of Texas Health Science Center, Houston, Texas
w
Center for Nutrition and Weight Management Director, Geisinger Obesity Institute, Danville, Pennsylvania
x
Employee Wellness, Geisinger Health System, Danville, Pennsylvania

Abstract Objective: The development of these updated clinical practice guidelines (CPG) was commissioned
by the American Association of Clinical Endocrinologists, The Obesity Society, the American Soci-
ety of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society
of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endo-
crinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.
Methods: Each recommendation was evaluated and updated based on new evidence from 2013 to the
present and subjective factors provided by experts.
Results: New or updated topics in this CPG include contextualization in an adiposity-based, chronic
disease complications–centric model, nuance-based, and algorithm/checklist-assisted clinical
decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariat-
ric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena.
There are 85 numbered recommendations that have updated supporting evidence, of which 61 are
revised and 12 are new. Noting that there can be multiple recommendation statements within a single
numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and
101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level
(EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).
Conclusions: Bariatric procedures remain a safe and effective intervention for higher-risk patients
with obesity. Clinical decision–making should be evidence-based within the context of a chronic dis-
ease. A team approach to perioperative care is mandatory with special attention to nutritional and
metabolic issues. (Surg Obes Relat Dis 2020;16:175–247.) Ó 2019 Published by Elsevier Inc. on
behalf of American Society for Bariatric Surgery.

Key words: Bariatric surgery; Obesity; Guidelines; Metabolic surgery; Nutrition

Lay Abstract interventions, and leads to substantial cost savings.

Improved cardiovascular outcomes and quality of life have
Obesity is an officially recognized global disease and
also been reported in patients undergoing bariatric surgery.
continues to be a risk factor for chronic medical conditions
New and emerging surgical and nonsurgical bariatric pro-
such as cardiovascular diseases, diabetes, chronic kidney
cedures are described. Criteria for bariatric procedures are
disease, nonalcoholic fatty liver disease, metabolic syn-
better defined. This update includes checklists to assist
drome, and many cancers. This updated guideline is based
healthcare professionals achieve greater precision in clinical
on an increased number and quality of the best available
decision-making and discusses the importance of a team
scientific studies to guide physicians in the clinical care of
approach to patient care with special attention on nutrition,
patients with obesity who undergo surgical and nonsurgical
metabolism, and interventions to improve recovery after
bariatric procedures. This guideline identifies patient candi-
bariatric surgery. Enhanced recovery after bariatric surgery
dates for bariatric procedures, discusses which types of
procedures are discussed in detail. Bariatric procedures
bariatric procedures should be offered, outlines manage-
remain a safe and effective intervention for higher-risk pa-
ment of patients before procedures, and recommends how
tients with obesity.
to optimize patient care during and after procedures. Since
publication of the previous guideline in 2013, the role of
bariatric surgery in the treatment of patients with type 2 Introduction
diabetes has grown substantially. Studies have demonstrated This 2019 clinical practice guideline (CPG) update pro-
that bariatric/metabolic surgery achieves superior improve- vides revised clinical management recommendations that
ments in glycemic control of patients with type 2 diabetes incorporate evidence from 2013 to the present, a period
and obesity, compared with various medical and lifestyle marked by a significant increase in the total number of

Table 1
Increased PubMed citations on bariatric surgery with each clinical practice guidelines update*
Years Non-English (% total) RCT (% D) Meta-analysis (% D) Review (% D) Guideline (% D) Total (% D)
,2008 975 (13) 204 20 1148 34 7746
2008–2012 576 (8) 201 (2.01) 46 (130) 1210 (5) 40 (18) 7254 (26)
2013–2018 605 (4) 746 (271) 218 (374) 2396 (98) 44 (0.1) 14,105 (94)
All Years 2156 (7) 1154 284 4754 118 29,105
RCT 5 randomized controlled trial.
Non-English figures were the difference of unfiltered amounts and the “English” language filter. Non-English percentages use “Total”
publications as the denominator. Percentage change (% D) uses the figure at the previous publication date range as the denominator. Simple
analysis shows that the greatest increase in total, RCT, meta-analysis, and reviews occurred since publication of the last American Asso-
ciation of Clinical Endocrinologists/American Society of Metabolic and Bariatric Surgery/The Obesity Society bariatric surgery clinical
practice guidelines update in 2013 [1]. The number of guidelines and non-English publications on bariatric surgery has remained generally
constant over the years.
* The search term used was “bariatric surgery” on December 31, 2018. Standard PubMed filters were used with customized publication
dates

publications on bariatric surgery, especially randomized (TOS)/American Society of Metabolic and Bariatric Sur-
controlled trials (RCTs), meta-analyses, and reviews gery (ASMBS) bariatric surgery CPG [1], obesity has
(Table 1). In addition, this update requires reinterpretation continued to be a major national and global health chal-
of the utility and decision-making process within the context lenge, as well as a risk factor for an expanding set of chronic
of an evolving obesity-care model, increasingly detailed diseases, including cardiovascular disease (CVD), diabetes,
management strategies and protocols, and the need for a chronic kidney disease, nonalcoholic fatty liver disease
more transparent tactical plan in a probing and scrutinizing (NAFLD), metabolic syndrome (MetS), and many cancers,
healthcare environment. New diagnostic terms, structured among other co-morbid conditions. Obesity is now included
lifestyle approaches, pharmaceutical options, and surgical among the global noncommunicable disease targets identi-
and nonsurgical procedures have reshaped the obesity-care fied by the World Health Organization (WHO) [2–4]. In
space. A general overview of the clinical pathway for bariat- 2015, a total of 107.7 million children and 603.7 million
ric surgery is provided in Fig. 1. Readers are advised to refer adults had obesity worldwide [5]. The prevalence of obesity
to earlier editions of this CPG for additional supporting ev- in the United States is among the highest in the world. Ac-
idence, including the basics of bariatric surgery mechanisms cording to the National Health and Nutrition Examination
of actions, risks, and benefits. Survey 2013–2016 data set, 38.9% of U.S. adults and
18.5% of youth aged 2 to 19 years had obesity [6,7]. This
Update on obesity as a disease and clinical assessment translates into 93.3 million adults and 13.7 million children
Since the publication of the 2013 American Association and youth, respectively. More women (40.8%) than men
of Clinical Endocrinologists (AACE)/The Obesity Society (36.5%) were obese, with non-Hispanic black women
(55.9%) showing the highest prevalence [6,7]. Although
the prevalence of obesity has been steady among adults
since 2011 to 2012, prevalence in certain subpopulations
continue to rise, particularly for those with severe (class
III, body mass index [BMI] 40 kg/m2) obesity, among
whom overall age-adjusted rates of prevalence are 5.5%
and 9.8% for men and women, respectively, and 16.8%
for non-Hispanic women [8].
The global burden of obesity is driven by the association
between BMI and increased morbidity and mortality.
Although BMI is simplistic (it is only an anthropometric
calculation of height-for-weight; or more specifically,
weight in kilograms divided by height in meters squared
and has been criticized as an insensitive marker of disease,
it currently provides the most useful population-level mea-
surement of overweight and obesity, and its utility as an es-
timate of risk has been validated in multiple large population
studies across multiple continents. The J-shaped curve for
BMI and mortality has recently been confirmed in a large
Fig. 1. Bariatric procedure decision-making. BMI 5 body mass index. meta-analysis [9] and a systematic review [10] that included

10.6 million and 30 million participants, respectively. These behavioral. The staging system was shown to predict
2 studies confirm that both overweight and obesity increase increased mortality in 2 large population cohorts [20,21].
the risk of all-cause mortality and should be prioritized on a The need to shift from BMI- to complications-centric deci-
population level. sion-making has applications beyond the United States
Based on the complexity of body-weight regulation, where, for example, in China, acceptance levels for bariatric
increased morbidity and mortality associated with obesity, surgery are principally based on the need for and expecta-
and the substantial burden on public health, obesity was offi- tions of weight loss, rather than treatment of severe
cially recognized as a disease by the American Medical As- obesity-related complications (ORC) [22,23].
sociation in 2013 and multiple other organizations, most
recently the World Obesity Federation [11]. Several guide- Update on nonsurgical therapies
lines for treatment of obesity have also been published as
Many bariatric surgical and nonsurgical procedures are
a resource for clinicians since 2013. Most notable are the
reimbursed by third-party payors, use U.S. Food and Drug
American Heart Association/American College of Cardiol-
Administration (FDA)-approved devices, or remain avail-
ogy/TOS Guideline for the Management of Overweight
able through clinical investigative protocols (Fig. 2). Ad-
and Obesity in Adults [12], the AACE and American Col-
vancements in nonsurgical approaches to obesity include
lege of Endocrinology (ACE) Clinical Practice Guidelines
development of endoscopic bariatric therapies and approval
for Comprehensive Care of Patients with Obesity [13], the
of newer antiobesity medications. Various endoscopic bar-
Obesity Medicine Association Obesity Management Algo-
iatric therapies function to reduce gastric volume by 1 of
rithm [14], and the Pharmacological Management of
the following 3 techniques: (1) reduce the stomach’s capac-
Obesity guidelines from the Endocrine Society [15]. In
ity via space-occupying devices, such as IGB, (2) remodel
2017, the American Gastroenterological Association issued
the stomach using endoscopic suturing/plication devices,
a Practice Guide on Obesity and Weight Management, Ed-
such as endoscopic sleeve gastroplasty, and (3) divert excess
ucation, and Resources that emphasized a comprehensive
calories away from the stomach, such as aspiration therapy
approach to assessment, treatment, and prevention [16].
[17]. Three gastric balloons have been approved by the FDA
This American Gastroenterological Association guideline
since 2015 for patients with a BMI 30 to 40 kg/m2, including
is particularly important for the increasing number of gas-
the ReShape Duo (ReShape Medical, San Clemente, CA,
troenterologists who are performing endoscopic procedures
USA), the Orbera intragastric balloon (Apollo EndoSurgery,
for the treatment of obesity that include placement of intra-
Austin, TX, USA), and the Obalon Balloon (Obalon Thera-
gastric balloons (IGB), plications and suturing of the stom-
peutics, Inc., Carlsbad, CA, USA). Although these endo-
ach, and insertion of a duodenal-jejunal bypass liner, among
scopically placed devices are associated with short-term (6
other emerging procedures [17].
mo) weight loss, their utility and safety in long-term obesity
In addition to these guidelines, efforts are also underway
management remain uncertain [24]. The other nonsurgical
to develop more practical and useful assessments to identify
resources for treatment of obesity are antiobesity medica-
patients who require increased medical attention for
tions, which are well defined in guidelines for obesity treat-
obesity-related conditions. Analogous to other staging sys-
ment based on demonstrable weight loss efficacy and
tems commonly used for congestive heart failure or chronic
associated metabolic improvements. Four medications
kidney disease, the AACE/ACE obesity CPG proposes an
have been approved by the FDA since 2012, including phen-
obesity-staging system that is based on ethnic-specific
termine/topiramate ER, lorcaserin, naltrexone/bupropion
BMI cutoffs along with assessment for adiposity-related
ER, and liraglutide 3.0 mg [25]. Antiobesity medications
complications [13]. Stage 0 is assigned to individuals who
are approved by the FDA for patients with a BMI 30 kg/
have overweight or obesity by BMI classification but have
m2 without ORC or 27 kg/m2 when associated with at
no complications, whereas Stage 1 and 2 are defined as in-
least 1 ORC. Based primarily on retrospective data and per-
dividuals who are overweight or obese by BMI classification
sonal experience, these medications are increasingly used in
and have 1 mild-to-moderate complications (Stage 1) or at
patients who have undergone bariatric surgery but have
least 1 severe complication (Stage 2). Building off this
experienced either insufficient weight loss or frank weight
complications-centric approach to obesity care, AACE/
regain.
ACE recently proposed a new diagnostic term for obesity
using the abbreviation “ABCD,” which stands for
Update on bariatric surgery
“adiposity-based chronic disease” [18]. A different func-
tional staging system for obesity was proposed by Sharma Significant additions to the evidence base have occurred
and Kushner [19]. Using a risk-stratification construct, since the publication of the 2013 TOS/ASMBS/AACE bar-
referred to as the “Edmonton Obesity Staging System,” in- iatric surgery CPG [1]. A PubMed computerized literature
dividuals with obesity are classified into 5 graded cate- search (performed between January 1, 2013 and December
gories, based on their morbidity and health-risk profile 31, 2018) using the search term “bariatric surgery”
along 3 domains, including medical, functional, and revealed a total of 14,105 citations. Update of this 2019

Fig. 2. Current surgical and endoscopic bariatric procedures. The 4 surgical procedures shown are endorsed by the American Society of Metabolic and Bariatric
Surgery. Laparoscopic sleeve gastrectomy comprises 70% of currently performed procedures, followed by laparoscopic gastric bypass (25%), adjustable gastric
banding (3%), and duodenal switch (2%). Endoscopic procedures include aspiration therapy (AspireAssist*), space-occupying gastric devices (Ellipse, Obalon,
Orbera, Reshape, Spatz balloons, and Gelesis capsule), gastric-emptying devices (Transpyloric Shuttle**), and suturing/plication procedures (Endoscopic
Sleeve Gastroplasty with Apollo Overstitch and primary obesity surgery endoluminal procedure with the Incisionless Operating Platform***). *Food and
Drug Administration–approved devices; **Food and Drug Administration trial underway; and ***Devices Food and Drug Administration approved for tissue
approximation.
Surgical procedure illustrations reprinted with permission from Atlas of Metabolic and Weight Loss Surgery, Jones et al. Cine-Med, 2010. Copyright of the book
and illustrations are retained by Cine-Med.

CPG focuses on the most significant advances and changes Based on these data, the Second Diabetes Surgery Summit
in clinical care of the patient who undergoes bariatric sur- Consensus Conference published guidelines in 2015 that
gery. Regarding procedure type, the sleeve gastrectomy were endorsed by .50 other organizations interested in
(SG) has continued to trend upward while the Roux-en-Y the treatment of T2D [29]. According to these guidelines,
gastric bypass (RYGB) and laparoscopic adjustable gastric metabolic surgery should be considered in patients with
band (LAGB) trended downward. In 1 large database from T2D and obesity (BMI .35.0 kg/m2) when hyperglycemia
2015, the SG accounted for 63% of procedures performed, is inadequately controlled with lifestyle and optimal medi-
compared to 30% and 2% for RYGB and LAGB, respec- cal therapy. The 2016 Standards of Care for Diabetes from
tively [26]. The increase in SG is principally due to com- the American Diabetes Association includes bariatric sur-
parable metabolic and weight loss outcomes, lower gery in the treatment algorithm for T2D. Warren et al.
complication rates [27], and fewer nutritional deficiencies [30] demonstrated that in a population-based model where
compared with RYGB. an increased number of bariatric surgeries are performed
One of the most significant advances since the 2013 CPG in patients with T2D, there is a substantial cost savings
has been the growing role of bariatric surgery in the treat- over a 10-year period, roughly $5.4 million per 1000
ment of patients with type 2 diabetes (T2D). A substantial patients.
body of evidence from 12 RCTs demonstrates that bariat- There have also been 2 cohort studies, 6 RCTs, and 5
ric/metabolic surgery achieves superior improvements in meta-analyses published since 2013 that report mortality
glycemic-control metrics in patients with T2D, compared and cardiovascular outcomes, such as myocardial infarction,
with various medical and lifestyle interventions. The stroke, CVD risk and events, hypertension (HTN), and dys-
improvement in glycemic control appears to be due to lipidemia [31–43]. Despite heterogeneity in study design,
both weight loss–dependent and –independent effects [28]. these data favor significantly improved CVD outcomes in

patients undergoing bariatric surgery. DiaSurg 2, a undergone bariatric surgery [53]. This team-based approach
randomized controlled multicenter trial comparing RYGB to bariatric surgery that also includes dieticians, mental
versus medical treatment in German patients with insulin- health professionals, and advanced practitioners (e.g., nurse
requiring T2D with BMI 26 to 35 kg/m2, is currently under- practitioner and physician assistant) is important in periop-
way [44]. The primary endpoint is composite time-to-event erative management. Thus, the tactical approach to an
using 8-year data, including CVD mortality, myocardial obesity epidemic that can effectively implement evidence-
infarction, coronary bypass, percutaneous coronary inter- based strategies, as well as increase exposure of healthcare
vention, nonfatal stroke, amputation, and surgery for periph- professionals (HCP) to patients having bariatric surgery,
eral atherosclerotic artery disease. mandates leadership roles of experts and champions for
The evolving role of bariatric procedures, or more obesity care, development of formal obesity-care teams,
generally speaking gastrointestinal (GI) procedures to and a friendly logistical infrastructure to facilitate favorable
decrease cardiometabolic risk, is more clearly envisioned outcomes.
within the nexus of ABCD and a newly proposed model
of dysglycemia-based chronic disease (DBCD) [45]. In
Methods
this model, abnormal adiposity intersects with stage I
DBCD as a driver for insulin resistance, T2D, and CVD The boards of directors for the AACE, TOS, ASMBS,
[45]. The recent findings of a large, multicenter, retrospec- Obesity Medicine Association, and American Society of
tive matched-cohort study by Fisher et al. [46] corroborate Anesthesiologists (ASA) approved this update of the 2008
this concept. They found a lower risk of macrovascular [54] and 2013 [1] AACE/TOS/ASMBS Medical Guidelines
outcomes associated with bariatric surgery in patients for Clinical Practice for the Perioperative Nutritional, Meta-
with T2D and severe obesity [46]. From a pragmatic bolic, and Nonsurgical Management of the Bariatric Sur-
standpoint, once this ABCD–DBCD model can be scientif- gery Patient. Selection of the co-chairs, primary writers,
ically validated, decision-making for the use of GI inter- and reviewers and the logistics for creating this 2019
ventional procedures on cardiometabolic risk reduction evidence-based CPG update were conducted in strict adher-
will be based on complication risk assessments, rather ence with the AACE Protocol for Standardized Production
than just hemoglobin A1C (HbA1C), BMI, or other of Clinical Practice Guidelines, Algorithms, and Checklists
simplistic metrics. — 2017 Update (2017 Guidelines for Guidelines [2017 G4
Quality of life was reported in 2 RCTs and was improved G]) [55] (Tables 2–5). This updated CPG methodology
in the patients undergoing bariatric surgery [33,34]. The provides for patient-first language (“patient undergoing bar-
impact of bariatric surgery on skeleton and fracture risk iatric procedures” instead of disease-first language, “bariat-
has also been recently studied [47–49]. Follow-up data ric patient”) and greater detail for evidence ratings and
from the National Institutes of Health–supported, prospec- structure for the involvement of the ACE Scientific Refer-
tive cohort Longitudinal Assessment of Bariatric Surgery encing Subcommittee, a dedicated resource for the rating
continue to inform clinical care regarding various aspects of evidence, mapping of grades, and general oversight of
of postoperative management, including weight loss trajec- the entire CPG production process. In addition, the term
tories [50], behavioral variables, 3-year weight changes “bariatric procedure” is used to broadly apply to both surgi-
[51], and risks for developing alcohol-use disorder [52]. cal and nonsurgical procedures. However, when the evi-
Last, postoperative weight regain is recognized as a signifi- dence specifically pertains to surgical procedures, the term
cant clinical issue that requires focused attention. “bariatric surgery” is used. A critical improvement in the
2017 G4GAC is to create documents that are easier to use
and less cumbersome. Nevertheless, as with all white papers
The American Board of Obesity Medicine
and increasing diligence on the part of the writing team and
Based on the increased prevalence and burden of over- sponsoring professional medical organizations, there re-
weight and obesity among U.S. adults and children, a mains an element of subjectivity that must be recognized
distinct need for more advanced competency in the field by the reader when interpreting the information.
of obesity, burgeoning approaches in obesity care expected Key updates are provided to highlight the most important
to continue over the next decade, and complex perioperative new recommendations in this CPG. The Executive Sum-
care of the patient undergoing bariatric surgery, the Amer- mary is reorganized into 7 clinical questions and provides
ican Board of Obesity Medicine was established in 2011 updated recommendation numbers (R1, R2, R3, . R85)
(www.abom.org). Certification as an American Board of in their entirety followed by the respective publication
Obesity Medicine diplomate signifies specialized knowl- year of the creation or last update in parentheses and an indi-
edge in the practice of obesity medicine and distinguishes cation of updated explanations and/or references by an
a physician as having achieved competency in obesity asterisk. In many cases, recommendations have been
care. As of 2018, .2600 physicians have become diplo- condensed for clarity and brevity. In other cases, recommen-
mates, of whom over half co-manage patients who have dations have been expanded for more clarity to assist with

Table 2 Key updates for 2019

Step I AACE G4GAC: evidence rating*
Numerical Semantic Methodology descriptor Technical: There is an increased amount and quality of
descriptory descriptor
recent evidence to guide clinical decision-making. The
Strong evidence analysis of evidence is based on the updated 2017
1 (1) RCT Randomized controlled trialz
G4GAC, and there are now 5 sponsoring professional med-
1 (1) MRCT Meta-analysis of only randomized
controlled trials ical societies that provide a greater fund of expert knowl-
Intermediate evidence edge and higher level of diligence in the iterative review
2 (2) MNRCT Meta-analysis including nonrandomized process.
prospective or case-controlled trials Disease context: The role for surgical and nonsurgical bar-
2 (new) NMA Network meta-analysis
iatric procedures has been re-examined in a complications-
2 (2) NRCT Nonrandomized controlled trial (or
unconfirmed randomization) centric framework of ABCD and DBCD, providing the
2 (2) PCS Prospective cohort study (does not potential for greater precision for clinical decision-
include open-label extension study) making based on biological correlates, clinical relevance,
2 (2) RCCS Retrospective case-control study cardiometabolic risk assessment, and ethnicity-related
2 (new) NCCS Nested case-control study
differences in anthropometrics.
2 (3; reassigned) CSS Cross-sectional study
Procedure selection: New and emergent surgical and nonsur-
2 (3; reassigned) ES Epidemiologic study (hypothesis driven;
includes survey, registry, data-mining, gical bariatric procedures are introduced and described,
with or without retrospective nuanced criteria for bariatric procedures are better defined,
univariate or multivariate analyses or and an algorithm with supporting tables and checklists are
propensity matching)
provided to assist the reader with decision-making.
2 (new) OLES Open-label extension study
Perioperative protocols: Proactive interventions to
2 (new) PHAS Post hoc analysis study
improve postoperative outcomes with an emphasis on peri-
Weak evidence
3 (new) DS Discovery science (explorative/ operative enhanced recovery after bariatric surgery
inductive; includes -omics, “big data,” (ERABS) clinical pathways are presented and explicated.
network analysis, systems biology,
Bayesian inference, modeling) Executive summary
3 (new) ECON Economic study (includes Markov
models, pharmaco-economics) There are 85 numbered recommendations in this 2019 up-
3 (3) CCS Consecutive case series (N . 1) date, compared with 74 updated recommendations in 2013
3 (3) SCR Single case report (N 5 1) and 164 original recommendations in 2008. There are 12
3 (new) PRECLIN Preclinical study (e.g., feasibility, safety) new recommendations in this 2019 update (14%); among
3 (new) BR Basic research (must be high impact and
the others, 61 were revised (72%). Unanimous consensus
relevant)
No evidence among primary writers was obtained for each of the recom-
4 (4) NE No evidence (theory, opinion, consensus, mendations. Updated recommendation numbers are indi-
review, position, policy, guideline) cated by the most recent update year, updated evidence by
4 (new) O Other (e.g., lower impact/relevant basic an asterisk after the year, and new recommendations by
research; any highly flawed study
“NEW.” The semantic descriptors of “must,” “should,”
AACE 5 American Association of Clinical Endocrinologists; and “may” generally, but not strictly, correlate with (or
G4GAC 5 Guidelines for Guidelines, Algorithms, and Checklists. map to) Grade A (strong), Grade B (intermediate), and
Reprinted with permission from Mechanick et al. [55].
* Based on principle that interventions, scientific control, generaliz-
Grade C (weak) recommendations, respectively; each se-
ability, methodological flaws, and evidentiary details determine strength, mantic descriptor can be used with Grade D (no conclusive
consistent with other evidence-based methodology systems. Numerical evidence and/or expert opinion) recommendations. Devia-
and semantic descriptors of evidence levels provided in online supplemen- tions from this mapping are not unusual and take into
tary material. consideration further decision-making requirements, logis-
y
The original numerical description from G4GAC 2004, 2010, and 2014
are provided in parentheses.
tics, and subjective factors. Bariatric procedures include
z
The superiority of RCT over all other studies, and in particular MRCT, is both surgical and nonsurgical procedures; the latter are
discussed in reference elsewhere. generally performed endoscopically. Recommendations
are oriented to the procedure type based on the respective
evidence base and expert opinion.
complex and/or nuanced-based decision-making. The rele-
vant evidence base, supporting tables, and figures for the
Q1. Which patients should be offered bariatric
updated recommendations follow the Executive Summary
procedures?
in an Appendix. The reader is encouraged to refer to the
2008 [54] and 2013 [1] AACE-TOS-ASMBS CPG for back- R1. (2019*). Patients with a BMI 40 kg/m2 without
ground material not covered in this 2019 update. coexisting medical problems and for whom bariatric

Table 3
Step II AACE G4GAC—scientific analysis and subjective factors*
Study design* Data analysisy Interpretation of results
Allocation concealment (randomization) Intent-to-treat Generalizability
Blindingz Modeling (e.g., Markov) Incompleteness
Comparator group Network analysis Logical
Endpoints (real clinical versus surrogate) Statistics Overstated
Hypothesis Appropriate follow-up Validity
Power analysis (too small sample size) Appropriate trial termination
Premise
Type 1 error (e.g., adjusted for PHAS)
AACE 5 American Association of Clinical Endocrinologists; G4GAC 5 guidelines for guidelines, algo-
rithms, and checklists; PHAS 5 post hoc analysis study.
Reprinted with permission from Mechanick et al. [55].
* These subjective factors pertain to an individual citation. Subjective factors are provided in online supple-
mentary material [55].
y
Are these elements appropriate for the given study?
z
Including patients, clinicians, data collectors, adjudicators of outcome, and data analysts.

procedures would not be associated with excessive risk are obesity, and considerably impaired quality of life (Grade
eligible for a bariatric procedure (Grade A; best evidence C; BEL 3).
level [BEL] 1). R3. (2019*). Patients with BMI 30 to 34.9 kg/m2 and
R2. (2019*). Patients with a BMI 35 kg/m2 and 1 se- T2D with inadequate glycemic control despite optimal life-
vere ORC remediable by weight loss, including T2D, high style and medical therapy should be considered for a bariat-
risk for T2D (insulin resistance, prediabetes, and/or ric procedure; current evidence is insufficient to support
MetS), poorly controlled HTN, NAFLD/nonalcoholic stea- recommending a bariatric procedure in the absence of
tohepatitis (NASH), obstructive sleep apnea (OSA), osteoar- obesity (Grade B; BEL 2).
thritis of the knee or hip, and urinary stress incontinence, R4. (NEW). The BMI criterion for bariatric procedures
should be considered for a bariatric procedure (Grade C; should be adjusted for ethnicity (e.g., 18.5–22.9 kg/m2 is
BEL 3). Patients with the following co-morbidities and healthy range, 23–24.9 kg/m2 overweight, and 25 kg/m2
BMI 35 kg/m2 may also be considered for a bariatric pro- obesity for Asians) (Grade D).
cedure, although the strength of evidence is more variable: R5. (2019*). Bariatric procedures should be considered to
obesity-hypoventilation syndrome and Pickwickian syn- achieve optimal outcomes regarding health and quality of
drome after a careful evaluation of operative risk, idiopathic life when the amount of weight loss needed to prevent or
intracranial HTN, gastroesophageal reflux disease (GERD), treat clinically significant ORC cannot be obtained using
severe venous stasis disease, impaired mobility due to only structured lifestyle change with medical therapy
(Grade B; BEL 2).

Table 4 Q2. Which bariatric procedure should be offered?

Step III AACE G4GAC–recommendation qualifiers*
Cascades (are there other recommendation versions based on ethnocultural
R6. (2019*). Selection of a bariatric procedure should be
factors? based on individualized goals of therapy (e.g., weight loss
Dissenting opinions (based on HCP and patient preferences) target and/or improvements in specific ORC), available
Economic (e.g., cost-effectiveness, cost-benefit, value) local–regional expertise (obesity specialists, bariatric sur-
Evidence base (are there significant gaps or is there overwhelming geon, and institution), patient preferences, personalized
evidence?)
Relevance (patient-oriented evidence that matters versus disease-oriented
risk stratification that prioritizes safety, and other nuances
evidence; social acceptability) as they become apparent (Tables 6–8) (Grade C; BEL 3).
Resource availability (limited or sufficient) Notwithstanding technical surgical reasons, laparoscopic
Risk to benefit bariatric procedures should be preferred over open
AACE 5 American Association of Clinical Endocrinologists; bariatric procedures due to lower early postoperative
G4GAC 5 Guidelines for Guidelines, Algorithms, and Checklists; morbidity and mortality (Grade B; BEL 2). LAGB,
HCP 5 healthcare professional. laparoscopic SG, laparoscopic RYGB, and laparoscopic
Reprinted with permission from Mechanick et al. [55]. biliopancreatic diversion without or with duodenal switch
* Each of these elements pertains to the recommendation statement, with
the evidence considered in aggregate. The element may be positive or nega- (BPD/DS) or related procedures should be considered as
tive and therefore modify a final recommendation grade. Recommendation primary bariatric and metabolic procedures performed in
qualifiers are provided in online supplementary material [55]. patients requiring weight loss and/or amelioration of ORC

Table 5
Step IV AACE G4GAC—creating initial recommendation grades*
Best evidence Predominantly negative Predominantly positive Consensus for recommendation EL to grade mapping Map to final
level SF and/or RQ SF and/or RQ and for grade recommendation grade
1 No No .66% Direct 1/A
Anyy No No 100% Rule Any / A (new)
2 No Yes .66% Adjust up 2/A
2 No No .66% Direct 2/B
1 Yes No .66% Adjust down 1/B
3 No Yes .66% Adjust up 3/B
3 No No .66% Direct 3/C
2 Yes No .66% Adjust down 2/C
4 No Yes .66% Adjust up 4/C
4 No No .66% Direct 4/D
3 Yes No .66% Adjust down 3/D
Anyy Yes/no Yes/no .66% Rule Any / AD (new)
AACE 5 American Association of Clinical Endocrinologists; G4GAC 5 guidelines for guidelines, algorithms, and checklists; RQ 5 recommendation qual-
ifiers; SF 5 subjective factors; EL 5 evidence level.
Reprinted with permission from Mechanick et al. [55].
* Recommendation Grade A 5 very strong; B 5 strong; C 5 not strong; D 5 primarily based on expert opinion. Mappings are provided in online supple-
mentary material [55].
y
Rule-based adjustment wherein any recommendation can be a “very strong” Grade A if there is 100% consensus on use of this designation. Similarly, if
.66% consensus is not reached, even with some degree of scientific substantiation, a “primarily based on expert opinion” Grade D designation is assigned. The
reasons for downgrading to D may be an inconclusive or inconsistent evidence base or simply failure of the expert writing committee to sufficiently agree. Note
that any formulated recommendation is omitted from the document if sufficiently flawed, so any Grade D recommendation in the final document must be deemed
sufficiently important. Rule-based adjustments are provided in online supplementary material [55].

(Grade A; BEL 1). Physicians must exercise caution when assess surgical risk (see Preoperative Checklist in Table 9)
recommending BPD, BPD/DS, or related procedures (Grade A; BEL 1).
because of the greater associated nutritional risks related R9. (2008). Medical records should contain clear docu-
to the increased length of bypassed small intestine (Grade mentation of the indications for bariatric surgery (Grade D).
A; BEL 1). Newer nonsurgical bariatric procedures may R10. (2019*). Because informed consent is a dynamic
be considered for selected patients who are expected to process, there must be a thorough discussion with the patient
benefit from short-term (i.e., w6 mo) intervention with regarding the risks and benefits, procedural options, choices
ongoing and durable structured lifestyle with or without of surgeon and medical institution, and the need for long-
medical therapy (Grade C; BEL 3). Investigational proced- term follow-up and vitamin supplementation (including
ures may be considered for selected patients based on avail- costs required to maintain appropriate follow-up and nutrient
able institutional review board–approved protocols, supplementation) (Grade D). Patients must also be provided
suitability for clinical targets, and individual patient factors with educational materials that are culturally and education-
and only after a careful assessment balancing the impor- ally appropriate and access to similar preoperative educa-
tance for innovation, patient safety, and demonstrated effec- tional sessions at prospective bariatric surgery centers
tiveness (Grade D). (Grade D). Consent should include the experience of the sur-
geon with the specific procedure offered and whether the hos-
pital has an accredited bariatric surgery program (Grade D).
Q3. How should potential candidates be managed before
R11. (2013). The bariatric surgery program must be able
bariatric procedures?
to provide all necessary financial information and clinical
R7. (2008). Patients must undergo preprocedure evalua- material for documentation so that, if needed, third-party
tion for ORC and causes of obesity, with special attention payor criteria for reimbursement are met (Grade D).
directed to those factors that could influence a recommenda- R12. (2013). Preprocedure weight loss can reduce liver
tion for bariatric procedures (see Preoperative Checklist in volume and may help improve the technical aspects of sur-
Table 9) (Grade A; BEL 1) and consider a referral to a gery in patients with an enlarged liver or fatty liver disease
specialist in obesity medicine (Grade D). and therefore may be recommended before a bariatric pro-
R8. (2008). The preprocedure evaluation must include a cedure (Grade B; BEL 1; downgraded due to inconsistent
comprehensive medical history, psychosocial history, phys- evidence). Preprocedure weight loss or medical nutritional
ical examination, and appropriate laboratory testing to therapy may be recommended to patients in selected cases

Table 6
Guiding bariatric procedure selection based on risks, benefits, and target weight loss: procedures endorsed by ASMBS and possibly covered by insurance
Procedure Target weight loss (%TWL) Favorable aspects Unfavorable aspects
LAGB [845] 20%–25% No anatomic alteration High explant rate
Removable Erosion
Adjustable Slip/prolapse
SG [845] 25%–30% Easy to perform Leaks difficult to manage
No anastomosis Little data beyond 5 yr
Reproducible 20%–30% GERD
Few long-term complications
Metabolic effects
Versatile for challenging patient populations
RYGB [845] 30%–35% Strong metabolic effects Few proven revisional options for weight
Standardized techniques regain
,5% major complication rate Marginal ulcers
Effective for GERD Internal hernias possible
Can be used as second stage after SG Long-term micronutrient deficiencies
BPD/DS [845] 35%–45% Very strong metabolic effects Malabsorptive
Durable weight loss 3%–5% protein-calorie malnutrition
Effective for patients with very high BMI GERD
Can be used as second stage after SG Potential for internal hernias
Duodenal dissection
Technically challenging
Higher rate of micronutrient deficiencies than
RYGB
TWL 5 total weight loss; LAGB 5 laparoscopic adjustable gastric banding; SG 5 sleeve gastrectomy; GERD 5 gastroesophageal reflux disease;
RYGB 5 Roux-en-Y gastric bypass; BPD/DS 5 biliopancreatic diversion with duodenal switch; BMI 5 body mass index; ORC 5 obesity-related com-
plications; T2D 5 type 2 diabetes; HTN 5 hypertension; NAFLD 5 nonalcoholic fatty liver disease; OSA 5 obstructive sleep apnea; PCOS 5 polycystic
ovary syndrome; MetS 5 metabolic syndrome; NASH 5 nonalcoholic steatohepatitis; GI 5 gastrointestinal.
Selection of the specific bariatric procedure is done after a decision is made to have a bariatric procedure. Estimate of bariatric surgery numbers can be
found at http://asmbs.org/resources/estimate-of-bariatric-surgery-numbers [239].
STEP 1: Identify durable target weight loss beyond that achieved with lifestyle and medications to mitigate relevant ORCs, a primary determinant of an
optimal procedure selection as follows: (1) .5%–10% weight loss: T2D, dyslipidemia, HTN, NAFLD, low testosterone, OSA/reactive airway disease,
urinary stress incontinence, PCOS; and (2) .10%–15% weight loss: MetS, prediabetes, NASH, osteoarthritis, GERD, and depression [13].
STEP 2: Identify other factors that can affect decision-making, including durability, eating behaviors, surgeon skills, institutional experience, cardi-
ometabolic effects, prior GI surgery, and GI disease. “Favorable” aspects show key parameters to favor selection of the respective procedure. “Unfavor-
able” aspects show key parameters against selection of the respective procedure.

to improve co-morbidities, such as preprocedure glycemic complications, extensive co-morbid conditions, or long-
targets (Grade D). standing diabetes in which the general goal has been diffi-
cult to attain despite intensive efforts (Grade A; BEL 1).
In patients with HbA1C .8% or otherwise uncontrolled
Q4. What are the elements of medical clearance for
diabetes, clinical judgment determines the need and timing
bariatric procedures?
for a bariatric procedure (Grade D).
R13. (NEW). A lifestyle medicine checklist should be R15. (2013*). Routine screening for primary hypothy-
completed as part of a formal medical clearance process roidism with a thyroid-stimulating hormone (TSH) level
for all patients considered for any bariatric procedure before a bariatric procedure is not recommended, though
(Table 9) (Grade D). many insurance plans require a preprocedure serum TSH
R14. (2019*). Preprocedure glycemic control must be level (Grade D). A serum TSH level should be obtained
optimized using a diabetes comprehensive care plan, only if clinical evidence of hypothyroid is present (Grade
including healthy low-calorie dietary patterns, medical B; BEL 2). Patients found to be hypothyroid must be
nutrition therapy, physical activity, and, as needed, pharma- treated with levothyroxine monotherapy (Grade A;
cotherapy (Grade A; BEL 1). Reasonable targets for preop- BEL 1).
erative glycemic control, which may be associated with R16. (2019*). A fasting lipid panel should be obtained in
shorter hospital stays and improved bariatric procedure all patients with obesity (Grade A; BEL 1). Treatment
outcomes, include an HbA1C value of 6.5% to 7.0% should be initiated according to available and current
and periprocedure blood glucose levels of 80 to 180 mg/ CPGs (see www.aace.com/files/lipid-guidelines.pdf and
dL (Grade B; BEL 2). More liberal preprocedure targets, www.lipid.org/recommendations) (Grade D).
such as a HbA1C of 7% to 8%, are recommended in patients R17. (2013*). Candidates for bariatric procedures should
with advanced microvascular or macrovascular avoid pregnancy preprocedure and for 12 to 18 months

Table 7
Guiding bariatric procedure selection based on risks, benefits, and target weight loss: procedures and devices not currently covered by insurance
Procedure Target weight Favorable aspects Unfavorable aspects
loss (%TWL)
Primary obesity surgery endoluminal [846] 5% Endoscopic Pain (45%)
4.7% adverse events Nausea (21%)
Device FDA approved for tissue apposition Vomiting (19%)
Questionable Durability
Gelesis100 (ingested hydrogel capsules) 6% Swallowed, noninvasive Minor gastrointestinal side effects
Not absorbed Only 24-wk trial; no long-term data
No major adverse events
Increased fullness
FDA approved
vBLOC [847,848] 8%–9% No anatomic changes Pain at neuroregulatory site
Low complication rate (4%) Explant required for conversion to another
FDA approved procedure
Intragastric balloon [17,849,850] 10%–12% Endoscopic or swallowed Temporary (6 mo) therapy
Good safety profile Temporary n/v, pain
FDA approved Early removal rate 10%–19%
AspireAssist [851] 12%–14% Endoscopic 1-yr therapy
Changes eating behavior Tube-related problems/complications
FDA approved 26% early removal
Transpyloric Shuttle [852] 14% Endoscopic 6-mo data
Delays gastric emptying Gastric ulcers
FDA approved
Endoscopic sleeve gastroplasty [853] 16%–20% Endoscopic One study, 2-yr data
Low adverse event rate No RCTs
Device FDA approved for tissue apposition Questionable Durability
TWL 5 total weight loss; FDA 5 Food and Drug Administration; vBLOC 5 vagal nerve-blocking device; n/v 5 nausea/vomiting; RCT 5 randomized con-
trol trial.

postprocedure (Grade D). Women who become pregnant af- be counseled about non-oral contraceptive therapies (Grade
ter bariatric procedures should be counseled and monitored D). Patients who become pregnant after bariatric procedure
for appropriate weight gain, nutritional supplementation, should have nutritional surveillance and laboratory
and fetal health (Grade C; BEL 3). All women of reproduc- screening for nutrient deficiencies every trimester, including
tive age should be counseled on contraceptive choices iron, folate, vitamin B12, vitamin D, and calcium; after a
before and after bariatric procedures (Grade D). Patients un- malabsorptive procedure, screening should be done for
dergoing RYGB or another malabsorptive procedure should fat-soluble vitamins, zinc, and copper (Grade D). Patients
Table 8
Guiding bariatric procedure selection based on risks, benefits, and target weight loss: emerging procedures not currently covered by insurance or endorsed by
ASMBS*
Procedure Target weight Favorable aspects Unfavorable aspects
loss (%TWL)
Laparoscopic greater 15%–25% Nonresectional Limited data beyond 2 yr
curvature plication [854] No staplers or devices GERD
Reversible/revisable Difficult to standardize
Disruption of plication
Dilation of stomach
Not “leak-proof”
OAGB [845] 35%–40% Simpler to perform than RYGB Potential for bile reflux
More malabsorptive Malabsorptive (long BP limb)
Strong metabolic effects Little experience in United States
No mesenteric defects
OADS (SIPS, SADI-S) 35%–45% Single anastomosis Little long-term data
[265,854] Simpler to perform than BPD/DS Nutritional and micronutrient deficiencies
Strong metabolic effects possible
Low early complication rate Duodenal dissection
ASMBS 5 American Society of Metabolic and Bariatric Surgery; TWL 5 total weight loss; GERD 5 gastroesophageal reflux disease; OAGB 5 one-
anastomosis gastric bypass; RYGB 5 Roux-en-Y gastric bypass; BP 5 biliopancreatic; OADS 5 one-anastomosis duodenal switch; SIPS 5 stomach intestinal
pylorus-sparing; SADI-S 5 single anastomosis duodeno-ileal bypass with sleeve gastrectomy; BPD/DS 5 biliopancreatic diversion with duodenal switch.
* Institutional review board or institutional review board exemption required (https://asmbs.org/resources/endorsed-procedures-and-devices).

Table 9 of the individual risk factors and findings on history and

Preprocedure checklist (including lifestyle medicine)* physical examination and should be based on the latest
☑ Complete H & P (obesity-related co-morbidities, causes of obesity, American College of Cardiology/American Heart Associa-
weight BMI, weight loss history, commitment, and exclusions related to tion Guideline on Perioperative Cardiovascular Evaluation
surgical risk)
and Management of Patients Undergoing Noncardiac Sur-
☑ Routine labs (including fasting blood glucose and lipid panel, kidney
function, liver profile, lipid profile, urine analysis, prothrombin time/ gery (http://circ.ahajournals.org/content/early/2014/07/31/
INR, blood type, CBC) CIR.0000000000000106) (Grade D). Patients with known
☑ Nutrient screening with iron studies, B12, and folic acid (RBC folate, heart disease require a formal cardiology consultation
homocysteine, methylmalonic acid optional), and 25-vitamin D before bariatric procedures (Grade D). Patients at risk for
(vitamins A and E optional); consider more extensive testing in patients
heart disease must undergo evaluation for periprocedure
undergoing malabsorptive procedures based on symptoms and risks
☑ Cardiopulmonary evaluation with sleep apnea screening (ECG, CSR, b-adrenergic blockade (Grade A; BEL 1).
echocardiography if cardiac disease or pulmonary hypertension R22. (2019*). In patients evaluated for bariatric proced-
suspected; deep-venous thrombosis evaluation, if clinically indicated) ures, clinical screening for OSA (with confirmatory poly-
☑ GI evaluation (H. pylori screening in areas of high prevalence; gallbladder somnography if screening tests are positive) should be
evaluation and upper endoscopy, if clinically indicated)
considered (Grade C, BEL 3). Patients with intrinsic lung
☑ Endocrine evaluation (HbA1C with suspected or diagnosed prediabetes or
diabetes; TSH with symptoms or increased risk of thyroid disease; disease or disordered sleep patterns should have a formal
androgens with PCOS suspicion [total/bioavailable testosterone, pulmonary evaluation, including arterial blood gas measure-
DHEAS, D4-androstenedione]; screening for Cushing’s syndrome if ment, when knowledge of the results would alter patient
clinically suspected (1-mg overnight dexamethasone test, 24-hour care (Grade C; BEL 3).
urinary free cortisol, 11 PM salivary cortisol)
R23. (2019*). Tobacco use must be avoided at all times
☑ Lifestyle medicine evaluation: healthy eating index; cardiovascular
fitness; strength training; sleep hygiene (duration and quality); mood and by all patients. In particular, patients who smoke cigarettes
happiness; alcohol use; substance abuse; community engagement should stop as soon as possible, preferably 1 year but at the
☑ Clinical nutrition evaluation by RD very least 6 weeks before bariatric procedures (Grade A;
☑ Psychosocial-behavioral evaluation BEL 2, upgraded by consensus). In addition, tobacco use
☑ Assess for individual psychological support/counseling
must be avoided after bariatric procedures given the
☑ Document medical necessity for bariatric surgery
☑ Informed consent increased risk of poor wound healing, anastomotic ulcer,
☑ Provide relevant financial information and overall impaired health (Grade A; BEL 1). Structured
☑ Continue efforts for preoperative weight loss intensive cessation programs are preferable to general
☑ Optimize glycemic control advice and should be implemented (Grade D).
☑ Pregnancy counseling
R24. (2013*). Patients with a history of deep venous
☑ Smoking-cessation counseling
☑ Verify cancer screening by primary care physician thrombosis (DVT) or cor pulmonale should undergo a risk
assessment for bariatric surgery and an appropriate diag-
H & P 5 history & physical; BMI 5 body mass index; INR 5 interna-
tional normalized ratio; CBC 5 complete blood count; RBC 5 red blood
nostic evaluation for DVT (Grade D). In selecting treatment
cell; ECG 5 electrocardiogram; CSR 5 Cheyne Stokes respriation; GI 5 approaches to prevent thrombosis, the routine placement of
gastrointestinal; HbA1C 5 glycosylated hemoglobin; TSH 5 thyroid- a vena cava filter is discouraged; however, prophylactic
stimulating hormone; PCOS 5 polycystic ovary syndrome; DHEAS 5 de- placement of a vena cava filter may be considered in indi-
hydroepiandrosterone-sulfate; RD 5 registered dietician. vidual patients after careful evaluation of the risks and ben-
* Based on information included in Mechanick et al. [1].
efits (Grade C; BEL 3).
who become pregnant post-LAGB should have band adjust- R25. (2019*). Clinically significant GI symptoms should
ments as necessary for appropriate weight gain for fetal be evaluated before bariatric procedures with imaging
health (Grade B; BEL 2). studies, upper GI series, or endoscopy (Grade D). The use
R18. (2008*). Estrogen therapy should be discontinued of preoperative endoscopy may be considered in all patients
before a bariatric procedure (1 cycle of oral contracep- being evaluated for SG (Grade D).
tives in premenopausal women; 3 wk of hormone R26. (2019*). Imaging studies are not recommended as a
replacement therapy in postmenopausal women) to routine screen for liver disease (Grade B, BEL 2). Abdom-
reduce the risks for postprocedure thromboembolic phe- inal ultrasound is indicated to evaluate symptomatic biliary
nomena (Grade D). disease and elevated liver function tests (Grade C, BEL 3).
R19. (2008*). Women should be advised that their Abdominal ultrasonography or elastography may be helpful
fertility status might be improved after a bariatric procedure and may be considered to identify NAFLD but may not be
(Grade D). diagnostic (Grade B, BEL 2). Consideration can be made
R20. (2019*). Case-by-case decisions to screen for for liver biopsy at the time of a bariatric procedure to docu-
monogenic and syndromic causes of obesity should be ment steatohepatitis and/or cirrhosis that may otherwise be
based on specific historical and physical findings (Grade D). unknown due to normal appearance on imaging and/or liver
R21. (2019*). The need for an electrocardiogram and function tests (Grade C, BEL 3). A comprehensive evalua-
other noninvasive cardiac testing is determined on the basis tion is recommended in those patients with clinically

significant and persistent abnormal liver function tests Table 10

(Grade A; upgraded by consensus rule). Summary of AHRQ safety program for improving surgical care and
enhanced recovery after bariatric surgery*
R27. (2013*). Routine screening for the presence of Hel-
icobacter pylori before bariatric procedures may be consid- Protocol component/intervention Outcome
ered in areas of high prevalence (Grade C; BEL 3). Immediate preoperative
R28. (2013*). Prophylactic treatment for gouty attacks Carbohydrate loading Decrease insulin resistance
Decrease protein catabolism,
should be considered before bariatric procedures in patients
LOS
with a history of gout (Grade C, BEL 3). Faster return of bowel function
R29. (2008*). There are insufficient data to warrant pre- Reduced fasting No adverse outcomes
procedure assessment of bone mineral density with dual- Multimodal preanesthesia medication Decreased pain, PONV,
energy x-ray absorptiometry or serum or urinary bone turn- opioid use
Intraoperative
over markers outside formal recommendations by the Na-
Standard intraoperative Decreased pain, PONV,
tional Osteoporosis Foundation (http://www.iscd.org/ anesthesia pathway opioid use
documents/2014/10/nof-clin-guidelines.pdf/) (Grade D). Protective ventilation strategies Decreased pulmonary
R30. (2019*). A formal psychosocial-behavioral evalua- complications
tion performed by a qualified behavioral health professional Goal-directed fluid management Decrease morbidity, LOS
Postoperative nausea and vomiting Decreased PONV
(i.e., licensed in a recognized behavioral health discipline,
prophylaxis
such as psychology, social work, psychiatry, or psychiatric Regional block Decreased pain, opioid use
nursing, and with specialized knowledge and training rele- Postoperative
vant to obesity, eating disorders, and/or bariatric proced- Standard multimodal analgesia Decreased pain, PONV,
ures) to assess environmental, familial, and behavioral regimen opioid use
Early ambulation Decreased VTE
factors and risk for suicide should be required for all patients
Early return of oral intake Easier return of bowel function
before a bariatric procedure (Grade C; BEL 3). Any patient
considered for a bariatric procedure with a known or sus- ARHQ 5 Agency for Healthcare Research and Quality; LOS 5 length of
stay; PONV 5 postoperative nausea and vomiting; VTE 5 venous
pected psychiatric illness, or substance abuse or depen-
thromboembolism.
dence, should undergo a formal mental health evaluation * Based on information included in Grant et al. [855]; Thorell et al. [568];
before the procedure (Grade C; BEL 3). After RYGB and Ljungqvist et al. [856]; Alvarez et al. [593]; and Bellamy et al. [549].
SG, high-risk groups should eliminate alcohol consumption
due to impaired alcohol metabolism and risk of alcohol-use
disorder postoperatively (Grade C; BEL 3). analgesia; thromboprophylaxis; and education about periop-
R31. (2013*). All patients should undergo evaluation of erative protocols (Table 10) (Grade B; BEL 2).
their ability to incorporate nutritional and behavioral
Q5. How can care be optimized during and within 5 days of
changes before and after any bariatric procedure (Grade
a bariatric procedure?
C; BEL 3).
R32. (2013*). All patients must undergo an appropriate R35. (NEW). Appropriate perioperative ERABS clinical
nutritional evaluation, including micronutrient measure- pathways should be implemented in all patients undergoing
ments, before any bariatric procedure (Table 9) (Grade A; bariatric surgery (Table 10) (Grade D). Routine pulmonary
BEL 1). In comparison with purely restrictive procedures, recruitment maneuvers (PRM) should be performed intrao-
more extensive nutritional evaluations are required for mal- peratively as needed (Grade D). Intraoperative use of dex-
absorptive procedures (Grade A; BEL 1). Whole-blood thia- medetomidine may be considered to decrease
mine levels may be considered in patients before bypass perioperative opioid use (Grade C; BEL 3). Intraoperative
procedures (RYGB and BPD/DS) (Grade C; BEL 3). protocols to detect possible silent bleeding sites should be
R33. (2013*). Patients should be followed by their pri- performed (Grade D). Consider dynamic indicators to guide
mary care physician and have age- and risk-appropriate can- goal-directed fluid therapy to avoid excess intraoperative
cer screening before bariatric procedures (Grade C; BEL 3). fluid administration (Grade B; BEL 2).
R34. (NEW). Preoperative ERABS clinical pathways R36. (NEW). A postoperative checklist should be
should be implemented in all patients who are having bariat- reviewed and implemented (Table 11). Appropriate postoper-
ric surgery to improve postoperative outcomes (Grade D). ative ERABS clinical pathways should be implemented in all
Comprehensive preoperative optimization (prehabilitation) patients who have had bariatric surgery (Table 10) (Grade D).
should be implemented, including but not limited to deep R37. (NEW). Preemptive antiemetic and nonopioid anal-
breathing exercises; continuous positive airway pressure gesic medications immediately before and during bariatric
(CPAP), as appropriate; incentive spirometry; leg exercises; procedures as part of a multimodal pain management strat-
continued oral nutrition with carbohydrates, including sips egy should be implemented to decrease early postprocedure
of clear liquids up to 2 hours preoperatively; H2 blocker opioid use and postoperative nausea and vomiting (Grade C;
or proton-pump inhibitor; opioid-sparing multimodal BEL 3).

Table 11
Postprocedure checklist*
Checklist item LAGB SG RYGB BPD/DS
Early postoperative care
U Monitored telemetry at least 24 hr if high risk for MI U U U U
U Protocol-derived staged meal progression supervised by RD U U U U
U Healthy-eating education by RD U U U U
U Multivitamin plus minerals (no. of tablets for minimal requirement) 1 2 2 2
U Elemental calcium (as calcium citrate), mg/d 1200–1500 1200–1500 1200–1500 1800–2400
U Vitamin D, at least 3000 units/d, titrate to .30 ng/mL U U U U
U Vitamin B12 as needed for normal range levels U U U U
U Maintain adequate hydration (usually .1.5 L/d PO) U U U U
U Monitor blood glucose with diabetes or hypoglycemic symptoms U U U U
U Pulmonary toilet, spirometry, DVT prophylaxis U U U U
U If unstable, consider PE, IL PE PE PE/IL PE/IL
U If rhabdomyolysis suspected, check CPK U U U U
Follow-up
U Visits: initial, interval until stable, once stable (mo) 1, 1–2, 12 1, 3, 6, 12 1, 3, 6–12 1, 3, 6
U Monitor progress with weight loss and evidence of complications each visit U U U U
U SMA-21, CBC/plt with each visit (and iron at baseline and after as needed) U U U U
U Avoid nonsteroidal anti-inflammatory drugs U U U U
U Adjust postoperative medications U U U U
U Consider gout and gallstone prophylaxis in appropriate patients U U U U
U Need for antihypertensive therapy with each visit U U U U
U Lipid evaluation every 6–12 mo based on risk and therapy U U U U
U Monitor adherence with physical activity recommendations U U U U
U Evaluate need for support groups U U U U
U Bone density (DXA) at 2 yr U U U U
U 24-hr urinary calcium excretion at 6 mo and then annuallyy x x x U
U B12 (annually; MMA and HCy optional; then q 3–6 mo if supplemented) U U U U
U Folic acid (RBC folic acid optional), iron studies, 25-vitamin D, iPTH x x U U
U Vitamin A (initially and q 6–12 mo thereafter) x x Optional U
U Copper, zinc, selenium evaluation with specific findings x x U U
U Thiamine evaluation with specific findings U U U U
U Consider eventual body contouring surgery U U U U
U Lifestyle medicine evaluation: healthy eating index; cardiovascular fitness; strength U U U U
training; sleep hygiene (duration and quality); mood and happiness; alcohol use;
substance abuse; community engagement
U Hemoglobin A1C, TSH evaluation in long-term follow-up U U U U
LAGB 5 laparoscopic adjustable gastric band; SG 5 sleeve gastrectomy; RYGB 5 Roux-en-Y gastric bypass; BPD/DS 5 biliopancreatic diversion with
duodenal switch; MI 5 myocardial infarction; RD 5 registered dietician; L/d 5 liters per day; PO 5 orally; DVT 5 deep vein thrombosis; PE 5 pulmonary
embolus; IL 5 intestinal leak; CPK 5 creatine phosphokinase; SMA-21 5 chemistry panel; CBC 5 complete blood count; plt 5 platelets; DXA 5 dual-energy
x-ray absorptiometry; MMA 5 methylmalonic acid; HCy 5 homocysteine; q 5 daily; RBC 5 red blood cell; iPTH 5 intact parathyroid hormone;
TSH 5 thyroid-stimulating hormone.
* Based on information included in Mechanick et al. [1] and Parrott et al. [448].
y
This testing should be considered for any patient after a bariatric procedure at 6 mo and then annually if there is a history of renal stones.

R38. (2013*). A low-sugar, clear-liquid meal program daily servings of fresh fruits and vegetables (Grade D). Pro-
can usually be initiated within 24 hours after any of the sur- tein intake should be individualized, assessed, and guided
gical bariatric procedures, but this diet and meal progression by an RD regarding sex, age, and weight (Grade D). A min-
should be discussed with the surgeon and guided by the imal protein intake of 60 g/d and up to 1.5 g/kg ideal weight
registered dietician (RD) (Table 12) (Grade C; BEL 3). A per day should be adequate; higher amounts of protein
consultation for postoperative meal initiation and progres- intake—up to 2.1 g/kg ideal weight per day—need to be
sion must be arranged with an RD who is knowledgeable assessed on an individualized basis (Grade D). Concentrated
about the postoperative bariatric diet (Grade A, BEL 1). sweets should be eliminated from the diet after RYGB to
Patients should receive education in a protocol-derived minimize symptoms of dumping syndrome and after any
staged meal progression based on their surgical procedure bariatric procedure to reduce caloric intake (Grade D).
(Grade D). Patients should be counseled to eat 3 small meals Crushed or liquid rapid-release medications should be
during the day and chew small bites of food thoroughly used instead of extended-release medications to maximize
before swallowing (Grade D). Patients should be counseled absorption in the immediate postprocedure period
about the principles of healthy eating, including at least 5 (Grade D).

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Table 12
Dietary recommendations after bariatric procedure
Recommendations UpToDate: postoperative nutritional 2008 ASMBS Allied Health Nutritional Guidelines for perioperative care Academy of Nutrition and Dietetics Pocket
management [857] Guidelines [858] in bariatric surgery: ERAS Guide to Bariatric Surgery, second edition
Society Recommendations [568] [859]
Diet progression Surgeon or institution specific Diet stage: Clear liquid meal regimen Postoperative nutrition care of the bariatric
Stage 1 and 2: hydration and liquids Clear liquid (1–2 d after surgery) initiated a couple of hours patient has 2 distinct stages during the first
postoperatively year:
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Sugar-free or low sugar Balanced meal plan to include

Clear liquid diet (brief period)
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.

Full liquids and possibly pureed foods, Full liquid (10–14 d after surgery) 0–3 mo

Jeffrey I. Mechanick et al. / Surgery for Obesity and Related Diseases 16 (2020) 175–247
which includes liquid sources of protein .5 servings of fruit and 3 mo–1 yr
and small amounts of carbohydrates (up to Sugar-free or low sugar vegetables daily for optimal Typically described in stages:
several weeks after surgery) fiber consumption, colonic
Pureed (10–141 d)
Stage 3: Solid foods with an emphasis on function, and phytochemical Diet stage 1—clear liquid diet: very short
protein sources, some carbohydrates, and intake
term; used in the hospital on POD 1 and
fiber (w10–14 d after surgery) Foods that have been blended or liquefied Avoid concentrated sweets to
2; liquids low in calories and sugar and free
Stage 4: Micronutrient supplementation (when with adequate fluid reduce caloric intake and to
of caffeine, carbonation, and alcohol
patient reaches a stable or maintenance Mechanically altered soft (.14 d after minimize symptoms of dumping Diet stage 2—full liquid diet: started
weight) surgery) (gastric bypass)
between POD 2 and POD 3; continues
Long-term diet:
for w14 d; clear liquids 1 full liquids that
Textured-modified are low in sugar with up to 25–30 g protein
Roux-en-Y gastric bypass: well-balanced Require minimal chewing per serving
diet containing all the essential nutrients Chopped, ground, mashed, flaked, or Diet stage 3—soft food texture
possible postoperative diets may include pureed foods progression: timing varies by type of
Regular textured (6–8 wk after surgery) surgery, and duration depends on patient’s
B My Plate * Purpose of nutrition care after surgical weight response to foods; replace protein-
B
loss procedures: containing full liquids with soft, semisolid
DASH Diet
The Vegetarian Resource Group protein sources (moist, soft, diced, ground,
Adequate energy and nutrients to support or pureed), 3–5 times/d, as tolerated
Diet stage 4: regular solid food diet

tissue healing after surgery and support
Sleeve gastrectomy: same advancement
preservation of lean body mass during
and recommendations post-SG as for
extreme weight loss
post-RYGB Foods and beverages must minimize reflux,
LAGB: generally resume a normal diet
early satiety, and dumping syndrome while
soon after surgery
Biliopancreatic diversion/duodenal switch:
maximizing weight loss and weight
maintenance
small, nutrient-dense meals that are high in
protein, along with fruits, vegetables,
whole grains, and omega-3 fatty acids and
avoidance of concentrated sweets
Recommendations UpToDate: postoperative nutritional 2008 ASMBS Allied Health Nutritional Guidelines for perioperative care Academy of Nutrition and Dietetics Pocket
management [857] Guidelines [858] in bariatric surgery: ERAS Guide to Bariatric Surgery, second edition
Society Recommendations [859]
[568]
(continued on next page )

189
190
Table 12 (continued )
Recommendations UpToDate: postoperative nutritional 2008 ASMBS Allied Health Nutritional Guidelines for perioperative care Academy of Nutrition and Dietetics Pocket
management [857] Guidelines [858] in bariatric surgery: ERAS Guide to Bariatric Surgery, second edition
Society Recommendations [568] [859]
Fluids Throughout all the diet stages, patients N/A .1.5 L daily 48–64 oz/d
should be counseled to consume adequate
fluid to prevent dehydration Women: 48 oz/d
Men: 64 oz/d
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50% goal should be met with clear liquids

Protein 46 g/d—women Exact needs have yet to be defined Should average 60–120 g daily Guidelines for protein consumption not

Jeffrey I. Mechanick et al. / Surgery for Obesity and Related Diseases 16 (2020) 175–247
56 g/d—men defined
Protein needs:

Should constitute 10%–35% of daily

caloric intake
Weight maintenance: .8–1.2 g/kg weight
per day
Active weight loss: 1.2 g/kg weight (BPD/
DS may require 1.5–2.0 g/kg weight per
day)
Carbohydrates Early postoperative—50 g/d N/A N/A N/A
As diet intake increases—130 g/d
Fat 20%–35% of the daily caloric intake; bulk of N/A N/A N/A
the fat intake should be unsaturated fat
Behavior Eat slowly Avoid/delay Multiple small meals each day Practice mindful eating
Chew food extensively Chewing food thoroughly Chew all food until it is smooth
Concentrated sweets
Stop eating as soon as reach satiety without drinking beverages at Make sure food is soft and moist enough to
Carbonated beverages
Avoid taking food and beverages at the the same time swallow without sticking
Fruit juice
same time Consume fluids slowly Do not drink liquids during meals
High-saturated fat, fried foods
Simple sugars should be limited to ,10% Wait 30 min after eating before resuming
Soft doughy bread, pasta, rice
of daily caloric intake Tough, dry, red meat fluid intake
Avoid bread, rice, and pasta until able to
Nuts, popcorn, other fibrous foods
Caffeine comfortably consume adequate protein,
Alcohol vegetables, and fruits
Recommendations UpToDate: postoperative nutritional 2008 ASMBS Allied Health Nutritional Guidelines for perioperative care Academy of Nutrition and Dietetics Pocket
management [857] Guidelines [858] in bariatric surgery: ERAS Guide to Bariatric Surgery, second edition
Society Recommendations [859]
[568]
(continued on next page )
Jeffrey I. Mechanick et al. / Surgery for Obesity and Related Diseases 16 (2020) 175–247 191

R39. (2019*). After consideration of preprocedure defi-

postsurgery patient and plays an important

ASMBS 5 American Society of Metabolic and Bariatric Surgery; ERAS 5 enhanced recovery after surgery; POD 5 postoperative day; SG 5 sleeve gastrectomy; RYGB 5 Roux-en-Y gastric bypass;
preoperative assessment of the patient to
Academy of Nutrition and Dietetics Pocket

RD responsible for the nutrition care of the

Guide to Bariatric Surgery, second edition

ciency states, as well as risks and benefits in the early (,5

long-term follow-up, evaluation, and

d) postprocedure period, patients with or at risk for demon-
role in every aspect of care, from strable micronutrient insufficiencies or deficiencies must be
treated with the respective micronutrient, which should be
adjusted based on recommendations for the late postproce-
dure period (Tables 11, 13, and 14) (Grade A, BEL 2,
upgraded by consensus). Minimal daily nutritional supple-
mentation for patients with BPD with or without DS,
monitoring

RYGB, and SG should be in chewable form initially and

then as 2 adult multivitamins plus minerals (each containing
[859]

iron, folic acid, and thiamine) (Grade B, BEL 2), elemental

LAGB 5 laparoscopic adjustable gastric bypass; N/A 5 not applicable; BPD/DS 5 biliopancreatic diversion with duodenal switch; RD 5 registered dietician.
calcium (1200–1500 mg/d for SG and RYGB and 1800–
2400 mg/d for BPD/DS in diet and as citrated supplement
guidance should be provided to

bariatric surgery and during the

progression, based on the type

Guidelines for perioperative care

Society Recommendations [568]

Consultation should be provided

of surgical procedure, should

postoperative hospital course
and reinforced at subsequent

with a dietician; a protocol-

in divided doses) (Grade B, BEL 2), at least 2000 to 3000

Nutritional and meal planning

patient and family before

in bariatric surgery: ERAS

IU of vitamin D (titrated to therapeutic 25-hydroxyvitamin

D levels .30 ng/mL) (Grade A, BEL 1), total iron as 18
derived staged meal

to 60 mg via multivitamins and additional supplements

outpatient visits

(Grade A, BEL 1), and vitamin B12 (parenterally as sublin-

be followed

gual, subcutaneous, or intramuscular preparations; orally if

determined to be adequately absorbed) (Grade B; BEL 2).
Minimal daily nutritional supplementation for patients
with LAGB should include 1 adult multivitamin plus min-
erals (including iron, folic acid, and thiamine) (Grade B,
Dietician’s role is a vital component of the

BEL 2), 1200 to 1500 mg/d of elemental calcium (in diet

2008 ASMBS Allied Health Nutritional

and as citrated supplement in divided doses), and at least

2000 to 3000 IU of vitamin D (titrated to therapeutic 25-
dihydroxyvitamin D levels) (Grade B, BEL 2). Additional
bariatric surgery process

recommendations to prevent micronutrient deficiencies are

included in Tables 11, 13, and 14.
R40. (2019*). Goal-directed intra- and early postproce-
Follow-up with RD
Guidelines [858]

dure fluid management should be guided by continuous

noninvasive measurements to avoid over- and underhydra-
tion (Grade B, BEL 2). Once patients can tolerate orals,
fluids should be consumed slowly, preferably at least 30 mi-
nutes after meals to prevent GI symptoms, and in sufficient
amounts to maintain adequate hydration (.1.5 L daily)
(Grade D).
R41. (2019*). Nutrition support (enteral nutrition [EN;
UpToDate: postoperative nutritional

tube feeds] or parenteral nutrition [PN]) should be consid-

ered in bariatric surgery patients at high nutritional risk;
Close monitoring with an RD

PN should be considered in those patients who are unable

to meet their needs using their GI tract for at least 5 to 7
days with noncritical illness or 3 to 7 days with critical
management [857]

illness (Grade D). In patients with severe protein malnutri-

tion and/or hypoalbuminemia not responsive to oral or
EN protein supplementation, PN should be considered
(Grade D). PN formulation for patients after bariatric pro-
cedures should be hypocaloric with relatively high nitrogen
Table 12 (continued )

(Grade D).
Recommendations

R42. (2019*). Intra-/perioperative intravenous (IV)

insulin is recommended for glycemic control (Grade B;
BEL 2). In immediately postoperative patients with T2D,
the use of all insulin secretagogues (sulfonylureas and
Other

meglitinides), sodium-glucose cotransporter-2 inhibitors,

Table 13
Nutrient deficiencies after bariatric procedures
Vitamin/mineral Prevalence of deficiency Screening
Vitamin B1 ,1%–49% depending on procedure Recommended for high-risk groups
(thiamine) and post-WLS time frame
Patients with risk factors for thiamine deficiency
Females
Blacks
Patients not attending a nutritional clinic after surgery
Patients with GI symptoms (intractable nausea and vomiting, jejunal dilation, mega-
colon, or constipation)
Patients with concomitant conditions, such as cardiac failure (especially those receiving
furosemide)
Patients with SBBO
Other risk factors such as malnutrition, excessive and/or rapid weight loss, and excessive
alcohol use increase the risk of thiamine deficiency
Post-WLS patients with signs and symptoms or risk factors should be assessed for thiamine
deficiency at least during the first 6 mo and then every 3–6 mo until symptoms resolve.
Vitamin B12 At 2–5 yr post-WLS Recommended for patients who have undergone RYGB, SG, or BPD/DS
(cobalamin) More frequent screening (every 3 mo) recommended in the first year postsurgery and then at
least annually or as clinically indicated for patients who chronically use medications that
RYGB: ,20%
exacerbate risk of B12 deficiency, such as nitrous oxide, neomycin, metformin,
SG: 4%–20%
colchicine, proton-pump inhibitors, and seizure medications
Screening should include serum MMA with or without homocysteine to identify metabolic
deficiency of B12 in symptomatic and asymptomatic patients and in patients with history
of B12 deficiency or preexisting neuropathy.
Vitamin B12 deficiencies can occur due to food intolerances or restricted intake of protein
and vitamin B12-containing foods.
Folate Up to 65% of patients Screening recommended for all patients
(folic acid) Particular attention should be given to female patients of childbearing age.
Poor dietary intake of folate-rich foods and suspected nonadherence with multivitamin may
contribute to folate deficiency.
Iron 3 mo–10 yr post-WLS Iron deficiency can occur after any bariatric procedure, despite routing supplementation.
Routine postbariatric screening is recommended within 3 mo after surgery, then every 3–6
mo until 12 mo, and annually thereafter for all patients.
AGB: 14%
Iron status should be monitored in postbariatric patients at regular intervals using an iron
SG: ,18%
panel, complete blood count, total iron-binding capacity, ferritin, and soluble transferrin
RYGB: 20%–55%
receptor (if available), along with clinical signs and symptoms.
BPD: 13%–62%
Additional screening should be performed based on clinical signs and symptoms and/or
DS: 8%–50%
laboratory findings or in cases in which deficiency is suspected.
Vitamin D and Up to 100% of patients Routine screening is recommended for all patients.
calcium 25(OH)D is the preferred biochemical assay.
Elevated PTH levels and increased bone formation/resorption markers may also be
considered.
Vitamin A Up to 70% of patients within 4 yr Screening is recommended within the first postoperative year, particularly for those who
postsurgery underwent BPD/DS, regardless of symptoms.
Screening is recommended in patients who have undergone RYGB and BPD/DS,
particularly in those with evidence of protein-calorie malnutrition.
Vitamin E Uncommon Screening is recommended in patients who are symptomatic.
Vitamin K Uncommon Screening is recommended in patients who are symptomatic.
Zinc Up to 70% of patients post-BPD/DS Zinc deficiency is possible, even during zinc supplementation and especially if primary
Up to 40% of patients post-RYGB sites of absorption (duodenum and proximal jejunum) are bypassed.
Up to 19% of patients post-SG Screening should be performed at least annually post-RYGB and post-BPD/DS.
Up to 34% of patients post-AGB Serum and plasma zinc are the preferred biomarkers for screening in postbariatric patients.
Copper Up to 90% in patients post-BPD/DS Screening is recommended at least annually after BPD/DS and RYGB, even in the absence
10%–20% in patients post-RYGB of clinical signs or symptoms.
1 case report for patients post-SG Serum copper and ceruloplasmin are recommended biomarkers for determining copper
No data for patients post-AGB status because they are closely correlated with physical symptoms of copper deficiency.
WLS 5 weight loss surgery; GI 5 gastrointestinal; SBBO 5 small bowel bacterial overgrowth; RYGB 5 Roux-en-Y gastric bypass; SG 5 sleeve gastrec-
tomy; BPS/DS 5 biliopancreatic diversion/duodenal switch; MMA 5 methylmalonic acid; AGB 5 adjustable gastric band; PTH 5 parathyroid hormone.
Adapted from Parrott et al. [448].

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Table 14
Nutrient supplementation and repletion after bariatric surgery
Micronutrient Supplementation to prevent deficiency Repletion for patients with deficiency
Vitamin B1 (thiamine) 12 mg thiamine daily; preferably a 50-100 mg daily dose of thiamine from a Bariatric patients with suspected thiamine deficiency should be treated before or in the
B-complex supplement or high-potency multivitamin absence of laboratory confirmation and monitored/evaluated for resolution of signs
and symptoms.
Repletion dose for thiamine deficiency varies based on route of administration and
severity of symptoms:
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Oral therapy: 100 mg 2–3 times daily until symptoms resolve

IV therapy: 200 mg 3 times daily to 500 mg once or twice daily for 3–5 d, followed

Jeffrey I. Mechanick et al. / Surgery for Obesity and Related Diseases 16 (2020) 175–247
by 250 mg/d for 3–5 d or until symptoms resolve, then consider treatment with 100
mg/d orally, indefinitely, or until risk factors have been resolved
IM therapy: 250 mg once daily for 3–5 d or 100–250 mg monthly
Magnesium, potassium, and phosphorus should be given simultaneously to patients at
risk for refeeding syndrome.
Vitamin B12 (cobalamin) Supplement dose varies based on route of administration 1000 mg/d to achieve normal levels and then resume dosages recommended to maintain
normal levels
Orally by disintegrating tablet, sublingual, or liquid: 350–1000 mg daily
Nasal spray as directed by manufacturer
Parenteral (IM or SQ): 1000 mg monthly
Folate (folic acid) 400–800 mg oral folate daily from their multivitamin Oral dose of 1000 mg of folate daily to achieve normal levels and then resume
800–1000 mg oral folate daily in women of childbearing age recommended dosage to maintain normal levels
.1 mg/d supplementation is not recommended because of the potential masking of
vitamin B12 deficiency
Iron Males and patients without a history of anemia: 18 mg of iron from multivitamin Oral supplementation should be increased to provide 150–200 mg of elemental iron
Menstruating females and patients who have undergone RYGB, SG, or BPD/DS: daily to amounts as high as 300 mg 2–3 times daily
45–60 mg of elemental iron daily (cumulatively, including iron from all vitamin Oral supplementation should be taken in divided doses separately from calcium
and mineral supplements) supplements, acid-reducing medications, and foods high in phytates or polyphenols.
Oral supplementation should be taken in divided doses separately from calcium Vitamin C supplementation may be added to increase iron absorption and decrease risk
supplements, acid-reducing medications, and foods high in phytates or polyphenols. of iron overload.
Intravenous iron infusion should be administered if iron deficiency does not respond to
oral therapy.
Vitamin D and calcium Appropriate dose of daily calcium from all sources varies by surgical procedure: All bariatric patients with vitamin D deficiency or insufficiency should be repleted as
follows:
BPD/DS: 1800–2400 mg/d
LAGB, SG, RYGB: 1200–1500 mg/d Vitamin D3 at least 3000 IU/d and as high as 6000 IU/d, or 50,000 IU vitamin D2 1–3
To enhance calcium absorption in post-WLS patients times weekly
Vitamin D is recommended over vitamin D as a more potent treatment when
3 2
Calcium should be given in divided doses comparing frequency and amount needed for repletion.
Calcium carbonate should be taken with meals Repletion of calcium deficiency varies by surgical procedure:
Calcium citrate may be taken with or without meals
Recommended preventative dose of vitamin D should be based on serum vitamin D BPD/DS: 1800–2400 mg/d
levels: LAGB, SG, RYGB: 1200–1500 mg/d
Recommended vitamin D3 dose is 3000 IU daily, until blood levels of 25 (OH) D are
greater than sufficient (30 ng/mL)
7%–90% lower vitamin D3 bolus is needed (compared to vitamin D2) to achieve the
same effects as those produced in healthy nonbariatric surgical patients
(continued on next page )

193
194
Table 14 (continued )
Micronutrient Supplementation to prevent deficiency Repletion for patients with deficiency
Vitamin A Dosage is based on type of procedure: For bariatric patients with vitamin A deficiency without corneal changes, a dose of
10,000–25,000 IU/d of vitamin A should be given orally until clinical improvement
LAGB: 5000 IU/d
RYGB and SG: 5000–10,000 IU/d is evident.
DS: 10,000 IU/d For bariatric patients with vitamin A deficiency with corneal changes, a dose of 50,000–
100,000 IU of vitamin A should be administered IM for 3 d, followed by 50,000 IU/
Higher maintenance doses of fat-soluble vitamins may be required for bariatric patients
d IM for 2 weeks.
with a previous history of vitamin A deficiency.
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Bariatric patients with vitamin A deficiency should also be evaluated for concurrent
Water-miscible forms of fat-soluble vitamins are also available to improve absorption.
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iron and/or copper deficiencies because these can impair resolution of vitamin A
Special attention should be paid to postbariatric supplementation of vitamin A in

Jeffrey I. Mechanick et al. / Surgery for Obesity and Related Diseases 16 (2020) 175–247
deficiency.
pregnant women.
Vitamin E 15 mg/d Optimal therapeutic dose of vitamin E for bariatric patients is not defined.
Higher maintenance doses of fat-soluble vitamins may be required for postbariatric Potential antioxidant benefits can be achieved with supplements of 100–400 IU/d,
patients with a history of vitamin E deficiency. which is higher than the amount found in multivitamins. Additional supplementation
Water-miscible forms of fat-soluble vitamins are also available to improve absorption. may be required for repletion.
Vitamin K Dosage is based on type of procedure: A parenteral dose of 10 mg is recommended for bariatric patients with acute
malabsorption.
LAGB: 90–120 mg/d
A dose of either 1–2 mg/d orally or 1–2 mg/week parenterally is recommended for post-
RYGB and SG: 90–120 mg/d
DS: 300 mg/d WLS patients with chronic malabsorption.
Higher maintenance doses of fat-soluble vitamins may be required for post-WLS
patients with a history of vitamin K deficiency.
Water-miscible forms of fat-soluble vitamins are also available to improve absorption.
Special attention should be paid to post-WLS supplementation of vitamin K in pregnant
women.
Zinc All post-WLS patients should take 4 RDA zinc, with dosage based on type of procedure: A dose-related recommendation for repletion cannot be made due to insufficient
evidence.
BPD/DS: Multivitamin with minerals containing 200% of the RDA (16–22 mg/d)
RYGB: Multivitamin with minerals containing 100%–200% of the RDA (8–22 mg/ Repletion doses should be chosen carefully to avoid inducing a copper deficiency.
Zinc status should be routinely monitored using consistent parameters throughout
d)
SG/LAGB: Multivitamin with minerals containing 100% of the RDA (8–11 mg/d) treatment.
The supplementation protocol should contain a ratio of 8–15 mg of supplemental zinc
per 1 mg of copper to minimize the risk of copper deficiency.
The formulation and composition of zinc supplements should be considered in post-
WLS patients to calculated accurate levels of elemental zinc provided by the
supplement.
Copper All post-WLS patients should take 4 RDA copper as part of routine multivitamin and Recommended repletion regimen varies with severity of deficiency:
mineral supplementation, with dosage based on type of procedure: Mild to moderate (including low hematologic indices): 3–8 mg/d oral copper
BPD/DS or RYGB: 200% of the RDA (2 mg/d) gluconate or sulfate until indices return to normal
SG or LAGB: 100% of the RDA (1 mg/d) Severe: 2–4 mg/d intravenous copper can be initiated for 6 d or until serum levels
Supplementation with 1 mg copper is recommended for every 8–15 mg of elemental return to normal and neurologic symptoms resolve
zinc to prevent copper deficiency in all post-WLS patients. Copper levels should be monitored every 3 months after they return to normal.
Copper gluconate or sulfate is the recommended source of copper for supplementation.
IV 5 intravenous; IM 5 intramuscular; SQ 5 subcutaneous; RYGB 5 Roux-en-Y gastric bypass; SG 5 sleeve gastrectomy; BPD/DS 5 biliopancreatic diversion/duodenal switch; WLS 5 weight loss
surgery; LAGB 5 laparoscopic adjust gastric band; RDA 5 recommended dietary allowance.
Adapted from Parrott et al. [448]
Jeffrey I. Mechanick et al. / Surgery for Obesity and Related Diseases 16 (2020) 175–247 195

and thiazolidinediones should be discontinued, and insulin Serum anti-Xa levels should be considered to guide low-
doses should be adjusted (due to low calorie intake) to molecular-weight heparin dosing in the prophylactic range
minimize the risk for hypoglycemia (Grade D). Except for (Grade A; BEL 1). Daily fondaparinux 5 mg should be
metformin and incretin-based therapies, antidiabetic medi- considered as a preventive option (Grade A; BEL 1).
cations should be withheld if there is no evidence of hyper- R46. (NEW). Respiratory distress or failure to wean from
glycemia (Grade D). Metformin and/or incretin-based ventilatory support should prompt a diagnostic workup for
therapies may be continued postoperatively in patients pulmonary embolus (Grade B; BEL 2).
with T2D until prolonged clinical resolution of T2D is R47. (2019*). Respiratory distress or failure to wean from
demonstrated by normalized glycemic targets (including fast- ventilatory support after a bariatric procedure should
ing and postprandial blood glucose and HbA1C) (Grade D). prompt a standard diagnostic workup with a particular
Subcutaneous insulin therapy, using a rapid-acting insulin emphasis on detecting anastomotic leak (Grade D). In the
analogue (insulin lispro, aspart, or glulisine) before meals clinically stable patient, computed tomography (CT;
and a basal long-acting insulin analogue (insulin glargine, preferred over upper-GI studies [water-soluble contrast fol-
detemir, or degludec) should be used to achieve glycemic tar- lowed by thin barium]) may be considered to evaluate for
gets (140–180 mg/dL) in hospitalized patients not in inten- anastomotic leaks in suspected patients (Grade C; BEL 3).
sive care (Grade D). In the intensive care unit (ICU), IV Exploratory laparotomy or laparoscopy is justified and
regular insulin as part of a standard intensive insulin therapy may therefore be considered in the setting of high clinical
protocol should be used to control hyperglycemia to a 140 to suspicion for anastomotic leaks (Grade A; BEL 1). A
180 mg/dL blood glucose target (Grade D). Endocrinology selected diatrizoate meglumine and diatrizoate sodium up-
consultation should be considered for patients with type 1 per GI study in the absence of abnormal signs or symptoms
diabetes (T1D) or with T2D and uncontrolled hyperglycemia may be considered to identify any subclinical leaks before
(Grade D). Once home, for patients with T2D, periodic fast- discharge of the patient from the hospital, but routine studies
ing blood glucose concentrations must be determined are not cost-effective (Grade C; BEL 3). C-reactive protein
(Grade A; BEL 1). Preprandial, 2-hour postprandial, and and/or procalcitonin testing should be considered if a post-
bedtime reflectance meter glucose (“fingerstick”) determina- operative leak is suspected or the patient is at increased risk
tions or the use of continuous glucose monitors in the home for a leak after hospital discharge (Grade B; BEL 2).
setting is also recommended, depending on the patient’s abil- R48. (2019*). Patients should have adequate padding at
ity to test the level of glycemic control targeted, use of oral pressure points during bariatric surgery (Grade D). When
agents or insulin, and overall care plan (Grade A; BEL 1). rhabdomyolysis is suspected, creatine kinase levels should
Reflectance meter glucose determinations or the use of be determined, urine output monitored, and adequate hydra-
continuous glucose monitors is recommended if symptoms tion provided (Grade C; BEL 3). The risk for rhabdomyol-
of hypoglycemia occur (Grade A; BEL 1). ysis increases as BMI increases (particularly with BMI
R43. (2013*). Patients with high perioperative risk for .55–60 kg/m2); therefore, screening creatine kinase levels
myocardial infarction should be managed in a telemetry- may be tested in these higher-risk groups (Grade D). Exces-
capable setting for at least the first 24 hours after a bariatric sive postoperative IV fluids should be avoided (Grade D).
surgical procedure (Grade B; BEL 2).
Q6. How can care be optimized 5 days after a bariatric
R44. (2019*). Pulmonary management includes aggres-
procedure?
sive pulmonary toilet and incentive spirometry, oxygen sup-
plementation to avoid hypoxemia, and early institution of R49. (2019*). Follow-up should be scheduled depending
CPAP when clinically indicated (Grade C, BEL 3). Routine on the bariatric procedure performed and the severity of co-
admission to an ICU should not be implemented in patients morbidities (Table 11) (Grade D). After LAGB procedures,
solely for the presence of severe OSA provided there is frequent nutritional follow-up and band adjustments are rec-
adequate CPAP use (Grade D). ommended to optimize safety and achieve weight loss tar-
R45. (2019*). Prophylaxis against DVT is recommended gets (Grade C; BEL 3). Significant weight regain or
for all patients after bariatric surgical procedures (Grade B; failure to lose weight should prompt a comprehensive eval-
BEL 2). Prophylactic regimens after bariatric surgery may uation for (1) decreased patient adherence with lifestyle
include sequential compression devices (Grade C; BEL 3), modification, (2) evaluation of medications associated
as well as subcutaneously administered unfractionated hep- with weight gain or impairment of weight loss, (3) develop-
arin or low-molecular-weight heparin given within 24 hours ment of maladaptive eating behaviors, (4) psychologic com-
after bariatric surgery (Grade B; BEL 2). Extended chemo- plications, and (5) radiographic or endoscopic evaluation to
prophylaxis after hospital discharge should be considered assess pouch enlargement, anastomotic dilation, formation
for high-risk patients, such as those with history of DVT, of a gastrogastric fistula among patients who underwent
known hypercoagulable state, or limited ambulation (Grade RYGB or inadequate band restriction among patients who
C, BEL 3). The use of DVT risk calculators (Grade C; BEL underwent a LAGB (Grade B; BEL 2). Interventions should
3) and early ambulation are encouraged (Grade C; BEL 3). first include dietary change, physical activity, behavioral

modification with frequent follow-up; if appropriate, phar- R54. (2008). In patients who have had RYGB or BPD/
macologic therapy and/or surgical revision should then be DS, bone density measurements with use of axial (spine
implemented (Grade B; BEL 2). In those patients with or and hip) dual-energy x-ray absorptiometry may be indicated
without complete resolution of their co-morbidities, such to monitor for osteoporosis at baseline and at approximately
as T2D, dyslipidemia, OSA, or HTN, continued surveillance 2 years (Grade D).
and management should be guided by current CPG for those R55. (2013*). Evaluation of patients for bone loss after
conditions (Grade D). Routine metabolic and nutritional bariatric procedures may include serum parathyroid hor-
monitoring is recommended after all bariatric procedures mone, total calcium, phosphorus, 25-hydroxyvitamin D,
(Grade A; BEL 1). and 24-hour urine calcium levels (Grade C; BEL 3). Antire-
R50. (2013*). Patients who have undergone RYGB, BPD sorptive agents (bisphosphonates or denosumab) should
with or without DS, or SG and who present with postpran- only be considered in patients after bariatric procedures
dial hypoglycemic symptoms that have not responded to with osteoporosis after appropriate therapy for calcium
nutritional manipulation should undergo an evaluation to and vitamin D insufficiency has been implemented (Grade
differentiate noninsulinoma pancreatogenous hypoglycemia D). If antiresorptive therapy is indicated after bariatric pro-
syndrome from factitious or iatrogenic causes, dumping cedures, IV-administered bisphosphonates should be used
syndrome, and insulinoma (Grade C; BEL 3). In patients (zoledronic acid, 5 mg once a year, or ibandronate, 3 mg
with noninsulinoma pancreatogenous hypoglycemia syn- every 3 mo), as concerns exist about adequate oral absorp-
drome, therapeutic strategies should be implemented and tion and potential anastomotic ulceration with orally admin-
include dietary changes (low-carbohydrate diet), octreotide, istered bisphosphonates (Grade D). If concerns about
diazoxide, acarbose, calcium-channel antagonists, gastric absorption or potential anastomotic ulceration are obviated,
restriction, and/or reversal procedures, with partial or total oral bisphosphonate administration can be provided (alendr-
pancreatectomy reserved for the rare recalcitrant cases onate, 70 mg/wk; risedronate, 35 mg/wk or 150 mg/mo; or
(Grade C; BEL 3). Continuous glucose monitoring may be ibandronate, 150 mg/mo). Alternatively, if bisphosphonates
considered in those patients with hypoglycemia syndromes are poorly tolerated or ineffective, denosumab (60 mg sub-
after bariatric procedures (Grade C, BEL 3). cutaneously every 6 mo) may be considered, again once
R51. (2013*). Unless specifically contraindicated, pa- appropriate therapy for calcium and vitamin D insufficiency
tients must be advised to incorporate at least some amount has been implemented (Grade D).
of physical activity, with a target of moderate aerobic phys- R56. (2013*). Management of oxalosis and calcium oxa-
ical activity that includes a minimum of 150 min/wk and late stones includes avoidance of dehydration (Grade D), a
goal of 300 min/wk, including strength training 2 to 3 times low-oxalate meal plan (Grade D), oral calcium (Grade B;
per week (Grade A; BEL 1). BEL 1; downgraded due to small evidence base), and potas-
R52. (2019*). All patients should be encouraged to sium citrate therapy (Grade B; BEL 1; downgraded due to
participate in ongoing support groups (Grade B; BEL 2), small evidence base). Probiotics containing Oxalobacter
self-monitoring (Grade B; BEL 2), and/or mobile technolo- formigenes may be used because they have been shown to
gies (Grade B; BEL 2) to improve weight loss and cardio- improve renal oxalate excretion and improve supersatura-
metabolic risks after bariatric procedures. tion levels (Grade C; BEL 3).
R53. (2019*). Baseline and annual postoperative evalua- R57. (2019*). Aggressive case finding (i.e., detecting a
tion for vitamin D deficiency is recommended after RYGB, disorder in patients at risk) for vitamin A undernutrition
SG, or BPD/DS (Grade B; BEL 2). In patients who have un- may be performed in the first postoperative year after
dergone RYGB, BPD, or BPD/DS, treatment with oral cal- RYGB or BPD/DS or with evidence of malnutrition in light
cium citrate and vitamin D (ergocalciferol [vitamin D2] or of the high prevalence of this deficiency state in these set-
cholecalciferol [vitamin D3]) is indicated to prevent or mini- tings (Grade C; BEL 3). Aggressive case finding for vitamin
mize secondary hyperparathyroidism without inducing frank E and K deficiencies should be reserved for those postoper-
hypercalciuria (Grade C; BEL 3). In patients with severe ative patients demonstrating symptoms (hemolytic anemia
vitamin D malabsorption, initial oral doses of vitamin D2 and neuromuscular, particularly ophthalmologic, for
50,000 IU 1 to 3 times weekly or D3 (minimum of 3000– vitamin E; excessive bleeding or bruising for vitamin K)
6000 IU/d) should be recommended. Of note, vitamin D3 is (Grade D). When indicated, the dosing strategies for vitamin
recommended as a more potent treatment than vitamin D2 A are 5000 IU/d for LAGB, 5000 to 10,000 IU/d for RYGB
based on frequency and amount of dosing needed for reple- and SG, and 10,000 IU/d for BPD/DS; for vitamin E 15 mg/
tion; however, both can be used (Grade B; BEL 2). Recalci- d for all procedures; and for vitamin K 90 to 120 mg/d for
trant cases may require concurrent oral administration of LAGB, RYGB, and SG and up to 300 mg/d for BPD/DS
calcitriol (1,25-dihydroxyvitamin D) (Grade D). Hypophos- (Grade D).
phatemia is usually due to vitamin D deficiency, and oral R58. (2008*). In the presence of any established fat-
phosphate supplementation should be provided for mild to soluble vitamin deficiency (vitamins A, D, E, and/or K)
moderate hypophosphatemia (1.5–2.5 mg/dL) (Grade D). with, for example, hepatopathy, neuromuscular impairment,

coagulopathy, or osteoporosis or suspected essential fatty risk of fetal neural tube defects (Grade A; BEL 1). B12 sta-
acid deficiency (symptoms include hair loss, poor wound tus should be assessed in patients on higher-dose folic acid
healing, and dry scaly skin), clinical and biochemical supplementation (.1000 mg/d) to detect a masked B12-
assessments of the other fat-soluble vitamins may be deficiency state (Grade D).
considered. Supplementation may be used if levels are R62. (2013). Nutritional anemias resulting from malab-
abnormally low (Grade D). In patients with suspected essen- sorptive bariatric procedures can involve deficiencies in
tial fatty acid deficiency in the setting of malabsorptive pro- vitamin B12, folate, protein, copper, selenium, and zinc,
cedures, therapeutic trials with topical borage, soybean, or and may be evaluated when routine aggressive case finding
safflower oil may be considered due to the low risk profile, for iron-deficiency anemia is negative (Grade C; BEL 3).
but these trials are unsupported at present (Grade D). R63. (2013). There is insufficient evidence to support
R59. (2019*). Anemia without evidence of blood loss routine selenium screening or supplementation after a bar-
warrants evaluation of nutritional deficiencies and iatric procedure (Grade D). However, selenium levels may
age-appropriate causes during the late postprocedure period be checked as part of aggressive case finding in patients
(Grade D). Iron status should be monitored in all patients with a malabsorptive bariatric surgical procedure who
within the first 3 months after bariatric procedures, then have unexplained anemia or fatigue, persistent diarrhea, car-
every 3 to 6 months until 12 months, and then annually diomyopathy, or metabolic bone disease (Grade C; BEL 3).
thereafter for all patients (Grade B; BEL 2). Treatment reg- R64. (2019*). Zinc supplementation should be included
imens include oral ferrous sulfate, fumarate, or gluconate to as part of a routine multivitamin-multimineral preparation
provide up to 150 to 200 mg of elemental iron daily (Grade with 8 to 22 mg/d to prevent a deficiency state; the amount
A; BEL 1). Vitamin C supplementation may be added indicated varies depending on the bariatric procedure per-
simultaneously to increase iron absorption (Grade C; BEL formed, with greater amounts required for RYGB and
3). IV iron infusion (preferably with ferric gluconate or su- BPD/DS (Grade C; BEL 3). Routine aggressive case finding
crose) may be needed for patients with severe intolerance to for zinc deficiency using serum and plasma zinc determina-
oral iron or refractory deficiency due to severe iron malab- tions should be performed after malabsorptive bariatric sur-
sorption (Grade D). gical procedures (RYGB and BPD/DS) (Grade C; BEL 3)
R60. (2019*). Baseline and annual post–bariatric proced- and zinc deficiency should also be considered after bariatric
ure evaluation for vitamin B12 deficiency should be per- procedure in any patient with chronic diarrhea, hair loss,
formed in all patients (Grade B; BEL 2). More frequent pica, or significant dysgeusia, or in male patients with unex-
aggressive case finding (e.g., every 3 mo) should be per- plained hypogonadism or erectile dysfunction (Grade D).
formed in the first postoperative year and then at least annu- Treatment of zinc deficiency should target normal biochem-
ally or as clinically indicated for patients who chronically ical levels with 1 mg/d copper also supplemented for every 8
use medications that exacerbate the risk of B12 deficiency, to 15 mg/d elemental zinc provided (Grade D).
including nitrous oxide, neomycin, metformin, colchicine, R65. (2019*). Routine aggressive case finding for copper
proton-pump inhibitors, and seizure medications (Grade deficiency using serum copper and ceruloplasmin may be
B, BEL 2). Because serum B12 may not be adequate to considered for all patients who have undergone RYGB or
identify B12 deficiency, consider measuring serum methyl- BPD/DS at least annually, even in the absence of clinical
malonic acid, with or without homocysteine, to identify a signs or symptoms of deficiency (Grade C, BEL 3), but
metabolic deficiency of B12 in symptomatic and asymptom- especially in patients who are experiencing anemia, neutro-
atic patients and in patients with a history of B12 deficiency penia, myeloneuropathy, or impaired wound healing (Grade
or preexisting neuropathy (Grade B, BEL 2). Oral supple- D). Copper supplementation (2 mg/d) should be included as
mentation (via disintegrating tablet, sublingual, or liquid) part of a routine multivitamin-multimineral preparation;
with crystalline vitamin B12 at a dosage of 350 to 1000 further supplementation varies depending on the surgical
mg daily or more is recommended to maintain normal procedure performed, with greater amounts required for pa-
vitamin B12 levels (Grade A; BEL 1). Intranasally adminis- tients who have had RYGB or BPD/DS (Grade D). In severe
tered vitamin B12 may also be considered (Grade D). Paren- deficiency, treatment can be initiated with IV copper (3–4
teral (intramuscular or subcutaneous) B12 supplementation, mg/d) for 6 days (Grade D). Subsequent treatment of severe
1000 mg/mo to 1000 to 3000 mg every 6 to 12 months, is deficiency, or treatment of mild-to-moderate deficiency, can
indicated if B12 sufficiency cannot be maintained using usually be achieved with oral copper sulfate or gluconate 3
oral or intranasal routes (Grade C; BEL 3). to 8 mg/d until levels normalize and symptoms resolve
R61. (2013). Folic acid supplementation (400–800 mg/d) (Grade D). Patients being treated for zinc deficiency or us-
should be part of a routine multivitamin-multimineral prep- ing supplemental zinc for hair loss should receive 1 mg of
aration (Grade B; BEL 2) and must be supplemented further copper for each 8 to 15 mg of elemental zinc because zinc
(1000 mg/d) when a deficiency state is suspected (e.g., with replacement can cause copper deficiency (Grade C; BEL
skin, nail, or mucosal changes) or found, as well as in all 3). Copper gluconate or sulfate is the recommended source
women of childbearing age (800–1000 mg/d) to reduce the of copper for supplementation (Grade C; BEL 3).

R66. (2019*). Thiamine (vitamin B1) supplementation 2). Patients with T2D who had their diabetes medication
above the recommended dietary allowance (RDA) is sug- stopped after bariatric procedures must be monitored
gested to prevent thiamine deficiency (Grade D). Routine closely for recurrence of hyperglycemia, particularly with
thiamine screening may be considered following bariatric weight regain or suboptimal weight loss (Grade B; BEL 2).
procedures (Grade C; BEL 3). Aggressive case finding R71. (NEW). In patients on thyroid hormone replacement
for thiamine deficiency and/or empiric thiamine supple- or supplementation, TSH levels must be monitored after
mentation is indicated for high-risk postprocedure patients, bariatric procedures and medication dosing adjusted; dose
such as those with established preprocedure risk factors for reductions are more likely with weight loss but can increase
thiamine deficiency, females, African Americans, patients with malabsorption (Grade B; BEL 2). Oral liquid forms of
not attending a nutritional clinic, patients with GI symp- levothyroxine may be considered in those patients who have
toms, and patients with heart failure, protracted vomiting, difficulty swallowing tablets after bariatric procedures
PN, excessive alcohol use, neuropathy or encephalopathy (Grade D). Oral liquid or softgel forms of levothyroxine
(Grade C; BEL 3), or small intestinal bacterial overgrowth may be considered in patients with significant malabsorp-
(SIBO) (Grade C; BEL 3). All post-WLS patients should tion in whom adequate TSH suppression to normal ranges
take at least 12 mg thiamine daily (Grade C; BEL 3). A is difficult after bariatric procedures (Grade C; BEL 3).
50-100 mg daily dose of thiamine from a B-complex sup- R72. (2019*). Persistent and severe GI symptoms (e.g.,
plement or high-potency multivitamin may be needed to nausea, vomiting, abdominal pain, diarrhea, and constipa-
maintain sufficient blood levels of thiamine and prevent tion) warrant evaluation using a pertinent history and phys-
thiamine deficiency in some patients (Grade D). Patients ical examination, appropriate laboratory testing, and
with severe thiamine deficiency (suspected or established) imaging (most commonly CT and/or upper GI series)
should be treated with IV (or intramuscular if IV access is (Grade C; BEL 3). Upper endoscopy with small-bowel bi-
not available) thiamine, 500 mg/d for 3 to 5 days, followed opsies and aspirates remains the gold standard and should
by 250 mg/d for 3 to 5 days or until resolution of symp- be part of the evaluation of celiac disease and bacterial over-
toms, with consideration of treatment with 100 mg/d orally growth in patients who have had a bariatric procedure
usually indefinitely or until risk factors have resolved (Grade C; BEL 3). Screening with a stool specimen should
(Grade C; BEL 3). Mild deficiency can be treated with be obtained if the presence of Clostridium difficile colitis is
intravenous thiamine, 100 mg/d for 7 to 14 days (Grade suspected (Grade C; BEL 3). Persistent steatorrhea after
C; BEL 3). In patients with recalcitrant or recurrent thia- BPD/DS should prompt evaluation for nutrient deficiencies
mine deficiency with 1 of the aforementioned risks, the (Grade C; BEL 3).
addition of antibiotics for SIBO should be considered R73. (NEW). Patients with de novo GERD and severe
(Grade C; BEL 3). symptoms after SG should be treated with proton-pump in-
R67. (NEW). Commercial products that are used for hibitor therapy, and those recalcitrant to medical therapy
micronutrient supplementation need to be discussed with a should be considered for conversion to RYGB (Grade C;
healthcare professional familiar with dietary supplements BEL 3).
because many products are adulterated and/or mislabeled R74. (2019*). Nonsteroidal anti-inflammatory drugs
(Grade D). (NSAIDs) should be avoided after bariatric procedures, if
R68. (2013*). Lipid levels and the need for lipid-lowering possible, because they (and steroids to a lesser extent)
medications should be periodically evaluated (Grade D). have been implicated in the development of anastomotic ul-
The effect of weight loss on dyslipidemia is variable and cerations, perforations, and leaks (Grade C; BEL 3); ideally,
incomplete; therefore, lipid-lowering medications should alternative pain medication should be identified before the
not be stopped unless clearly indicated (Grade C; BEL 3). bariatric procedure (Grade D). If the use of NSAIDs is un-
R69. (2019*). The need for antihypertensive medications avoidable, then the use of proton-pump inhibitors may be
should be evaluated repeatedly and frequently during the considered (Grade C; BEL 3).
active phase of weight loss (Grade D). Because the effect R75. (2019*). Endoscopy is safe and should be the
of weight loss on blood pressure is variable, incomplete, preferred procedure to evaluate GI symptoms suggestive
and at times transient, antihypertensive medications should of stricture or foreign body (e.g., suture or staple) because
not be stopped unless clearly indicated; however, dosages it can be both diagnostic and therapeutic (e.g., endoscopic
may need to be titrated downward as blood pressure im- dilation or foreign body removal) (Grade C; BEL 3). Endos-
proves (Grade D). copy may also be used for H. pylori testing as a possible
R70. (NEW). Close attention to dosing of diabetes medi- contributor to persistent GI symptoms after bariatric proced-
cation is recommended for those who have had SG, RYGB, ures (Grade D).
or BPD/DS because these patients generally have dosing R76. (NEW). Anastomotic ulcers after bariatric proced-
reduced in the early postoperative period, whereas those ures should be treated with proton-pump inhibitors; prophy-
who have undergone LAGB must experience significant lactic therapy with proton-pump inhibitors should be
weight loss before dosing must be reduced (Grade B; BEL considered for 90 days to 1 year, depending on risk (Grade

B; BEL 2). H2 receptor blockers and sucralfate may also be with an abdominal and pelvic CT scan to exclude the poten-
considered for postprocedure anastomotic ulcers. If H. py- tially life-threatening complication of a closed-loop bowel
lori is identified, triple therapy, including antibiotics, bis- obstruction (Grade D). Exploratory laparotomy or laparos-
muth, and proton-pump inhibitors, may be used (Grade C; copy is indicated in patients who are suspected of having
BEL 3). an internal hernia because this complication can be missed
R77. (2013*). Patients who have undergone RYGB with a with upper GI x-ray studies and CT scans (Grade C; BEL 3).
nonpartitioned stomach and developed a gastrogastric fis- R82. (2013*). Body-contouring surgery may be per-
tula with symptoms (e.g., weight regain, marginal ulcer, formed after bariatric procedures to manage excess tissue
stricture, or GERD) may be considered for a revisional pro- that impairs hygiene, causes discomfort, and is disfiguring
cedure (Grade C; BEL 3). (Grade C; BEL 3). Body-contouring surgery is best pursued
R78. (2019*). Persistent vomiting, regurgitation, and up- after weight loss has stabilized (12–18 mo after bariatric
per GI obstruction after LAGB should be treated with imme- surgery) (Grade D).
diate removal of fluid from the adjustable band (Grade D).
Persistent symptoms of GERD, regurgitation, chronic Q7. What are the criteria for hospital admission after a
cough, or recurrent aspiration pneumonia in a patient after bariatric procedure?
LAGB raise concern for band slippage, esophageal dilation, R83. (2013). Severe malnutrition or hypoglycemia after a
and, in some cases, erosion, and should prompt evaluation of bariatric procedure should prompt hospital admission
the patient with upper GI endoscopy or fluoroscopy (Grade (Grade D). The initiation and formulation of EN (tube
C; BEL 3), immediate referral to a bariatric surgeon, and, feeding) or PN should be guided by current CPG (Grade
depending on the clinical course, consideration of conver- D). Hospital admission is required for the management of
sion to SG or RYGB (Grade D). GI complications after bariatric procedures in clinically un-
R79. (2019*). Ultrasound should be used to evaluate pa- stable patients (Grade D). Surgical management should be
tients with right upper-quadrant pain for cholecystitis pursued for GI complications not amenable or responsive
(Grade D). Patients who undergo SG, RYGB, or BPD/ to medical therapy (Grade D). However, if not dehydrated,
DS are at increased risk for cholelithiasis as a result of patients may undergo endoscopic stomal dilation for stric-
rapid weight loss, and oral administration of ursodeoxy- ture as an outpatient procedure (Grade D).
cholic acid is recommended: 500 mg once daily for SG R84. (2008). Revision of a bariatric surgical procedure
and 300 mg twice a day for RYGB or BPD/DS (Grade can be recommended when serious complications related
A; BEL 1). In asymptomatic patients with known gall- to previous bariatric surgery cannot be managed medically
stones and a history of RYGB or BPD/DS, prophylactic (Grade C; BEL 3).
cholecystectomy may be considered to avoid choledocho- R85. (2008). Reversal of a bariatric surgical procedure is
lithiasis because traditional endoscopic retrograde cholan- recommended when serious complications related to previ-
giopancreatography can no longer be performed in these ous bariatric surgery cannot be managed medically and are
patients. Otherwise, cholecystectomy should be reserved not amenable to surgical revision (Grade D).
for patients with symptomatic biliary disease due to a
generally low incidence of biliary complications (Grade
Updated evidence base for 2019
B; BEL 2).
R80. (2013*). Although uncommon, suspected SIBO in This evidence base pertains to the 7 questions and 85
the biliopancreatic limb after BPD/DS may be treated updated numbered recommendations. There are 858 cita-
empirically with metronidazole or rifaximin (Grade C; tions, of which 81% were published in 2013 or later, with
BEL 3). For antibiotic-resistant cases of bacterial over- 81 (9.4%) evidence level (EL) 1, 562 (65.5%) EL 2, 72
growth, probiotic therapy with Lactobacillus plantarum (8.4%) EL 3, and 143 (16.7%) EL 4, compared with 32
299v and/or Lactobacillus GG may be considered (Grade (7.9%) EL 1, 129 (32%) EL 2, 173 (43%) EL 3, and 69
D). Thiamine deficiency may be suspected in patients with (17.1%) EL 4 in the 2013 AACE/TOS/ASMBS CPG and
SIBO after bariatric procedures, especially when gut dys- 13 (1.7%) EL 1, 112 (14.4%) EL 2, 460 (59.2%) EL 3,
motility occurs (Grade C; BEL 3). and 192 (24.7%) EL 4 in the 2008 AACE/TOS/ASMBS
R81. (2008*). Definitive repair of asymptomatic abdom- CPG. There is a relatively high proportion (75%) of strong
inal wall hernias can be deferred until weight loss has stabi- (EL 1 and 2) studies, compared with 40% in the 2013
lized and nutritional status has improved to allow for AACE/TOS/ASMBS CPG and only 16% in the 2008
adequate wound healing (12–18 mo after bariatric surgery) AACE/TOS/ASMBS CPG. The primary evidence base, sup-
(Grade D). Symptomatic hernias that occur after bariatric porting tables, and unrevised recommendations for general
surgery may require prompt surgical evaluation (Grade C; information are not provided in this document and may be
BEL 3). Patients with sudden onset of severe cramping, found in the 2008 [54] and 2013 AACE/TOS/ASMBS
periumbilical pain, or recurrent episodes of severe abdom- CPG [1]. Readers are strongly encouraged to review these
inal pain any time after bariatric surgery should be evaluated past CPG to place the updated explanations and references

into better context. The technical evidence ratings for these and RCTs have demonstrated clinical benefits in patients
updated references are found in the reference section of this with BMI 35 kg/m2 and the following complications:
document, appended at the end of each citation. T2D [31,36,40,42,88–90], high risk for T2D (prediabetes
and/or MetS) [72,73,91–94], poorly controlled HTN
[88,95–97], NAFLD/NASH [98–104], OSA [105–110],
Q1. Which patients should be offered bariatric
osteoarthritis of the knee or hip [111–116] and improving
procedures?
outcomes of knee or hip replacement [114,116–119], and
R1. (2019*). Mortality rates, the risk and prevalence of urinary stress incontinence [120–123].
ORC conferring disease morbidity, and social costs of Several other co-morbidities may be ameliorated by bar-
obesity are highest in those patients with class III severe iatric procedures, although the evidence is weaker, often
obesity (i.e., BMI 40 kg/m2) [56–58]. The evidence base consisting of case reports and case series; these co-
for recommending bariatric surgery for patients with BMI morbidities include obesity-hypoventilation syndrome and
40 kg/m2 without coexisting medical problems or Pickwickian syndrome after a careful evaluation of opera-
severe ORC is supported by recent studies demonstrating tive risk [75,124,125], idiopathic intracranial HTN [126–
benefit with respect to reduced mortality [32,38,58–63], 130], GERD preferentially employing RYGB
improvements in cardiovascular risk factors [33,38,64], [13,110,131–136], severe venous stasis disease [137,138],
reduced rates of some cancers [65–67], substantial weight impaired mobility due to obesity [77,78,139], and consider-
loss that is persistent in most patients [38,58,62,63,68–71], ably impaired quality of life [77,78,139].
diabetes prevention [72–74], improved pulmonary
function [75], and better mobility and quality of life [76–
Clinical benefits with BMI 35 kg/m2
78]. Currently, the WHO classification scheme for obesity
determines diagnostic and therapeutic management based Type 2 diabetes
on BMI. However, BMI is a surrogate measure of adipose Bariatric surgery can be considered in patients with T2D
tissue mass, is confounded by ethnic differences and when the BMI is 35 kg/m2, especially if diabetes is diffi-
aspects of body composition [79–83], and does not cult to control with lifestyle and pharmacologic therapy
provide information regarding the impact of excess [1,31,36,40,42,88–90,140]. The Surgical Treatment and
adiposity on the health of the patient [13]. Improved risk Medications Potentially Eradicate Diabetes Efficiently
stratification strategies for bariatric surgery involving (STAMPEDE) trial is a randomized controlled, single-
patients with BMI 40 kg/m2 may incorporate the risk, center study comparing outcomes of intensive medical ther-
presence, and severity of ORC [13,19,84], the functional apy alone versus intensive medical therapy plus RYGB or
status of the patient, and body-composition technologies SG [34,88,141]. One-, 3-, and 5-year outcomes showed
[83] to more precisely evaluate the mass and distribution that a significantly higher percentage of patients after bariat-
of adipose tissue [79,80,85]. The benefits of bariatric pro- ric surgery met the primary endpoint of HbA1C 6%,
cedures must be balanced against the inherent risks of com- which was associated with a decrease in the number of dia-
plications and mortality, potential nutritional deficiencies, betes medications compared with the patients treated by
weight regain in some patients, and the need for lifelong medical therapy alone. These data underscore the effective-
lifestyle support and medical care. Factors found to be asso- ness of bariatric surgery but should be interpreted cautiously
ciated with poor outcome include open procedures, male when comparing medical and bariatric approaches because
sex, older age, congestive heart failure, peripheral vascular glycemic control in the medically treated patients was not
disease, DVT, pulmonary embolism, OSA, impaired func- optimal, and the study did not include a weight loss arm us-
tional status, chronic kidney disease, and suicidality ing intensive lifestyle/behavior therapy plus weight loss
[86,87]. Therefore, further studies are needed that use clin- medications. The Swedish Obese Subjects study is a non-
ical risk-stratification systems to optimize patient selection randomized, prospective, controlled study in 4047 patients
criteria in patients with BMI 40 kg/m2 who do not have with obesity who underwent bariatric surgery or received
severe complications and that evaluate consequent patient conventional treatment [31,94]. In a subgroup analysis of
outcomes. 343 patients with T2D at baseline, bariatric surgery brought
R2. (2019*). Bariatric procedures can prevent and/or 72% into remission (i.e., blood glucose 110 mg/dL on no
ameliorate ORC that are responsive to weight loss, and these diabetes drugs) compared with 16% in remission in medi-
clinical benefits augment the benefit-risk ratio of the proced- cally treated controls at 2 years, decreasing to 30% in remis-
ure and the salutary effects on the health of the patient. The sion versus 7% in controls at 15 years [31]. Additional trials
strength of evidence for efficacy of bariatric procedures to and cohort studies have demonstrated clinical benefits of
ameliorate ORC varies according to the complication. As bariatric surgery in T2D [40,89,142–146].
described below, there exists strong evidence to support bar- Meta-analyses that include RCTs, nonrandomized inter-
iatric procedures in the prevention and/or treatment of ventional trials, and single-arm observational studies
several ORC. Specifically, interventional cohort studies concluded that bariatric surgical procedures led to T2D

remission rates of 60%–66% [37,147–150], with an order of cohort study, HTN was present in 68% of 2458 patients
effectiveness as follows: BPD/DS . RYGB SG . LAGB with obesity (median BMI 45.9 kg/m2) [50]. After 3 years,
[149]. The relative effectiveness of individual procedures HTN remained in remission in 269 of 705 patients (38%)
producing T2D remission is not entirely clear because undergoing RYGB (weight loss 31.5%) and 43 of 247 pa-
some studies favor RYGB over SG [149,151,152] and tients (17%) who had LAGB (weight loss 15.9%) [50]. Ef-
many others conclude that these procedures are equally fects of SG to produce complete remission of HTN in a
effective [153–156]. Many [149,151,157], but not all retrospective cohort study occurred in 46% of patients at
[152,153], studies indicate that greater degrees of weight year 1, 48% at year 3, and 46% at year 5 [178].
loss after surgery are more likely to result in T2D remission.
One study found that a composite scoring system (e.g., age, Type 1 diabetes
BMI, C-peptide level, and duration of T2D) predicted There are limited data on the effects of bariatric or meta-
response in glycemic markers to bariatric surgery [158]. bolic procedures on T1D. In a 2018 meta-analysis by Hus-
In another study, higher baseline BMI was associated with sain [179], only 9 studies (N 5 78 patients) demonstrated
a greater improvement in T2D after RYGB [159]. In any improvements in HbA1C, insulin dosing, and BMI. Im-
event, “remission” is the proper terminology as opposed to provements in diabetes management were not exclusively
“cure,” because overt T2D returns in over half of these pa- related to excess weight loss, arguing for roles of other fac-
tients in ,10 years [31]. Bariatric surgery must be balanced tors. More data are needed to better define a role for GI pro-
against the inherent risks of surgical complications and mor- cedures in the management of T1D.
tality, potential nutritional deficiencies, weight regain in
some patients, and the need for lifelong lifestyle support Nonalcoholic steatohepatitis
and medical monitoring [1,157,160,161]. In patients with NAFLD and NASH, bariatric surgery re-
sults in reductions in liver fat and improvements in histolog-
Prediabetes, MetS, and T2D prevention ic manifestations of liver injury, inflammation, and fibrosis
Rates of incident T2D were reduced after a variety of bar- [98–104,180–182]. In 39 patients undergoing RYGB, a
iatric surgical procedures [72,73,91–93,155,161]. In 2 postoperative weight loss of 50 kg over 18 months led to
studies, bariatric surgery led to a 76% to 80% reduction in marked improvements in histologic steatosis,
rates of T2D [72,73], which was similar to the degree of pre- hepatocellular ballooning, centrilobular fibrosis, lobular
vention when lifestyle intervention [162] and/or weight loss inflammation, and fibrosis stage [98]. Nineteen patients
medications [163,164] achieved 10% weight loss, even with biopsy-proven NASH at the time of RYGB lost 40%
though bariatric surgery produced greater weight loss than of total body weight after 21 months, and repeat biopsy
observed with lifestyle and pharmacotherapy. These com- demonstrated marked improvements in histologic steatosis,
bined data suggest that 10% weight loss will reduce the lobular inflammation, and portal and lobular fibrosis [99].
risk of future T2D by approximately 80%, and this repre- Importantly, histopathologic criteria for NASH were no
sents a threshold above which further weight loss will not longer present in 89% of patients. Mummadi et al. [100]
result in additional preventive benefits. conducted a meta-analysis of 15 interventional studies that
included 766 paired liver biopsies; the reductions in BMI af-
Hypertension ter bariatric surgeries ranged from 19.11% to 41.76%, and
Bariatric surgery is effective in lowering blood pressure the pooled proportion of patients with improvement or res-
in patients with obesity. This has been demonstrated in mul- olution was 91.6% for steatosis, 81.3% for steatohepatitis,
tiple uncontrolled interventional cohort studies [165,166], 65.5% for fibrosis, and 69.5% for complete resolution of
controlled clinical trials [95,96,167–172], RCTs NASH. Bariatric surgery has been observed to result in
[88,146,173,174], and meta-analyses [36,97,175]. Bariatric long-term reductions in liver transaminases in the Swedish
surgery promotes weight loss and lowering of blood pres- Obese Subjects study, consistent with persisting salutary ef-
sure across all levels of obesity, as demonstrated by system- fects in NAFLD [104]. Transient deterioration in liver func-
atic reviews in class I [36,175] and class-II [175] obesity and tion has also been observed after bariatric surgery in some
in patients with severe obesity and BMI .50 kg/m2 [176]. patients with NASH [101].
When different bariatric surgical approaches are compared,
patients experiencing greater weight loss generally have bet- Obstructive sleep apnea
ter outcomes regarding blood pressure and HTN [167,175]. Weight loss of approximately 10% can improve OSA as
Analysis of the Bariatric Outcomes Longitudinal Database assessed by polysomnography and the apnea-hypopnea in-
found that HTN was better resolved after BPD/DS dex (AHI) [183]. Multiple trials assessing the efficacy of
compared with SG or RYGB [177]. Beneficial effects of bar- bariatric surgery have demonstrated efficacy for improve-
iatric surgery in patients with HTN are maintained long term ments in symptomatology and AHI scores in patients with
in many but not all patients [50,178]. In the Longitudinal OSA [105–110,184]. For example, bariatric surgery result-
Assessment of Bariatric Surgery multicenter observational ing in 27% to 47% weight loss produced a 49% to 98%

reduction in the AHI [107]. In another study, LAGB resulted recommended both before and after knee replacement sur-
in 20.2% weight loss and 54% improvement in sleepiness gery in patients with overweight and obesity. Many centers
scores [99]. Dixon et al. [183] found that LAGB was effec- require the BMI to be below a specified threshold (e.g.,
tive but not superior to conventional weight loss programs in ,35–40 kg/m2) before arthroplasty is considered [192],
patients with OSA as measured by the AHI score. although this is controversial [193]. Bariatric surgery can
therefore be used to reduce BMI to a level that will permit
Osteoarthritis arthroplasty.
Multiple studies have demonstrated that bariatric surgery
can reduce pain and improve function in patients with oste- Urinary stress incontinence
oarthritis [112,113,185–187]. In 59 consecutive patients Interventional cohort studies employing bariatric surgery
followed prospectively after bariatric surgery, there was a have demonstrated improvements in urinary incontinence
significant increase in medial joint space on knee x-ray [120–122,194–196]. A systematic review identified 5
and clear improvements in the Knee Society Score [186]. interventional cohort studies involving bariatric surgery,
A meta-analysis of studies assessing effects of bariatric sur- all of which reported improvements in stress incontinence
gery on osteoarthritis included 13 studies and 3837 patients, symptoms in the clear majority of patients [123]. In 1
but only 2 studies had a control group and 11 were uncon- such study, RYGB in 1025 patients (78% women) produced
trolled prospective studies [113]. All studies measuring in- a decrease in mean BMI from 51 to 33 kg/m2 and a decrease
tensity of knee pain, knee physical function, and knee in urinary incontinence from 23% of the patients being
stiffness showed a significant improvement after bariatric affected at baseline to only 2% of patients affected at 1 to
surgery, with weight loss ranging from 14.5% to 35.2%. 2 years postoperatively [121].
The quality of evidence was considered low for most of R3. (2019*). Since 2013, there has been increasing evi-
the included studies and moderate for 1 study. A case- dence from RCTs and meta-analyses regarding the meta-
control study by Peltonen et al. [112] that included patients bolic benefits of bariatric procedures in patients with BMI
who underwent bariatric surgery enrolled in the Swedish of 30 to 34.9 kg/m2 (i.e., class I obesity). With respect to
Obese Subjects study was the one deemed to be of moderate weight loss, per se, multiple studies [40,197,198] document
quality in this meta-analysis. Weight loss associated with efficacy in patients with class I obesity. As a result, the FDA
bariatric surgery was associated with a significant improve- approved the adjustable gastric band for patients with a BMI
ment in pain, including work-restricting pain in knees and of 30 to 34.9 kg/m2 with an ORC. However, the preponder-
ankles of men and women with odds ratios (ORs) of 1.4 ance of studies in patients with class I obesity have focused
to 4.8 [112]. A second systematic review of the literature on the clinical benefits of bariatric procedures in those
in patients with obesity undergoing bariatric surgery [187] patients with T2D. A substantial number of RCTs and
identified 6 studies for analysis: 5 were case series and 1 cohort interventional trials have demonstrated that bariatric
was the case-controlled trial by Peltonen et al. [112]. All surgical procedures can effectively result in sustained
studies demonstrated improvements in pain, functional improvement in glycemic control concomitant with reduc-
scores, and/or joint space width, resulting in a conclusion tions in diabetes medications in patients with BMI 30 to
by these authors that bariatric surgery can benefit patients 34.9 kg/m2 [42,88,90,159,173,199–207]. Multiple meta-
with knee and hip osteoarthritis, but they recognized the analyses that specifically examine bariatric surgery out-
need for further investigation with RCTs. comes in patients with BMI ,35 kg/m2 have been published
Obesity is associated with higher rates of treatment and support clinical benefits regarding glycemic control and
involving arthroplasty or knee and hip replacement [188]. weight loss [36,208–210]. In patients with T2D and class I
The evidence base addressing efficacy and safety of knee obesity, bariatric surgery can also lead to improvements in
replacement consists of observational and retrospective an- blood pressure and dyslipidemia [36]. Importantly, a signif-
alyses. Patients with obesity undergoing total knee replace- icant number of patients will experience remission of
ment can experience significant improvements in pain and T2D with maintenance of normal or near-normal blood
functionality, often assessed using the Knee Society Score, glucose values in the absence of diabetes medications
the Western Ontario and McMaster Universities Osteoar- [88,141,173,200,207,210–214].
thritis Index, or other instruments [117–119,189,190]. How- The STAMPEDE trial randomized patients with T2D and
ever, knee replacement surgery in patients with obesity is BMI 27 to 43 kg/m2 to medical therapy or to RYGB or SG
more often associated with complications, such as deep with the primary endpoint being HbA1C 6% on or off
prosthetic infections, wound healing, superficial infections, medications. After 1, 3, and 5 years, this outcome was
and DVT [117–119,189,190]. Patients with severe obesity met by 42%, 38%, and 29%, respectively, in the RYGB
can experience inferior survival of the prosthesis after group; 37%, 24%, and 23% in the SG group; and 12%,
total knee replacement compared with patients without 5%, and 5% in patients treated with medical therapy
obesity [114–116], although this was not consistently [34,88,141]. Overall, the patients randomized to bariatric
observed [190,191]. For these reasons, weight loss is surgery maintained lower HbA1C with fewer diabetes

medications, improved lipids, and better quality of life than overweight, 25 to 29.9 kg/m2 obese class I, and 30 kg/m2
the medically treated patients. Nevertheless, the STAM- obese class II [219]. The prevalence of various ORC may
PEDE trial indicates that, although remission rates can be also vary as a function of region and ethnicity, and this should
higher in the immediate years after surgery, over time, be considered in the transculturalization application of these
T2D tends to recur consistent with the progressive nature guidelines in the evaluation of patients with obesity.
of the disease. In the Swedish Obese Subjects study, remis- Waist circumference measurements provide additional in-
sion of T2D was observed to be 72% at 2 years and falling to formation regarding risk of cardiometabolic disease and
30% at 15 years, compared with 16% and 7%, respectively, should be taken in all patients, especially when BMI is
in matched controls [31]. Shorter duration of T2D is associ- ,35 kg/m2. Risks conferred by waist circumference are
ated with a higher likelihood of remission in both mild [210] continuous despite the use of categorical cutoff values,
and severe [31] obesity. and, at any given BMI (above and below 35 kg/m2), risks
Because of increasing evidence, the second Diabetes of T2D and CVD increase progressively with additional in-
Surgery Summit Consensus Conference guidelines recom- crements in waist circumference [228]. However, when the
mend that bariatric surgery be considered for BMI 30 to BMI exceeds 35 kg/m2, most patients will exceed categori-
34.9 kg/m2 in patients with T2D [210]. It will be important cal waist circumference cutoff values by a high BMI
to continue to follow these patients long term to determine whether they are insulin resistant and have cardiometabolic
the lifelong impact of bariatric surgery on metabolic status risk factors. Thus, above a BMI of 35 kg/m2, waist circum-
and CVD risk. A rigorous definition of “T2D remission” ference cutoff values become less effective in describing
should be standardized and applied across studies [215] cardiometabolic risk. Waist circumference cutoff points
and the a priori predictors for efficacy of T2D remission for predicting CVD also exhibit ethnic variation, including
will need to be better defined to optimize the benefit-risk a consistently lower threshold in South Asian, Southeast
ratio of the procedure [216,217]. Finally, with SG now be- Asian, and East Asian adults. Therefore, ethnic-specific cut-
ing the most common bariatric surgical procedure per- offs as advocated in the 2009 Joint Interim Statement of the
formed, future studies will need to elucidate the International Diabetes Federation Task Force on Epidemi-
differential impact of multiple current surgical treatments ology and Prevention should be used. Waist circumference
for efficacy and safety. The ongoing DiaSurg2 trial has ran- predicted increased risk with values starting at 84 cm
domized patients with BMI 26 to 35 kg/m2 and insulin- for men and 74 cm for women in a large Hong Kong
requiring T2D to RYGB or standard medical therapy cohort, whereas a value of 85 cm for men and 80 cm for
[44]. The primary endpoint is a composite time-to-event women was recommended as cutoffs for central obesity in
endpoint, including cardiovascular death, myocardial Chinese adults, according to the Cooperative Meta-
infarction, coronary bypass, percutaneous coronary inter- Analysis Group of the Working Group on Obesity in China
vention, nonfatal stroke, amputation, and surgery for pe- [220,229]. Waist circumference estimates relative accumu-
ripheral atherosclerotic artery disease, with follow-up of lation of visceral adipose tissue relevant to the ABCD
8 years. These and other trials should help better define model, which incorporates abnormal distribution (in addi-
evidence-based utilization of bariatric surgery in patients tion to amount and function) of adiposity as an important
with mild obesity. metric [18].
R4. (NEW). BMI cutoffs for identifying excess adiposity R5. (2019*). The following clinical questions best frame
and risk of cardiometabolic disease are lower for some eth- goal-directed obesity care using a bariatric procedure:
nicities and should be taken into account during screening
Are baseline and target anthropometrics (e.g., BMI,
and diagnosis [85,192,218]. Specifically, a lower BMI
threshold for screening of obesity is recommended in South weight, excess weight) determinants of whether a bariatric
Asian, Southeast Asian, and East Asian adult populations. procedure should be recommended?
Are ORC determinants of whether a bariatric procedure
Based on the evidence that lower BMI values are correlated
with risk of T2D, the American Diabetes Association [81], should be recommended?
Should patients with qualifying indications proceed
the WHO Expert Consult Group [219], and the Working
Group on Obesity in China [220] recommend that screening directly to a bariatric procedure or rather proceed only after
for diabetes be considered for all Asian American adults a trial of more intensive lifestyle change with or without
who present with BMI 23 kg/m2 and that a BMI cutoff weight loss medications?
of 23 kg/m2 would be the optimal single criterion for
screening all Asian ethnicities for obesity based upon corre- The main purpose of any therapeutic intervention is to
lations with cardiometabolic risk factors and increased risk improve the health and quality of life of the patient.
of mortality [82,220–227]. Based on epidemiologic data, Morbidity and mortality associated with obesity arise from
the WHO has proposed the following weight classifications complications that result from increased adiposity mass, dis-
in adult Asians: BMI ,18.5 kg/m2 indicates underweight, tribution, and/or function [13,18,230]. BMI provides an in-
18.5 to 22.9 kg/m2 healthy weight, 23 to 24.9 kg/m2 direct anthropometric measure of adipose tissue mass, but

BMI alone is not sufficient to indicate health status in pa- 36.7%, and SG was ranked third at 17.8% [239]. By 2015,
tients with obesity [231]. The impact of obesity on health these numbers significantly changed, with SG as the domi-
is directly related to the risk, presence, and severity of nant bariatric procedure at 53.8% and RYGB second at
ORC [13,231–234]. ORC are wide ranging [13,231–234] 23.1% [239]. According to an analysis of the Metabolic
and include problems related to cardiometabolic, and Bariatric Surgery Accreditation and Quality Improve-
biomechanical, and psychologic processes. The amount of ment Program data registry, SG had approximately half
weight loss that is necessary to predictably prevent or the risk-adjusted odds of mortality, serious morbidity, and
treat ORC varies as a function of the specific complication leak in the first 30 days compared with laparoscopic
profile unique to each patient [231–234]. In short, RYGB [240]. The benefits of SG on weight loss were also
bariatric procedures optimally address health and quality similar in patients over age 50 years compared with younger
of life when enough weight loss needed to prevent or treat patients [241]. A novel single-incision laparoscopic SG has
ORC cannot be obtained using lifestyle or medical also been developed and has comparable mean operative
therapy alone. times, hospital length of stay, and complication rates, but
better cosmetic results, compared with conventional SG
Q2. Which bariatric procedure should be offered? [242]. However, in a 2018 report by the National Institute
for Health Research, RYGB was found to be the costliest
R6. (2019*). Shifts in procedure preference by bariatric but also the most cost-effective intervention for obesity
surgeons and their teams reflect an evolution in decision- (BMI 35 kg/m2) compared with orlistat or weight-
making based on technical surgical factors, risk-benefit management programs, with or without very low-calorie di-
analysis, costs, and other logistics, as well as new surgical ets [243]. Another swing in the numbers has been the steady
and nonsurgical bariatric procedures and an updated knowl- decline in the number of LAGB, from 35.4% of all bariatric
edge base for mechanisms of action and clinical goals in procedures in 2011 to ,5.7% in 2015 [239]. There are also
current obesity-care models (Tables 6–8). Unfortunately, declines in the number of BPD/DS procedures performed,
there are very few preoperative factors among the wealth primarily due to the risks involved and decreased number
of available biochemical and clinical information that are of surgeons trained in this technique [239].
sufficiently predictive of actual weight loss for an The most recent estimate (2016) of bariatric procedures
individual patient after a specific bariatric procedure. To provided by the ASMBS found that the total number of pro-
this point, Courcoulas et al. [235] analyzed data from cedures performed in the United States is 216,000 (18%
2006 to 2009 in 10 hospitals, extracted .100 preoperative RYGB, 58% SG, 3.5% LAGB, 1% BPD/DS, and 14% revi-
variables, and found only a few variables with statistically sions) [244]. Notwithstanding the published benefits of
significant predictive power for weight loss, including dia- LAGB [245], in a meta-analysis, Chang et al. [246] found
betes, kidney function, and tobacco history for RYGB and that LAGB had relatively low complication rates but high
band size for LAGB. Additionally, Robinson et al. [236] reoperation rates, with SG having weight loss effects com-
found that behavioral variables, such as increased dietary parable with RYGB, which had more complications. The
adherence and decreased grazing, were associated with emergence of GERD as a long-term complication after
greatest weight loss after bariatric surgery. Seyssell et al. SG, however, may temper some of the enthusiasm about
[237] developed a predictive model for 5-year weight loss this procedure or lead to a more tailored approach for these
after RYGB and validated the tool with a cohort of French procedures [247].
patients. Higher BMI, younger age, and male sex were the The laparoscopic greater curvature (gastric) plication
best predictors of more weight loss, and this calculator (LGP) is an alternative to the SG that is reversible and
can be used to provide patients with realistic expectations avoids gastrectomy but has less weight loss at 2 years
about their long-term weight loss outcomes after RYGB. compared with the conventional SG procedure [248,249].
The emergence of new information, technology, and clinical However, LGP has not gained popularity in the United
trial data on established and emergent procedures will hope- States and is still considered investigational by the ASMBS
fully provide more concrete direction in shaping clinical [250]. In addition, when LGP is performed with LAGB
decision-making and the calculus for selecting specific bar- (laparoscopic adjustable gastric banded plication
iatric procedures. As an example, Samczuk et al. [238] [LAGBP]), there is greater weight loss at 36 months and
found different molecular pathways affected by SG versus less band slippage [251]. In a retrospective, matched-
RYGB in patients with obesity and T2D, which in the future control analysis of LAGBP and SG, Cottam et al. [252]
can improve the highly sought precision in bariatric proced- found that weight regain started at 1 year with the SG, but
ure selection. not with the LAGBP, which still showed weight stability.
RYGB, once the most frequently performed bariatric pro- The mini-gastric bypass, or more recently termed single-
cedure, was relegated to the second most performed bariat- or one-anastomosis gastric bypass (OAGB), is a simple
ric procedure in 2015 [239]. Specifically, in 2011, RYGB alternative to RYGB performed with one anastomosis but
was the most highly performed bariatric procedure at results in more acid and bile reflux [253,254]. In patients

with very high BMI (60 kg/m2), Parmar et al. [255] found weight loss, reoperative procedures have been shown to
that OAGB achieved greater weight loss at 18 and 24 improve metabolic outcomes, specifically diabetes improve-
months compared with RYGB. Moreover, in patients with ment and remission rates [276,277]. In a study by Boru et al.
milder BMI elevations, OAGB with a longer (80 cm) bilio- [278], among high-volume bariatric surgery centers, only
pancreatic limb had better T2D remission rates than RYGB 3% of patients having an SG required reoperations.
[256]. In a meta-analysis, Wang et al. [257] found that the Salama and Sabry [279] have proposed both OAGB and
OAGB had a greater weight reduction effect compared RYGB as a conversion option for vertical-banded gastro-
with RYGB. The OAGB is not recommended for patients plasty, depending on the pouch length available. The
with GERD or hiatus hernia [253]. Although it remains a optimal conversion of SG for GERD is RYGB, and conver-
concern, the long-term risk of bile reflux–related adenocar- sions for additional weight loss after SG can either be
cinoma of the esophagus appears to be small based on the RYGB or DS. Conversion of SG to DS results in greater
current literature [258]. Currently, the OAGB is not weight loss than conversion to RYGB but poses a higher
endorsed by the ASMBS because of these and other con- risk of long-term nutritional deficiencies. Conversions to
cerns [259]. RYGB or SG after LAGB can be performed in 1 or 2 stages
A loop (single-anastomosis) duodenal-jejunal bypass (band removal with interval procedure). Behavioral factors,
with laparoscopic SG has also been developed in China such as binge-eating, may be responsible for increased risk
with specific application to patients with mild obesity of poor weight outcomes after reoperation after LAGB
(ethnicity-adjusted; BMI .27.5 and ,32.4 kg/m2) and [280]. Retrospective data suggest a higher leak rate with a
T2D [260]. There were comparable benefits in weight single-stage approach, particularly with conversion to SG
loss, glycemic control, insulin resistance, b-cell function, [275]. There are currently very little data to provide
lipids, and uric acid compared with laparoscopic RYGB evidence-based decision-making for reoperative strategies
[260]. Interestingly, the loop (single-anastomosis) for RYGB after weight regain. Revision of the gastric pouch
duodenal-jejunal bypass with laparoscopic SG affected in- and gastrojejunostomy, as well as conversion to a distal
testinal microbiota differently than SG alone [261]. bypass, have been proposed with variable success rates
Another type of single-anastomosis procedure has also [275].
emerged. The one-anastomosis DS (also referred to in the Many of the new bariatric procedures involve endo-
literature as single-anastomosis duodeno-ileal bypass with scopic disruption of normal physiology and/or the inser-
sleeve or stomach intestinal pylorus-sparing procedure) tion of a device, with variable weight loss results
has been developed as a primary procedure but is still under [262,264–271,281,282]. Vagal nerve-blocking device ther-
review by the ASMBS. This procedure involves creating an apy is an FDA-approved surgically implanted medical
SG (larger volume than a primary sleeve) with duodenal device that intermittently blocks vagus nerve signaling,
transection and a loop duodenoileostomy. The length of affecting both hunger and satiety [281,283–286]. IGB are
the efferent alimentary limb (anastomosis to colon) varies space-occupying devices inserted into the stomach. IGB
from 150 to 300 cm. These procedures have been shown work by occupying space in the stomach, especially
to be safe and as effective as a Roux-en-Y DS with a trend when the antrum is involved, thereby limiting capacity
toward fewer nutritional deficiencies at midterm (3–5 yr) and altering gastric motility [17,281,287]. Three of the
follow-up [262–271]. Compared with LAGB and RYGB, products (ReShape, Orbera, and Obalon) have been FDA
single-anastomosis DS was most effective for weight loss approved for patients with a BMI 30 to 40 kg/m2 and age
in patients age 70 years [272]. Stomach intestinal 22 years and older (for Reshape: age 22–60 yr and 1 co-
pylorus-sparing surgery has also been used to treat GERD morbidity) [281]. IGB have a maximal implantation time
in patients with severe obesity, with [273,274] and without of 6 months with variable amount of fill in the balloon(s)
laparoscopic fundoplication [274]. Due to the lack of robust as per product recommendations [281]. Using the Orbera
longer-term follow-up, the one-anastomosis DS procedures device, the early removal rate was 16.7% (median 8 wk)
have not been endorsed by the ASMBS as primary associated with use of selective serotonin or serotonin-
procedures. norepinephrine reuptake inhibitors; it had an average
The choice of reoperative bariatric surgery depends on weight loss of 8.5% (3 mo), 11.8% (6 mo), and 13.3% (9
the type of primary operation and the indications for reoper- mo) and significant reduction of lipid and glycemic status
ation. The ASMBS has developed nomenclature for reoper- markers at 6 months [288]. Other balloon products (e.g.,
ative bariatric surgery to better characterize this BioEnterics and End-ball [nonadjustable] [289,290], Spatz
heterogeneous group of procedures [275]. Reoperations Balloon [adjustable] [290], and Elipse Balloon [a proce-
that result in a new or different type of procedure are consid- dureless device that is swallowed] [291]) are not FDA
ered conversions, operations intended to resolve a complica- approved at this time but function similarly to other
tion or anatomic defect are called corrective procedures, and space-occupying devices within the stomach. Medications
those that attempt to restore normal anatomy are called re- that reduce nausea and production of gastric acid are
versals. In addition to providing additional therapy for frequently used concomitantly [291–293]. Common

complications include abdominal discomfort, balloon (according to predictors of long-term remission, such as pre-
deflation, and late intolerance [294]. Rare complications, operative number of T2D medications, insulin use, duration
such as gastric perforation, erosive esophagitis, and acute of T2D, and glycemic control), SG was the preferred bariat-
pancreatitis, support regular follow-up and appropriate ric procedure for patients with a higher risk profile. Aminian
timing for device removal [292,295–297]. The FDA et al. [217] recently published a calculator to predict 5-year
issued a communication to HCP informing them of 5 T2D remission rates after SG based on the severity of the
reported deaths since 2016 that occurred unexpectedly in disease at the time of surgery. The findings were validated
patients who had been treated with fluid-filled IGB, though with data from another institution, and the study concluded
root causes of these deaths are not yet available [24,298]. that early T2D remission rates were high with either proced-
Aspiration therapy is an endoluminal device that can ure (but favored RYGB); patients with moderately severe
eliminate gastric content through a gastrostomy [17]. This diabetes had significantly higher 5-year remission rates
“A-tube” is inserted endoscopically and has FDA approval compared with SG, and those with severe, long-standing
for patients with a BMI of 35 to 55 kg/m2 [17]. The mech- diabetes at the time of surgery had equally low remission
anism of action is primarily through the postprandial elimi- rates after both procedures. Although other factors should
nation of 25% to 30% of the consumed meal but may also be considered regarding procedure choice (NSAID use, in-
include behavioral changes [17]. flammatory bowel disease, GERD, or organ transplant),
Primary obesity surgery endoluminal [299] and endo- this calculator is a valuable tool to be used as part of the
scopically sutured gastroplasty [300–303] are 2 informed consent and education process for those patients
endoscopic procedures that are safe and alter the anatomy with diabetes at the time of a bariatric procedure [217].
of the stomach to limit the capacity for intake [304]. In a Additionally, Haskins et al. [314] reported a small increased
single-center retrospective cohort study by Novikov risk in 30-day morbidity and mortality among smokers
et al. [302], endoscopically sutured gastroplasty achieved (compared with nonsmokers) after SG. RYGB was the bar-
12-month weight loss amounts (13.3% total weight loss) be- iatric surgery of choice for patients with GERD or Barrett’s
tween that with SG and LAGB but had lower morbidity rates esophagus. Sudan and Jain-Spangler [177] found that SG
and hospital lengths of stay compared with the other proced- and RYGB were associated with higher resolution of
ures. Other endoscopic bariatric and metabolic devices/pro- GERD compared with BPD/DS [315]. Of note, Casillas
cedures being developed include small-bowel therapy, such et al. [316] studied 48 patients undergoing conversion of
as the duodenal-jejunal bypass liner [305–310] and SG to RYGB for reflux, highlighting the importance of
duodenal mucosal resurfacing [311], as well as transoral reflux as a specific ORC in the determination of a best sur-
gastroplasty, transoral endoscopic restrictive implant sys- gical procedure.
tem, articulating circular endoscopic stapler, gastric botuli- Further recommendations for the SG were endorsed by
num toxin A injection, endoscopic sclerotherapy, and expert surgeons at the Fifth International Consensus Confer-
radiofrequency ablation [304]. ence, including a stand-alone procedure in high-risk pa-
Clinical decision-making regarding the selection of an tients, kidney and liver transplant candidates, MetS, BMI
appropriate bariatric procedure depends not only on a stipu- 30 to 35 kg/m2 with associated co-morbidities, inflamma-
lated target weight loss and therefore indirect effects to tory bowel disease, and the elderly [317].
manage specific ORC, but also the direct effects of the pro- There are no data available to guide definitive recommen-
cedure on those specific complications [13,312]. Cardiome- dations for referral to a regional or national center. However,
tabolic risks, such as dysglycemia, HTN, and dyslipidemia, bariatric surgery programs accredited through the Metabolic
qualify as these strategic targets [313]. Hence, a joint and Bariatric Surgery Accreditation and Quality Improve-
statement by several international diabetes organizations ment Program must meet criteria for patient acuity based
indicates that metabolic surgery should be recommended on the accredited level of practice. At present, all centers
to treat T2D in patients with class III obesity (BMI should be available to manage any patient requiring services
.40 kg/m2) and in those with class II obesity (BMI 35.0– based on the level of accreditation. Patients beyond the
39.9 kg/m2) when hyperglycemia is inadequately controlled scope of accreditation should be referred to a center with
by lifestyle and optimal medical therapy [29]. Surgery appropriate accreditation. Specifically, patients aged 65
should also be considered for patients with T2D and BMI years, males with a BMI .55 kg/m2 and females with a
30.0 to 34.9 kg/m2 if hyperglycemia is inadequately BMI .60 kg/m2, patients with organ failure, organ trans-
controlled despite treatment with either oral or injectable plant, or significant cardiac or pulmonary impairment, pa-
medications [29]. tients on a transplant list, and nonambulatory patients
More recent data [217] indicate procedure-specific rec- should be referred to an accredited comprehensive center.
ommendations based on the severity of T2D using an Indi- Patients ,18 years age should be referred to a center
vidualized Metabolic Surgery score and risk-benefit accredited for adolescents [318]. Improvements in overall
analysis. Based on the Individualized Metabolic Surgery clinical outcomes have been, at least in part, attributed to fa-
score, which classifies T2D as mild, moderate, or severe cility accreditation [319] (though Doumouras et al. [320]

found no association in a Canadian cohort), and despite comparable to those with Medicare or private insurance
longer travel times, centralization of care to these accredited coverage [348]. In 2010, the cost-effectiveness of bariatric
facilities has actually improved access, particularly among surgery was ,$25,000 per quality-adjusted life year versus
underserved populations [321]. no treatment and well below benchmarks of $50,000 to
Decisions regarding bariatric procedures should also be $100,000 [349,350]. However, in a 2013 longitudinal anal-
based on safety concerns regarding specific organ systems. ysis of claims data, bariatric surgery, regardless of type,
In general, the greater the inherent risk of a specific bariatric was not associated with reduced healthcare costs [351]. In
procedure, independent of the risk of not treating obesity a 2015 report, inpatient mortality rates with bariatric surgery
and severity of ORC, the less complicated the procedure decreased 9-fold with only modest increases in cost after
selected [322]. In addition, preoperative estimation of the adjusting for inflation (lower increase than for appendec-
likelihood that a patient will experience a cardiac complica- tomy) [352]. What is alarming, however, is a report that
tion at the time of noncardiac surgery can guide procedure with 22% of medically acceptable candidates not approved
selection and prevent postoperative morbidity and mortality. for insurance reimbursement, the mortality rate increases
In addition to history and physical examination and 12-lead 3-fold [353]. Taken together, these data support a shift in
electrocardiogram, several risk assessment tools are avail- emphasis from cost savings to relevant health-related met-
able for risk stratification. These include the Revised Car- rics for patients, on a population scale, undergoing bariatric
diac Risk Index [323–325] and the Gupta Myocardial surgery [354].
Infarction [326] or Cardiac Arrest Calculator [327]. The Coverage for bariatric surgery is often lacking, even when
Revised Cardiac Risk Index [323–325] includes the there is a perception by employees that their wellness pro-
following 6 independent prognostic factors: (1) high-risk grams will reimburse for these procedures [354]. When
intervention (including intra-abdominal); (2) history of available, coverage for bariatric surgery under the Afford-
coronary disease; (3) past or present heart failure; (4) stroke; able Care Act varies from state to state [355], even though
(5) diabetes needing insulin; and (6) creatinine .2.0 mg/dL. 2015 data do not show an association of coverage with
Similarly, the Gupta Myocardial [326] Infarction or Cardiac increased monthly premiums [356]. Unfortunately, in a
Arrest Calculator [327] (not externally validated) includes retrospective study by Jensen-Otsu et al. [357] of patients
20 patient risk factors, such as increasing age, ASA class, having RYGB, patients with Medicaid coverage, in aggre-
preoperative serum creatinine .1.5 mg/dL, functional gate, had longer lengths of hospital stays and higher hospital
status, and the surgical procedure. Other dedicated organ- readmission rates within 30 days of discharge compared
system assessments that affect selection of procedure with those with commercial insurance coverage. On the
include, but are not limited to, diabetes [13], behavioral other hand, among patients having LAGB, there was no dif-
health [328–338], and reproductive health [339]. ference in postoperative weight loss between those paying
Procedure selection also depends on cost, insurance out of pocket and those covered by private insurance
coverage, and ability to pay. For the general population, bar- [358]. An assessment of the cost evaluation in patients
iatric surgery had a cost until postoperative years 4 to 5, receiving Medicare reimbursements demonstrated signifi-
when cost savings appeared; these were higher in patients cantly lower payments at hospitals with low complication
with T2D [340,341]. In contrast, overall healthcare costs rates [359]. With increased variation in hospital episode
in the Brazilian system were not reduced as a result of payments, bundled payment programs are being considered
decreased ORC after bariatric surgery, indicating that for bariatric procedures [360].
many direct and indirect economic factors likely are After LAGB in an Australian retrospective study, drug
involved [342]. Demonstrable drivers of costs related to bar- utilization—especially treating T2D and CVD—is
iatric surgery in the United States are suboptimal outcomes decreased and significantly contributes to cost reductions
[343] and the rising number of malpractice claims, though [361]. However, in a large retrospective study of 19,221
these appear to simply parallel the increased number of sur- LAGB procedures from 2004 to 2010 in the state of New
gical procedures performed [344]. Bariatric surgery is asso- York, the total revision rate was 34.2% [362]. In another
ciated with a positive effect on social transfer payments retrospective review among Medicare beneficiaries who un-
(e.g., social security, unemployment benefits, and welfare) derwent LAGB from 2006 to 2013, device-related reopera-
but has no real effect on income [345]. Similarly, in the tion was common, costly, and varied widely across hospital
adolescent population with severe obesity, bariatric surgery referral regions [363]. Based on these and other similar find-
initially incurred substantial costs and morbidity; however, ings, it has been suggested that payors should reconsider
when assessed over a 5-year period, bariatric surgery was their coverage of LAGB [363].
found to be a cost-effective treatment in adolescents [346]. RYGB continues to demonstrate sustained long-term
Unfortunately, there has been inconsistent support for weight loss results as well as improvement and resolution
Medicaid coverage of bariatric surgery for adolescents of ORC, such as GERD, CVD, degenerative joint disease,
with severe obesity [347], even though among middle- T2D, OSA, HTN, pulmonary disease, and psychiatric dis-
aged patients with Medicaid coverage, weight loss was ease [364–367]. In addition to weight loss and co-morbid

disease improvement/resolution, both the RYGB and SG lower all-cause morbidity after bariatric surgery. However,
were further validated as durable bariatric surgeries with Kwon et al. [386] did find a favorable association of accred-
significant improvement in patient-reported outcomes based itation with lower rates of bariatric reoperations and compli-
on quality-of-life scores [368]. cations. Then again, Scally et al. [387] demonstrated no
The preference of the individual bariatric surgeon, perfor- association of the Medicare distinction of Center of Excel-
mance of medical institutions, learning curve of the bariatric lence status with savings to the healthcare system for bariat-
surgeon, and the subjective experience base of the referring ric surgery. Furthermore, Nicholas et al. [388] found that the
physician also play significant roles in procedure selection. Center of Excellence designation had the unintended conse-
For robotic surgery in general, an adequate number of cases quence of reducing bariatric surgery utilization in non-
deemed necessary for surgical competence was 10 to 128 White Medicare beneficiaries. However, this was refuted
cases, depending on the procedure involved and determined by a different study using the National Inpatient Sample
primarily by docking, robot, and total operative time [369]. from 2006 to 2011, where the Center of Excellence designa-
The learning curve for robot-assisted RYGB was 66 cases tion was not associated with limited access to bariatric sur-
in a study by Starnes et al. [370]. Another study of gery [389]. These and other inconsistent studies have fueled
robot-assisted RYGB found 100 cases on the learning curve the controversy about the need for and nature of accredita-
to be a discriminator in terms of operative time but without tion for bariatric surgery, especially considering the subse-
any differences in outcomes or complications [371]. This quent elimination of the Center of Excellence
100-case mark was also reported in a study by Beitner accreditation requirement for Medicare reimbursement of
et al. [372] for RYGB, in which late complication and reop- bariatric surgery and in the context of selecting specific bar-
eration rates were eventually improved with modification in iatric procedures and settings [390,391].
surgical technique. In a Chinese study of patients undergo- Such intertwining relative risks support a nuance-based,
ing RYGB, the learning curve is more associated with oper- clinical decision-making approach to the selection of bariat-
ating time and morbidity than mortality or amount of ric procedures. Despite all this available information, both
eventual weight loss [373]. However, Rausa et al. [374] scientific and vetted in the popular lay press, the lack of
found that the relative superiority of laparoscopic RYGB knowledge about bariatric procedures by patients and refer-
over open RYGB may be due to extended learning curves ring HCP remains a distinct barrier to effective decision-
in the former. For LAGB, the learning curve is closer to making [392]. Hence, a critical analysis of the above factors
50 cases [375]. For SG, the learning curve is in the same is provided as an algorithm in Fig. 1 (incorporating informa-
or a higher range compared with that for RYGB at 100 to tion in Tables 6–8) to assist with clinical decision-making
200 cases, numbers below which correlate with increased for bariatric procedure selection.
risk for a proximal leak [376–378]. Guebbels et al. [379]
found that bariatric surgery learning curves depend on
Q3. How should potential candidates be managed before
mentorship and improve as the preceding surgeon’s skill im-
bariatric procedures?
proves. The superiority of 3- over 2-dimensional laparos-
copy was observed at early and later stages in the learning R7. (2008). Decision-making concerning the use and type
curve [380]. In Polish [381] and Dutch studies [382], the of bariatric procedures should be based on comprehensive
involvement of residents in training with an experienced health goals, meaning the prevention and management of
teacher does not compromise complication rates or ORC in patients with obesity. This overarching precept is
weight-reduction outcomes after bariatric surgery. detailed in the AACE obesity-care model [393].
Mastery refers to having outcomes significantly better R8. (2008). The preoperative checklist in Table 9 com-
than the average surgeon, whereas competency (the learning piles evidence-based items that should be evaluated to miti-
curve figure discussed above) refers to having outcomes gate operative and postoperative risks of bariatric
comparable to the average surgeon. Mastery for RYGB sur- procedures. The primary goal of checklists is to maximize
geries is approximated at 500 cases [383]. Thus, the ques- safety. However, this tool can also assist with decision-
tion arises of whether selection of a bariatric surgery making by highlighting potential variables that can influ-
procedure should, in some fashion, depend on availability ence selection of bariatric procedure. Other variables should
of a surgeon with competency versus mastery for the spe- also be considered to guide decision-making. Unfortunately,
cific procedure. in a review of RCTs, Colquitt et al. [394] found that adverse
The likelihood of malpractice lawsuits was also found to events and reoperation rates were poorly reported with
correlate with the number of procedures performed and years follow-up times of only 1 to 2 years, precluding any conclu-
in practice by the bariatric surgeon [384]. Nevertheless, there sions about long-term effects. Risks for readmission, which
does not appear to be correlation of hospital charges with can be better integrated into decision-making, include surgi-
improved bariatric surgery outcomes [385]. cal complexity, ASA class, prolonged operative time, and
Doumouras et al. [320] found that surgeon volume and a major postoperative complications [395]. Overall risks for
teaching hospital setting (but not accreditation) predicted morbidity and mortality with bariatric procedures primarily

correlate with age and BMI, but also with male sex, gastric undergoing SG. Notwithstanding the potential benefits of
bypass procedure, and open procedures [396,397]. Interest- improved preoperative health associated with weight loss
ingly, there was no statistical association of advancing on postoperative outcomes, taken together, these studies
chronic kidney disease stage with 30-day postoperative argue against weight loss as a prerequisite for bariatric sur-
complication rates [398], with good safety and efficacy in gery because a likely adverse effect of failure is denial of a
those patients on dialysis [399]. SG has been identified as potentially life-saving procedure (i.e., denial of a timely bar-
a preferable option in those over age 65 years [400]. Various iatric procedure). Routine prehabilitation clinical pathways
composite scoring systems have been devised for estimating that include deep breathing exercises, CPAP as appropriate,
risks of bariatric procedures, and further validation studies incentive spirometry, leg exercises, sips of clear liquids up
are eagerly awaited [397,401]. Various preoperative psycho- to 2 hours preoperatively, H2 blocker or proton-pump inhib-
logic instruments have also been used to predict postopera- itor, thromboprophylaxis, and education about perioperative
tive outcomes [338,402,403]. The use of chronic steroids is protocols, in conjunction with intraoperative and postopera-
associated with mortality and serious postoperative compli- tive ERABS protocols, are associated with improved out-
cations after stapled bariatric procedures, with no difference comes [414].
between patients undergoing RYGB and patients undergo-
ing SG [404,405]. Q4. What are the elements of medical clearance for
R9. (2008). Pre–bariatric surgery insurance requirements
bariatric procedures?
and correct documentation of medical necessity can be
onerous, despite a lack of evidence that they correlate R13. (NEW). Lifestyle medicine is the nonpharmaco-
with improved clinical outcomes. Love et al. [406] found logic and nonsurgical management of chronic disease (and
that surgical dropout during this process was due to a longer to reemphasize: obesity is a chronic disease) [415]. A signif-
diet requirement (OR .88; P , .0001), primary-care physi- icant number of patients fail to meet target metrics after bar-
cian letter (OR .33; P , .0001), cardiology evaluation iatric procedures. This is not only due to biological factors,
(OR .22; P , .038), and advanced laboratory testing (OR selection pitfalls, and technical issues but also to preopera-
5.75; P , .019). tive lifestyle habits. Gilbertson et al. [416] provide evidence
R10. (2019*). The informed consent process should that supports the hypothesis that lifestyle intervention is
include the provision of appropriate educational materials. beneficial in those patients with unhealthy lifestyles and bar-
Mahoney et al. [407] found that levels of education and iatric surgery resistance. However, in a prospective, ran-
health literacy figure prominently in a patient’s ability to domized intervention study (N 5 143) on preoperative
adhere with postoperative instructions and avoid hospital behavioral lifestyle using face-to-face and telephone en-
readmissions. counters for 6 months, there were no improvements in
R11. (2013). The costs of bariatric procedures vary weight loss by 24 months postoperatively [417]. Neverthe-
greatly and mainly depend on ORC and other co- less, completing the lifestyle medicine component of the
morbidities, concurrent procedures, robotic platform, surgi- preoperative checklist (Table 9) can be useful, particularly
cal complexity, and length of hospital stay [408]. For because formal lifestyle medicine training is seldom part
example, in a 2017 study by Khorgami et al. [408], the of formal medical education, though the specific timing,
calculated cost (median and interquartile range) was content, and methodology of preoperative lifestyle interven-
$12,543 ($9970–$15,857) for RYGB, $10,531 ($8248– tion, beyond usual standards of care for patients with
$13,527) for SG, and $9219 ($7545–$12,106) for LAGB. obesity, remain to be determined.
R12. (2013). A review from 2016 [56] suggests little R14. (2019*). Current evidence-based glycemic control
impact of preoperative weight loss attempts on surgical out- targets are provided by updated AACE/ACE [418] and
comes. In a retrospective review of 1432 patients having American Diabetes Association [419] CPG and algorithms
bariatric surgery, insurance-mandated preoperative weight [420]. In general, chronic hyperglycemia is associated
loss programs were not associated with better outcomes at with poor surgical outcomes [421]. Achieving preoperative
2 years [409]. In another observational study, preoperative glycemic control within months without weight gain can be
weight loss was not associated with greater postoperative facilitated using an interprofessional diabetes team [422].
weight loss, co-morbidity resolution at 1 year, or lower Better preoperative glycemic control, with pharmaco-
30- or 90-day rates of readmission [410]. In fact, Keith therapy and low-calorie diets, correlates with complete
et al. [411] found that insurance-mandated preoperative di- T2D remission rates after RYGB [423–425]. Aminian
ets have been found to delay treatment and adversely affect et al. [217] individualized bariatric surgery procedure selec-
weight outcomes. On the other hand, Deb et al. [412] also tion in patients with T2D using a Metabolic Surgery Score
found that preoperative weight loss did not affect long- based on T2D duration, number of preoperative T2D medi-
term postoperative weight loss outcomes. Watanabe et al. cations, insulin use, and glycemic control (HbA1C ,7%). If
[413] even found minor beneficial effects of preoperative there is doubt concerning diabetes type in a preoperative
weight loss on postoperative complications in patients evaluation, beyond history (more abrupt onset, possibly

with an episode of diabetic ketoacidosis with T1D), glycemic control and b-cell function [440]. Somewhat sur-
C-peptide and autoantibodies (e.g., antiglutamic acid decar- prisingly, Lima et al. [441] found a high rate of chromium
boxylase, insulin autoantibodies, insulinoma-associated-2 deficiency—55 of 73 (75.3%) patients tested who were
autoantibodies, zinc transporter 8) may be ordered to assist awaiting bariatric surgery—and this low-chromium state
in differentiating T1D (usually antibody-positive with very was associated with lower cholesterol and higher triglycer-
low C-peptide) from T2D (usually antibody-negative with ide levels. More studies are required to understand the role
low, normal, or elevated C-peptide) [426]. of chromium nutrition on insulin sensitivity, obesity, and re-
R15. (2013*). Patients evaluated for bariatric procedures sponses to bariatric surgery.
have a significant number of endocrine abnormalities with R17. (2013*). Bariatric surgery has a significant effect on
nodular goiter and autoimmune thyroiditis among the increased fertility [442]. Fetal growth is positively corre-
most prevalent; for instance, 18.1% had hypothyroidism lated with protein supply and negatively correlated with
[427]. Obesity is associated with TSH elevation in the maternal iron status. This need for monitoring increases
absence of a primary thyroid disease, with reference ranges with increasing malabsorptive procedures [443,444].
increasing based on the following BMI classes: underweight Typical recommendations for time to conception have
(BMI ,20 kg/m2), .6 to 4.8 mUI/mL; healthy weight and been based primarily on nutritional concerns, with the
overweight (BMI 20–29.9 kg/m2), .6 to 5.5 mUI/mL; obese implication that weight stability (12–24 mo) is important.
(BMI 30–39.9 kg/m2), .5–5.9 mUI/mL; and severe obese However, there are no studies showing outcome differences
(BMI 40 kg/m2), .7–7.5 mUI/mL [428,429]. TSH levels for conception at ,1 year postoperatively, with 1 large study
are therefore not recommended as a routine screen before showing no differences in outcomes at ,1 year [445–447].
bariatric procedures because the higher upper limit with Multiple studies show an improvement in fertility and lower
obesity may result in considerable overdiagnosis and unnec- risk for gestational diabetes and large-for-gestational-age
essary lifestyle levothyroxine treatment. However, many in- births after bariatric surgery. By contrast, risk for small-
surance companies still require preoperative TSH testing for-gestational-age births was increased, with possibly a
before bariatric procedures [1]. Postoperatively, thyroid hor- small increase in premature births [445,446]. The harmful
mone replacement or supplementation requirements are var- effects of various deficiencies (iron, calcium, B12, folic
iable due to decreased requirements as body mass and acid, and vitamin D) and teratogens (vitamin A) are well
volume of distribution decrease or increased requirements known. Appropriate monitoring and supplementation are
as thyroiditis progresses in some; variable effects such as recommended [445,448].
GI absorption may worsen or actually improve [430,431]. R18. (2008*). Hormone therapy, including oral hormonal
R16. (2019*). Evidence-based recommendations to contraception, postmenopausal hormone therapy, and use of
manage lipid disorders are provided in recent AACE/ACE selected estrogen-receptor modulators, had been associated
[432] and National Lipid Association CPG [433,434], with an increased risk of venous thromboembolism (VTE)
with an emphasis on bariatric surgery in another CPG by [449,450]. There is insufficient evidence for any recommen-
ASMBS/National Lipid Association/Obesity Medicine As- dation regarding optimal timing of hormone therapy
sociation [435,436]. Baseline preoperative abnormalities resumption after a bariatric procedure.
in the lipid profile can guide procedure selection. In a sys- R19. (2008*). Bariatric surgery can improve both inci-
tematic review and meta-analysis, Christelle et al. [437] dence of polycystic ovary syndrome and associated infer-
found that RYGB was superior to SG in not only improving tility and reduce risk of endometrial hyperplasia [339,451].
weight loss and glycemic control but also improving short- R20. (2019*). Most rare causes of severe obesity will
(1-year) and midterm (5 yr) lipid metabolism, with and manifest in childhood. A recent review found 79 distinct
without T2D. In a small (N 5 38) prospective cohort trial obesity syndromes, of which 19 have been elucidated genet-
before and after RYGB, preoperative n-3 polyunsaturated ically [452]. Prader-Willi syndrome is the most common
fatty acid and vitamin A levels were correlated negatively syndromic monogenic cause (incidence: 1/15,000), and
with fasting insulinemia and high-sensitivity C-reactive pro- MC4R defects are the most common nonsyndromic mono-
tein and positively with high-density lipoprotein choles- genic cause (2%–4% of pediatric obesity) [453,454]. Cra-
terol; preoperative linoleic levels were associated with niopharyngiomas and resultant surgery are rare causes of
postoperative weight loss [438]. In a meta-analysis, Heffron hypothalamic obesity [455]. A small study of 8 matched pa-
et al. [439] found that mean low-density lipoprotein tients with craniopharyngioma showed benefit from RYGB
decreased by 42.5 mg/dL with BPD/DS, 24.7 mg/dL with but not SG [456,457].
RYGB, 8.8 mg/dL with LAGB, and 7.9 mg/dL with SG R21. (2019*). The latest American College of Cardiol-
(the changes for LAGB and SG were not significantly less ogy/American Heart Association guideline on Perioperative
than those among patients in the nonsurgical control group). Cardiovascular Evaluation and Management of Patients
Interestingly, in a longitudinal study, improvements in Undergoing Noncardiac Surgery provides the evidence
pancreatic lipid metabolism (fat volume and fatty acid up- base for recommendations regarding preoperative, noninva-
take) with RYGB or SG were associated with better sive cardiac testing [458]. Additional guidelines are

provided by Feely et al. [459] and the European Society of all have some predictive value, there are no reliable noninva-
Cardiology and European Society of Anaesthesiology [460]. sive presurgical predictors of disease severity or progression
R22. (2019*). Studies have shown prolonged hospital [489–491]. Liver biopsy remains the diagnostic standard
stays and higher complication rates after bariatric surgery [492]. Severity of liver disease as determined by Model of
in patients with OSA [461–463]. Hence, routine End-Stage Liver Disease score correlates with short-term out-
preoperative clinical screening for OSA with confirmatory comes [493]. Bariatric surgery improves multiple metabolic
polysomnography may be considered, with further conditions, including insulin resistance, glucose metabolism,
diagnostic testing and treatment of appropriate at-risk pa- HTN, plasma lipids, transaminases, liver steatosis, steatohe-
tients [461,464–467]. However, these data are generally patitis, and fibrosis [494].
mixed in terms of overall benefit of screening, with R27. (2013*). Two recent studies illustrate a relationship
several studies showing no risk reduction with OSA between H. pylori and the occurrence of marginal ulcers
screening or treatment [463,466,468–472]. postoperatively [495,496]. Specifically, Mocanu et al.
R23. (2019*). Recent data support the association of [496] found a 10-fold increase in the rate of this complica-
cigarette smoking with an increased risk of postoperative tion in H. pylori–positive versus –negative patients after un-
morbidity [473]. Among 12,062 patients undergoing bariat- dergoing RYGB.
ric surgery in Western Australia, anesthetic complications R28. (2013*). Long-term studies have shown a beneficial
were uncommon (.5%) but accounted for 9.7% of all ICU effect of bariatric surgery on urate levels and gout incidence
postoperative readmissions; smoking history (and not [497–499].
BMI) was the only prognostic factor for airway-related R29. (2008*). Decreases in bone density over time are
complications [474]. All smokers must be advised to stop common after bariatric surgery, particularly in postmeno-
smoking at any time before bariatric surgery, even if it is pausal women [500–502]. Abnormalities of bone
within 6 weeks before surgery [475]. Unfortunately, in a metabolism, including secondary hyperparathyroidism and
retrospective review of the National Surgical Quality vitamin D deficiency, are common in obesity both before
Improvement Program database, Haskins et al. [314] found and after bariatric surgery [503,504]. Current screening rec-
that smoking within the year before SG was associated with ommendations for bone mineral density testing vary some-
increased 30-day morbidity and mortality risk compared what but generally agree that postmenopausal women and
with nonsmokers. Structured cessation programs are more women aged .65 years should be screened [505].
effective than general advice, which is more effective than R30. (2019*). The important role of behavioral medicine
usual care [476]. in the preoperative and continuing management of patients
R24. (2013*). Recent position papers continue to undergoing bariatric surgery is strengthened, particularly
recommend routine prophylactic measures to prevent in the context of durable interdisciplinary team manage-
VTE, which includes both DVT and PE, after bariatric sur- ment, assessing and enhancing patient readiness for surgery,
gery [477,478]. improving patient-centered care by increasing a patient’s
R25. (2019*). Survey data in the United Kingdom fail to knowledge about postoperative behavioral regimens and po-
show consensus on the use of routine versus selective preop- tential challenges, and reducing risk, liability, and clinic
erative esophagogastroduodenal endoscopy in patients burdens [506]. Formal domains for preoperative psychoso-
considered for bariatric surgery [479]. Yet, in one notable cial evaluation are weight history, eating-disorder symptoms
exception in a primarily Chinese population with obesity, (e.g., night-eating syndrome, binge eating, compensatory
routine preoperative upper GI endoscopy demonstrated sig- behaviors, anorexia nervosa), psychosocial history, develop-
nificant abnormalities [480]. Systematic reviews, meta- mental and family history, current and past mental health
analyses, and other retrospective studies have demonstrated treatment, cognitive functioning, personality traits and
benefit of preoperative endoscopy in patients with GI symp- temperament, current stressors, social support, quality of
toms, where results altered surgical planning in roughly 7% life, health-related behaviors (substance abuse, smoking his-
to 12% of patients [481–485]. A retrospective study by tory, adherence, and physical activity), motivation and
Yormaz et al. [486] found that in patients undergoing bariat- knowledge base (including weight loss expectations)
ric surgery, the Gastrointestinal Symptom Rating Scale and [337], and self-harm and suicide [507]. Formal psychomet-
upper GI symptoms were independent predictive markers of ric testing is commonly employed preoperatively and should
abnormalities found with preoperative esophagogastroduo- be performed by qualified behavioral HCP providing a writ-
denal endoscopy. The correlation of preoperative endo- ten report and organizing appropriate postoperative moni-
scopic abnormalities with postoperative complications is toring [337]. Alcohol metabolism and addiction are
not clear based on current evidence [486,487]. recognized problems that occur in patients who have under-
R26. (2019*). NAFLD is common across age groups in gone malabsorptive bariatric surgical procedures. In a report
obesity [488]. Although age, waist circumference, serum alanine by Acevedo et al. [508,509], SG was similar to RYGB with
aminotransferase, serum triglycerides, aminotransferase-to- respect to adverse effects on a patient’s response to alcohol
platelet ratio, and ultrasound and transient elastography ingestion. In fact, in these patients, faster and higher peak

blood alcohol concentrations result in underestimation of cancers [543] in patients after bariatric surgery. Esophageal
alcohol levels by breath analyzers [508]. carcinoma represents a unique challenge because, when
R31. (2013*). Preoperative binge-eating disorder was diagnosed after bariatric surgery, surgical resection carries
associated with less weight loss after RYGB or LAGB, a high risk [544]. Gastric carcinomas in the gastric pouch
but patients still lost more weight than those receiving life- or excluded stomach are rare and also represent a unique
style modification alone [510]. Postoperative engagement clinical challenge without clear guidelines [545,546]. These
with behavioral therapy, psychologic services, and spousal findings affirm the relevance and potential benefit of preop-
engagement are positive predictors of outcome for all pa- erative screening and, when appropriate, aggressive case
tients undergoing bariatric surgery and therefore are advised finding, though much more evidence is needed for more
[510–512]. Bariatric surgery was associated with a slight detailed recommendations. Interestingly, cancer survivors
increase in suicide and self-harm, but the absolute risks had weight loss effects after bariatric surgery comparable
were still low [513]. to that in patients without a history of cancer [547].
R32. (2013*). Recent guidelines provide an updated, R34. (NEW). ERABS clinical pathways focus on obesity-
initial evidence-based approach to micronutrient supple- related perioperative risks specific for the patient undergo-
mentation after bariatric surgery [448]. Of note, adherence ing bariatric surgery and are based on the enhanced recovery
to vitamin therapy after bariatric surgery is lower than in after surgery general recommendations (Table 10). Periop-
self-reports and represents a potential risk to patients’ health erative noninvasive ventilation is associated with decreased
that needs to be promptly addressed [514–516]. Iron studies risk for postoperative respiratory complications [548].
including ferritin, fat-soluble vitamins other than 25-
vitamin D (vitamins A, E, and K), and vitamin C levels
Q5. How can care be optimized during and within 5 days of
do not need to be ordered routinely preoperatively but
a bariatric procedure?
may be considered in patients at risk for deficiency states
related to these nutrients [517–520]. R35. (NEW). Best practice anesthetic and intraoperative
In general, thiamine deficiency occurs in 15.5% to 29% of techniques, as part of an overall ERABS clinical pathway,
patients with obesity [521]. Thiamine testing may be are provided in Table 10 [549]. King et al. [550] found
considered preoperatively in light of reports describing rela- that these clinical pathways were not associated with
tively high prevalence rates of thiamine deficiency in pa- increased postoperative day 1 discharges but were associ-
tients awaiting bariatric surgery (16%–47%, depending on ated with reduced perioperative opioid use, postoperative
ethnicity), early-onset Wernicke’s encephalopathy (WE) 2 nausea, and emergency room visits within 7 days after hos-
weeks after bariatric surgery instead of the more usual 3 pital discharge. Key components of intraoperative care
months, and the potential prevention of WE with diligent include proper positioning and monitoring of patients, ac-
preoperative thiamine replacement protocols [522–524]. A counting for obesity-related changes in pharmacology,
single-institution, retrospective observational study of 400 adjusting for potentially difficult tracheal intubations and
patients undergoing bariatric surgery showed that 16.5% airway management, and applying ventilatory strategies,
had clinical thiamine deficiency preoperatively (consistent including PRM [551]. Dupanovic et al. [552] identified
symptomatology and either low biochemical levels or sig- intraoperative factors with LAGB that affected postopera-
nificant improvement with thiamine supplementation) and tive outcomes, including meticulous surgical technique,
18% after RYGB [525]. However, in another study of pa- least number of access ports, and multimodal analgesic
tients after SG, the preoperative prevalence of thiamine defi- approach.
ciency was only 3.4%, with rates decreasing by Laparoscopic techniques for bariatric surgery induce a
postoperative year 2 [526]. In a small (N 5 22) prospective CO2 pneumoperitoneum, which adversely affects cardiopul-
study of women undergoing LAGB, 38% had low thiamine monary function that may already be compromised due to
levels [527]. obesity. PRM can improve anesthesia-related functional re-
R33. (2013*). All patients should have age-appropriate sidual capacity reductions intraoperatively, but not postop-
screening for cancer according to U.S. Preventive Services eratively, in patients undergoing bariatric surgery
Task Force recommendations [528]. Mechanistic studies [553,554]. However, PRM can improve postoperative pain
implicate chronic inflammation and crosstalk between adi- intensity and opioid requirements after SG or RYGB
pose tissues and cancer-prone cells [529,530]. Recent [555]. In a study by Eichler et al. [556], noninvasive intrao-
studies have demonstrated improved clinical oncologic met- perative monitoring using electrical impedance tomography
rics for certain malignancies (e.g., risk, biomarkers, sur- [554], with increasing positive end-expiratory pressure de-
vival) in general [531–534] and for breast [535] and mand during capnoperitoneum to maintain positive trans-
colorectal [536–538] cancer in particular. In contrast, pulmonary pressures throughout the respiratory cycle, was
other studies have shown poorer prognosis in another associated with improved postoperative oxygenation. In
cohort study of colorectal cancer by Tao et al. [539] and addition, intraoperative transcutaneous CO2 monitoring
in endometrial [540,541], liver [542], and pancreatic has been found to provide a better estimate of arterial CO2

partial pressure in patients undergoing laparoscopic bariat- morbidity optimization, as well as evidence-based intrao-
ric surgery than end-tidal CO2 partial pressure [557]. Nonin- perative clinical pathways [414]. Implementation of
vasive hemodynamic monitoring has potential advantages, ERABS in patients decreases length of hospital stay [574–
especially among patients at high risk for CVD, but at pre- 578] without increasing morbidity, readmission rates
sent these methods lack sufficient accuracy and require [579–584], or postdischarge resource utilization [585,586].
more study in the obesity and bariatric surgery settings ERABS may also decrease costs of care in the early post-
[558]. operative period [576,584,587]. A meta-analysis of ERABS
In an unmatched, case-controlled study, the use of the barriers by Ahmed et al. [588], prospective cohort studies by
analgesia nociception index was associated with decreased Mannaerts et al. [589] and Blanchet et al. [590], and a retro-
intraoperative use of sufentanil but not postoperative opiate spective study of consecutive patients by Matlok et al. [582]
use [559]. In an observational study by Vaughns et al. [560] affirm these correlations and find ERABS generally safe and
of 26 consecutive adolescent patients undergoing bariatric effective. Factors that delayed discharge after SG as re-
surgery, the intraoperative use of dexmedetomidine, 1.62 ported by Jonsson et al. [591] include preoperative opioid
mg/kg (.89–2.032; median total dose and interquartile use, history of psychiatric illnesses, chronic kidney disease,
range), as initial bolus and then continuous infusion was and revisional procedures, but not ASA class, diabetes,
associated with lower opioid requirements intraoperatively congestive heart failure, HTN, distance to home, and insur-
and in the first 48 hours postoperatively. These results ance status. Length of hospital stay after SG was reduced by
were affirmed in a meta-analysis involving a broader range early operating start time and treated OSA, whereas length
of patients having bariatric surgery [561] and a guideline of stay was increased with creatinine .1.5 mg/dL, ejection
implementation study demonstrating feasibility and signifi- fraction ,50%, and increased operative time [591].
cant cost avoidance [562]. Of note, adolescents with severe Deneuvy et al. [592] found that in a French multicenter
obesity have increased fentanyl clearance, underscoring the study that ERABS compliance was 79.6%, arguing for
need for more pharmacologic data on this population [563]. continued training and audits, with the elements least often
The short-acting inhalation anesthetic agents sevoflurane applied being limb intermittent pneumatic compression dur-
and desflurane are safe with bariatric surgery and may be ing surgery (23.3%), multimodal analgesia (49.5%), and
considered as alternatives for maintenance of anesthesia optimal perioperative fluid management (43.8%). On the
[564]. Postoperative bleeding is a rare but serious complica- other hand, ERABS may need to be deferred in patients
tion, occurring in ,1% of patients, and can be prevented with extremes of age (,18 or .60 yr), poor adherence or
with a standard intraoperative protocol that increases blood motivation, cognitive impairment, poor social support, or
pressure and reduces the pneumoperitoneum to identify location of residence at a significant distance from a hospital
possible silent bleeding sites [565]. Goal-directed fluid ther- [593]. Even though ERABS implementation is associated
apy is also recommended during bariatric surgery, and the with improved clinical outcomes, reporting systems will
potential for excessive IV fluid administration can be miti- need to be optimized [594].
gated using dynamic indicators such as the Pleth Variability R37. (NEW). Providing the patient with preemptive anti-
Index [566]. emetic and nonopioid analgesic medications pre- and intra-
R36. (NEW). A protocol-based approach with ERABS operatively as part of a multimodal pain management
strategies is critical to improve the early postoperative strategy improves postoperative pain control, decreases
care of patients undergoing bariatric surgery. These proto- opioid use [572], and decreases postoperative nausea and
cols continue to evolve and be applied to a growing number vomiting [595].
of programs (Table 10). In general, clinical “enhanced re- R38. (2013*). Recent reviews have commented on the
covery” pathways focus on decreasing surgical stress and early postoperative dietary strategy [596,597]. Patients
maintaining normal homeostasis as much as possible and should be allowed to start drinking clear liquids the night
avoiding the routine use of catheters, drains, and radiologic of surgery. Clear liquid intake and an emphasis on oral hy-
testing after surgery. These protocols also include focused dration should continue the day after surgery; the patient can
education about the bariatric surgery process and are associ- also be advanced to full liquids as tolerated on postoperative
ated with decreased length of stay postoperatively [567]. day 1. Each of the nutritional components of enhanced re-
These protocols are based on experience in other specialties, covery after surgery, as outlined by the European Society
such as orthopedic and colorectal surgery [568–571]. of Parenteral and Enteral Nutrition [598], should be imple-
Enhanced recovery can only be accomplished with an mented as follows: avoid long periods of preoperative fast-
interdisciplinary strategy to manage key components of ing (e.g., sips of clear liquids with carbohydrates up to 2 hr),
the early postoperative care plan, to include multimodal postoperative oral feedings as soon as possible with nutri-
pain management strategies [572], minimization of opioid tion support as needed based on early risk assessments, early
use during and after surgery [573], goal-directed fluid man- recognition and correction of factors leading to catabolism
agement, and tight glycemic control. Ideally, ERABS is and/or GI dysfunction, and early mobilization to optimize
combined with preoperative prehabilitation and co- protein synthesis and muscle recovery (Table 12).

After discharge from the hospital, patients should [604,605], and vitamin D [606,607]. With respect to
continue drinking full liquids (stage 2) with an emphasis routine vitamin D supplementation, patients who have
on protein intake and hydration. Within several days of had an SG or RYGB had 12-month safety and effectiveness
the surgery, the patient should be tolerating at least 60 oz comparable to that with early postoperative individualized
(1800 mL) of fluid daily to avoid dehydration. This should dosing starting with only 800 IU/d and up-titrated based on
continue for 10 to 14 days until an assessment can be serum levels or a fixed high dose with 2000 IU/d [607]. In
made by the clinical team at the initial postoperative this CPG, the latter approach is still recommended based
appointment regarding their intake and suitability for diet on the weight of evidence with titration to target levels in
progression. Patients who tolerate stage 2 well can then be the late postoperative period. In a randomized, prospective
advanced to a pureed diet (stage 3) approximately 2 weeks cohort study of 50 patients, there were no significant differ-
after surgery. This can be described to the patient as food ences in micronutrient deficiencies in the early postopera-
that can be eaten without chewing. The consistency and tive period between those undergoing laparoscopic SG
texture should progress gradually. Patients should continue versus RYGB [169].
in stage 3 for another week and, if intake is improving, R40. (2019*). Intraoperative and postoperative fluid
they can advance on their own to soft foods (stage 4). Pa- management in patients undergoing bariatric surgery
tients should be instructed to limit stage 4 foods to those should be goal directed [566]. Use of continuous noninva-
that can be mashed or do not require excessive chewing. Af- sive measurements of fluid status, such as the Pleth Vari-
ter 1 or 2 weeks on soft foods, most patients begin intro- ability Index, stroke volume variation, or other
ducing some solid food and can progress to all solids as technologies, results in less fluid administration during
tolerated (stage 5), generally 4 to 6 weeks after surgery. Pa- bariatric surgery than empiric calculations of volume re-
tients should be instructed that when solid food is intro- quirements [566–608] or monitoring of urine output
duced, only several bites will be tolerated until they adapt [609]. Administration of excess IV fluids can increase
to their new anatomy and the postoperative edema and the rate of postoperative nausea and length of stay after
inflammation have resolved. Typical patients should also surgery [596,610]. To decrease the chances of preoperative
avoid drinking 30 minutes before or after eating solid dehydration, patients should be allowed to drink clear liq-
food. Typical daily calorie intake the first week after surgery uids up to 2 hours before surgery. This should be extended
is 400 kcal/d and progresses to 600 to 800 kcal/d by weeks 3 to 4 hours for patients with known gastroparesis or delayed
to 4. Several months after surgery, patients should consume gastric emptying [611].
1200 to 1500 kcal/d, with most patients consuming approx- R41. (2019*). EN support has been used for treatment-
imately 1500 to 1800 kcal/d 6 months postoperatively and refractory dumping syndrome after bariatric surgery [612]
long term. Refer to Tables 12 to 14 for additional and leaks after SG [613]. The need for EN and/or PN sup-
information regarding diet progression. If patients do not port in some patients with OAGB indicates the need for
progress through these stages of their diet in the similar close follow-up for nutritional problems as with
appropriate time periods due to nausea, vomiting, or other malabsorptive bariatric procedures [614]. When PN
dysphagia, careful evaluation of nutrition should be support is required for patients undergoing bariatric surgery
performed, and the surgeon should consider investigating based on high nutritional risk and inadequate intestinal func-
potential causes (e.g., early anastomotic ulcer, stricture, tion, CPG from the American Society for Parenteral and
and mechanical obstruction) [599]. Enteral Nutrition recommend a high-nitrogen (1.2 g/kg
R39. (2019*). Recommendations for initial micronu- actual or 2–2.5 g/kg ideal weight of amino acid), low-
trient dosing in the early postoperative period immediately energy (50%–70% estimated requirements) formulation
after the bariatric procedure and, if applicable, during the [615]. This type of formulation also avoids overfeeding in
initial hospitalization are based on preoperative deficiency a setting where, in the absence of indirect calorimetry mea-
states, type of procedure performed, dietary progression surements of actual energy consumption, formulaic calcula-
protocols, and oral tolerances, with the intention to adjust tions frequently overestimate needs [616]. In a randomized,
in the late postoperative period based on clinical course, controlled study of patients undergoing RYGB, preoperative
symptoms, and judicious biochemical testing, as outlined oral carbohydrate loading and perioperative peripheral PN
in subsequent recommendations (Tables 11, 13, and 14). were safe but not associated with improved body composi-
Special attention should be paid to avoiding oversupple- tion or clinical outcomes compared with standard nutritional
mentation during this period, which could be a result of management [617]. Refeeding syndrome is a potential
faulty a priori decision-making, various mutations/poly- complication of PN in patients who have had severe weight
morphisms, altered physiology especially decreased bind- loss after bariatric surgery, especially after BPD/DS [618],
ing proteins, confounded or unnecessary biochemical prompting special attention to adequate micronutrition
testing, and indiscriminate/inappropriate continuation (especially phosphate, magnesium, potassium, calcium, vi-
that induces other metabolic derangements [600]. This in- tamins, and trace elements) with initial limited nonprotein
cludes, but is not limited to, iron [601–603], zinc calories (especially dextrose).

R42. (2019*). IV insulin for tight glycemic control is immediate postoperative period is not necessary [470].
associated with improved outcomes after GI and bariatric However, there is a need for additional research to assess
surgery [619–622]. In a comprehensive review, Batterham risk factors and impact of sleep-associated desaturation,
and Cummings [623] review a broad range of mechanisms, which is not unusual in patients after bariatric surgery [640].
acting in concert, that mitigate/reverse the T2D state. Within R45. (2019*). VTE is a leading cause of morbidity and
1 week after RYGB, first-phase insulin secretion and hepatic mortality after bariatric surgery and includes both DVT
insulin sensitivity increase, consistent with clinical findings and PE. Portal-splenic-mesenteric venous system throm-
of rapid amelioration of hyperglycemia postoperatively bosis is a rare but potentially lethal VTE complication after
[624]. In fact, among patients with T2D, blood glucose bariatric surgery [641]. Patients who experienced upper-
levels were significantly reduced by 48 hours after SG and extremity DVT after bariatric surgery also have been
RYGB, regardless of diabetes medication (oral, noninsulin described [642]. In a recent study by Helm et al. [643],
injectables, or insulin) [625]. Moreover, glycemic control the postoperative incidence of VTE was .5%, with an
in the early postoperative period is associated with higher average time to diagnosis of 11.6 days and 80% occurring
rates of long-term T2D remission [626]. Diabetes status after hospital discharge. After bariatric surgery, major com-
does not appear to be associated with postoperative infec- plications occurred before VTE in 22.6% of patients, with
tion rates during the first month after bariatric surgery VTE likelihood directly related to the number of complica-
[627]. Patients with insulin-requiring T2D before surgery tions and an unadjusted 30-day mortality increasing 13.89-
will have up to 87% reduction in their total daily insulin re- fold with VTE [643].
quirements by postoperative day 2 [628]. These more recent DVT prophylaxis is recommended for every patient after
findings further support the practice of holding or dramati- bariatric surgery [477]. At minimum, sequential compres-
cally reducing diabetes medication in the early postopera- sion devices and early ambulation should be used for all pa-
tive period to not only decrease the risk of hypoglycemia tients. Chemoprophylaxis should begin before surgery with
but also avoid unnecessary medication. unfractionated or low-molecular-weight heparin and be
R43. (2013*). ICU monitoring is recommended for those continued throughout the hospital stay unless there is a
patients at high cardiopulmonary risk [629,630]. Patients contraindication [477,644]. More than 80% of DVT events
with left ventricular systolic dysfunction (left ventricular after bariatric surgery are diagnosed after hospital discharge
ejection fraction ,50%) had a slight excess in early postop- [645]. Therefore, extended postdischarge chemoprophylaxis
erative heart failure and myocardial infarction but no excess should be used for patients who are at high risk for DVT,
mortality at 1 year [631]. In a systematic review and meta- such as those with a personal history of DVT, known hyper-
analysis by Chang et al. [632], the 30-day rate for myocar- coagulable state, or limited ambulation. Risk calculators are
dial infarction was .37% with a mortality rate of .37%. available to guide prophylaxis regimens [645]. Congestive
RYGB had higher rates than SG or LAGB [632]. The risk heart failure, paraplegia, dyspnea at rest, and reoperation
for cardiac events after bariatric surgery may be increased are associated with the highest risk of postdischarge DVT.
with OSA and this risk mitigated with the use of CPAP Postoperative bleeding and subsequent transfusion after bar-
[633], though other studies fail to demonstrate these associ- iatric surgery are also associated with increased VTE risk,
ations [469,470]. Parenthetically, even though bariatric sur- most likely due to withholding chemoprophylaxis [646].
geries involving senior-level residents had more statistically Using risk calculators can prompt routine postdischarge
significant morbidities, including postoperative cardiac chemoprophylaxis for high-risk patients (i.e., DVT risk
events, this association is more likely related to periopera- ..4%) [645,647]. Additional risk factors for postoperative
tive rather than intraoperative care [634]. This finding ar- DVT are advanced age, BMI .60 kg/m2, open or revisional
gues for greater emphasis on resident training in surgery, age .50 years, anastomotic leakage, nicotine use,
perioperative bariatric surgery care. past DVT/PE, venous insufficiency, hypoventilation, or
R44. (2019*). Patients who use CPAP preoperatively thrombophilia (e.g., protein-S deficiency, which is more
should have this therapy initiated as early as the postanes- likely with obesity) [648,649]. Serum anti-Xa levels can
thesia care unit to minimize the risk of apnea, hypoxia, or be used to guide low-molecular-weight heparin dosing in
other pulmonary complications [635,636]. The use of the prophylactic range [650–652]. Fondaparinux 5 mg
CPAP immediately after bariatric surgery is not associated once daily achieves appropriate prophylactic anti-Xa levels
with increased risk of anastomotic or suture-line leaks more often than enoxaparin 40 mg twice daily after bariatric
[637]. According to guidelines, patients with OSA who surgery [653].
have had bariatric surgery should have continuous moni- Of note, patients undergoing bariatric surgery who are
toring with pulse oximetry in the early postoperative period chronically anticoagulated preoperatively have increased
with minimization of sedatives and opioids [638,639]. risk for postoperative complications and all-cause readmis-
Because patients with OSA and adequate CPAP use are at sion rates [654]. Whether the benefits of inferior vena cava
low risk for cardiopulmonary complications after laparo- filter placement before bariatric surgery are outweighed by
scopic bariatric surgery, routine ICU admission in the the risks is unclear based on the current literature; however,

it is important to note that inferior vena cava filters are asso- are relatively few studies on the nature of retention and attri-
ciated with higher rates of postoperative DVT and mortality tion after bariatric surgery [676]. Nevertheless, among
after bariatric surgery [655–657]. 46,381 patients who had some follow-up within 12 months
R46. (NEW). Pulmonary embolism is a leading cause of after surgery (30.6% of all patients having RYGB), com-
mortality after bariatric surgery, with an incidence of plete postoperative follow-up (75.6% of 46,381 patients)
approximately 1% [632,658] but a leading cause of death was associated with greater co-morbidity improvement
at 20.7% [659] and accounting for 40% of all deaths within and remission rates, compared with incomplete follow-up
30 days postoperatively [643]. Mortality rates from PE are [677]. In a review of 79 papers (of 872 searched), with a ma-
lower after laparoscopic, compared with open, bariatric pro- jority representing retrospective reviews of prospectively
cedures [660]. collected clinical data, adherence with follow-up appoint-
R47. (2019*). Respiratory distress or failure to wean from ments was generally poor, with up to 89% attrition and
ventilatory support should also raise suspicion for an anas- worse with lesser amounts of weight loss achieved, younger
tomotic leak. Anastomotic or staple-line leaks can present age, unemployment, and lower BMI [678]. Other predictors
with clinical signs of sustained resting tachycardia, hypoxia, of increased adherence with 2-year follow-up were LAGB
and fever and are highly morbid events [661]. There is no and attendance at the 6-month appointment, whereas dys-
evidence that routine placement of a drain after bariatric sur- thymia was associated with decreased follow-up [679].
gery is beneficial. In fact, placement of a drain may increase Similar results were found in a 5-year French cohort of
morbidity and should only be used in select, high-risk cases 16,620 patients [680]. Long-term success after bariatric sur-
[662]. If a leak is suspected in a stable patient, CT imaging is gery also depended on adherence to physical activity,
a more sensitive and specific diagnostic test than an upper vitamin supplementation, and healthy eating patterns, the
GI contrast study and should be the diagnostic test of choice last of which was impaired in patients with poorer mood,
to evaluate all the surgical anatomy [663,664]. In the setting preference for sweets, and eating disorders [678].
of worrisome clinical signs and normal imaging, laparo- Because increased adherence to follow-up is associated
scopic or open operative exploration is warranted to rule with improved outcomes, various strategies should be
out GI leak [664]. Nonoperative methods of GI leak treat- implemented to minimize attrition, such as the use of tele-
ment after both RYGB or SG include endoscopic endolumi- medicine [676] and better collaboration between inpatient
nal self-expandable stents, clips, and sutures, endoscopic and outpatient teams, including those with specialization
and percutaneously placed drains, and biologic glue/tissue in obesity medicine [677,681–683]. Moreover, though
sealants [665–671]. Because length of hospital stay after there is little consensus on what defines an acceptable
bariatric surgery continues to decrease with the use of amount of postoperative weight regain, patients often
ERABS, some septic complications will occur after the express anxiety and a sense of failure with any amount of
relatively earlier hospital discharge [672]. In fact, most weight regain, leading to guilt, shame, and a reluctance to
SG leaks occur after hospital discharge. Serum markers, attend critical follow-up appointments. Hence, clarity is
such as CRP and procalcitonin, are sensitive and specific needed regarding weight regain. Notwithstanding the pre-
in predicting surgical-site infections in patients after bariat- ceding, in a cohort study of 794 patients with 90% follow-
ric surgery [673]. up over 10 years, there was a 38% rate of band removal
R48. (2019*). Rhabdomyolysis (defined as a postopera- with higher rates for those with age ,40 years, BMI .50
tive serum creatinine kinase level .1000 U/L) is associated kg/m2, female sex, and longer duration of time [684].
with longer operative times (.230 min) and can be effec- R50. (2013*). The diagnosis of hyperinsulinemic hypo-
tively treated with fluid therapy and diuretics within 24 glycemia can be challenging due to the variability in pre-
hours of surgery [674]. The development of rhabdomyolysis senting symptoms, which can be autonomic or
is also associated with increasing volumes of IV fluid after neuroglycopenic in nature. Hyperinsulinemic hypoglycemia
bariatric surgery, suggesting that decreasing intravenous has been reported after SG [685], in addition to BPD/DS and
fluid administration (goal-directed fluid management) may RYGB. Newer studies have found an association of
lower the risk of rhabdomyolysis [675]. post–bariatric surgery hypoglycemia with weight regain
[686]. To confirm the diagnosis of hyperinsulinemia
hypoglycemia, patients must have confirmed postprandial
Q6. How can care be optimized 5 days after a bariatric
hypoglycemia in combination with symptoms [687]. A
procedure?
low-carbohydrate, low-glycemic index diet with adequate
R49. (2019*). Recommended follow-up intervals are protein and inclusion of heart-healthy fats along with
generally based on expert opinion (Table 11). There are restricting alcohol and caffeine intake recently has been
very few bariatric surgery studies reporting long-term re- shown to be an effective strategy to manage post–bariatric
sults with sufficient follow-up of patients (only 29 of 7371 surgery hypoglycemia [688]. In fact, most patients with
with at least 2-year follow-up and 80% of initial cohort rep- post–bariatric surgery hypoglycemia will respond to dietary
resented), creating bias in outcome reporting [175]. There modification or pharmacologic intervention [687–692]. As

an example, continuous glucose monitoring was useful in a loading, physical activity, and various hormonal and other
pregnant patient with dumping syndrome after RYGB and humoral factors), and increased risk of falls [734–736]. In
poor adherence to conventional glucose monitoring [693]. fact, the nature of decreased bone strength, independent of
R51. (2013*). The beneficial role of physical activity bone density, is an area of intense interest.
(e.g., high-intensity interval training, moderate-intensity Frederiksen et al. [737] used high-resolution peripheral
continuous training) in patients with obesity, especially dur- quantitative CT to affirm microarchitecture changes after
ing the active treatment phase, has been described previ- RYGB that suggest accelerated endosteal resorption and
ously [694–700]. Patients who undergo weight loss, disintegration of trabecular structure. Screening guidelines
especially with bariatric procedures, are particularly for osteoporotic fracture for all patients may be guided by
susceptible to skeletal muscle loss or sarcopenia, which is recommendations from the U.S. Preventive Services Task
associated with physical disability, poor quality of life, Force [505]. Schafer et al. [502] found that significant
and increased mortality risk [701]. Biweekly physical activ- bone loss after RYGB occurred in postmenopausal women
ity training sessions for 6 months after RYGB improved car- as early as 6 months postoperatively and persisted through
diometabolic risk factors and muscle strength, but patients the study duration, which was only 12 months. Using the
did not maintain these benefits (compared with controls) trabecular bone score as an indirect assessment of skeletal
in follow-up [702,703]. However, physical activity was microarchitecture, women had preserved bone microarchi-
able to induce and maintain improved health-related quality tecture for at least 3 years after RYGB [738]. In a smaller
of life for up to 2 years after RYGB [704]. In several studies, study of both sexes, bone strength by high-resolution, pe-
there are positive correlations between the amount of phys- ripheral, quantitative CT was preserved for a year after bar-
ical activity and the amount of weight loss after bariatric iatric surgery (LAGB, RYGB, or BPD/DS) [739]. However,
surgery [705–707]. In 1 systematic review of 50 studies, in another small study, bone strength declined by a year after
there was more physically active time (e.g., step count) bariatric surgery [740]. Bone loss after RYGB and SG was
during the first 6 months postoperative, but the intensity comparable (at w8%–9% loss in patients with T2D)
was less [708]. Taking this into account, patients should [741], though loss was greater at total hip and femoral
be counseled on physical activity preoperatively and long neck with RYGB [501]. In a meta-analysis of 10 studies
term after bariatric surgery [709,710]. The use of wearable (of 1299 screened), bone density significantly decreased in
technologies and activity monitors should be also consid- the femoral neck, but not in the lumbar spine after bariatric
ered as they can have a positive effect on healthy physical surgery, compared with nonsurgical controls [742].
activity behaviors in patients with obesity [711]. There are Indices of bone marrow adipose tissue (inversely related
many web-based resources on general recommendations to bone density) may serve as a potential marker of skeletal
for physical activity in adults [712,713]. risk in patients after bariatric surgery [501,743]. Although
R52. (2019*). The simple practice of self-monitoring ultrasound of the phalanges yields results comparable to
(e.g., daily self-weighing using smart scales) may lead to those with dual-energy x-ray absorptiometry in patients
improved weight loss results [714]. However, the incorpora- not having bariatric surgery, results are discordant in those
tion of more sophisticated mobile technologies using a vari- having bariatric surgery, most likely due to mechanical
ety of delivery methods (e.g., text messaging, e-mail, cell loading effects [744]. In short, there are insufficient data
phone interactions, diet tracking, and virtual reality soft- to provide a more specific recommendation at this time
ware) shows promising results (many with RCTs) in terms other than monitoring dual-energy x-ray absorptiometry at
of additional or alternative low-cost, patient-support modal- lumbar spine and proximal femur sites, at baseline and 2
ities [715–726]. years after bariatric surgery, with interventions based on
R53. (2019*). In patients who have undergone SG, there clinical judgment (e.g., treating patients with persistent
is a potential increase in GERD requiring long-term proton- loss and increased fracture risk) [734,745].
pump inhibitor therapy [727–729], which can interfere with R55. (2013*). In a large Taiwanese database (N 5 2064),
absorption of calcium, thus further increasing the risk of bariatric surgery (primarily with malabsorptive procedures)
secondary hyperparathyroidism [729,730]. Additional re- was associated with increased fracture risk in the first 1 to 2
views [448,731], a cross-sectional study [732], and a pro- postoperative years [47]. In a case-matched study of 120 pa-
spective study [733] further delineate the effects of tients using lumbar spine and total hip dual-energy x-ray ab-
bariatric surgery on calcium and vitamin D status. sorptiometry, RYGB was associated with greater bone loss
R54. (2008). Patients who have had bariatric surgery are than LAGB or SG [746]. However, in another study of 66
at increased risk for fracture (w1.2-fold) [47] due to bone patients, bone loss was comparable between RYGB and
loss (primarily related to malabsorptive procedures and ef- SG [747]. Secondary hyperparathyroidism may play a sig-
fects on protein, calcium, vitamin D, and possibly copper nificant role or be a significant marker of this bone loss pro-
and vitamin K, though bone density is generally higher in cess. Among 1470 patients undergoing various bariatric
patients with obesity), abnormal bone microarchitecture (in- surgical procedures, the overall prevalence of secondary hy-
dependent of bone mass and primarily related to mechanical perparathyroidism was 21.0% preoperatively, 35.4% at 1

year postoperatively, and 63.3% at 5 years postoperatively, safflower oil [756,757] are rich in EFA and may be applied
with some procedural differences in these 5-year rates as to the affected skin areas with EFA deficiency, though
follows: OAGB (73.6%) . RYGB (56.6%) . LAGB conclusive clinical trials, particularly with oral supplemen-
(38.5%) . SG (41.7%) (504). Hence, every effort should tation, are lacking, especially in patients after bariatric sur-
be made to screen for and appropriately treat both secondary gery. A rational approach of screening for multiple
hyperparathyroidism and osteoporosis to lower fracture risk. nonestablished fat-soluble vitamin deficiencies with at least
There are no data on the use of antiresorptive agents spe- 1 established or suspected EFA deficiency remains to be
cifically for management of bone loss resulting from a bar- proven.
iatric procedure, including both bisphosphonates and R59. (2019*). In the recent ASMBS CPG, iron deficiency
denosumab [748]. The use of specific bisphosphonates in was as high as 45% of patients with obesity before bariatric
patients with chronic kidney disease are reviewed by Miller surgery and therefore justifies a preoperative aggressive
et al. [749]. Upper GI adverse effects of oral bisphospho- case-finding approach, which may include ferritin levels
nates are discussed by Lanza et al. [750]. The potential for [448]. Key clinical features of iron deficiency prompting
secondary hyperparathyroidism, hypocalcemia, and vitamin suspicion include fatigue, microcytic anemia, glossitis,
D insufficiency/deficiency should be strongly considered and nail dystrophy. Postoperatively, iron status should
and effectively managed when starting antiresorptive agents continue to be monitored, but ferritin levels are less helpful
after a bariatric procedure [748]. because they are confounded by inflammation, age, and
R56. (2013*). The pathophysiology of calcium oxalate infection [448]. Moreover, postoperatively, iron deficiency
stone disease after bariatric surgery is related to hyperoxalu- is 14% after LAGB, 20% to 55% after RYGB, 8% to 62%
ria, low urinary volume, and hypocitraturia [751]. after BPD/DS and can occur despite routine supplementa-
R57. (2019*). A recent review by the ASMBS [448] re- tion, again justifying routine testing [448]. Oral supplemen-
ported higher prevalence rates of certain nutrient defi- tation should be in divided doses because malabsorption can
ciencies among patients with obesity considered for be exacerbated with calcium supplements, decreased gastric
bariatric surgery. For example, the prevalence of preopera- acid, and phytate- or polyphenol-rich foods [448]. Vitamin
tive deficiencies among fat-soluble vitamins is 14% for C can be provided with iron supplementation to both
vitamin A and 2.2% for vitamin E, but no data are available improve iron absorption and decrease the risk of iron over-
for vitamin K [448]. Postoperatively within 4 years, vitamin load [758].
A deficiency occurs in up to 70% after RYGB and BPD/DS, R60. (2019*). In the recent ASMBS CPG, B12 deficiency
whereas vitamin E and K deficiencies are uncommon. The was found in 2% to 18% of patients with obesity (6%–30%
impact of RYGB on vitamin A undernutrition is particularly in those on proton-pump inhibitors) before bariatric surgery
severe in pregnant women [752]. Micronutrient dosing stra- and justifies preoperative aggressive case finding with
tegies are outlined in Table 14. However, caution should be biochemical testing, specifically using methylmalonic acid
exercised in the interpretation of biochemical results; for [448,759]. Two to 5 years after bariatric surgery, B12 defi-
example, vitamin A levels may need to be adjusted for ciency is ,20% in RYGB and 4% to 20% after SG [448].
retinol-binding protein levels and vitamin E for cholesterol However, in a meta-analysis directly examining the 2 pro-
levels to avoid oversupplementation [600]. Additional cedures, there was a decreased risk for B12 deficiency
micronutrient deficiency prevalence rates, which are dis- (but not anemia or iron deficiency) after SG compared
cussed in subsequent recommendations, are presented by with RYGB [760]. Notwithstanding the paucity of informa-
surgical procedure performed and serve to guide decision- tion about vitamin B12 status after LAGB, global recom-
making about appropriate biochemical testing, therapeutic mendations for ongoing biochemical testing and
dosing for prevention of deficiencies, and therapeutic dosing appropriate B12 supplementation in all patients undergoing
to manage established deficiencies [753]. bariatric surgery, especially those on folic acid supplemen-
R58. (2008*). There are few data about essential fatty tation, may be reasonable because there is virtually no risk
acid (EFA) status or comprehensive strategies for the from B12 dosing.
workup of fat-soluble vitamin levels after bariatric surgery. R61. (2013). In the recent ASMBS CPG, folate defi-
Forbes et al. [754] found transient increases in 20:4 N6 ciency was found in as many as 45% of patients with obesity
(118%) and 22:6 N3 (111%) with decreases in 20:3 N6 before bariatric surgery and justifies aggressive case finding
(247%) and 20:5 N3 (279 and 67%) at 1 and 6 months, preoperatively with biochemical testing, specifically using
respectively, after RYGB but not LAGB. The 20:5 N3 sensitive markers, such as red blood cell folate and homo-
reduction is most concerning because this EFA is a precur- cysteine (methylmalonic acid is normal with folate defi-
sor for anti-inflammatory eicosanoids. However, the impact ciency and normal B12 status) [448]. Up to 65% of
of these results is mitigated by decreased postoperative patients after bariatric surgery have a folate deficiency, in
intake of dietary fat, decreased body fat postoperatively, part due to poor consumption of folate-rich foods (e.g.,
and lack of data on the clinical benefit of treatment postop- various beans, lentils, peas, and other vegetables and fruits)
eratively. Topical borage oil [755], soybean oil [756], or and possible multivitamin nonadherence, again justifying

ongoing biochemical monitoring, especially in female pa- RYGB, to 16 to 22 mg (200% of usual multivitamin-
tients of childbearing age [448]. Concerns remain about multimineral supplement zinc content) after BPD/DS
masking B12 deficiencies (and therefore starting B12 sup- [448]. Moreover, to avoid copper undernutrition with
plementation) on higher doses of folic acid (1 mg/d); chronic zinc supplementation, zinc dosing should be in the
further research is required, especially after bariatric surgery range of no more than 8 to 15 mg per mg of copper supple-
[761,762]. mented [448].
R62. (2013). Approximately 10% to 12% of patients with R65. (2019*). Copper is primarily absorbed in the duo-
obesity have anemia before bariatric surgery, 33% to 49% of denum, proximal jejunum, and stomach, so surgeries
patients have anemia within 2 years after bariatric surgery, affecting this functional anatomy can potentially induce a
and this postoperative prevalence is 17% after SG and low copper state. At 5 years postoperatively, 13.48% and
45% to 50% after the malabsorptive procedures RYGB only 1.92% of patients had low copper levels after RYGB
and BPD/DS [763,764]. Though iron deficiency is the and BPD/DS, respectively [771]. This compares with pa-
most common culprit, folate and vitamin B12 deficiencies tients undergoing Roux-en-Y reconstruction for gastric can-
are also highly associated with anemia. Though less com- cer, in whom copper deficiency was relatively infrequent
mon, additional micronutrient deficiencies can contribute (5.9%) and symptoms were rare [772]. In the same study,
to anemia after malabsorptive bariatric surgery, namely vi- copper levels among those having RYGB or BPD/DS
tamins A, B1, D, E, and K and zinc, selenium, and copper were lower with younger age, shorter follow-up (,3 yr),
[764–766]. Whether a nutritional anemia workup should and male sex [772]. The amount of copper supplementation
be expanded to checking these less common biochemical varies depending on the surgical procedure performed, with
markers, and supplementing if positive, depends on greater amounts required for patients after RYGB and BPD/
clinical judgment based on other specific signs/symptoms DS, and is guided by serum copper levels [448]. Initial sup-
of deficiency. The association of low protein levels with plementation dosing ranges from 3 to 8 mg/d oral copper as
anemia may be causative in chronic disorders [767] but gluconate or sulfate to 2 to 4 mg/d IV and then titrated to
may be more of an indirect marker of poor nutrition and normal levels and amelioration of signs/symptoms [448].
other contributory factors after bariatric surgery. R66. (2019*). In a study by Nath et al. [525], 16.5% of
R63. (2013). Clinically significant selenium deficiency is patients after RYGB had clinical thiamine deficiency,
associated with myopathy, cardiomyopathy, arrhythmia, defined by the presence of consistent clinical symptoms
impaired immunity, hypothyroidism, loss of skin/hair and either low whole-blood thiamine levels or significant
pigmentation, and encephalopathy [768]. Massoure et al. improvement after thiamine supplementation. Thiamine is
[769] reported heart failure in a patient 9 months after the first vitamin depleted in patients who experience chronic
RYGB that resolved with 2 mg/kg/d ! 3 months oral sele- nausea/vomiting or food intolerance [521]. Among those
nium with furosemide and an angiotensin-converting with clinical thiamine deficiency, 70% had cardiac, 59%
enzyme inhibitor. Among 437 patients having LAGB or had peripheral neurologic, 14% had GI, and 5% had neuro-
SG, selenium deficiency (below normal range .75–1.85 psychiatric symptoms. Abnormal intestinal microbiota is
mmol/L) occurred in 2.3% patients preoperatively (3.2% in thought to be a contributory factor to low thiamine levels af-
another, smaller study) [518] and then, while taking a ter RYGB, and levels improved with antibiotics [773].
multivitamin-mineral supplement, in 14.9% patients at 3 Early/aggressive supplementation of thiamine in at-risk pa-
months postoperatively, 13.8% at 6 months, 13.1% at 12 tients (those with chronic nausea/vomiting, decreased intake
months, 15.4% at 18 months, 11.4% at 24 months, and by mouth) can avert the adverse effects of clinically signif-
14.3% at 36 months [765]. In another study, selenium intake icant thiamine deficiency. Of note, there is increased urinary
and markers of deficiency were most evident at 3 months af- thiamine excretion with both T1D (76% decreased thiamine
ter RYGB, but not LAGB, prompting recommendations for levels) and T2D (75% decreased thiamine levels) [774]. On
routine increases in high-selenium foods and use of routine the other hand, Aaseth et al. [775] found that thiamine levels
multivitamin supplements with .55 mg/d selenium [768]. In after RYGB were relatively constant up to 5 years postoper-
a more recent report, Shoar et al. [770] found approximately atively. Interestingly, elevated thiamine levels were found in
50% of patients undergoing single-anastomosis duodeno- 43% of patients already on micronutrient supplementation
ileal bypass with sleeve had a selenium deficiency. up to 12 months after BPD/DS in a study by Homan et al.
R64. (2019*). At 5 years postoperatively, 21.15% and [776]. Additional information on thiamine deficiency and
44.94% of patients, respectively, have low zinc levels after supplementation can be found in the 2008 and 2013 versions
RYGB and BPD/DS [771]. The amount of routine daily of these guidelines [1,54].
zinc supplementation after bariatric surgery depends on WE has been reported after purely restrictive procedures
the specific procedure, ranging from 8 to 11 mg (100% of (e.g., LAGB, SG, and IGB) and may in large part reflect pre-
usual multivitamin-multimineral supplement zinc content) existing thiamine undernutrition; routine assessment of thia-
after SG or LAGB, to 8 to 22 mg (100%–200% of usual mine status in any patient after bariatric surgery with
multivitamin-multimineral supplement zinc content) after any early or suggestive features of WE is recommended

[777–779]. For example, in patients after bariatric surgery, the medications postoperatively [789]. Overall, there are re-
fundoscopic examination can detect the early findings of a ductions in CVD risk, events, and mortality after bariatric
severe thiamine deficiency at risk for WE: retinal surgery [94,790]. Decreased blood pressure can occur post-
hemorrhage, optic disc edema, and peripapillary operatively even before appreciable weight loss, particularly
telangiectasia [780]. An unusual presentation initially diag- in patients with orthostatic intolerance and possible dysau-
nosed as an ischemic stroke was described by Blum et al. tonomia [791].
[781] in a patient 9 months after SG who was ultimately R70. (NEW). The ongoing need for medications for T2D
diagnosed with WE. There are also ethnicity differences depends on the specific bariatric surgical procedure and
in prevalence rates of thiamine deficiency, with up to 33% needs to be monitored postoperatively. In a retrospective re-
in Latinos preoperatively where the total (all ethnicities) view of 400 patients in the Bariatric Outcomes Longitudinal
rate was only 1.8% [732]. Updated physiology, recommen- Database, the use of oral hypoglycemic agents or insulin
dations, and discussion for thiamine supplementation are decreased after bariatric surgery by 18.8% and 4.2%,
provided in the ASMBS guidelines [448] and a review by respectively [792]. In a prospective, single-center cohort
Frank [782]. Although evidence is limited, if IV access is study of 65 patients having SG, there was a 50% reduction
not available in the acute setting, intramuscular thiamine in diabetes medications [785]. Among 183 patients post-SG
dosing may be considered [783]. (with 58.4% 2-yr median loss of excess weight), 78.9% and
R67. (NEW). Many commercial dietary supplement 15.8% of those with T2D had their diabetes medications dis-
products are adulterated with compounds that are not continued or reduced, respectively [789]. In a retrospective
included in the manufacturer’s labeling. These products study of 79 patients undergoing LAGB and followed for 10
can have intrinsic toxicity; mitigate or intensify the desired years, diabetes control, blood pressure, lipid profile, and
clinical action; interact with certain foods, other supple- quality of life improved but without significant changes in
ments, or specific medications; or have unknown but poten- diabetes medication and with a high rate of revisional sur-
tially harmful effects [784]. The best principle is for HCP gery [793].
and patients to discuss all supplements at each encounter. R71. (NEW). Thyroid dosing is generally decreased after
U.S. Pharmacopeia products, supplements that have been bariatric surgery due to weight loss, but some case studies
used in published clinical trials, or other brands with which have reported increased dosing with significant malabsorp-
the prescribing HCP has a positive (safe and effective) expe- tion [794]. Several case reports have demonstrated the
rience are preferred. benefit of liquid forms of levothyroxine in postoperative pa-
R68. (2013*). In a prospective, single-center cohort study tients with hypothyroidism, significant malabsorption, and
of 65 patients after SG, there was a 6% reduction in lipid- difficulty normalizing elevated TSH levels [795]. Liquid
lowering medication use at 1 month and 24% at 6 months forms may also be indicated in those patients with swallow-
[785]. The pathophysiology of bariatric surgery on lipids ing difficulties after bariatric surgery [796]. The use of soft-
is complex, with salutary effects on lipid metabolism post- gel levothyroxine may also be considered in patients with
operatively but also downstream effects of lipids on micro- established or suspected malabsorption of tablet forms
nutrient status and effects of micronutrients on lipid status [796,797].
[435,436,786]. These networked effects among obesity, bar- R72. (2019*). In a retrospective review of patients with
iatric surgical disruption of GI physiology, lipid status, RYGB or BPD/DS, CT is the most appropriate imaging
micronutrient status, and CVD risk will need further eluci- tool to help identify an intestinal obstruction or internal her-
dation and research. nia [798]. In some cases, conclusive findings are missed on
R69. (2019*). In a meta-analysis, 32 of 57 clinical studies imaging, and diagnostic laparoscopy should be considered if
reported improvement of HTN in 32,628 of 51,241 patients, symptoms persist. Severe abdominal pain after SG may be
and 46 of these studies reported resolution of HTN in 24,902 the result of mesenteric venous thrombosis, which is associ-
of 49,844 patients after bariatric surgery [97]. In another ated with shorter courses of VTE prophylaxis and best diag-
analysis of 23 studies with a pooled group of 1022 patients, nosed with contrast-enhanced CT [641,799]. In a multi-
bariatric surgery was cardioprotective and induced a institutional, matched, case-controlled study using a U.S.
decrease in left ventricular mass and left-atrium diameter database from 2008 to 2012 (8980 patients in the study
and improvement of left-ventricular diastolic function, but group and 43,059 controls), there were 15 cases of inflam-
without changes in left-ventricular ejection fraction [787]. matory bowel disease in those with a history of bariatric sur-
Renal function also improves after bariatric surgery in those gery (OR 1.93; 95% confidence interval 1.34–2.79) [800].
patients with HTN [788]. In a prospective, single-center R73. (NEW). In a retrospective study of 919 patients un-
cohort study of 65 patients after SG, there was a 12% reduc- dergoing SG, 13% had preexisting GERD and 3% devel-
tion in antihypertensive medication use at 1 month and 25% oped de novo GERD, with the majority responding to
at 6 months [785]. One more study of 183 consecutive pa- proton-pump inhibitors, but 1 patient with de novo and 3 pa-
tients undergoing SG showed that 50% of the patients tients with preexisting GERD requiring conversion to
reduced blood pressure medications and 34% discontinued RYGB [727].

R74. (2019*). Although short-term postoperative use of morbidities is effective but, due to the complex nature of
NSAIDs for patients after bariatric surgery is standard prac- the procedure, associated with morbidity [812]. There are
tice, long-term use generally should be avoided. In a retro- inadequate data for a formal recommendation about band-
spective review of 1001 patients who had RYGB, NSAID to-bypass conversional surgery. In a retrospective review
and tobacco use significantly increased the risk of marginal of 1273 patients, gastrogastric fistula occurred in 106% of
ulceration, and upper endoscopy is useful to exclude or those who had RYGB, generally due to gastric ischemia, fis-
detect and then dilate strictures in patients who have had tula, or ulceration, and the majority presented with weight
RYGB [801]. Proton-pump inhibitor use was protective in regain (80%) and pain (73.3%), where surgical revision
these patients exposed to NSAIDs [801]. In a retrospective was based on anatomy as follows: low fistula with gastric
cohort study of 13,082 patients having colorectal or bariatric resection and gastrojejunal anastomotic revision, or high fis-
surgery by Hakkareinen et al. [802], NSAID use was asso- tula with sleeve of the pouch and sleeve resection of the
ciated with an increased rate of anastomotic leak. Simply remnant stomach [813]. Revisional surgery has also been
providing letters or written notification to avoid or discon- performed to improve glycemic control in bariatric surgery
tinue use of NSAIDs after RYGB (and other bariatric pro- patients with persistent T2D, with subsequent T2D improve-
cedures by extension) is ineffective [803]. ment in 65% to 100% of patients [277].
R75. (2019*). Upper GI endoscopy in the early postoper- R78. (2019*). Evaluation with upper GI contrast study is
ative period after RYGB is safe [485,804]. The use of GI the primary imaging modality to detect band slippage, esoph-
endoscopy in patients who have had bariatric surgery is sup- ageal dilation, and, in some patients, erosion [814,815].
ported by the study by Wilson et al. [801]. Interestingly, R79. (2019*). Rapid weight loss is the primary risk factor
recent data from an RCT demonstrate the utility of intrao- for gallstones, detected by abdominal ultrasound, after SG
perative endoscopy to detect technical defect-related leaks or RYGB [816]. In general, cholecystectomy should be
using the air-leak test [805]. reserved for patients with symptomatic biliary disease as
R76. (NEW). In a systematic review of 41 studies the risk of needing a postoperative cholecystectomy is 6%
involving 16,987 patients having RYGB, marginal ulcers to 10% [817]. In asymptomatic patients with known gall-
as diagnosed by upper endoscopy occurred in .6% to stones and a history of RYGB or BPD/DS, prophylactic
25% and were associated with pouch size and position, cholecystectomy may be considered to avoid choledocholi-
smoking, alcohol consumption, and NSAID use [806]. In thiasis because traditional endoscopic retrograde cholangio-
a retrospective cohort study [807] and a meta-analysis of pancreatography can no longer be performed in these
7 prospective cohort studies involving 2917 (2114 patients [818]. Because the aggregate complication risk of
analyzed) patients [808], prophylactic administration of a cholecystectomy is lower when performed before,
proton-pump inhibitor for 90 days postoperatively was su- compared with during or after, RYGB, the appropriate use
perior to 30 days in the prevention of symptomatic mar- of preoperative cholecystectomy and optimization of pre-
ginal ulcers. However, because most marginal ulcers ventive measures postoperatively are critical [819]. In a
occur within the first 12 months after surgery, extension retrospective review of a prospectively collected database,
of proton-pump inhibitor therapy for the first postoperative ursodeoxycholic acid 500 mg daily for 1 year efficiently
year should be considered in patients at high risk as a pre- prevented gallstones after SG, with twice daily dosing effec-
ventive measure [801]. tive for RYGB [820]. A meta-analysis of 8 studies (retro-
R77. (2013*). A meta-analysis of 175 studies (many were spective, prospective cohort, and randomized controlled)
single-center retrospective reviews) on patients with inade- with 816 patients by Magouliotis et al. [821] supported
quate weight loss after bariatric surgery demonstrated the role of 500 to 600 mg/d ursodeoxycholic acid for 6
improved weight loss and reduction of co-morbidities with months after bariatric surgery. A more definitive, random-
revisional surgery (though complication rates were higher ized, double-blind multicenter trial (N 5 900 patients with
with reoperative compared with primary surgery) [275]. In SG or RYGB) assessed the efficacy of ursodeoxycholic
a 1:1 comparison, case-matched analysis of primary versus acid 900 mg/d ! 6 months on symptomatic gallstones by
revisional RYGB, co-morbidity resolution and total weight 24 months [822].
loss were similar, with weight loss after revisional surgery R80. (2013*). Of note, SIBO is fairly common (15%–
being less than after primary surgery. Revisional surgery 17%) preoperatively in patients who had RYGB (N 5
was found to be safe [809]. Among 1300 patients having 378), rises to 40% after RYGB (but not LAGB), and may
SG, conversion to RYGB was associated with a mean loss be associated with lower overall weight loss [823,824].
of excess weight of 61.3% after 1 year [810]. Based on retro- Thiamine deficiency is associated with SIBO after RYGB
spective analysis of 2 cohorts, endoscopic gastrojejunos- (49% of patients) due to bacterial thiaminase production
tomy revision also has demonstrated greater effectiveness in the setting of compromised thiamine transporter-1 and
than medical management for weight regain after RYGB -2 with shortened biliopancreatic limb, relatively low in-
[811]. Band-to-bypass conversional surgery for inadequate takes, and small reserves, especially with obesity, while
weight loss, symptoms, clinical goals, and/or co- also leading to gut dysmotility (e.g., constipation)

[773,825]. SIBO is also associated with severe hepatic stea- readmission (SG: OR 1.89, 95% confidence interval 1.52–
tosis in patients with obesity [824]. 2.33; RYGB: OR 3.06, 95% confidence interval 2.46–
R81. (2008*). Timing of repair of abdominal wall hernias 3.81) [837]. Similar trends were noted in another study,
is debatable with insufficient evidence for a recommenda- with readmission rates highest for LRYGB at 11.6%, fol-
tion; strategy would depend on the hernia size, location, lowed by SG with 7.6% and LAGB with 4.5% [838]. Read-
and type [826]. missions are highest within 30 days. Readmissions that
R82. (2013*). Body contouring may be associated with occur at .30 days are more frequently associated with
weight loss benefits after bariatric surgery, including an in- RYGB than SG and LAGB [839].
crease in total weight loss and an improvement in long- R84. (2008). Risk factors for readmission are multifacto-
term weight loss maintenance [827,828]. Currently, an esti- rial and include longer index hospital length of stay, proced-
mated 6% to 41% of patients undergo body contouring after ure choice, prolonged index operation, and complication
bariatric surgery, with the large amount of variability likely during index hospitalization. Complication during index
due to poor access to care due to limited insurance coverage hospitalization is associated with greater need for readmis-
[827,829,830]. When plastic surgery practice surveys and in- sion that requires intervention, such as reoperation or
surance coverage requirements were analyzed by Dreifuss endoscopy [839,840]. RYGB is associated with increased
and Rubin [831], discrepancies were noted regarding the long-term (.30 d) readmissions, compared with SG and
criteria for panniculectomies, arguing for greater input by sur- LAGB [26,839,840]. Race and insurance status were also
geons in the development of coverage guidelines. Correcting risk factors for readmission in other studies [26]. Preopera-
underlying nutritional deficiencies is important in decreasing tive education, planning, and postoperative care coordination
the frequency of complications that can occur with body- with early follow-up can reduce preventable emergency
contouring surgery [832]. For example, because iron- room visits and readmissions for mild dehydration, nausea,
deficiency anemias, which may be found in patients after bar- or dietary intolerance issues [838–841]. Morton et al. [842]
iatric surgery, could complicate a body-contouring procedure, showed a reduction in 30-day readmission rates from 8%
IV iron therapy may be needed [833]. Although the overall to 2.5% over 18 months by implementation of a readmission
complication rate of body contouring after bariatric surgery bundle and ongoing vigilance to readmission.
is high, the majority of such complications are considered mi- R85. (2008). A recent systematic review identified 35 ar-
nor [834]. In a retrospective, multiple regression analysis of ticles encompassing a total of 100 patients undergoing
205 patients having body-contouring surgery after bariatric reversal of RYGB. Malnutrition was the most common indi-
surgery, no main risk factors were identified [835]. cation for reversal (12.3%), followed by severe dumping
syndrome (9.4%), postprandial hypoglycemia (8.5%), and
excessive weight loss (8.5%) [843]. Protein malnutrition
Q7. What are the criteria for hospital admission after a
and excessive weight loss remain the most common causes
bariatric procedure?
of reversal after BPD/DS [844].
R83. (2013). There has been a notable shift in case type
since 2011 with significantly increased numbers of SG Acknowledgements
(58.1% in 2016) and revisional procedures (13.9% in
Reviewers: Michael A. Bush, M.D., F.A.C.E., AACE Past
2016), with SG now the most commonly performed bariatric
President; CA-AACE Past Clinical Chief, Division of Endo-
surgery, and a decrease in RYGB (18.7% in 2016 compared
crinology, Sinai Medical Center; Associate Clinical Profes-
with 37.5% in 2012) and a significant decline in LAGB pro-
sor, Geffen School of Medicine, UCLA, Beverly Hills, CA
cedures (3.4% in 2016 compared with 35.4% in 2011) [239]. Scott Isaacs, M.D., F.A.C.P., F.A.C.E., Adjunct Assistant
There has been an interval reduction in average length of
Professor of Medicine, Emory University School of Medi-
stay and hospital readmission rate. Accreditation of centers
cine, Atlanta, GA
and utilization of ERABS protocols are associated with
Ann M. Rogers, M.D., F.A.C.S., Director, Penn State Sur-
shorter lengths of stay [584,836]. However, in this case, a
gical Weight Loss Program; Professor of Surgery, Vice
shorter length of stay does not appear to be associated
Chair for Leadership and Professional Development, Penn
with increased readmission rates [584]. Readmission rates
State Milton S. Hershey Medical Center, Hershey, PA
within 30 days were evaluated in 130,007 patients undergo-
Dace L. Trence, M.D., M.A.C.E., Professor of Medicine;
ing primary bariatric surgery, for a total of 4.4%. Specif- Director, Endocrine Fellowship Program; University of
ically, LAGB had the lowest rate of 1.4%, followed by SG
Washington, Seattle, WA
at 2.8% and RYGB at 4.9% [837]. The most common cause
for readmission was nausea, vomiting, fluid, electrolyte, and
Disclosures
nutritional depletion (35.4%), followed by abdominal pain
(13.5%), anastomotic leak (6.4%), and bleeding (5.8%), ac- Chair of the Task Force: Jeffrey I. Mechanick, M.D.,
counting for .61% of readmissions [837]. Compared with M.A.C.E.: Abbott Nutrition, honoraria for lectures and pro-
LAGB, SG and RYGB had significantly higher rates of gram development.

Co-Chairs of the Task Force: Caroline Apovian, M.D.: Society, and American Society for Metabolic & Bariatric Surgery.
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Mechanick 2020 AACE TOS ASMBS Guidelines

Uploaded by

Mechanick 2020 AACE TOS ASMBS Guidelines

Uploaded by

Surgery for Obesity and Related Diseases 16 (2020) 175–247

Clinical practice guidelines for the perioperative nutrition, metabolic,

Key words: Bariatric surgery; Obesity; Guidelines; Metabolic surgery; Nutrition

Lay Abstract interventions, and leads to substantial cost savings.

Table 2 Key updates for 2019

Table 4 Q2. Which bariatric procedure should be offered?

Table 9 of the individual risk factors and findings on history and

significant and persistent abnormal liver function tests Table 10

Sugar-free or low sugar Balanced meal plan to include

50% goal should be met with clear liquids

Should constitute 10%–35% of daily

R39. (2019*). After consideration of preprocedure defi-

postsurgery patient and plays an important

RD responsible for the nutrition care of the

ciency states, as well as risks and benefits in the early (,5

long-term follow-up, evaluation, and

RYGB, and SG should be in chewable form initially and

iron, folic acid, and thiamine) (Grade B, BEL 2), elemental

bariatric surgery and during the

progression, based on the type

Society Recommendations [568]

Consultation should be provided

of surgical procedure, should

with a dietician; a protocol-

in divided doses) (Grade B, BEL 2), at least 2000 to 3000

patient and family before

IU of vitamin D (titrated to therapeutic 25-hydroxyvitamin

to 60 mg via multivitamins and additional supplements

(Grade A, BEL 1), and vitamin B12 (parenterally as sublin-

gual, subcutaneous, or intramuscular preparations; orally if

BEL 2), 1200 to 1500 mg/d of elemental calcium (in diet

and as citrated supplement in divided doses), and at least

recommendations to prevent micronutrient deficiencies are

dure fluid management should be guided by continuous

tube feeds] or parenteral nutrition [PN]) should be consid-

PN should be considered in those patients who are unable

illness (Grade D). In patients with severe protein malnutri-

R42. (2019*). Intra-/perioperative intravenous (IV)

meglitinides), sodium-glucose cotransporter-2 inhibitors,

Oral therapy: 100 mg 2–3 times daily until symptoms resolve

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