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New guidelines

AACE updates perioperative bariatric surgery guidelines

The AACE's document updates and consolidates recommendations first made in 2008.
Updated recommendations include new evidence and reflect current trends in metabolic surgery
Original 164 recommendations condensed into 74, including two new recommendation

The American Association of Clinical Endocrinologists (AACE) have updated their clinical guidelines for perioperative care after bariatric surgery, re-evaluating and clarifying the recommendations made in the original 2008 document.

The new document, which condenses the original 164 recommendations into 74, takes into account new evidence published after the publication of the original guidelines, and trends in bariatric surgery since 2008, such as the widespread adoption of sleeve gastrectomy.

The guidelines are co-sponsored by the AACE, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery.

“With the number of severely obese individuals on the rise and a broader range of available surgical techniques being introduced, both surgical and endoscopic, the potentially increased need for this type of surgery demands an update of clinical best practices,” said Dr Jeffrey Mechanick, AACE member and co-chair of the guidelines.

The guidelines will be published in the March/April issue of AACE’s journal, Endocrine Practice, and are available online ahead of print.

The authors say that the level of evidence that they base their recommendations on has been improved: 16.5% of the citations in the 2008 guidelines were evidence level 1 or 2 studies (randomised and non-randomised controlled trials, and meta-analyses of these), compared to 40.4% in the new edition.

Recommendations

The guidelines cover seven broad areas:

  1. Which patients should be offered bariatric surgery?

  2. Which bariatric surgical procedure should be offered?

  3. How should potential candidates for bariatric surgery be managed preoperatively?

  4. What are the elements of medical clearance for bariatric surgery?

  5. How can early postoperative care be optimised?

  6. How can optimal follow-up of bariatric surgery be achieved?

  7. What are the criteria for hospital admission after bariatric surgery?

They recommend that patients undergoing bariatric surgery should have a BMI of 40 or above, or 35 and above with one or more comorbidities. Patients with a BMI of 30-35 and diabetes or metabolic syndrome can be considered for surgery, although the authors note that the current evidence supporting this approach is relatively limited.

The guidelines recommend the use of gastric banding, sleeve gastrectomy, gastric bypass, and duodenal switch for surgery, depending on the goals of the surgery, the available surgical expertise, patient preference, and risk stratification, although the paper states that there is still insufficient evidence to generalise in favour of any particular approach. It also advises that physicians should “exercise caution” when recommending the duodenal switch, due to the associated nutritional risks.

The guidelines also include the following recommendations:

  • Before the operation, the patient should exercise preoperative glycemic control, with a “reasonable target” recommended of a HbA1c value of 6.5-7% or below, a fasting blood glucose level of 110mg/dL or below, and a two-hour postprandial blood glucose concentration of 140mg/dL or below.

  • Pregnancy should be avoided preoperatively, and 12 to 18 months post-operatively.

  • Following gastric bypass and sleeve gastrectomy, the patient should be put on a nutritional supplement course including two adult multivitamins plus mineral supplements, calcium, vitamin D and B12 as needed. Gastric banding patients should have one adult multivitamin, calcium and vitamin D.

  • Recommended follow-up depends on the procedure performed, and the severity of the patient’s comorbidities, although it recommends “frequent nutritional follow-up and/or band adjustments” for gastric banding patients, in order to maximise weight loss. It also recommends routine metabolic and nutritional monitoring.

  • The guidelines recommend hospital admission for severe malnutrition and gastrointestinal complications in clinically unstable patients. Revision is recommended when serious complications cannot be managed medically, and a reversal is recommended when the complications are unable to be managed medically and are not amenable to revision.

As well as the revised recommendations, two new recommendations have been added: firstly, that patients should be followed by their primary care physician and be given age- and risk-appropriate cancer screening before their surgery; and secondly, that copper supplementation should be given as part of the routine mineral supplements.

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