Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Bariatric operations for management of obesity: Indications and preoperative preparation

Robert B Lim, MD, FACS, COL, MC, USA
Section Editor
Daniel Jones, MD
Deputy Editor
Wenliang Chen, MD, PhD


Obesity, defined as a body mass index (BMI) ≥30 kg/m2 [1,2], is a chronic illness identified in children, adolescents, and adults worldwide [3-6]. According to the World Health Organization, worldwide there are approximately 500 million obese adults and 42 million obese children under the age of five years [7]. In the United States, 35 percent of adults (roughly 100 million people) and 17 percent of children are obese [8].

The surgical procedures performed to manage obesity are collectively referred to as metabolic or "bariatric" surgery (from the Greek words "baros" meaning "weight" and "iatrikos" meaning "medicine"). This topic will discuss the indications and contraindications for a bariatric surgical procedure as well as the optimal preoperative preparation in a multidisciplinary setting. A description of the types of bariatric procedures, as well as the complications and outcomes, is found in separate topics.

(See "Bariatric procedures for the management of severe obesity: Descriptions".)

(See "Late complications of bariatric surgical operations".)

(See "Medical outcomes following bariatric surgery".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Sep 2017. | This topic last updated: Feb 15, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults--The Evidence Report. National Institutes of Health. Obes Res 1998; 6 Suppl 2:51S.
  2. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000; 894:i.
  3. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. www.cdc.gov/obesity/data/trends.html (Accessed on January 28, 2010).
  4. Peeters A, Barendregt JJ, Willekens F, et al. Obesity in adulthood and its consequences for life expectancy: a life-table analysis. Ann Intern Med 2003; 138:24.
  5. Vlad I. Obesity costs UK economy 2bn pounds sterling a year. BMJ 2003; 327:1308.
  6. Duda RB, Darko R, Adanu RMK, et al. Prevalence of Obesity in an Urban West African Population: Results of the Women’s Health Study of Accra. African J Health Sciences 2007; 14:154.
  7. http://www.who.int/mediacentre/factsheets/fs311/en/ (Accessed on January 12, 2015).
  8. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014; 311:806.
  9. Arterburn DE, Olsen MK, Smith VA, et al. Association between bariatric surgery and long-term survival. JAMA 2015; 313:62.
  10. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013; 23:427.
  11. Ludwig DS, Pollack HA. Obesity and the economy: from crisis to opportunity. JAMA 2009; 301:533.
  12. Frezza EE, Wachtel MS, Ewing BT. The impact of morbid obesity on the state economy: an initial evaluation. Surg Obes Relat Dis 2006; 2:504.
  13. Cawley J, Meyerhoefer C. The medical care costs of obesity: an instrumental variables approach. J Health Econ 2012; 31:219.
  14. Singh RB, Pella D, Mechirova V, et al. Prevalence of obesity, physical inactivity and undernutrition, a triple burden of diseases during transition in a developing economy. The Five City Study Group. Acta Cardiol 2007; 62:119.
  15. NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann Intern Med 1991; 115:956.
  16. Burguera B, Agusti A, Arner P, et al. Critical assessment of the current guidelines for the management and treatment of morbidly obese patients. J Endocrinol Invest 2007; 30:844.
  17. Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring) 2013; 21 Suppl 1:S1.
  18. Pontiroli AE, Morabito A. Long-term prevention of mortality in morbid obesity through bariatric surgery. a systematic review and meta-analysis of trials performed with gastric banding and gastric bypass. Ann Surg 2011; 253:484.
  19. Buchwald H, Rudser KD, Williams SE, et al. Overall mortality, incremental life expectancy, and cause of death at 25 years in the program on the surgical control of the hyperlipidemias. Ann Surg 2010; 251:1034.
  20. Padwal R, Klarenbach S, Wiebe N, et al. Bariatric surgery: a systematic review and network meta-analysis of randomized trials. Obes Rev 2011; 12:602.
  21. Garb J, Welch G, Zagarins S, et al. Bariatric surgery for the treatment of morbid obesity: a meta-analysis of weight loss outcomes for laparoscopic adjustable gastric banding and laparoscopic gastric bypass. Obes Surg 2009; 19:1447.
  22. Valezi AC, Mali Junior J, de Menezes MA, et al. Weight loss outcome after silastic ring Roux-en-Y gastric bypass: 8 years of follow-up. Obes Surg 2010; 20:1491.
  23. Toouli J, Kow L, Ramos AC, et al. International multicenter study of safety and effectiveness of Swedish Adjustable Gastric Band in 1-, 3-, and 5-year follow-up cohorts. Surg Obes Relat Dis 2009; 5:598.
  24. Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med 2009; 122:248.
  25. Hofsø D, Nordstrand N, Johnson LK, et al. Obesity-related cardiovascular risk factors after weight loss: a clinical trial comparing gastric bypass surgery and intensive lifestyle intervention. Eur J Endocrinol 2010; 163:735.
  26. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012; 366:1567.
  27. Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med 2012; 366:1577.
  28. Hofsø D, Jenssen T, Bollerslev J, et al. Beta cell function after weight loss: a clinical trial comparing gastric bypass surgery and intensive lifestyle intervention. Eur J Endocrinol 2011; 164:231.
  29. O'Brien PE, Dixon JB, Laurie C, et al. Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: a randomized trial. Ann Intern Med 2006; 144:625.
  30. Sultan S, Parikh M, Youn H, et al. Early U.S. outcomes after laparoscopic adjustable gastric banding in patients with a body mass index less than 35 kg/m2. Surg Endosc 2009; 23:1569.
  31. Parikh M, Duncombe J, Fielding GA. Laparoscopic adjustable gastric banding for patients with body mass index of <or=35 kg/m2. Surg Obes Relat Dis 2006; 2:518.
  32. Dixon JB, O'Brien PE, Playfair J, et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA 2008; 299:316.
  33. Lee WJ, Chong K, Ser KH, et al. Gastric bypass vs sleeve gastrectomy for type 2 diabetes mellitus: a randomized controlled trial. Arch Surg 2011; 146:143.
  34. Lee WJ, Wang W, Lee YC, et al. Effect of laparoscopic mini-gastric bypass for type 2 diabetes mellitus: comparison of BMI>35 and <35 kg/m2. J Gastrointest Surg 2008; 12:945.
  35. Cohen RV, Pinheiro JC, Schiavon CA, et al. Effects of gastric bypass surgery in patients with type 2 diabetes and only mild obesity. Diabetes Care 2012; 35:1420.
  36. Choi J, Digiorgi M, Milone L, et al. Outcomes of laparoscopic adjustable gastric banding in patients with low body mass index. Surg Obes Relat Dis 2010; 6:367.
  37. Fried M, Ribaric G, Buchwald JN, et al. Metabolic surgery for the treatment of type 2 diabetes in patients with BMI <35 kg/m2: an integrative review of early studies. Obes Surg 2010; 20:776.
  38. Lee WJ, Chong K, Chen CY, et al. Diabetes remission and insulin secretion after gastric bypass in patients with body mass index <35 kg/m2. Obes Surg 2011; 21:889.
  39. Demaria EJ, Winegar DA, Pate VW, et al. Early postoperative outcomes of metabolic surgery to treat diabetes from sites participating in the ASMBS bariatric surgery center of excellence program as reported in the Bariatric Outcomes Longitudinal Database. Ann Surg 2010; 252:559.
  40. Lee WJ, Ser KH, Chong K, et al. Laparoscopic sleeve gastrectomy for diabetes treatment in nonmorbidly obese patients: efficacy and change of insulin secretion. Surgery 2010; 147:664.
  41. Geloneze B, Geloneze SR, Fiori C, et al. Surgery for nonobese type 2 diabetic patients: an interventional study with duodenal-jejunal exclusion. Obes Surg 2009; 19:1077.
  42. Ramos AC, Galvão Neto MP, de Souza YM, et al. Laparoscopic duodenal-jejunal exclusion in the treatment of type 2 diabetes mellitus in patients with BMI<30 kg/m2 (LBMI). Obes Surg 2009; 19:307.
  43. Li Q, Chen L, Yang Z, et al. Metabolic effects of bariatric surgery in type 2 diabetic patients with body mass index < 35 kg/m2. Diabetes Obes Metab 2012; 14:262.
  44. Huang CK, Shabbir A, Lo CH, et al. Laparoscopic Roux-en-Y gastric bypass for the treatment of type II diabetes mellitus in Chinese patients with body mass index of 25-35. Obes Surg 2011; 21:1344.
  45. Shah SS, Todkar JS, Shah PS, Cummings DE. Diabetes remission and reduced cardiovascular risk after gastric bypass in Asian Indians with body mass index <35 kg/m(2). Surg Obes Relat Dis 2010; 6:332.
  46. Wee CC, Pratt JS, Fanelli R, et al. Best practice updates for informed consent and patient education in weight loss surgery. Obesity (Silver Spring) 2009; 17:885.
  47. Rubino F, Nathan DM, Eckel RH, et al. Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. Surg Obes Relat Dis 2016; 12:1144.
  48. Brito JP, Montori VM, Davis AM. Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. JAMA 2017; 317:635.
  49. Hsu WC, Araneta MR, Kanaya AM, et al. BMI cut points to identify at-risk Asian Americans for type 2 diabetes screening. Diabetes Care 2015; 38:150.
  50. Yermilov I, McGory ML, Shekelle PW, et al. Appropriateness criteria for bariatric surgery: beyond the NIH guidelines. Obesity (Silver Spring) 2009; 17:1521.
  51. asmbs.org/2012/06/pre-surgical-psychological-assessment/#sthash.94cACW9F.dpuf (Accessed on October 21, 2013).
  52. LeMont D, Moorehead MK, Parish MS, Reto CS, Ritz SJ. Suggestions for the pre-surgical psychological assessment of bariatric surgery candidates. American Society for Bariatric Surgery. October 2004. s3.amazonaws.com/publicASMBS/GuidelinesStatements/Guidelines/PsychPreSurgicalAssessment.pdf (Accessed on October 21, 2013).
  53. Nepomnayshy D, Hesham W, Erickson B, et al. Sleep apnea: is routine preoperative screening necessary? Obes Surg 2013; 23:287.
  54. de Luis DA, Pacheco D, Izaola O, et al. Micronutrient status in morbidly obese women before bariatric surgery. Surg Obes Relat Dis 2013; 9:323.
  55. Hoogwerf BJ. Perioperative management of diabetes mellitus: how should we act on the limited evidence? Cleve Clin J Med 2006; 73 Suppl 1:S95.
  56. Underwood P, Askari R, Hurwitz S, et al. Preoperative A1C and clinical outcomes in patients with diabetes undergoing major noncardiac surgical procedures. Diabetes Care 2014; 37:611.