Clinical Practice Guidelines for the Cosponsored by ...

1 Clinical Practice Guidelines for thePerioperative Nutritional, Metabolic, andNonsurgical Support of the BariatricSurgery Patient 2013 Update: Cosponsored by american association ofClinical Endocrinologists, The ObesitySociety, and american Society forMetabolic & bariatric Surgery*Jeffrey I. Mechanick, , Adrienne Youdim, , Daniel B. Jones, , , W. Timothy Garvey, ,Daniel L. Hurley, , M. Molly McMahon, , Leslie J. Heinberg, , Robert Kushner, ,Ted D. Adams, , , Scott Shikora, , John B. Dixon, , Stacy Brethauer, :The development of these updated Guidelines was commissioned by the AACE, TOS, andASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production ofclinical Practice Guidelines (CPG).

2 Each recommendation was re-evaluated and updated based on theevidence and subjective factors per protocol. Examples of expanded topics in this update include: theroles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery forpatients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164original recommendations in 2008. There are 403 citations, of which 33 ( ) are EL 1, 131 ( ) areEL 2, 170 ( ) are EL 3, and 69 ( ) are EL 4.

3 There is a relatively high proportion ( ) ofstrong (EL 1 and 2) studies, compared with only in the 2008 AACE-TOS-ASMBS CPG. Theseupdated Guidelines reflect recent additions to the evidence base. bariatric surgery remains a safe and1Co-Chair, Icahn School of Medicine at Mount Sinai, New York, New York. Correspondence: Cedars Sinai MedicalCenter, Los Angeles, California;3Co-Chair, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts;4 Primary Writer, AACE,University of Alabama at Birmingham, Birmingham VA Medical Center, Birmingham, Alabama;5 Primary Writer AACE, Division of Endocrinology, Diabetes,Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota;6 Primary Writer TOS, Cleveland Clinic Lerner College of Medicine, BMI Director ofBehavioral Services, Cleveland, Ohio.

4 7 Primary Writer TOS, Northwestern University, Feinberg School of Medicine, Chicago, Illinois;8 Primary Writer TOS,Health & Fitness Institute, Intermountain Healthcare and Cardiovascular Genetics Division, University of Utah School of Medicine, Salt Lake City,Utah;9 Primary Writer ASMBS, Harvard Medical School, Center for Metabolic Health and bariatric Surgery, Brigham and Women s Hospital, Boston, Massachusetts;10 Primary Writer ASMBS, Professor and Head of Clinical Obesity Research, Baker IDI Heart and Diabetes Institute, Melbourne, Australia;11 Primary WriterASMBS, Cleveland Clinic Lerner College of Medicine, bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio*These Guidelines are endorsed by the European association for the Study of Obesity (EASO), International association for the Study of Obesity (IASO), InternationalSociety for the Perioperative Care of the Obese Patient (ISPCOP), Society american Gastrointestinal Endoscopic Surgeons (SAGES), american College of Surgery (ACS),and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO).

5 By mutual agreement among the authors and editors of their respective journals, this work is being published jointly inSurgery for Obesity and Related Diseases2013;doi: ,Obesity2013; doi: andEndocrine Practice2013; :AACE, american association of Clinical Endocrinologists; ACS, american College of Surgery; ASMBS, american association of Metabolic and BariatricSurgery; BAC, blood alcohol content; BED, binge eating disorder; BEL, best evidence level; BMI, body mass index; BPD-DS, biliopancreatic diversionwith duodenalswitch; CCS, Clinical case series; CK, creatine kinase; CPAP, continuous positive airway pressure; CPG, Clinical Practice Guidelines ; CSS, cross-sectional study; CT,computerized tomography; CVD, cardiovascular disease; DCCP, diabetes comprehensive care plan; DVT, deep venous thrombosis; DXA, dual-energy x-rayabsorptiometry; EL, evidence level; EN, enteral nutrition; FDA, Food and Drug Administration; GERD, gastrointestinal reflux disease; HDL, high-density lipoprotein;ICU, intensive care unit; LABS, longitudinal assessment of bariatric surgery.

6 LAGB, laparoscopic adjustable gastric band; LDL, low-density lipoprotein; LSG, laparoscopicsleeve gastrectomy; MI, myocardial infarction; MNRCT, meta-analysis of nonrandomized controlled trials; MRCT, meta-analysis of randomized controlled trials; NAFLD,nonalcoholic fatty liver disease; NASH, nonalcoholic steatohepatitis; NE, no evidence; NIH, National Institutes of Health; OHS, obesity hypoventilation syndrome; OSA,obstructive sleep apnea; OS-MRS, obesity surgery mortality risk score; PTH, parathyroid hormone; PCOS, polycystic ovary syndrome; PCS, prospective cohort study; PE,pulmonary embolism; PN, parenteral nutrition; PPI, proton pump inhibitor; RCT, randomized controlled trial; RML, rhabdomyolysis; RYGB, Roux-en-Y gastric bypass; SCR,single case report; SG, sleeve gastrectomy; SOS, Swedish Obesity Subjects; SS, surveillance survey; T2D, type 2 diabetes mellitus; TOS, The ObesitySociety; TSH,thyroid-stimulating hormone; UGI, upper gastrointestinal; VTE, venous :23 December 2012 Accepted:27 December 2012 Published online 26 March 2013.

7 |VOLUME 21 | NUMBER S1 | MARCH 2013S1 AACE/TOS/ASMBS GuidelinesObesityeffective intervention for select patients with obesity. A team approach to perioperative care is mandatorywith special attention to nutritional and metabolic : bariatric surgery; Obesity; Metabolic surgery; Diabetes surgery; Metabolic syndrome; Clinical practiceguidelines; Best Practice Guidelines ; Weight loss surgeryObesity(2013)21, S1-S27. continues to be a major public health problem in the UnitedStates, with more than one third of adults considered obese in 2009-2010, as defined by a body mass index (BMI) 30 kg/m2(1 [EL 3,SS]).

8 Obesity has been associated with an increased hazard ratio forall-cause mortality (2 [EL 3, SS]), as well as significant medical andpsychological co-morbidity. Indeed, obesity is not only a chronicmedical condition but should be regarded as a bona fide diseasestate (3 [EL 4, NE]). Nonsurgical management can effectivelyinduce 5%-10% weight loss and improve health in severely obeseindividuals (4 [EL 1, RCT]) resulting in cardiometabolic surgery procedures are indicated for patients with clinicallysevere obesity.

9 Currently, these procedures are the most successfuland durable treatment for obesity. Furthermore, although overallobesity rates and bariatric surgery procedures have plateaued in theUnited States, rates of severe obesity are still increasing and nowthere are approximately 15 million people in the United States witha BMI 40 kg/m2(1 [EL 3, SS]; 5 [EL 3, SS]). Only 1% of theclinically eligible population receives surgical treatment for obesity(6 [EL 3, SS]). Given the potentially increased need for bariatricsurgery as a treatment for obesity, it is apparent that Clinical practiceguidelines (CPG) on the subject keep pace and are kept the 2008 TOS/ASMBS/AACE CPG for the perioperativenutritional, metabolic, and nonsurgical support of the bariatric sur-gery patient (7 [EL 4; CPG]), significant data have emerged regard-ing a broader range of available surgeries for the treatment of obe-sity.

10 A PubMed computerized literature search (performed onDecember 15, 2012) using the search term bariatric surgery reveals a total of 14,287 publications with approximately 6800 cita-tions from 2008 to 2012. Updated CPG are therefore needed toguide clinicians in the care of the bariatric surgery are the salient advances in bariatric surgery since 2008? Thesleeve gastrectomy (SG; laparoscopic SG [LSG]) has demonstratedbenefits comparable to other bariatric procedures and is no longerconsidered investigational (8 [EL 4, NE]).