WHAT ARE THE CURRENT TRENDS IN OBESITY SURGERY?

Clinical practice guidelines of the EAES on bariatric surgery: update 2020 endorsed by IFSO‑EC, EASO and ESPCOP

-Black Sentences: STRONG recommendation for the intervention or the comparator

-Purple Sentences: CONDITIONAL recommendation for the intervention or the comparator

-Orange Sentences: POSITION STATEMENT reflect the opinion of the panel, are not necessarily based upon research evidence and should not be considered formal, evidence-based recommendations

Indication for Bariatric Surgery

Laparoscopic bariatric surgery should be considered for patients with BMI ≥ 40 kg/m2 and for patients with BMI ≥ 35–40 kg/m2 with associated comorbidities that are expected to improve with weight loss.

Laparoscopic bariatric/metabolic surgery should be considered for patients with ≥ BMI 30–35 kg/m2 and type 2 diabetes and/or arterial hypertension with poor control despite optimal medical therapy.

Preoperative work-up

No recommendation can be made for either routine H. pylori eradicationor no eradication prior to bariatric surgery on the basis of available evidence.

Preoperative dietitian consultation should be considered for patients undergoing bariatric surgery

Esophagogastroscopy can be considered as a routine diagnostic test prior to bariatric surgery.

Psychological evaluation can be considered before bariatric surgery. A previous diagnosis of binge eating or depression may not be considered as an absolute contraindication to surgery.

Perioperative Management

Screening for obstructive sleep apnea using the STOP-BANG criteria can be considered prior to bariatric surgery.

Perioperative CPAP should be considered in patients with severe obstructive sleep apnea syndrome who are undergoing bariatric surgery.

No recommendation can be made on the dose and duration of pharmacological thromboprophylaxis in patients after bariatric surgery.

Inferior vena cava filter is not recommended for thromboprophylaxis in patients undergoing bariatric surgery.

No recommendation for either an ERAS protocol or standard care can be made on the basis of available evidence

Perioperative multimodal analgesia with minimal opioid usage may be considered in patients undergoing bariatric surgery.

Non-Bypass Procedures

Adjustable gastric banding surgeries are associated with a high rate of reoperations for complications or conversion to another bariatric procedure for insufficient weight loss in the long term.

Sleeve gastrectomy may be preferred over adjustable gastric banding for weight loss and control/resolution of metabolic comorbidities

Sleeve gastrectomy may offer improved short-term weight loss and resolution of type 2 diabetes compared to gastric plication. No significant differences are observed at mid-term. Long-term comparative data on weight loss and metabolic effects are, however, lacking.

There is insufficient evidence to recommend routine stapler line reinforcementa to reduce the leak rate

Staple line reinforcement in sleeve gastrectomy should be considered to reduce the risk of perioperative complications.

A bougie size < 36F compared to a bougie sized ≥ 36F may be recommended for calibration in sleeve gastrectomy as it is associated with greater weight loss in the mid-term.

More extensive antral resection (2–3 cm from the pylorus versus > 5 cm antral preservation) potentially offers greater weight loss in the short term without a significant increase in post-operative complications. Long term data are, however, lacking.

Bypass Procedures

RYGB should be preferred over adjustable gastric banding.

RYGB results in greater weight loss and control/remission of insulin resistance and type 2 diabetes compared to gastric plication.

RYGB offers similar mid-term weight loss and control/remission of metabolic comorbidities compared to sleeve gastrectomy. Longterm comparative data are, however, lacking.

RYGB can be preferred over sleeve gastrectomy in patients with severe gastroesophageal reflux disease and/or severe esophagitis.

No recommendation for either BPD/DS or sleeve gastrectomy can be made on the basis of available comparative evidence

With regard to mid-term weight loss there is no difference between BPD/DS and RYGB. BPD/DS is superior to RYGB for control/remission of type 2 diabetes. Long-term comparative data are, however, lacking

One Anastomosis Procedures

OAGB may offer greater short-term weight loss compared to RYGB, gastric plication, adjustable gastric banding and sleeve gastrectomy. Long-term comparative data are, however, lacking. The effect on nutritional deficiencies remains controversial

No recommendation on SADI-S compared with OAGB, BPD/DS, RYGB or sleeve gastrectomy can be made on the basis of available evidence.

Revisional Surgery

No evidence-based criteria for indication to revisional bariatric/metabolic surgery are available to date

The panel advises that the clinical decision to proceed to revisional bariatric/metabolic surgery be based on a complete multidisciplinary assessment of the patient, as recommended for the primary procedure

Postoperative Care

Scheduled multidisciplinary post-operative follow-up should be providedto every patient undergoing bariatric/metabolic surgery.

Treatment with ursodeoxycholic acid could be considered during theweight loss phase to prevent gallstones formation.

Micro and/or macronutrients supplementation is recommended afterbariatric surgery according to the type of the procedure and to the deficiencies documented during the follow-up.

PPI therapy should be given to patients undergoing bypass procedures for the prevention of marginal ulcers.

Postoperative nutritional and behavioral advice should be provided to patients undergoing bariatric surgery.

Pregnancy following bariatric surgery should be delayed during the weight loss phase

Investigational Procedures

For duodenal-jejunal bypass sleeves, aspiration devices, gastric electrical stimulation, vagal blockade and duodenal mucosal resurfacing, the quality of evidence was too low to provide any recommendations.

Endoluminal suturing procedures may have a role in the treatment of patients with obesity with BMI < 40 kg/m2

Position statements do not constitute recommendations. BMI body mass index, CPAP continuous positive airway pressure, ERAS Enhanced recovery after surgery, BPD/DS biliopancreatic diversion with duodenal switch, OAGB one anastomosis gastric bypass, SADIS single-anastomosis duodeno-ileal switch, PPI proton-pump inhibitor

Surgical Endoscopy (2020) 34:2332–2358 2339