Interpretation of the 2022 ASMBS/IFSO Guidelines for Bariatric and Metabolic Surgery Indications

doi:10.3877/cma.j.issn.2095-9605.2023.04.001

Abstract

Abstract:

With the passage of time and the emergence of a wealth of clinical research evidence, the new guidelines jointly released by ASMBS and IFSO in 2022 have made substantial updates to the 1991 NIH consensus across multiple aspects. The revised guidelines have lowered the BMI threshold for bariatric surgery, aiming to encourage a greater number of patients to consider undergoing the procedure. The predominant surgical approaches include laparoscopic minimally invasive procedures, sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB). Furthermore, the updated guidelines underscore the safety and effectiveness of these surgeries, confirming their ability to reduce overall mortality rates and mitigate cardiovascular and cancer risks. Age is no longer a limiting factor, as both elderly individuals and the pediatric/adolescent populations are now eligible candidates for weight loss surgery. Revisional procedures are also mentioned in the article, along with the application of weight loss surgery as a preparatory measure prior to other surgical treatments. This paper summarizes the key updates of the latest guidelines.

Key words: ASMBS, IFSO, Metabolic and bariatric surgery, Sleeve gastrectomy, Roux-en-Y gastric bypass, Indications, Guidelines

Zhiyong Dong, Cunchuan Wang. Interpretation of the 2022 ASMBS/IFSO Guidelines for Bariatric and Metabolic Surgery Indications[J]. Chinese Journal of Obesity and Metabolic Diseases(Electronic Edition), 2023, 09(04): 225-230.

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References 40

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	"1991年共识"^[1]	"2022年指南"^[2]	第9版人卫教科书^[4]	2019版中国减重手术指南^[5]	2020版中国糖尿病治疗指南^[6,7]
BMI	BMI超过40 kg/m²的重度肥胖患者，可进行手术	BMI≥35 kg/m²建议手术	BMI≥35 kg/m²的建议手术	BMI≥37.5 kg/m²或BMI≥32.5 kg/m²合并2型糖尿病的建议手术	BMI≥32.5 kg/m²，有或无合并症的2型糖尿病，可行手术
	35 kg/m²≤BMI<40 kg/m²且的合并严重的心肺疾病（严重睡眠呼吸暂停，肥胖通气不足综合征，或严重糖尿病），可考虑手术	30 kg/m²≤BMI<35 kg/m²合并代谢疾病，应考虑手术，亚洲人群BMI≥27.5 kg/m²合并代谢疾病应考虑手术	27.5 kg/m²≤BMI<35 kg/m²合并2型糖尿病血糖控制不佳或两种以上的代谢疾病的考虑手术	BMI≥27.5 kg/m²合并2型糖尿病代谢疾病应考虑考虑；中心性肥胖的可提高手术推荐级别	27.5 kg/m²≤BMI<32.5 kg/m²且合并2型糖尿病，尤其存在其他心血管风险因素时，可慎重选择手术经生活方式干预和各种药物治疗难以控制的2型糖尿病[糖化血红蛋白（glycated hemoglobin A1c，HbA1c）>7.0%]或伴发疾病应考虑手术
年龄	儿童和青少年即使BMI>40 kg/m²也不建议手术	适当筛选后的儿童/青少年应考虑手术	建议18~55岁	16~65岁	18~60岁

	"1991年共识"^[1]	"2022年指南"^[2]	第9版人卫教科书^[4]	2019版中国减重手术指南^[5]	2020版中国糖尿病治疗指南^[6,7]
BMI	BMI超过40 kg/m²的重度肥胖患者，可进行手术	BMI≥35 kg/m²建议手术	BMI≥35 kg/m²的建议手术	BMI≥37.5 kg/m²或BMI≥32.5 kg/m²合并2型糖尿病的建议手术	BMI≥32.5 kg/m²，有或无合并症的2型糖尿病，可行手术
	35 kg/m²≤BMI<40 kg/m²且的合并严重的心肺疾病（严重睡眠呼吸暂停，肥胖通气不足综合征，或严重糖尿病），可考虑手术	30 kg/m²≤BMI<35 kg/m²合并代谢疾病，应考虑手术，亚洲人群BMI≥27.5 kg/m²合并代谢疾病应考虑手术	27.5 kg/m²≤BMI<35 kg/m²合并2型糖尿病血糖控制不佳或两种以上的代谢疾病的考虑手术	BMI≥27.5 kg/m²合并2型糖尿病代谢疾病应考虑考虑；中心性肥胖的可提高手术推荐级别	27.5 kg/m²≤BMI<32.5 kg/m²且合并2型糖尿病，尤其存在其他心血管风险因素时，可慎重选择手术经生活方式干预和各种药物治疗难以控制的2型糖尿病[糖化血红蛋白（glycated hemoglobin A1c，HbA1c）>7.0%]或伴发疾病应考虑手术
年龄	儿童和青少年即使BMI>40 kg/m²也不建议手术	适当筛选后的儿童/青少年应考虑手术	建议18~55岁	16~65岁	18~60岁

更新要点	项目	主要内容
1. BMI	≥35 kg/m²	BMI≥35 kg/m²有无2型糖尿病或其他代谢疾病，建议进行减重与代谢手术
	30-34.9 kg/m²	合并代谢疾病，应考虑减重与代谢手术
	27.5-32.5 kg/m²	亚洲人群BMI≥27.5 kg/m²合并代谢疾病应考虑减重与代谢手术
2.年龄	老年人	没有明确的年龄限制，根据临床实际情况来评估。
	儿童青少年	不再考虑年龄，而应该根据实际情况来评估权衡利弊
3.桥接方案	关节置换术	术前施行减重手术可以缩短手术、住院时间并减少术后早期并发症。严重肥胖——技术挑战，增加伤口感染和深静脉血栓形成风险
	腹壁疝修补术	严重肥胖需要修补的腹壁疝患者，首先应减重手术减轻体重，从而降低与疝修补术相关的并发症发生率并增加修补的持久性。
	器官移植	患有肥胖症和终末期肺病的患者在减重手术后可能会因减重达标从而被列入移植名单
4.高危患者	肝硬化	肥胖和代偿期肝硬化患者减重手术后的围手术期死亡风险更高，但风险仍然很小（<1%），获益显著
	心力衰竭	接受减重手术可以显著改善左心室射血分数（LVEF）、心脏功能能力，并增加接受心脏移植的机会
		多学科团队对患者进行围手术期管理可能会降低并发症的发生率
5.患者评估	体重减轻和合并症改善	术前减重：这种做法被认为有歧视性、主观的且没有科学根据，会导致患者流失、延误治疗以及导致合并症进展，甚至危及生命术前需纠正微量营养素缺乏症。术前需进行营养教育管理食物不耐受、吸收不良、微量营养素缺乏以及体重反弹的术后患者术前评估过程旨在优化手术结果并加以干预，以解决饮食失调、严重不受控制的精神疾病或活性物质滥用等问题
6.主要结局指标	癌症风险	减重术后癌症的风险降低
	死亡率	证实了减重手术能降低肥胖患者的总体死亡率，或者延长预期寿命
	修正手术	患者在初次手术后接受修正手术可进一步减重、减少合并症和死亡率，使并发症发生率降低至可接受水平

更新要点	项目	主要内容
1. BMI	≥35 kg/m²	BMI≥35 kg/m²有无2型糖尿病或其他代谢疾病，建议进行减重与代谢手术
	30-34.9 kg/m²	合并代谢疾病，应考虑减重与代谢手术
	27.5-32.5 kg/m²	亚洲人群BMI≥27.5 kg/m²合并代谢疾病应考虑减重与代谢手术
2.年龄	老年人	没有明确的年龄限制，根据临床实际情况来评估。
	儿童青少年	不再考虑年龄，而应该根据实际情况来评估权衡利弊
3.桥接方案	关节置换术	术前施行减重手术可以缩短手术、住院时间并减少术后早期并发症。严重肥胖——技术挑战，增加伤口感染和深静脉血栓形成风险
	腹壁疝修补术	严重肥胖需要修补的腹壁疝患者，首先应减重手术减轻体重，从而降低与疝修补术相关的并发症发生率并增加修补的持久性。
	器官移植	患有肥胖症和终末期肺病的患者在减重手术后可能会因减重达标从而被列入移植名单
4.高危患者	肝硬化	肥胖和代偿期肝硬化患者减重手术后的围手术期死亡风险更高，但风险仍然很小（<1%），获益显著
	心力衰竭	接受减重手术可以显著改善左心室射血分数（LVEF）、心脏功能能力，并增加接受心脏移植的机会
		多学科团队对患者进行围手术期管理可能会降低并发症的发生率
5.患者评估	体重减轻和合并症改善	术前减重：这种做法被认为有歧视性、主观的且没有科学根据，会导致患者流失、延误治疗以及导致合并症进展，甚至危及生命术前需纠正微量营养素缺乏症。术前需进行营养教育管理食物不耐受、吸收不良、微量营养素缺乏以及体重反弹的术后患者术前评估过程旨在优化手术结果并加以干预，以解决饮食失调、严重不受控制的精神疾病或活性物质滥用等问题
6.主要结局指标	癌症风险	减重术后癌症的风险降低
	死亡率	证实了减重手术能降低肥胖患者的总体死亡率，或者延长预期寿命
	修正手术	患者在初次手术后接受修正手术可进一步减重、减少合并症和死亡率，使并发症发生率降低至可接受水平

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