Surgery for Obesity and Related Diseases 1 (2005) 371–381 2004 ASBS Consensus Conference Consensus Conference Statement Bariatric surgery for morbid obesity: Health implications for patients, health professionals, and third-party payers Henry Buchwald, M.D., Ph.D., F.A.C.S. For the Consensus Conference Panel This Consensus Statement on the state of bariatric sur- this assessment is made with the realization that new knowl- gery for morbid obesity has been prepared by a panel of edge, recommendations, and procedures will continue to broadly based and experienced experts based on presenta- emerge through medical research. tions by investigators working in areas relevant to current The Consensus Conference was convened and this Con- questions in this field during a 1½-day public session; ques- sensus Statement was prepared to update the 1991 NIH tions and statements from conference attendees during open Consensus Statement on “Gastrointestinal Surgery for Se- discussion periods that were part of the public sessions; and vere Obesity.” closed deliberations by the panel. This statement is an in- Findings and conclusions of the Consensus Panel in- dependent report of the panel and is not a policy statement clude: of the American Society for Bariatric Surgery or any of the sponsors or endorsers of the Consensus Conference. 1. Bariatric surgery is the most effective therapy avail- Though the Consensus Conference is modeled on the format able for morbid obesity and can result in improve- used by the National Institutes of Health (NIH), the plan- ment or complete resolution of obesity comorbidi- ning, execution, and development of the conference and ties. preparation of this statement were carried out without any 2. Types of operative procedures for morbid obesity relationship with the NIH. In addition, although the Con- have increased since 1991 and are continuously ference was addressed by the Honorable Tommy Thomp- evolving; there are currently four types of proce- son, Secretary of Health and Human Services, this report is dures that can be used to achieve sustained weight not a policy statement of the federal government. loss: gastric bypass (standard, long-limb, and very This statement reflects the panel’s assessment of medical long-limb Roux), alone or in combination with ver- knowledge available at the time it was written. Knowledge tical banded gastroplasty; laparoscopic adjustable about bariatric surgery and morbid obesity is dynamic, and gastric banding; vertical banded gastroplasty; and biliopancreatic diversion and duodenal switch. 3. Both open and laparoscopic bariatric operations are This consensus statement is from the participants and in no way is an endorsement by the Journal of the American College of Surgeons or the effective therapies for morbid obesity and represent American College of Surgeons. complementary state-of-the-art procedures. Cosponsored by the American Society for Bariatric Surgery and the 4. Bariatric surgery candidates should have attempted American Society for Bariatric Surgery Foundation. to lose weight by nonoperative means, including Members of the Consensus Conference Panel are listed in the Appendix at the end of the article. self-directed dieting, nutritional counseling, and Henry Buchwald, MD, PhD, FACS provides consultative services to commercial and hospital-based weight loss pro- Ethicon Endo-Surgery, Inc., a Johnson & Johnson Company, and to Trans- grams, but should not be required to have completed neuronix, Inc. formal nonoperative obesity therapy as a precondi- Presented at the Georgetown University Conference Center, Washing- tion for the operation. ton, DC, May 2004. Correspondence address: Henry Buchwald, 420 Delaware St SE, 5. The bariatric surgery patient is best evaluated andء University of Minnesota, Mayo Mail Code 290, Minneapolis, MN 55455. subsequently cared for by a multidisciplinary team. Reprinted with permission from Buchwald H. Consensus Conference Statement: Bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. J Am Coll Surg 2005;200:593–604. 372 Reprinted with permission from H. Buchwald, J Am Coll Surg 2005;200:593–604 6. Bariatric surgery candidates should have a compre- Class II (BMI 35.0 kg/m2 to 39.9 kg/m2), and Class III hensive medical evaluation before the operation; (BMI Ն 40 kg/m2). evaluation by subspecialists (eg, cardiologists, psy- Morbid obesity is estimated to afflict 20% of the obese chiatrists, and psychologists) is not routinely needed population or over 8 million of the US population. Indeed, but should be available if indicated. the relative rise of morbid obesity over the already expo- 7. Bariatric surgery, performed only by experienced nential rise of obesity in the past 25 years can be charac- centers, should be considered in morbidly obese terized as an epidemic within an epidemic. Between 1986 adolescents. and 2000, prevalence of obesity (BMI Ն 30 kg/m2) dou- 8. Extending bariatric surgery to patients with Class I bled, morbid obesity (BMI Ն 40 kg/m2) quadrupled, and 2 obesity (body mass index [BMI] 30 to 34.9 kg/m2), super obesity (BMI Ն 50 kg/m ) increased fivefold in US who have a comorbid condition that can be cured or adults. A similar pattern of increasing degrees of obesity has markedly improved by substantial and sustained been demonstrated in the pediatric population. weight loss, may be warranted and requires addi- Obesity should be considered a chronic disease that has tional data and longterm risk and benefit analyses. serious health consequences. An expert panel convened by 9. Bariatric surgery can be cost effective before the 4th the National Heart, Lung and Blood Institute stated that, year of followup. “obesity is a complex multifactorial chronic disease that 10. Bariatric surgery offers rich opportunities for both develops from an interaction of genotype and the environ- basic and translational patient-oriented research to ment.” In 1997, the World Health Organization defined provide a better understanding of the factors in- obesity as “a disease in which excess fat is accumulated to volved in the regulation of food intake, pathophys- an extent that health may be adversely affected.” WHO has iology of obesity, metabolic and clinical effects of listed obesity as a disease condition in its International sustained weight loss, and best treatment options for Classification of Disease since 1979. In the United States, obese persons. the National Center for Health Statistics and the Centers for Medicare and Medicaid Services have assigned obesity a specific ICD-9, clinical modification code of #278.00, and There is a world epidemic of overweight, defined as a morbid obesity, #278.01. BMI Ն 25 to 29.9 kg/m2, and obesity, defined as a BMI Ն Morbid obesity is the harbinger of many other diseases 30 kg/m2, that is estimated to encompass 1.7 billion people. that affect essentially every organ system: cardiovascular According to the Worldwatch Institute, the number of over- (hypertension, atherosclerotic heart and peripheral vascular weight people is approximately equal to the number of disease with myocardial infarction and cerebral vascular underweight people in the world. accidents, peripheral venous insufficiency, thrombophlebi- Approximately two-thirds of the US population is over- tis, pulmonary embolism); respiratory (asthma, obstructive weight, and of these, about one-half are obese; one of four sleep apnea, obesity-hypoventilation syndrome); metabolic adults, or over 50 million people, in the United States are (type 2 diabetes, impaired glucose tolerance, hyperlipid- obese. Prevalence of obesity is particularly high in many emia); musculoskeletal (back strain, disc disease, weight- ethnic minority women, such as African, Mexican, Native, bearing osteoarthritis of the hips, knees, ankles, feet); gas- and Pacific Islander American women. trointestinal (cholelithiasis, gastroesophageal reflux disease, In children and adolescents, overweight is defined by nonalcoholic fatty liver disease [steatosic steatohepatitis], Ն gender- and age-specific BMI 95th percentile on growth hepatic cirrhosis, hepatic carcinoma, colorectal carcinoma); charts determined by the National Center of Health Statis- urologic (stress incontinence); endocrine and reproductive tics. In the United States, overweight tripled in children (polycystic ovary syndrome, increased risk of pregnancy between 1970 and 2000. Approximately, 15% of children and fetal abnormalities, male hypogonadism, cancer of the and adolescents (6 to 19 years old) are overweight. An endometrium, breast, ovary, prostate, pancreas); dermato- estimated 250,000 children and adolescents have a BMI Ն logic (intertriginous dermatitis); neurologic (pseudotumor 95th percentile. Overweight children and adolescents have a cerebri, carpal tunnel syndrome); and psychologic (depres- higher risk of becoming obese adults. sion, eating disorders, body image disturbance). Nearly Morbid obesity, also referred to as “clinically severe 30% of overweight adolescents in the United States meet obesity” or “extreme obesity,” was defined as the criteria for the criteria for metabolic syndrome, which increases risk of bariatric surgery by the 1991 NIH Consensus Conference type 2 diabetes and coronary heart disease. Statement on Gastrointestinal Surgery for Severe Obesity as The impact of obesity on longevity has been well docu- aBMIՆ 40 kg/m2 oraBMIՆ 35 kg/m2 in the presence of mented. In the world, over 2.5 million deaths annually can high-risk comorbid conditions.