Appropriate candidates for weight-loss surgical procedures?

In general, the indications for surgical treatment established by the 1991 National Institutes of Health Consensus Development Conference Panel include a BMI greater than 40 or a BMI greater than 35 in combination with life-threatening cardiopulmonary problems or severe diabetes mellitus. Nonetheless, strict absolute weight determinants should serve only as an overall guide, especially in regard to third-party payers. For instance, few thoughtful physicians would argue that a 40-year-old man with hypertension, type II diabetes mellitus, severe degenerative joint disease in his knees and lower back area, and sleep apnea who has a BMI of only 33 does not have morbid obesity. Thus, all patients with severe, direct weight-related morbidity may be considered, but each patient should be considered individually.

For some patients who have a history of failed conservative treatments and a BMI of approximately 35, a trial of pharmacologic appetite suppression might be the next reasonable choice, especially if the weight-related morbidity is not severe. Substantial and prolonged weight loss (greater than 50% of excess body weight), however, would be distinctly unusual with this approach, and thus this type of regimen should not be expected to be successful in most patients with morbid obesity and severe comorbidities due to weight.

The overall guidelines should be as follows. Patients who fulfill the absolute weight criteria and have active weight-related morbidity or younger obese subjects (older than 20 years of age) who have a family history of weight-related morbidity but who have not yet experienced any complications should be considered preliminary candidates. Chronologic age, previous abdominal operations, or previous bariatric procedures that are functionally ineffective are not necessarily contraindications. In contrast, active substance abuse and psychiatric disorders (for example, schizophrenia, borderline personality disorder, active suicidal ideation, or uncontrolled depression) should be considered absolute contraindications.