Advances in preoperative medical management of metabolic surgery
SHAN Yingyi,, YU Haoyong,
Department of Endocrinology and Metabolism, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine; Shanghai Clinical Medical Center of Diabetes; Shanghai Clinical Center for Metabolic Disease; Shanghai Key Laboratory of Diabetes, Shanghai 200233, China
Obesity is a chronic metabolic disease that is increasing in prevalence and has become a major public health problem and epidemic in many countries, including China. Obesity and its associated complications, such as type 2 diabetes (T2DM), non-alcoholic fatty liver disease, hypertension, and cardiovascular disease, seriously damage health. With the continuous development of metabolic surgery, it has become a widely used, safe and effective method for treating obesity and its associated complications. Metabolic surgery can significantly lose weight, improve metabolic indicators, reduce the risk of chronic diseases such as diabetes and hypertension, improve the quality of life of patients, and bring comprehensive health benefits to patients. However, there is currently a lack of standardized preoperative medical management for metabolic surgery, which may lead to metabolic disorders, nutrient deficiencies, and other complications, increasing the risk of surgery and postoperative complications, and affecting the efficacy of weight loss and the prognosis of patients. Through the systematic review of literature related to preoperative weight loss, glycemic control, blood pressure and lipid control, micronutrient supplementation, and psychological and behavioral modifications, this paper reviews preoperative medical management of metabolic surgery with the aim of providing reference for effectively improving the safety and efficacy of metabolic surgery and improving the prognosis of patients.
Keywords：metabolic surgery
;
obesity
;
diabetes
;
medical management
SHAN Yingyi, YU Haoyong. Advances in preoperative medical management of metabolic surgery. Journal of Shanghai Jiao Tong University (Medical Science)[J], 2023, 43(10): 1332-1338 doi:10.3969/j.issn.1674-8115.2023.10.016
肥胖是体内脂肪堆积过多导致的一种慢性代谢性疾病，通常伴随着其他疾病，例如2型糖尿病（type 2 diabetes mellitus，T2DM）、非酒精性脂肪肝、高血压、心血管疾病和睡眠呼吸暂停等，严重危害身体健康。目前肥胖人数日益增多。据世界卫生组织统计，2021年全球肥胖人数比1975年增加了近2倍［1］。中国成人平均体质量指数（body mass index，BMI）和肥胖率从20世纪80年代初期开始持续增长，其中平均BMI从2004年的22.7 kg/m2上升到2018年的24.4 kg/m2［2］。肥胖已成为包括中国在内的许多国家的流行病。因此，及时干预治疗肥胖是十分有必要的。
随着腹腔镜技术的发展，代谢手术在临床上得到了广泛的应用。2018年全球代谢手术总数接近70万例［7］，而在中国，2010—2015年期间代谢手术的数量相比于2001—2005年期间增加了148.7倍［8］。代谢手术带来的积极效果使得BMI下限不断降低。美国减重代谢外科学会（American Society for Metabolic and Bariatric Surgery，ASMBS）、国际肥胖与代谢病外科联盟（International Federation for the Surgery of Obesity and Metabolic Disorders，IFSO）2022年联合发布声明，BMI≥35 kg/m2的单纯肥胖者或BMI在30.0~34.9 kg/m2且有代谢性疾病者可考虑手术［9］。中华医学会糖尿病学分会（Chinese Diabetes Society，CDS）2020年版指南则表示BMI≥32.5 kg/m2或有合并症的BMI≥27.5 kg/m2的患者可选择代谢手术［10］。
Tab 1 Recommendations for preoperative treatment with oral hypoglycemic agents and non-insulin injectables
Treatment
Preoperative treatment
Note
Metformin
To discontinue on the day of surgery
Gastrointestinal discomfort and lactic acidosis should be avoided; Patients with stage 4 severe chronic kidney disease (CKD) [estimated glomerular filtration rate 30 mL·min-1·(1.73 m2)-1] are contraindicated
Sulfonylureas and meglitinides
To discontinue at the start of preoperative diet (i.e., 2‒4 weeks before surgery)
Hypoglycemia and weight gain should be avoided
Thiazolidinediones
To discontinue on the day of surgery
Weight gain, fluid retention, and edema should all be avoided
ɑ-glucosidase inhibitors
To discontinue on the day before metabolic surgery
Gastrointestinal side effects should be avoided
Dipeptidyl peptidase-4 (DPP-4) inhibitors
To discontinue on the day of surgery
Patients with heart failure, arthralgia, skin conditions, allergic reactions and acute pancreatitis should use it with caution
Sodium-glucose cotransporter-2 (SGLT2) inhibitors
To discontinue 3 d prior to surgery
(2 weeks prior to surgery for those on a low-calorie ketogenic diet)
Genitourinary tract infections, hypotension, fractures, acute kidney injury, ketoacidosis, and rare cases of Fournier's gangrene should all be taken seriously
Glucagon-like peptide 1 (GLP-1) receptor agonists
To discontinue on the day of surgery
Gastrointestinal side effects should be avoided; Patients with a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2 are contraindicated
Tab 2 Prevention and treatment of micronutrient deficiencies
Micronutrient
Prevention
Treatment
Iron
45‒60 mg/d by oral administration
150‒200 mg/d by oral administration
Zinc
15 mg/d by oral administration
60 mg twice a day by oral administration
Copper
2 mg/d by oral administration (≥1 mg Cu per 8‒15 mg Zn to prevent copper deficiency is recommended)
Severe deficiency: 2‒4 mg/d by intravenous injection for 6 d
Vitamin A
6 000 IU/d by oral administration
Without corneal changes: 10 000‒25 000 IU/d by oral administration. With corneal changes: 50 000‒100 000 IU by intramuscular injection for 3 d, followed by 50 000 IU/d by intramuscular injection for 2 weeks to achieve clinical improvement
Vitamin B1
12 mg/d by oral administration
500 mg/d by intravenous injection for 3‒5 d, followed by 250 mg/d by intravenous injection for 3‒5 d or until symptoms disappear. If further treatment is required, 100 mg/d is taken by oral administration
Vitamin B6
400 μg/d by oral administration
1 000 μg/d by oral administration
Vitamin B12
250‒350 μg/d or 1 000 μg/wk by sublingual administration
1 000‒2 000 μg/d by sublingual administration
Vitamin D2 or D3
Vitamin D2 or D3 3 000 IU/d by oral administration to reach normal concentrations of 30 ng/mL
Vitamin D2 or D3 50 000 IU/week for 8 weeks, followed by maintenance therapy of 1 500‒2 000 IU/d by oral administration to achieve normal concentrations
Vitamin E
400 IU/d by oral administration
800‒1 200 IU/d by oral administration
Vitamin K
300 μg/d by oral administration
10 mg by intramuscular injection, followed by 1‒2 mg/week by oral administration
The review was conceived by SHAN Yingyi and YU Haoyong. The manuscript was drafted by SHAN Yingyi, and revised by SHAN Yingyi and YU Haoyong. Both authors have read the last version of paper and consented for submission.
利益冲突声明
所有作者声明不存在利益冲突。
All authors disclose no relevant conflict of interests.
World Health Organization. Obesity and overweight[EB/OL]. (2021-06-09) [2023-03-28]. https://www.who.int/en/news-room/fact-sheets/detail/obesity-and-overweight.
WANG L, ZHOU B, ZHAO Z, et al. Body-mass index and obesity in urban and rural China: findings from consecutive nationally representative surveys during 2004-18[J]. Lancet, 2021, 398(10294): 53-63.
SCHAUER P R, BHATT D L, KIRWAN J P, et al. Bariatric surgery versus intensive medical therapy for diabetes: 5-year outcomes[J]. N Engl J Med, 2017, 376(7): 641-651.
MINGRONE G, PANUNZI S, DE GAETANO A, et al. Metabolic surgery versus conventional medical therapy in patients with type 2 diabetes: 10-year follow-up of an open-label, single-centre, randomised controlled trial[J]. Lancet, 2021, 397(10271): 293-304.
SYN N L, CUMMINGS D E, WANG L Z, et al. Association of metabolic-bariatric surgery with long-term survival in adults with and without diabetes: a one-stage meta-analysis of matched cohort and prospective controlled studies with 174 772 participants[J]. Lancet, 2021, 397(10287): 1830-1841.
ANGRISANI L, SANTONICOLA A, IOVINO P, et al. Bariatric surgery survey 2018: similarities and disparities among the 5 IFSO chapters[J]. Obes Surg, 2021, 31(5): 1937-1948.
EISENBERG D, SHIKORA S A, AARTS E, et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): indications for metabolic and bariatric surgery[J]. Surg Obes Relat Dis, 2022, 18(12): 1345-1356.
Chinese Diabetes Society. Guideline for the prevention and treatment of type 2 diabetes mellitus in China (2020 edition) [J]. Chinese Journal of Endocrinology and Metabolism, 2021, 37(4): 311-398.
VAN WISSEN J, BAKKER N, DOODEMAN H J, et al. Preoperative methods to reduce liver volume in bariatric surgery: a systematic review[J]. Obes Surg, 2016, 26(2): 251-256.
KOUTOUKIDIS D A, KOSHIARIS C, HENRY J A, et al. The effect of the magnitude of weight loss on non-alcoholic fatty liver disease: a systematic review and meta-analysis[J]. Metabolism, 2021, 115: 154455.
ROMAN M, MONAGHAN A, SERRAINO G F, et al. Meta-analysis of the influence of lifestyle changes for preoperative weight loss on surgical outcomes[J]. Br J Surg, 2019, 106(3): 181-189.
SAMAAN J S, ZHAO J, QIAN E, et al. Preoperative weight loss as a predictor of bariatric surgery postoperative weight loss and complications[J]. J Gastrointest Surg, 2022, 26(1): 86-93.
ANDERIN C, GUSTAFSSON U O, HEIJBEL N, et al. Weight loss before bariatric surgery and postoperative complications: data from the Scandinavian Obesity Registry (SOReg)[J]. Ann Surg, 2015, 261(5): 909-913.
SARNO G, CALABRESE P, FRIAS-TORAL E, et al. The relationship between preoperative weight loss and intra and post-bariatric surgery complications: an appraisal of the current preoperative nutritional strategies[J]. Crit Rev Food Sci Nutr, 2022: 1-9.
HUTCHEON D A, HALE A L, EWING J A, et al. Short-term preoperative weight loss and postoperative outcomes in bariatric surgery[J]. J Am Coll Surg, 2018, 226(4): 514-524.
TABESH M R, MALEKLOU F, EJTEHADI F, et al. Nutrition, physical activity, and prescription of supplements in pre- and post-bariatric surgery patients: a practical guideline[J]. Obes Surg, 2019, 29(10): 3385-3400.
WOLF R M, OSHIMA K, CANNER J K, et al. Impact of a preoperative low-calorie diet on liver histology in patients with fatty liver disease undergoing bariatric surgery[J]. Surg Obes Relat Dis, 2019, 15(10): 1766-1772.
STEVEN S, HOLLINGSWORTH K G, AL-MRABEH A, et al. Very low-calorie diet and 6 months of weight stability in type 2 diabetes: pathophysiological changes in responders and nonresponders[J]. Diabetes Care, 2016, 39(5): 808-815.
PARRETTI H M, JEBB S A, JOHNS D J, et al. Clinical effectiveness of very-low-energy diets in the management of weight loss: a systematic review and meta-analysis of randomized controlled trials[J]. Obes Rev, 2016, 17(3): 225-234.
GASTALDO I, CASAS R, MOIZÉ V. Clinical impact of Mediterranean diet adherence before and after bariatric surgery: a narrative review[J]. Nutrients, 2022, 14(2): 393.
TETTAMANZI F, BAGNARDI V, LOUCA P, et al. A high protein diet is more effective in improving insulin resistance and glycemic variability compared to a Mediterranean diet: a cross-over controlled inpatient dietary study[J]. Nutrients, 2021, 13(12): 4380.
VICENTE MARTIN C, RABAGO TORRE L R, CASTILLO HERRERA L A, et al. Preoperative intragastric balloon in morbid obesity is unable to decrease early postoperative morbidity of bariatric surgery (sleeve gastrectomy and gastric bypass): a clinical assay[J]. Surg Endosc, 2020, 34(6): 2519-2531.
SARI C, SEIP R L, UMASHANKER D. Case report: off label utilization of topiramate and metformin in patients with BMI ≥50 kg/m2 prior to bariatric surgery[J]. Front Endocrinol (Lausanne), 2021, 12: 588016.
AMINIAN A, BRETHAUER S A, ANDALIB A, et al. Individualized metabolic surgery score: procedure selection based on diabetes severity[J]. Ann Surg, 2017, 266(4): 650-657.
JONES C E, GRAHAM L A, MORRIS M S, et al. Association between preoperative hemoglobin A1c levels, postoperative hyperglycemia, and readmissions following gastrointestinal surgery[J]. JAMA Surg, 2017, 152(11): 1031-1038.
HART A, GOFFREDO P, CARROLL R, et al. Optimizing bariatric surgery outcomes: the impact of preoperative elevated hemoglobin A1c levels on composite perioperative outcome measures[J]. Surg Endosc, 2021, 35(8): 4618-4623.
American Diabetes Association Professional Practice Committee. 16. diabetes care in the hospital: standards of medical care in diabetes-2022[J]. Diabetes Care, 2022, 45(Suppl 1): S244-S253.
MOREY-VARGAS O L, AMINIAN A, STECKNER K, et al. Perioperative management of diabetes in patients undergoing bariatric and metabolic surgery: a narrative review and the Cleveland Clinic practical recommendations[J]. Surg Obes Relat Dis, 2022, 18(8): 1087-1101.
COURCOULAS A P, KING W C, BELLE S H, et al. Seven-year weight trajectories and health outcomes in the longitudinal assessment of bariatric surgery (LABS) study[J]. JAMA Surg, 2018, 153(5): 427-434.
HAYOZ C, HERMANN T, RAPTIS D A, et al. Comparison of metabolic outcomes in patients undergoing laparoscopic roux-en-Y gastric bypass versus sleeve gastrectomy: a systematic review and meta-analysis of randomised controlled trials[J]. Swiss Med Wkly, 2018, 148: w14633.
Joint Committee on the Chinese Guidelines for Lipid Management. Chinese guidelines for lipid management (2023)[J]. Chinese Journal of Cardiology, 2023, 51(3): 221-255.
GUAN B S, YANG J G, CHEN Y Y, et al. Nutritional deficiencies in Chinese patients undergoing gastric bypass and sleeve gastrectomy: prevalence and predictors[J]. Obes Surg, 2018, 28(9): 2727-2736.
ENANI G, BILGIC E, LEBEDEVA E, et al. The incidence of iron deficiency anemia post-Roux-en-Y gastric bypass and sleeve gastrectomy: a systematic review[J]. Surg Endosc, 2020, 34(7): 3002-3010.
PARROTT J M, CRAGGS-DINO L, FARIA S L, et al. The optimal nutritional programme for bariatric and metabolic surgery[J]. Curr Obes Rep, 2020, 9(3): 326-338.
SHERF DAGAN S, GOLDENSHLUGER A, GLOBUS I, et al. Nutritional recommendations for adult bariatric surgery patients: clinical practice[J]. Adv Nutr, 2017, 8(2): 382-394.
PARROTT J, FRANK L, RABENA R, et al. American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the surgical weight loss patient 2016 update: micronutrients[J]. Surg Obes Relat Dis, 2017, 13(5): 727-741.
MOHAN S, SAMAAN J S, SAMAKAR K. Impact of smoking on weight loss outcomes after bariatric surgery: a literature review[J]. Surg Endosc, 2021, 35(11): 5936-5952.
INADOMI M, IYENGAR R, FISCHER I, et al. Effect of patient-reported smoking status on short-term bariatric surgery outcomes[J]. Surg Endosc, 2018, 32(2): 720-726.
WOOD G C, BENOTTI P N, LEE C J, et al. Evaluation of the association between preoperative clinical factors and long-term weight loss after Roux-en-Y gastric bypass[J]. JAMA Surg, 2016, 151(11): 1056-1062.
MALIK S, MITCHELL J E, ENGEL S, et al. Psychopathology in bariatric surgery candidates: a review of studies using structured diagnostic interviews[J]. Compr Psychiatry, 2014, 55(2): 248-259.
MÜLLER M, NETT P C, BORBÉLY Y M, et al. Mental illness has a negative impact on weight loss in bariatric patients: a 4-year follow-up[J]. J Gastrointest Surg, 2019, 23(2): 232-238.
CHAO A M, WADDEN T A, FAULCONBRIDGE L F, et al. Binge-eating disorder and the outcome of bariatric surgery in a prospective, observational study: two-year results[J]. Obesity (Silver Spring), 2016, 24(11): 2327-2333.
PEKKARINEN T, MUSTONEN H, SANE T M, et al. Long-term effect of gastric bypass and sleeve gastrectomy on severe obesity: do preoperative weight loss and binge eating behavior predict the outcome of bariatric surgery?[J]. Obes Surg, 2016, 26(9): 2161-2167.
FUCHS H F, LAUGHTER V, HARNSBERGER C R, et al. Patients with psychiatric comorbidity can safely undergo bariatric surgery with equivalent success[J]. Surg Endosc, 2016, 30(1): 251-258.
MECHANICK J I, APOVIAN C, BRETHAUER S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures—2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, the Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists[J]. Obesity (Silver Spring), 2020, 28(4): O1-O58.
CARTER J, CHANG J, BIRRIEL T J, et al. ASMBS position statement on preoperative patient optimization before metabolic and bariatric surgery[J]. Surg Obes Relat Dis, 2021, 17(12): 1956-1976.
MAREK R J, HEINBERG L J, LAVERY M, et al. A review of psychological assessment instruments for use in bariatric surgery evaluations[J]. Psychol Assess, 2016, 28(9): 1142-1157.
... 随着腹腔镜技术的发展，代谢手术在临床上得到了广泛的应用.2018年全球代谢手术总数接近70万例［7］，而在中国，2010—2015年期间代谢手术的数量相比于2001—2005年期间增加了148.7倍［8］.代谢手术带来的积极效果使得BMI下限不断降低.美国减重代谢外科学会（American Society for Metabolic and Bariatric Surgery，ASMBS）、国际肥胖与代谢病外科联盟（International Federation for the Surgery of Obesity and Metabolic Disorders，IFSO）2022年联合发布声明，BMI≥35 kg/m2的单纯肥胖者或BMI在30.0~34.9 kg/m2且有代谢性疾病者可考虑手术［9］.中华医学会糖尿病学分会（Chinese Diabetes Society，CDS）2020年版指南则表示BMI≥32.5 kg/m2或有合并症的BMI≥27.5 kg/m2的患者可选择代谢手术［10］. ...
1
... 随着腹腔镜技术的发展，代谢手术在临床上得到了广泛的应用.2018年全球代谢手术总数接近70万例［7］，而在中国，2010—2015年期间代谢手术的数量相比于2001—2005年期间增加了148.7倍［8］.代谢手术带来的积极效果使得BMI下限不断降低.美国减重代谢外科学会（American Society for Metabolic and Bariatric Surgery，ASMBS）、国际肥胖与代谢病外科联盟（International Federation for the Surgery of Obesity and Metabolic Disorders，IFSO）2022年联合发布声明，BMI≥35 kg/m2的单纯肥胖者或BMI在30.0~34.9 kg/m2且有代谢性疾病者可考虑手术［9］.中华医学会糖尿病学分会（Chinese Diabetes Society，CDS）2020年版指南则表示BMI≥32.5 kg/m2或有合并症的BMI≥27.5 kg/m2的患者可选择代谢手术［10］. ...
1
... 随着腹腔镜技术的发展，代谢手术在临床上得到了广泛的应用.2018年全球代谢手术总数接近70万例［7］，而在中国，2010—2015年期间代谢手术的数量相比于2001—2005年期间增加了148.7倍［8］.代谢手术带来的积极效果使得BMI下限不断降低.美国减重代谢外科学会（American Society for Metabolic and Bariatric Surgery，ASMBS）、国际肥胖与代谢病外科联盟（International Federation for the Surgery of Obesity and Metabolic Disorders，IFSO）2022年联合发布声明，BMI≥35 kg/m2的单纯肥胖者或BMI在30.0~34.9 kg/m2且有代谢性疾病者可考虑手术［9］.中华医学会糖尿病学分会（Chinese Diabetes Society，CDS）2020年版指南则表示BMI≥32.5 kg/m2或有合并症的BMI≥27.5 kg/m2的患者可选择代谢手术［10］. ...
1
... 随着腹腔镜技术的发展，代谢手术在临床上得到了广泛的应用.2018年全球代谢手术总数接近70万例［7］，而在中国，2010—2015年期间代谢手术的数量相比于2001—2005年期间增加了148.7倍［8］.代谢手术带来的积极效果使得BMI下限不断降低.美国减重代谢外科学会（American Society for Metabolic and Bariatric Surgery，ASMBS）、国际肥胖与代谢病外科联盟（International Federation for the Surgery of Obesity and Metabolic Disorders，IFSO）2022年联合发布声明，BMI≥35 kg/m2的单纯肥胖者或BMI在30.0~34.9 kg/m2且有代谢性疾病者可考虑手术［9］.中华医学会糖尿病学分会（Chinese Diabetes Society，CDS）2020年版指南则表示BMI≥32.5 kg/m2或有合并症的BMI≥27.5 kg/m2的患者可选择代谢手术［10］. ...
1
... 随着腹腔镜技术的发展，代谢手术在临床上得到了广泛的应用.2018年全球代谢手术总数接近70万例［7］，而在中国，2010—2015年期间代谢手术的数量相比于2001—2005年期间增加了148.7倍［8］.代谢手术带来的积极效果使得BMI下限不断降低.美国减重代谢外科学会（American Society for Metabolic and Bariatric Surgery，ASMBS）、国际肥胖与代谢病外科联盟（International Federation for the Surgery of Obesity and Metabolic Disorders，IFSO）2022年联合发布声明，BMI≥35 kg/m2的单纯肥胖者或BMI在30.0~34.9 kg/m2且有代谢性疾病者可考虑手术［9］.中华医学会糖尿病学分会（Chinese Diabetes Society，CDS）2020年版指南则表示BMI≥32.5 kg/m2或有合并症的BMI≥27.5 kg/m2的患者可选择代谢手术［10］. ...
