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11.5-33.5T128 499q183 25 282 141t110 290Zm-71-715q12-17 31.5-16.5T512 216q45 63 78.5 138T631 480q-39 18-87 58.5T481 601q-14-22-64.5-64.5T331 480q8-50 40.5-126.5T449 215Zm386 284q19-2 32 10.5t12 32.5q-8 161-87.5 261.5T599 944q-2-61-18.5-138.5T529 672q43-66 127.5-114T835 499Z"></path></svg></div><div class="SecondaryNavigationDesktop_secondary-list-item__YWsVF SecondaryNavigationDesktop_secondary-list-item--active__ADoJv"><h2>Healthy living</h2><p>Expert insight and opinion on nutrition, physical and mental health.</p></div></div><div class="SecondaryNavigationDesktop_secondary-list-navicon__Phe1K "><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 0 24 24"><path d="M5.67318 20.289L13.8612 12L5.67318 3.711C5.63754 3.678 5.60289 3.643 5.57022 3.605C5.2168 3.223 5 2.709 5 2.144C5 0.959999 5.95136 0 7.12448 0C7.68975 0 8.20553 0.224001 8.58469 0.589001C8.61241 0.615001 8.63815 0.641999 8.66389 0.667999L18.3349 10.436C18.3607 10.462 18.3864 10.488 18.4112 10.515C18.9002 11.034 19.122 11.79 18.9329 12.536C18.8388 12.905 18.6547 13.228 18.4112 13.486C18.3983 13.499 18.3518 13.547 18.3399 13.558L8.66389 23.332C8.63815 23.358 8.61241 23.385 8.58469 23.411C8.20553 23.776 7.68975 24 7.12448 24C5.95136 24 5 23.04 5 21.855C5 21.291 5.2168 20.777 5.57022 20.394C5.60289 20.357 5.63754 20.322 5.67318 20.289"></path></svg></div></a><div class="SecondaryNavigationDesktop_tertiary-inactive__uNEtz"><ul><li class="TertiaryNavigationDesktop_tertiary-content__JmUfL"><h6 class="TertiaryNavigationDesktop_tertiary-title__j9zHz">Healthy living</h6><div class="TertiaryNavigationDesktop_tertiary-section__NpW9N"><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/news-and-features" data-testid="ter_healthyliving_tertiarymenu"><p>Latest features</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/cold-and-flu-season" data-testid="ter_healthyliving_tertiarymenu"><p>Cold and flu 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56t-23 56L742 952q-23 23-56 23t-56-23L508 830Zm-28-134q17 0 28.5-11.5T520 656q0-17-11.5-28.5T480 616q-17 0-28.5 11.5T440 656q0 17 11.5 28.5T480 696Zm-80-80q17 0 28.5-11.5T440 576q0-17-11.5-28.5T400 536q-17 0-28.5 11.5T360 576q0 17 11.5 28.5T400 616Zm160 0q17 0 28.5-11.5T600 576q0-17-11.5-28.5T560 536q-17 0-28.5 11.5T520 576q0 17 11.5 28.5T560 616Zm-335-69L104 426q-23-23-23-56t23-56l114-114q23-23 56-23t56 23l122 122-227 225Zm255-11q17 0 28.5-11.5T520 496q0-17-11.5-28.5T480 456q-17 0-28.5 11.5T440 496q0 17 11.5 28.5T480 536Z"></path></svg></div><div class="SecondaryNavigationDesktop_secondary-list-item__YWsVF SecondaryNavigationDesktop_secondary-list-item--active__ADoJv"><h2>Managing conditions</h2><p>From ACE inhibitors for high blood pressure, to steroids for eczema, find out what options are available, how they work and the possible side effects.</p></div></div><div class="SecondaryNavigationDesktop_secondary-list-navicon__Phe1K "><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 0 24 24"><path d="M5.67318 20.289L13.8612 12L5.67318 3.711C5.63754 3.678 5.60289 3.643 5.57022 3.605C5.2168 3.223 5 2.709 5 2.144C5 0.959999 5.95136 0 7.12448 0C7.68975 0 8.20553 0.224001 8.58469 0.589001C8.61241 0.615001 8.63815 0.641999 8.66389 0.667999L18.3349 10.436C18.3607 10.462 18.3864 10.488 18.4112 10.515C18.9002 11.034 19.122 11.79 18.9329 12.536C18.8388 12.905 18.6547 13.228 18.4112 13.486C18.3983 13.499 18.3518 13.547 18.3399 13.558L8.66389 23.332C8.63815 23.358 8.61241 23.385 8.58469 23.411C8.20553 23.776 7.68975 24 7.12448 24C5.95136 24 5 23.04 5 21.855C5 21.291 5.2168 20.777 5.57022 20.394C5.60289 20.357 5.63754 20.322 5.67318 20.289"></path></svg></div></a><div class="SecondaryNavigationDesktop_tertiary-inactive__uNEtz"><ul><li class="TertiaryNavigationDesktop_tertiary-content__JmUfL"><h6 class="TertiaryNavigationDesktop_tertiary-title__j9zHz">Featured conditions</h6><div class="TertiaryNavigationDesktop_tertiary-section__NpW9N"><a 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data-testid="ter_managingconditions_tertiarymenu"><p>Crohn's disease</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/diabetes/diabetes-mellitus-leaflet" data-testid="ter_managingconditions_tertiarymenu"><p>Diabetes</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/womens-health/pelvic-pain-in-women/endometriosis" data-testid="ter_managingconditions_tertiarymenu"><p>Endometriosis</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/signs-symptoms/tiredness-fatigue/fibromyalgia" data-testid="ter_managingconditions_tertiarymenu"><p>Fibromyalgia</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/digestive-health/diarrhoea/gastroenteritis" data-testid="ter_managingconditions_tertiarymenu"><p>Gastroenteritis</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/skin-conditions/hives-inducible-urticaria" data-testid="ter_managingconditions_tertiarymenu"><p>Hives</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/digestive-health/irritable-bowel-syndrome-leaflet" data-testid="ter_managingconditions_tertiarymenu"><p>Irritable bowel syndrome</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/womens-health/polycystic-ovary-syndrome-leaflet" data-testid="ter_managingconditions_tertiarymenu"><p>Polycystic ovary syndrome</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/skin-conditions/psoriasis-leaflet" data-testid="ter_managingconditions_tertiarymenu"><p>Psoriasis</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/skin-conditions/viral-rashes/scarlet-fever" data-testid="ter_managingconditions_tertiarymenu"><p>Scarlet fever</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/infections/strep-a-group-a-strep-gas" data-testid="ter_managingconditions_tertiarymenu"><p>Strep A</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/ears-nose-throat-mouth/sore-throat-2/tonsillitis" data-testid="ter_managingconditions_tertiarymenu"><p>Tonsillitis</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/sexual-health/vaginal-discharge-female-discharge/vaginal-thrush-yeast-infection" data-testid="ter_managingconditions_tertiarymenu"><p>Vaginal thrush</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/signs-symptoms/dizziness/vertigo" data-testid="ter_managingconditions_tertiarymenu"><p>Vertigo</p></a></div><div class="TertiaryNavigationDesktop_tertiary-section__NpW9N"><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/managing-conditions" data-testid="ter_managingconditions_tertiarymenu"><p>Health conditions A-Z</p></a></div></li></ul></div></div><div class="SecondaryNavigationDesktop_secondary-content__X6m4s"><a href="https://patient.info" class="SecondaryNavigationDesktop_secondary-list__67206" data-testid="sec_medicine_information"><div class="SecondaryNavigationDesktop_secondary-list-menu__Chqv2"><div class="SecondaryNavigationDesktop_secondary-list-icon__4jDqd SecondaryNavigationDesktop_navigation-item--health-advice__IBQM_ SecondaryNavigationDesktop_secondary-list-icon--inactive__FLGa2 "><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 -960 960 960"><path d="M136-266q-32 0-46.5-21T86-337l109-304q8-22 30.5-37.5T272-694q23 0 45 15.5t30 37.5l112 306q11 29-3.5 49T410-266q-14 0-25.5-8.5T368-296l-24-68H200l-20 66q-4 13-17 22.5t-27 9.5Zm94-188h80l-34-132h-8l-38 132Zm379 188q-28 0-47.5-19.5T542-333q0-13 6.5-30t14.5-27l181-210H597q-20 0-33.5-13.5T550-647q0-20 13.5-33.5T597-694h194q28 0 47.5 19.5T858-626q0 13-6.5 29.5T837-570L658-360h155q20 0 33.5 13.5T860-313q0 20-13.5 33.5T813-266H609ZM411-760q-17 0-24-16t5-28l72-72q3-3 18-7 3 0 18 7l72 72q12 12 5 28t-24 16H411Zm71 683q-3 0-18-7l-72-72q-12-12-5-28t24-16h142q17 0 24 16t-5 28l-72 72q-3 3-18 7Z"></path></svg></div><div class="SecondaryNavigationDesktop_secondary-list-item__YWsVF SecondaryNavigationDesktop_secondary-list-item--active__ADoJv"><h2>Medicine information</h2><p>Information and fact sheets for patients and professionals. Find out side effects, medicine names, dosages and uses.</p></div></div><div class="SecondaryNavigationDesktop_secondary-list-navicon__Phe1K "><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 0 24 24"><path d="M5.67318 20.289L13.8612 12L5.67318 3.711C5.63754 3.678 5.60289 3.643 5.57022 3.605C5.2168 3.223 5 2.709 5 2.144C5 0.959999 5.95136 0 7.12448 0C7.68975 0 8.20553 0.224001 8.58469 0.589001C8.61241 0.615001 8.63815 0.641999 8.66389 0.667999L18.3349 10.436C18.3607 10.462 18.3864 10.488 18.4112 10.515C18.9002 11.034 19.122 11.79 18.9329 12.536C18.8388 12.905 18.6547 13.228 18.4112 13.486C18.3983 13.499 18.3518 13.547 18.3399 13.558L8.66389 23.332C8.63815 23.358 8.61241 23.385 8.58469 23.411C8.20553 23.776 7.68975 24 7.12448 24C5.95136 24 5 23.04 5 21.855C5 21.291 5.2168 20.777 5.57022 20.394C5.60289 20.357 5.63754 20.322 5.67318 20.289"></path></svg></div></a><div class="SecondaryNavigationDesktop_tertiary-inactive__uNEtz"><ul><li class="TertiaryNavigationDesktop_tertiary-content__JmUfL"><h6 class="TertiaryNavigationDesktop_tertiary-title__j9zHz">Medicine information</h6><div class="TertiaryNavigationDesktop_tertiary-section__NpW9N"><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/medicine" data-testid="ter_medicineinformation_tertiarymenu"><p>All medicines A-Z</p></a></div><div class="TertiaryNavigationDesktop_tertiary-section__NpW9N"><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/allergy-medicines" data-testid="ter_medicineinformation_tertiarymenu"><p>Allergy medicines</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/analgesics-and-pain-medication" data-testid="ter_medicineinformation_tertiarymenu"><p>Analgesics and pain medication</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/anti-inflammatory-medicines" data-testid="ter_medicineinformation_tertiarymenu"><p>Anti-inflammatory medicines</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/breathing-treatment-and-respiratory-care" data-testid="ter_medicineinformation_tertiarymenu"><p>Breathing treatment and respiratory care</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/cancer-treatment-and-drugs" data-testid="ter_medicineinformation_tertiarymenu"><p>Cancer treatment and drugs</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/contraceptive-medicines" data-testid="ter_medicineinformation_tertiarymenu"><p>Contraceptive medicines</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/diabetes-medicines" data-testid="ter_medicineinformation_tertiarymenu"><p>Diabetes medicines</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/ent-and-mouth-care" data-testid="ter_medicineinformation_tertiarymenu"><p>ENT and mouth care</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/eye-care-medicine" data-testid="ter_medicineinformation_tertiarymenu"><p>Eye care medicine</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/gastrointestinal-treatment" data-testid="ter_medicineinformation_tertiarymenu"><p>Gastrointestinal treatment</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/genito-urinary-medicine" data-testid="ter_medicineinformation_tertiarymenu"><p>Genitourinary medicine</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/heart-disease-treatment-and-prevention" data-testid="ter_medicineinformation_tertiarymenu"><p>Heart disease treatment and prevention</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/hormonal-imbalance-treatment" data-testid="ter_medicineinformation_tertiarymenu"><p>Hormonal imbalance treatment</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/hormone-deficiency-treatment" data-testid="ter_medicineinformation_tertiarymenu"><p>Hormone deficiency treatment</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/immunosuppressive-drugs" data-testid="ter_medicineinformation_tertiarymenu"><p>Immunosuppressive drugs</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/infection-treatment-medicine" data-testid="ter_medicineinformation_tertiarymenu"><p>Infection treatment medicine</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/treatment-for-kidneys" data-testid="ter_medicineinformation_tertiarymenu"><p>Kidney conditions treatments</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/muscle-bone-and-joint-pain-treatment" data-testid="ter_medicineinformation_tertiarymenu"><p>Muscle, bone and joint pain treatment</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/nausea-medicine-and-vomiting-treatment" data-testid="ter_medicineinformation_tertiarymenu"><p>Nausea medicine and vomiting treatment</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/nervous-system-drugs" data-testid="ter_medicineinformation_tertiarymenu"><p>Nervous system drugs</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/fertility-treatment" data-testid="ter_medicineinformation_tertiarymenu"><p>Reproductive health</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/treatments-for-skin-conditions" data-testid="ter_medicineinformation_tertiarymenu"><p>Skin conditions treatments</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/substance-abuse-treatment" data-testid="ter_medicineinformation_tertiarymenu"><p>Substance abuse treatment</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/vaccines-and-immunisation" data-testid="ter_medicineinformation_tertiarymenu"><p>Vaccines and immunisation</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/vitamin-and-mineral-supplements" data-testid="ter_medicineinformation_tertiarymenu"><p>Vitamin and mineral supplements</p></a></div></li></ul></div></div><div class="SecondaryNavigationDesktop_secondary-content__X6m4s"><a href="https://patient.info" class="SecondaryNavigationDesktop_secondary-list__67206" data-testid="sec_tests_investigations"><div class="SecondaryNavigationDesktop_secondary-list-menu__Chqv2"><div class="SecondaryNavigationDesktop_secondary-list-icon__4jDqd SecondaryNavigationDesktop_navigation-item--health-advice__IBQM_ SecondaryNavigationDesktop_secondary-list-icon--inactive__FLGa2 "><svg xmlns="http://www.w3.org/2000/svg" height="25" width="24" viewBox="0 0 24 25"><path d="M19 22.9932C18.45 22.9932 17.979 22.7975 17.587 22.4062C17.1957 22.0142 17 21.5432 17 20.9932V19.8932C15.85 19.6598 14.8957 19.0892 14.137 18.1812C13.379 17.2725 13 16.2098 13 14.9932V9.99316C13 9.44316 13.1917 8.97216 13.575 8.58016C13.9583 8.18883 14.4333 7.99316 15 7.99316H21C21.55 7.99316 22.021 8.18883 22.413 8.58016C22.8043 8.97216 23 9.44316 23 9.99316V14.9932C23 16.2098 22.621 17.2725 21.863 18.1812C21.1043 19.0892 20.15 19.6598 19 19.8932V20.9932H21C21.2833 20.9932 21.5207 21.0892 21.712 21.2812C21.904 21.4725 22 21.7098 22 21.9932C22 22.2765 21.904 22.5138 21.712 22.7052C21.5207 22.8972 21.2833 22.9932 21 22.9932H19ZM19.75 13.9932H21V9.99316H15V11.9932H15.75C16.3 11.9932 16.8207 12.1182 17.312 12.3682C17.804 12.6182 18.2167 12.9598 18.55 13.3932C18.6833 13.5932 18.8583 13.7432 19.075 13.8432C19.2917 13.9432 19.5167 13.9932 19.75 13.9932ZM6 17.9932H5C4.45 17.9932 3.979 17.7975 3.587 17.4062C3.19567 17.0142 3 16.5432 3 15.9932V8.49316C2.71667 8.49316 2.47933 8.3975 2.288 8.20616C2.096 8.01416 2 7.7765 2 7.49316C2 7.20983 2.096 6.97216 2.288 6.78016C2.47933 6.58883 2.71667 6.49316 3 6.49316H6V4.99316H5.5C5.21667 4.99316 4.979 4.89716 4.787 4.70516C4.59567 4.51383 4.5 4.2765 4.5 3.99316C4.5 3.70983 4.59567 3.47216 4.787 3.28016C4.979 3.08883 5.21667 2.99316 5.5 2.99316H8.5C8.78333 2.99316 9.021 3.08883 9.213 3.28016C9.40433 3.47216 9.5 3.70983 9.5 3.99316C9.5 4.2765 9.40433 4.51383 9.213 4.70516C9.021 4.89716 8.78333 4.99316 8.5 4.99316H8V6.49316H11C11.2833 6.49316 11.521 6.58883 11.713 6.78016C11.9043 6.97216 12 7.20983 12 7.49316C12 7.7765 11.9043 8.01416 11.713 8.20616C11.521 8.3975 11.2833 8.49316 11 8.49316V15.9932C11 16.5432 10.8043 17.0142 10.413 17.4062C10.021 17.7975 9.55 17.9932 9 17.9932H8V22.4932C8 22.6932 7.90833 22.8432 7.725 22.9432C7.54167 23.0432 7.36667 23.0265 7.2 22.8932L6.4 22.2932C6.26667 22.1932 6.16667 22.0765 6.1 21.9432C6.03333 21.8098 6 21.6598 6 21.4932V17.9932ZM5 15.9932H9V14.4932H7.25C7.05 14.4932 6.875 14.4182 6.725 14.2682C6.575 14.1182 6.5 13.9432 6.5 13.7432C6.5 13.5432 6.575 13.3682 6.725 13.2182C6.875 13.0682 7.05 12.9932 7.25 12.9932H9V11.4932H7.25C7.05 11.4932 6.875 11.4182 6.725 11.2682C6.575 11.1182 6.5 10.9432 6.5 10.7432C6.5 10.5432 6.575 10.3682 6.725 10.2182C6.875 10.0682 7.05 9.99316 7.25 9.99316H9V8.49316H5V15.9932Z"></path></svg></div><div class="SecondaryNavigationDesktop_secondary-list-item__YWsVF SecondaryNavigationDesktop_secondary-list-item--active__ADoJv"><h2>Tests & investigations</h2><p>Information and guidance about tests and an easy, fast and accurate symptom checker.</p></div></div><div class="SecondaryNavigationDesktop_secondary-list-navicon__Phe1K "><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 0 24 24"><path d="M5.67318 20.289L13.8612 12L5.67318 3.711C5.63754 3.678 5.60289 3.643 5.57022 3.605C5.2168 3.223 5 2.709 5 2.144C5 0.959999 5.95136 0 7.12448 0C7.68975 0 8.20553 0.224001 8.58469 0.589001C8.61241 0.615001 8.63815 0.641999 8.66389 0.667999L18.3349 10.436C18.3607 10.462 18.3864 10.488 18.4112 10.515C18.9002 11.034 19.122 11.79 18.9329 12.536C18.8388 12.905 18.6547 13.228 18.4112 13.486C18.3983 13.499 18.3518 13.547 18.3399 13.558L8.66389 23.332C8.63815 23.358 8.61241 23.385 8.58469 23.411C8.20553 23.776 7.68975 24 7.12448 24C5.95136 24 5 23.04 5 21.855C5 21.291 5.2168 20.777 5.57022 20.394C5.60289 20.357 5.63754 20.322 5.67318 20.289"></path></svg></div></a><div class="SecondaryNavigationDesktop_tertiary-inactive__uNEtz"><ul><li class="TertiaryNavigationDesktop_tertiary-content__JmUfL"><h6 class="TertiaryNavigationDesktop_tertiary-title__j9zHz">Tests & investigations</h6><div class="TertiaryNavigationDesktop_tertiary-section__NpW9N"><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/about-tests-and-investigations" data-testid="ter_testsinvestigations_tertiarymenu"><p>About tests & investigations</p></a></div><div class="TertiaryNavigationDesktop_tertiary-section__NpW9N"><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/symptom-checker" data-testid="ter_testsinvestigations_tertiarymenu"><p>Symptom checker</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/treatment-medication/blood-tests" data-testid="ter_testsinvestigations_tertiarymenu"><p>Blood tests</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/doctor/bmi-calculator" data-testid="ter_testsinvestigations_tertiarymenu"><p>BMI calculator</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/doctor/pregnancy-due-date-calculator" data-testid="ter_testsinvestigations_tertiarymenu"><p>Pregnancy due date calculator</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/signs-symptoms" data-testid="ter_testsinvestigations_tertiarymenu"><p>General signs and symptoms</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/doctor/patient-health-questionnaire-phq-9" data-testid="ter_testsinvestigations_tertiarymenu"><p>Patient health questionnaire</p></a><a class="TertiaryNavigationDesktop_tertiary-menu__AI1gf" href="https://patient.info/doctor/generalised-anxiety-disorder-assessment-gad-7" data-testid="ter_testsinvestigations_tertiarymenu"><p>Generalised anxiety disorder assessment</p></a></div></li></ul></div></div></div></li><li><div role="navigation" class="SecondaryNavigationDesktop_secondary-sidebar__svZYs SecondaryNavigationDesktop_secondary-navigation-item--health-research__Y0SVM SecondaryNavigationDesktop_secondary-sidebar-hide__A4W4s"></div><div role="navigation" class="SecondaryNavigationDesktop_secondary__cbbXD SecondaryNavigationDesktop_secondary-inactive__dSi2Y"></div></li><li><div role="navigation" class="SecondaryNavigationDesktop_secondary-sidebar__svZYs SecondaryNavigationDesktop_secondary-navigation-item--professional-hub__nczDM SecondaryNavigationDesktop_secondary-sidebar-hide__A4W4s"></div><div role="navigation" class="SecondaryNavigationDesktop_secondary__cbbXD SecondaryNavigationDesktop_secondary-inactive__dSi2Y"><div class="SecondaryNavigationDesktop_secondary-content__X6m4s"><a href="https://patient.info" class="SecondaryNavigationDesktop_secondary-list__67206" data-testid="sec_hub"><div class="SecondaryNavigationDesktop_secondary-list-menu__Chqv2"><div class="SecondaryNavigationDesktop_secondary-list-icon__4jDqd SecondaryNavigationDesktop_navigation-item--professional-hub__TLTw0 SecondaryNavigationDesktop_secondary-list-icon--inactive__FLGa2 "><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 96 960 960"><path d="M440 696v80q0 17 11.5 28.5T480 816q17 0 28.5-11.5T520 776v-80h80q17 0 28.5-11.5T640 656q0-17-11.5-28.5T600 616h-80v-80q0-17-11.5-28.5T480 496q-17 0-28.5 11.5T440 536v80h-80q-17 0-28.5 11.5T320 656q0 17 11.5 28.5T360 696h80ZM160 976q-33 0-56.5-23.5T80 896V416q0-33 23.5-56.5T160 336h160v-80q0-33 23.5-56.5T400 176h160q33 0 56.5 23.5T640 256v80h160q33 0 56.5 23.5T880 416v480q0 33-23.5 56.5T800 976H160Zm240-640h160v-80H400v80Z"></path></svg></div><div class="SecondaryNavigationDesktop_secondary-list-item__YWsVF SecondaryNavigationDesktop_secondary-list-item--active__ADoJv"><h2>Medical professional hub</h2><p>Information and tools written by clinicians for medical professionals, and training resources provided by FourteenFish.</p></div></div><div class="SecondaryNavigationDesktop_secondary-list-navicon__Phe1K "><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 0 24 24"><path d="M5.67318 20.289L13.8612 12L5.67318 3.711C5.63754 3.678 5.60289 3.643 5.57022 3.605C5.2168 3.223 5 2.709 5 2.144C5 0.959999 5.95136 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They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the <a href="https://patient.info/healthy-living/obesity-overweight/weight-loss-surgery">Weight loss surgery</a> article more useful, or one of our other <a href="https://patient.info/health">health articles</a>.</p></div></div></div></div><div class="InThisArticle_wrapper__PysyZ" data-testid="in-this-article-wrapper"><div class="InThisArticle_title__NDDRL" data-testid="in-this-article-title"><h3>In this article:</h3></div><div class="InThisArticle_content__niE0Z" data-testid="in-this-article-content"><ul data-testid="in-this-article-list" role="navigation"><li data-testid="in-this-article-list-item"><a href="https://patient.info/doctor/bariatric-surgery#what-is-bariatric-surgery" class="Link_linkcontainer__NFFuY Link_link-quicklink__LWSK_ Link_link-professionals__uur2P InThisArticle_link__yAqS0" data-testid="in-this-article-list-link"><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 0 24 24"><path d="M5.67318 20.289L13.8612 12L5.67318 3.711C5.63754 3.678 5.60289 3.643 5.57022 3.605C5.2168 3.223 5 2.709 5 2.144C5 0.959999 5.95136 0 7.12448 0C7.68975 0 8.20553 0.224001 8.58469 0.589001C8.61241 0.615001 8.63815 0.641999 8.66389 0.667999L18.3349 10.436C18.3607 10.462 18.3864 10.488 18.4112 10.515C18.9002 11.034 19.122 11.79 18.9329 12.536C18.8388 12.905 18.6547 13.228 18.4112 13.486C18.3983 13.499 18.3518 13.547 18.3399 13.558L8.66389 23.332C8.63815 23.358 8.61241 23.385 8.58469 23.411C8.20553 23.776 7.68975 24 7.12448 24C5.95136 24 5 23.04 5 21.855C5 21.291 5.2168 20.777 5.57022 20.394C5.60289 20.357 5.63754 20.322 5.67318 20.289"></path></svg><span>What is bariatric surgery?</span></a></li><li data-testid="in-this-article-list-item"><a href="https://patient.info/doctor/bariatric-surgery#who-is-considered-for-bariatric-surgery" class="Link_linkcontainer__NFFuY Link_link-quicklink__LWSK_ Link_link-professionals__uur2P InThisArticle_link__yAqS0" data-testid="in-this-article-list-link"><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 0 24 24"><path d="M5.67318 20.289L13.8612 12L5.67318 3.711C5.63754 3.678 5.60289 3.643 5.57022 3.605C5.2168 3.223 5 2.709 5 2.144C5 0.959999 5.95136 0 7.12448 0C7.68975 0 8.20553 0.224001 8.58469 0.589001C8.61241 0.615001 8.63815 0.641999 8.66389 0.667999L18.3349 10.436C18.3607 10.462 18.3864 10.488 18.4112 10.515C18.9002 11.034 19.122 11.79 18.9329 12.536C18.8388 12.905 18.6547 13.228 18.4112 13.486C18.3983 13.499 18.3518 13.547 18.3399 13.558L8.66389 23.332C8.63815 23.358 8.61241 23.385 8.58469 23.411C8.20553 23.776 7.68975 24 7.12448 24C5.95136 24 5 23.04 5 21.855C5 21.291 5.2168 20.777 5.57022 20.394C5.60289 20.357 5.63754 20.322 5.67318 20.289"></path></svg><span>Who is considered for bariatric surgery? </span></a></li><li data-testid="in-this-article-list-item"><a href="https://patient.info/doctor/bariatric-surgery#contra-indications-and-cautions" class="Link_linkcontainer__NFFuY Link_link-quicklink__LWSK_ Link_link-professionals__uur2P InThisArticle_link__yAqS0" data-testid="in-this-article-list-link"><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 0 24 24"><path d="M5.67318 20.289L13.8612 12L5.67318 3.711C5.63754 3.678 5.60289 3.643 5.57022 3.605C5.2168 3.223 5 2.709 5 2.144C5 0.959999 5.95136 0 7.12448 0C7.68975 0 8.20553 0.224001 8.58469 0.589001C8.61241 0.615001 8.63815 0.641999 8.66389 0.667999L18.3349 10.436C18.3607 10.462 18.3864 10.488 18.4112 10.515C18.9002 11.034 19.122 11.79 18.9329 12.536C18.8388 12.905 18.6547 13.228 18.4112 13.486C18.3983 13.499 18.3518 13.547 18.3399 13.558L8.66389 23.332C8.63815 23.358 8.61241 23.385 8.58469 23.411C8.20553 23.776 7.68975 24 7.12448 24C5.95136 24 5 23.04 5 21.855C5 21.291 5.2168 20.777 5.57022 20.394C5.60289 20.357 5.63754 20.322 5.67318 20.289"></path></svg><span>Contra-indications and cautions  </span></a></li><li data-testid="in-this-article-list-item"><a href="https://patient.info/doctor/bariatric-surgery#types-of-procedure-for-bariatric-surgery" class="Link_linkcontainer__NFFuY Link_link-quicklink__LWSK_ Link_link-professionals__uur2P InThisArticle_link__yAqS0" data-testid="in-this-article-list-link"><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 0 24 24"><path d="M5.67318 20.289L13.8612 12L5.67318 3.711C5.63754 3.678 5.60289 3.643 5.57022 3.605C5.2168 3.223 5 2.709 5 2.144C5 0.959999 5.95136 0 7.12448 0C7.68975 0 8.20553 0.224001 8.58469 0.589001C8.61241 0.615001 8.63815 0.641999 8.66389 0.667999L18.3349 10.436C18.3607 10.462 18.3864 10.488 18.4112 10.515C18.9002 11.034 19.122 11.79 18.9329 12.536C18.8388 12.905 18.6547 13.228 18.4112 13.486C18.3983 13.499 18.3518 13.547 18.3399 13.558L8.66389 23.332C8.63815 23.358 8.61241 23.385 8.58469 23.411C8.20553 23.776 7.68975 24 7.12448 24C5.95136 24 5 23.04 5 21.855C5 21.291 5.2168 20.777 5.57022 20.394C5.60289 20.357 5.63754 20.322 5.67318 20.289"></path></svg><span>Types of procedure for bariatric surgery  </span></a></li><li data-testid="in-this-article-list-item"><a href="https://patient.info/doctor/bariatric-surgery#follow-up" class="Link_linkcontainer__NFFuY Link_link-quicklink__LWSK_ Link_link-professionals__uur2P InThisArticle_link__yAqS0" data-testid="in-this-article-list-link"><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 0 24 24"><path d="M5.67318 20.289L13.8612 12L5.67318 3.711C5.63754 3.678 5.60289 3.643 5.57022 3.605C5.2168 3.223 5 2.709 5 2.144C5 0.959999 5.95136 0 7.12448 0C7.68975 0 8.20553 0.224001 8.58469 0.589001C8.61241 0.615001 8.63815 0.641999 8.66389 0.667999L18.3349 10.436C18.3607 10.462 18.3864 10.488 18.4112 10.515C18.9002 11.034 19.122 11.79 18.9329 12.536C18.8388 12.905 18.6547 13.228 18.4112 13.486C18.3983 13.499 18.3518 13.547 18.3399 13.558L8.66389 23.332C8.63815 23.358 8.61241 23.385 8.58469 23.411C8.20553 23.776 7.68975 24 7.12448 24C5.95136 24 5 23.04 5 21.855C5 21.291 5.2168 20.777 5.57022 20.394C5.60289 20.357 5.63754 20.322 5.67318 20.289"></path></svg><span>Follow-up </span></a></li><li data-testid="in-this-article-list-item"><a href="https://patient.info/doctor/bariatric-surgery#benefits-of-bariatric-surgery-procedures" class="Link_linkcontainer__NFFuY Link_link-quicklink__LWSK_ Link_link-professionals__uur2P InThisArticle_link__yAqS0" data-testid="in-this-article-list-link"><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 0 24 24"><path d="M5.67318 20.289L13.8612 12L5.67318 3.711C5.63754 3.678 5.60289 3.643 5.57022 3.605C5.2168 3.223 5 2.709 5 2.144C5 0.959999 5.95136 0 7.12448 0C7.68975 0 8.20553 0.224001 8.58469 0.589001C8.61241 0.615001 8.63815 0.641999 8.66389 0.667999L18.3349 10.436C18.3607 10.462 18.3864 10.488 18.4112 10.515C18.9002 11.034 19.122 11.79 18.9329 12.536C18.8388 12.905 18.6547 13.228 18.4112 13.486C18.3983 13.499 18.3518 13.547 18.3399 13.558L8.66389 23.332C8.63815 23.358 8.61241 23.385 8.58469 23.411C8.20553 23.776 7.68975 24 7.12448 24C5.95136 24 5 23.04 5 21.855C5 21.291 5.2168 20.777 5.57022 20.394C5.60289 20.357 5.63754 20.322 5.67318 20.289"></path></svg><span>Benefits of bariatric surgery procedures </span></a></li><li data-testid="in-this-article-list-item"><a href="https://patient.info/doctor/bariatric-surgery#complications-and-disadvantages-of-surgery" class="Link_linkcontainer__NFFuY Link_link-quicklink__LWSK_ Link_link-professionals__uur2P InThisArticle_link__yAqS0" data-testid="in-this-article-list-link"><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 0 24 24"><path d="M5.67318 20.289L13.8612 12L5.67318 3.711C5.63754 3.678 5.60289 3.643 5.57022 3.605C5.2168 3.223 5 2.709 5 2.144C5 0.959999 5.95136 0 7.12448 0C7.68975 0 8.20553 0.224001 8.58469 0.589001C8.61241 0.615001 8.63815 0.641999 8.66389 0.667999L18.3349 10.436C18.3607 10.462 18.3864 10.488 18.4112 10.515C18.9002 11.034 19.122 11.79 18.9329 12.536C18.8388 12.905 18.6547 13.228 18.4112 13.486C18.3983 13.499 18.3518 13.547 18.3399 13.558L8.66389 23.332C8.63815 23.358 8.61241 23.385 8.58469 23.411C8.20553 23.776 7.68975 24 7.12448 24C5.95136 24 5 23.04 5 21.855C5 21.291 5.2168 20.777 5.57022 20.394C5.60289 20.357 5.63754 20.322 5.67318 20.289"></path></svg><span>Complications and disadvantages of surgery </span></a></li></ul></div></div><div class="Body_wrapper__87Ugw" data-testid="body"><div class=" Markup_markup__hjGOW Body_markup__5QVEm " data-testid="markup"><div class="InlineAds_inlineads__KhwOX" data-index="1" id="inlinead"><p class="InlineAds_adslinebreak__o_d8f"><span>Continue reading below</span><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 -960 960 960"><path d="M480-362q-8 0-15-2.5t-13-8.5L268-557q-11-11-11-28t11-28q11-11 28-11t28 11l156 156 156-156q11-11 28-11t28 11q11 11 11 28t-11 28L508-373q-6 6-13 8.5t-15 2.5Z"></path></svg></p><div class="InlineAds_adswrapper__q54f_"><div class="InlineAds_wrapper__D6jdy" aria-label="Side rail Advertisement" role="complementary" data-testid="inlineads-wrapper"><div id="div-gpt-ad-1698311650922-0" data-adunit="Side Rail-App" data-dimensions="300,250" data-targeting="{}" class="InlineAds_wrapper-active__1EvdQ" data-testid-adspossibledimensions="300,250"></div></div></div></div><h2 class="ScrollMargin_anchor__VQzBd" id="what-is-bariatric-surgery" data-testid="heading-2">What is bariatric surgery?</h2><p>Bariatric surgical procedures are an option for treating severe obesity, by reducing intake or absorption of calories. There are various options, all of which have potential complications.</p><p>A 2014 Cochrane review concluded that surgery results in greater improvement in weight loss outcomes and weight-associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-1" title="Colquitt JL, Pickett K, Loveman E, et al; Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014 Aug 8;8:CD003641. doi: 10.1002/14651858.CD003641.pub4."><span>1</span></a></sup> </p><p>One meta-analysis at 10 or more years and a single-centre study of laparoscopic adjustable gastric banding with 20 years of follow-up found that all current procedures are associated with substantial and durable weight loss.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-2" title="O'Brien PE, Hindle A, Brennan L, et al; Long-Term Outcomes After Bariatric Surgery: a Systematic Review and Meta-analysis of Weight Loss at 10 or More Years for All Bariatric Procedures and a Single-Centre Review of 20-Year Outcomes After Adjustable Gastric Banding. Obes Surg. 2019 Jan;29(1):3-14. doi: 10.1007/s11695-018-3525-0."><span>2</span></a></sup> </p><p>One randomised controlled trial found that, among obese participants with type 2 diabetes, bariatric surgery with two years of an adjunctive low-level lifestyle intervention resulted in more disease remission than did lifestyle intervention alone.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-3" title="Courcoulas AP, Belle SH, Neiberg RH, et al; Three-Year Outcomes of Bariatric Surgery vs Lifestyle Intervention for Type 2 Diabetes Mellitus Treatment: A Randomized Clinical Trial. JAMA Surg. 2015 Oct;150(10):931-40. doi: 10.1001/jamasurg.2015.1534."><span>3</span></a></sup> </p><p>Bariatric surgery should always be performed in a specialist centre and long-term follow-up of patients is necessary.</p><p>For more general information regarding obesity and its management, see the separate articles <a href="https://patient.info/doctor/obesity-in-adults" class="Link_linkcontainer__NFFuY Link_link-professionals__uur2P " data-testid="wrapper-link">Obesity in Adults</a> and <a href="https://patient.info/doctor/obesity-in-children" class="Link_linkcontainer__NFFuY Link_link-professionals__uur2P " data-testid="wrapper-link">Obesity in Children</a>.</p><h2 class="ScrollMargin_anchor__VQzBd" id="who-is-considered-for-bariatric-surgery" data-testid="heading-2">Who is considered for bariatric surgery?<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-4" title="Obesity: identification, assessment and management; NICE Clinical guideline, November 2014 - last updated July 2023"><span>4</span></a></sup> </h2><p>Bariatric surgery is an option in severely obese patients, where lifestyle and medication have been evaluated but found not to be effective. Surgery can be combined with other treatments. Referrals are usually made via a specialised obesity management service.</p><p>There are clear guidelines from the National Institute for Health and Care Excellence (NICE) about who should be considered for bariatric surgery:</p><p><b>Adults</b></p><ul><li><p>BMI ≥40 kg/m<sup>2</sup> OR BMI 35-40 kg/m<sup>2</sup> with other significant disease (eg, type 2 diabetes, hypertension) that could be improved by weight loss and:</p><ul><li><p>All appropriate non-surgical measures have failed to achieve or maintain adequate clinically beneficial weight loss.</p></li><li><p>They are receiving or will receive intensive specialist management.</p></li><li><p>They are generally fit for anaesthesia and surgery.</p></li><li><p>They commit to the need for long-term follow-up.</p></li></ul></li><li><p>Bariatric surgery is the option of choice (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m<sup>2</sup> when other interventions have not been effective.</p></li><li><p>For people with recent onset (within the previous ten years) type 2 diabetes mellitus:</p><ul><li><p>If BMI ≥35 kg/m<sup>2</sup>, expedite assessment for bariatric surgery (as long as they will receive assessment in a specialist tier 3 service.)</p></li><li><p>Consider assessment for bariatric surgery in a tier 3 service if BMI is 30-34.9 kg/m<sup>2</sup>.</p></li><li><p>For those of Asian origin, consider assessment for bariatric surgery in a tier 3 service at lower BMI than other populations.</p></li></ul></li></ul><p><b>Young people</b></p><p>Surgery is not generally recommended, as it is fraught with ethical issues and the potential long-term benefits and complications are not yet known.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-5" title="Caniano DA; Ethical issues in pediatric bariatric surgery. Semin Pediatr Surg. 2009 Aug;18(3):186-192."><span>5</span></a></sup></p><p> NICE suggests that it may be considered in exceptional circumstances, if:</p><ul><li><p>They have achieved or nearly achieved physiological maturity.</p></li><li><p>They are receiving or will receive intensive specialist management. This will include:</p><ul><li><p>Full information on procedures available and risks and benefits.</p></li><li><p>Management of comorbidities.</p></li><li><p>Psychological support before and after surgery.</p></li><li><p>Regular postoperative assessment, including specialist dietetic and surgical follow-up</p></li><li><p>Information about access to plastic surgery, such as apronectomy, where appropriate.</p></li><li><p>Access to suitable equipment for obese young people.</p></li><li><p>Assessment of fitness for anaesthesia and surgery.</p></li></ul></li><li><p>They have had a comprehensive psychological, educational, family and social assessment before undergoing bariatric surgery.</p></li><li><p>They have had a full medical evaluation, including genetic screening or assessment before surgery to exclude rare, treatable causes of obesity. They should also have had a specialist assessment to exclude eating disorders.</p></li></ul><table><tbody><tr><th><p>Editor's note</p></th></tr><tr><td><p><a href="https://patient.info/authors/dr-krishna-vakharia" class="Link_linkcontainer__NFFuY Link_link-professionals__uur2P " data-testid="wrapper-link">Dr Krishna Vakharia</a>, 28th July 2023</p><p><b>Obesity: identification, assessment and management</b><sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-4" title="Obesity: identification, assessment and management; NICE Clinical guideline, November 2014 - last updated July 2023"><span>4</span></a></sup> </p><p>NICE has updated its guidance on referral for bariatric surgery for at risk groups. </p><p>They advise to consider: </p><p>A referral for people of South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background using a lower BMI threshold - 37.5 or 32.5 and 37.5 with a health condition such as cardiovascular disease, hypertension, idiopathic intracranial hypertension, non-alcoholic fatty liver disease with or without steatohepatitis, obstructive sleep apnoea or Type 2 diabetes.</p><p>An expedited referral for people of South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background using a lower BMI threshold - BMI 27.5 to 32.5 - who have recent-onset (diagnosed within the past 10 years) type 2 diabetes.</p><p> </p></td></tr></tbody></table><p>Orlistat may be used to maintain or reduce weight before surgery for people who have been recommended surgery as a first-line option, if it is considered that the waiting time for surgery is excessive.</p><p>There are increasing demands for bariatric surgery to be considered as a valid option in children and adolescents in the face of the increasing prevalence of obesity in this age group.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-6" title="Hsia DS, Fallon SC, Brandt ML; Adolescent bariatric surgery. Arch Pediatr Adolesc Med. 2012 Aug;166(8):757-66. doi: 10.1001/archpediatrics.2012.1011."><span>6</span></a></sup> </p><p>Some research suggests that it may also be worthwhile for those with a BMI of 30-35.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-7" title="Picot J, Jones J, Colquitt JL, et al; Weight loss surgery for mild to moderate obesity: a systematic review and economic evaluation. Obes Surg. 2012 Sep;22(9):1496-506. doi: 10.1007/s11695-012-0679-z."><span>7</span></a></sup> Few procedures are performed on the elderly but the risk is thought to be no higher than any other gastrointestinal procedure.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-8" title="Varela JE, Wilson SE, Nguyen NT; Outcomes of bariatric surgery in the elderly. Am Surg. 2006 Oct;72(10):865-9."><span>8</span></a></sup> The risk:benefit ratio for those with a BMI >70 is currently being researched but one study of 49 patients reported that it was a safe procedure.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-9" title="Eldar SM, Heneghan HM, Brethauer SA, et al; Laparoscopic bariatric surgery for those with body mass index of 70-125 kg/m2. Surg Obes Relat Dis. 2012 Nov-Dec;8(6):736-40. doi: 10.1016/j.soard.2011.09.024. Epub 2011 Oct 14."><span>9</span></a></sup> </p><div class="InlineAds_inlineads__KhwOX" data-index="2" id="inlinead"><p class="InlineAds_adslinebreak__o_d8f"><span>Continue reading below</span><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 -960 960 960"><path d="M480-362q-8 0-15-2.5t-13-8.5L268-557q-11-11-11-28t11-28q11-11 28-11t28 11l156 156 156-156q11-11 28-11t28 11q11 11 11 28t-11 28L508-373q-6 6-13 8.5t-15 2.5Z"></path></svg></p><div class="InlineAds_adswrapper__q54f_"><div class="InlineAds_wrapper__D6jdy" aria-label="Side rail Advertisement" role="complementary" data-testid="inlineads-wrapper"><div id="div-gpt-ad-1698311751337-0" data-adunit="Side Rail-App" data-dimensions="300,250" data-targeting="{}" class="InlineAds_wrapper-active__1EvdQ" data-testid-adspossibledimensions="300,250"></div></div></div></div><h2 class="ScrollMargin_anchor__VQzBd" id="contra-indications-and-cautions" data-testid="heading-2">Contra-indications and cautions<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-10" title="Guidelines for Clinical Application of Laparoscopic Bariatric Surgery; Society of American Gastrointestinal and Endoscopic Surgeons, 2008"><span>10</span></a></sup> <sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-11" title="Pories WJ; Bariatric surgery: risks and rewards. J Clin Endocrinol Metab. 2008 Nov;93(11 Suppl 1):S89-96. doi: 10.1210/jc.2008-1641."><span>11</span></a></sup> </h2><ul><li><p>Unfit for surgery.</p></li><li><p>Uncontrolled alcohol or drug dependency.</p></li><li><p>Uncontrolled emotional disorders.</p></li><li><p>Lack of ability to understand surgery, consequences, need for follow-up.</p></li><li><p>Some centres advise pre-operative psychiatric and nutritionist assessment.</p></li></ul><h2 class="ScrollMargin_anchor__VQzBd" id="types-of-procedure-for-bariatric-surgery" data-testid="heading-2">Types of procedure for bariatric surgery<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-12" title="Arterburn DE, Courcoulas AP; Bariatric surgery for obesity and metabolic conditions in adults. BMJ. 2014 Aug 27;349:g3961. doi: 10.1136/bmj.g3961."><span>12</span></a></sup> <sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-13" title="BOSPA - British Obesity Surgery Patient Association"><span>13</span></a></sup> </h2><ul><li><p>Procedures are classified as restrictive, malabsorptive or both. <br/></p><ul><li><p>Restrictive procedures produce a feeling of fullness with lower food intake.</p></li><li><p>Malabsorptive procedures limit calorie uptake from the intestine.</p></li><li><p>It may be that these methods of action overlap, and that the effect is physiological, via endocrine and neuronal means, rather than purely limiting calorie intake.</p></li></ul></li><li><p>There are various procedures and variations on them, and these have evolved over a period of 50 years. The vast majority are now performed with a minimally invasive or laparoscopic approach.</p></li></ul><div class="TopicHighlights_topichighlights__cVzgP TopicHighlights_topichighlights-important__e8cUj" data-testid="topichighlights"><div data-testid="topichighlights-general" class="TopicHighlights_topichighlights__cVzgP TopicHighlights_topichighlights-general__4tMiE TopicHighlights_topichighlights-important__e8cUj"><div class=" Markup_markup__hjGOW TopicHighlights_custommarkup__0EpVt " data-testid="markup"><p><b>Bariatric surgery procedures currently used</b></p><ul><li><p>Restrictive: </p><ul><li><p>Laparoscopic adjustable gastric banding.</p></li><li><p>Vertical sleeve gastrectomy.</p></li></ul></li><li><p>Malabsorptive:</p><ul><li><p>Biliopancreatic diversion with/without duodenal switch.</p></li></ul></li><li><p>Both restrictive and malabsorptive:</p><ul><li><p>Roux-en-Y gastric bypass (RYGB).</p></li><li><p>Other types of gastric bypass.</p></li></ul></li><li><p>Other procedures:</p><ul><li><p>Gastric stimulation.</p></li><li><p>Intragastric balloon.</p></li></ul></li></ul><p></p></div></div></div><h3>Choice of procedure<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-4" title="Obesity: identification, assessment and management; NICE Clinical guideline, November 2014 - last updated July 2023"><span>4</span></a></sup> </h3><p>Bariatric surgery should be performed by a specialised team in a tertiary centre. The choice of procedure is partly determined by local expertise; it is important that all operations be performed by an experienced surgeon in a specialised multidisciplinary unit. Factors to take into account are:</p><ul><li><p>Fitness for surgery.</p></li><li><p>Degree of obesity.</p></li><li><p>Goals.</p></li><li><p>Comorbidities.</p></li><li><p>Best available evidence about effectiveness and long-term effects.</p></li><li><p>Facilities available, and experience of surgeon.</p></li><li><p>Some centres have a two-stage approach, using a restrictive procedure initially, followed by a malabsorptive procedure later if necessary.</p></li></ul><p>The use of the laparoscopic sleeve gastrectomy has increased in recent years.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-14" title="Nguyen NT, Nguyen B, Gebhart A, et al; Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy. J Am Coll Surg. 2013 Feb;216(2):252-7. doi: 10.1016/j.jamcollsurg.2012.10.003. Epub 2012 Nov 21."><span>14</span></a></sup> The most commonly used procedures in the UK currently are laparoscopic adjustable gastric banding, sleeve gastrectomy and gastric bypass.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-15" title="Too Lean a Service?; National Confidential Enquiry into Patient Outcome and Death, 2012"><span>15</span></a></sup> </p><p>Many studies and meta-analyses have tried to make comparisons between available procedures. The Cochrane review of 2014 concluded that outcomes were similar between RYGB and sleeve gastrectomy, and both of these procedures had better outcomes than adjustable gastric banding.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-1" title="Colquitt JL, Pickett K, Loveman E, et al; Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014 Aug 8;8:CD003641. doi: 10.1002/14651858.CD003641.pub4."><span>1</span></a></sup> </p><p>In those with very high BMI, biliopancreatic diversion with duodenal switch were found to result in greater weight loss than RYGB. It was noted that across all studies adverse event rates and re-operation rates were generally poorly reported, and the long-term effects of surgery remain unclear.</p><h3>Explanation of bariatric procedures</h3><ul><li><p><b>Laparoscopic adjustable gastric banding</b>: places a constricting ring around the stomach, below the gastro-oesphageal junction. The bands incorporate an inflatable balloon which can adjust the size of the ring, to regulate food intake.</p></li><li><p><b>Sleeve gastrectomy</b>: most of the stomach is removed, leaving a sleeve-shaped cylinder of stomach with reduced capacity. This procedure is irreversible.</p></li><li><p><b>Gastric bypass</b>: creates a small gastric pouch (restrictive) joined to the jejunum, bypassing the duodenum and proximal jejunum (malabsorptive). The RYGB is the usual procedure at the current time.</p></li><li><p><b>Biliopancreatic diversion</b>: is a more extensive form of the gastric bypass, with the gastric pouch joined to the ileum, totally bypassing the duodenum and jejunum. It produces more extreme <a href="https://patient.info/doctor/gastrointestinal-malabsorption" class="Link_linkcontainer__NFFuY Link_link-professionals__uur2P " data-testid="wrapper-link">malabsorption</a>.</p></li><li><p><b>Duodenal switch</b>: biliopancreatic diversion is sometimes performed with a duodenal switch. This produces a short distal length of small intestine, severely limiting caloric absorption. This is a complex operation which takes some hours to complete.</p></li><li><p><b>Gastric stimulation</b>: uses an implanted pacemaker-type device to produce electrical gastric stimulation, thought to cause a feeling of satiety.</p></li><li><p><b>Intragastric balloon</b>: this is an endoscopic rather than surgical procedure, placing a silicone balloon inflated in the stomach to promote a feeling of satiety. There is insufficient evidence to assess its effectiveness and there have been complications such as gastric erosions and ulcers. It is therefore usually removed after six months.</p></li><li><p><b>Endoscopic techniques</b>: apart from balloon insertion, various other endoscopic procedures are being developed but are not currently in common NHS use. These are collectively known as primary obesity surgery endolumenal (POSE).<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-16" title="Familiari P, Boskoski I, Marchese M, et al; Endoscopic treatment of obesity. Expert Rev Gastroenterol Hepatol. 2011 Dec;5(6):689-701. doi: 10.1586/egh.11.77."><span>16</span></a></sup> </p></li></ul><div class="InlineAds_inlineads__KhwOX" data-index="3" id="inlinead"><p class="InlineAds_adslinebreak__o_d8f"><span>Continue reading below</span><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 -960 960 960"><path d="M480-362q-8 0-15-2.5t-13-8.5L268-557q-11-11-11-28t11-28q11-11 28-11t28 11l156 156 156-156q11-11 28-11t28 11q11 11 11 28t-11 28L508-373q-6 6-13 8.5t-15 2.5Z"></path></svg></p><div class="InlineAds_adswrapper__q54f_"><div class="InlineAds_wrapper__D6jdy" aria-label="Side rail Advertisement" role="complementary" data-testid="inlineads-wrapper"><div id="div-gpt-ad-1698311686220-0" data-adunit="Side Rail-App" data-dimensions="300,250" data-targeting="{}" class="InlineAds_wrapper-active__1EvdQ" data-testid-adspossibledimensions="300,250"></div></div></div></div><h2 class="ScrollMargin_anchor__VQzBd" id="follow-up" data-testid="heading-2">Follow-up<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-4" title="Obesity: identification, assessment and management; NICE Clinical guideline, November 2014 - last updated July 2023"><span>4</span></a></sup> </h2><p>Those who have had bariatric surgery should be followed up by the specialist bariatric service for a minimum of two years. This should include:</p><ul><li><p>Monitoring nutritional intake (including protein and vitamins) and mineral deficiencies.</p></li><li><p>Dietary and nutritional advice and support.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-17" title="GP Guidance: Management of nutrition following bariatric surgery; The British Obesity and Metabolic Surgery Society, Aug 2014"><span>17</span></a></sup> </p></li><li><p>Physical activity advice and support.</p></li><li><p>Psychological support.</p></li><li><p>Monitoring for comorbidities.</p></li><li><p>Medication review.</p></li><li><p>Information about professionally led or peer-led support groups. For example, the British Obesity Surgery Patients Association (BOSPA).<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-13" title="BOSPA - British Obesity Surgery Patient Association"><span>13</span></a></sup> </p></li></ul><p>After discharge from bariatric surgery service follow-up, ensure that all people are offered at least annual monitoring of nutritional status and appropriate supplementation according to need.</p><h2 class="ScrollMargin_anchor__VQzBd" id="benefits-of-bariatric-surgery-procedures" data-testid="heading-2">Benefits of bariatric surgery procedures<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-18" title="Sjostrom L; Review of the key results from the Swedish Obese Subjects (SOS) trial - a prospective controlled intervention study of bariatric surgery. J Intern Med. 2013 Mar;273(3):219-34. doi: 10.1111/joim.12012. Epub 2013 Feb 8."><span>18</span></a></sup> </h2><ul><li><p>Weight loss. In a long-term Swedish trial, weight loss averaged 18% after 20 years.</p></li><li><p>Remission of diabetes mellitus. The Swedish trial showed a 72% remission rate two years after surgery.</p></li><li><p>The Swedish study also reported a reduction in overall mortality of 29%, and a reduction in the incidence of myocardial infarction, stroke and cancer.</p></li><li><p>Evidence suggests that non-alcoholic fatty liver disease (including <a href="https://patient.info/doctor/steatohepatitis-and-steatosis-fatty-liver" class="Link_linkcontainer__NFFuY Link_link-professionals__uur2P " data-testid="wrapper-link">steatosis</a>, <a href="https://patient.info/doctor/steatohepatitis-and-steatosis-fatty-liver" class="Link_linkcontainer__NFFuY Link_link-professionals__uur2P " data-testid="wrapper-link">steatohepatitis</a> and fibrosis) appears to improve or completely resolve in the majority of patients after bariatric surgery-induced weight loss.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-19" title="Tai CM, Huang CK, Hwang JC, et al; Improvement of nonalcoholic fatty liver disease after bariatric surgery in morbidly obese Chinese patients. Obes Surg. 2012 Jul;22(7):1016-21. doi: 10.1007/s11695-011-0579-7."><span>19</span></a></sup> </p></li></ul><h2 class="ScrollMargin_anchor__VQzBd" id="complications-and-disadvantages-of-surgery" data-testid="heading-2">Complications and disadvantages of surgery<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-12" title="Arterburn DE, Courcoulas AP; Bariatric surgery for obesity and metabolic conditions in adults. BMJ. 2014 Aug 27;349:g3961. doi: 10.1136/bmj.g3961."><span>12</span></a></sup> </h2><p>Pre-operative discussion is important; patients may have unrealistic ideas about the amount of weight they are likely to lose, the need for follow-up and the potential complications.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-20" title="Kim JH, Wolfe B; Bariatric/metabolic surgery: short- and long-term safety. Curr Atheroscler Rep. 2012 Dec;14(6):597-605. doi: 10.1007/s11883-012-0287-3."><span>20</span></a></sup> Data from 3.6 million patients have shown an overall pooled perioperative mortality of 0.08%.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-21" title="Huppler L, Robertson AG, Wiggins T, et al; How safe bariatric surgery is-An update on perioperative mortality for clinicians and patients. Clin Obes. 2022 Jun;12(3):e12515. doi: 10.1111/cob.12515. Epub 2022 Mar 9."><span>21</span></a></sup> </p><p>The incidence of complications within the first six months varies from 4-25%, and depends on procedure used, duration of follow-up and individual patient characteristics. Complications to consider include:</p><ul><li><p>Peri-operative complications as for any abdominal surgery include venous thromboembolism. The use of prophylaxis has reduced the incidence of deep vein thrombosis and pulmonary embolism considerably.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-22" title="Stroh C, Birk D, Flade-Kuthe R, et al; Evidence of thromboembolism prophylaxis in bariatric surgery-results of a quality assurance trial in bariatric surgery in Germany from 2005 to 2007 and review of the literature. Obes Surg. 2009 Jul;19(7):928-36. doi: 10.1007/s11695-009-9838-2. Epub 2009 May 5."><span>22</span></a></sup> </p></li><li><p>Possible complications of banding are band slippage, leakage, infection or migration.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-23" title="Eid I, Birch DW, Sharma AM, et al; Complications associated with adjustable gastric banding for morbid obesity: a surgeon's guides. Can J Surg. 2011 Feb;54(1):61-6."><span>23</span></a></sup> </p></li><li><p>Surgical complications of bypass surgery include leakage or stenosis of the stoma, gastrointestinal ulcers or bleeding, small bowel obstruction and hernias.</p></li><li><p>Nausea and vomiting may occur due to overeating or to stenosis at the surgery site.</p></li><li><p>Dumping syndrome: symptoms are flushing, light-headedness, palpitations, fatigue and diarrhoea, typically triggered by sugar after a RYGB. It is a neurohormonal reaction. It may help to discourage overeating.</p></li><li><p>Malnutrition: micronutrient deficiencies are a recognised problem, especially with malabsorptive procedures. Iron-deficiency anaemia is the most common complication. Calcium, zinc, folate and vitamin D deficiencies can occur. Thiamine, B12 and copper deficiencies may cause neurological symptoms and should be remembered. Protein-calorie malnutrition can also occur. Long-term follow-up is important.</p></li><li><p>Gallstones can develop as a consequence of rapid weight loss.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-24" title="Desbeaux A, Hec F, Andrieux S, et al; Risk of biliary complications in bariatric surgery. J Visc Surg. 2010 Aug;147(4):e217-20. doi: 10.1016/j.jviscsurg.2010.08.001."><span>24</span></a></sup> </p></li><li><p>Hyperoxaluria which can be mitigated to some extent by aggressive fluid intake, oral calcium and citrate supplementation.</p></li><li><p>Inadequate weight loss and weight regain. The latter is affected by behavioural patterns that can be assessed pre-operatively in order to identify individuals particularly at risk.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-25" title="Odom J, Zalesin KC, Washington TL, et al; Behavioral Predictors of Weight Regain after Bariatric Surgery. Obes Surg. 2009 Jun 25."><span>25</span></a></sup> </p></li><li><p>Up to 35% may require revisional procedures, particularly in gastric banding.</p></li><li><p>Bariatric surgery patients show a higher suicide rate than the general population.<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-26" title="Peterhansel C, Petroff D, Klinitzke G, et al; Risk of completed suicide after bariatric surgery: a systematic review. Obes Rev. 2013 Jan 9. doi: 10.1111/obr.12014."><span>26</span></a></sup> </p></li><li><p>Removal of excess skin after significant weight loss may not be available on the NHS.</p></li></ul><h3>The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report</h3><p>The NCEPOD report on bariatric surgery was published in 2012. In order to reduce mortality and morbidity associated with bariatric surgery, the following initiatives were suggested:<sup class="Body_reference__h__Rq" data-testid="body-reference"><a class=" Body_professionals__iDFsA " href="https://patient.info/doctor/bariatric-surgery#ref-15" title="Too Lean a Service?; National Confidential Enquiry into Patient Outcome and Death, 2012"><span>15</span></a></sup> </p><ul><li><p>Surgeons should undergo a minimum number of procedures before being allowed to operate unsupervised.</p></li><li><p>Service provision should be restricted to a number of accredited centres with a set minimum number of procedures per annum.</p></li><li><p>All patients must have access to the full range of specialised professionals appropriate for their needs in line with NICE guidelines.</p></li><li><p>Psychological support should be initiated at an earlier stage in the process.</p></li><li><p>Consent should be a two-stage process and should not be taken on the day of surgery.</p></li><li><p>A clear discharge plan should be provided to the GP as soon as possible, including detailed dietary advice.</p></li><li><p>Postoperative psychological advice should be made available if required.</p></li></ul></div></div><div class="FurtherReading_furtherreading__rzIRH"><div class="Accordion_accordion-empty__ihyBX undefined" role="region"><div role="button" tabindex="0" class="Accordion_accordion-header__YUsYL"><h3 data-testid="furtherReading_header">Further reading and references</h3><div class="Accordion_accordion-icon__VMjnF"><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 96 960 960"><path d="M268 683q-11-11-11-28t11-28l184-184q6-6 13-8.5t15-2.5q8 0 15 2.5t13 8.5l185 185q11 11 11 27t-12 28q-11 11-28 11t-28-11L480 527 323 684q-11 11-27 11t-28-12Z"></path></svg></div></div><div class="Accordion_accordion-content__n7Fz_"><div class="FurtherReading_furtherreading-content__7yw9j FurtherReading_furtherreading-content-professionals__4Tg5J"><div class=" Markup_markup__hjGOW FurtherReading_markup__LrR_5 " data-testid="markup"><ul><li><a href="https://cks.nice.org.uk/topics/obesity/" target="_blank" rel="noreferrer" data-testid="furtherReading_url">Obesity<svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 96 960 960"><path d="M200 936q-33 0-56.5-23.5T120 856V296q0-33 23.5-56.5T200 216h240q17 0 28.5 11.5T480 256q0 17-11.5 28.5T440 296H200v560h560V616q0-17 11.5-28.5T800 576q17 0 28.5 11.5T840 616v240q0 33-23.5 56.5T760 936H200Zm160-240q-11-11-11-28t11-28l344-344H600q-17 0-28.5-11.5T560 256q0-17 11.5-28.5T600 216h200q17 0 28.5 11.5T840 256v200q0 17-11.5 28.5T800 496q-17 0-28.5-11.5T760 456V352L415 697q-11 11-27 11t-28-12Z"></path></svg></a><span data-testid="furtherReading_text">; NICE CKS, August 2023 (UK access only)</span></li><li><a href="https://www.nice.org.uk/guidance/ta875" target="_blank" rel="noreferrer" data-testid="furtherReading_url">Semaglutide for managing overweight and obesity<svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 96 960 960"><path d="M200 936q-33 0-56.5-23.5T120 856V296q0-33 23.5-56.5T200 216h240q17 0 28.5 11.5T480 256q0 17-11.5 28.5T440 296H200v560h560V616q0-17 11.5-28.5T800 576q17 0 28.5 11.5T840 616v240q0 33-23.5 56.5T760 936H200Zm160-240q-11-11-11-28t11-28l344-344H600q-17 0-28.5-11.5T560 256q0-17 11.5-28.5T600 216h200q17 0 28.5 11.5T840 256v200q0 17-11.5 28.5T800 496q-17 0-28.5-11.5T760 456V352L415 697q-11 11-27 11t-28-12Z"></path></svg></a><span data-testid="furtherReading_text">; NICE Technology appraisal guidance, March 2023</span></li><li><a href="https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-obesity-physical-activity-and-diet" target="_blank" rel="noreferrer" data-testid="furtherReading_url">Statistics on Obesity, Physical Activity and Diet<svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 96 960 960"><path d="M200 936q-33 0-56.5-23.5T120 856V296q0-33 23.5-56.5T200 216h240q17 0 28.5 11.5T480 256q0 17-11.5 28.5T440 296H200v560h560V616q0-17 11.5-28.5T800 576q17 0 28.5 11.5T840 616v240q0 33-23.5 56.5T760 936H200Zm160-240q-11-11-11-28t11-28l344-344H600q-17 0-28.5-11.5T560 256q0-17 11.5-28.5T600 216h200q17 0 28.5 11.5T840 256v200q0 17-11.5 28.5T800 496q-17 0-28.5-11.5T760 456V352L415 697q-11 11-27 11t-28-12Z"></path></svg></a><span data-testid="furtherReading_text">; NHS Digital.</span></li><li><a href="https://bomss.org/" target="_blank" rel="noreferrer" data-testid="furtherReading_url"><svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 96 960 960"><path d="M200 936q-33 0-56.5-23.5T120 856V296q0-33 23.5-56.5T200 216h240q17 0 28.5 11.5T480 256q0 17-11.5 28.5T440 296H200v560h560V616q0-17 11.5-28.5T800 576q17 0 28.5 11.5T840 616v240q0 33-23.5 56.5T760 936H200Zm160-240q-11-11-11-28t11-28l344-344H600q-17 0-28.5-11.5T560 256q0-17 11.5-28.5T600 216h200q17 0 28.5 11.5T840 256v200q0 17-11.5 28.5T800 496q-17 0-28.5-11.5T760 456V352L415 697q-11 11-27 11t-28-12Z"></path></svg></a><span data-testid="furtherReading_text">British Obesity & Metabolic Surgery Society</span></li><li><a href="https://www.nice.org.uk/guidance/qs127/chapter/Quality-statement-6-Follow-up-care-after-bariatric-surgery" target="_blank" rel="noreferrer" data-testid="furtherReading_url">Obesity: clinical assessment and management<svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 96 960 960"><path d="M200 936q-33 0-56.5-23.5T120 856V296q0-33 23.5-56.5T200 216h240q17 0 28.5 11.5T480 256q0 17-11.5 28.5T440 296H200v560h560V616q0-17 11.5-28.5T800 576q17 0 28.5 11.5T840 616v240q0 33-23.5 56.5T760 936H200Zm160-240q-11-11-11-28t11-28l344-344H600q-17 0-28.5-11.5T560 256q0-17 11.5-28.5T600 216h200q17 0 28.5 11.5T840 256v200q0 17-11.5 28.5T800 496q-17 0-28.5-11.5T760 456V352L415 697q-11 11-27 11t-28-12Z"></path></svg></a><span data-testid="furtherReading_text">; NICE Quality standard [QS127]. 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Am Surg. 2006 Oct;72(10):865-9.</span></li><li class="ScrollMargin_anchor__VQzBd" id="ref-9" data-testid="further-reading-reference-item"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=22093378" target="_blank" rel="noreferrer" data-testid="further-reading-reference-link">Eldar SM, Heneghan HM, Brethauer SA, et al<svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 96 960 960"><path d="M200 936q-33 0-56.5-23.5T120 856V296q0-33 23.5-56.5T200 216h240q17 0 28.5 11.5T480 256q0 17-11.5 28.5T440 296H200v560h560V616q0-17 11.5-28.5T800 576q17 0 28.5 11.5T840 616v240q0 33-23.5 56.5T760 936H200Zm160-240q-11-11-11-28t11-28l344-344H600q-17 0-28.5-11.5T560 256q0-17 11.5-28.5T600 216h200q17 0 28.5 11.5T840 256v200q0 17-11.5 28.5T800 496q-17 0-28.5-11.5T760 456V352L415 697q-11 11-27 11t-28-12Z"></path></svg></a><span data-testid="further-reading-reference-text">; Laparoscopic bariatric surgery for those with body mass index of 70-125 kg/m2. 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J Clin Endocrinol Metab. 2008 Nov;93(11 Suppl 1):S89-96. doi: 10.1210/jc.2008-1641.</span></li><li class="ScrollMargin_anchor__VQzBd" id="ref-12" data-testid="further-reading-reference-item"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=25164369" target="_blank" rel="noreferrer" data-testid="further-reading-reference-link">Arterburn DE, Courcoulas AP<svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 96 960 960"><path d="M200 936q-33 0-56.5-23.5T120 856V296q0-33 23.5-56.5T200 216h240q17 0 28.5 11.5T480 256q0 17-11.5 28.5T440 296H200v560h560V616q0-17 11.5-28.5T800 576q17 0 28.5 11.5T840 616v240q0 33-23.5 56.5T760 936H200Zm160-240q-11-11-11-28t11-28l344-344H600q-17 0-28.5-11.5T560 256q0-17 11.5-28.5T600 216h200q17 0 28.5 11.5T840 256v200q0 17-11.5 28.5T800 496q-17 0-28.5-11.5T760 456V352L415 697q-11 11-27 11t-28-12Z"></path></svg></a><span data-testid="further-reading-reference-text">; Bariatric surgery for obesity and metabolic conditions in adults. 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Obes Surg. 2009 Jun 25.</span></li><li class="ScrollMargin_anchor__VQzBd" id="ref-26" data-testid="further-reading-reference-item"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=23297762" target="_blank" rel="noreferrer" data-testid="further-reading-reference-link">Peterhansel C, Petroff D, Klinitzke G, et al<svg xmlns="http://www.w3.org/2000/svg" height="24" width="24" viewBox="0 96 960 960"><path d="M200 936q-33 0-56.5-23.5T120 856V296q0-33 23.5-56.5T200 216h240q17 0 28.5 11.5T480 256q0 17-11.5 28.5T440 296H200v560h560V616q0-17 11.5-28.5T800 576q17 0 28.5 11.5T840 616v240q0 33-23.5 56.5T760 936H200Zm160-240q-11-11-11-28t11-28l344-344H600q-17 0-28.5-11.5T560 256q0-17 11.5-28.5T600 216h200q17 0 28.5 11.5T840 256v200q0 17-11.5 28.5T800 496q-17 0-28.5-11.5T760 456V352L415 697q-11 11-27 11t-28-12Z"></path></svg></a><span data-testid="further-reading-reference-text">; Risk of completed suicide after bariatric surgery: a systematic review. Obes Rev. 2013 Jan 9. doi: 10.1111/obr.12014.</span></li></ol></div></div></div></div></div><div class=" Markup_markup__hjGOW ArticleHistory_articlehistory__L8Zqh " data-testid="markup"><h2>Article history</h2><p class="ArticleHistory_articlehistory-desc__2QL_N" data-testid="article-history-desc">The information on this page is written and peer reviewed by qualified clinicians.</p><div class="ArticleHistory_reviewdate__K36Xw" data-testid="article-history-data"><ul><li class="ArticleHistory_reviewlist__h0dfS " data-testid="review-due"><div class="ArticleHistory_dotted__8aA5T"><h6 data-testid="review-due-date">Next review due: 23 Apr 2028</h6></div></li><li class=""><h6 class="ArticleHistory_date__QGJMl" data-testid="last-updated-date">25 Apr 2023 <span class="ArticleHistory_date-desc__zu5gX">| Latest version</span></h6><div class="ArticleHistory_noborder__NFsQ5" data-testid="last-updated-content"><p class="ArticleHistory_updateby__j5fGu">Last updated by</p><a 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There are various options, all of which have potential complications.","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"A 2014 Cochrane review concluded that surgery results in greater improvement in weight loss outcomes and weight-associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_40098","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"One meta-analysis at 10 or more years and a single-centre study of laparoscopic adjustable gastric banding with 20 years of follow-up found that all current procedures are associated with substantial and durable weight loss.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_65716","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"One randomised controlled trial found that, among obese participants with type 2 diabetes, bariatric surgery with two years of an adjunctive low-level lifestyle intervention resulted in more disease remission than did lifestyle intervention alone.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_65715","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Bariatric surgery should always be performed in a specialist centre and long-term follow-up of patients is necessary.","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"For more general information regarding obesity and its management, see the separate articles ","marks":[],"data":{}},{"nodeType":"entry-hyperlink","data":{"target":{"sys":{"id":"doc_3006","type":"Link","linkType":"Entry"}}},"content":[{"nodeType":"text","value":"Obesity in Adults","marks":[],"data":{}}]},{"nodeType":"text","value":" and ","marks":[],"data":{}},{"nodeType":"entry-hyperlink","data":{"target":{"sys":{"id":"doc_4037","type":"Link","linkType":"Entry"}}},"content":[{"nodeType":"text","value":"Obesity in Children","marks":[],"data":{}}]},{"nodeType":"text","value":".","marks":[],"data":{}}]},{"nodeType":"heading-2","data":{},"content":[{"nodeType":"text","value":"Who is considered for bariatric surgery?","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_65333","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Bariatric surgery is an option in severely obese patients, where lifestyle and medication have been evaluated but found not to be effective. Surgery can be combined with other treatments. Referrals are usually made via a specialised obesity management service.","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"There are clear guidelines from the National Institute for Health and Care Excellence (NICE) about who should be considered for bariatric surgery:","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Adults","marks":[{"type":"bold"}],"data":{}}]},{"nodeType":"unordered-list","data":{},"content":[{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"BMI ≥40 kg/m","marks":[],"data":{}},{"nodeType":"text","value":"2","marks":[{"type":"superscript"}],"data":{}},{"nodeType":"text","value":" OR BMI 35-40 kg/m","marks":[],"data":{}},{"nodeType":"text","value":"2","marks":[{"type":"superscript"}],"data":{}},{"nodeType":"text","value":" with other significant disease (eg, type 2 diabetes, hypertension) that could be improved by weight loss and:","marks":[],"data":{}}]},{"nodeType":"unordered-list","data":{},"content":[{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"All appropriate non-surgical measures have failed to achieve or maintain adequate clinically beneficial weight loss.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"They are receiving or will receive intensive specialist management.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"They are generally fit for anaesthesia and surgery.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"They commit to the need for long-term follow-up.","marks":[],"data":{}}]}]}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Bariatric surgery is the option of choice (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m","marks":[],"data":{}},{"nodeType":"text","value":"2","marks":[{"type":"superscript"}],"data":{}},{"nodeType":"text","value":" when other interventions have not been effective.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"For people with recent onset (within the previous ten years) type 2 diabetes mellitus:","marks":[],"data":{}}]},{"nodeType":"unordered-list","data":{},"content":[{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"If BMI ≥35 kg/m","marks":[],"data":{}},{"nodeType":"text","value":"2","marks":[{"type":"superscript"}],"data":{}},{"nodeType":"text","value":", expedite assessment for bariatric surgery (as long as they will receive assessment in a specialist tier 3 service.)","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Consider assessment for bariatric surgery in a tier 3 service if BMI is 30-34.9 kg/m","marks":[],"data":{}},{"nodeType":"text","value":"2","marks":[{"type":"superscript"}],"data":{}},{"nodeType":"text","value":".","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"For those of Asian origin, consider assessment for bariatric surgery in a tier 3 service at lower BMI than other populations.","marks":[],"data":{}}]}]}]}]}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Young people","marks":[{"type":"bold"}],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Surgery is not generally recommended, as it is fraught with ethical issues and the potential long-term benefits and complications are not yet known.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_7553","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":"","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":" NICE suggests that it may be considered in exceptional circumstances, if:","marks":[],"data":{}}]},{"nodeType":"unordered-list","data":{},"content":[{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"They have achieved or nearly achieved physiological maturity.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"They are receiving or will receive intensive specialist management. This will include:","marks":[],"data":{}}]},{"nodeType":"unordered-list","data":{},"content":[{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Full information on procedures available and risks and benefits.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Management of comorbidities.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Psychological support before and after surgery.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Regular postoperative assessment, including specialist dietetic and surgical follow-up","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Information about access to plastic surgery, such as apronectomy, where appropriate.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Access to suitable equipment for obese young people.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Assessment of fitness for anaesthesia and surgery.","marks":[],"data":{}}]}]}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"They have had a comprehensive psychological, educational, family and social assessment before undergoing bariatric surgery.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"They have had a full medical evaluation, including genetic screening or assessment before surgery to exclude rare, treatable causes of obesity. They should also have had a specialist assessment to exclude eating disorders.","marks":[],"data":{}}]}]}]},{"nodeType":"table","data":{},"content":[{"nodeType":"table-row","content":[{"nodeType":"table-header-cell","content":[{"nodeType":"paragraph","content":[{"nodeType":"text","value":"Editor's note","marks":[],"data":{}}],"data":{}}],"data":{}}],"data":{}},{"nodeType":"table-row","content":[{"nodeType":"table-cell","content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"","marks":[],"data":{}},{"nodeType":"entry-hyperlink","data":{"target":{"sys":{"type":"Link","linkType":"Entry","id":"36e3dfe8-745e-4a8c-97de-7cc2f29ba3fa"}}},"content":[{"nodeType":"text","value":"Dr Krishna Vakharia","marks":[],"data":{}}]},{"nodeType":"text","value":", 28th July 2023","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Obesity: identification, assessment and management","marks":[{"type":"bold"}],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_65333","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"NICE has updated its guidance on referral for bariatric surgery for at risk groups. ","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"They advise to consider: ","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"A referral for people of South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background using a lower BMI threshold - 37.5 or 32.5 and 37.5 with a health condition such as cardiovascular disease, hypertension, idiopathic intracranial hypertension, non-alcoholic fatty liver disease with or without steatohepatitis, obstructive sleep apnoea or Type 2 diabetes.","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"An expedited referral for people of South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background using a lower BMI threshold - BMI 27.5 to 32.5 - who have recent-onset (diagnosed within the past 10 years) type 2 diabetes.","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":" ","marks":[],"data":{}}]}],"data":{}}],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Orlistat may be used to maintain or reduce weight before surgery for people who have been recommended surgery as a first-line option, if it is considered that the waiting time for surgery is excessive.","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"There are increasing demands for bariatric surgery to be considered as a valid option in children and adolescents in the face of the increasing prevalence of obesity in this age group.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_29685","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Some research suggests that it may also be worthwhile for those with a BMI of 30-35.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_29707","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" Few procedures are performed on the elderly but the risk is thought to be no higher than any other gastrointestinal procedure.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_29686","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" The risk:benefit ratio for those with a BMI \u003e70 is currently being researched but one study of 49 patients reported that it was a safe procedure.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_29687","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"heading-2","data":{},"content":[{"nodeType":"text","value":"Contra-indications and cautions","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_29689","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_40099","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"unordered-list","data":{},"content":[{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Unfit for surgery.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Uncontrolled alcohol or drug dependency.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Uncontrolled emotional disorders.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Lack of ability to understand surgery, consequences, need for follow-up.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Some centres advise pre-operative psychiatric and nutritionist assessment.","marks":[],"data":{}}]}]}]},{"nodeType":"heading-2","data":{},"content":[{"nodeType":"text","value":"Types of procedure for bariatric surgery","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_40100","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_7552","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"unordered-list","data":{},"content":[{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Procedures are classified as restrictive, malabsorptive or both.\r\n","marks":[],"data":{}}]},{"nodeType":"unordered-list","data":{},"content":[{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Restrictive procedures produce a feeling of fullness with lower food intake.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Malabsorptive procedures limit calorie uptake from the intestine.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"It may be that these methods of action overlap, and that the effect is physiological, via endocrine and neuronal means, rather than purely limiting calorie intake.","marks":[],"data":{}}]}]}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"There are various procedures and variations on them, and these have evolved over a period of 50 years. The vast majority are now performed with a minimally invasive or laparoscopic approach.","marks":[],"data":{}}]}]}]},{"nodeType":"embedded-entry-block","data":{"target":{"sys":{"id":"THL_1_1844_hig","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"heading-3","data":{},"content":[{"nodeType":"text","value":"Choice of procedure","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_65333","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Bariatric surgery should be performed by a specialised team in a tertiary centre. The choice of procedure is partly determined by local expertise; it is important that all operations be performed by an experienced surgeon in a specialised multidisciplinary unit. Factors to take into account are:","marks":[],"data":{}}]},{"nodeType":"unordered-list","data":{},"content":[{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Fitness for surgery.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Degree of obesity.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Goals.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Comorbidities.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Best available evidence about effectiveness and long-term effects.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Facilities available, and experience of surgeon.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Some centres have a two-stage approach, using a restrictive procedure initially, followed by a malabsorptive procedure later if necessary.","marks":[],"data":{}}]}]}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"The use of the laparoscopic sleeve gastrectomy has increased in recent years.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_29691","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" The most commonly used procedures in the UK currently are laparoscopic adjustable gastric banding, sleeve gastrectomy and gastric bypass.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_29682","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Many studies and meta-analyses have tried to make comparisons between available procedures. The Cochrane review of 2014 concluded that outcomes were similar between RYGB and sleeve gastrectomy, and both of these procedures had better outcomes than adjustable gastric banding.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_40098","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"In those with very high BMI, biliopancreatic diversion with duodenal switch were found to result in greater weight loss than RYGB. It was noted that across all studies adverse event rates and re-operation rates were generally poorly reported, and the long-term effects of surgery remain unclear.","marks":[],"data":{}}]},{"nodeType":"heading-3","data":{},"content":[{"nodeType":"text","value":"Explanation of bariatric procedures","marks":[],"data":{}}]},{"nodeType":"unordered-list","data":{},"content":[{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Laparoscopic adjustable gastric banding","marks":[{"type":"bold"}],"data":{}},{"nodeType":"text","value":": places a constricting ring around the stomach, below the gastro-oesphageal junction. The bands incorporate an inflatable balloon which can adjust the size of the ring, to regulate food intake.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Sleeve gastrectomy","marks":[{"type":"bold"}],"data":{}},{"nodeType":"text","value":": most of the stomach is removed, leaving a sleeve-shaped cylinder of stomach with reduced capacity. This procedure is irreversible.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Gastric bypass","marks":[{"type":"bold"}],"data":{}},{"nodeType":"text","value":": creates a small gastric pouch (restrictive) joined to the jejunum, bypassing the duodenum and proximal jejunum (malabsorptive). The RYGB is the usual procedure at the current time.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Biliopancreatic diversion","marks":[{"type":"bold"}],"data":{}},{"nodeType":"text","value":": is a more extensive form of the gastric bypass, with the gastric pouch joined to the ileum, totally bypassing the duodenum and jejunum. It produces more extreme ","marks":[],"data":{}},{"nodeType":"entry-hyperlink","data":{"target":{"sys":{"id":"doc_2183","type":"Link","linkType":"Entry"}}},"content":[{"nodeType":"text","value":"malabsorption","marks":[],"data":{}}]},{"nodeType":"text","value":".","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Duodenal switch","marks":[{"type":"bold"}],"data":{}},{"nodeType":"text","value":": biliopancreatic diversion is sometimes performed with a duodenal switch. This produces a short distal length of small intestine, severely limiting caloric absorption. This is a complex operation which takes some hours to complete.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Gastric stimulation","marks":[{"type":"bold"}],"data":{}},{"nodeType":"text","value":": uses an implanted pacemaker-type device to produce electrical gastric stimulation, thought to cause a feeling of satiety.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Intragastric balloon","marks":[{"type":"bold"}],"data":{}},{"nodeType":"text","value":": this is an endoscopic rather than surgical procedure, placing a silicone balloon inflated in the stomach to promote a feeling of satiety. There is insufficient evidence to assess its effectiveness and there have been complications such as gastric erosions and ulcers. It is therefore usually removed after six months.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Endoscopic techniques","marks":[{"type":"bold"}],"data":{}},{"nodeType":"text","value":": apart from balloon insertion, various other endoscopic procedures are being developed but are not currently in common NHS use. These are collectively known as primary obesity surgery endolumenal (POSE).","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_29710","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]}]}]},{"nodeType":"heading-2","data":{},"content":[{"nodeType":"text","value":"Follow-up","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_65333","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Those who have had bariatric surgery should be followed up by the specialist bariatric service for a minimum of two years. This should include:","marks":[],"data":{}}]},{"nodeType":"unordered-list","data":{},"content":[{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Monitoring nutritional intake (including protein and vitamins) and mineral deficiencies.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Dietary and nutritional advice and support.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_40175","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Physical activity advice and support.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Psychological support.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Monitoring for comorbidities.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Medication review.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Information about professionally led or peer-led support groups. For example, the British Obesity Surgery Patients Association (BOSPA).","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_7552","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]}]}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"After discharge from bariatric surgery service follow-up, ensure that all people are offered at least annual monitoring of nutritional status and appropriate supplementation according to need.","marks":[],"data":{}}]},{"nodeType":"heading-2","data":{},"content":[{"nodeType":"text","value":"Benefits of bariatric surgery procedures","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_29694","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"unordered-list","data":{},"content":[{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Weight loss. In a long-term Swedish trial, weight loss averaged 18% after 20 years.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Remission of diabetes mellitus. The Swedish trial showed a 72% remission rate two years after surgery.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"The Swedish study also reported a reduction in overall mortality of 29%, and a reduction in the incidence of myocardial infarction, stroke and cancer.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Evidence suggests that non-alcoholic fatty liver disease (including ","marks":[],"data":{}},{"nodeType":"entry-hyperlink","data":{"target":{"sys":{"id":"doc_2799","type":"Link","linkType":"Entry"}}},"content":[{"nodeType":"text","value":"steatosis","marks":[],"data":{}}]},{"nodeType":"text","value":", ","marks":[],"data":{}},{"nodeType":"entry-hyperlink","data":{"target":{"sys":{"id":"doc_2799","type":"Link","linkType":"Entry"}}},"content":[{"nodeType":"text","value":"steatohepatitis","marks":[],"data":{}}]},{"nodeType":"text","value":" and fibrosis) appears to improve or completely resolve in the majority of patients after bariatric surgery-induced weight loss.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_7564","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]}]}]},{"nodeType":"heading-2","data":{},"content":[{"nodeType":"text","value":"Complications and disadvantages of surgery","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_40100","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Pre-operative discussion is important; patients may have unrealistic ideas about the amount of weight they are likely to lose, the need for follow-up and the potential complications.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_29703","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" Data from 3.6 million patients have shown an overall pooled perioperative mortality of 0.08%.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_65717","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"The incidence of complications within the first six months varies from 4-25%, and depends on procedure used, duration of follow-up and individual patient characteristics. Complications to consider include:","marks":[],"data":{}}]},{"nodeType":"unordered-list","data":{},"content":[{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Peri-operative complications as for any abdominal surgery include venous thromboembolism. The use of prophylaxis has reduced the incidence of deep vein thrombosis and pulmonary embolism considerably.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_29702","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Possible complications of banding are band slippage, leakage, infection or migration.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_29704","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Surgical complications of bypass surgery include leakage or stenosis of the stoma, gastrointestinal ulcers or bleeding, small bowel obstruction and hernias.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Nausea and vomiting may occur due to overeating or to stenosis at the surgery site.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Dumping syndrome: symptoms are flushing, light-headedness, palpitations, fatigue and diarrhoea, typically triggered by sugar after a RYGB. It is a neurohormonal reaction. It may help to discourage overeating.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Malnutrition: micronutrient deficiencies are a recognised problem, especially with malabsorptive procedures. Iron-deficiency anaemia is the most common complication. Calcium, zinc, folate and vitamin D deficiencies can occur. Thiamine, B12 and copper deficiencies may cause neurological symptoms and should be remembered. Protein-calorie malnutrition can also occur. Long-term follow-up is important.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Gallstones can develop as a consequence of rapid weight loss.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_40157","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Hyperoxaluria which can be mitigated to some extent by aggressive fluid intake, oral calcium and citrate supplementation.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Inadequate weight loss and weight regain. The latter is affected by behavioural patterns that can be assessed pre-operatively in order to identify individuals particularly at risk.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_7567","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Up to 35% may require revisional procedures, particularly in gastric banding.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Bariatric surgery patients show a higher suicide rate than the general population.","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_29706","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Removal of excess skin after significant weight loss may not be available on the NHS.","marks":[],"data":{}}]}]}]},{"nodeType":"heading-3","data":{},"content":[{"nodeType":"text","value":"The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report","marks":[],"data":{}}]},{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"The NCEPOD report on bariatric surgery was published in 2012. In order to reduce mortality and morbidity associated with bariatric surgery, the following initiatives were suggested:","marks":[],"data":{}},{"nodeType":"embedded-entry-inline","data":{"target":{"sys":{"id":"ref_29682","type":"Link","linkType":"Entry"}}},"content":[]},{"nodeType":"text","value":" ","marks":[],"data":{}}]},{"nodeType":"unordered-list","data":{},"content":[{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Surgeons should undergo a minimum number of procedures before being allowed to operate unsupervised.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Service provision should be restricted to a number of accredited centres with a set minimum number of procedures per annum.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"All patients must have access to the full range of specialised professionals appropriate for their needs in line with NICE guidelines.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Psychological support should be initiated at an earlier stage in the process.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Consent should be a two-stage process and should not be taken on the day of surgery.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"A clear discharge plan should be provided to the GP as soon as possible, including detailed dietary advice.","marks":[],"data":{}}]}]},{"nodeType":"list-item","data":{},"content":[{"nodeType":"paragraph","data":{},"content":[{"nodeType":"text","value":"Postoperative psychological advice should be made available if required.","marks":[],"data":{}}]}]}]}]},"__typename":"PagePatientProfessionalArticleBody","links":{"__typename":"PagePatientProfessionalArticleBodyLinks","entries":{"__typename":"PagePatientProfessionalArticleBodyEntries","inline":[{"sys":{"id":"ref_40098","__typename":"Sys"},"__typename":"TopicReferences","pubMedId":"25105982","internalName":"40098 : Surgery for weight loss in adults.","url":"http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve\u0026db=PubMed\u0026dopt=Abstract\u0026list_uids=25105982","referenceText":"Colquitt JL, Pickett K, Loveman E, et al; Surgery for weight loss in adults. 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Obes Surg. 2012 Jul;22(7):1016-21. doi: 10.1007/s11695-011-0579-7."},{"sys":{"id":"ref_29703","__typename":"Sys"},"__typename":"TopicReferences","pubMedId":"23054663","internalName":"29703 : Bariatric/metabolic surgery: short- and long-term safety.","url":"http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve\u0026db=PubMed\u0026dopt=Abstract\u0026list_uids=23054663","referenceText":"Kim JH, Wolfe B; Bariatric/metabolic surgery: short- and long-term safety. Curr Atheroscler Rep. 2012 Dec;14(6):597-605. doi: 10.1007/s11883-012-0287-3."},{"sys":{"id":"ref_65717","__typename":"Sys"},"__typename":"TopicReferences","pubMedId":"35261160","internalName":"65717 : How safe bariatric surgery is-An update on perioperative mortality for clinicians and patients.","url":"http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve\u0026db=PubMed\u0026dopt=Abstract\u0026list_uids=35261160","referenceText":"Huppler L, Robertson AG, Wiggins T, et al; How safe bariatric surgery is-An update on perioperative mortality for clinicians and patients. Clin Obes. 2022 Jun;12(3):e12515. doi: 10.1111/cob.12515. Epub 2022 Mar 9."},{"sys":{"id":"ref_29702","__typename":"Sys"},"__typename":"TopicReferences","pubMedId":" 19415404","internalName":"29702 : Evidence of thromboembolism prophylaxis in bariatric surgery-results of a quality assurance trial in bariatric surgery in Germany from 2005 to 2007 and review of the literature.","url":"http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve\u0026db=PubMed\u0026dopt=Abstract\u0026list_uids=19415404","referenceText":"Stroh C, Birk D, Flade-Kuthe R, et al; Evidence of thromboembolism prophylaxis in bariatric surgery-results of a quality assurance trial in bariatric surgery in Germany from 2005 to 2007 and review of the literature. Obes Surg. 2009 Jul;19(7):928-36. doi: 10.1007/s11695-009-9838-2. 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