Challenges in the care and treatment of patients with extreme obesity

Abstract

Obesity is a prevalent chronic disease. The management of extreme obesity - i.e., body mass index (BMI) ≥ 50 kg/m² or obesity class IV and V - is still far from ideal. Individuals with extreme obesity have a high risk of surgical complications, mortality, comorbidities, and reduced weight loss following bariatric surgery. Although lifestyle changes and anti-obesity medications are recommended for all patients with extreme obesity as adjuvants to weight loss, these measures are less effective than bariatric surgery. As a first step, sleeve gastrectomy or an inpatient very-low-calorie diet should be incentivized to enhance weight loss before definitive surgery. Although malabsorptive procedures lead to greater weight loss, they are associated with an increased risk of early complications and malnutrition. Nonstandard techniques employed in clinical trial protocols, such as transit bipartition, may be performed as they maintain a weight loss potency comparable to that of the classic duodenal switch but with fewer nutritional problems. Anatomical causes should be investigated in patients with postoperative suboptimal clinical response or recurrent weight gain. In these cases, the initiation of anti-obesity drugs, endoscopic therapies, or a conversion procedure might be recommended. More studies are needed to address the specific population of patients with extreme obesity, as their outcomes are expected to be distinct from those of patients with lower BMI.

Keywords: Bariatric surgery; GLP-1 receptor agonists; anti-obesity drugs; extreme obesity; mortality.

Figure 1. Abdominal magnetic resonance images (coronal plane) of a patient who underwent an inpatient very-low-calorie diet for 20 weeks. The images illustrate a remarkable reduction in liver size and in subcutaneous and visceral abdominal adipose tissue. (A) Before weight loss: weight 249 kg, body mass index (BMI) 77 kg/m2. (B) After a weight loss of 76 kg: weight 173 kg, BMI 54 kg/m2 (courtesy Prof. Dr. Marco Aurélio Santo).

Figure 2. Suggested management approach for patients with extreme obesity.