Need of Standardization in Bariatric Surgery: Is it Time to Think About? Comment on Contreras JE, Santander C, Court I, Bravo J. Correlation Between Age and Weight Loss After Bariatric Surgery. Obesity Surgery 2013; 23(8):1286–9

We carefully read and appreciated the contribution by Contreras et al. [1] which focuses on a very controversial issue in bariatric surgery, age as an independent factor of weight loss. As similarly reported in the article of Scozzari et al. [2], age could be considered a predictor of weight loss with a significant relationship of inverse proportionality.

This arouses a thought on standardization of bariatric surgery.

We all know that bariatric surgery must be tailored on patient’s features, anthropometric, nutritional, metabolic, psychologic, and socioeconomic, too. So, global evaluation, careful preoperative work-up, and patient’s selection are absolutely mandatory to modulate the best procedure for each patient.

On the other hand, bariatric surgery needs standardization for daily clinical practice (and for better comparison of our results) as well as in other surgical fields.

So is it time to propose a standardization of bariatric procedures first of all focused on age?

If not, is it time at least to think of a standardization based on the evidences and the results available?

For young patients, independently of BMI, is it better to propose a more definitive procedure with extremely good results in terms of weight loss such as gastric bypass or is it reasonable to plan a sequential treatment with a restrictive procedure firstly followed by a gastric bypass in case of failure? We should consider that in young patients, treatment of obesity may be planned over longer time and the risk of nutrient deficiencies related to gastric bypass may be more harmful.

On the other hand, in elderly patients, we should take a different point of view. We know that elderly patients are more at risk of complications and it seems, according to Contreras, that they get lower BMI decrease after bariatric surgery than young patients. In evaluating the best treatment for elderly patients, we should consider not only comorbidities and ASA score but also life expectancy, quality of life, different metabolism, reduced energy requirement, and compliance to clinical controls. Last (but not least), we should consider the need to solve obesity and related problems with only a single procedure if possible to minimize hospitalization for redo surgery.

So is it better to submit elderly patients, independently from BMI and comorbidities, to the safest and simplest procedure (but) with uncertain results in terms of weight loss (i.e., gastric banding) or is it better to propose the more effective procedure even if burdened of more risk of complications?

Only examining long-term follow-up and predictors of weight loss it will be possible to draft standardized age-based protocols.