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ORIGINAL CONTRIBUTIONSOSSI(Obesity and Metabolic Surgery Society of India)Guidelinesfor Patient and Procedure Selection for Bariatric and MetabolicSurgeryA.G.Bhasker1&A.Prasad2&P.Praveen Raj3&R.Wadhawan4&M.Khaitan5&A.J.Agarwal6&O.Tantia7&S.Baig8&R.Palaniappan9&H.V.Shivram10&S.Shah11&V.Soni12&M.Bhandari13&R.Shivahare14&S.Dhorepatil15&P.Chowbey16&M.Narwaria17&S.Shah18,19&R.Khullar20#Springer Science+Business Media,LLC,part of Springer Nature 2020AbstractBackground India isthe largesthub for bariatric andmetabolic surgeryinAsia.OSSI iscommittedtoimprove the qualityofcareand set the standards for its practice in India.Methods The first draft of OSSI guidelines was prepared by the secretary,Dr.Praveen Raj under the guidance of currentPresident,Dr.Arun Prasad.All executive council members were given voting privileges,and the proposed guidelines werecirculated on email for approval of the executive council.Guidelines were finalized after 100%agreement from all votingmembers and were also circulated among all OSSI members for their suggestions.Results OSSI upholds the BMI criteria for bariatric and metabolic surgery of 2011 IFSO-APC guidelines.In addition to this,werecognize that waist circumference of 80 cm in females and 90 cm in males along with obesity related co-morbidities may beconsidered for surgery.In addition to standard procedures as recommended by IFSO,OSSI acknowledges the additionalprocedures,and a review of literature for these procedures is presented in the discussion.*A.G.BA.PP.Praveen Rajdrrajgeminstitute.inR.WM.KA.J.AO.TS.BR.PH.V.SS.SV.Sonivandan_M.BR.SS.DP.CM.NS.SR.KExtended author information available on the last page of the articleObesity Surgeryhttps:/doi.org/10.1007/s11695-020-04497-1 Conclusion The burden of obesity in India is one of the highest in the world and with numbers of bariatric and metabolicprocedures rising rapidly;there is a need for country specific guidelines.The Indian population is unique in its phenotype,genotype and nutritional make up.This document enlists guidelines for surgeons and allied health practitioners as also multipleother stake-holders like primary health physicians,policy makers,insurance companies and the Indian government.Keywords ObesityandMetabolicSurgerySocietyofIndia(OSSI).Guidelines.Bariatricandmetabolicsurgery.Bodymassindex(BMI).Waistcircumference.India.AsianIndianphenotypeIntroductionHome to more than 1.37 billion people,India today has the thirdhighest number of people suffering from obesity in the worldafterUSAandChina 1.Withrapidincrease inlevelsofobesityin India,bariatric and metabolic surgery has emerged as a validoption for treatment of clinically severe obesity 2.The Obesityand Metabolic Surgery Society of India(OSSI)was establishedin the year 2002 with eight founding members.The OSSI hadreleased its first position statement in the year 2013,whereinbariatric/metabolic surgeries were consideredas“gastrointestinalsurgeries”aimed at improving and/or treating clinically severeobesity and associated co-morbidities.It was also stated thatbariatric/metabolic surgery is not a“cosmetic surgery”,but a“life-saving”one.Today,the society has 450 registered members practicingbariatric/metabolic surgery.In the last two decades,the num-bers of bariatric and metabolic surgical procedures havegrown more than tenfold in India.As per OSSI data,20,242bariatric and metabolic procedures were reportedly performedin India in 2018,and according to the IFSO global registryreport 2018,India isthe largest hub for bariatric surgery in theAsian continent 3.A guideline is a systematically developed statement to as-sist practitioner and patient decisions about appropriate healthcarefor specificclinicalcircumstances 4.Every country pre-sentsadifferentsetofhealthcarechallenges.Localacceptanceof various treatment options varies from region to region,andthere are cultural differences that must be taken into account.The burden of obesity in India is one of the highest in theworld with numbers of bariatric and metabolic proceduresrising rapidly,as the national society,we feel the need forcountry specific guidelines that will help us to set standardsand improve the quality of care for our patients.In the last three decades,there has been exponential eco-nomic growth in India.In addition to the changing environ-ment,Indians also have a genetic preponderance to higherbody fat percentage,and that has led to a dual epidemic ofobesity and type two diabetes 5.The Asian Indian pheno-type is also characterized with greater central obesity 6.Studies have shown that in Indian population there is a higherassociation of central obesity with development of type twodiabetes mellitus than that of generalized obesity 7.Alongwiththis,itisseenthatobesity-relatedmetabolicdiseasestendto develop at a much lower body mass index(BMI)in theAsian population 8.Thus,in the Indian context,not onlydoweneedtohavelowerBMIcriteriaascomparedtowesterncountries,we also need to take waist circumference into ac-count for classifying obesity.While on one hand,wehavea burgeoning healthcareprob-lem in the form of obesity and type two diabetes mellitus,onthe other hand,we are struggling with resources to battle non-communicable diseases.Unlike most western countries,Indiadoes not have state sponsored health coverage.Health insur-ance sector is dominated mainly by private insurance players.Until recently,the Indian insurance sector classified obesityand related disorders as a“cosmetic”issue and any kind oftreatment for“obesity”,and related disorders was excludedfrom insurance coverage.In October 2019,InsuranceRegulatory and Development Authority of India(IRDAI)has finally acceded to include bariatric and metabolic surgeryas a treatment option for clinically severe obesity and its re-lateddiseases.Thoughthisisawelcomechange,inabsenceofcountry specific guidelines,IRDAI has chosen to follow thearchaicNIHguidelinesforbariatricandmetabolicsurgery2.As a result of this,many deserving patients will get excludedandwillnotbeabletoavailinsurancebenefitfor thetreatmentof obesity and related metabolic disorders.These guidelines recommended in this paper are based onpreviously published guidelines like NIH,JSSO,APMBSS,OSSANZ,ACMOMS,ADSS,DSS and IFSO-APC 2,912.IFSO APC guidelines of 2011 are the most recent publishedguideline for the Asian region;however,these are now almosta decade old 9.The trends in bariatric/metabolic surgery havechangedconsiderably in the last decade,and there is an influxofnew literature.While the OSSI guidelines acknowledge theseguidelines and have borrowed from them,there was a need toreviewthenewliteratureandproposeanupdatedcountryspecif-ic guideline for bariatric/metabolic surgery.The aim of this document is to enlist the OSSI guidelinesfor patient and procedure selection for surgeons and alliedhealth practitioners practicing bariatric and metabolic surgery.These guidelines intend to guide IRDAI and multiple otherstake-holders such as primary health physicians,specialtydoctors,patients,policy makers and the Indian government.We also acknowledge that these guidelines are not rigid rec-ommendations to be enforced in all situations and ultimatelyclinical discretion is of greatest importance.OBES SURG MethodsThe first draft of the OSSI guidelines was prepared by theOSSI Secretary,Dr.Praveen Raj under the guidance of thecurrent President,Dr.Arun Prasad.All the executive councilmembers were given voting privileges,and the proposedguidelines were circulated on email for suggestions and sub-sequent approval of the executive council.The OSSI execu-tive council consists of the president,secretary,treasurer,jointsecretary,the past presidents of the society and two electedmembers from the North,South,East,West and Centralzonesof the country.The elected members serve as the representa-tives of their respective zones.Table 1 delineates the list ofexecutive council members who served as moderators andvoting members for the formulation of these guidelines.These guidelines were finalized after 100%agreement fromall voting members.They were also circulated among allOSSI members for their valuable suggestions.This articledoes not contain any studies with human participants or ani-mals performed by any of the authors,and a statement ofinformed consent does not apply in this case.GuidelinesIndications for Bariatric/Metabolic Surgery1.Bariatric/metabolic surgery should be considered a treatmentoption for acceptable Indian patients with a BMI35 kg/m2,with/withoutpresenceofanyobesityrelatedco-morbidity9.2.Bariatric/metabolic surgery should be considered a treat-ment option for acceptable Indian patients with a BMI30 kg/m2,in presence of two or more obesity related co-morbidities 9.3.Bariatric/metabolic surgery should be considered as anon-primary treatment option for acceptable Indian pa-tients with a BMI27.5 kg/m2,with uncontrolled type2 diabetes despite optimum medical management 9.4.Any bariatric/metabolic surgery for an Indian patient withBMI 150 cm withOAGB/MGB is ill-advised.Obes Surg.2017;27(8):21645.31.Kota SK,Ugale S,Gupta N,et al.Ileal interposition with sleevegastrectomy for treatment of type 2 diabetes mellitus.Indian JEndocrinol Metab.2012;16(4):58998.32.Kota SK,Ugale S,Gupta N,et al.Ileal interposition with divertedsleeve gastrectomy for treatment of type 2 diabetes.Indian JEndocrinol Metab.2012;16(Suppl 2):S4589.33.Baig SJ,Priya P,Mahawar KK,et al.Weight regain after bariatricsurgery-a multicentre study of 9617 patients from Indian bariatricsurgery outcome reporting group.Obes Surg.2019;29(5):158392.34.Huang C-K.Sleeve and sleeve plus.Annals of laparoscopic andendoscopic.Surgery.2017;2:244.https:/doi.org/10.21037/ales.2017.01.10.35.Dayyeh BKA,Rajan E,Costout CJ.Endoscopic sleevegastroplasty:a potential endoscopic alternative to surgical sleevegastrectomy for treatment of obesity.Gastrointest Endosc.2013;78:5305.36.Lpez Nava G,Galvao M,Bautista-Castao I,et al.Endoscopicsleeve gastroplasty with 1-year follow-up:factors predictive ofsuccess.Endosc Int Open.2016;4:2227.37.Lpez Nava G,Galvao MP,Bautista-Castao I,et al.Endoscopicsleeve gastroplasty:how I do it?Obes Surg.2015;25:15348.38.Sharaiha RZ,Kumta NA,Saumoy M,et al.Endoscopic sleevegastroplasty significantly reduces body mass index and metaboliccomplications in obese patients.Clin Gastroenterol Hepatol.2017;15:50410.39.American Society for Gastrointestinal Endoscopy and theAmerican Society for Metabolic and Bariatric Surgery Task Forceon Endoscopic Bariatric Therapy,Ginsberg GG.A pathway toendoscopic bariatric therapies.Gastrointest Endosc.2011;74:94352.Publishers Note Springer Nature remains neutral with regard to jurisdic-tional claims in published maps and institutional affiliations.AffiliationsA.G.Bhasker1&A.Prasad2&P.Praveen Raj3&R.Wadhawan4&M.Khaitan5&A.J.Agarwal6&O.Tantia7&S.Baig8&R.Palaniappan9&H.V.Shivram10&S.Shah11&V.Soni12&M.Bhandari13&R.Shivahare14&S.Dhorepatil15&P.Chowbey16&M.Narwaria17&S.Shah18,19&R.Khullar201Global Hospital,Mumbai,Apollo Group of Hospitals,Mumbai,India2Department of Surgery,Department of Surgical Gastroenterologyand Department of Bariatric Surgery,Manipal Hospitals,NewDelhi,India3Department of Bariatric Surgery,Division of SurgicalGastroenterology,Gem Hospital&Research Centre,Coimbatore,India4Department of Minimal Access,Bariatric&GI Surgery,FortisHospital,Vasant Kunj,New Delhi,India5Bariatric and Metabolic Surgery,Global and Apollo Group ofHospitals,Mumbai,India6Sevenhills Hospital,Hinduja Healthcare,Apollo Spectre Hospitals,Criticare Hospitals,Bhakti Vedanta Hospital,Mumbai,India7ILS Hospitals,Kolkata,India8GI and Minimal Access Surgery,Belle Vue Clinic,Kolkata,India9Institute of Bariatrics,Apollo Hospitals,Chennai,India10Aster CMI Hospital,Bangalore,India11Max Smart Super Speciality Hospital,Saket,New Delhi,India12Max Super Speciality Hospital,New Delhi,India13Mohak Bariatrics and Robotics Center,Indore,India14Apollo hospital,Indore,India15Shree Hospital&Diagnostic Centre Pvt.Ltd.,Pune,India16Max Institute of Minimal Access,Metabolic&Bariatric Surgery,Max Super Speciality Hospital,Saket,New Delhi,India17Asian Bariatric,Ahmedabad,India18Laparo-Obeso Centre,Pune,India19Lilavati Hospital Mumbai and Hinduja Healthcare Surgical,Mumbai,India20Institute of Minimal Access,Metabolic and Bariatric Surgery,MaxSuper Speciality Hospital,Saket,New Delhi,IndiaOBES SURG
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