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1Hong Kong Medical Journal 2024 Hong Kong Academy of Medicine.All rights reservedA B S T R A C T The surgical management of obesity in Hong Kong has rapidly evolved over the past 20 years.Despite increasing public awareness and demand concerning bariatric and metabolic surgery,service models generally are not standardised across bariatric practitioners.Therefore,a working group was commissioned by the Hong Kong Society for Metabolic and Bariatric Surgery to review relevant literature and provide recommendations concerning eligibility criteria for bariatric and metabolic interventions within the local population in Hong Kong.The current position statement aims to provide updated guidance regarding the indications and contraindications for bariatric surgery,metabolic surgery,and bariatric endoscopic procedures.Recommendations for eligibility criteria concerning bariatric and metabolic surgical and endoscopic procedures for obese Hong Kong adults 2024:Hong Kong Society for Metabolic and Bariatric Surgery Position StatementShirley YW Liu,Carol MS Lai,Enders KW Ng,Fion SY Chan,SK Leung,Wilfred LM Mui,Daniel KH Tong,Dennis CT Wong,Patricia PC Yam,Simon KH Wong*Obesity is a complex multifactorial disease caused by diverse combinations of genetic,behavioural,environmental,and endocrine aetiologies.In 2013,obesity was recognised by the American Medical Association as a disease state requiring treatment and prevention efforts.1 Obesity substantially increases an individuals risks of cardiovascular diseases,metabolic illnesses,musculoskeletal problems,and cancer.For healthcare policymakers,the financial burden of treating and preventing obesity and its related conditions is exponentially growing.At the community level,reduced workforce productivity from obesity-related adverse health outcomes can lead to detrimental impacts on the broader economy.According to the World Health Organization,adults are considered overweight when their body mass index(BMI)is 25 kg/m2 and obese when their BMI is 30 kg/m2.2 However,Asian populations have a higher percentage of body fat and greater metabolic risk at lower BMIs.3 A World Health Organization expert consultation identified potential public health action points for Asians as 23.0 kg/m2,27.5 kg/m2,Hong Kong Med J 2024;30:Epubhttps:/doi.org/10.12809/hkmj22106561 SYW Liu,FRCS,FHKAM(Surgery)1 CMS Lai,FRCS,FHKAM(Surgery)1 EKW Ng,FRCS,FHKAM(Surgery)2 FSY Chan,FRCS,FHKAM(Surgery)3 SK Leung,FRCS,FHKAM(Surgery)4 WLM Mui,FRCS,FHKAM(Surgery)5 DKH Tong,FRACS,FHKAM(Surgery)6 DCT Wong,FRACS,FHKAM(Surgery)3 PPC Yam,FRCS,FHKAM(Surgery)1 SKH Wong*,FRCS,FHKAM(Surgery)1 Department of Surgery,Prince of Wales Hospital,Faculty of Medicine,The Chinese University of Hong Kong,Hong Kong SAR,China2 Department of Surgery,Queen Mary Hospital,Li Ka Shing Faculty of Medicine,The University of Hong Kong,Hong Kong SAR,China3 Department of Surgery,Tuen Mun Hospital,Hong Kong SAR,China4 Hong Kong Bariatric and Metabolic Institute,Hong Kong SAR,China5 Hong Kong Sanatorium&Hospital,Hong Kong SAR,China6 St Teresas Hospital,Hong Kong SAR,China*Corresponding author:wongkhmosurgery.cuhk.edu.hk32.5 kg/m2,and 37.5 kg/m2;these values generally were 2.5 kg/m2 lower than the thresholds established for Caucasians.4 Because of differences in body frame and visceral fat distribution,lower BMI thresholds were used to define overweight(23 kg/m2)and obesity(25 kg/m2)in Asians.3 Similar to other regions of the world,obesity is a substantial public health problem in Hong Kong.5 According to the latest Population Health Survey 2020/22 conducted by the Department of Health,the prevalences of obesity and overweight in people aged 15 to 84 years were 32.6%and 22.0%,respectively.6 These prevalences indicate that at least half of the local Hong Kong population faces health risks associated with overweight or obesity.Bariatric and metabolic surgeryBariatric surgery(ie,surgical treatment for obesity)has been continuously evolving worldwide over the past 50 years,with increasingly diverse procedural options and indications.7 In 1991,the National MEDICAL PRACTICEThis article was published on 3 Jun 2024 at www.hkmj.org.This version may differ from the print version.#Liu et al#2Hong Kong Medical Journal 2024 Hong Kong Academy of Medicine.All rights reserved香港成年人接受減重及代謝外科手術及內窺鏡治療的建議準則：香港代謝及減重外科醫學會2024年立場聲明廖玉華、黎敏詩、吳國偉、陳小燕、梁兆基、梅力文、唐琼雄、黃頌德、任寶珠、黃健鴻香港肥胖症的外科治療在過去二十年間迅速發展。儘管大眾對減重和代謝手術的認識和需求不斷增加，但從事減重外科的醫護人員對手術應有的服務模式缺乏統一標準。因此，香港代謝及減重外科醫學會成立了工作小組，審查相關文獻，並就香港成年人進行減重及代謝外科手術及內窺鏡治療的資格標準提供建議。本立場聲明之目的為針對減重手術、代謝手術和減重內窺鏡治療的適應症和禁忌症提供最新指引。Institutes of Health published the first international consensus endorsing the use of gastrointestinal surgery as treatment for severe obesity.8,9 Since then,numerous studies have confirmed the effectiveness of bariatric surgery in achieving sustainable weight loss and substantial improvement in co-morbidities among obese patients.10 According to a systematic review and meta-analysis of 22 094 morbidly obese patients across 136 studies,bariatric surgery resulted in 61.2%excess weight loss.10 Resolution of diabetes,hypertension,and obstructive sleep apnoea were achieved in 76.8%,61.7%,and 85.7%of patients,respectively.10 In a prospective randomised trial of 150 morbidly obese diabetic patients,bariatric surgery plus intensive medical therapy was associated with significantly better glycaemic and metabolic outcomes at 5 years compared with intensive medical therapy alone.11 Because bariatric surgery has demonstrated efficacy in treating type 2 diabetes mellitus(T2DM),the term metabolic surgery was established to describe the role of bariatric interventions in treating T2DM and metabolic syndrome.7,16 In 2016,metabolic surgery was formally endorsed by 44 international diabetes organisations as a treatment option for adults with T2DM and obesity(defined as BMI 30 kg/m2 for Caucasians and 27.5 kg/m2 for Asians),particularly those with co-morbidities which cannot be controlled by lifestyle changes and pharmacological therapy.17 Although operative safety is a concern for morbidly obese individuals undergoing any type of major surgery,current evidence suggests that bariatric surgery has low perioperative mortality rates,ranging from 0.03%to 0.2%.12 In a systematic review and meta-analysis of 161 756 patients undergoing bariatric surgery,the 30-day mortality rates ranged from 0.08%to 0.22%,whereas the postoperative complication rates were between 9.8%and 17.0%.13 Currently,the most widely performed bariatric procedures are sleeve gastrectomy and Roux-en-Y gastric bypass.Common operative morbidities of sleeve gastrectomy include bleeding,leakage,stricture,and symptoms of gastroesophageal reflux.14 Roux-en-Y gastric bypass is associated with bleeding,leakage,stricture,stomal ulcer,small bowel obstruction,internal herniation,and dumping syndrome.15 Data from randomised controlled trials suggest that sleeve gastrectomy and Roux-en-Y gastric bypass are comparable in terms of 30-day mortality and morbidity rates.15Primary bariatric endoscopic interventionIn recent decades,bariatric endoscopic procedures have been developed for individuals who prefer less invasive,non-surgical alternatives.18 These endoscopic therapies include intragastric space-occupying devices(intragastric balloons IGBs),gastric aspiration devices,endoluminal bypass barrier sleeves,the POSE(primary obesity surgery endoluminal)procedure,endoscopic sleeve gastroplasty,and duodenal mucosal resurfacing.All of these procedures can produce clinically significant short-term weight loss and improvements in obesity-related co-morbidities.19 The first bariatric endoscopic intervention in Hong Kong,IGB therapy,was introduced in 2004.An early local report confirmed its efficacy in weight reduction and co-morbidity improvement among obese patients at 6 months after treatment.20 Compared with weight-reduction medication,IGB therapy was associated with better compliance and superior weight reduction for up to 2 years after treatment.21 Because of its efficacy regarding short-term weight loss and co-morbidity improvement,IGB therapy can also serve as a bridging treatment prior to bariatric or other operative interventions;it facilitates preoperative weight loss that can reduce anaesthetic risks.Thus,IGB therapy is a justifiable non-surgical bariatric option for primary weight loss and preoperative weight loss.Overview of bariatric and metabolic surgery in Hong KongHong Kongs first bariatric surgery programme was established in 2002 at Prince of Wales Hospital,affiliated with The Chinese University of Hong Kong.22 Encouraged by the success and safety of the early Prince of Wales Hospital obesity surgery service,23 increasing numbers of public and private hospitals have begun to provide bariatric surgical interventions to obese patients in Hong Kong(Table).With the goal of promoting public and professional awareness about obesity treatment,leading local bariatric practitioners formed the#Obese adults in HK 2024#3Hong Kong Medical Journal 2024 Hong Kong Academy of Medicine.All rights reservedMetabolic and Bariatric Surgery Group under the Hong Kong Association for the Study of Obesity in 2012.In 2017,the Hong Kong Society for Metabolic and Bariatric Surgery(HKSMBS)was established as an independent society.Surveys concerning bariatric surgery types and case volumes are carried out annually by the two bodies.Metabolic and bariatric surgery options are broadly classified as restrictive procedures and malabsorptive procedures.In Hong Kong,common restrictive procedures are gastric banding and sleeve gastrectomy.The most common malabsorptive procedure is Roux-en-Y gastric bypass.Other less common malabsorptive procedures are one anastomosis gastric bypass,sleeve gastrectomy plus duodenojejunal bypass,and biliopancreatic diversion with or without duodenal switch.Between 2013 and 2020,1582 bariatric surgical and endoscopic procedures were performed in Hong Kong(Table).Compared with 2002 when bariatric surgery was first introduced,the number of bariatric surgeries performed each year has exponentially increased from 180 cases per year in 2020.Current data indicate that more than two-thirds of these surgeries are performed in government hospitals.Sleeve gastrectomy is the most common bariatric procedure in Hong Kong(70%)and the second most common procedure is Roux-en-Y gastric bypass.Gastric banding,popular two decades ago,has not been favoured since 2013(27.5 kg/m2 should be offered metabolic and bariatric surgery options.29 In response to these revised BMI thresholds for metabolic and bariatric surgery,published in December 2022,extensive discussions and debates have arisen in various professional bodies focusing on metabolic and bariatric surgery in Asia,including groups in Hong Kong.Due to limited experience offering metabolic and bariatric surgery to patients with BMI 7.0%despite medical treatment involving two or more oral hypoglycaemic agents or any injectable medications(including insulin or glucagon-like peptide-1 receptor agonist)for 6 months.32,33 Fasting C-peptide levels should be checked if type 1 diabetes mellitus or latent autoimmune diabetes in adults is suspected.Eligibility for bariatric endoscopic interventionsIntragastric balloon therapy Intragastric balloon therapy is a minimally invasive space-occupying system intended to provide temporary weight loss by reducing gastric volume and altering gastric motility.34,35 The following recommendations regarding IGB therapy are suggested:1.As a bridging treatment for preoperative weight loss,IGB therapy can be considered:a.prior to metabolic or bariatric surgery for the optimisation of medical and/or anaesthetic status in severely obese individuals with very high BMI(eg,50 kg/m2)who fail to respond to non-surgical optimisation;andb.prior to non-bariatric surgery(eg,joint replacement surgery,ventral hernia repair,etc)for the optimisation of medical and/or anaesthetic status in obese individuals with BMI 30 kg/m2.2.As a primary interventional treatment,IGB therapy can be considered:a.in individuals with BMI ranging from 27.5 to 32.5 kg/m2(30-35 kg/m2 for Caucasians)who fail to achieve weight loss through optimal lifestyle and dietary interventions;andb.in obese individuals who meet the eligibility criteria for bariatric or metabolic surgery but are surgically unfit or reluctant to undergo bariatric or metabolic surgery.3.Intragastric balloon therapy should be used for a duration shorter than the maximum approved or recommended duration(usually 4 to 12 months,depending on IGB brand),or for a duration to be decided on a case-by-case basis.Patients should be informed about the intended duration of use.Other endoscopic proceduresCurrently,many restrictive and malabsorptive endoscopic procedures are available.These include,but are not limited to,the following:1.space-occupying restrictive gastric devices(eg,TransPyloric Shuttle,SatiSphere,Plenity,etc);2.gastric diversion devices(eg,AspireAssist aspiration therapy);3.endoscopic gastric plication techniques(eg,endoscopic sleeve gastroplasty,the POSE procedure);and4.malabsorptive techniques(eg,duodenojejunal bypass liner).Some of these procedures have been approved by the United States Food and Drug Administration,whereas others remain investigational in most countries.Except for endoscopic gastric plication,AspireAssist aspiration therapy and endoscopic sleeve gastroplasty,most of these endoscopic procedures have not been explored in Hong Kong.Due to the lack of scientific evidence and universal consensus regarding their indications,efficacy,and safety,these procedures should only be conducted after careful evaluation and the acquisition of informed patient consent and/or approval from institutional review board.ContraindicationsDespite the beneficial effects of metabolic and bariatric surgery with clinically significant improvements in obesity-related co-morbidities,these procedures are not without surgical and anaesthetic risks.Moreover,most bariatric procedures involve a gastric restrictive component;an individuals ability to maintain postoperative dietary and lifestyle changes can substantially affect surgical outcomes.Therefore,the position statement committee reached a consensus on the following suggestions.Contraindications for bariatric and metabolic surgical and endoscopic interventionsBariatric and metabolic surgical and endoscopic procedures should not be performed in the following situations or for the following individuals:1.absence of multidisciplinary medical,dietary,and behavioural guidance;2.no fully informed consent from the patient or his/her guardian regarding the risks,benefits,and real expectations for weight loss,co-morbidity management,and durability;3.individuals with BMI 27.5 kg/m2(30 kg/m2 for Caucasians),unless the procedures are performed under a research protocol approved by a local institutional review board and/or research ethics committee and informed patient consent ha
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