Bariatric Times

MAR 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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20 The Medical Student Notebook Bariatric Times • March 2017 mean BMI from 49 to 27.5kg/m 2 r eported improvement of visual field deficits in every patient. 85 The other study that reported data on visual field deficits included four patients who underwent LAGB, two o f whom had pre-operative visual field deficits. Both experienced improvement, but not full resolution, of visual field deficits postoperatively. 87 In comparison, p atients in the nonsurgical group experienced improvement of papilledema in 66.7 percent of cases, visual field deficits in 75.4 percent of cases, headache in 23.2 p ercent of cases, and an average decrease in CSF opening pressure of 61.0mmHg. Comparing these outcomes between the surgical and nonsurgical groups demonstrates s uperior efficacy of bariatric surgery in alleviating disease burden of IIH. This is in keeping with the well-established evidence that bariatric surgery leads to g reater and more sustained weight loss as well as higher remission rates of several other obesity related comorbidities than nonoperative management. 7,88 Limitations. While this systematic review suggests a prominent role for weight loss in the treatment of IIH, and specifically the potential efficacy of bariatric surgery, there are several important limitations. First, the surgical studies are relatively small and comprise a total of only 65 patients. Second, the individual studies included are generally observation rather than prospective, randomized, control trials. Third, bariatric surgery would not be an appropriate treatment in the subset of patients with IIH who do not have obesity or overweight or who are not suitable surgical candidates. Additionally, bariatric surgery is not appropriate in the subset of patients with rapidly progressive visual loss, given that it entails a lengthy pre- operative process as well as postoperative time required for significant reduction in BMI. Nevertheless, bariatric surgery remains a promising component of IIH treatment that directly intervenes on one of the presumed underlying disease processes of IIH rather than simply treating the downstream effects of these processes as do other interventions, such as nonbariatric surgical interventions like CSF shunting procedures. CONCLUSION Several authors have suggested that IIH be formally and consistently included in worldwide clinical practice guidelines for indications for bariatric surgery. 83,89 While the theoretical basis for benefit of bariatric surgery in patients with IIH is clear and the a vailable data supports the notion of significant clinical improvement following bariatric surgery, further research is necessary to answer several remaining questions, i ncluding which bariatric procedure is most beneficial for these patients as well as the most appropriate BMI and symptomatic criteria such that the expected benefits outweigh the r isks of surgery. ACKNOWLEDGEMENT The author of this article would like to thank Nurhan Torun, MD for h er invaluable assistance with reviewing this article. Dr. Torun is on staff in the Division of Ophthalmology at Beth Israel Deaconess Medical Center (BIDMC) a nd serves as Assistant Professor of Ophthalmology at Harvard Medical School, Boston, Massachusetts. 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