Referral for bariatric surgery
Best Practice Guidance
There are a variety of surgical options available for promoting weight loss. These bariatric procedures include Roux-en-Y gastric bypass, one anastomosis (mini) gastric bypass, vertical sleeve gastrectomy and adjustable gastric banding. The specific type of procedure should be decided as part of a shared decision making conversation between the patient and the surgeon, during which risks and possible outcomes are discussed.
Bariatric procedures aim to promote weight loss and improve other metabolic complications of obesity. This proposed guidance establishes criteria for referral of a patient to a bariatric surgical centre for consideration of performing a bariatric surgical procedure.
This guidance applies to those aged 18 years and over.
For patients with a BMI of 50 or more, surgery should be considered as a first-line treatment intervention.
Patients with a BMI less than 50 should be referred for consideration of bariatric surgery if they meet the following criteria:
- The patient has a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m with significant obesity-related complications likely to improve with weight loss (for example, type 2 diabetes, sleep apnoea or hypertension)
- The patient has a BMI of 30 kg/m2 or more with type 2 diabetes of less than 10 years duration. This BMI threshold should be reduced to 27.5 kg/m2 if the patient is of Asian family origin.
All patients being considered for bariatric surgery must also meet the following criteria:
- Appropriate non-surgical measures have been tried but the patient has not achieved or maintained adequate, clinically beneficial weight loss
- The patient has been receiving or will receive intensive management in a tier 3 service or equivalent. For more information on tier 3 services, please refer to NHS England’s report of the working group into joined up clinical pathways for obesity and The Royal College of Surgeon’s Weight Assessment and Management Tier Services Commissioning Guide.
- The patient is otherwise fit for anaesthesia and surgery
- The patient commits to long-term follow-up
- The patient and clinician have undertaken appropriate shared decision-making consultation regarding undergoing surgery including discussion of risks and benefits of surgical intervention.
After surgery, the host bariatric surgery unit should follow up with the patient for two years. Thereafter, responsibility for follow up should be handed over to the either the local nonsurgical Tier 3 service OR the patient’s GP, who should conduct yearly appointments. These appointments should include weight measurement and a request for nutritional blood tests. See British Obesity & Metabolic Surgery Society (BOMSS) guidance for more details.
Please note that this guidance is intended as a standard threshold for access. However, if you/ your patient falls outside of these criteria, the option to apply for an Individual Funding Request is still available to you.
Rationale for recommendation
According to NICE guideline CG189 surgery for the treatment of obesity is recommended if specific criteria are met, relating to the patient’s body mass index and the presence of obesity-related complications. This balances the risk of surgery with its potential positive long-term impact on the patient. When commissioned appropriately, obesity surgery is highly effective in promoting weight loss, and more importantly, reducing mortality and morbidity burden. It is also one of the most cost-effective treatments in the field of surgery. The penetrance of obesity surgery remains very low even though thousands of eligible patients stand to benefit from this life-saving intervention with the associated health benefits it provides.
There are a variety of minimally invasive surgical options to help weight loss (bariatric surgery) and improve health. These include Roux-en-Y gastric bypass, one anastomosis (mini) gastric bypass, vertical sleeve gastrectomy and adjustable gastric banding. NICE guideline CG189 states that surgery for obesity is an option if specific criteria are met, balancing the risk of surgery with the long-term benefits of alleviating ill health caused by obesity.
Evidence shows that when commissioned as recommended, surgery is highly effective in causing weight loss, reduces the long-term impact of poor health and reduces the risk of premature death from obesity-related conditions. Despite this, the UK has one of the lowest rates of bariatric surgery in the developed world.
We recommend using the BRAN principles (Benfits, Risks, Alternatives and do Nothing) when speaking with patients about this.
Further information on patient involvement in EBI can be found on the EBI for patients section.
WHEN LEFT(der.Spell_Dominant_Procedure,4) IN ( 'G281', 'G282', 'G283', 'G284', 'G285', 'G301’, 'G302', 'G303', 'G304', 'G321', 'G328', 'G329’, 'G331', 'G338', 'G339’) AND ( APCS.Der_Diagnosis_All LIKE '%E66%’) AND APCS.Admission_Method NOT LIKE '2%’ THEN '3F_Bariatric_Surgery’
Procedure codes (OPCS)
G281 Partial gastrectomy and anastomosis of stomach to duodenum
G282 Partial gastrectomy and anastomosis of stomach to transposed jejunum
G283 Partial gastrectomy and anastomosis of stomach to jejunum NEC
G301 Gastroplasty NEC
G321 Bypass of stomach by anastomosis of stomach to transposed jejunum
G328 Other specified connection of stomach to transposed jejunum
G329 Unspecified connection of stomach to transposed jejunum
G331 Bypass of stomach by anastomosis of stomach to jejunum NEC
G338 Other specified other connection of stomach to jejunum
G339 Unspecified other connection of stomach to jejunum
G284 Sleeve gastrectomy and duodenal switch
G285 Sleeve gastrectomy NEC
G302 Partitioning of stomach NEC
G304 Partitioning of stomach using staples
G303 Partitioning of stomach using band
Diagnosis codes (ICD)
E660 Obesity due to excess calories
E661 Drug-induced obesity
E662 Extreme obesity with alveolar hypoventilation
E668 Other obesity
E669 Obesity, unspecified
There is no standard for BMI used as a diagnosis but often trusts will have local policies, e.g. >30 – 39 = E669, 40> = E668). Should be excluded as a secondary diagnosis.
Included in policy
E110 Type 2 diabetes mellitus – With coma
E111 Type 2 diabetes mellitus – With ketoacidosis
E112 Type 2 diabetes mellitus – With renal complications
E113 Type 2 diabetes mellitus – With ophthalmic complications
E114 Type 2 diabetes mellitus – With neurological complications
E115 Type 2 diabetes mellitus – With peripheral circulatory complications
E116 Type 2 diabetes mellitus – With other specified complications
E117 Type 2 diabetes mellitus – With multiple complications
E118 Type 2 diabetes mellitus – With unspecified complications
E119 Type 2 diabetes mellitus – Without complications
G473 Sleep apnoea
I10X Essential (primary) hypertension
I110 Hypertensive heart disease with (congestive) heart failure
I119 Hypertensive heart disease without (congestive) heart failure
I120 Hypertensive renal disease with renal failure
I129 Hypertensive renal disease without renal failure
I130 Hypertensive heart and renal disease with (congestive) heart failure
I131 Hypertensive heart and renal disease with renal failure
I132 Hypertensive heart and renal disease with both (congestive) heart failure and renal failure
I139 Hypertensive heart and renal disease, unspecified
I150 Renovascular hypertension
I151 Hypertension secondary to other renal disorders
I152 Hypertension secondary to endocrine disorders
I158 Other secondary hypertension
I159 Secondary hypertension, unspecified
All may be present as a secondary.
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and apcs.der_diagnosis_all not like '%D0%' and apcs.der_diagnosis_all not like '%D3%' and apcs.der_diagnosis_all not like '%D4%’
This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
— Private Appointment Exclusion
- Geltrude Mingrone, Simona Panunzi, Andrea De Gaetano, et al. Metabolic surgery versus conventional medical therapy in patients with type 2 diabetes: 10-year followup of an open-label, single-centre, randomised controlled trial. Lancet 2021; 397:293–304
- Chen G, Kusel J, Buguth B, Higgins A, Belarbi S. Cost effectiveness of surgery compared to conventional treatment from a societal perspective in Germany, France, Italy and the UK. Value in Health. 2017 20 A399-A811. PSY74
- Miras A, Kamocka A, Patel D, et al. Obesity surgery makes patients healthier and more fnctional: real world results from the United Kingdom National Bariatric Surgery Registry. 2018. Surgery for Obesity and Related Diseases 2018;14:1033-1040
- Picot J, Jones J, Colquitt J, Loveman E, Clegg A. Weight loss surgery for mild to moderate obesity: a systematic review and economic evaluation. Obes surg (2012) 22;1496-1506. DOI 10.1007/s11695-012-0679-z
- R. F. Pollock, J. Chilcott, G. Muduma & W. J. Valentine (2013) Laparoscopic adjustable gastric banding vs standard medical management in obese patients with type 2 diabetes: a budget impact analysis in the UK. Journal of Medical Economics, 16:2, 249-259, DOI:10.3111/13696998.2012.751388
- Qing Xia, Julie A. Campbell, Hasnat Ahmad, Lei Si1, Barbara de Graaff, Andrew J. Palmer. Bariatric surgery is a cost‐saving treatment for obesity — A comprehensive meta‐analysis and updated systematic review of health economic evaluations of bariatric surgery. Obesity Reviews. 2020;21:e12932
- Philip R. Schauer, M.D., Deepak L. Bhatt, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes — 5-Year Outcomes. N Engl J Med 2017;376:641-51.DOI:10.1056/NEJMoa1600869
- Richard Welbourn, Marianne Hollyman, Robin Kinsman, et al. Bariatric Surgery Worldwide: Baseline Demographic Description and One-Year Outcomes from the Fourth IFSO Global Registry Report 2018. Obesity Surgery (2019) 29:782–795. https://doi.org/10.1007/s11695-018-3593-1
- Francesco Rubino, David M. Nathan, Robert H. Eckel, et al. Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. Diabetes Care 2016; 39:861–877
- Picot J, Jones J, Colquitt JL, Gospodarevskaya E, Loveman E, Baxter L, Clegg AJ. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess. 2009 Sep;13(41):1-190, 215-357, iii-iv. doi: 10.3310/hta13410
- Borisenko O, Adam D, Funch-Jensen P, et al. Bariatric Surgery can Lead to Net Cost Savings to Health Care Systems: Results from a Comprehensive European Decision Analytic Model. Obes Surg. 2015;25(9):1559-1568. doi:10.1007/s11695-014-1567-5
- Ali Aminian, M.D. Alisan Fathalizadeh, M.D. Chao Tu, M.S. Raul J. Rosenthal, M.D. Bartolome Burguera, M.D. Steven E. Nissen, M.D. Association of prior metabolic and bariatric surgery with severity of coronavirus disease 2019 (COVID-19) in patients with obesity. SOARD 2021 17;1:P208-214
- NICE guidance and Bariatric Surgery in England. 2010. Shedding the pounds: obesity management. Office of Health Economics. ISBN: 978-1-899040-93-3
- The United Kingdom National Bariatric Surgery Registry. Second registry report. 2014
- NHS England. Guidance for Clinical Commissioning Groups (CCGs): Clinical Guidance: Surgery for Severe and Complex Obesity 2016. CCG Pack; Guidance for commissioning obesity surgery Appendix 7
- NHS England. Report of the working group into: Joined up clinical pathways for obesity. 2014
- NHS England. Appendix 9 Guidance for Clinical Commissioning Groups (CCGs): Service Specification Guidance for Obesity Surgery. 2016.
- The Royal College of Surgeons. Weight Assessment and Management Tier Services – Commissioning Guide. 2014.
- NHS England. Weight loss surgery Availability.
- NICE. Obesity: identification, assessment and management [CG189]. 2014
- NICE. BMI: preventing ill health and premature death in black, Asian and other minority ethnic groups.
- British Obesity & Metabolic Surgery Society. Guidelines on peri-operative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery. 2014.
How up to date is this information?
Last revised December 2023
December 2023 - Coding updated