Selon Elon Musk, les analogues du récepteur GLP-1 peuvent prévenir l’obésité, réduire les maladies associées dont le diabète et, par conséquent améliorer la qualité de vie des Américains. Une croisade pour un poids idéal est lancée dont la pertinence, l’efficience et les ressorts méritent réflexion. Ce projet est le prototype d’une mutation de la communication en santé et de l’expansion du marché parallèle du médicament.

BACKGROUND:Concerns are rising about the late adverse events following gastric bypass and sleeve gastrectomy. We aimed to assess, over a 7-year period, the late adverse events after gastric bypass and sleeve gastrectomy compared with matched control groups. METHODS:In this nationwide, observational, population-based, cohort study, we used data extracted from the French National Health Insurance (Système National des Données de Santé) database. All patients undergoing gastric bypass or sleeve gastrectomy in France in 2009, except those who had undergone bariatric surgery in the previous 4 years before inclusion, were matched with control patients with obesity in terms of age, sex, BMI category, baseline antidiabetic therapy, and baseline insulin therapy. Exclusion criteria for the control group included cancer, pregnancy, chronic infectious disease, serious acute or chronic disease in 2008-09, or previous (2005-09) or forthcoming (2010-11) bariatric surgery. The incidence rate was calculated for each type of adverse event leading to inpatient hospital admission over a 7-year period; incidence rate ratios (with 95% CIs) were computed to compare the rate of complications among the bariatric surgery and control groups. Risks of complications during follow-up were compared using Cox proportional-hazards regression analyses. Data were analysed according to the intention-to-treat methodology. FINDINGS:From Jan 1, 2009, to Dec 31, 2009, 8966 patients who underwent bariatric surgery (7359 [82%] women; mean age 40·4 years [SD 11·3]) and 8966 matched controls (7359 [82%] women; mean age 40·9 years [11·4]) were included in analyses 4955 (55%) off 8966 patients in the bariatric surgery group had a primary gastric bypass and 4011 (45%) patients had sleeve gastrectomy. With a mean follow-up of 6·8 years (SD 0·2), mortality was lower in the gastric bypass group than in its control group (hazard ratio 0·64 [95% CI 0·52-0·78]; p<0·0001) and in the sleeve gastrectomy group than in its control group (0·38 [0·29-0·50]; p<0·0001). The gastric bypass and sleeve gastrectomy groups had higher risk than did their control groups for invasive gastrointestinal surgery or endoscopy (incidence rate ratio 2·4 [95% CI 2·1-2·7], p<0·0001, for gastric bypass vs control and 1·5 [1·3-1·7], p<0·0001, for sleeve gastrectomy vs control); for gastrointestinal disorders not leading to invasive procedures (1·9 [1·7-2·1]), p<0·0001, for gastric bypass vs control and 1·2 [1·1-1·4], p<0·0001, for sleeve gastrectomy vs control); and for nutritional disorders (4·9 [3·8-6·4], p<0·0001, for gastric bypass vs control and 1·8 [1·3-2·5], p<0·0001, for sleeve gastrectomy vs control). For psychiatric disorders, there was no significant association (1·1 [0·9-1·4], p=0·190, for gastric bypass vs control and 1·1 [0·8-1·3], p=0·645, for sleeve gastrectomy vs control), except for gastric bypass and alcohol dependence (1·8 [1·1-2·8], p=0·0124). INTERPRETATION:Despite lower 7-year mortality, patients undergoing gastric bypass or sleeve gastrectomy had higher risk of hospital admission at least once for late adverse events, except for psychiatric disorders, than did control patients, with a higher risk observed after gastric bypass than with sleeve gastrectomy. FUNDING:None.

La revue Obésité aborde les différents aspects de la maladie : des facteurs de risque aux complications, de la prévention au traitement. Multidisciplinaire, elle réunit des experts de la recherche fondamentale et clinique, ainsi que des sciences humaines

IMPORTANCE Few large-scale long-term prospective cohort studies have assessed changes in antidiabetes treatment after bariatric surgery. OBJECTIVE To describe the association between bariatric surgery and rates of continuation, discontinuation, or initiation of antidiabetes treatment 6 years after bariatric surgery compared with a matched control obese group. DESIGN, SETTING, AND PARTICIPANTS This nationwide observational population-based cohort study extracted health care reimbursement data from the French national health insurance database from January 1, 2008, to December 31, 2015. All patients undergoing primary bariatric surgery in France between January 1 and December 31, 2009, were matched on age, sex, body mass index category, and antidiabetes treatment with control patients hospitalized for obesity in 2009 with no bariatric surgery between 2005 and 2015. EXPOSURES Bariatric surgery, including adjustable gastric banding (AGB), gastric bypass (GBP), and sleeve gastrectomy (SG). MAIN OUTCOME AND MEASURE Reimbursement for antidiabetes drugs. Mixed-effects logistic regression models estimated factors of discontinuation or initiation of antidiabetes treatment over a period of 6 years. RESULTS In 2009, a total of 15 650 patients (mean [SD] age, 38.9 [11.2] years; 84.6% female; 1633 receiving antidiabetes treatment) underwent primary bariatric surgery, with 48.5% undergoing AGB, 27.7% undergoing GBP, and 22.0% undergoing SG. Among patients receiving antidiabetes treatment at baseline, the antidiabetes treatment discontinuation rate was higher 6 years after bariatric surgery than in controls (-49.9% vs -9.0%, P <.001). In multivariable analysis, the main predictive factors for discontinuation were the following: GBP (odds ratio [OR], 16.7; 95% CI, 13.0-21.4), SG (OR, 7.30; 95% CI, 5.50-9.50), and AGB (OR, 4.30; 95% CI, 3.30-5.60) compared with no bariatric surgery, as well as insulin use (OR, 0.17; 95% CI, 0.13-0.22), dual therapy without insulin (OR, 0.38; 95% CI, 0.32-0.45) vs monotherapy, lipid-lowering treatment (OR, 0.76; 95% CI, 0.63-0.91), antidepressant treatment (OR, 0.67; 95% CI, 0.55-0.81), and age (OR, 0.96; 95% CI, 0.95-0.97) per year. For patients without antidiabetes treatment at baseline, the 6-year antidiabetes treatment initiation rate was much lower after bariatric surgery than in controls (1.4% vs 12.0%, P <.001). In multivariable analysis, protective factors were GBP (OR, 0.06; 95% CI, 0.04-0.09), SG (OR, 0.08; 95% CI, 0.06-0.11), and AGB (OR, 0.16; 95% CI, 0.14-0.20) vs controls, and risk factors were as follows: body mass index category (OR, 2.04; 95% CI, 1.68-2.47 for >= 50.0 vs 30.0-39.9 and OR, 1.68; 95% CI, 1.49-1.90 for 40.0-49.9 vs 30.0-39.9), antihypertensive treatment (OR, 1.49; 95% CI, 1.33-1.67), low income (OR, 1.43; 95% CI, 1.26-1.62), and age (OR, 1.04; 95% CI, 1.03-1.05) per year. CONCLUSIONS AND RELEVANCE Bariatric surgery was associated with a significantly higher 6-year postoperative antidiabetes treatment discontinuation rate compared with baseline and with an obese control group without bariatric surgery.

Obese patients are increasingly being offered weight loss surgery, the success of which depends in part on the quality of a long-term follow-up after the procedure. A study was conducted with a cohort of 207 patients operated on in 2007 and 2008 who received follow-up care in a specialized nutrition department, with the aim of identifying factors affecting their adherence to their post-operative care agenda. Factors strongly linked to a lower level of adherence were the type of surgery and a patient's place of residence. These results enable us to discuss the importance of using care coordination to optimize post-operative monitoring.

BACKGROUND:Few studies have assessed changes in antihypertensive and lipid-lowering therapy after bariatric surgery. The aim of this study was to assess the 6-year rates of continuation, discontinuation or initiation of antihypertensive and lipid-lowering therapy after bariatric surgery compared with those in a matched control group of obese patients.METHODS:This nationwide observational population-based cohort study used data extracted from the French national health insurance database. All patients undergoing gastric bypass or sleeve gastrectomy in France in 2009 were matched with control patients. Mixed-effect logistic regression models were used to analyse factors that influenced discontinuation or initiation of treatment over a 6-year interval.RESULTS:In 2009, 8199 patients underwent primary gastric bypass (55·2 per cent) or sleeve gastrectomy (44·8 per cent). After 6 years, the proportion of patients receiving antihypertensive and lipid-lowering therapy had decreased more in the bariatric group than in the control group (antihypertensives: -40·7 versus -11·7 per cent respectively; lipid-lowering therapy: -53·6 versus -20·2 per cent; both P < 0·001). Gastric bypass was the main predictive factor for discontinuation of therapy for hypertension (odds ratio (OR) 9·07, 95 per cent c.i. 7·72 to 10·65) and hyperlipidaemia (OR 11·91, 9·65 to 14·71). The proportion of patients not receiving treatment at baseline who were subsequently started on medication was lower after bariatric surgery than in controls for hypertension (5·6 versus 15·8 per cent respectively; P < 0·001) and hyperlipidaemia (2·2 versus 9·1 per cent; P < 0·001). Gastric bypass was the main protective factor for antihypertensives (OR 0·22, 0·18 to 0·26) and lipid-lowering medication (OR 0·12, 0·09 to 0·15).CONCLUSION:Bariatric surgery is associated with a good discontinuation of antihypertensive and lipid-lowering therapy, with gastric bypass being more effective than sleeve gastrectomy.

La cirugia bariatrica se ofrece cada vez mas a los pacientes obesos. Su exito depende en parte de la calidad del seguimiento a largo plazo despues de la intervencion. Se realizo un estudio descriptivo retrospectivo para determinar los factores que influyen en el cumplimiento el paciente del programa de seguimiento postoperatorio en una cohorte de 207 pacientes operados en 2007 y 2008 y atendidos en un servicio de nutricion dentro de un centro integrado para la obesidad. Los factores que se asocian significativamente con un menor cumplimiento son el tipo de cirugia y el lugar de residencia. Estos resultados permiten discutir las formas de mejorar las practicas y posicionar el papel de la coordinacion de los cuidados en la optimizacion del seguimiento.

Cette cohorte nationale étudie l’évolution à 6 ans de la consommation de médicaments antidiabétiques après une chirurgie bariatrique (CB) réalisée en 2009 comparée à un groupe témoin. Les 15 650 patients opérés de CB en 2009, en France, ont été suivis jusqu’en 2015 et appariés à un groupe de patients obèses morbides hospitalisés en 2009 et non opérés entre 2005–2015. Les données de remboursements ont été extraites du SNIIRAM pour 2008–2015. L’arrêt complet du traitement à 6 ans était plus fréquent après CB (50 % vs 9 % ; p < 0,001). En multivariée, les principaux facteurs associés à l’arrêt du traitement à 6 ans étaient (OR ; IC95 %) un GBP = 16,7 (13,0–21,4) et l’absence initiale d’insulinothérapie (5,8 [4,6–7,4]). Le taux d’apparition d’un traitement à 6 ans était moins fréquent chez les opérés que chez les témoins (1 % vs 12 % ; p > 0,001). En multivariée, le GBP était le meilleur facteur protecteur d’apparition de traitement antidiabétique (0,06 [0,04–0,09]). À 6 ans, la CB conduit plus souvent à l’arrêt du traitement antidiabétique et à l’absence de nouveau traitement en comparaison à un groupe témoin d’obèses non opérés. Cet impact semble plus marqué pour le GBP.

Objective: The aim of the present study was to assess the incidence, risk factors, and the impact of posthospital discharge (PHD) chemoprophylaxis on venous thromboembolism (VTE) in patients undergoing bariatric surgery (BS). Background: VTE is a major concern after BS, especially during the PHD period. No large-scale study has previously focused on the clinical value of PHD chemoprophylaxis. Methods: In this nationwide observational population-based cohort study, all data from patients undergoing BS were extracted from the French National Health Insurance database (SNIIRAM) from 1st January 2012 to 31st September 2014. Logistic regression models were used to compute odds ratios for potential risk factors for VTE occurring within 90 postoperative days (PODs). The association between use of PHD chemoprophylaxis (heparin) and VTE was also assessed. Results: The majority (56%) of the 110,824 patients had sleeve gastrectomy. VTE rates during the first 30 and 90 PODs were 0.34% and 0.51%, respectively. On multivariate analyses, the major risk factors for VTE during the first 90 PODs were history of VTE [odds ratio = 6.33 95% confidence interval (4.44–9.00)], postoperative complications [9.23 (7.30–11.70)], heart failure [2.45 (1.48–4.06)], and open surgery [2.38 (1.59–3.45)]. PHD chemoprophylaxis was delivered to 75% of patients. No use of PHD chemoprophylaxis [1.27 (1.01–1.61)] was an independent predictive factor of VTE during the first 90 PODs [in the gastric bypass group: 1.51 (1.01–2.29)). Conclusions: In the modern era of BS, this nationwide study shows a non-negligible rate of VTE especially after sleeve gastrectomy, depending on the individual risk level. Use of PHD chemoprophylaxis may decrease the risk of PHD VTE.

Lifelong medical follow-up is mandatory after bariatric surgery. The aim of this study was to assess the 5-year follow-up after bariatric surgery in a nationwide cohort of patients.All adult obese patients who had undergone primary bariatric surgery in 2009 in France were included. Data were extracted from the French national health insurance database. Medical follow-up (medical visits, micronutrient supplementation and blood tests) during the first 5 years after bariatric surgery was assessed, and compared with national and international guidelines.Some 16 620 patients were included in the study. The percentage of patients with at least one reimbursement for micronutrient supplements decreased between the first and fifth years for iron (from 27.7 to 24.5 per cent; P < 0.001) and calcium (from 14·4 to 7·7 per cent; P < 0·001), but increased for vitamin D (from 33·1 to 34·7 per cent; P < 0·001). The percentage of patients with one or more visits to a surgeon decreased between the first and fifth years, from 87·1 to 29·6 per cent (P < 0·001); similar decreases were observed for visits to a nutritionist/endocrinologist (from 22·8 to 12·4 per cent; P < 0·001) or general practitioner (from 92·6 to 83·4 per cent; P < 0·001). The mean number of visits to a general practitioner was 7·0 and 6·1 in the first and the fifth years respectively. In multivariable analyses, male sex, younger age, absence of type 2 diabetes and poor 1-year follow-up were predictors of poor 5-year follow-up.Despite clear national and international guidelines, long-term follow-up after bariatric surgery is poor, especially for young men with poor early follow-up.

Objective: This study aims at assessing the status of obesity management in the European region and identifying future goals and objectives of professionals working in the field of obesity. Methods: Presidents of all 31 EASO-affiliated (EASO = European Association for the Study of Obesity) national associations for the study of obesity were asked to invite 5 obesity experts from their country to participate in a survey. A total of 74 obesity professionals out of 23 countries participated. Questions addressed the development of guidelines, the status of obesity management, and goals and objectives for the future in obesity management. Further, EASO's three vice-presidents participated in in-depth, semi-structured interviews, in which they were asked to provide their reflection on the survey data. Results: Most countries define obesity as a clinical and chronic disease, but various differences in obesity management standards exist across Europe. Existing guidelines mainly focus on the acute treatment of obesity rather than on long-term approaches. Conclusion: Multidisciplinary approaches for obesity management and the collaboration between general practitioners and hospitals as well as between professionals at the local level and networks of obesity management centers need to be improved across Europe. Good practices and evidence are available.

Bariatric surgery is a well-accepted procedure for severe and massive obesity management. We aimed to determine trends, geographical variations, and factors influencing bariatric surgery and the choice of procedure in France in a large observational study.The Health Insurance Fund for Salaried Workers (Caisse National Assurance Maladie Travailleurs Salariés) covers about 86% of the French population. The Système National d'Information Inter-régimes de l'Assurance Maladie database contains individualized and anonymized patient data on all reimbursements for healthcare expenditure. All types of primary bariatric procedures (Roux-en-Y gastric bypass [RYGB] or omega loop, adjustable gastric banding [AGB], or longitudinal sleeve gastrectomy [LSG]) performed during 2011 to 2013 were systematically recorded. Surgical techniques performed by region of residence and age-range relative risks with 95% confidence intervals of undergoing LSG or RYGB versus AGB were computed.In 2013, LSG was performed more frequently than RYGB and AGB (57% vs 31% and 13%, respectively). A total of 41,648 patients underwent a bariatric procedure; they were predominantly female (82%) with a mean (±standard deviation) age of 40 (±12) years and a body mass index ≥40 kg/m for 68% of them. A total of 114 procedures were performed in patients younger than 18 years and 2381 procedures were performed in patients aged 60 years and older. Beneficiaries of the French universal health insurance coverage for low-income patients were more likely to undergo surgery than the general population. Large nationwide variations were observed in the type choice of bariatric surgical procedures. Significant positive predictors for undergoing RYGB compared to those for undergoing AGB were as follows: referral to a center performing a large number of surgeries or to a public hospital, older age, female gender, body mass index ≥50 kg/m, and treatment for obstructive sleep apnea syndrome, diabetes, or depression. Universal health insurance coverage for low-income patients was inversely correlated with the probability of RYGB.Differences in access to surgery have been observed in terms of the patient's profile, geographical variations, and predictors of types of procedures. Several challenges must be met when organizing the medical care of this growing number of patients, when delivering surgery through qualified centers while assuring the quality of long-term follow-up for all patients.

Background: Gastroesophageal reflux disease (GERD) is a common obesity-related co-morbidity that routinely is treated by continuous proton pump inhibitor (PPI) therapy. A number of concerns have been raised regarding the risk of de novo GERD or exacerbation of preexisting GERD after sleeve gastrectomy (SG).Objective: To assess PPI use at 4 years after bariatric surgery.Setting: French National Health Insurance.Methods: Data were extracted from the French National Health Insurance database. All adult obese patients who had undergone gastric bypass (GBP) (n = 8250) or SG (n = 11,923) in 2011 in France were included. Patients were considered to be on continuous PPI therapy when PPIs were dispensed >= 6 times per year. Logistic regression models were used to compute odds ratios for potential risk factors for PPI reimbursement 4 years after surgery.Results: Overall, continuous use of PPIs increased from baseline to 4 years after SG and GBP, from 10.9% to 26.5% (P < .001) and from 11.4% to 21.9% (P < .001), respectively. Among patients who underwent PPI therapy before surgery, those who had undergone SG were more likely to continue PPI therapy 4 years after surgery compared with those who underwent GBP (72.7% versus 59.2%; P < .001). In multivariate analyses, the major risk factors for persistent continuous PPI treatment 4 years after surgery were the following: SG (odds ratio [OR] = 1.87; 95% confidence interval [CI] 1.55-2.25), higher body mass index (OR 1.85; 95% CI 1.35-2.5), and preoperative antidepressant treatment (OR 1.89; 95% CI 1.56-2.29).Conclusion: At a nationwide scale, continuous PPI treatment is used by 1 of 10 obese patients before bariatric surgery, but by 1 of 4 patients 4 years after surgery. SG compared with GBP, higher body mass index, and other coexisting conditions are the 3 major risk factors for medium-term continuous PPI therapy. (C) 2017 American Society for Metabolic and Bariatric Surgery. All rights reserved.

La Haute Autorité de Santé recommande que l'équipe pluridisciplinaire qui a posé l'indication de chirurgie bariatrique suive le patient. L'objectif de l'étude est de décrire le suivi post chirurgie bariatrique en France. Les actes de chirurgie bariatrique ont été extraits du PMSI 2009 pour les patients sans chirurgie préalable depuis 2006. Le recours aux soins de ces patients a été extrait du système national d'information inter-régime d'assurance maladie (SNIIRAM) de 2009 à 2013. Parmi les 16 000 personnes primo-opérées en 2009 et ayant au moins une consommation de soins jusqu'en 2013, plus de 85 % ont consulté un médecin généraliste chaque année (4 fois/an). Un quart a consulté un endocrinologue ou interniste ou eu une hospitalisation de jour en lien avec la chirurgie l'année suivante, et 15 % la quatrième année. Parmi les 4 400 patients opérés d'un bypass, 57 % ont été remboursés de ≥ 1 délivrance de fer l'année suivante et 46 % la quatrième année. La première année, 39 % ont reçu ≥ 1 délivrance de calcium et 19 % la quatrième. La vitamine D a été délivrée à 67 % dans l'année et 56 % quatre ans après. Parmi les 3 500 patients opérés d'une sleeve, 25 % ont été remboursés de ≥ 1 délivrance de fer l'année suivante et 23 % la quatrième année. La première année, 9 % ont reçu ≥ 1 délivrance de calcium et 5 % la quatrième. La vitamine D a été délivrée à 37 % dans l'année et 35 % quatre ans après. Un demi-million de personnes auront été opérées en 2017 : le médecin généraliste joue un rôle central dans leur suivi. La supplémentation nécessaire après bypass et sleeve est insuffisante, même lorsqu'elle est remboursée. Un parcours de soins pérenne, au service du patient opéré, organisé par le médecin traitant en coordination avec les autres professionnels de santé, est nécessaire, après formation spécifique.

Bariatric surgery in teen-agers is increasing. This surgical option in the severely obese adolescent raises a series of questions on clinical pathway and ethics. It should be realized in highly specialized centers gathering skills in bariatric surgery, pediatric endocrinology and nutrition and psychology. It is a longstanding multifocal and proactive management including the transition to adulthood. Expert centers should be identified.

La chirurgie bariatrique est actuellement la seule option thérapeutique permettant chez l'adulte une perte de poids majeure et durable avec réduction à long terme de la mortalité et des comorbidités. Dans certaines situations extrêmes, l'indication d'une telle chirurgie peut être discutée plus tôt dans la vie, l'anneau gastrique étant l'option la plus fréquemment choisie en France. Nous rapportons ici pour la première fois en France le devenir à moyen terme d'adolescents massivement obèses ayant nécessité une chirurgie bariatrique par bypass ou manchon gastrique (sleeve gastrectomie) du fait d'une obésité massive associée à de nombreuses comorbidités. 14 adolescents (10 filles ; âge médian 17,5 ans [13–19 ans]) ayant une obésité massive (IMC 56,7 kg/m2 [43–68] ont bénéficié d'une chirurgie bariatrique après discussion au cas par cas en staff pluridisciplinaire avec un suivi régulier clinique et biologique d'au moins 12 mois après la chirurgie. Tous les sujets avaient avant la chirurgie au moins une comorbidité associée à l'obésité massive (syndrome d'apnées du sommeil (SAS) avec pression positive continue (n = 5) ; stéatose hépatique (n = 9) ; diabète de type 2 (n = 4) ; syndrome des ovaires polykystiques (n = 1) ; hypertension artérielle (n = 2) ; dyslipidémie (n = 8) ; hypertension intracrâ-nienne idiopathique (n = 1)). Onze bypass et 3 manchons gastriques ont été réalisés. L'évolution post-opératoire immédiate a été simple dans tous les cas. Seules 3 complications ont été rapportées chez 2 patients au cours de la 1re année (érosion sus-anastomotique et calculs rénaux avec coliques néphrétiques chez 1 patient ; 2 occlusions sur éventration chez l'autre patient). Ces complications ont été traitées en temps utile et l'évolution a été favorable dans tous les cas. Une perte de poids significative a été observée chez tous les patients à 1 an post-opératoire (IMC : 56,7 ± 7,3 kg/m2 à T0 vs 41,8 ± 10,7 kg/m2 à M12 ; p < 0,05). Une évolution favorable de la composition corporelle a été observée avec une réduction significative de la masse grasse (52,6 % à T0 vs 41,5 % à M12 en moyenne) et un maintien de la masse maigre (45,5 % à T0 vs 55,7 % à M12). En post-opératoire, toutes les comorbidités ont disparu à 1 an chez tous les patients sauf 1 SAS persistant. Bien que 64 % seulement des jeunes prenaient les suppléments vitaminiques tous les jours, aucune carence vitaminique n'a été observée. Certains patients ont été suivi au-delà (suivi moyen 3 ans) avec une bonne stabilisation pondérale. La chirurgie bariatrique par bypass ou manchon gastrique est une intervention efficace et bien tolérée à moyen terme dans des situations extrêmes d'obésité avec comorbidités chez l'adolescent. Son indication qui reste limitée, doit être discutée au cas par cas et en multidisciplinarité (pédiatres, médecins d'adultes, chirurgiens, psychologues, diététiciennes, anesthésistes) en raison des particularités de cette population.

La prise en charge des maladies chroniques liées aux évolutions des modes de vie, notamment des habitudes alimentaires, est un modèle pour développer des parcours personnalisés de soins prenant en compte les caractéristiques individuelles, la « niche écologique » du patient et le contexte social. Le développement de parcours de santé est un domaine émergent, qui a déjà été exploré en cancérologie, et pour lequel les spécialistes de nutrition doivent faire des propositions. Cet article vise à lancer la réflexion et le débat sur la place des professionnels impliqués dans les actions de nutrition.

Le parcours de soins après chirurgie bariatrique est émaillé de situations urgentes, précoces ou tardives. Des symptômes souvent atypiques, des difficultés d’examen posent des problèmes de diagnostic. Deux règles impératives :–tachycardie (> 120 batt./min), gêne respiratoire, sepsis, agitation, avec ou sans douleur abdominale, ou vomissement, doivent faire évoquer une complication chirurgicale et imposent un avis du chirurgien qui décidera d’une éventuelle exploration chirurgicale en urgence ;–des signes évocateurs de carences vitaminiques, notamment neurologiques, justifient l’administration immédiate de vitamine B1.

Les systèmes de santé font face à une hausse constante de la prévalence des maladies chroniques.Les approches centrées sur une maladie, comme le propose le Chronic Care Model, améliorent certains indicateurs propres à la maladie ciblée.La présence de plusieurs maladies chroniques chez un même patient, ou multimorbidité, est la situation la plus fréquente dans la population générale. Dans ce cas, la fragmentation de la prise en charge, qui découle des approches centrées à chaque fois sur une seule maladie, a des effets néfastes au niveau des patients et des soignants.Une approche centrée sur la personne permet de répondre à la combinaison originale de problèmes de santé de chaque individu.Une fonction de coordination et de synthèse est nécessaire pour assurer la continuité des soins au patient au sein du réseau de soignants issus de différentes interfaces. Cette fonction est tributaire d’une première ligne de soins organisée.Healthcare systems are concerned with the growing prevalence of chronic diseases.Single disease approach, based on the Chronic Care Model, is known to improve specific indicators for the targeted disease.However, the co-existence of several chronic disease, or multimorbidity, within a same patient is the most frequent situation. The fragmentation of care, as consequence of the single disease approach, has negative impact on the patient and healthcare professionals.A person centred approach is a method addressing the combination of health issues of each patient.The coordination and synthesis role is key to ensure continuity of care for the patient within a network of healthcare professionals from several settings of care. This function is the main characteristic of an organized first level of care.