Thresholds, risk scores, trial choice, and lifelong follow-up

(A) Indications and mortality scoring (4 marks). Offer surgery at BMI over 35 regardless of comorbidity and consider it at 30-34.9 with metabolic disease; both vignette patients qualify — the woman by recommendation, and class I consideration applies from BMI 30 with disease.^[8] Score the man at OS-MRS 5 of 5: BMI 50 or more, male, hypertension, PE-risk history, age 45 or more at one point each — derivation mortality 7.56 percent class C against 0.31 class A, validated at 2.4 against 0.2 percent across 4,431 bypasses with class C carrying twelvefold mortality.^[9][10] Consent him as the highest-risk stratum, not as a routine bypass.^[10]

(B) Sleeve versus bypass (3 marks). Quote SLEEVEPASS 5 years: excess weight loss 49 percent sleeve against 57 percent bypass with equivalence failed on the minus 9 to plus 9 margins; diabetes tied 37 against 45 percent; morbidity 19 against 26 percent.^[13] Quote SM-BOSS 5 years: weight a statistical draw (61.1 against 68.3 percent) but reflux remission 60.4 against 25.0 percent favouring bypass with worsening 6.3 against 31.8 percent.^[14] For the refluxing, regaining sleeved patient add the conversion ledger: sleeve-to-other-anatomy conversion 29.9 against 5.5 percent beyond 10 years with more de-novo reflux after sleeve — revise, do not repeat the sleeve.^[17]

(C) Durability, clots, food (3 marks). Counsel the woman with Mingrone 5 years (50 percent surgical remission held, relapse in 53 percent of bypass and 37 percent of BPD 2-year remitters — surveilled, not cured) and STAMPEDE 5 years (HbA1c 6.0 or less 5 percent medical against 29 percent bypass and 23 percent sleeve).^[19][21] Dose heparin by weight: 0.54 against 2.0 percent VTE with bleeding level at 1.6 against 2.3 percent.^[28] Book lifelong nutrition: deficiencies rare but iron worse after bypass (41 against 14 percent) with sleeve adherence lower (71 against 89 percent) — iron watched after bypass, adherence chased after sleeve, nobody discharged.^[37]