Some patients might decide not to opt for weight-loss surgery following screening, others might be deemed unsuitable; such patients should ideally be picked up in primary care.

The screening process might pick up biochemical evidence of an undiagnosed cause for obesity, or individuals for whom non-invasive management is clearly a better option. Patients might lose so much weight as a ‘preoperative’ measure that surgery is no longer necessary. In others there might be a psychological or underlying psychiatric condition that calls either for a different treatment altogether or needs to be dealt with before surgery is considered. Schizophrenia, personality disorder and uncontrolled depression are absolute contraindications for surgery. Individuals whose obesity is caused simply by love of food, or patients with binge eating disorder might find the postoperative adjustment of behaviour overwhelmingly difficult.

Prior to embarking on surgery, the risk : benefit ratio is considered and patients might be deemed unsuitable for surgery because of their comorbidities, anaesthetic risk and general well-being.

Women of childbearing age should be treated with extreme caution because of the increased nutritional needs of pregnancy being hampered by the reduced capacity for absorption of nutrients. Such patients are advised not to become pregnant after surgery until their weight has stabilized and their micronutrient status has been checked; contraceptive advice is essential.

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