BENEFITS...

Nearly all morbidly obese patients with satisfactory postoperative weight loss experience substantial improvement in the quality of their lives. Improved health status is characterized by increased exercise tolerance and improvement or resolution of obesity-related comorbidities. Improvement of obesity-related medical problems (discussed in the article by Klein elsewhere in this issue) is a primary goal of gastric bypass. The patient's ability to interact with others in social situations is also enhanced. At present, RYGB may be the only bariatric operation that has produced durable long-term weight loss at an acceptable level of risk. [References: 42]

Assessment of the outcome of obesity operations is exceedingly complex. Currently there is no consensus among bariatric surgeons as to what constitutes successful weight loss. Furthermore, weight loss data must be regularly reevaluated to account for later regaining of lost weight. There is no question that surgically-induced weight loss results in improvement or resolution of obesity-related medical problems in most patients. Yet it is not known whether sustained long-term weight loss will result in extended amelioration of these medical problems. Analysis of outcome is further complicated by difficulties in maintaining consistent long-term follow-up in such a way that the benefits of weight loss can be objectively evaluated. The next decade should provide improvements in a number of these problem areas. The new computer registry of the American Society of Bariatric Surgery has access to thousands of bariatric surgical patients. This registry will hopefully provide for some standardization in analysis and reporting of results of bariatric operations. The registry may eventually be able to provide the type of actuarial analysis of long-term results necessary to assess the true impact of bariatric operations on the morbidity and mortality risks associated with morbid obesity. It is also probable that more sophisticated patient selection methods will improve the likelihood of successful weight loss both by excluding patients who are prone to failure and by identification of patient profiles that are better suited for treatment by one type of operation over another. In the final analysis, there is no question that morbid obesity poses an increased risk to health and longevity. Thus it is only logical that substantial weight loss in this group of patients could be expected to improve both longevity and quality of life, provided that the treatment methods employed are free of serious side-effects. At present, surgery offers the only realistic hope for successful weight loss in the morbidly obese. [References: 70]

Severe obesity is associated with multiple comorbidities and is refractory to dietary management with or without behavioral or drug therapies. There are a number of surgical procedures for the treatment of morbid obesity, including purely gastric restrictive, a combination of malabsorption and gastric restriction or primary malabsorption. The purely gastric restrictive procedures, including vertical banded gastroplasty and laparoscopic adjustable silicone gastric banding, do not provide adequate weight loss. African-American patients do especially poorly after the banding procedure with the loss of only 11% of excess weight in one study. Gastric bypass (GBP) is associated with the loss of 66% of excess weight at 1 to 2 years after surgery, 60% at 5 years and 50% at 10 years. For unknown reasons, African-American patients lose significantly less weight than Caucasians after GBP. There is a risk of micronutrient deficiencies after GBP, including iron deficiency anemia in menstruating women, vitamin B12, and calcium deficiencies. Prophylactic supplementation of these nutrients is necessary. Recurrent vomiting after bariatric surgery may be associated with a severe polyneuropathy and must be aggressively treated with endoscopic dilatation before this complication is allowed to develop. The malabsorptive procedures include the partial biliopancreatic bypass (BPD) and BPD with duodenal switch (BPD/DS). The BPD appears to cause severe protein-calorie malnutrition in American patients; the BPD/DS may be associated with less malnutrition. Weight loss failure after GBP does not respond to tightening a dilated gastrojejunal stoma or reducing the size of the gastric pouch. These patients may require conversion to a malabsorptive distal GBP, similar to the BPD. However, because of the risk of severe protein-calorie malnutrition and calcium deficiency BPD should be reserved for patients with severe obesity comorbidity. The risk of death following bariatric surgery is between 1% and 2% in most series but is significantly higher in patients with respiratory insufficiency of obesity. In most patients, surgically induced weight loss will correct hypertension, type II diabetes mellitus, sleep apnea, obesity hypoventilation syndrome, gastroesophageal reflux, venous stasis disease, urinary incontinence, female sexual hormone dysfunction, pseudotumor cerebri, degenerative joint disease pains, as well as improved self-image and employability. [References: 61]

Breakdown of the in-continuity gastric staple line after gastroplasty and gastric bypass is frequently associated with either complications or unsatisfactory weight loss. Although there is wide variation in the reported incidence of staple-line disruption after gastric bariatric operations, this complication is most frequently recognized by surgeons who routinely examine the integrity of the staple line at 12 months or more after operation. Upper gastrointestinal contrast studies are more sensitive than upper endoscopy in detecting small defects in the stapled gastric partition. The stomach should be routinely divided in patients who require reoperation for late staple-line disruption. This complication could be prevented by routine transection of the stomach at the initial gastric restrictive operation. [References: 43]

Surgeons, gastroenterologists, endocrinologists, psychiatrists, nutritionists, and other health care professionals, as well as members of the public convened to address nonsurgical treatments for severe obesity, surgical treatments for severe obesity, and criteria for selection, the efficacy, and risks of surgical treatments for severe obesity, and the need for future research on and epidemiologic evaluation of these therapies. The National Institutes of Health Consensus Development Panel recommended that patients seeking therapy for severe obesity for the first time should be considered for treatment in a nonsurgical program that integrates a dietary regimen, appropriate exercise, behavior modification, and psychological support; that gastric restrictive or bypass procedures could be considered for well-informed and motivated patients in whom the operative risks were acceptable; that patients who are candidates for surgical procedures should be selected carefully after evaluation by a multidisciplinary team with medical, surgical, psychiatric, and nutritional expertise; that surgery be done by a surgeon who has substantial experience in the particular procedure and who works in a clinical setting with adequate support for all aspects of management and assessment; and that patients undergo lifelong medical surveillance after surgery. [References: 0]

Unique Identifier 9625222
Authors Hsu LK. Benotti PN. Dwyer J. Roberts SB. Saltzman E. Shikora S. Rolls BJ. Rand W.
Institution Department of Psychiatry, Tufts University School of Medicine, New England Medical Center, Boston, Massachusetts 02111, USA.
Title Nonsurgical factors that influence the outcome of bariatric surgery: a review. [Review] [120 refs]
Source Psychosomatic Medicine. 60(3):338-46, 1998 May-Jun.
Abstract

OBJECTIVE: Severe obesity (ie, at least 100% overweight or body mass > or =40 kg/m2) is associated with significant morbidity and increased mortality. It is apparently becoming more common in this country. Conventional weight-loss treatments are usually ineffective for severe obesity and bariatric surgery is recommended as a treatment option. However, longitudinal data on the long-term outcome of bariatric surgery are sparse. Available data indicate that the outcome of bariatric surgery, although usually favorable in the short term, is variable and weight regain sometimes occurs at 2 years after surgery. The objective of this study is to present a review of the outcome of bariatric surgery in three areas: weight loss and improvement in health status, changes in eating behavior, and psychosocial adjustment. The study will also review how eating behavior, energy metabolism, and psychosocial functioning may affect the outcome of bariatric surgery. Suggestions for additional research in these areas are made.
METHOD: Literature review.
RESULTS: On average, most patients lose 60% of excess weight after gastric bypass and 40% after vertical banded gastroplasty. In about 30% of patients, weight regain occurs at 18 months to 2 years after surgery. Binge eating behavior, which is common among the morbidly obese, may recur after surgery and is associated with weight regain. Energy metabolism may affect the outcome of bariatric surgery, but it has not been systematically studied in this population. Presurgery psychosocial functioning does not seem to affect the outcome of surgery, and psychosocial outcome is generally encouraging over the short term, but there are reports of poor adjustment after weight loss, including alcohol abuse and suicide.
CONCLUSIONS: Factors leading to poor outcome of bariatric surgery, such as binge eating and lowered energy metabolism, should be studied to improve patient selection and outcome. Long-term outcome data on psychosocial functioning are lacking. Longitudinal studies to examine the long-term outcome of bariatric surgery and the prognostic indicators are needed. [References: 120]

Unique Identifier 11186223
Authors Sjostrom L.
Institution
The SOS, Secretariat, Sahlgrenska University Hospital, Goteborg, Sweden. lars.sjostrom@medfak.gu.se
Title Surgical intervention as a strategy for treatment of obesity. [Review] [130 refs]
Source Endocrine Journal-Uk. 13(2):213-30, 2000 Oct.
Abstract

A very large number of weight-reducing surgical techniques have been developed over the last 25 years. Today only a handful of these techniques can be recommended. Gastric bypass, vertical banded gastroplasty, and variable banding can all be recommended although gastric bypass should be reserved for heavier patients. For the heaviest, biliopancreatic diversion or biliopancreatic diversion with duodenal switch might be considered. The controlled intervention study Swedish Obese Subjects has shown that most but not all cardiovascular risk factors are improved over 10 years by surgically induced weight loss. Quality of life as well as cardiac structure and function are dramatically improved. The average weight loss for gastric bypass and vertical banded gastroplasty was 16% after 10 years. No non-surgical treatment available today can achieve such results, not even over 2 years. Surgical treatment for obesity needs to become much more common, particularly in obese patients with metabolic disturbances. [References: 130]

Laparoscopic

Unique Identifier 11589250
Authors Schauer PR. Ikramuddin S.
Institution Department of Surgery, The University of Pittsburgh, Pennsylvania, USA. schauerpr@msx.upmc.edu
Title Laparoscopic surgery for morbid obesity. [Review] [80 refs]
Source Surgical Clinics of North America. 81(5):1145-79, 2001 Oct.
Abstract

Minimally invasive approaches to bariatric surgery offer significant advantages over those of open surgery. The potential of laparoscopic approaches to reduce the morbidity of these operations may exceed that of laparoscopic cholecystecomy and laparoscopic Nissen fundoplication because the access incisions for open bariatric operations have relatively greater potential for harming the morbidly obese patient. Early results of laparoscopic VBG suggest a significant decrease in perioperative morbidity compared to the open approach, with similar weight-loss results. LGB may have the lowest perioperative morbidity and mortality of all current bariatric operations. However, the reoperation rate for device-related complications or failure of the patient to lose sufficient weight appears significant. Long-term esophageal motility also remains questionable for the LGB. It is hoped that the FDA trial will address many of the issues regarding LGB. Results of Lap RYGBP are accumulating and appear promising. The early experience suggests that it is technically feasible and safe in the hands of surgeons who have appropriate training. It is associated with low perioperative morbidity, short hospital stay, and rapid recovery compared to expected results of open RYGBP. Weight loss for Lap RYGBP after 5 years is excellent. It is, however, a technically formidable operation requiring long operating times and a steep learning curve. Early results indicate that technical complications may be greater than those experienced with open RYGBP because of the learning curve. Lap RYGBP is a promising bariatric procedure with potentially significant advantages over open RYGBP. Thus, for patients in the United States, Lap RYGBP may become the preferred weight-reduction procedure. The value of hand-assisted bariatric procedures and laparoscopic malabsorption procedures must await further study. [References: 80]

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