Endocrinology and Metabolism Clinics of North America
Surgical Approaches to the Treatment of Obesity: Bariatric Surgery
Section snippets
Bariatric surgery as treatment for severe obesity
Obesity is a chronic disease that has become a major nutritional health problem in most industrialized countries, and its prevalence is increasing in the United States. A recent study involving data from the National Health and Nutrition Examination Survey (NHANES) from 2003 to 2004 indicates that obesity was present in 28.5% of adults aged 20 to 39 years, 36.8% aged 40 to 59 years, and 31.0% aged 60 years or older, with obesity defined as a body mass index (BMI) of 30.0 or higher.1 The number
Patient selection and workup
Based on the 1991 NIH Consensus Development Conference Panel14 for the treatment of severe obesity, individuals who have a BMI greater than 35 kg/m2 with associated medical comorbidities or whose BMI is greater than 40 kg/m2 qualify for bariatric surgery. Patients generally should have a chronic history of obesity with no underlying endocrine abnormality that can contribute to obesity. Nonsurgical means of weight loss should also have been attempted with failed results. These qualifications for
Facility requirements
For bariatric surgery to be safely performed, the health care facility must be able to accommodate morbidly obese patients in all aspects, starting with a system for evaluation through follow-up. The institution should have a bariatric surgical team, skilled staff, appropriate operating room equipment, and sufficient institutional resources. A bariatric surgical team consists of experienced surgeons and physicians, anesthesiologists, nurses, psychologists, and nutritionists. Specialists in the
Surgical operations
Mason and Ito20 conceived the original gastric bypass operation in the 1960s as a variation of gastric ulcer surgery. Weight loss was noted in a large percentage of patients who had undergone partial gastrectomy as primary treatment for peptic ulcer disease. The concept has since evolved through numerous modifications to achieve optimal weight loss while minimizing surgical morbidity and nutritional deficiency, with the emergence of a few safe operations. Although many surgical operations for
Surgical outcomes
Bariatric surgical outcomes have become a significant area of scrutiny, predominately because of higher-than-expected morbidity and mortality rates that accompanied the introduction of laparoscopic gastric bypass at the turn of this century. It became evident that certain groups of patients, including men, elderly individuals, and the super-morbidly obese were at an increased risk for death from this operation, and a steep learning curve exists for laparoscopic gastric bypass.
Studies covering
Comparison of gastric banding, gastric bypass, and sleeve gastrectomy
Three case-controlled studies have compared the outcomes of laparoscopic gastric banding with laparoscopic gastric bypass. Jan and colleagues48 reported the outcomes of 219 patients who underwent laparoscopic gastric bypass compared with 154 patients who underwent Lap-Band. One death occurred in each group. The incidence of major and minor complications was similar, although the reoperation rate was higher in the Lap-Band group and weight loss was greater with gastric bypass.
In a matched
Effects of bariatric surgery on mortality
Several studies have shown improved survival for patients who undergo bariatric surgery compared with a control cohort of severely obese patients who did not.12, 51, 52 Christou and MacLean51 compared a cohort of patients (n = 1035) who underwent bariatric surgery with a control cohort (n = 5746) of age- and gender-matched severely obese patients who did not undergo weight-reduction surgery. At a maximum of 5-year follow-up from inception, the mortality rate in the bariatric surgery cohort was
Effects of bariatric surgery on obesity-related comorbidities
In addition to the well-documented long-term efficacy of bariatric surgery in achieving sustainable weight loss, numerous studies have also evaluated the efficacy of bariatric surgery in ameliorating specific obesity-related comorbidities, particularly type 2 diabetes, hypertension, and dyslipidemia. However, because standards for evaluating the effect of surgery on metabolic diseases have not been established, results should be interpreted with the understanding that many studies lack
Mechanisms for diabetes remission
Type 2 diabetes mellitus has long been and continues to be a significant source of morbidity and mortality and a substantial economic burden on worldwide health care.73 Development of type 2 diabetes is rooted in two fundamental pathophysiologic processes: decreased production of endogenous insulin and cellular insulin resistance. Bariatric surgery has been shown to resolve or substantially improve glucose control.60, 74 Although no clear understanding exists of the mechanisms through which
Summary
As the obesity epidemic continues to grow in the Unites States, so does the search for the ideal nonsurgical or surgical solution. Bariatric surgery continues to be the most sustainable form of weight loss available to morbidly obese patients. In addition, bariatric surgery has established an acceptable safety profile with respect to morbidity and mortality. With the number of elective bariatric cases growing in recent years, it is unsurprising that results have improved and better data are
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