Surgical Approaches to the Treatment of Obesity: Bariatric Surgery

https://doi.org/10.1016/j.ecl.2008.08.001Get rights and content

As bariatric surgery for the treatment of morbid obesity enters its sixth decade, much has been and continues to be learned from the results of several key bariatric operations, particularly the Roux-en-Y gastric bypass. Because of the obesity epidemic and development of the laparoscopic approach, bariatric procedures have increased exponentially in the past decade and are now among the more commonly performed gastrointestinal operations. Emerging data support the role of bariatric surgery as an effective treatment for improvement or remission of type 2 diabetes, hypertension, dyslipidemia, and multiple other comorbid conditions that accompany obesity. The mechanisms involved in the remission of these conditions, however, remain poorly understood and constitute an exciting area of research. This article delineates the current types of bariatric surgery, their respective outcomes, and their impact on obesity-related medical comorbidities.

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

References (94)

  • B. Kreymann et al.

    Glucagon-like peptide-1 7-36: a physiological incretin in man

    Lancet

    (1987)
  • S.R. Bloom et al.

    Gut hormones

    Adv Clin Chem

    (1980)
  • C.L. Ogden et al.

    Prevalence of overweight and obesity in the United States, 1999–2004

    JAMA

    (2006)
  • C.L. Ogden et al.

    Prevalence and trends in overweight among US children and adolescents, 1999–2000

    JAMA

    (2002)
  • A.M. Wolf

    What is economic case for treating obesity?

    Obes Res

    (1998)
  • A. Must et al.

    The disease burden associated with overweight and obesity

    JAMA

    (1999)
  • D.B. Allison et al.

    Annual deaths attributable to obesity in the United States

    JAMA

    (1999)
  • C.D. Sjostrom et al.

    Reduction in incidence of diabetes, hypertension and lipid disturbances after intentional weight loss induced by bariatric surgery: the SOS intervention study

    Obes Res

    (1999)
  • K. MacDonald et al.

    The gastric bypass operation reduces the progression and mortality of non-insulin-dependent diabetes mellitus

    J Gastrointest Surg

    (1997)
  • N.V. Christou et al.

    Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients

    Ann Surg

    (2004)
  • P.E. O'Brien et al.

    Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: a randomized trial

    Ann Intern Med

    (2006)
  • T.D. Adams et al.

    Long-term mortality after gastric bypass surgery

    N Engl J Med

    (2007)
  • L. Sjöström et al.

    Effects of bariatric surgery on mortality in Swedish obese subjects

    N Engl J Med

    (2007)
  • NIH Conference: gastrointestinal surgery for severe obesity: consensus development conference panel

    Ann Intern Med

    (1991)
  • T. Andersen et al.

    Long-term (5-year) results after either horizontal gastroplasty or very-low-calorie diet for morbid obesity

    Int J Obes

    (1988)
  • H. Buchwald

    Overview of bariatric surgery

    J Am Coll Surg

    (2005)
  • P.G. Shekelle et al.

    Pharmacological and surgical treatment of obesity

    Evid Rep Technol Assess (Summ)

    (2004)
  • E. Elakkary et al.

    Do support groups play a role in weight loss after laparoscopic adjustable gastric banding?

    Obes Surg

    (2006)
  • J.S. Azagra et al.

    Laparoscopic gastric reduction surgery: preliminary results of a randomized, prospective trial of laparoscopic vs open vertical banded gastroplasty

    Surg Endosc

    (1999)
  • M. Suter et al.

    Early results of laparoscopic gastric banding compared with open vertical banded gastroplasty

    Obes Surg

    (1999)
  • C.D. Gerhart

    Hand-assisted laparoscopic vertical banded gastroplasty: report of a series

    Arch Surg

    (2000)
  • M. Morino et al.

    Laparoscopic vertical banded gastroplasty for morbid obesity: assessment of efficacy

    Surg Endosc

    (2002)
  • F. Kalfarentzos et al.

    Weight loss following vertical banded gastroplasty: intermediate results of a prospective study

    Obes Surg

    (2001)
  • R.A. Rabkin et al.

    Laparoscopic technique for performing duodenal switch with gastric reduction

    Obes Surg

    (2003)
  • A.C. Wittgrove et al.

    Laparoscopic gastric bypass, Roux-en-Y 500 patients: technique and results, with 3–60 month follow-up

    Obes Surg

    (2000)
  • R.T. Marema et al.

    Comparison of the benefits and complications between laparoscopic and open Roux-en-Y gastric bypass surgeries

    Surg Endosc

    (2005)
  • D. Oliak et al.

    Short-term results of laparoscopic gastric bypass in patients with BMI > 60

    Obes Surg

    (2002)
  • K.D. Higa et al.

    Laparoscopic Roux-en-Y gastric bypass: technique and 3-year follow-up

    J Laparoendosc Adv Surg Tech

    (2001)
  • C. Ballesta-Lopez et al.

    Learning curve for laparoscopic Roux-en-Y gastric bypass with totally hand-sewn anastomosis: analysis of first 600 consecutive patients

    Surg Endosc

    (2005)
  • L. Biertho et al.

    Laparoscopic gastric bypass versus laparoscopic adjustable gastric banding: a comparative study of 1,200 cases

    J Am Coll Surg

    (2003)
  • A. Westling et al.

    Laparoscopic vs open Roux-en-Y gastric bypass: a prospective, randomized trial

    Obes Surg

    (2001)
  • J.A. Lugan et al.

    Laparoscopic versus open gastric bypass in the treatment of morbid obesity: a randomized prospective study

    Ann Surg

    (2004)
  • M. Sundbom et al.

    Randomized clinical trial of hand-assisted laparoscopic versus open Roux-en-Y gastric bypass for the treatment of morbid obesity

    Br J Surg

    (2004)
  • N.T. Nguyen et al.

    Result of a national audit of bariatric surgery performed at academic centers

    Arch Surg

    (2006)
  • J. Dargent

    Laparoscopic adjustable gastric banding: lessons from the first 500 patients in a single institution

    Obes Surg

    (1999)
  • P.E. O'Brien et al.

    Lap-Band®: outcomes and results

    J Laparoendosc Adv Surg Tech

    (2003)
  • R. Weiner et al.

    Outcome after laparoscopic adjustable gastric banding—8 years experience

    Obes Surg

    (2003)
  • Cited by (64)

    • Morphological changes of the human face after massive weight-loss due to bariatric surgery

      2020, Journal of Cranio-Maxillofacial Surgery
      Citation Excerpt :

      To prevent people from suffering these comorbidities and having a reduced life expectancy, bariatric surgery is used as a therapy for severe obesity. One of the surgical approaches is gastric bypass (Smith et al., 2008). The literature has shown that bariatric surgery reduces weight in 6–12 months and patients lose about 60–70% of their overweight (Schauer et al., 2017; Buchwald et al., 2004).

    View all citing articles on Scopus
    View full text