Surgical Management of Severe Obesity

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Surgical management of severe obesity

Authors Edward C Mun, MD,FACSAli Tavakkolizadeh, MD

Section Editors F Xavier Pi-Sunyer, MD,MPHJ Thomas LaMont, MD

Deputy Editor Kathryn A Martin,MD

Last literature review version 1 7.1: January 2009 | This topic last updated:February 9, 2009 (More)

INTRODUCTION Obesity is a chronic disease that is increasing inprevalence in the United States and worldwide. Defined as a body mass index(BMI) >30 kg/m2, the percentage of obese men nearly doubled between 1991and 1998, and the percentage of obese women increased by 50 percent.More recently, the trend of increasing obesity has leveled off with nosignificant increase in the rate of obesity in the adult population between2003 to 2004 and 2005 to 2006 [ 1 ] .

More than 33 percent of adults in the United States (approximately 72 million

people) are obese [ 2,3 ] . Furthermore, more than 64 percent of Americans areoverweight (BMI 25 kg/m2). ( See "Overview of therapy for obesity in adults"section on Prevalence)

There are several well-established health hazards associated with obesityincluding type 2 diabetes, heart disease, stroke, certain cancers,osteoarthritis, liver disease, obstructive sleep apnea, and depression ( showtable 1 ). The risk of development of complications rises with increasingadiposity while weight loss can reduce the risk. ( See "Health hazardsassociated with obesity in adults" ).

There are many behavioral, medical, and surgical options for achieving weightloss. This topic review will focus on surgical procedures, which have beencollectively referred to as "bariatric" surgery (from the Greek words "baros"meaning "weight" and "iatrikos" meaning "medicine"). Complications of theseprocedures and a general approach to the management of obesity arediscussed separately. ( See "Complications of bariatric surgery" and see"Overview of therapy for obesity in adults" ).

DEFINITIONS Body mass index (BMI) is considered to represent the most


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practical measure of a person's adiposity. It is calculated by dividing theweight in kilograms by the height in meters squared (kg/m2). In adults, a BMIof

25 to 29.9 kg/m2 is considered overweight30 to 34.9 kg/m2 is considered obese (class I obesity)35 to 39.9 kg/m2 is considered moderately obese (class II obesity)

40 to 49.9 kg/m2 is considered severely (or extremely or morbidly)obese (class III obesity)>50.0 kg/m2 is considered super morbidly obese (class IV obesity)

EFFECTIVENESS OF BARI ATRI C SURGERY The goal of surgery is toreduce the morbidity and mortality associated with obesity and to improvemetabolic and organ function. Several studies have demonstrated thatbariatric surgery is effective in reducing obesity-related comorbidities, whilehaving additional benefits such as reducing monthly medication costs and thenumber of sick days and improving quality of life [ 4-14 ] . A benefit on overalland cause-specific mortality has also been demonstrated [ 15,16 ] . However,bariatric surgery is also associated with significant perioperative complicationsand mortality. ( See "Complications of bariatric surgery" ).

At least two meta-analyses have summarized data from various, mainlyobservational studies [ 17,18 ] . One included 136 studies in which patientshad undergone a variety of bariatric procedures:

The mean overall percentage of excess weight lost was 61 percent(95% CI 58-64%), varying according to the specific bariatric procedure

performed. Excess weight loss refers to the difference between thepreoperative BMI and a BMI of 20 to 30 kg/m2 (depending upon thestudy).

30-day mortality was 0.1 percent for purely restrictive procedures(defined below), 0.5 percent for gastric bypass, and 1.1 percent forbiliopancreatic diversion or duodenal switch.

Diabetes completely resolved in 77 percent and resolved or improved in86 percent.

Hyperlipidemia improved in 70 percent or more of patients.

Hypertension resolved in 62 percent and resolved or improved in 79percent.

Obstructive sleep apnea resolved in 86 percent and resolved orimproved in 84 percent.

A second meta-analysis that included 147 studies concluded that the evidence


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supporting a benefit of bariatric surgery was strongest in patients with a BMIof >40 while the benefits in those with BMI of 35 to 39 were less clear [ 18 ] .Greater weight loss was observed with gastric bypass procedures comparedwith gastroplasty. Overall mortality was less than 1 percent while adverseevents occurred in approximately 20 percent of patients. A laparoscopicapproach resulted in fewer wound complications compared with an openapproach.

The striking benefits on important obesity-related morbidity contrast withrelatively disappointing results in the management of severe obesity withmedical and behavioral therapy. The Swedish Obese Subjects Trial (SOS) isthe largest trial comparing surgical versus medical treatment of morbidobesity. A total of 6328 obese (BMI >34 kg/m2 for men and >38 kg/m2 forwomen) subjects were recruited of whom 2010 underwent surgery for obesity(gastric banding, gastroplasty or gastric bypass) while 2037 choseconventional treatment. Although the study was not randomized, there wasan attempt to match patients by relevant covariates. Begun in 1987, the SOShas spawned multiple publications; the following summarizes the majorobservations [ 15,19-27 ] :

After two years, weight had increased by 0.1 percent in the controlgroup while it had decreased by 23 percent in the surgery group [ 27 ] .After 10 years, weight had increased by 1.6 percent and decreased by16 percent, in the two groups respectively. Energy intake was lowerand the proportion of physically active subjects higher in the surgerygroup throughout the observation period. Two and 10-year rates of

recovery were better for diabetes (Odds ratio [OR] 8.42 and 3.45,respectively), hypertriglyceridemia (5.28 and 2.57, respectively), lowlevels of high-density lipoprotein cholesterol (5.28 and 2.35,respectively), hypertension (1.72 and 1.68, respectively) andhyperuricemia (5.36 and 2.37, respectively). There was no difference inrates of recovery from hypercholesterolemia. The surgery group hadlower two and 10-year incidence rates of diabetes (OR 0.14 and 0.25,respectively), hypertriglyceridemia (OR 0.29 and 0.61, respectively) andhyperuricemia (OR 0.22 and 0.49, respectively). There were no

significant differences in the incidence of hypercholesterolemia andhypertension.

Surgically treated patients were significantly less likely to requiremedications for cardiovascular disease or diabetes at two and six years(risk ratio 0.56 to 0.77) [ 23 ] . Among those not already requiring suchmedications, surgery reduced the proportion who required initiation of treatment (risk ratio 0.08 to 0.80).

Costs of medications were reduced significantly in the surgically treated


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group [ 24 ] .

Surgically treated patients had dramatic improvement in scores onvalidated measures of quality of life compared with only minor andsporadic improvement in medically treated patients at two years [ 19 ] .The magnitude of benefit was related mostly to the degree of weightloss, which was greater in the surgical group. Similar benefits were

observed on validated batteries of psychiatric dysfunction [ 25 ] .However, at 10 years of follow-up, the improvements in quality of lifehad diminished somewhat in the surgery group due to weight regain,but overall outcome was still significantly better in the surgical than themedically treated group [ 28 ] .

In patients undergoing weight loss surgery, there was a 29 percentreduction in risk death [ 15 ] .

Thus, the reduction in comorbidities appears to translate into a reduction inmortality. These findings were confirmed in a large cohort study, in whichnearly 8000 patients who had undergone weight loss surgery were matchedto a similar sized obese cohort [ 16 ] . Deaths from all causes were reduced by40 percent, from diabetes by 92 percent, from coronary disease by 56percent, and from cancers by 60 percent. However, there was an increase inmortality rates from accidental death as well as suicide. ( See "Complications of bariatric surgery" ).

A similar mortality benefit was found in a population based study that included1035 patients who had undergone bariatric surgery who were compared withan age- and gender-matched severely obese control population identifiedfrom a population database [ 4 ] . Patients who had undergone bariatricsurgery were significantly less likely to develop cardiovascular disease, cancer,and endocrine, infectious and psychiatric disorders, although they were morelikely to develop digestive diseases. The overall mortality rate in the bariatriccohort (0.7 percent) was significantly lower than controls (6.2 percent, RR0.11, 95% CI 0.04-0.27).

Although these data would appear to make a compelling argument fortreatment of obese patients with surgery, most of these studies werenon-randomized, and there have been few well-designed, randomized,prospective trials comparing specific surgical approaches to optimal medicalcare. One such study found that laparoscopic adjustable gastric banding wassignificantly more effective than medical management at two years follow-upin patients with mild to moderate obesity (BMI 30 to 35 kg/m(2)) [ 29 ] . Meanexcess weight loss was 87 percent in the group randomized to laparoscopicadjustable gastric banding compared with only 22 percent in the optimalmedical care group.


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Although the majority of mortality data for bariatric surgery comes frompatients under age 65, a retrospective cohort analysis suggests that survivalis improved, even in patients over age 65 [ 30 ] .

Type 2 diabetes The predominantly observational studies described abovehave generated much interest in the role of weight loss surgery in thetreatment algorithm of diabetes, with some suggesting that bariatric surgery

is one of the best treatments for type 2 diabetes. However, there are fewrandomized trials comparing surgical versus medical therapy, specifically inobese patients with diabetes. In one such trial, 60 obese subjects (BMIbetween 30 and 40 kg/m2), with type 2 diabetes diagnosed within theprevious two years, were randomly assigned to conventional therapy (lifestylemodification and medical therapy) or laparoscopic adjustable banding andconventional therapy [ 31 ] . Remission of diabetes occurred more often in thesurgical group (73 versus 13 percent). Remission was related to lowerbaseline A1C values and to weight loss.

Although these findings are encouraging, the optimal surgical approach forimprovement of diabetes, cost-effectiveness, and role in the management of recent onset, obesity-related type 2 diabetes are unclear. ( See "Initialmanagement of blood glucose in type 2 diabetes mellitus" , section on Surgicaltreatment of obesity).

The mechanism for diabetes improvement depends upon the type of surgeryperformed [ 32 ] . One study suggested that insulin sensitivity improved inproportion to weight loss with the use of predominantly restrictive proceduresbut was reversed completely by predominantly malabsorptive approaches

long before normalization of body weight [ 33 ] . The rapid normalization of insulin sensitivity after bypass types of bariatric procedures may be related toduodenal isolation following the bypass surgery and subsequent changes ingastrointestinal hormones (the incretins, glucagon-like peptide andglucose-dependent insulinotrophic polypeptide) following surgery. In a studyof eight obese women with type 2 diabetes, the release of incretins after oralglucose and their effect on insulin secretion improved within one month of Roux-en-Y gastric bypass surgery [ 34 ] . The role of gastrointestinal peptidesin glucose homeostasis is reviewed in detail elsewhere. ( See "GLP-1-basedtherapies for the treatment of type 2 diabetes mellitus" , section on GLP-1).

INDICATIONS Indications for the surgical management of morbid obesitywere first outlined by the National Institutes of Health (NIH) ConsensusDevelopment Panel in 1991 ( show table 2 ) [ 35 ] . Potentially eligible patientsshould:

Be well-informed and motivatedHave a BMI >40Have acceptable risk for surgery


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Have failed previous non-surgical weight lossThe NIH also suggested that adults with a BMI >35 who have seriouscomorbidities such as diabetes, sleep apnea, obesity-relatedcardiomyopathy, or severe joint disease may also be candidates

Contraindications to bariatric surgery include patients with untreated majordepression or psychosis, binge eating disorders, current drug and alcohol

abuse, severe cardiac disease with prohibitive anesthetic risks, severecoagulopathy, or inability to comply with nutritional requirements includinglife-long vitamin replacement. Bariatric surgery in advanced (above 65) or veryyoung age (under 18) is controversial.

Bariatric surgery needs to be performed in conjunction with a comprehensivefollow-up plan consisting of nutritional, behavioral, and medical programs. TheAmerican Society of Metabolic and Bariatric Surgeons (ASMBS) and theAmerican College of Surgeons (ACS) have announced guidelines forestablishing Centers of Excellence (COE) for bariatric facilities [ 36 ] . Patient

safety is clearly the driving force behind such a process and is emphasized byseveral items:

An integrated program that is capable of providing the pre- andpost-operative care of a bariatric patient by necessary multi-specialtyconsultants

Ability to follow 75 percent of post-surgical patients long-term out tofive years

Monitored credentialing of bariatric surgeons and hospitals based upondemonstration of adequate training, equipment, and periodic outcomesassessment

TYP ES OF BARI ATRI C PROCEDURES Bariatric surgical procedures can bedivided fundamentally into two varieties, malabsorptive and restrictive, basedupon the mechanism by which they induce weight loss ( show table 3 ).

Restrictive procedures limit caloric intake by downsizing the stomach'sreservoir capacity. Vertical banded gastroplasty (VBG) and laparoscopicadjustable gastric banding (LAGB) are purely restrictive procedures andshare similar anatomical configurations. Both limit solid food intake byrestriction of stomach size as the only mechanism of action, leaving theabsorptive function of the small intestine intact. Although theseprocedures are simpler in comparison to malabsorptive procedures,they tend to produce more gradual weight loss.

The primary mechanism of malabsorptive procedures is to decrease theeffectiveness of nutrient absorption by shortening the length of the


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functional small intestine. Jejunoileal bypass (JIB), the biliopancreaticdiversion (BPD), and duodenal switch operation (DS) are examples of malabsorptive procedures. Profound weight loss can be achieved by themalabsorptive operations depending upon the effective length of thefunctional small bowel segment. However, the benefit of superiorweight loss is often offset by the significant metabolic complicationssuch as protein calorie malnutrition and various micronutrientdeficiencies.

Some procedures have both a restrictive and malabsorptive component. TheRoux-en-Y gastric bypass (RYGB), for example, is primarily a restrictiveoperation in which a small gastric pouch limits oral intake. However, the smallbowel reconfiguration provides additional mechanisms favoring weight lossincluding dumping physiology and mild malabsorption.

Minimally invasive techniques were first applied in bariatric surgery in the1990s. The first laparoscopic RYGB series was reported in 1994 in the UnitedStates [ 37 ] . Although technically intensive with a steep learning curve,laparoscopic RYGB can be performed safely by experienced surgeons. Thelaparoscopic approach offers the advantages of decreased post-operativepain, shorter hospital stay, and decreased rates of wound infection andhernia formation.

An increasing number of laparoscopic RYGB and LAGB are being performed inthe United States, indicating a trend towards minimally invasive approaches tobariatric surgery. Investigation of the cost-effectiveness and safety of theselaparoscopic procedures is ongoing.

Choosing a procedure The most commonly performed bariatric surgeryprocedures are laparoscopic adjustable gastric banding (LAGB) and Roux-en-Ygastric bypass (RYGB). There are benefits and risks associated with eachprocedure. The comparative efficacy and safety of the procedures wereevaluated in a five-year trial of 50 obese patients (mean BMI 43 kg/m2)randomly assigned to LAGB versus laparoscopic RYGB (LRYGB) [ 38 ] . After fiveyears, patients in the LRYGB group lost a greater percentage of excess bodyweight (67 versus 47 percent) and had a lower failure rate (4 versus 35percent).

A meta-analysis of 14 studies (13 observational and one randomized trial [ 38 ]) evaluating clinical outcomes after LAGB and RYGB showed the followingadvantages and disadvantages of RYGB [ 39 ] :

Weight loss at one year was superior (median difference 26 percent,95% CI 19-34 percent)

Resolution of comorbidities, such as diabetes and dyslipidemia, wasbetter


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Operative times and length of hospitalization were longer (mediandifferences of 68 minutes and two days, respectively)

Perioperative complications (9 versus 5 percent) were greater butreoperation rates (16 versus 24 percent) lower

Mortality was higher, although it was low in both groups (0.06 and 0.17percent for LAGB and RYGB, respectively)

Thus, in this meta-analysis of predominantly observational studies, RYGB wasassociated with greater long-term success but higher short-term morbidity.

Larger randomized trials comparing RYGB (particularly laparoscopic) and LAGBare required to confirm the superior efficacy of RYGB, given its highershort-term complication rates. Until then, the choice of procedure dependsupon patient preference, the institution, and expertise of the surgeons.

RESTRICTIVE

Vertical banded gastroplasty Vertical banded gastroplasty (VBG) is apurely restrictive procedure in which the upper part of the stomach ispartitioned by a vertical staple line with a tight outlet wrapped by a prostheticmesh or band ( show figure 1 ).

The small upper stomach pouch gets filled quickly by solid food and preventsconsumption of a large meal. Weight loss occurs because of decreased caloricintake of solid food. Patients who have undergone VBG can be expected tohave excess weight loss (EWL) of up to 66 percent at two years, whichsubsequently decreases to 55 percent at nine years [ 40 ] . The effectivenessof such a restrictive mechanism depends upon the durability of pouch andstoma (outlet) size.

Ingestion of high-calorie liquid meals and gradually increased pouch capacitydue to overeating have been some of the major causes of its failure. Sweetseaters who rely on soft meals (ie, ice cream, milk shakes) do not benefitsignificantly from this procedure [ 41 ] .

VBG has been replaced largely by other procedures due to lack of

sustained/desired weight loss as well as the high incidence of complicationsrequiring revision (20 to 56 percent) [ 41-46 ] . The majority of revisions arerequired for staple line disruption, stomal stenosis, band erosion, banddisruption, pouch dilatation, vomiting, and gastroesophageal reflux disease.(See "Complications of bariatric surgery" ).

Laparoscopic adjustable gastric banding Laparoscopic gastric banding(LAGB) is a purely restrictive procedure that compartmentalizes the upperstomach by placing a tight, adjustable prosthetic band around the entrance tothe stomach ( show figure 2 ). Although it has been performed extensively in


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Europe and Australia for almost a decade, it was not until June 2001 when thefirst adjustable band (LapBand(TM) (Inamed)) was approved for use in theUnited States.More recently, another adjustable gastric band received FDA approval(Realize(TM) band (Ethicon)) [ 47 ] . It works on similar principle, and has similarshort-term outcomes to LapBand.

The adjustable gastric bands consist of a soft, locking silicone ring connectedto an infusion port placed in the subcutaneous tissue. The port may beaccessed with relative ease by a syringe and needle. Injection of saline intothe port leads to reduction in the band diameter, resulting in an increaseddegree of restriction. The currently available band is adjustable and is placedlaparoscopically [ 48,49 ] .

Indications for the use of LAGB are similar to the indications for gastric bypassand patients must meet full NIH criteria ( show table 2 ) [ 35 ] . LAGB is generallycontraindicated in patients with portal hypertension, connective tissue

disorders with esophageal dysmotility, or chronic steroid use (relativecontraindication).

LAGB is gaining significant attention among bariatric surgeons and patientsprimarily because of its simplicity and lower complication rates when comparedto more involved procedures such as RYGB [ 50 ] . Because of its manyadvantages, it has largely replaced the conventional VBG as the mainrestrictive procedure for treatment of morbid obesity:

It does not require division of the stomach or intestinal resection. As a

result, it has the lowest mortality rate (0 to 0.5 percent) among allbariatric procedures [ 51,52 ] .

The band eliminates the need for staple lines used in VBG that maybreak down and cause weight regain.

Avoidance of a fixed prosthetic mesh at the stoma reduces theincidence of stomal stenosis seen in VBG.

The adjustability of the outlet by the new band design offers atheoretical advantage of addressing various nutritional issues aftersurgery. As an example, a patient who becomes pregnant following thisprocedure may have her stoma widened to allow for greater caloric andfluid intake, if necessary. In addition, the band is reversible, allowing foreasy restoration of the original anatomy by the removal of the band.

The effectiveness of the LAGB for achieving weight loss has been variable indifferent reports. European and Australian data indicate a 15 to 20 percentEWL at three months, 40 to 53 percent EWL at one year, with eventualincreases in up to 45 to 58 percent EWL after year two [ 53 ] . Initial American


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experience in a seminal study was disappointing with two year EWL of only 36percent [ 52 ] . However, the design and conduct of the study were criticized asthe causes of the relatively poor outcome [ 54 ] . Subsequent American datawere similar to the European and Australian experience, with EWL of 45 to 75percent at two years [ 55-57 ] .

As a general rule, weight loss following LAGB is more gradual and less

compared with gastric bypass procedures, but some have reportedcomparable long-term outcomes [ 51 ] . Persistent weight loss requires closefollow-up and frequent band adjustments. In addition to weight loss, LAGB isassociated with improvements in various comorbidities (diabetes, asthma,sleep apnea, hypertension) and quality of life [ 7,8,51,58-61 ] .

Other

Sleeve gastrectomy Sleeve gastrectomy is a technique that was initiallyoffered to patients with super morbid obesity as the first stage in surgicalmanagement [ 62,63 ] . The procedure consists of a laparoscopic partialgastrectomy in which the majority of the greater curvature of the stomach isremoved and a tubular stomach is created. The tubular stomach is small in itscapacity (restriction), resistant to stretching due to absence of fundus, anddevoid of ghrelin producing cells (a gut hormone involved in regulating foodintake). ( See "Pathogenesis of obesity" and see "Ghrelin" ).

Sleeve gastrectomy is safer than gastric bypass, technically easier, avoidsmultiple anastomoses, reduces postoperative risk of internal herniation, andprotein and mineral malabsorption [ 64,65 ] . The procedure allows surgeons to

perform the less technically challenging partial gastrectomy first, delaying themore technically rigorous laparoscopic Roux-en-Y gastric bypass or BPD untilafter the patients have reached a lower weight [ 63 ] .

Studies evaluating sleeve gastrectomy have reported that patientsexperienced approximately 33 percent EWL in one year [ 63 ] . Randomizedstudies comparing this procedure to the adjustable gastric banding, haveshown that sleeve gastrectomy results in better weight loss and hungercontrol at one and three years after surgery [ 66 ] . Similar results have beenfound in short-term studies (6 and 12 months). The benefits have been

attributed in part to significantly better suppression of ghrelin compared withgastric bypass [ 67 ] .

Such data suggest that sleeve gastrectomy is likely to gain more acceptanceas an alternative bariatric procedure in the future. A potential limitation is therisk of long-term weight regain with the need to convert to a Roux-en-Ygastric bypass or a BPD years later [ 68 ] .

In tragastric balloon The intragastric balloon (Bioenterics IntragastricBalloon, Inamed) is a temporary alternative for weight loss in moderately


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obese individuals [ 69-72 ] . It consists of a soft, saline-filled balloon placedendoscopically that promotes a feeling of satiety and restriction. It is currentlynot available for use in the United States, but is undergoing extensive testingin Europe and Brazil. Mean excess weight loss is reported to be 38 percentand 48 percent for 500 and 600 mL balloons, respectively [ 70 ] . However, theresults of a Brazilian multi-center study indicate weight loss is transient, withonly 26 percent of patients maintaining over 90 percent of the excess weightloss out over one year [ 71 ] . It appears to reduce the risk of conversion toopen surgery and the risk of intraoperative complications when it is used forpreoperative weight loss in super-obese patients before a definitive bariatricprocedure [ 72 ] . Side-effects include nausea, vomiting, abdominal pain,ulceration, and balloon migration.

Endolumin al vertical gastroplasty Endoscopic methods for suturing thestomach have been developed, which offer the potential to perform gastricrestrictive procedures endoluminally. Initial experience is promising but longerterm studies are needed [ 73 ] .

MALABSORPTIVE

Jejunoil eal bypass The jejunoileal bypass was one of the first bariatricoperations, performed initially in 1969 [ 74 ] . It has since been abandoned dueto the high complication rate and frequent need for revisional surgery. Itsimportance lies in care of surviving patients who have undergone thisprocedure.

The procedure was performed by dividing the jejunum close to the ligament of

Treitz and connecting it a short distance proximal to the ileocecal valve ( showfigure 3 ), thereby diverting a long segment of small bowel, resulting inmalabsorption. Although excess weight loss was excellent, jejunoileal bypasswas associated with multiple complications such as liver failure (up to 30percent), death, diarrhea, electrolyte imbalances, oxalate renal stones,vitamin deficiencies, malnutrition, and arthritis [ 75-79 ] .

Patients who have undergone this procedure should be monitored closely forcomplications (particularly liver disease) and undergo reversal if suchcomplications arise. ( See "Complications of bariatric surgery" ).

Biliopancreatic diversion The biliopancreatic diversion (BPD) wasintroduced as a solution to the high rates of liver failure resulting from bowelexclusion in the jejunoileal bypass [ 80 ] ( show figure 4 ). The procedureconsists of a partial gastrectomy and gastroileostomy with a long segment of Roux limb and a short common channel (the part of the small bowel thatreceives both food and biliopancreatic secretions) resulting in malnutrition. Upto 72 percent excess weight loss up to 18 years have been reported.Laparoscopic BPD has also been performed with acceptable outcomes [ 81 ] .Its use has been limited by the high rates of protein malnutrition, anemia,


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diarrhea, and stomal ulceration [ 82 ] .

Biliopancreatic diversion w ith duodenal sw itch The biliopancreaticdiversion with duodenal switch (BPD/DS) is a variant of the BPD and isprimarily a malabsorptive operation [ 83 ] ( show figure 5 ). The procedureinvolves a partial sleeve gastrectomy with preservation of the pylorus, andcreation of a Roux limb with a short common channel. The BPD/DS procedure

differs from the BPD in the portion of the stomach that is removed, as well aspreservation of the pylorus [ 82,83 ] .

This procedure has been advocated for patients with super-morbid obesity(BMI >50), a group in which it has been associated with improved weight loss.It is associated with a lower incidence of stomal ulceration and diarrhea thanwith BPD alone. Although complex, BPD/DS has been performedlaparoscopically by several groups [ 84,85 ] . This procedure is performed atonly a few centers in the United States, where it is not widely accepted as afirst-line surgical treatment for morbid obesity, partly due to inconsistent

recognition and reimbursement for this procedure by the insurance companies.MIXED

Roux-en-Y gastric bypass Roux-en-Y gastric bypass (RYGB) was developedin the 1960s based on the observation that patients who underwent partialgastrectomy experienced significant long-term weight loss [ 86 ] . Manysubsequent modifications have been made to improve the weight lossoutcome and limit operative complications. It is the most common bariatricprocedure performed in the United States and is considered the gold standard

among bariatric procedures.While the RYGB is primarily a restrictive operation, a malabsorptive componentalso contributes to weight loss. RYGB has been shown repeatedly to be betterthan purely-restrictive procedures such as Vertical Banded Gastroplasty (VBG)in long-term weight reduction [ 41 ] .

Its current configuration is characterized by a small (less than 30 mL) proximalgastric pouch divided and separated from the stomach remnant with drainageof food to the rest of the gastrointestinal tract via a tight stoma and aRoux-en-Y small bowel arrangement ( show figure 6 ). The small pouch and thetight outlet act to restrict caloric intake, as seen in VBG and LAGB. A muchlarger gastric remnant becomes disconnected from the food stream whilesecretion of gastric acid, pepsin, and intrinsic factor continues.

The small intestine is then divided at a distance of 30 to 50 cm distal to theLigament of Treitz. By dividing the bowel, the surgeon creates a proximalbiliopancreatic limb that transports the secretions from the gastric remnant,liver, and pancreas. The Roux limb (or alimentary limb) is anastomosed to thenew gastric pouch and functions to drain consumed food. The cut ends of the


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biliopancreatic limb and the Roux limb are then connected 75 to 150 cmdistally from the gastrojejunostomy. Major digestion and absorption of nutrients then occurs in the common channel where pancreatic enzymes andbile mix with ingested food.

Weight loss following gastric bypass is mostly attributed to restriction, butother mechanisms such as dumping syndrome, Roux limb length, and gut

hormones may have a role in the weight loss seen following gastric bypass.Gastrojejunostomy anatomy (connection between the stomach pouchand jejunum) is associated with dumping physiology, and causesunpleasant symptoms of lightheadedness, nausea, diaphoresis and/orabdominal pain, and diarrhea when a high sugar meal is ingested [ 87 ] .This response may serve as a negative conditioning response againstconsumption of high sugar diet postoperatively.

The optimal length of the Roux limb in achieving the best balance

between weight reduction and complications of malabsorption iscontroversial. Increasing Roux limb length can lead to increasedmalabsorption, since lengthening the Roux limb effectively shortens thecommon limb where major digestion and absorption of the ingestednutrients occur. At present, most surgeons do not make the Rouxlength longer than 100 cm. Distal gastric bypass with a short commonlimb has been used to treat patients with inadequate weight lossfollowing standard RYGB, but the risk for metabolic complicationsincrease similar to other malabsorptive operations [ 88 ] .

Ghrelin is a peptide hormone secreted in the foregut (stomach andduodenum) that stimulates the early phase of meal consumption. Thenormal pulsatile release of this orexigenic (appetite-producing) hormoneappears to be inhibited in gastric bypass patients due to its uniqueforegut bypass configuration [ 89-91 ] . Such inhibition of ghrelin has notbeen observed in other bariatric procedures [ 90 ] , with the possibleexception of laparoscopic sleeve gastrectomy [ 67 ] . The reduced ghrelinlevels may contribute to the characteristic loss of appetite seen in postRYGB patients. An exaggerated response of peptide YY (PYY) may alsocontribute to the loss of appetite [ 91 ] . ( See "Pathogenesis of obesity"and see "Ghrelin" ).

RYGB can be safely performed laparoscopically in well-trained hands. Despiteits steep learning curve [ 92 ] , laparoscopic RYGB provides several advantagessuch as lower incidence of incisional hernia, wound infection, faster recovery,and a shorter hospital stay [ 93-95 ] . Although the procedure can be limited bypatient size, instrument and trocar length, even the extremely large patientshave been successfully operated laparoscopically [ 96 ] .


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Excess weight loss after gastric bypass is durable and reliable. On average,62 to 68 percent EWL is reported after the first year. Early weight lossfollowing gastric bypass is typically rapid, but usually reaches a plateau afterone to two years to an average EWL percent between 50 to 75 percent[93,94,97,98 ] . Sustained weight loss is seen up to 16 years [ 97 ] , whichmakes this procedure an excellent tool for a permanent surgical weight loss.

Improvement and/or resolution of comorbid conditions (including diabetes,sleep apnea, hypertension, and dyslipidemia) following gastric bypass hasalso been well established [ 93,97-99 ] .

LIPOSUCTION Although not generally considered to be a bariatricprocedure, removal of fat by aspiration after injection of physiologic saline hasbeen used to remove and contour subcutaneous fat. While this can result inreduction in fat mass and weight, the amount of weight loss is insignificant incomparison with bariatric procedures and it does not appear to improveinsulin sensitivity or risk factors for coronary heart disease [ 100 ] . ( See

"Overview of therapy for obesity in adults" , section on Liposuction).INFORMATION FOR P ATIENTS Educational materials on this topic areavailable for patients. ( See "Patient information: Weight loss treatments" andsee "Patient information: Weight loss surgery" ). We encourage you to print ore-mail these topic reviews, or to refer patients to our public web site,www.uptodate.com/patients , which includes these and other topics.

SUMMARY A ND RECOMMENDATI ONS Obesity is a major health problem inthe United States and its incidence is increasing rapidly. Severe obesity leads

to numerous medical problems and a shortened life expectancy.Non-surgical treatments for the morbidly obese are rarely effective. Surgicaltherapies are based primarily on two main mechanisms: restriction of caloricintake via a small stomach reservoir and malabsorption of nutrients viashortened functional small bowel length. All bariatric procedures are effectivein achieving weight loss and improving the associated comorbidities in themorbidly obese. Restrictive procedures are generally simpler in techniques butseem to achieve less weight loss. Malabsorptive procedures are highlyeffective in weight loss but carry significant metabolic complications.

Roux-en-Y gastric bypass is the most commonly performed procedure inthe United States due to its multiple mechanisms of action and provensuccess in long term weight loss.

Laparoscopic RYGB performed by well-trained bariatric surgeons canlower surgical pain, infectious and hernia complications, as well asallowing for quicker postoperative recovery.

Laparoscopic adjustable gastric banding is becoming increasingly more


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popular in the United States due to its simplicity in technique,adjustability, reversibility, and exceedingly small mortality.

Indications and contraindications for bariatric surgery are described above.(See "Indications" above ).

Complications of these procedures are discussed separately. ( See"Complications of bariatric surgery" ).

Clinical practice guidelines from the American College of Physicians formanagement of obesity in primary care are discussed elsewhere. ( See"Overview of therapy for obesity in adults" , section on Clinical guidelines).

ACKNOWLEDGMENT The author and editors would like to thank Dr. VivianM Sanchez and Dr. Benjamin E Schneider, who provided earlier versions of thistopic review.

Use of UpToDate is subject to the Subscription and License Agreement .REFERENCES

Ogden, CL, Caroll, MD, McDowell, MA, et al. Obesity among adults in theUnited states No statistically significant change since 2003-2004.NCHS data brief no 1. Hyattsville, MD: National Center for HealthStatistics 2007 (http://www.cdc.gov/nchs/data/databriefs/db01.pdf).

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GRAPHICS

Health risks associated w ith obesity

Coronary artery disease, hypertension


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Hyperlipidemia

Type II diabetes mellitus

Asthma, obesity hypoventilation syndrome, obstructive sleep apnea

Gastroesophageal reflux, esophagitis

Fatty liver, cholelithiasis, non-alcoholic steatohepatitis (NASH), cirrhosis

Stress urinary incontinence

Venous stasis disease, deep vein thrombosis, pulmonary embolus,superficial thrombophlebitis

Hernias (inguinal, ventral, umbilical, incisional)

Irregular menstruation, hirsutism, gynecomastia, infertility, polycysticovary syndrome

Cancer (colon, prostate, uterine, breast)

Infection (cellulitis, panniculitis, post-operative wound infections)

Degenerative joint disease, osteoarthritis

Pseudotumor cerebri (idiopathic intracranial hypertension)

Clinical depression

Courtesy of Vivian Sanchez, MD and Edward Mun, MD.

I ndications for surgical management of severe obesity

Obesity Class BMI Exceptions

II >35 With comorbidities

>III >40.0 Regardless of comorbidities

Courtesy of Vivian Sanchez, MD, and Edward Mun, MD.

Types of bariatric procedures


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Restrictive

Vertical banded gastroplasty

Laparoscopic adjustable gastric band

Sleeve gastrectomy

Malabsorptive

Jejunoileal bypass

Biliopancreatic diversion

Biliopancreatic diversion with duodenal switch

Combination of restrictive and malabsorptive

Roux-en-Y gastric bypass

Vertical banded gastroplasty

Reproduced with permission from: Mun, EC, Blackburn, GL,


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Matthews, JB. Current Status of medical and surgical therapyfor obesity. Gastroenterology 2001; 120:669. Copyright 2001American Gastroenterological Society.

Laparoscop ic adjustable gastric band (LA GB)

This figure depicts the stomach's appearance after laparoscopicgastric banding (LAGB), which compartmentalizes the upperstomach by placing a silicone band around the entrance to thestomach. The band is connected to a narrow tube that extendsto an access port just beneath the skin; a healthcare provider

can narrow or widen the entrance to the stomach by injection orremoval of saline through the port. As with gastroplasty, thepassage of food from the upper pouch to the rest of thestomach is delayed, and the patient feels full after eating less.


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Jejunoileal bypass

Reproduced with permission from: Mun, EC, Blackburn, GL,Matthews, JB. Current Status of medical and surgical therapy forobesity. Gastroenterology 2001; 120:669. Copyright 2001American Gastroenterological Society.


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Biliopancreatic diversion

Reproduced with permission from: Mun, EC, Blackburn, GL,

Matthews, JB. Current Status of medical and surgical therapy forobesity. Gastroenterology 2001; 120:669. Copyright 2001American Gastroenterological Society.


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Biliopancreatic diversion w ith duodenal sw itch

Reproduced with permission from: Mun, EC, Blackburn, GL,Matthews, JB. Current Status of medical and surgical therapy forobesity. Gastroenterology 2001; 120:669. Copyright 2001American Gastroenterological Society.


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Roux-en-Y gastric bypass (RYGB)

This figure depicts the stomach's appearance after gastricbypass, which creates a small stomach pouch by dividing thestomach and attaching it to the small intestine. The pouch isonly able to hold about an ounce of food, causing a feeling of fullness after consuming a very small amount; over time, thepouch stretches to hold about one cup. Additionally, the body


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absorbs fewer calories since food bypasses the majority of thestomach as well as the upper small intestine (duodenum). Thisintestinal arrangement (Roux-en-Y) seems to cause decreasedappetite and improved metabolism by changing the release of various hormones.

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Surgical Management of Severe Obesity

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