Surgical Management of Severe Obesity

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Surgical management of severe obesity
Authors Edward C Mun, MD, FACS Ali Tavakkolizadeh, MD Section Editors F Xavier Pi-Sunyer, MD, MPH J Thomas LaMont, MD Deputy Editor Kathryn A Martin, MD
  

Last literature review version 17.1: January 2009 | This topic last updated: February 9, 2009 (More) INTRODUCTION — Obesity is a chronic disease that is increasing in prevalence in the United States and worldwide. Defined as a body mass index (BMI) >30 kg/m2, the percentage of obese men nearly doubled between 1991 and 1998, and the percentage of obese women increased by 50 percent. More recently, the trend of increasing obesity has leveled off with no significant increase in the rate of obesity in the adult population between 2003 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 are overweight (BMI ≥ 25 kg/m2). (See "Overview of therapy for obesity in adults" section on Prevalence) There are several well-established health hazards associated with obesity including type 2 diabetes, heart disease, stroke, certain cancers, osteoarthritis, liver disease, obstructive sleep apnea, and depression ( show table 1 ). The risk of development of complications rises with increasing adiposity while weight loss can reduce the risk. ( See "Health hazards associated with obesity in adults" ). There are many behavioral, medical, and surgical options for achieving weight loss. This topic review will focus on surgical procedures, which have been collectively referred to as "bariatric" surgery (from the Greek words "baros" meaning "weight" and "iatrikos" meaning "medicine"). Complications of these procedures and a general approach to the management of obesity are discussed 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

practical measure of a person's adiposity. It is calculated by dividing the weight in kilograms by the height in meters squared (kg/m2). In adults, a BMI of 25 to 29.9 kg/m2 is considered overweight 30 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 BARIATRIC SURGERY — The goal of surgery is to reduce the morbidity and mortality associated with obesity and to improve metabolic and organ function. Several studies have demonstrated that bariatric surgery is effective in reducing obesity-related comorbidities, while having additional benefits such as reducing monthly medication costs and the number of sick days and improving quality of life [ 4-14] . A benefit on overall and cause-specific mortality has also been demonstrated [ 15,16] . However, bariatric surgery is also associated with significant perioperative complications and mortality. (See "Complications of bariatric surgery" ). At least two meta-analyses have summarized data from various, mainly observational studies [ 17,18] . One included 136 studies in which patients had 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 the preoperative BMI and a BMI of 20 to 30 kg/m2 (depending upon the study). 30-day mortality was 0.1 percent for purely restrictive procedures (defined below), 0.5 percent for gastric bypass, and 1.1 percent for biliopancreatic diversion or duodenal switch. Diabetes completely resolved in 77 percent and resolved or improved in 86 percent. Hyperlipidemia improved in 70 percent or more of patients. Hypertension resolved in 62 percent and resolved or improved in 79 percent. Obstructive sleep apnea resolved in 86 percent and resolved or improved in 84 percent. A second meta-analysis that included 147 studies concluded that the evidence

supporting a benefit of bariatric surgery was strongest in patients with a BMI of >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 compared with gastroplasty. Overall mortality was less than 1 percent while adverse events occurred in approximately 20 percent of patients. A laparoscopic approach resulted in fewer wound complications compared with an open approach. The striking benefits on important obesity-related morbidity contrast with relatively disappointing results in the management of severe obesity with medical and behavioral therapy. The Swedish Obese Subjects Trial (SOS) is the largest trial comparing surgical versus medical treatment of morbid obesity. A total of 6328 obese (BMI >34 kg/m2 for men and >38 kg/m2 for women) subjects were recruited of whom 2010 underwent surgery for obesity (gastric banding, gastroplasty or gastric bypass) while 2037 chose conventional treatment. Although the study was not randomized, there was an attempt to match patients by relevant covariates. Begun in 1987, the SOS has spawned multiple publications; the following summarizes the major observations [ 15,19-27] : After two years, weight had increased by 0.1 percent in the control group while it had decreased by 23 percent in the surgery group [ 27] . After 10 years, weight had increased by 1.6 percent and decreased by 16 percent, in the two groups respectively. Energy intake was lower and the proportion of physically active subjects higher in the surgery group 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), low levels of high-density lipoprotein cholesterol (5.28 and 2.35, respectively), hypertension (1.72 and 1.68, respectively) and hyperuricemia (5.36 and 2.37, respectively). There was no difference in rates of recovery from hypercholesterolemia. The surgery group had lower two and 10-year incidence rates of diabetes (OR 0.14 and 0.25, respectively), hypertriglyceridemia (OR 0.29 and 0.61, respectively) and hyperuricemia (OR 0.22 and 0.49, respectively). There were no significant differences in the incidence of hypercholesterolemia and hypertension. Surgically treated patients were significantly less likely to require medications for cardiovascular disease or diabetes at two and six years (risk ratio 0.56 to 0.77) [23] . Among those not already requiring such medications, 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

group [ 24] . Surgically treated patients had dramatic improvement in scores on validated measures of quality of life compared with only minor and sporadic improvement in medically treated patients at two years [ 19] . The magnitude of benefit was related mostly to the degree of weight loss, 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 life had diminished somewhat in the surgery group due to weight regain, but overall outcome was still significantly better in the surgical than the medically treated group [ 28] . In patients undergoing weight loss surgery, there was a 29 percent reduction in risk death [ 15] . Thus, the reduction in comorbidities appears to translate into a reduction in mortality. These findings were confirmed in a large cohort study, in which nearly 8000 patients who had undergone weight loss surgery were matched to a similar sized obese cohort [ 16] . Deaths from all causes were reduced by 40 percent, from diabetes by 92 percent, from coronary disease by 56 percent, and from cancers by 60 percent. However, there was an increase in mortality 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 included 1035 patients who had undergone bariatric surgery who were compared with an age- and gender-matched severely obese control population identified from a population database [ 4] . Patients who had undergone bariatric surgery were significantly less likely to develop cardiovascular disease, cancer, and endocrine, infectious and psychiatric disorders, although they were more likely to develop digestive diseases. The overall mortality rate in the bariatric cohort (0.7 percent) was significantly lower than controls (6.2 percent, RR 0.11, 95% CI 0.04-0.27). Although these data would appear to make a compelling argument for treatment of obese patients with surgery, most of these studies were non-randomized, and there have been few well-designed, randomized, prospective trials comparing specific surgical approaches to optimal medical care. One such study found that laparoscopic adjustable gastric banding was significantly more effective than medical management at two years follow-up in patients with mild to moderate obesity (BMI 30 to 35 kg/m(2)) [ 29] . Mean excess weight loss was 87 percent in the group randomized to laparoscopic adjustable gastric banding compared with only 22 percent in the optimal medical care group.

Although the majority of mortality data for bariatric surgery comes from patients under age 65, a retrospective cohort analysis suggests that survival is improved, even in patients over age 65 [ 30] . Type 2 diabetes — The predominantly observational studies described above have generated much interest in the role of weight loss surgery in the treatment algorithm of diabetes, with some suggesting that bariatric surgery is one of the best treatments for type 2 diabetes. However, there are few randomized trials comparing surgical versus medical therapy, specifically in obese patients with diabetes. In one such trial, 60 obese subjects (BMI between 30 and 40 kg/m2), with type 2 diabetes diagnosed within the previous two years, were randomly assigned to conventional therapy (lifestyle modification and medical therapy) or laparoscopic adjustable banding and conventional therapy [ 31] . Remission of diabetes occurred more often in the surgical group (73 versus 13 percent). Remission was related to lower baseline A1C values and to weight loss. Although these findings are encouraging, the optimal surgical approach for improvement of diabetes, cost-effectiveness, and role in the management of recent onset, obesity-related type 2 diabetes are unclear. ( See "Initial management of blood glucose in type 2 diabetes mellitus" , section on Surgical treatment of obesity). The mechanism for diabetes improvement depends upon the type of surgery performed [ 32] . One study suggested that insulin sensitivity improved in proportion to weight loss with the use of predominantly restrictive procedures but 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 to duodenal isolation following the bypass surgery and subsequent changes in gastrointestinal hormones (the incretins, glucagon-like peptide and glucose-dependent insulinotrophic polypeptide) following surgery. In a study of eight obese women with type 2 diabetes, the release of incretins after oral glucose and their effect on insulin secretion improved within one month of Roux-en-Y gastric bypass surgery [ 34] . The role of gastrointestinal peptides in glucose homeostasis is reviewed in detail elsewhere. ( See "GLP-1-based therapies for the treatment of type 2 diabetes mellitus" , section on GLP-1). INDICATIONS — Indications for the surgical management of morbid obesity were first outlined by the National Institutes of Health (NIH) Consensus Development Panel in 1991 ( show table 2 ) [35] . Potentially eligible patients should: Be well-informed and motivated Have a BMI >40 Have acceptable risk for surgery

Have failed previous non-surgical weight loss The NIH also suggested that adults with a BMI >35 who have serious comorbidities such as diabetes, sleep apnea, obesity-related cardiomyopathy, or severe joint disease may also be candidates Contraindications to bariatric surgery include patients with untreated major depression or psychosis, binge eating disorders, current drug and alcohol abuse, severe cardiac disease with prohibitive anesthetic risks, severe coagulopathy, or inability to comply with nutritional requirements including life-long vitamin replacement. Bariatric surgery in advanced (above 65) or very young age (under 18) is controversial. Bariatric surgery needs to be performed in conjunction with a comprehensive follow-up plan consisting of nutritional, behavioral, and medical programs. The American Society of Metabolic and Bariatric Surgeons (ASMBS) and the American College of Surgeons (ACS) have announced guidelines for establishing Centers of Excellence (COE) for bariatric facilities [ 36] . Patient safety is clearly the driving force behind such a process and is emphasized by several items: An integrated program that is capable of providing the pre- and post-operative care of a bariatric patient by necessary multi-specialty consultants Ability to follow 75 percent of post-surgical patients long-term out to five years Monitored credentialing of bariatric surgeons and hospitals based upon demonstration of adequate training, equipment, and periodic outcomes assessment TYPES OF BARIATRIC PROCEDURES — Bariatric surgical procedures can be divided fundamentally into two varieties, malabsorptive and restrictive, based upon the mechanism by which they induce weight loss ( show table 3 ). Restrictive procedures limit caloric intake by downsizing the stomach's reservoir capacity. Vertical banded gastroplasty (VBG) and laparoscopic adjustable gastric banding (LAGB) are purely restrictive procedures and share similar anatomical configurations. Both limit solid food intake by restriction of stomach size as the only mechanism of action, leaving the absorptive function of the small intestine intact. Although these procedures are simpler in comparison to malabsorptive procedures, they tend to produce more gradual weight loss. The primary mechanism of malabsorptive procedures is to decrease the effectiveness of nutrient absorption by shortening the length of the

functional small intestine. Jejunoileal bypass (JIB), the biliopancreatic diversion (BPD), and duodenal switch operation (DS) are examples of malabsorptive procedures. Profound weight loss can be achieved by the malabsorptive operations depending upon the effective length of the functional small bowel segment. However, the benefit of superior weight loss is often offset by the significant metabolic complications such as protein calorie malnutrition and various micronutrient deficiencies. Some procedures have both a restrictive and malabsorptive component. The Roux-en-Y gastric bypass (RYGB), for example, is primarily a restrictive operation in which a small gastric pouch limits oral intake. However, the small bowel reconfiguration provides additional mechanisms favoring weight loss including dumping physiology and mild malabsorption. Minimally invasive techniques were first applied in bariatric surgery in the 1990s. The first laparoscopic RYGB series was reported in 1994 in the United States [ 37] . Although technically intensive with a steep learning curve, laparoscopic RYGB can be performed safely by experienced surgeons. The laparoscopic approach offers the advantages of decreased post-operative pain, shorter hospital stay, and decreased rates of wound infection and hernia formation. An increasing number of laparoscopic RYGB and LAGB are being performed in the United States, indicating a trend towards minimally invasive approaches to bariatric surgery. Investigation of the cost-effectiveness and safety of these laparoscopic procedures is ongoing. Choosing a procedure — The most commonly performed bariatric surgery procedures are laparoscopic adjustable gastric banding (LAGB) and Roux-en-Y gastric bypass (RYGB). There are benefits and risks associated with each procedure. The comparative efficacy and safety of the procedures were evaluated in a five-year trial of 50 obese patients (mean BMI 43 kg/m2) randomly assigned to LAGB versus laparoscopic RYGB (LRYGB) [ 38] . After five years, patients in the LRYGB group lost a greater percentage of excess body weight (67 versus 47 percent) and had a lower failure rate (4 versus 35 percent). A meta-analysis of 14 studies (13 observational and one randomized trial [ ) evaluating clinical outcomes after LAGB and RYGB showed the following advantages 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, was better 38]

Operative times and length of hospitalization were longer (median differences of 68 minutes and two days, respectively) Perioperative complications (9 versus 5 percent) were greater but reoperation rates (16 versus 24 percent) lower Mortality was higher, although it was low in both groups (0.06 and 0.17 percent for LAGB and RYGB, respectively) Thus, in this meta-analysis of predominantly observational studies, RYGB was associated with greater long-term success but higher short-term morbidity. Larger randomized trials comparing RYGB (particularly laparoscopic) and LAGB are required to confirm the superior efficacy of RYGB, given its higher short-term complication rates. Until then, the choice of procedure depends upon patient preference, the institution, and expertise of the surgeons. RESTRICTIVE Vertical banded gastroplasty —Vertical banded gastroplasty (VBG) is a purely restrictive procedure in which the upper part of the stomach is partitioned by a vertical staple line with a tight outlet wrapped by a prosthetic mesh or band ( show figure 1 ). The small upper stomach pouch gets filled quickly by solid food and prevents consumption of a large meal. Weight loss occurs because of decreased caloric intake of solid food. Patients who have undergone VBG can be expected to have excess weight loss (EWL) of up to 66 percent at two years, which subsequently decreases to 55 percent at nine years [ 40] . The effectiveness of such a restrictive mechanism depends upon the durability of pouch and stoma (outlet) size. Ingestion of high-calorie liquid meals and gradually increased pouch capacity due to overeating have been some of the major causes of its failure. Sweets eaters who rely on soft meals (ie, ice cream, milk shakes) do not benefit significantly 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 complications requiring revision (20 to 56 percent) [ 41-46] . The majority of revisions are required for staple line disruption, stomal stenosis, band erosion, band disruption, 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 upper stomach by placing a tight, adjustable prosthetic band around the entrance to the stomach ( show figure 2 ). Although it has been performed extensively in

Europe and Australia for almost a decade, it was not until June 2001 when the first adjustable band (LapBand(TM) (Inamed)) was approved for use in the United States. More recently, another adjustable gastric band received FDA approval (Realize(TM) band (Ethicon)) [47] . It works on similar principle, and has similar short-term outcomes to LapBand. The adjustable gastric bands consist of a soft, locking silicone ring connected to an infusion port placed in the subcutaneous tissue. The port may be accessed with relative ease by a syringe and needle. Injection of saline into the port leads to reduction in the band diameter, resulting in an increased degree of restriction. The currently available band is adjustable and is placed laparoscopically [ 48,49] . Indications for the use of LAGB are similar to the indications for gastric bypass and patients must meet full NIH criteria ( show table 2 ) [35] . LAGB is generally contraindicated in patients with portal hypertension, connective tissue disorders with esophageal dysmotility, or chronic steroid use (relative contraindication). LAGB is gaining significant attention among bariatric surgeons and patients primarily because of its simplicity and lower complication rates when compared to more involved procedures such as RYGB [ 50] . Because of its many advantages, it has largely replaced the conventional VBG as the main restrictive 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 all bariatric procedures [ 51,52] . The band eliminates the need for staple lines used in VBG that may break down and cause weight regain. Avoidance of a fixed prosthetic mesh at the stoma reduces the incidence of stomal stenosis seen in VBG. The adjustability of the outlet by the new band design offers a theoretical advantage of addressing various nutritional issues after surgery. As an example, a patient who becomes pregnant following this procedure may have her stoma widened to allow for greater caloric and fluid intake, if necessary. In addition, the band is reversible, allowing for easy restoration of the original anatomy by the removal of the band. The effectiveness of the LAGB for achieving weight loss has been variable in different reports. European and Australian data indicate a 15 to 20 percent EWL at three months, 40 to 53 percent EWL at one year, with eventual increases in up to 45 to 58 percent EWL after year two [ 53] . Initial American

experience in a seminal study was disappointing with two year EWL of only 36 percent [ 52] . However, the design and conduct of the study were criticized as the causes of the relatively poor outcome [ 54] . Subsequent American data were similar to the European and Australian experience, with EWL of 45 to 75 percent 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 reported comparable long-term outcomes [ 51] . Persistent weight loss requires close follow-up and frequent band adjustments. In addition to weight loss, LAGB is associated 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 initially offered to patients with super morbid obesity as the first stage in surgical management [ 62,63] . The procedure consists of a laparoscopic partial gastrectomy in which the majority of the greater curvature of the stomach is removed and a tubular stomach is created. The tubular stomach is small in its capacity (restriction), resistant to stretching due to absence of fundus, and devoid of ghrelin producing cells (a gut hormone involved in regulating food intake). (See "Pathogenesis of obesity" and see "Ghrelin" ). Sleeve gastrectomy is safer than gastric bypass, technically easier, avoids multiple anastomoses, reduces postoperative risk of internal herniation, and protein and mineral malabsorption [ 64,65] . The procedure allows surgeons to perform the less technically challenging partial gastrectomy first, delaying the more technically rigorous laparoscopic Roux-en-Y gastric bypass or BPD until after the patients have reached a lower weight [ 63] . Studies evaluating sleeve gastrectomy have reported that patients experienced approximately 33 percent EWL in one year [ 63] . Randomized studies comparing this procedure to the adjustable gastric banding, have shown that sleeve gastrectomy results in better weight loss and hunger control at one and three years after surgery [ 66] . Similar results have been found in short-term studies (6 and 12 months). The benefits have been attributed in part to significantly better suppression of ghrelin compared with gastric bypass [ 67] . Such data suggest that sleeve gastrectomy is likely to gain more acceptance as an alternative bariatric procedure in the future. A potential limitation is the risk of long-term weight regain with the need to convert to a Roux-en-Y gastric bypass or a BPD years later [ 68] . Intragastric balloon —The intragastric balloon (Bioenterics Intragastric Balloon, Inamed) is a temporary alternative for weight loss in moderately

obese individuals [ 69-72] . It consists of a soft, saline-filled balloon placed endoscopically that promotes a feeling of satiety and restriction. It is currently not available for use in the United States, but is undergoing extensive testing in Europe and Brazil. Mean excess weight loss is reported to be 38 percent and 48 percent for 500 and 600 mL balloons, respectively [ 70] . However, the results of a Brazilian multi-center study indicate weight loss is transient, with only 26 percent of patients maintaining over 90 percent of the excess weight loss out over one year [ 71] . It appears to reduce the risk of conversion to open surgery and the risk of intraoperative complications when it is used for preoperative weight loss in super-obese patients before a definitive bariatric procedure [ 72] . Side-effects include nausea, vomiting, abdominal pain, ulceration, and balloon migration. Endoluminal vertical gastroplasty —Endoscopic methods for suturing the stomach have been developed, which offer the potential to perform gastric restrictive procedures endoluminally. Initial experience is promising but longer term studies are needed [ 73] . MALABSORPTIVE Jejunoileal bypass — The jejunoileal bypass was one of the first bariatric operations, performed initially in 1969 [ 74] . It has since been abandoned due to the high complication rate and frequent need for revisional surgery. Its importance lies in care of surviving patients who have undergone this procedure. 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 ( show figure 3), thereby diverting a long segment of small bowel, resulting in malabsorption. Although excess weight loss was excellent, jejunoileal bypass was associated with multiple complications such as liver failure (up to 30 percent), death, diarrhea, electrolyte imbalances, oxalate renal stones, vitamin deficiencies, malnutrition, and arthritis [ 75-79] . Patients who have undergone this procedure should be monitored closely for complications (particularly liver disease) and undergo reversal if such complications arise. ( See "Complications of bariatric surgery" ). Biliopancreatic diversion — The biliopancreatic diversion (BPD) was introduced as a solution to the high rates of liver failure resulting from bowel exclusion in the jejunoileal bypass [ 80] (show figure 4 ). The procedure consists of a partial gastrectomy and gastroileostomy with a long segment of Roux limb and a short common channel (the part of the small bowel that receives both food and biliopancreatic secretions) resulting in malnutrition. Up to 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,

diarrhea, and stomal ulceration [ 82] . Biliopancreatic diversion with duodenal switch — The biliopancreatic diversion with duodenal switch (BPD/DS) is a variant of the BPD and is primarily a malabsorptive operation [ 83] (show figure 5 ). The procedure involves a partial sleeve gastrectomy with preservation of the pylorus, and creation 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 as preservation 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 than with BPD alone. Although complex, BPD/DS has been performed laparoscopically by several groups [ 84,85] . This procedure is performed at only a few centers in the United States, where it is not widely accepted as a first-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 developed in the 1960s based on the observation that patients who underwent partial gastrectomy experienced significant long-term weight loss [ 86] . Many subsequent modifications have been made to improve the weight loss outcome and limit operative complications. It is the most common bariatric procedure performed in the United States and is considered the gold standard among bariatric procedures. While the RYGB is primarily a restrictive operation, a malabsorptive component also contributes to weight loss. RYGB has been shown repeatedly to be better than 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) proximal gastric pouch divided and separated from the stomach remnant with drainage of food to the rest of the gastrointestinal tract via a tight stoma and a Roux-en-Y small bowel arrangement ( show figure 6 ). The small pouch and the tight outlet act to restrict caloric intake, as seen in VBG and LAGB. A much larger gastric remnant becomes disconnected from the food stream while secretion of gastric acid, pepsin, and intrinsic factor continues. The small intestine is then divided at a distance of 30 to 50 cm distal to the Ligament of Treitz. By dividing the bowel, the surgeon creates a proximal biliopancreatic limb that transports the secretions from the gastric remnant, liver, and pancreas. The Roux limb (or alimentary limb) is anastomosed to the new gastric pouch and functions to drain consumed food. The cut ends of the

biliopancreatic limb and the Roux limb are then connected 75 to 150 cm distally from the gastrojejunostomy. Major digestion and absorption of nutrients then occurs in the common channel where pancreatic enzymes and bile mix with ingested food. Weight loss following gastric bypass is mostly attributed to restriction, but other 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 pouch and jejunum) is associated with dumping physiology, and causes unpleasant symptoms of lightheadedness, nausea, diaphoresis and/or abdominal pain, and diarrhea when a high sugar meal is ingested [ 87] . This response may serve as a negative conditioning response against consumption of high sugar diet postoperatively. The optimal length of the Roux limb in achieving the best balance between weight reduction and complications of malabsorption is controversial. Increasing Roux limb length can lead to increased malabsorption, since lengthening the Roux limb effectively shortens the common limb where major digestion and absorption of the ingested nutrients occur. At present, most surgeons do not make the Roux length longer than 100 cm. Distal gastric bypass with a short common limb has been used to treat patients with inadequate weight loss following standard RYGB, but the risk for metabolic complications increase similar to other malabsorptive operations [ 88] . Ghrelin is a peptide hormone secreted in the foregut (stomach and duodenum) that stimulates the early phase of meal consumption. The normal pulsatile release of this orexigenic (appetite-producing) hormone appears to be inhibited in gastric bypass patients due to its unique foregut bypass configuration [ 89-91] . Such inhibition of ghrelin has not been observed in other bariatric procedures [ 90] , with the possible exception of laparoscopic sleeve gastrectomy [ 67] . The reduced ghrelin levels may contribute to the characteristic loss of appetite seen in post RYGB patients. An exaggerated response of peptide YY (PYY) may also contribute to the loss of appetite [ 91] . (See "Pathogenesis of obesity" and see "Ghrelin" ). RYGB can be safely performed laparoscopically in well-trained hands. Despite its steep learning curve [ 92] , laparoscopic RYGB provides several advantages such as lower incidence of incisional hernia, wound infection, faster recovery, and a shorter hospital stay [ 93-95] . Although the procedure can be limited by patient size, instrument and trocar length, even the extremely large patients have been successfully operated laparoscopically [ 96] .

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 loss following gastric bypass is typically rapid, but usually reaches a plateau after one 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] , which makes 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 has also been well established [ 93,97-99] . LIPOSUCTION —  Although not generally considered to be a bariatric procedure, removal of fat by aspiration after injection of physiologic saline has been used to remove and contour subcutaneous fat. While this can result in reduction in fat mass and weight, the amount of weight loss is insignificant in comparison with bariatric procedures and it does not appear to improve insulin sensitivity or risk factors for coronary heart disease [ 100] . (See "Overview of therapy for obesity in adults" , section on Liposuction). INFORMATION FOR PATIENTS — Educational materials on this topic are available for patients. ( See "Patient information: Weight loss treatments" and see "Patient information: Weight loss surgery" ). We encourage you to print or e-mail these topic reviews, or to refer patients to our public web site, www.uptodate.com/patients , which includes these and other topics. SUMMARY AND RECOMMENDATIONS — Obesity is a major health problem in the 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. Surgical therapies are based primarily on two main mechanisms: restriction of caloric intake via a small stomach reservoir and malabsorption of nutrients via shortened functional small bowel length. All bariatric procedures are effective in achieving weight loss and improving the associated comorbidities in the morbidly obese. Restrictive procedures are generally simpler in techniques but seem to achieve less weight loss. Malabsorptive procedures are highly effective in weight loss but carry significant metabolic complications. Roux-en-Y gastric bypass is the most commonly performed procedure in the United States due to its multiple mechanisms of action and proven success in long term weight loss. Laparoscopic RYGB performed by well-trained bariatric surgeons can lower surgical pain, infectious and hernia complications, as well as allowing for quicker postoperative recovery. Laparoscopic adjustable gastric banding is becoming increasingly more

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. ( "Complications of bariatric surgery" ). See

Clinical practice guidelines from the American College of Physicians for management 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. Vivian M Sanchez and Dr. Benjamin E Schneider, who provided earlier versions of this topic review.

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GRAPHICS

Health risks associated with obesity
Coronary artery disease, hypertension

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, polycystic ovary 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.

Indications for surgical management of severe obesity Obesity Class
II >III

BMI
>35 >40.0

Exceptions
With comorbidities Regardless of comorbidities

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

Types of bariatric procedures

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,

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

Laparoscopic adjustable gastric band (LAGB)

This figure depicts the stomach's appearance after laparoscopic gastric banding (LAGB), which compartmentalizes the upper stomach by placing a silicone band around the entrance to the stomach. The band is connected to a narrow tube that extends to an access port just beneath the skin; a healthcare provider can narrow or widen the entrance to the stomach by injection or removal of saline through the port. As with gastroplasty, the passage of food from the upper pouch to the rest of the stomach is delayed, and the patient feels full after eating less.

Jejunoileal bypass

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

Biliopancreatic diversion

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

Biliopancreatic diversion with duodenal switch

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

Roux-en-Y gastric bypass (RYGB)

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

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

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