Quick fix or long-term cure? Pros and cons of bariatric surgery James A. Madura, II1 and John K. DiBaisecorresponding author2 Author information ► Copyright and License information ► Go to: Abstract The past decade has seen an enormous increase in the number of bariatric, or weight loss, operations performed. This trend is likely to continue, mirroring the epidemic of obesity around the world and its rising prevalence among children. Bariatric surgery is considered by many to be the most effective treatment for obesity in terms of maintenance of long-term weight loss and improvement in obesity-related comorbid conditions. Although overly simplified, the primary mechanisms of the surgical interventions currently utilized to treat obesity are the creation of a restrictive or malabsorptive bowel anatomy. Operations based on these mechanisms include the laparoscopic adjustable gastric band and laparoscopic vertical sleeve gastrectomy (considered primarily restrictive operations), the laparoscopic biliopancreatic diversion with or without a duodenal switch (primarily malabsorptive operation), and the laparoscopic Roux-en-Y gastric bypass (considered a combination restrictive and selective malabsorptive procedure). Each operation has pros and cons. Important considerations, for the patient and surgeon alike, in the decision to proceed with bariatric surgery include the technical aspects of the operation, postoperative complications including long-term nutritional problems, magnitude of initial and sustained weight loss desired, and correction of obesity-related comorbidities. Herein, the pros and cons of the contemporary laparoscopic bariatric operations are reviewed and ongoing controversies relating to bariatric surgery are discussed: appropriate patient selection, appropriate operation selection for an individual patient, surgeon selection, and how to measure success after surgery. Go to: Introduction Obesity is a problem of epidemic proportions in many developed countries and is becoming an increasing concern in developing countries, which have historically dealt with the burden of undernutrition [1]. Obesity is a major health problem because of its serious health consequences, increased mortality risk, and associated social, psychological and economic costs. Presently, bariatric surgery is the only available treatment for morbid obesity that consistently achieves and maintains substantial weight loss, decreases the incidence and severity of obesity-related comorbidities, and improves overall quality of life and survival [2]. The first bariatric surgery performed in humans was reported in 1954 [3]. The jejunoileal bypass was a purely malabsorptive procedure, bypassing the vast majority of the small intestine, thus limiting the ability of the patient to digest and absorb nutrients regardless of the amount consumed. Unfortunately, this led to several long-term health consequences including severe protein and micronutrient deficiencies, ultimately leading to its abandonment in the late 1970s. Due to the continued demand for weight loss operations, subsequent procedures were developed that focused more on gastric restriction and limited malabsorption. The most commonly performed bariatric operations at present are the Roux-en-Y gastric bypass and the adjustable gastric band. Other bariatric operations include the vertical sleeve gastrectomy, which seems to be gaining in popularity recently, and the biliopancreatic diversion with or without a duodenal switch, an operation generally reserved for the most severely obese patient. Although the mechanism of weight loss with these operations tends to rely on restriction of food intake, malabsorption of ingested food, or a combination of the two, the exact mechanism(s) appears to be far more complex, implicating hormonal, inflammatory, central nervous system and gut microbial factors [4-6]. Bariatric operations were performed infrequently until the introduction of laparoscopic technology to bariatric operations in the mid 1990s [7-9]. Laparoscopy allows surgery to be performed through small incisions, minimizing pain and wound complications associated with traditional open interventions. Commensurate with the growing obesity epidemic, the promulgation of guidelines regarding patient selection, and the increasing use of laparoscopy, the stage was set for a profound growth in the rate of performance of bariatric operations as documented by the increase from 13,000 procedures in 1998 to over 220,000 by 2008. Unfortunately, comparing the success and complications of the contemporary bariatric operations has been difficult, in part because there are few direct prospective comparisons, controversies regarding how best to measure outcomes including success, and inconsistent monitoring of nutritional and other complications. Go to: Contemporary bariatric operations Laparoscopic Roux-en-Y gastric bypass Laparoscopic Roux-en-Y gastric bypass is considered by many to be the gold standard bariatric operation and is the most commonly performed bariatric operation in the United States (Figure 1). Although oversimplified, the mechanism of action is generally considered threefold: a restriction in food intake, selective malabsorption, and the development of dumping syndrome, limiting patients’ consumption of triggering foods (e.g. simple sugars). Long-term follow-up data are available, in some cases up to nearly two decades [10]. Weight loss averages 65% for most patients with over 85% of patients losing and maintaining 50% initial excess weight loss. Contemporary series have documented mortality rates of approximately 0.1% and serious early complication rates of 5%. Long-term issues with fat malabsorption, protein-energy malnutrition and micronutrient deficiencies are relatively uncommon and can usually be managed with oral supplementation. Reoperations are infrequently needed for failures or complications. Despite the high likelihood of success both in weight loss and correction of obesity-related medical conditions, the operation requires advanced laparoscopic surgical skills with a learning curve as long as 100 cases, and a 10-15% long-term failure rate. Laparoscopic Roux-en-Y gastric bypass
Posted on: Thu, 23 Jan 2014 00:25:37 +0000
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