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Surgical Approaches to Obesity
SUPPLEMENT ARTICLE SURGICAL APPROACHES TO OBESITY
Surgical Approaches to Obesity MICHAEL L. KENDRICK, MD, AND GREGORY F. DAKIN, MD Bariatric surgery has evolved considerably since the introduction of jejunoileal bypass in the 1950s. With modifications of early procedures, implementation of new techniques, and establishment of minimally invasive approaches, operative intervention has become the mainstay in the treatment of extreme (class III) obesity. The laparoscopic adjustable gastric band technique is the most common purely restrictive procedure. Advantages of the laparoscopic adjustable gastric band include reduced perioperative morbidity and mortality compared to other bariatric procedures, but this procedure has been associated with substantial intermediate and long-term complications. Although vertical banded gastroplasty was associated with decreased perioperative morbidity and acceptable early weight loss, results from long-term follow-up have been discouraging. Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure performed in the United States because of its effectiveness in long-term weight loss and low rates of serious complications. Modifications of RYGB to induce malabsorption have led to greater weight loss but increased risks of metabolic and nutritional sequelae. Duodenal switch is a malabsorptive procedure associated with excellent weight loss and resolution of weight-related comorbidities, but concerns regarding potential metabolic and nutritional sequelae have limited its widespread use. Laparoscopic approaches to bariatric procedures have reduced wound-related complications and improved patient recovery. However, the incidence of anastomotic leak and internal hernia is higher after laparoscopic RYGB compared to the open approach. Each of the currently available bariatric procedures has both advantages and disadvantages that must be considered in determining which operation should be selected for an individual patient.
(DS), and gastric banding. Each of these procedures has undergone several modifications in both design and approach to improve operative morbidity and outcomes. A 1991 National Institutes of Health consensus statement on the surgical management of obesity supported Roux-en-Y gastric bypass (RYGB) and vertical banded gastroplasty (VBG) as safe and effective procedures for the treatment of obesity.2 Today, multiple additional procedures and approaches are available that were either not conceptualized or not adequately evaluated at the time of that consensus statement. Currently, bariatric operations are the only effective method of achieving substantive and sustained weight loss in patients with extreme (class III) obesity. In addition to considerable weight loss, bariatric procedures provide concomitant improvement in or resolution of multiple weightrelated comorbidities such as diabetes mellitus, hypertension, dyslipidemia, obstructive sleep apnea, and gastroesophageal reflux disease (GERD). The purpose of this article is to describe the surgical treatment of obesity with an emphasis on the most commonly performed procedures and approaches.
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BARIATRIC OPERATIONS
BMI = body mass index; BPD = biliopancreatic diversion; DS = duodenal switch; EWL = excess weight loss; GERD = gastroesophageal reflux disease; LAGB = laparoscopic adjustable gastric band; RYGB = Roux-enY gastric bypass; VBG = vertical banded gastroplasty; VVLL-RYGB = very, very long-limb RYGB
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perative intervention for obesity began with the introduction of jejunoileal bypass in the 1950s. By bypassing a major portion of the small intestine, this procedure induces a state of malabsorption resulting in effective weight loss. Unfortunately, the procedure was associated with several severe metabolic and nutritional complications, such as protein-calorie malnutrition, vitamin and mineral deficiencies, and bacterial overgrowth leading to liver failure, septic arthritis, osteoporosis, night blindness, and oxalate nephropathy (renal stones and failure).1 Concern about the incidence of these complications after jejunoileal bypass led to its abandonment as a bariatric procedure. The ongoing and increasing need for effective treatment of obesity prompted the design of several additional bariatric procedures, including biliopancreatic diversion (BPD), gastric bypass, various gastroplasty techniques, duodenal switch S18
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Bariatric operations can be broadly categorized by their mechanism of either restricting food intake or inducing maldigestion/malabsorption. Current procedures focus on one or both of these principles to achieve adequate and sustained weight loss. In addition, certain bariatric operations can lead to important alterations of the gastrointestinal neurohormonal system and alter feedback signals to the brain affecting appetite and satiety. Thus, each bariatric operation has inherent advantages and disadvantages related to patient satisfaction, perioperative morbidity, and long-term outcomes, which fuels the ongoing search for the optimal bariatric procedure. Table 1 lists common bariatric procedures and their potential advantages and disadvantages. Each of these procedures is discussed in regard to operative principles and outcomes. From the Division of Gastroenterologic and General Surgery, Mayo Clinic College of Medicine, Rochester, Minn (M.L.K.); and Department of Surgery, Weill College of Medicine of Cornell University, New York, NY (G.F.D.). Address correspondence to Michael L. Kendrick, MD, Department of Surgery, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905 (e-mail: [email protected]). © 2006 Mayo Foundation for Medical Education and Research
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SURGICAL APPROACHES TO OBESITY
TABLE 1. Overview of Operations Commonly Performed for Treatment of Obesity Procedure
Mechanism
Advantages
Disadvantages
Laparoscopic adjustable gastric band
Restrictive
No anastomosis Low perioperative risks Adjustable Reversible No anastomosis Low perioperative risks
Vertical banded gastroplasty
Restrictive
Roux-en-Y gastric bypass (RYGB)
Restrictive, maldigestive
Duodenal switch
Restrictive, malabsorptive
Biliopancreatic diversion
Malabsorptive
Sustained weight loss Antireflux anatomy Dumping symptoms (avoids maladaptive eating) Avoids dumping physiology Improved weight loss Improved reduction in comorbidities Improved weight loss
Very, very long-limb RYGB, distal RYGB
Restrictive, malabsorptive
Improved weight loss in superobese (body mass index >50 kg/m2) patients
LAPAROSCOPIC ADJUSTABLE GASTRIC BAND The laparoscopic adjustable gastric band (LAGB) was approved for use in the United States in 2001 and is currently the most commonly performed purely restrictive bariatric procedure. This device consists of 2 components, a silicone band with an inner inflatable cuff and a reservoir connected by tubing. The band is placed around the gastric cardia to create a small (15 mL) proximal gastric pouch with an adjustable restrictive outlet that limits the amount of food that can be consumed (Figure 1). The reservoir is implanted in the subcutaneous tissue of the abdominal wall where it can be accessed percutaneously to either add or subtract saline to adjust the inflatable cuff. This adjustable feature provides the ability to fine-tune the desired effect of restriction while avoiding excessive adverse effects. The gastric band is placed laparoscopically, and the operation is generally performed as an outpatient procedure or with an overnight hospital stay. Because this technique involves no bowel transection or anastomosis, operative morbidity and mortality are lower in comparison with other bariatric procedures. Patients typically have an initial band adjustment within the first month postoperatively. Additional small volume adjustments (≤1 mL) are made on the basis of symptoms and weight loss to achieve the desired effect. Disadvantages of the LAGB technique are its apparent inferior outcomes regarding weight loss and resolution of weight-related comorbidities compared to RYGB, adjustability (prompting repeated appropriate and inapproMayo Clin Proc.
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Inferior weight loss? Inappropriate requests for adjustment Long-term band complications Stomal complications Frequent gastroesophageal reflux symptoms Frequent revision necessary Inferior weight loss Anastomosis Dumping symptoms Obstruction Stomal complications Metabolic/nutritional sequelae Increased technical difficulty Metabolic/nutritional sequelae Stomal ulceration Dumping symptoms Diarrhea Metabolic/nutritional sequelae Dumping symptoms Diarrhea Stomal complications
priate requests for adjustment), ability to permit maladaptive eating (high-energy liquids), and lack of established long-term outcomes. Moreover, intermediate and longterm complications can be substantial, with reports of band slippage, gastric perforation, band erosion, and malfunction requiring reoperation in up to 20% of patients.3,4 Pertinent to the comparison of LAGB and RYGB is the observance of a disparity in the rate of weight loss between these 2 procedures. Peak weight loss is generally achieved at 18 months postoperatively with RYGB,
FIGURE 1. Laparoscopic adjustable gastric band procedure.
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development of maladaptive eating patterns (high-energy liquids not impeded by restriction). Additionally, severe symptomatic complications (GERD and stomal stenosis) necessitate revisional procedures after VBG in many patients.9,10 When VBG was compared with other purely restrictive procedures, early results were favorable in regard to weight loss. In a prospective randomized trial comparing LAGB operations with VBG, van Dielen et al11 found that VBG was associated with improved percentages of EWL (70% vs 55%; P<.001) 2 years postoperatively but was also associated with increased perioperative complications (18% vs 6%). Although VBG still has proponents, poor long-term results and increased complication rates have led most bariatric surgeons to abandon this procedure.
FIGURE 2. Vertical banded gastroplasty.
whereas it generally occurs 2 to 3 years postoperatively with LAGB. Thus, early reports touting inferior weight loss with LAGB compared to RYGB have been challenged recently on the basis of longer follow-up. In a comparative trial of RYGB and LAGB, Jan et al5 reported similar percentages of excess weight loss (EWL) at 3 years (60% vs 57%). Nevertheless, RYGB is still considered the gold standard, having demonstrated sustained weight loss and reduction of comorbidities with long-term follow-up.6 Importantly, lessons learned from other purely restrictive procedures should be noted. For example, initial enthusiasm for VBG and other purely restrictive gastroplasties was dampened by long-term evaluations demonstrating poor outcomes and increased procedure-related complications.7 Whether the LAGB procedure will stand the test of time is yet to be determined. VERTICAL BANDED GASTROPLASTY Initially designed to avoid the complications of RYGB, VBG consists of a stapled proximal gastric pouch with a fixed (nonadjustable) outlet created by a mesh band or Silastic ring (Figure 2). Although restriction without the inherent risks of an anastomosis led to decreased perioperative morbidity and acceptable early weight loss compared to RYGB, results after longer follow-up have been discouraging. Several randomized trials have demonstrated inferior weight loss with VBG compared to RYGB.4,8 In a prospective randomized trial comparing laparoscopic RYGB to VBG, Olbers et al4 demonstrated improved EWL (84% vs 60%; P<.001) at 2 years with RYGB. The failure of VBG to provide sustained weight loss has been attributed to disruption of the gastroplasty or S20
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ROUX-EN-Y GASTRIC BYPASS Since its description in 1967 by Mason and Ito,12 gastric bypass has undergone several modifications. The initial procedure consisted of a jejunal loop brought up to a relatively large, horizontally oriented, undivided gastric pouch. Complications of bile reflux esophagitis, stomal ulceration, pouch enlargement, and gastro-gastric fistula prompted modifications including the use of a Roux limb, reduced pouch size, and vertically oriented and divided gastric pouch. The current RYGB technique uses a small proximal cardia pouch (10-30 mL) and a 75- to 150-cm Roux limb (Figure 3). Several techniques for constructing the gastrojejunostomy have been described, including hand-sewn or stapled (linear or circular stapler) approaches, each of which has advocates. The recommended length of the Roux limb varies, and each has several purported advantages. Shorter Roux limb lengths (75-100 cm) may allow future endoscopic access to the afferent limb and remnant stomach if necessary, whereas a longer Roux limb (150 cm) may improve weight loss in selected patients. Several randomized trials have evaluated the effect of Roux limb length on weight loss and nutritional sequelae.13-15 In patients with superobesity (body mass index [BMI], calculated as weight in kilograms divided by the square of height in meters, ≥50 kg/m2), a Roux limb of 150 cm results in increased weight loss compared to shorter limbs without apparent increased risk of nutritional complications.13,14 Conversely, in patients with a BMI less than 50 kg/m2, weight loss is unchanged with limb lengths between 50 and 150 cm, and a longer limb may increase the risk of internal hernia.13,14 The standard RYGB (Roux limb ≤150 cm) is generally considered maldigestive rather than globally malabsorptive. With limb lengths of 200 cm or more, evidence of malabsorption is apparent. In addition to its restrictive and maldigestive effects, RYGB results in alterations of the gastrointestinal
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SURGICAL APPROACHES TO OBESITY
FIGURE 3. Roux-en-Y gastric bypass.
neurohormonal response in both fasting and postprandial states. Advantages of RYGB include established long-term effectiveness for sustained weight loss, reduction of comorbidities, and minimal risk for long-term nutritional sequelae. The presence of dumping syndrome may have the benefit of reducing maladaptive eating patterns in some patients. Patients undergoing RYGB are less likely to require operative revision for complications or unsuccessful weight loss than are patients having VBG.9 An additional advantage of RYGB is its antireflux properties. Gastroesophageal reflux symptoms have been reported in more than 50% of obese patients.16,17 Among the currently available bariatric operations, only RYGB has consistently produced effective relief of GERD symptoms, with several authors reporting greater than 95% success in symptom resolution.18-20 Conversely, patients undergoing VBG are likely to develop new or worsened GERD symptoms.10 Therefore, patients with extreme obesity and predominant symptoms of GERD should undergo RYGB rather than other bariatric procedures.21 In the vast majority of series, RYGB has provided greater initial and sustained weight loss than that produced by purely restrictive operations such as VBG and LAGB. However, with an intermediate follow-up of 3 or more Mayo Clin Proc.
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FIGURE 4. Duodenal switch procedure. A, Greater curvature sleeve gastrectomy has been performed. B, Duodenoileostomy is constructed 250 cm from the ileocecal valve with a common channel of 100 cm.
years, LAGB may result in weight loss rates comparable to those obtained with RYGB.5 The need for long-term comparative studies of RYGB and LAGB is underscored by the results of a 10-year prospective, controlled, nonrandomized study in which EWL of 20% or more was sustained in only 28% of patients after gastric banding compared to 74% after RYGB.22 DUODENAL SWITCH First described as a bariatric operation by Hess and Hess,23 the DS was developed as a hybrid procedure combining the BPD reported by Scopinaro et al24 and the operation described by DeMeester et al.25 Although conceptualized to avoid the risk of stomal ulceration and dumping symptoms, large case series have reported a decreased incidence of severe protein-energy malnutrition with the DS technique compared to that reported with BPD. The procedure involves transection of the first portion of the duodenum with resection of the greater curvature of the stomach, leaving a 100- to 150-mL lesser curvature–based gastric sleeve with an intact antrum and pylorus (Figure 4, A). The proximal ileum is divided 250 cm from the ileocecal junction, and the biliopancreatic limb is anastomosed to the distal ileum creating a short (100 cm) common channel. A duodenoileostomy
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Other malabsorptive procedures represent modifications of RYGB, including long-limb RYGB, very, very long-limb RYGB (VVLL-RYGB), and distal RYGB. Each maintains the restrictive component of RYGB and essentially modifies the length of the common channel to promote malabsorptive, rather than predominantly maldigestive, physiology. Advantages of these procedures are similar to those of other malabsorptive operations. They may be most useful in superobese (BMI ≥50 kg/m2) patients in whom results with RYGB are less effective.28 These modifications of RYGB appear to improve weight loss but are associated with an increased risk of protein malnutrition, bone mineral disease, oxalate nephropathy, and diarrhea. The VVLL-RYGB consists of a common channel length of 100 cm, a small (<10 mL) gastric pouch, and a variable Roux limb length of 300 to 500 cm (Figure 5).29 At our institution, highly selected patients with a BMI of 50 kg/m2 or greater undergo either DS or VVLL-RYGB to enhance outcomes of weight loss and resolution of weight-related comorbidities. OPEN VS LAPAROSCOPIC APPROACHES FIGURE 5. Very, very long-limb Roux-en-Y gastric bypass consisting of a small (<10 mL) gastric pouch, variable Roux limb length (300500 cm), and a common channel of 100 cm.
is then constructed by bringing the Roux limb up to the gastric sleeve (Figure 4, B). The lengths of the common channel and Roux limb are either based on a percentage of the total bowel length23 or configured at a standard 100- and 150-cm length, respectively.26 Advantages of DS include reduced stomal complications, absence of dumping, and excellent long-term maintenance of weight loss. To date, no randomized trials have compared DS with RYGB or LAGB. However, large series have reported excellent outcomes with DS, exceeding those typically reported for RYGB or LAGB in percentage of EWL and resolution of comorbidities. In a large meta-analysis, Buchwald et al27 reported EWL of 47%, 62%, and 70% and resolution of diabetes in 48%, 84%, and 98% of patients after LAGB, RYGB, and BPD with or without DS, respectively. OTHER MALABSORPTIVE PROCEDURES Several additional malabsorptive procedures merit brief discussion. The BPD described by Scopinaro24 is a malabsorptive (short common channel) procedure combined with a distal gastrectomy that is capable of producing marked and sustained weight loss. However, the increased incidence of stomal ulceration, severe proteinenergy malnutrition, diarrhea, and dumping has limited its broad acceptance. S22
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Minimally invasive approaches to bariatric surgery have contributed substantially to the acceptability of operative intervention for obesity. Despite the expanding epidemic of obesity and the National Institutes of Health 1991 consensus statement endorsing bariatric procedures, the number of bariatric operations performed annually in the 1990s pales in comparison to the more than 170,000 operations performed in 2005. Wittgrove et al30 reported the first series of 5 patients who underwent laparoscopic RYGB in 1994. Since that time, the volume of bariatric procedures performed in the United States has increased substantially. The prevalence of obesity and thus the need for bariatric operations have increased dramatically during the past decade, and the advent of minimally invasive techniques has increased the acceptance of bariatric surgery by both patients and the medical community. The need for minimally invasive approaches is underscored by the high incidence of wound complications (infection or hernia) after open bariatric procedures. Three randomized prospective trials that compared laparoscopic with open RYGB showed reduced blood loss, narcotic requirement, hospital stay, and wound complications with the laparoscopic approach.31-33 In a 3-year follow-up of the randomized study by Nguyen et al,31 the authors reported a substantial reduction in the incidence of incisional herniae after laparoscopic RYGB (5%) compared to open RYGB (39%).34 Conversely, the incidence of anastomotic complications after laparoscopic RYGB appears to be greater than that associated with open approaches.
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SURGICAL APPROACHES TO OBESITY
Laparoscopic approaches also reduce adhesion formation, potentially decreasing the incidence of adhesive bowel obstruction. However, during RYGB, multiple transmesenteric or intermesenteric defects are created in which internal herniae may develop and cause partial or even closed-loop obstruction (Figure 6). Although internal herniae can occur after open RYGB, they are exceedingly rare. Closure of these defects after either approach is important to prevent this potentially life-threatening complication.35 Antecolic routing of the Roux limb has been advocated to prevent formation of a mesocolic hernia defect (Figure 6, A), but suture fixation of the Roux limb where it traverses the mesocolon can obviate herniae at this site. ON THE HORIZON Several new or revised operative strategies are emerging for the treatment of obesity. Endoscopic approaches include plication techniques to create proximal gastric restriction, either primarily or as revision of stomal dilation after RYGB. With the emergence of natural orifice translumenal endoscopic surgery, the technique of endoscopic gastrojejunostomy may lead to potential endoscopic interventions for obesity.36 The use of electrical stimulation in the treatment of obesity is under investigation. Implantable gastric stimulators have been shown to result in EWL as high as 25%.37 Recently, a novel approach involving direct vagal nerve modulation to control gastric and pancreatic physiology was described.38 By using high-frequency electrical vagal blockade, reversible inhibition of pancreatic exocrine secretion and gastric contractions has been observed, suggesting potential for this novel intervention in the treatment of obesity. Laparoscopic sleeve gastrectomy represents a new purely restrictive procedure in the treatment of obesity. This technique consists of the restrictive component of the DS, a resection of the greater curvature of the stomach over a 45- to 50-F bougie positioned along the lesser curvature (Figure 4, A). The antrum and pylorus are preserved, resulting in a lesser curvature–based “restrictive” gastric sleeve. Early reports of sleeve gastrectomy have shown substantial weight loss with a low perioperative complication rate. It has been suggested for use as a primary operation or as part of a staged bariatric procedure for highest-risk obese patients.39-41
FIGURE 6. Defects created by Roux-en-Y gastric bypass in which internal herniae may develop. Sites where mesocolic (A), mesenteric-mesocolic (Petersen) (B), and mesenteric (C) herniae may develop are shown.
dure and approach. Both patients and surgeons must balance the advantages, risks, adverse effects, and long-term results when selecting the appropriate procedure. The very existence of multiple “accepted” procedures refutes the concept of one “best procedure” for the treatment of obesity. Although data are currently insufficient to predict which procedure is most appropriate for a particular patient, several patient-related factors, such as eating behaviors, BMI, previous operations, and specific weight-related comorbidities, may influence procedure selection. Patients classified as superobese are less likely to achieve and maintain an EWL of 50% or more with restrictive procedures or RYGB than with malabsorptive operations. As a result, several bariatric centers, including the Mayo Clinic, typically recommend malabsorptive procedures for compliant, well-informed patients with a BMI of 50 kg/m2 or greater.
PROCEDURE SELECTION Several factors influence the selection of the type of bariatric procedure for each patient. With the increasing level of awareness and education of the public regarding bariatric operations, patients often request a particular proceMayo Clin Proc.
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SUMMARY Until successful nonoperative methods for the treatment of obesity emerge, surgery remains the mainstay of therapy for extreme obesity. Several operations are currently avail-
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able, each with advantages and disadvantages that require careful patient selection to ensure the optimal outcome and patient satisfaction. Additional minimally invasive procedures are on the horizon for the treatment of obesity, with the hope that they will improve operative risks, patient satisfaction, and long-term outcomes. REFERENCES 1. Griffen WO Jr, Bivins BA, Bell RM. The decline and fall of the jejunoilieal bypass. Surg Gynecol Obestet. 1983;157:301-308. 2. National Institutes of Health Consensus Development Conference. Gastrointestinal surgery for severe obesity. Am J Clin Nutr. 1992;55(2, suppl): 487S-619S. 3. Chapman AE, Kiroff G, Game P, et al. Laparoscopic adjustable gastric banding in the treatment of obesity: a systematic literature review. Surgery. 2004;135:326-351. 4. Olbers T, Fagevik-Olsen M, Maleckas A, Lonroth H. Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic vertical banded gastroplasty for obesity. Br J Surg. 2005;92:557-562. 5. Jan JC, Hong D, Pereira N, Patterson EJ. Laparoscopic adjustable gastric banding versus laparoscopic gastric bypass for morbid obesity: a single-institution comparison study of early results. J Gastrointest Surg. 2005;9:30-39. 6. Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases longterm mortality, morbidity, and health care use in morbidly obese patients. Ann Surg. 2004;240:416-423. 7. Balsiger BM, Poggio JL, Mai J, Kelly KA, Sarr MG. Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity. J Gastrointest Surg. 2000;4:598-605. 8. Howard L, Malone M, Michalek A, Carter J, Alger S, Van Woert J. Gastric bypass and vertical banded gastroplasty—a prospective randomized comparison and 5-year follow-up. Obes Surg. 1995;5:55-60. 9. van Gemert WG, van Wersch MM, Greve JW, Soeters PB. Revisional surgery after failed vertical banded gastroplasty: restoration of vertical banded gastroplasty or conversion to gastric bypass. Obes Surg. 1998;8:21-28. 10. Balsiger BM, Murr MM, Mai J, Sarr MG. Gastroesophageal reflux after intact vertical banded gastroplasty: correction by conversion to Roux-en-Y gastric bypass. J Gastrointest Surg. 2000;4:276-281. 11. van Dielen FM, Soeters PB, de Brauw LM, Greve JW. Laparoscopic adjustable gastric banding versus open vertical banded gastroplasty: a prospective randomized trial. Obes Surg. 2005;15:1292-1298. 12. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967; 47:1345-1351. 13. Choban PS, Flancbaum L. The effect of Roux limb lengths on outcome after Roux-en-Y gastric bypass: a prospective, randomized clinical trial. Obes Surg. 2002;12:540-545. 14. Inabnet WB, Quinn T, Gagner M, Urban M, Pomp A. Laparoscopic Roux-en-Y gastric bypass in patients with BMI <50: a prospective randomized trial comparing short and long limb lengths. Obes Surg. 2005;15:51-57. 15. Brolin RE, Kenler HA, Gorman JH, Cody RP. Long-limb gastric bypass in the superobese: a prospective randomized study. Ann Surg. 1992;215:387-395. 16. Suter M, Dorta G, Giusti V, Calmes JM. Gastro-esophageal reflux and esophageal motility disorders in morbidly obese patients. Obes Surg. 2004;14: 959-966. 17. Murray L, Johnston B, Lane A, et al. Relationship between body mass and gastro-oesophageal reflux symptoms: the Bristol Helicobacter Project. Int J Epidemiol. 2003;32:645-650. 18. Frezza EE, Ikramuddin S, Gourash T, et al. Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-enY gastric bypass. Surg Endosc. 2002 Jul;16:1027-1031. Epub 2002 May 3.
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19. Jones KB Jr, Allen TV, Manas KJ, McGuinty DP, Wilder WM, Wadsworth ED. Roux-Y gastric bypass: an effective anti-reflux procedure. Obes Surg. 1991;1:295-298. 20. Smith SC, Edwards CB, Goodman GN. Symptomatic and clinical improvement in morbidly obese patients with gastroesophageal reflux disease following Roux-en-Y gastric bypass. Obes Surg. 1997;7:479-484. 21. Kendrick ML, Houghton SG. Gastroesophageal reflux disease in obese patients: the role of obesity in management. Dis Esophagus. 2006;19:57-63. 22. Sjostrom L, Lindroos AK, Peltonen M, et al, Swedish Obese Subjects Study Scientific Group. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351:2683-2693. 23. Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg. 1998;8:267-282. 24. Scopinaro N, Gianetta E, Civalleri D, Bonalumi U, Bachi V. Biliopancreatic bypass for obesity, II: initial experience in man. Br J Surg. 1979; 66:618-620. 25. DeMeester TR, Fuchs KH, Ball CS, Albertucci M, Smyrk TC, Marcus JN. Experimental and clinical results with proximal end-to-end duodenojejunostomy for pathologic duodenogastric reflux. Ann Surg. 1987;206:414426. 26. Marceau P, Hould FS, Simard S, et al. Biliopancreatic diversion with duodenal switch. World J Surg. 1998;22:947-954. 27. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724-1737. 28. MacLean LD, Rhode BM, Nohr CW. Late outcome of isolated gastric bypass. Ann Surg. 2000;231:524-528. 29. Nelson WK, Fatima J, Houghton SG, et al. The malabsorptive very, very long limb Roux-en-Y gastric bypass for super obesity: results in 257 patients. Surgery. In press. 30. Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg. 1994;4:353-357. 31. Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg. 2001;234:279-289. 32. Westling A, Gustavsson S. Laparoscopic vs open Roux-en-Y gastric bypass: a prospective, randomized trial. Obes Surg. 2001;11:284-292. 33. Lujan, JA, Frutos MD, Hernandez Q, et al. Laparoscopic versus open gastric bypass in the treatment of morbid obesity: a randomized prospective study. Ann Surg. 2004;239:433-437. 34. Puzziferri N, Austrheim-Smith IT, Wolfe FM, Wilson SE, Nguyen NT. Three-year follow-up of a prospective randomized trial comparing laparoscopic versus open gastric bypass. Ann Surg. 2006;243:181-188. 35. Comeau E, Gagner M, Inabnet WB, Herron DM, Quinn TM, Pomp A. Symptomatic internal hernias after laparoscopic bariatric surgery. Surg Endosc. 2005 Jan;19:34-39. Epub 2004 Nov 11. 36. Kantsevoy SV, Jagannath SB, Niiyama H, et al. Endoscopic gastrojejunostomy with survival in a porcine model. Gastrointest Endosc. 2005;62:287292. 37. Cigaina V. Long-term follow-up of gastric stimulation for obesity: the Mestre 8-year experience. Obes Surg. 2004;14:S14-S22. 38. Tweden KS, Sarr MG, Camilleri M, et al. Vagal blocking for obesity control (VBLOC): studies of pancreatic and gastric function and safety in a porcine model [abstract]. Surg Obes Rel Dis. 2006;2:301. Abstract 46. 39. Regan JP, Inabnet WB, Gagner M, Pomp A. Early experience with twostage laparoscopic Roux-en-Y gastric bypass as an alternative in the supersuper obese patient. Obes Surg. 2003;13:861-864. 40. Moon Han S, Kim WW, Oh JH. Results of laparoscopic sleeve gastrectomy (LSG) at 1 year in morbidly obese Korean patients. Obes Surg. 2005; 15:1469-1475. 41. Baltasar A, Serra C, Perez N, Bou R, Bengochea M, Ferri L. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg. 2005;15:1124-1128.
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Surgical Approaches to Obesity MICHAEL L. KENDRICK, MD, AND GREGORY F. DAKIN, MD Bariatric surgery has evolved considerably since the introduction of jejunoileal bypass in the 1950s. With modifications of early procedures, implementation of new techniques, and establishment of minimally invasive approaches, operative intervention has become the mainstay in the treatment of extreme (class III) obesity. The laparoscopic adjustable gastric band technique is the most common purely restrictive procedure. Advantages of the laparoscopic adjustable gastric band include reduced perioperative morbidity and mortality compared to other bariatric procedures, but this procedure has been associated with substantial intermediate and long-term complications. Although vertical banded gastroplasty was associated with decreased perioperative morbidity and acceptable early weight loss, results from long-term follow-up have been discouraging. Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure performed in the United States because of its effectiveness in long-term weight loss and low rates of serious complications. Modifications of RYGB to induce malabsorption have led to greater weight loss but increased risks of metabolic and nutritional sequelae. Duodenal switch is a malabsorptive procedure associated with excellent weight loss and resolution of weight-related comorbidities, but concerns regarding potential metabolic and nutritional sequelae have limited its widespread use. Laparoscopic approaches to bariatric procedures have reduced wound-related complications and improved patient recovery. However, the incidence of anastomotic leak and internal hernia is higher after laparoscopic RYGB compared to the open approach. Each of the currently available bariatric procedures has both advantages and disadvantages that must be considered in determining which operation should be selected for an individual patient.
(DS), and gastric banding. Each of these procedures has undergone several modifications in both design and approach to improve operative morbidity and outcomes. A 1991 National Institutes of Health consensus statement on the surgical management of obesity supported Roux-en-Y gastric bypass (RYGB) and vertical banded gastroplasty (VBG) as safe and effective procedures for the treatment of obesity.2 Today, multiple additional procedures and approaches are available that were either not conceptualized or not adequately evaluated at the time of that consensus statement. Currently, bariatric operations are the only effective method of achieving substantive and sustained weight loss in patients with extreme (class III) obesity. In addition to considerable weight loss, bariatric procedures provide concomitant improvement in or resolution of multiple weightrelated comorbidities such as diabetes mellitus, hypertension, dyslipidemia, obstructive sleep apnea, and gastroesophageal reflux disease (GERD). The purpose of this article is to describe the surgical treatment of obesity with an emphasis on the most commonly performed procedures and approaches.
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BMI = body mass index; BPD = biliopancreatic diversion; DS = duodenal switch; EWL = excess weight loss; GERD = gastroesophageal reflux disease; LAGB = laparoscopic adjustable gastric band; RYGB = Roux-enY gastric bypass; VBG = vertical banded gastroplasty; VVLL-RYGB = very, very long-limb RYGB
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perative intervention for obesity began with the introduction of jejunoileal bypass in the 1950s. By bypassing a major portion of the small intestine, this procedure induces a state of malabsorption resulting in effective weight loss. Unfortunately, the procedure was associated with several severe metabolic and nutritional complications, such as protein-calorie malnutrition, vitamin and mineral deficiencies, and bacterial overgrowth leading to liver failure, septic arthritis, osteoporosis, night blindness, and oxalate nephropathy (renal stones and failure).1 Concern about the incidence of these complications after jejunoileal bypass led to its abandonment as a bariatric procedure. The ongoing and increasing need for effective treatment of obesity prompted the design of several additional bariatric procedures, including biliopancreatic diversion (BPD), gastric bypass, various gastroplasty techniques, duodenal switch S18
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Bariatric operations can be broadly categorized by their mechanism of either restricting food intake or inducing maldigestion/malabsorption. Current procedures focus on one or both of these principles to achieve adequate and sustained weight loss. In addition, certain bariatric operations can lead to important alterations of the gastrointestinal neurohormonal system and alter feedback signals to the brain affecting appetite and satiety. Thus, each bariatric operation has inherent advantages and disadvantages related to patient satisfaction, perioperative morbidity, and long-term outcomes, which fuels the ongoing search for the optimal bariatric procedure. Table 1 lists common bariatric procedures and their potential advantages and disadvantages. Each of these procedures is discussed in regard to operative principles and outcomes. From the Division of Gastroenterologic and General Surgery, Mayo Clinic College of Medicine, Rochester, Minn (M.L.K.); and Department of Surgery, Weill College of Medicine of Cornell University, New York, NY (G.F.D.). Address correspondence to Michael L. Kendrick, MD, Department of Surgery, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905 (e-mail: [email protected]). © 2006 Mayo Foundation for Medical Education and Research
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SURGICAL APPROACHES TO OBESITY
TABLE 1. Overview of Operations Commonly Performed for Treatment of Obesity Procedure
Mechanism
Advantages
Disadvantages
Laparoscopic adjustable gastric band
Restrictive
No anastomosis Low perioperative risks Adjustable Reversible No anastomosis Low perioperative risks
Vertical banded gastroplasty
Restrictive
Roux-en-Y gastric bypass (RYGB)
Restrictive, maldigestive
Duodenal switch
Restrictive, malabsorptive
Biliopancreatic diversion
Malabsorptive
Sustained weight loss Antireflux anatomy Dumping symptoms (avoids maladaptive eating) Avoids dumping physiology Improved weight loss Improved reduction in comorbidities Improved weight loss
Very, very long-limb RYGB, distal RYGB
Restrictive, malabsorptive
Improved weight loss in superobese (body mass index >50 kg/m2) patients
LAPAROSCOPIC ADJUSTABLE GASTRIC BAND The laparoscopic adjustable gastric band (LAGB) was approved for use in the United States in 2001 and is currently the most commonly performed purely restrictive bariatric procedure. This device consists of 2 components, a silicone band with an inner inflatable cuff and a reservoir connected by tubing. The band is placed around the gastric cardia to create a small (15 mL) proximal gastric pouch with an adjustable restrictive outlet that limits the amount of food that can be consumed (Figure 1). The reservoir is implanted in the subcutaneous tissue of the abdominal wall where it can be accessed percutaneously to either add or subtract saline to adjust the inflatable cuff. This adjustable feature provides the ability to fine-tune the desired effect of restriction while avoiding excessive adverse effects. The gastric band is placed laparoscopically, and the operation is generally performed as an outpatient procedure or with an overnight hospital stay. Because this technique involves no bowel transection or anastomosis, operative morbidity and mortality are lower in comparison with other bariatric procedures. Patients typically have an initial band adjustment within the first month postoperatively. Additional small volume adjustments (≤1 mL) are made on the basis of symptoms and weight loss to achieve the desired effect. Disadvantages of the LAGB technique are its apparent inferior outcomes regarding weight loss and resolution of weight-related comorbidities compared to RYGB, adjustability (prompting repeated appropriate and inapproMayo Clin Proc.
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Inferior weight loss? Inappropriate requests for adjustment Long-term band complications Stomal complications Frequent gastroesophageal reflux symptoms Frequent revision necessary Inferior weight loss Anastomosis Dumping symptoms Obstruction Stomal complications Metabolic/nutritional sequelae Increased technical difficulty Metabolic/nutritional sequelae Stomal ulceration Dumping symptoms Diarrhea Metabolic/nutritional sequelae Dumping symptoms Diarrhea Stomal complications
priate requests for adjustment), ability to permit maladaptive eating (high-energy liquids), and lack of established long-term outcomes. Moreover, intermediate and longterm complications can be substantial, with reports of band slippage, gastric perforation, band erosion, and malfunction requiring reoperation in up to 20% of patients.3,4 Pertinent to the comparison of LAGB and RYGB is the observance of a disparity in the rate of weight loss between these 2 procedures. Peak weight loss is generally achieved at 18 months postoperatively with RYGB,
FIGURE 1. Laparoscopic adjustable gastric band procedure.
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development of maladaptive eating patterns (high-energy liquids not impeded by restriction). Additionally, severe symptomatic complications (GERD and stomal stenosis) necessitate revisional procedures after VBG in many patients.9,10 When VBG was compared with other purely restrictive procedures, early results were favorable in regard to weight loss. In a prospective randomized trial comparing LAGB operations with VBG, van Dielen et al11 found that VBG was associated with improved percentages of EWL (70% vs 55%; P<.001) 2 years postoperatively but was also associated with increased perioperative complications (18% vs 6%). Although VBG still has proponents, poor long-term results and increased complication rates have led most bariatric surgeons to abandon this procedure.
FIGURE 2. Vertical banded gastroplasty.
whereas it generally occurs 2 to 3 years postoperatively with LAGB. Thus, early reports touting inferior weight loss with LAGB compared to RYGB have been challenged recently on the basis of longer follow-up. In a comparative trial of RYGB and LAGB, Jan et al5 reported similar percentages of excess weight loss (EWL) at 3 years (60% vs 57%). Nevertheless, RYGB is still considered the gold standard, having demonstrated sustained weight loss and reduction of comorbidities with long-term follow-up.6 Importantly, lessons learned from other purely restrictive procedures should be noted. For example, initial enthusiasm for VBG and other purely restrictive gastroplasties was dampened by long-term evaluations demonstrating poor outcomes and increased procedure-related complications.7 Whether the LAGB procedure will stand the test of time is yet to be determined. VERTICAL BANDED GASTROPLASTY Initially designed to avoid the complications of RYGB, VBG consists of a stapled proximal gastric pouch with a fixed (nonadjustable) outlet created by a mesh band or Silastic ring (Figure 2). Although restriction without the inherent risks of an anastomosis led to decreased perioperative morbidity and acceptable early weight loss compared to RYGB, results after longer follow-up have been discouraging. Several randomized trials have demonstrated inferior weight loss with VBG compared to RYGB.4,8 In a prospective randomized trial comparing laparoscopic RYGB to VBG, Olbers et al4 demonstrated improved EWL (84% vs 60%; P<.001) at 2 years with RYGB. The failure of VBG to provide sustained weight loss has been attributed to disruption of the gastroplasty or S20
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ROUX-EN-Y GASTRIC BYPASS Since its description in 1967 by Mason and Ito,12 gastric bypass has undergone several modifications. The initial procedure consisted of a jejunal loop brought up to a relatively large, horizontally oriented, undivided gastric pouch. Complications of bile reflux esophagitis, stomal ulceration, pouch enlargement, and gastro-gastric fistula prompted modifications including the use of a Roux limb, reduced pouch size, and vertically oriented and divided gastric pouch. The current RYGB technique uses a small proximal cardia pouch (10-30 mL) and a 75- to 150-cm Roux limb (Figure 3). Several techniques for constructing the gastrojejunostomy have been described, including hand-sewn or stapled (linear or circular stapler) approaches, each of which has advocates. The recommended length of the Roux limb varies, and each has several purported advantages. Shorter Roux limb lengths (75-100 cm) may allow future endoscopic access to the afferent limb and remnant stomach if necessary, whereas a longer Roux limb (150 cm) may improve weight loss in selected patients. Several randomized trials have evaluated the effect of Roux limb length on weight loss and nutritional sequelae.13-15 In patients with superobesity (body mass index [BMI], calculated as weight in kilograms divided by the square of height in meters, ≥50 kg/m2), a Roux limb of 150 cm results in increased weight loss compared to shorter limbs without apparent increased risk of nutritional complications.13,14 Conversely, in patients with a BMI less than 50 kg/m2, weight loss is unchanged with limb lengths between 50 and 150 cm, and a longer limb may increase the risk of internal hernia.13,14 The standard RYGB (Roux limb ≤150 cm) is generally considered maldigestive rather than globally malabsorptive. With limb lengths of 200 cm or more, evidence of malabsorption is apparent. In addition to its restrictive and maldigestive effects, RYGB results in alterations of the gastrointestinal
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FIGURE 3. Roux-en-Y gastric bypass.
neurohormonal response in both fasting and postprandial states. Advantages of RYGB include established long-term effectiveness for sustained weight loss, reduction of comorbidities, and minimal risk for long-term nutritional sequelae. The presence of dumping syndrome may have the benefit of reducing maladaptive eating patterns in some patients. Patients undergoing RYGB are less likely to require operative revision for complications or unsuccessful weight loss than are patients having VBG.9 An additional advantage of RYGB is its antireflux properties. Gastroesophageal reflux symptoms have been reported in more than 50% of obese patients.16,17 Among the currently available bariatric operations, only RYGB has consistently produced effective relief of GERD symptoms, with several authors reporting greater than 95% success in symptom resolution.18-20 Conversely, patients undergoing VBG are likely to develop new or worsened GERD symptoms.10 Therefore, patients with extreme obesity and predominant symptoms of GERD should undergo RYGB rather than other bariatric procedures.21 In the vast majority of series, RYGB has provided greater initial and sustained weight loss than that produced by purely restrictive operations such as VBG and LAGB. However, with an intermediate follow-up of 3 or more Mayo Clin Proc.
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FIGURE 4. Duodenal switch procedure. A, Greater curvature sleeve gastrectomy has been performed. B, Duodenoileostomy is constructed 250 cm from the ileocecal valve with a common channel of 100 cm.
years, LAGB may result in weight loss rates comparable to those obtained with RYGB.5 The need for long-term comparative studies of RYGB and LAGB is underscored by the results of a 10-year prospective, controlled, nonrandomized study in which EWL of 20% or more was sustained in only 28% of patients after gastric banding compared to 74% after RYGB.22 DUODENAL SWITCH First described as a bariatric operation by Hess and Hess,23 the DS was developed as a hybrid procedure combining the BPD reported by Scopinaro et al24 and the operation described by DeMeester et al.25 Although conceptualized to avoid the risk of stomal ulceration and dumping symptoms, large case series have reported a decreased incidence of severe protein-energy malnutrition with the DS technique compared to that reported with BPD. The procedure involves transection of the first portion of the duodenum with resection of the greater curvature of the stomach, leaving a 100- to 150-mL lesser curvature–based gastric sleeve with an intact antrum and pylorus (Figure 4, A). The proximal ileum is divided 250 cm from the ileocecal junction, and the biliopancreatic limb is anastomosed to the distal ileum creating a short (100 cm) common channel. A duodenoileostomy
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Other malabsorptive procedures represent modifications of RYGB, including long-limb RYGB, very, very long-limb RYGB (VVLL-RYGB), and distal RYGB. Each maintains the restrictive component of RYGB and essentially modifies the length of the common channel to promote malabsorptive, rather than predominantly maldigestive, physiology. Advantages of these procedures are similar to those of other malabsorptive operations. They may be most useful in superobese (BMI ≥50 kg/m2) patients in whom results with RYGB are less effective.28 These modifications of RYGB appear to improve weight loss but are associated with an increased risk of protein malnutrition, bone mineral disease, oxalate nephropathy, and diarrhea. The VVLL-RYGB consists of a common channel length of 100 cm, a small (<10 mL) gastric pouch, and a variable Roux limb length of 300 to 500 cm (Figure 5).29 At our institution, highly selected patients with a BMI of 50 kg/m2 or greater undergo either DS or VVLL-RYGB to enhance outcomes of weight loss and resolution of weight-related comorbidities. OPEN VS LAPAROSCOPIC APPROACHES FIGURE 5. Very, very long-limb Roux-en-Y gastric bypass consisting of a small (<10 mL) gastric pouch, variable Roux limb length (300500 cm), and a common channel of 100 cm.
is then constructed by bringing the Roux limb up to the gastric sleeve (Figure 4, B). The lengths of the common channel and Roux limb are either based on a percentage of the total bowel length23 or configured at a standard 100- and 150-cm length, respectively.26 Advantages of DS include reduced stomal complications, absence of dumping, and excellent long-term maintenance of weight loss. To date, no randomized trials have compared DS with RYGB or LAGB. However, large series have reported excellent outcomes with DS, exceeding those typically reported for RYGB or LAGB in percentage of EWL and resolution of comorbidities. In a large meta-analysis, Buchwald et al27 reported EWL of 47%, 62%, and 70% and resolution of diabetes in 48%, 84%, and 98% of patients after LAGB, RYGB, and BPD with or without DS, respectively. OTHER MALABSORPTIVE PROCEDURES Several additional malabsorptive procedures merit brief discussion. The BPD described by Scopinaro24 is a malabsorptive (short common channel) procedure combined with a distal gastrectomy that is capable of producing marked and sustained weight loss. However, the increased incidence of stomal ulceration, severe proteinenergy malnutrition, diarrhea, and dumping has limited its broad acceptance. S22
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Minimally invasive approaches to bariatric surgery have contributed substantially to the acceptability of operative intervention for obesity. Despite the expanding epidemic of obesity and the National Institutes of Health 1991 consensus statement endorsing bariatric procedures, the number of bariatric operations performed annually in the 1990s pales in comparison to the more than 170,000 operations performed in 2005. Wittgrove et al30 reported the first series of 5 patients who underwent laparoscopic RYGB in 1994. Since that time, the volume of bariatric procedures performed in the United States has increased substantially. The prevalence of obesity and thus the need for bariatric operations have increased dramatically during the past decade, and the advent of minimally invasive techniques has increased the acceptance of bariatric surgery by both patients and the medical community. The need for minimally invasive approaches is underscored by the high incidence of wound complications (infection or hernia) after open bariatric procedures. Three randomized prospective trials that compared laparoscopic with open RYGB showed reduced blood loss, narcotic requirement, hospital stay, and wound complications with the laparoscopic approach.31-33 In a 3-year follow-up of the randomized study by Nguyen et al,31 the authors reported a substantial reduction in the incidence of incisional herniae after laparoscopic RYGB (5%) compared to open RYGB (39%).34 Conversely, the incidence of anastomotic complications after laparoscopic RYGB appears to be greater than that associated with open approaches.
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Laparoscopic approaches also reduce adhesion formation, potentially decreasing the incidence of adhesive bowel obstruction. However, during RYGB, multiple transmesenteric or intermesenteric defects are created in which internal herniae may develop and cause partial or even closed-loop obstruction (Figure 6). Although internal herniae can occur after open RYGB, they are exceedingly rare. Closure of these defects after either approach is important to prevent this potentially life-threatening complication.35 Antecolic routing of the Roux limb has been advocated to prevent formation of a mesocolic hernia defect (Figure 6, A), but suture fixation of the Roux limb where it traverses the mesocolon can obviate herniae at this site. ON THE HORIZON Several new or revised operative strategies are emerging for the treatment of obesity. Endoscopic approaches include plication techniques to create proximal gastric restriction, either primarily or as revision of stomal dilation after RYGB. With the emergence of natural orifice translumenal endoscopic surgery, the technique of endoscopic gastrojejunostomy may lead to potential endoscopic interventions for obesity.36 The use of electrical stimulation in the treatment of obesity is under investigation. Implantable gastric stimulators have been shown to result in EWL as high as 25%.37 Recently, a novel approach involving direct vagal nerve modulation to control gastric and pancreatic physiology was described.38 By using high-frequency electrical vagal blockade, reversible inhibition of pancreatic exocrine secretion and gastric contractions has been observed, suggesting potential for this novel intervention in the treatment of obesity. Laparoscopic sleeve gastrectomy represents a new purely restrictive procedure in the treatment of obesity. This technique consists of the restrictive component of the DS, a resection of the greater curvature of the stomach over a 45- to 50-F bougie positioned along the lesser curvature (Figure 4, A). The antrum and pylorus are preserved, resulting in a lesser curvature–based “restrictive” gastric sleeve. Early reports of sleeve gastrectomy have shown substantial weight loss with a low perioperative complication rate. It has been suggested for use as a primary operation or as part of a staged bariatric procedure for highest-risk obese patients.39-41
FIGURE 6. Defects created by Roux-en-Y gastric bypass in which internal herniae may develop. Sites where mesocolic (A), mesenteric-mesocolic (Petersen) (B), and mesenteric (C) herniae may develop are shown.
dure and approach. Both patients and surgeons must balance the advantages, risks, adverse effects, and long-term results when selecting the appropriate procedure. The very existence of multiple “accepted” procedures refutes the concept of one “best procedure” for the treatment of obesity. Although data are currently insufficient to predict which procedure is most appropriate for a particular patient, several patient-related factors, such as eating behaviors, BMI, previous operations, and specific weight-related comorbidities, may influence procedure selection. Patients classified as superobese are less likely to achieve and maintain an EWL of 50% or more with restrictive procedures or RYGB than with malabsorptive operations. As a result, several bariatric centers, including the Mayo Clinic, typically recommend malabsorptive procedures for compliant, well-informed patients with a BMI of 50 kg/m2 or greater.
PROCEDURE SELECTION Several factors influence the selection of the type of bariatric procedure for each patient. With the increasing level of awareness and education of the public regarding bariatric operations, patients often request a particular proceMayo Clin Proc.
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SUMMARY Until successful nonoperative methods for the treatment of obesity emerge, surgery remains the mainstay of therapy for extreme obesity. Several operations are currently avail-
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able, each with advantages and disadvantages that require careful patient selection to ensure the optimal outcome and patient satisfaction. Additional minimally invasive procedures are on the horizon for the treatment of obesity, with the hope that they will improve operative risks, patient satisfaction, and long-term outcomes. REFERENCES 1. Griffen WO Jr, Bivins BA, Bell RM. The decline and fall of the jejunoilieal bypass. Surg Gynecol Obestet. 1983;157:301-308. 2. National Institutes of Health Consensus Development Conference. Gastrointestinal surgery for severe obesity. Am J Clin Nutr. 1992;55(2, suppl): 487S-619S. 3. Chapman AE, Kiroff G, Game P, et al. Laparoscopic adjustable gastric banding in the treatment of obesity: a systematic literature review. Surgery. 2004;135:326-351. 4. Olbers T, Fagevik-Olsen M, Maleckas A, Lonroth H. Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic vertical banded gastroplasty for obesity. Br J Surg. 2005;92:557-562. 5. Jan JC, Hong D, Pereira N, Patterson EJ. Laparoscopic adjustable gastric banding versus laparoscopic gastric bypass for morbid obesity: a single-institution comparison study of early results. J Gastrointest Surg. 2005;9:30-39. 6. Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases longterm mortality, morbidity, and health care use in morbidly obese patients. Ann Surg. 2004;240:416-423. 7. Balsiger BM, Poggio JL, Mai J, Kelly KA, Sarr MG. Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity. J Gastrointest Surg. 2000;4:598-605. 8. Howard L, Malone M, Michalek A, Carter J, Alger S, Van Woert J. Gastric bypass and vertical banded gastroplasty—a prospective randomized comparison and 5-year follow-up. Obes Surg. 1995;5:55-60. 9. van Gemert WG, van Wersch MM, Greve JW, Soeters PB. Revisional surgery after failed vertical banded gastroplasty: restoration of vertical banded gastroplasty or conversion to gastric bypass. Obes Surg. 1998;8:21-28. 10. Balsiger BM, Murr MM, Mai J, Sarr MG. Gastroesophageal reflux after intact vertical banded gastroplasty: correction by conversion to Roux-en-Y gastric bypass. J Gastrointest Surg. 2000;4:276-281. 11. van Dielen FM, Soeters PB, de Brauw LM, Greve JW. Laparoscopic adjustable gastric banding versus open vertical banded gastroplasty: a prospective randomized trial. Obes Surg. 2005;15:1292-1298. 12. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967; 47:1345-1351. 13. Choban PS, Flancbaum L. The effect of Roux limb lengths on outcome after Roux-en-Y gastric bypass: a prospective, randomized clinical trial. Obes Surg. 2002;12:540-545. 14. Inabnet WB, Quinn T, Gagner M, Urban M, Pomp A. Laparoscopic Roux-en-Y gastric bypass in patients with BMI <50: a prospective randomized trial comparing short and long limb lengths. Obes Surg. 2005;15:51-57. 15. Brolin RE, Kenler HA, Gorman JH, Cody RP. Long-limb gastric bypass in the superobese: a prospective randomized study. Ann Surg. 1992;215:387-395. 16. Suter M, Dorta G, Giusti V, Calmes JM. Gastro-esophageal reflux and esophageal motility disorders in morbidly obese patients. Obes Surg. 2004;14: 959-966. 17. Murray L, Johnston B, Lane A, et al. Relationship between body mass and gastro-oesophageal reflux symptoms: the Bristol Helicobacter Project. Int J Epidemiol. 2003;32:645-650. 18. Frezza EE, Ikramuddin S, Gourash T, et al. Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-enY gastric bypass. Surg Endosc. 2002 Jul;16:1027-1031. Epub 2002 May 3.
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19. Jones KB Jr, Allen TV, Manas KJ, McGuinty DP, Wilder WM, Wadsworth ED. Roux-Y gastric bypass: an effective anti-reflux procedure. Obes Surg. 1991;1:295-298. 20. Smith SC, Edwards CB, Goodman GN. Symptomatic and clinical improvement in morbidly obese patients with gastroesophageal reflux disease following Roux-en-Y gastric bypass. Obes Surg. 1997;7:479-484. 21. Kendrick ML, Houghton SG. Gastroesophageal reflux disease in obese patients: the role of obesity in management. Dis Esophagus. 2006;19:57-63. 22. Sjostrom L, Lindroos AK, Peltonen M, et al, Swedish Obese Subjects Study Scientific Group. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351:2683-2693. 23. Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg. 1998;8:267-282. 24. Scopinaro N, Gianetta E, Civalleri D, Bonalumi U, Bachi V. Biliopancreatic bypass for obesity, II: initial experience in man. Br J Surg. 1979; 66:618-620. 25. DeMeester TR, Fuchs KH, Ball CS, Albertucci M, Smyrk TC, Marcus JN. Experimental and clinical results with proximal end-to-end duodenojejunostomy for pathologic duodenogastric reflux. Ann Surg. 1987;206:414426. 26. Marceau P, Hould FS, Simard S, et al. Biliopancreatic diversion with duodenal switch. World J Surg. 1998;22:947-954. 27. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724-1737. 28. MacLean LD, Rhode BM, Nohr CW. Late outcome of isolated gastric bypass. Ann Surg. 2000;231:524-528. 29. Nelson WK, Fatima J, Houghton SG, et al. The malabsorptive very, very long limb Roux-en-Y gastric bypass for super obesity: results in 257 patients. Surgery. In press. 30. Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg. 1994;4:353-357. 31. Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg. 2001;234:279-289. 32. Westling A, Gustavsson S. Laparoscopic vs open Roux-en-Y gastric bypass: a prospective, randomized trial. Obes Surg. 2001;11:284-292. 33. Lujan, JA, Frutos MD, Hernandez Q, et al. Laparoscopic versus open gastric bypass in the treatment of morbid obesity: a randomized prospective study. Ann Surg. 2004;239:433-437. 34. Puzziferri N, Austrheim-Smith IT, Wolfe FM, Wilson SE, Nguyen NT. Three-year follow-up of a prospective randomized trial comparing laparoscopic versus open gastric bypass. Ann Surg. 2006;243:181-188. 35. Comeau E, Gagner M, Inabnet WB, Herron DM, Quinn TM, Pomp A. Symptomatic internal hernias after laparoscopic bariatric surgery. Surg Endosc. 2005 Jan;19:34-39. Epub 2004 Nov 11. 36. Kantsevoy SV, Jagannath SB, Niiyama H, et al. Endoscopic gastrojejunostomy with survival in a porcine model. Gastrointest Endosc. 2005;62:287292. 37. Cigaina V. Long-term follow-up of gastric stimulation for obesity: the Mestre 8-year experience. Obes Surg. 2004;14:S14-S22. 38. Tweden KS, Sarr MG, Camilleri M, et al. Vagal blocking for obesity control (VBLOC): studies of pancreatic and gastric function and safety in a porcine model [abstract]. Surg Obes Rel Dis. 2006;2:301. Abstract 46. 39. Regan JP, Inabnet WB, Gagner M, Pomp A. Early experience with twostage laparoscopic Roux-en-Y gastric bypass as an alternative in the supersuper obese patient. Obes Surg. 2003;13:861-864. 40. Moon Han S, Kim WW, Oh JH. Results of laparoscopic sleeve gastrectomy (LSG) at 1 year in morbidly obese Korean patients. Obes Surg. 2005; 15:1469-1475. 41. Baltasar A, Serra C, Perez N, Bou R, Bengochea M, Ferri L. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg. 2005;15:1124-1128.
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