Bariatric Surgery
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Obesity is a major health problem worldwide and has reached an epidemic proportion in the Western society. Evidence continues to accumulate that obesity is a major risk factor for many diseases and is associated with significant morbidity and mortality.
The most widely accepted measure of obesity is the body mass index (BMI). This number is calculated by dividing a patient’s mass (kg) by his or her height (m2). A normal BMI is considered in the range of 18.5-24.9 kg/m2. A BMI of 25-29.9 kg/m2 is considered overweight. A BMI of 30 kg/m2 or greater is classified as obese; this classification is further subdivided into class I, II, or III obesity.
Considering other factors (eg, total muscle mass, waist circumference) besides the BMI may be important. For example, an extremely muscular individual may have an elevated BMI without being considered overweight. Waist circumference has been shown to be an excellent indicator of abdominal fat mass. A circumference of greater than 88 cm (35 in.) in women or greater than 102 cm (40 in.) in men strongly correlates with an increased risk of obesity-related disease.
Bariatric surgery is currently the only modality that provides a significant, sustained weight loss for morbidly obese patients, with resultant improvement in obesity-related comorbidities. A prospective, controlled Swedish study involving 4047 obese patients, half of whom had undergone bariatric procedures, followed up over 14.7 years, found that compared to usual care, bariatric surgery was associated with a significantly reduced number of cardiovascular deaths and a lower incidence of cardiovascular events in obese adults. [1]
In 1954, Kremen and Linner introduced jejunoileal bypass, the first effective surgery for obesity in the United States. In this procedure, the proximal jejunum was connected directly to the distal ileum, bypassing 90% of the small intestine out of the intestinal stream of ingested nutrients (blind loop). The procedure induced a state of malabsorption, which led to significant weight loss.
However, many patients developed complications secondary to malabsorption (eg, steatorrhea, diarrhea, vitamin deficiencies, oxalosis) or due to the toxic overgrowth of bacteria in the bypassed intestine (eg, liver failure, severe arthritis, skin problems). Consequently, many patients have required reversal of the procedure, and the procedure has been abandoned. This led to a search for better operations.
Modifications in the original procedures and the development of new techniques led to the following three basic concepts for bariatric surgery (see Surgical Therapy):
In recent years, the field of bariatric surgery has been enriched by data from numerous clinical investigations and experience. The direction of future clinical investigations are proceeding in a number of directions, including the following:
For patient education resources, see the Healthy Living Center, as well as Obesity and Surgery in the Treatment of Obesity.
Obesity occurs as the result of an imbalance between energy expenditure and caloric intake. This imbalance has been thought to be under genetic and environmental influence. The discovery of immunologic abnormalities in obesity that are related to the leptin-proopiomelanocortin system and elevated tumor necrosis factor alpha (TNF-α) brought a new perspective to the understanding of obesity.
Leptin (from Greek leptos, “thin”) is a hormone made primarily in adipocytes. The circulating leptin levels reflect the amount of stored body fat. Leptin is a negative feedback signal that acts on the hypothalamus to alter the expression of several neuroendocrine peptides that regulate energy intake and expenditure. Central resistance to leptin is a prominent feature of obesity.
Increased leptin levels in individuals who are obese are independent of the lipid profile but strongly correlate with the BMI. Leptin exhibits direct effects on monocytes that results in secretion of the interleukin (IL)-1 receptor antagonist (IL-1RA). This cytokine antagonist has anti-inflammatory properties. Although leptin treatment works very well in patients who are leptin-deficient, the use of leptin in patients who are obese and who already have high levels of leptin has shown limited efficacy.
Obesity is a complex, multifactorial chronic disease influenced by the interaction of several factors, such as genetic, endocrine, metabolic, environmental (social and cultural), behavioral, and psychological components. The basic mechanism involves energy intake that exceeds energy output.
The number of overweight individuals in the world is estimated at 1.7 billion. In the United States, the problem is at epidemic proportions. As much as two thirds of the population in the United States is overweight, and half of the people in this group can be classified as obese.
The Swedish Obese Subjects (SOS) study is an ongoing, prospective study of 2010 obese participants who underwent bariatric surgery and 2037 obese patients who received usual care in the primary health care system. Compared to the control group, obese adults who underwent surgery experienced a reduced number of cardiovascular deaths and a lower incidence of heart attack and stroke. [1, 2] A 2017 report from the SOS group found that bariatric surgery reduced the long-term incidence of female-specific cancer, particularly endometrial cancer. [3]
Low back pain is a common complaint among obese patients. A retrospective study of morbidly obese patients who underwent bariatric surgery found that patients experienced a significant decrease in low back and radicular pain after surgery, which led to improvements in quality of life. Patients also experienced a marked increase in the L4-5 intervertebral disc height. [4]
An Australian study by Keating et al compared the results of weight-loss treatments in patients who had been diagnosed with type 2 diabetes mellitus in class I/II obesity, estimating the lifetime costs and quality-adjusted life-years (QALYs) for individuals who had undergone surgically induced weight loss and for patients who had utilized conventional weight loss treatment. [5]
In this study, the mean duration of diabetes remission over a lifetime was 11.4 years in the surgical therapy group and 2.1 years in the conventional therapy group. [5] Over the remainder of their lifetime, surgical therapy patients lived 15.7 discounted QALYs, compared with 14.5 discounted QALYs for conventional therapy patients. Mean discounted lifetime costs were AUD $98,900 per surgical therapy patient and AUD $101,400 per conventional therapy patient (AUD $1 = USD $0.74). Compared with conventional therapy, surgical therapy yielded a mean healthcare saving of AUD $2400 and 1.2 additional QALYs per patient.
In another study, Keating et al looked at the within-trial cost efficacy, over 2 years, of surgical treatment relative to that of conventional therapy for achieving remission in patients recently diagnosed with type 2 diabetes mellitus with class I/II obesity. [6] Trial intervention costs included gastric banding surgery, mitigation of complications, outpatient medical consultations, medical investigations, pathology, weight-loss therapies, and medication.
An incremental cost-effectiveness analysis demonstrated that the mean 2-year intervention costs per patient were Au $13,400 for surgical therapy and Au $3400 for conventional therapy; laparoscopic adjustable gastric band (LAGB) surgery was responsible for 85% of the difference. [6] For surgical patients, outpatient medical consultation costs were threefold greater than those for conventional patients, but medication costs were 1.5 times higher for patients who underwent conventional therapy. The cost differences occurred primarily in the trial’s first 6 months. In relation to conventional treatment, the incremental cost-effectiveness ratio for surgical therapy was Au $16,600 per case of diabetes remitted.
An updated Cochrane review from 2014 that included 22 trials with 1798 participants concluded that surgical treatment of obesity yielded greater improvement in weight loss and weight-associated comorbidities than nonsurgical interventions did, regardless of the type of procedure, [7] though certain procedures were associated with greater weight loss and fewer comorbidities than others.
In this review, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy had comparable outcomes, and both had better outcomes than adjustable gastric banding. [7] In very-high-BMI patients, biliopancreatic diversion with duodenal switch yielded better weight loss than RYGB did. Outcomes were comparable for duodenojejunal bypass with sleeve gastrectomy and laparoscopic RYGB. Isolated sleeve gastrectomy led to better weight loss than adjustable gastric banding. Weight-related outcomes were similar for laparoscopic gastric imbrication and laparoscopic sleeve gastrectomy.
In general, with all 22 studies taken into account, rates of adverse events and reoperation were not well reported. [7] Because the follow-up period in most of the trials reviewed was only 1 or 2 years, the long-term effects of bariatric surgery could not be definitively established.
A study by Jakobsen et al assessed obesity-related comorbidities in 1888 severely obese patients undergoing either bariatric surgery (n = 932; 92 gastric bypass) or specialized medical treatment (n = 956). [8] Median follow-up was 6.5 years (range, 0.2-10.1 years). Surgical patients were more likely to experience remission and diabetes remission and were less likely to experience new-onset hypertension; however, they also had a greater risk of new-onset depression and treatment with opioids and were more likely to undergo at least one additional GI surgical procedure.
Ikramuddin et al evaluated lifestyle intervention and medical management with (n = 60) and without RYGB (n = 60) for achieving control of type 2 diabetes (composite triple end point: HbA1c < 7.0%, LDL cholesterol < 100 mg/dL, systolic blood pressure < 130 mm Hg). [9] Of the 120 patients, 98 completed 5-year follow-up. At 5 years, there remained a significantly better composite triple end point in the surgical group; however, the effect size diminished over 5 years, indicating the need for further follow-up to better define the durability of the improvement.
Sjöström L, Peltonen M, Jacobson P, Sjöström CD, Karason K, Wedel H, et al. Bariatric surgery and long-term cardiovascular events. JAMA. 2012 Jan 4. 307 (1):56-65. [Medline].
Romeo S, Maglio C, Burza MA, Pirazzi C, Sjöholm K, Jacobson P, et al. Cardiovascular events after bariatric surgery in obese subjects with type 2 diabetes. Diabetes Care. 2012 Dec. 35 (12):2613-7. [Medline].
Anveden Å, Taube M, Peltonen M, Jacobson P, Andersson-Assarsson JC, Sjöholm K, et al. Long-term incidence of female-specific cancer after bariatric surgery or usual care in the Swedish Obese Subjects Study. Gynecol Oncol. 2017 May. 145 (2):224-229. [Medline].
Lidar Z, Behrbalk E, Regev GJ, Salame K, Keynan O, Schweiger C, et al. Intervertebral disc height changes after weight reduction in morbidly obese patients and its effect on quality of life and radicular and low back pain. Spine (Phila Pa 1976). 2012 Nov 1. 37 (23):1947-52. [Medline].
Keating CL, Dixon JB, Moodie ML, Peeters A, Bulfone L, Maglianno DJ, et al. Cost-effectiveness of surgically induced weight loss for the management of type 2 diabetes: modeled lifetime analysis. Diabetes Care. 2009 Apr. 32 (4):567-74. [Medline].
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Jakobsen GS, Småstuen MC, Sandbu R, Nordstrand N, Hofsø D, Lindberg M, et al. Association of Bariatric Surgery vs Medical Obesity Treatment With Long-term Medical Complications and Obesity-Related Comorbidities. JAMA. 2018 Jan 16. 319 (3):291-301. [Medline].
Ikramuddin S, Korner J, Lee WJ, Thomas AJ, Connett JE, Bantle JP, et al. Lifestyle Intervention and Medical Management With vs Without Roux-en-Y Gastric Bypass and Control of Hemoglobin A1c, LDL Cholesterol, and Systolic Blood Pressure at 5 Years in the Diabetes Surgery Study. JAMA. 2018 Jan 16. 319 (3):266-278. [Medline].
[Guideline] Nobili V, Vajro P, Dezsofi A, Fischler B, Hadzic N, Jahnel J, et al. Indications and limitations of bariatric intervention in severely obese children and adolescents with and without nonalcoholic steatohepatitis: ESPGHAN Hepatology Committee Position Statement. J Pediatr Gastroenterol Nutr. 2015 Apr. 60 (4):550-61. [Medline].
[Guideline] Rubino F, Nathan DM, Eckel RH, Schauer PR, Alberti KG, Zimmet PZ, et al. Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. Diabetes Care. 2016 Jun. 39 (6):861-77. [Medline].
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Lee WJ, Lee KT, Ser KH, Chen JC, Tsou JJ, Lee YC. Laparoscopic adjustable gastric banding (LAGB) with gastric plication: short-term results and comparison with LAGB alone and sleeve gastrectomy. Surg Obes Relat Dis. 2015 Jan-Feb. 11 (1):125-30. [Medline].
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Himpens J, Dapri G, Cadière GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg. 2006 Nov. 16 (11):1450-6. [Medline].
Lee CM, Cirangle PT, Jossart GH. Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results. Surg Endosc. 2007 Oct. 21 (10):1810-6. [Medline].
Cottam D, Qureshi FG, Mattar SG, Sharma S, Holover S, Bonanomi G, et al. Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc. 2006 Jun. 20 (6):859-63. [Medline].
Hamoui N, Anthone GJ, Kaufman HS, Crookes PF. Sleeve gastrectomy in the high-risk patient. Obes Surg. 2006 Nov. 16 (11):1445-9. [Medline].
Silecchia G, Boru C, Pecchia A, Rizzello M, Casella G, Leonetti F, et al. Effectiveness of laparoscopic sleeve gastrectomy (first stage of biliopancreatic diversion with duodenal switch) on co-morbidities in super-obese high-risk patients. Obes Surg. 2006 Sep. 16 (9):1138-44. [Medline].
Himpens J, Dapri G, Cadière GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg. 2006 Nov. 16 (11):1450-6. [Medline].
Baltasar A, Serra C, Pérez N, Bou R, Bengochea M, Ferri L. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg. 2005 Sep. 15 (8):1124-8. [Medline].
Roa PE, Kaidar-Person O, Pinto D, Cho M, Szomstein S, Rosenthal RJ. Laparoscopic sleeve gastrectomy as treatment for morbid obesity: technique and short-term outcome. Obes Surg. 2006 Oct. 16 (10):1323-6. [Medline].
Langer FB, Bohdjalian A, Felberbauer FX, Fleischmann E, Reza Hoda MA, Ludvik B, et al. Does gastric dilatation limit the success of sleeve gastrectomy as a sole operation for morbid obesity?. Obes Surg. 2006 Feb. 16 (2):166-71. [Medline].
Melissas J, Koukouraki S, Askoxylakis J, Stathaki M, Daskalakis M, Perisinakis K, et al. Sleeve gastrectomy: a restrictive procedure?. Obes Surg. 2007 Jan. 17 (1):57-62. [Medline].
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Milone L, Strong V, Gagner M. Laparoscopic sleeve gastrectomy is superior to endoscopic intragastric balloon as a first stage procedure for super-obese patients (BMI > or =50). Obes Surg. 2005 May. 15 (5):612-7. [Medline].
Moy J, Pomp A, Dakin G, Parikh M, Gagner M. Laparoscopic sleeve gastrectomy for morbid obesity. Am J Surg. 2008 Nov. 196 (5):e56-9. [Medline].
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American Society for Metabolic and Bariatric Surgery – Statements, Guidelines, Action Items. Available at http://www.asmbs.org/Newsite07/resources/asmbs_items.htm. Accessed: 5/24/2009.
Hutter MM, Schirmer BD, Jones DB, Ko CY, Cohen ME, Merkow RP, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011 Sep. 254 (3):410-20; discussion 420-2. [Medline].
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de Zwaan M, Georgiadou E, Stroh CE, Teufel M, Köhler H, Tengler M, et al. Body image and quality of life in patients with and without body contouring surgery following bariatric surgery: a comparison of pre- and post-surgery groups. Front Psychol. 2014. 5:1310. [Medline].
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Ungaro R, Fausel R, Chang HL, Chang S, Chen LA, Nakad A, et al. Bariatric surgery is associated with increased risk of new-onset inflammatory bowel disease: case series and national database study. Aliment Pharmacol Ther. 2018 Apr. 47 (8):1126-1134. [Medline].
Alan A Saber, MD, MS, FACS, FASMBS Director of Bariatric and Metabolic Surgery, University Hospitals Case Medical Center; Surgical Director, Bariatric Surgery, Metabolic and Nutrition Center, University Hospitals Digestive Health Institute; Associate Professor of Surgery, Case Western Reserve University School of Medicine
Alan A Saber, MD, MS, FACS, FASMBS is a member of the following medical societies: American College of Surgeons, American Society for Gastrointestinal Endoscopy, American Society for Metabolic and Bariatric Surgery
Disclosure: Nothing to disclose.
Tarek H El-Ghazaly, MD Fellow of Minimally Invasive and Bariatric Surgery Research, Michigan State University, Kalamazoo Center for Medical Studies
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
John Geibel, MD, DSc, MSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow
John Geibel, MD, DSc, MSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract
Disclosure: Nothing to disclose.
Brian J Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine
Brian J Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, Southern Surgical Association, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, Tennessee Medical Association
Disclosure: Nothing to disclose.
We wish to thank Ollie J Jackson III, MD, Department of General Surgery, Michigan State University, Kalamazoo Center for Medical Studies, for previous contributions to this entry.
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