Bariatric Surgery 

  • Author: Alan A Saber, MD, MS, FACS, FASMBS; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Jan 31, 2012
 

Background

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.

Bariatric surgery is currently the only modality that provides a significant, sustained weight loss for the patient who is morbidly obese, with resultant improvement in obesity-related comorbidities.

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History of the Procedure

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 have led to 3 basic concepts for bariatric surgery: (1) gastric restriction (adjustable gastric banding, sleeve gastrectomy), (2) gastric restriction with mild malabsorption (Roux-en-Y gastric bypass), and (3) a combination of mild gastric restriction and malabsorption (duodenal switch). (See images below.)

Adjustable gastric banding. Adjustable gastric banding. Sleeve gastrectomy. Sleeve gastrectomy. Laparoscopic Roux-en-Y gastric bypass. Laparoscopic Roux-en-Y gastric bypass. Long Roux-en-Y gastric bypass. Long Roux-en-Y gastric bypass. Biliopancreatic diversion with duodenal switch. Biliopancreatic diversion with duodenal switch.
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Problem

The most widely accepted measure of obesity is the body mass index (BMI). This number is calculated by dividing a patient's mass (in kilograms) by his or her height (in meters, squared). 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.

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Epidemiology

Frequency

The number of overweight individuals in the world is estimated at 1.7 billion. In the United States, the problem is at epidemic proportions. Up to two thirds of the population in the United States is overweight, and half of the people in this group can be classified as obese.

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Etiology

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 occurs when energy intake exceeds energy output.

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Pathophysiology

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 immunological abnormalities in obesity that are related to the leptin-proopiomelanocortin system and elevated tumor necrosis factor-alpha brought a new perspective to the understanding of obesity.

Leptin is a hormone made primarily in adipocytes. Leptin is from the Greek word leptos, for thin. 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-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.

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Presentation

Morbid obesity is the harbinger of many other diseases that affect essentially every organ system.

  • Cardiovascular (eg, hypertension, atherosclerotic heart and peripheral vascular disease with myocardial infarction and cerebral vascular accidents, peripheral venous insufficiency, thrombophlebitis, pulmonary embolism)
  • Respiratory (eg, asthma, obstructive sleep apnea, obesity-hypoventilation syndrome)
  • Metabolic (eg, type 2 diabetes, impaired glucose tolerance, hyperlipidemia)
  • Musculoskeletal (eg, back strain; disc disease; weightbearing osteoarthritis of the hips, knees, ankles, and feet)
  • Gastrointestinal (eg, cholelithiasis, gastroesophageal reflux disease, nonalcoholic fatty liver disease [steatosis steatohepatitis], hepatic cirrhosis, hepatic carcinoma, colorectal carcinoma)
  • Urologic (eg, stress incontinence)
  • Endocrine and reproductive (eg, polycystic ovary syndrome, increased risk of pregnancy and fetal abnormalities, male hypogonadism)
  • Cancer of the endometrium, breast, ovary, prostate, and pancreas
  • Dermatologic (eg, intertriginous dermatitis)
  • Neurologic (eg, pseudotumor cerebri, carpal tunnel syndrome)
  • Psychologic (eg, depression, eating disorders, body image disturbance)
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Indications

Surgery for obesity should be considered as a treatment of last resort after dieting, exercise, psychotherapy, and drug treatments have failed.

Developed at the 1991 National Institutes of Health (NIH) Consensus Development Conference Panel, the generally accepted criteria for surgical treatment include a BMI of greater than 40 kg/m2 or a BMI of greater than 35 kg/m2 in combination with high-risk comorbid conditions, such as sleep apnea, Pickwickian syndrome, diabetes mellitus, or degenerative joint disease.

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Contraindications

Contraindications to bariatric surgery include illnesses that greatly reduce life expectancy and are unlikely to be improved with weight reduction, including advanced cancer and end-stage renal, hepatic, and cardiopulmonary disease.

Patients who are unable to understand the nature of bariatric surgery or the behavioral changes required afterward, including untreated schizophrenia, active substance abuse, and noncompliance with previous medical care, are also considered contraindications to bariatric surgery.

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Contributor Information and Disclosures
Author

Alan A Saber, MD, MS, FACS, FASMBS  Associate Professor of Surgery, Case Western Reserve University School of Medicine; Director of Metabolic Surgery, Case Medical Center

Alan A Saber, MD, MS, FACS, FASMBS is a member of the following medical societies: American College of Surgeons, American Society for Gastrointestinal Endoscopy, and American Society for Metabolic and Bariatric Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

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.

Specialty Editor Board

Brian James 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 James Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association

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: Medscape Salary Employment

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA 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, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

Additional Contributors

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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Laparoscopic Roux-en-Y gastric bypass.
Adjustable gastric banding.
Sleeve gastrectomy.
Long Roux-en-Y gastric bypass.
Biliopancreatic diversion with duodenal switch.
Progression of surgical techniques, with open surgery in the first image and single-incision, transumbilical laparoscopic surgery in the third illustration.
 
 
 
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