eMedicine Specialties > General Surgery > Abdomen

Bariatric Surgery

Author: Alan A Saber, MD, MS, FACS, Chief, Minimally Invasive Surgery and Bariatric Surgery, Associate Professor, Department of Surgery, Michigan State University
Coauthor(s): Tarek H El-Ghazaly, MD, Fellow of Minimally Invasive and Bariatric Surgery Research, Michigan State University, Kalamazoo Center for Medical Studies
Contributor Information and Disclosures

Updated: May 26, 2009

Introduction

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.

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 and Images 1-5.)

Adjustable gastric banding.

Adjustable gastric banding.

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Adjustable gastric banding.

Adjustable gastric banding.



Sleeve gastrectomy.

Sleeve gastrectomy.

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Sleeve gastrectomy.

Sleeve gastrectomy.



Laparoscopic Roux-en-Y gastric bypass.

Laparoscopic Roux-en-Y gastric bypass.

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Laparoscopic Roux-en-Y gastric bypass.

Laparoscopic Roux-en-Y gastric bypass.



Long Roux-en-Y gastric bypass.

Long Roux-en-Y gastric bypass.

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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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Biliopancreatic diversion with duodenal switch.

Biliopancreatic diversion with duodenal switch.

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.

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.

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.

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.

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)

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.

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.

More on Bariatric Surgery

Overview: Bariatric Surgery
Workup: Bariatric Surgery
Treatment: Bariatric Surgery
Follow-up: Bariatric Surgery
Multimedia: Bariatric Surgery
References
Further Reading
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References

  1. MacLean LD, Rhode BM, Nohr CW. Late outcome of isolated gastric bypass. Ann Surg. Apr 2000;231(4):524-8. [Medline].

  2. Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic Gastric Bypass, Roux-en-Y: Preliminary Report of Five Cases. Obes Surg. Nov 1994;4(4):353-357. [Medline].

  3. Higa KD, Ho T, Boone KB. Laparoscopic Roux-en-Y gastric bypass: technique and 3-year follow-up. J Laparoendosc Adv Surg Tech A. Dec 2001;11(6):377-82. [Medline].

  4. Regan JP, Inabnet WB, Gagner M, et al. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg. Dec 2003;13(6):861-4. [Medline].

  5. 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. Nov 2006;16(11):1450-6. [Medline].

  6. Lee CM, Cirangle PT, Jossart GH. Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results. Surg Endosc. Oct 2007;21(10):1810-6. [Medline].

  7. Cottam D, Qureshi FG, Mattar SG, Sharma S, Holover S, Bonanomi G. Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc. Jun 2006;20(6):859-63. [Medline].

  8. Hamoui N, Anthone GJ, Kaufman HS, Crookes PF. Sleeve gastrectomy in the high-risk patient. Obes Surg. Nov 2006;16(11):1445-9. [Medline].

  9. Silecchia G, Boru C, Pecchia A, Rizzello M, Casella G, Leonetti F. Effectiveness of laparoscopic sleeve gastrectomy (first stage of biliopancreatic diversion with duodenal switch) on co-morbidities in super-obese high-risk patients. Obes Surg. Sep 2006;16(9):1138-44. [Medline].

  10. 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. Nov 2006;16(11):1450-6. [Medline].

  11. Baltasar A, Serra C, Pérez N, Bou R, Bengochea M, Ferri L. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg. Sep 2005;15(8):1124-8. [Medline].

  12. 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. Oct 2006;16(10):1323-6. [Medline].

  13. Langer FB, Bohdjalian A, Felberbauer FX, Fleischmann E, Reza Hoda MA, Ludvik B. Does gastric dilatation limit the success of sleeve gastrectomy as a sole operation for morbid obesity?. Obes Surg. Feb 2006;16(2):166-71. [Medline].

  14. Melissas J, Koukouraki S, Askoxylakis J, Stathaki M, Daskalakis M, Perisinakis K. Sleeve gastrectomy: a restrictive procedure?. Obes Surg. Jan 2007;17(1):57-62. [Medline].

  15. Almogy G, Crookes PF, Anthone GJ. Longitudinal gastrectomy as a treatment for the high-risk super-obese patient. Obes Surg. Apr 2004;14(4):492-7. [Medline].

  16. 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. May 2005;15(5):612-7. [Medline].

  17. Moy J, Pomp A, Dakin G, Parikh M, Gagner M. Laparoscopic sleeve gastrectomy for morbid obesity. Am J Surg. Nov 2008;196(5):e56-9. [Medline].

  18. Saber AA, Elgamal MH, Itawi EA, Rao AJ. Single incision laparoscopic sleeve gastrectomy (SILS): a novel technique. Obes Surg. Oct 2008;18(10):1338-42. [Medline].

  19. Gagner M, Gumbs AA, Milone L, Yung E, Goldenberg L, Pomp A. Laparoscopic sleeve gastrectomy for the super-super-obese (body mass index >60 kg/m(2)). Surg Today. 2008;38(5):399-403. [Medline].

  20. 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.

  21. [Best Evidence] Keating CL, Dixon JB, Moodie ML, et al. Cost-effectiveness of surgically induced weight loss for the management of type 2 diabetes: modeled lifetime analysis. Diabetes Care. Apr 2009;32(4):567-74. [Medline].

  22. [Best Evidence] Keating CL, Dixon JB, Moodie ML, et al. Cost-efficacy of surgically induced weight loss for the management of type 2 diabetes: a randomized controlled trial. Diabetes Care. Apr 2009;32(4):580-4. [Medline].

  23. Balsiger BM, Murr MM, Poggio JL, Sarr MG. Bariatric surgery. Surgery for weight control in patients with morbid obesity. Med Clin North Am. Mar 2000;84(2):477-89. [Medline].

  24. Belachew M, Legrand M, Vincent V, Lismonde M, Le Docte N, Deschamps V. Laparoscopic adjustable gastric banding. World J Surg. Sep 1998;22(9):955-63. [Medline].

  25. Brolin RE, Kenler HA, Gorman JH, Cody RP. Long-limb gastric bypass in the superobese. A prospective randomized study. Ann Surg. Apr 1992;215(4):387-95. [Medline].

  26. Considine RV, Sinha MK, Heiman ML, Kriauciunas A, Stephens TW, Nyce MR, et al. Serum immunoreactive-leptin concentrations in normal-weight and obese humans. N Engl J Med. Feb 1 1996;334(5):292-5. [Medline].

  27. Mantzoros CS. The role of leptin in human obesity and disease: a review of current evidence. Ann Intern Med. Apr 20 1999;130(8):671-80. [Medline].

  28. Nguyen NT, Goldman C, Rosenquist CJ, Arango A, Cole CJ, Lee SJ, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg. Sep 2001;234(3):279-89; discussion 289-91. [Medline].

  29. Podnos YD, Jimenez JC, Wilson SE, Stevens CM, Nguyen NT. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg. Sep 2003;138(9):957-61. [Medline].

  30. Saber AA. Gastric pacing: a new modality for the treatment of morbid obesity. J Invest Surg. Mar-Apr 2004;17(2):57-9. [Medline].

  31. Saber AA, Boros MJ, Mancl T, et al. The effect of laparoscopic Roux-en-Y gastric bypass on fibromyalgia. Obes Surg. Apr 8 2008;[Medline].

  32. Saber AA, Elgamal MH, McLeod MK. Bariatric surgery: the past, present, and future. Obes Surg. Jan 2008;18(1):121-8. [Medline].

  33. Saber AA, Jackson O. Omental wrap: a simple technique for reinforcement of the gastrojejunostomy during Roux-en-Y gastric bypass. Obes Surg. Jan 2007;17(1):15-8. [Medline].

  34. Saber AA, Scharf KR, Turk AZ, Elgamal MH, Martinez RL. Early Experience with Intraluminal Reinforcement of Stapled Gastrojejunostomy During Laparoscopic Roux-En-Y Gastric Bypass. Obes Surg. Mar 7 2008;[Medline].

  35. Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. Oct 2000;232(4):515-29. [Medline].

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Further Reading

Related eMedicine topics:
Body Contouring, Abdominoplasty
Laparoscopic Gastric Bypass
Laparoscopic Lap Band Placement
Obesity [Endocrinology]
Obesity [Pediatrics: General Medicine]

Clinical guidelines:
American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. American Association of Clinical Endocrinologists - Medical Specialty Society
American Society for Metabolic and Bariatric Surgery - Professional Association
The Obesity Society - Disease Specific Society.  2008 Jul-Aug.  83 pages.  NGC:006716

Expert panel on weight loss surgery. Massachusetts Department of Public Health - State/Local Government Agency [U.S.].  2004 Aug 4 (revised 2007 Dec 12).  106 pages.  NGC:006638

Role of endoscopy in the bariatric surgery patient. American Society for Gastrointestinal Endoscopy - Medical Specialty Society.  2008 Jul.  10 pages.  NGC:006609

SAGES guideline for clinical application of laparoscopic bariatric surgery. Society of American Gastrointestinal and Endoscopic Surgeons - Medical Specialty Society.  2003 Jul (revised 2008 Oct).  20 pages.  NGC:006413

Clinical trials:
Energy Expenditure and Gastric Bypass Surgery Study

Hepatic Effects of Gastric Bypass Surgery

Impact of GBS on CVD in Type 2 Diabetes Mellitus

Randomized Controlled Trial of Laparoscopic Gastric Bypass Plus Omentectomy Versus Laparoscopic Gastric Bypass Alone in Improving Diabetic Indices

Trial of Leptin Administration After Roux-en-Y Gastric Bypass

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Keywords

bariatric surgery, gastric bypass, stomac h, obesity, gastric, bariatric, weight loss surgery, weight surgery, stomach surgery, gastric banding, gastrectomy, Roux-en-Y, gastric sleeve, gastric bypass surgery, body mass index, BMI, laparoscopic gastric bypass, duodenal switch, gastric bypass complications, adjustable gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, biliopancreatic diversion with duodenal switch

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Contributor Information and Disclosures

Author

Alan A Saber, MD, MS, FACS, Chief, Minimally Invasive Surgery and Bariatric Surgery, Associate Professor, Department of Surgery, Michigan State University
Alan A Saber, MD, MS, FACS 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.

Medical Editor

Brian James Daley, MD, MBA, FACS, Associate Program Director, Professor, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee School of Medicine
Brian James Daley, MD, MBA, FACS 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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

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 Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of 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 Other

 
 
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