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Bariatric Surgery Treatment & Management

  • Author: Alan A Saber, MD, MS, FACS; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Jun 15, 2016
 

Approach Considerations

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 body mass index (BMI) higher than 40 kg/m2 or a BMI higher than 35 kg/m2 in combination with high-risk comorbid conditions, such as sleep apnea, pickwickian syndrome, diabetes mellitus, or degenerative joint disease. Guidelines have also been developed for the use of bariatric surgery in pediatric patients and patients with type 2 diabetes mellitus (see Guidelines).

Contraindications for 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. Conditions that may render patients 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 for bariatric surgery.

Favorable outcomes of bariatric surgery can lead to socioeconomic advancement, which may require patient guidance. Postoperative care may also include planning for reconstructive operations after weight stabilization for certain patients.

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Medical Therapy

A preoperative trial of weight loss is beneficial to ensure patient compliance with the postoperative diet protocol. Also, a preoperative liquid diet can shrink the liver, thus facilitating the surgical procedure.

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Surgical Therapy

Surgical options

Types of bariatric surgery include the following:

  • Restrictive procedures (eg, adjustable gastric banding, sleeve gastrectomy)
  • Restrictive procedures with some malabsorption (eg, Roux-en-Y gastric bypass)
  • Malabsorptive procedures with some restriction (eg, biliopancreatic diversion with duodenal switch)

Bariatric surgery can be performed either via an open approach or via a laparoscopic approach. The laparoscopic approach has become the more popular one.

Preoperative considerations

The diversity of clinical and occult obesity-related comorbidities necessitates a multidisciplinary team approach in the preoperative evaluation of the patient who is morbidly obese. This evaluation will enhance the postoperative outcome. Preoperative cardiac, pulmonary, psychiatric, and endocrine evaluations may be necessary. These evaluations help to exclude patients who may not benefit from surgery; at the same time, they optimize those considered being potential good candidates for surgery. Preoperative nutritional consultation helps in obtaining a detailed diet history and in explaining preoperative and postoperative diet protocol.

Gastric bypass

Gastric bypass is currently the most popular procedure performed in the United States. (See the image below.) This procedure has earned the reputation of being the gold standard, against which other procedures are compared. The procedure has a restrictive and a malabsorptive component.

Laparoscopic Roux-en-Y gastric bypass. Laparoscopic Roux-en-Y gastric bypass.

The gastric bypass provides a substantial amount of dietary restriction. The restriction is created by the small stomach pouch, which gives the patient a feeling of satiety after eating a small meal. The restrictive element of the operation consists of the creation of a small gastric pouch (approximately 20 mL in volume) and probably a small outlet that, on distention by food, causes the sensation of satiety.

In addition, the gastric bypass provides a small-to-moderate degree of intentional malabsorption due to the separation of food, which passes through the alimentary limb of the Y, from the biliopancreatic secretions, which pass through the biliopancreatic limb of the Y. The degree of malabsorption can be adjusted by modifying the length of the alimentary and biliopancreatic limbs.

The malabsorptive element is a result of bypassing the distal stomach, the entire duodenum, and varying the length of the jejunum. The extent of the bypass of the intestine determines the degree of macronutrient malabsorption. The standard Roux limb is about 75 cm. More extensive malabsorptive variations consist of gastric bypasses with a 150-cm Roux limb (long-limb) or with a very long-limb (distal gastric bypass). In addition to restricting food intake, causing some degree of malabsorption, it also causes dumping syndrome in response to a high-sugar liquid meal.

Weight loss after a standard 75-cm Roux gastric bypass usually exceeds 100 lb or about 65-70% of excess body weight and about 35% of BMI. The longer-limb bypasses are used to obtain comparable weight reductions in patients who are super obese (BMI >50 kg/m2). Weight loss generally levels off in 1-2 years, and a regain of up to 20 lb from the weight loss nadir to a long-term plateau is common.

Reversal

For all bariatric procedures, pure reversal without conversion to another bariatric procedure is almost certainly followed by a return to morbid obesity. Gastric bypass can be reversed, though this is rarely required.

Revision

A standard Roux gastric bypass with failed weight loss can be revised to a very-long-limb Roux-en-Y procedure (see the image below), or the dilated gastric pouch can be revised.

Long Roux-en-Y gastric bypass. Long Roux-en-Y gastric bypass.

Results

After gastric bypass surgery, some patients may experience dumping syndrome upon ingestion of sweets. This is caused by the rapid passage of gastric pouch contents directly into the small bowel, unimpeded by a pyloric valve. The presence of concentrated simple sugars in the Roux limb presents a substantial osmotic load that may result in cramping and abdominal discomfort; additionally, the ensuing rapid release of insulin by the pancreas may cause symptomatic hypoglycemia. This unpleasant reaction to sugar is considered to be a desired effect of gastric bypass surgery, and it has been referred to by patients as the postoperative police officer.

Weight loss after gastric bypass has been shown to be greater than that obtained by dietary, medical, behavioral, or combined approaches to weight loss.

A long-term follow-up study performed by MacLean et al defined postoperative success as a reduction in weight to a BMI of less than 35 kg/m2.[8] By this criterion, a successful outcome was achieved in 93% of patients with an initial BMI of less than 50 kg/m2 and in 57% of patients with an initial BMI of greater than 50 kg/m2.

Since its initial description in 1994 by Wittgrove et al, laparoscopic gastric bypass has been shown to combine the efficacy of the open approach with the decreased pain, lower wound morbidity, and shorter convalescence of a minimally invasive procedure.[9] Results of several laparoscopic gastric bypass series have paralleled or improved upon those of open surgery. In Higa's series of 400 laparoscopic procedures, patients lost an average of 69% of their initial excess weight by 12 months after the procedure.[10] Schauer's group reported even better weight loss; a group of 275 patients undergoing laparoscopic gastric bypass lost an average of 83% of excess weight at 24 months after surgery.

A prospective, randomized trial was completed that compared the results of laparoscopic gastric bypass to the results of open gastric bypass. Patients who had undergone laparoscopic gastric bypass were found to have substantially less impairment of pulmonary function after surgery and decreased postoperative pain.

In the author's experience, convalescence after laparoscopic gastric bypass is substantially reduced relative to open procedures, with some patients returning to work in 2 weeks or less.

Laparoscopic adjustable gastric banding

Laparoscopic adjustable gastric banding is the most common bariatric procedure and is performed in Europe, Australia, and South America. (See the image below.) Currently, two devices are approved by the US Food and Drug Administration (FDA) for this use in the United States: the Lap-Band (Apollo Endosurgery, Austin, TX) and the Realize Band (Ethicon Endo-Surgery, Somerville, NJ).

Adjustable gastric banding. Adjustable gastric banding.

In this procedure, an adjustable inflatable band is placed around the proximal part of the stomach. This creates a small gastric pouch (~15 mL in volume) and a small stoma. Band restriction is adjustable by adding or removing saline from the inflatable band by a reservoir system of saline attached to the band and accessible through a port, which is attached by a catheter to the band. The port is placed subcutaneously in the anterior abdominal wall after the band is secured around the stomach.

Adjustment of the band through the access port is an essential part of laparoscopic adjustable gastric banding therapy. Appropriate adjustments, performed as often as six times annually, are critical for successful outcomes. Patients must chew food thoroughly to allow food to pass through the band. Adjusting the inflation of the cuff changes the size of the opening through which food passes but does not change the size of the gastric pouch; deflation of the cuff is useful when the outlet is obstructed.

Weight loss after laparoscopic adjustable gastric banding is about 50-60% of excess body weight in approximately 2 years.

Laparoscopic adjustable gastric banding can be completely reversed with removal of the band, tubing, and port.

Combining laparoscopic adjustable gastric banding with gastric plication may improve weight-loss outcomes, at least in the short term.[11]

Biliopancreatic diversion with duodenal switch

Biliopancreatic diversion with duodenal switch (see the image below) includes the following:

  • Lateral 75% gastrectomy, resulting in a tubular stomach
  • Duodenum divided past the pyloric valve
  • Ileum divided
  • Distal end anastomosed to proximal duodenum
  • Common channel created distally with Y-anastomosis
  • Optional appendectomy and cholecystectomy
Biliopancreatic diversion with duodenal switch. Biliopancreatic diversion with duodenal switch.

Malabsorption is achieved by separating food from biliopancreatic digestive fluids. More weight loss results from fat malabsorption. Protein absorption is also reduced. This has the best weight loss with the least regain. There is less disruption of eating patterns. Early weight loss is from restriction and malabsorption, and, later, it is mostly from malabsorption; 75-85% of excess body weight loss is at 18 months. Pyloric preservation protects against marginal ulceration and dumping syndrome.

The procedure is technically challenging and difficult to reverse. Insurance companies may not cover this procedure, because it is still considered investigational.

Laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG), a type of unbanded gastroplasty, employs subtotal gastric resection to create a long lesser curvature–based gastric conduit. (See the image below.)

Sleeve gastrectomy. Sleeve gastrectomy.

In this procedure, the stomach is reduced to about 15-20% of its original size by the surgical removal of a large portion of the stomach, following the greater curve. The mechanism of weight loss and resultant comorbidity improvement that follows sleeve gastrectomy may be related to gastric restriction or to neurohumoral changes observed following the procedure (due to the gastric resection).

Sleeve gastrectomy has been used as the first stage of a two-stage procedure for high-risk patients,[12] but owing to its simplicity and favorable outcomes,[13] it is currently being offered as a standalone primary procedure. In the first decade of the 21st century, many hundreds of sleeve gastrectomies were performed in the United States. On the basis of follow-up periods of 6 months to 3 years, patients were found to have lost 33-83% of their excess weight.[14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28]

Compared with other bariatric procedures, sleeve gastrectomy is the more physiologic treatment because it does not involve malabsorption, abnormal tracts, blind tracts, or the placement of a foreign body. This procedure is widely performed laparoscopically.[26]

Hutter et all conducted the first large, prospective, multi-institutional study comparing 1-yr outcomes of LSG to other procedures. Results show LSG has morbidity and effectiveness between laparoscopic adjustable gastric banding and standard Roux bypass.[29]

As with other bariatric procedures that involve stomach transection, the main drawback of sleeve gastrectomy is the severity of postoperative complications. The use of staple-line reinforcement was shown to be associated with improved perioperative outcomes and can be considered as an effective method for preventing leaks.[30]

A larger prospective comparative study involving 187 patients undergoing laparoscopic sleeve gastrectomy found that reinforcement of the staple line with bovine pericardium strips was associated with a significant reduction in bleeding from the staple line and intra-abdominal collections, whereas the leak rate was not significantly reduced. It is unclear, though, whether controlling for high BMI, previous bariatric surgery, and diabetes was taken into account.[31]

In a randomized study that involved 120 patients who had undergone laparoscopic sleeve gastrectomy, using either polyglycolide acid with tri-methylene carbonate or gelatin fibrinmatrix for SLR was found to be faster as compared with oversewing, whereas no significant differences in postoperative complications were observed between the three methods.[32]

Incision reduction strategies

There has been a growing trend in bariatric surgery toward reduction of abdominal incisions, a change offering much-improved cosmetic outcomes and, potentially, shorter patient hospital stays. (See the image below.)

Progression of surgical techniques, with open surg Progression of surgical techniques, with open surgery in the first image and single-incision, transumbilical laparoscopic surgery in the third illustration.

Such minimally invasive surgery also provides, as a result of decreased abdominal trauma, reductions in pain, scarring, and tissue injury. Saber et al developed a single-incision transumbilical laparoscopic approach for sleeve gastrectomies, in which the procedure is performed mainly through the umbilicus; the sleeve is extracted through the umbilicus without extending the incision.[26]

In addition, Saber et al developed a single-incision transumbilical laparoscopic technique for the placement of an adjustable gastric band; in addition to offering the aforementioned benefits of such an approach, this technique facilitates later outpatient adjustment of the band.

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Postoperative Care

After surgery, patients must remain on a high-protein, low-fat diet, and they must supplement their diet with multivitamins, iron, and calcium, usually on a twice-daily basis. Ursodiol may be given to minimize the risk of developing gallstones during the period of acute weight loss. Patients must modify their eating habits by avoiding chewy meats and other foods that may inhibit normal emptying of their stomach pouch.

Nutritional and metabolic blood tests must be performed on a frequent basis; in the author's practice, these tests are performed at 6 months after surgery, 12 months after surgery, and then annually thereafter.

Postoperative body contouring

Massive weight loss is associated with negative consequences for the body, such as flabby skin, abdominal skin overhang, and pendulous breasts. The excess skin does not regain the tightness it had before the weight gain. Redundant rolls of tissue may also be associated with intertrigo and significant hygiene problems. Surgical correction of these body deformities can significantly enhance physical and physiologic changes. The usual time lapse between gastric bypass and plastic surgery procedures is 12-18 months.

Treatment alternatives for body contouring procedures are as follows:

  • Lipoplasty
  • Conventional surgery
  • Combination of the two procedures

Conventional contouring procedures include abdominoplasty, buttock lift, lower body lift, thigh lift, upper arm lift, facelift, breast reduction, mastopexy, and augmentation. Multiple procedures are usually required, and a staged approach to body contouring surgery following bariatric surgery seems to improve safety and outcomes.

Complications of body contouring procedures include hematomas and seromas, as well as fat necrosis, skin slough, infection, and deep vein thrombosis (DVT). In addition, the patient should be involved with a team that assesses nutritional and psychological issues as needed.[33]

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Complications

Early complications of Roux-en-Y gastric bypass are as follows:

  • Anastomotic leak (1-3%)
  • Pulmonary embolism, DVT (<1%)
  • Wound infection (more common with open approach)
  • Gastrointestinal hemorrhage, bleeding (0.5-2%)
  • Respiratory insufficiency, pneumonia
  • Acute distention of the distal stomach

Late complications (less frequent and less dramatic than with gastric banding) of the Roux-en-Y procedure are as follows:

  • Stomal stenosis, most common (20%)
  • Bowel obstruction, small bowel obstruction (1%)
  • Internal hernia
  • Cholelithiasis
  • Micronutrient deficiencies
  • Marginal ulcer
  • Staple line disruption
  • Ventral hernia formation (more prevalent after open approach)

Although there is a statistical increase in the number of patients needing cholecystectomy after obesity surgery, the number is small enough to prevent suggesting a prophylactic procedure at the time of their bariatric surgery.[34]

Risk factors associated with an increased risk of postoperative morbidity include the following[35] :

  • Recent myocardial infarction/angina
  • Stroke
  • Bleeding disorder
  • Hypertension
  • Higher BMI

Operative (30-day) mortality for gastric bypass when performed by skilled surgeons is about 0.5%. The risk of dying in the first month after a Roux-en-Y gastric bypass from complications of the operation is about 0.2-0.5% in expert centers. Studies have demonstrated that the mortality reported by hospitals with less experience with the procedure is far higher than that reported by expert centers. Compared with open procedures, laparoscopic gastric bypass has a higher rate of intra-abdominal complications, whereas the duration of hospitalization is shorter, wound complications are lower, and the postoperative patient comfort is higher.

Lifelong oral or intramuscular vitamin B12 supplementation and iron, vitamin B, folate, and calcium supplementation are recommended to avoid specific nutrient deficiency conditions, such as anemia.

Early complications of the adjustable gastric band procedure are as follows:

  • Injury of the stomach or esophagus
  • Bleeding
  • Food intolerance (most common immediate postoperative complication)
  • Wound infection
  • Pneumonia

Late complications are as follows:

  • Food intolerance or noncompliance to band (13%)
  • Band slippage (stomach prolapse) (2.2-8%)
  • Pouch dilatation
  • Band erosion into the stomach
  • Port complications
  • Reoperation rate (2-41%)
  • Esophageal dilatation
  • Failure to lose weight
  • Port infection, band infection
  • Leakage of the balloon or tubing
  • Mortality (0.5%; 0% in some series)

Because the biliopancreatic diversion with duodenal switch procedure is less well known, the complications are potentially more problematic if the surgeon is unfamiliar with the procedure.

Fat malabsorption results in diarrhea and foul-smelling gas in approximately 30% of patients.

The potential nutritional deficiencies mandate frequent follow-up visits, with close monitoring and supplementation of multivitamins and minerals.

  • Malabsorption of fat soluble vitamins (vitamins A, D, E, and K)
  • Vitamin A deficiency, which causes night blindness
  • Vitamin D deficiency, which causes osteoporosis
  • Iron deficiency (similar incidence to Roux-en-Y gastric bypass procedure)
  • Protein-energy malnutrition (may require a second operation to lengthen the common channel)
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Long-Term Monitoring

Care of the postoperative bariatric surgery patient is recommended for the lifetime of the patient, with at least three follow-up visits with the bariatric surgery team within the first year. Laparoscopic adjustable gastric banding requires more frequent visits for band adjustment. Postoperative dietary changes (including vitamin, mineral, and possibly liquid protein supplementation), exercise, and lifestyle changes should be reinforced by counseling, support groups, and the patient's family physician.

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Contributor Information and Disclosures
Author

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 is a member of the following medical societies: American College of Surgeons, American Society for Metabolic and Bariatric Surgery, American Society for Gastrointestinal Endoscopy

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

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.

Chief Editor

John Geibel, MD, DSc, MSc, 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; American Gastroenterological Association Fellow

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

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Additional Contributors

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.

Acknowledgements

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.

References
  1. 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].

  2. 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].

  3. 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 Aug 1. [Medline].

  4. Lidar Z, Behrbalk E, Regev GJ, Salame K, Keynan O, Schweiger C, et al. Intervertebral Disc Height Changes after Weight Reduction in Morbid Obese Patients, its Effect on Life Quality, Radicular and Low Back Pain. Spine (Phila Pa 1976). 2012 May 29. [Medline].

  5. 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. 2009 Apr. 32(4):567-74. [Medline].

  6. 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. 2009 Apr. 32(4):580-4. [Medline].

  7. Colquitt JL, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014 Aug 8. 8:CD003641. [Medline].

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

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

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

  11. 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. 2014 Jun 6. [Medline].

  12. 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. 2003 Dec. 13(6):861-4. [Medline].

  13. 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].

  14. 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].

  15. 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. 2006 Jun. 20(6):859-63. [Medline].

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

  17. 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. 2006 Sep. 16(9):1138-44. [Medline].

  18. 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].

  19. 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].

  20. 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].

  21. 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. 2006 Feb. 16(2):166-71. [Medline].

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

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

  24. 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].

  25. 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].

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

  27. 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].

  28. 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.

  29. 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):410-422. [Medline].

  30. Daskalakis M, Berdan Y, Theodoridou S, Weigand G, Weiner RA. Impact of surgeon experience and buttress material on postoperative complications after laparoscopic sleeve gastrectomy. Surg Endosc. 2011 Jan. 25(1):88-97. [Medline].

  31. Stamou KM, Menenakos E, Dardamanis D, Arabatzi C, Alevizos L, Albanopoulos K, et al. Prospective comparative study of the efficacy of staple-line reinforcement in laparoscopic sleeve gastrectomy. Surg Endosc. 2011 Nov. 25(11):3526-30. [Medline].

  32. Gentileschi P, Camperchioli I, D'Ugo S, Benavoli D, Gaspari AL. Staple-line reinforcement during laparoscopic sleeve gastrectomy using three different techniques: a randomized trial. Surg Endosc. 2012 Mar 23. [Medline].

  33. 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].

  34. Plecka Östlund M, Wenger U, Mattsson F, Ebrahim F, Botha A, Lagergren J. Population-based study of the need for cholecystectomy after obesity surgery. Br J Surg. 2012 Mar 7. [Medline].

  35. Gupta PK, Franck C, Miller WJ, Gupta H, Forse RA. Development and Validation of a Bariatric Surgery Morbidity Risk Calculator Using the Prospective, Multicenter NSQIP Dataset. J Am Coll Surg. 2011 Mar. 212(3):301-9. [Medline].

  36. Tucker ME. New guidelines address bariatric surgery in children. Medscape Medical News. January 19, 2015. [Full Text].

  37. 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 Non-alcoholic Steatohepatitis: the ESPGHAN Hepatology Committee Position Statement. J Pediatr Gastroenterol Nutr. 2015 Feb 2. [Medline].

  38. 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].

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

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

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

  42. 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. 1996 Feb 1. 334(5):292-5. [Medline].

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

  44. 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. 2001 Sep. 234(3):279-89; discussion 289-91. [Medline].

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

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

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

  48. Saber AA, El-Ghazaly TH. Early experience with single incision transumbilical laparoscopic adjustable gastric banding using the SILS Port. Int J Surg. 2009 Oct. 7(5):456-9. [Medline].

  49. Saber AA, El-Ghazaly TH. Early experience with single-access transumbilical adjustable laparoscopic gastric banding. Obes Surg. 2009 Oct. 19(10):1442-6. [Medline].

  50. Saber AA, El-Ghazaly TH, Elian A. Single-Incision Transumbilical Laparoscopic Sleeve Gastrectomy. J Laparoendosc Adv Surg Tech A. 2009 Sep 11. [Medline].

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

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

  53. 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. 2008 Mar 7. [Medline].

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

  55. Song S, Itawi EA, Saber AA. Natural orifice translumenal endoscopic surgery (NOTES). J Invest Surg. 2009 May-Jun. 22(3):214-7. [Medline].

 
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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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