Chapter 27: The Surgical Management of Obesity

1. Surgical therapy is the only effective and proven therapy for patients with severe obesity (body mass index >40 kg/m²). Bariatric operations prolong survival and resolve comorbid medical conditions associated with severe obesity.

2. During the years 1999 to 2003, called the Bariatric Revolution in the United States, the availability of a laparoscopic approach for bariatric operations caused major changes in the field, including a massive increase in the number of procedures performed as well as an increased publc and professional awareness and understanding of the field.

3. Bariatric operations involve either restriction of caloric intake or malabsorption of nutrients, or both. Long-term follow-up is essential before the merits of an operation can be confirmed.

4. Patients who develop a bowel obstruction after laparoscopic gastric bypass require surgical and not conservative therapy due to the high incidence of internal hernias and the potential for bowel infarction.

5. Malabsorptive operations are highly effective in producing durable weight loss but have considerable nutritional side effects. Patients undergoing such procedures require complete follow-up and must take appropriate nutritional supplements.

6. The Roux-en-Y gastric bypass is the most commonly performed bariatric procedure, whereas the sleeve gastrectomy is the most rapidly increasing procedure worldwide.

7. All bariatric operations are tools that serve to allow the patient to lose weight, become healthier, and improve their quality of life. These changes are only maintained long-term if the patient permanently adopts the new eating patterns and exercise habits that are taught and expected in the early year(s) after surgery.

8. Bariatric surgery is also metabolic surgery, treating the varied metabolic consequences of the comorbid diseases arising from severe obesity. Some operations are particularly effective treatments for such metabolic consequences, such as gastric bypass for type 2 diabetes.

The surgical treatment of obesity has evolved to focus more specifically on the treatment of medical comorbidities associated with obesity than simply obesity itself. While bariatric surgery remains the overriding name of the field, the importance of treatment of the metabolic aspects of obesity has caused the primary society of surgeons treating these problems to rename the society the American Society for Metabolic and Bariatric Surgery (ASMBS). The nomenclature reflects the new emphasis of treating the metabolic consequences of obesity surgically. For the first time in the history of bariatric surgery, considerable effort is being devoted to scientifically study the physiologic mechanisms that help promote weight loss and, more importantly, resolution of comorbid medical problems associated with obesity.

Other major changes in the field of bariatric surgery in the United States since the last edition of this text include the introduction and rapid adoption worldwide of the laparoscopic sleeve gastrectomy and the simultaneous decreasing popularity of the laparoscopic adjustable gastric banding procedure.

The bariatric surgery community also has focused on improvement of outcomes and treatment for patients. The Centers of Excellence (COE) concept is an obvious example in the United States, but internationally, greater attention to outcomes and optimal results has been uniform. Improved outcomes have been documented in the literature, as have notable prospective randomized trials of medical versus surgical therapy. In the United States, a very recent study has challenged the concept that improved outcomes arise in COEs, citing data that Medicare patients had similar complication rates after surgery before and after the institution of a policy of surgery approval only at COEs.¹

Extension of the indication for metabolic surgery to patients with class 1 obesity (body mass index, 30–35 kg/m²) has been another development during the past few years.² The regulatory and scientific communities have been more willing to acknowledge the efficacy of metabolic surgery for treating comorbid medical problems, such as diabetes, than have the payors. Insurance coverage for appropriately qualified patients remains one of the biggest barriers to the access of appropriate care for patients suffering from morbid obesity.

Acknowledgement of morbid obesity as a disease has recently been adopted by the American Medical Association.³ This comes years after the recognition by the Centers for Medicare and Medicaid Services (CMS) of obesity as a disease,⁴ a reversal of the usual situation in which medical organizations are ahead of payors in recognition of such issues. Despite CMS recognition, regional administrators of CMS still raise unnecessary barriers and make access to care for morbidly obese patients difficult. Long waiting periods, denials for arbitrary issues, and mandatory 6- to 12-month “diet” plans with no requirement for actually losing weight continue to dominate the landscape of the patient seeking metabolic and bariatric surgery. What is also becoming as big an issue for other patients who have had bariatric surgery is denial of subsequent coverage for any emergency complications of the original operation if the patient’s new insurance plan does not cover bariatric surgery. Although the new Affordable Care Act will potentially eliminate the inability to obtain insurance because of pre-existing conditions, there is no guarantee that patients who have had bariatric surgery will be afforded the same rights to payment for emergent and needed surgery should a subsequent complication arise.

The merger of the COE systems of the ASMBS and the American College of Surgeons (ACS) has been a major positive event in recent years as well. Thanks to the leadership of Robin Blackwell, M.D., ASMBS President from 2011 to 2012, supported by the ASMBS Executive Council, the ASMBS took the initiative to merge with the ACS to create a single uniform system acceptable to both groups and clearly more authoritative due to its singular position. The ACS, to its credit, provided large fiscal and human resources to support the merger and adoption of a single COE system. Since the merger, the incorporation of virtually all the centers in the two systems has occurred under one new system. Outcomes, as reported for review by the oversight committee, are better than ever. Our patients have thus been well served.

Obesity is the second leading cause of preventable death in the United States, currently outdone only by smoking. However, obesity as a separate disease entity is still underappreciated and certainly misunderstood. The fact that the American Medical Association waited until the summer of 2013 to acknowledge obesity as a disease entity illustrates this statement.

Obesity is a disease and is likely multifactorial in its origin. We may come to a simpler and direct understanding of its pathogenesis in the future with increased understanding of molecular genetics, but for now, it remains a complex issue. The components of the disease likely include a combination of environmental and genetic factors. The recent rapid rise in the incidence of obesity in less than a generational time suggests that genetic etiologies alone cannot be responsible for the disease. Nevertheless, the numerous factors contributing to the disease increase the difficulty in understanding its causes.

The degrees of obesity are defined by body mass index (BMI = weight [kg]/height [m]²), which correlates body weight with height. Controversy exists as to the most accurate system by which to classify obesity. BMI has its inaccuracies, especially for the heavily muscled individual who may weigh more but have a low amount of body fat. However, BMI is the clinically easiest system to use, employing the simply measured parameters of height and weight. The World Health Organization classification of obesity is given in Table 27-1. It should be noted that for Asian populations, classifications remain the same as the international classification, but the public health action points for interventions are set at 23, 27.5, 32.5, and 37.5 kg/m².

Prevalence and Contributing Factors

Severe obesity is reaching epidemic proportions in the United States and dramatically increasing throughout the rest of the world. Since 1960, surveys of the prevalence of obesity have been conducted every decade by the National Center for Health Statistics. Data on obesity statistics have been updated annually since 1985. The latest figures for obesity incidence in the United States are that 35.7% of U.S. adults are obese (class 1 or higher).⁵

Genetic and environmental factors contribute to the development of obesity. While children of parents of normal weight have a 10% chance of becoming obese, the children of two obese parents have an 80% to 90% chance of developing obesity by adulthood. The weight of adopted children correlates strongly with the weight of their birth parents. Furthermore, concordance rates for obesity in monozygotic twins are doubled compared to others.⁶ Diet and culture are important factors as well; these environmental factors contribute significantly to the epidemic of obesity in the United States since the rapid increase in obesity during the past two decades cannot be explained by any genetic etiology.

Other factors appear to contribute significantly to severe obesity. Intermittent or consistent excessive caloric intake occurs. The lack of satiety, on a consistent or intermittent basis, appears to be strongly correlated to such episodes of excessive caloric ingestion. As yet, the physiologic basis for the explanation of such lack of satiety is not understood. Other factors commonly suggested to play a role in the disease of obesity include decreased energy expenditure from reduced metabolic activity, reduction in the thermogenic response to meals, an abnormally high set-point for body weight, or a decrease in the loss of heat energy. Another factor that may influence absorption of ingested food is intraluminal bacterial composition of the intestinal tract. Studies have documented a difference in the composition of the intestinal flora of obese versus normal-weight individuals.⁷

Obese individuals have excessive adipose cells, both in size and number. The number of such cells often is determined early in life; adult-onset obesity is largely a product of increase in adipose cell size. Weight gain results from increase in both adipose cell size and number. Adipose tissue may be deposited in large quantities in the subcutaneous layer of the abdominal wall or the viscera. Males tend to have central visceral fat distribution, whereas females more often have a peripheral or gluteal fat distribution. Central or visceral fat distribution is associated with metabolic diseases such as diabetes, hypertension, and the metabolic syndrome.⁸

Concurrent Medical and Social Problems

The severely obese patient often presents with chronic weight-related problems, detailed below. However, the single most difficult aspect of the disease of severe obesity for those suffering from it is the discrimination they face from the rest of the population with respect to social stigmatization. This prejudice against obesity remains the last unlegislated discrimination in existence. Obese individuals are routinely discriminated against in terms of employment. Public facilities often do not allow them to participate in activities. Examples include the size of airline seats and bathrooms, the availability of appropriate clothing options, and the size of automobile cabins. Severely obese individuals are thought of by much of the public as being lazy or gluttonous and lacking self-discipline. They often endure not only discrimination and prejudice, but outright ridicule and disrespect. Consequently, the stigma of severe obesity has a major impact on social function and emotional well-being. Thus, psychological disorders such as depression are found in an extraordinarily high incidence in this population versus the general public. Poor self-image is almost universal among obese individuals.

Significant comorbidities, defined as medical problems associated with or caused by obesity, are numerous. The most prevalent and acknowledged of these include degenerative joint disease, low back pain, hypertension, obstructive sleep apnea, gastroesophageal reflux disease (GERD), cholelithiasis, type 2 diabetes, hyperlipidemia, hypercholesterolemia, asthma, hypoventilation syndrome of obesity, fatal cardiac arrhythmias, right-sided heart failure, migraine headaches, pseudotumor cerebri, venous stasis ulcers, deep venous thrombosis, fungal skin rashes, skin abscesses, stress urinary incontinence, infertility, dysmenorrhea, depression, abdominal wall hernias, and an increased incidence of various cancers such as those of the uterus, breast, colon, and prostate.⁹

Prognosis

Obesity has a profound effect on overall health and life expectancy, largely secondary to weight-related comorbidities. It is estimated that a severely obese male at age 21 will live 12 years less and a woman 9 years less than a nonobese individual. The incidence of severe obesity in the population is comparable for females below and above the age of 50 years, whereas for men, it is decreased above age 50. This is due to the fact that the severely obese man often is dead of comorbid medical conditions, especially cardiac arrhythmias and coronary artery disease, by age 50. A study carried out by the Veterans Administration showed a 12-fold increase in mortality among 200 morbidly obese men age 25 to 34 years and a six-fold increase in mortality among those age 35 to 44 years over a 7-year follow-up period.¹⁰ Decreased quality of life also results due to severe obesity. Most patients seeking surgical treatment of severe obesity do so because of the medical issues they face from comorbid conditions or the decreased quality of life they are experiencing as a result of severe obesity. Bariatric surgery can significantly prolong the lifespan of a severely obese individual, as well as improve the quality of that life.

Medical treatment for severe obesity is aimed at reducing body weight with a combination of decreased caloric intake and accompanying increases in energy expended from moderate exercise. This method of weight loss is the safest possible and may work well for obese individuals who have modest amounts of weight to lose to regain normal body weight or return to being simply overweight instead of obese. However, for the severely obese individual, who usually must lose at least 75 or more pounds to achieve elimination of obesity, this daunting task is extremely difficult. The success rate for the severely obese patient population that tries dieting and exercise as a means of losing enough weight to no longer be obese and maintaining that weight loss is only approximately 3%.

Although the success rate is limited with diet and exercise alone, all severely obese individuals are asked to attempt this route of weight loss prior to undertaking any surgical therapy. There are two main reasons for this. The first is to allow those who can achieve such weight loss through the safest possible means to do so. The second, and by far the most practical, is to have the severely obese individual begin to appreciate and practice the lifestyle changes that must ultimately become routine for them once weight loss is achieved, by whatever means. Thus the dieting and exercise of conservative weight loss plans are important preparation for the incorporation of such habits into the patient’s lifestyle postoperatively after bariatric surgery. The adjustment of the patient’s lifestyle to include these measures is the key to long-term success with any bariatric operation. Failure to do so usually results in regain of weight and sacrifice of any health benefits initially gained by the immediate postoperative weight loss.

The treatment of severe obesity should be initiated with simple lifestyle changes, including moderate reduction of caloric intake and beginning an exercise plan. Walking is the most common choice for this patient population, who may be unable to perform extremely vigorous exercise initially. Medical comorbidities must be identified and treated. Usually the patient’s primary care physician will have already accomplished this, but we do at times identify bariatric-related comorbidities on initial history and physical examination in our clinic.

The severely obese patient will usually have been given dietary counseling by his or her primary care physician and often placed on a medically supervised diet. Most patients also have attempted commercially sponsored diets and diet plans. Success following these is not uncommon, but sustained weight loss for more than a year after stopping the program is uncommon. While primary care physicians usually do an outstanding job of identifying and treating comorbid medical problems, their offices usually do not have the related support staff in terms of nutritionists and psychologists, who are often very helpful in providing services to the severely obese patient undergoing significant lifestyle changes.

Lifestyle changes of diet, exercise, and behavior modification constitute the first tier of therapy for obesity. Dietary restriction and exercise can each independently create a caloric deficit. A daily energy deficit of 500 kcal/d, resulting in a weekly deficit of 3500 kcal, results in the loss of 1 lb of fat weekly. It has been shown that low-calorie diets (800–1500 kcal/d) are as effective as very-low-calorie diets at 1 year, but result in a lower rate of nutritional deficiencies.¹¹ Such diets may produce an average of 8% body weight loss over a 6-month period. Longer follow-up shows recidivism. Physical activity of a moderate daily nature can produce a 2% to 3% body weight loss.¹²

A behavioral modification program, which provides desirable rewards for meeting short-term dietary or exercise requirements, was shown in combination with diet and exercise to produce as much as a 10% weight loss at 6 months in one study. This weight loss was only sustained in 60% of patients at 40 weeks,¹³ and at 1 year, the average sustained weight loss was decreased to 8.6%.¹⁴

Dietary, exercise, or behavior modification therapy is appropriate treatment for patients who are overweight (BMI <30 kg/m²) and highly recommended for patients with a BMI between 30 and 35 kg/m². Most of the studies looking at dietary therapy do not include a patient population that is largely obese (BMI >30 kg/m²). Dietary therapy can be effective in producing improvements in comorbid conditions such as diabetes mellitus, with weight loss of 2.3% to 3.7% influencing the disease.¹⁵ Thus, lifestyle changes can be effective in improving the health of the nonobese, but less so for the obese population.

Pharmacologic therapy is also an option for patients attempting to lose weight. Unfortunately, the number of effective pharmacologic agents is small compared to the number of products sold with allegations that they will promote or support weight loss. Pharmacotherapy is normally used only after lifestyle changes and dietary therapies have failed. It is used either as primary therapy alone or in conjunction with simultaneous diet and exercise therapy.

Orlistat inhibits gastric and pancreatic lipase enzymes that promote lipid absorption in the intestine.¹⁶ It produces a weight loss of between 6% and 10% of body weight after 1 year, but cessation of the drug usually results in prompt regain of lost weight.¹⁶ Pharmacotherapy is recommended as an adjunctive or supplementary therapy to lifestyle changes including diet and exercise or behavioral therapy by the National Institutes of Health (NIH) consensus guidelines for treatment of obesity.¹⁷ Two new medications have been approved by the Food and Drug Administration (FDA) within the past few years for weight loss. Qsymia, a combination of phentermine and topiramate, produced a 5% weight loss in over 70% of patients after 1 year.¹⁸ Lorcaserin (Belviq), a central serotonin agonist, produced a 5% weight loss in 47% of patients taking the medication.¹⁹

Since medical therapies are almost uniformly ineffective long-term for patients with severe obesity, the severely obese patient tends to continue to gain weight over time. The number and strength of prescribed medications slowly increase as the medical comorbidities become increasingly worse. Unfortunately, for the majority of severely obese patients, this process continues unabated until death results eventually from the comorbidities. Until recently, less than 1% of severely obese patients underwent surgical treatment for obesity annually. That number has now increased, but still is not over 2% of individuals. Even accounting for patients referred for surgery and felt to be poor candidates, it is likely that less than 5% of patients with severe obesity are referred on an annual basis. Part of this issue may be patient aversion to surgical therapy. Primary care physician awareness, patient reticence, and economic concerns about potentially losing employment due to time off required for surgery or its complications have been the primary reasons cited for the lack of increased performance of bariatric and metabolic surgery. Lack of insurance coverage by many patients is also a primary reason for not seeking surgical therapy for the medical problems associated with severe obesity. Disincentives posed by insurance companies, such as required dietary periods that clearly have no scientific or clinical basis of merit, are still used to discourage patients from pursuing surgical therapy. The lack of efficacy and potential harm to patients of such policies has been clearly demonstrated in the literature.^20,21

Bariatric operations produce weight loss through at least two mechanisms and probably many more that are not known. The most common is restriction of intake. Malabsorption of ingested food is the second mechanism. Restrictive operations may include no or only a modest malabsorptive component. Malabsorptive operations may have some restrictive component, but it is secondary to the malabsorptive aspect of the operation. Table 27-2 describes the common currently performed operations listed by mechanism of action.

This chapter focuses on the operations listed in Table 27-2, whether they are done via a laparoscopic or an open incision approach. Any other procedures to produce weight loss are so infrequently done that they will not be discussed in detail. Vertical banded gastroplasty (VBG), although still one of the approved operations for the surgical treatment of severe obesity based on the NIH Consensus Conference of 1991,²² is now so infrequently performed and has such poor long-term follow-up results²³ that it is of historic interest only.

Evolution of Bariatric Surgery

During the 1950s, operations were first performed to treat severe hyperlipidemia with associated obesity.²⁴ These were ileocolic bypass operations to limit absorption and were associated with severe nutritional complications and liver failure postoperatively. The jejunoileal bypass was then devised and popularized in the mid-1970s.²⁵ It was also a malabsorptive operation, but bypassed only a portion of the small intestine. Complications after this procedure included severe diarrhea, electrolyte disturbances, protein-calorie malnutrition, renal stones, and liver failure.

In 1969, Mason and Ito performed the first gastric bypass, describing a loop of jejunum connected to a transverse proximal gastric pouch.²⁶ Bile reflux esophagitis was severe postoperatively, causing Griffin and colleagues to describe the Roux-en-Y modification of the gastric bypass in 1977.²⁷ The gastric pouch was altered from transverse to vertical using the upper lesser curvature as well.

During the 1970s, the dismal failure of the jejunoileal bypass resulted in a very bad reputation in general for bariatric surgery among general surgeons who had performed the procedure or cared for patients suffering from its complications. The reputation was not enhanced by the many variations of gastric stapling that then became common during the 1970s and early 1980s. Such operations often consisted of a few rows of staples partially across the upper stomach for restrictive purposes. Since the procedure was easily done, some surgeons performed it in prolific numbers. Staple breakdown predictably occurred months to years later, with subsequent weight regain. These procedures added to the string of failures of bariatric operations.²⁸

In 1980, Mason²⁹ first performed the VBG, which was a restrictive procedure using a stapled proximal gastric pouch of the upper lesser curvature of the stomach with a restrictive band for its outlet to the rest of the stomach. This operation produced excellent initial weight loss (50% of excess weight or more) with low morbidity and mortality. It rapidly became the most commonly performed bariatric operation in the United States during the 1980s. However, by the early 1990s, it became clear that patients who underwent VBG tended to adopt a diet of high-calorie liquids and regained weight.³⁰ A significant incidence of stenosis at the band was also a problem.³¹ Long-term weight loss was poor,²³ and by the 1990s in the United States, Roux-en-Y gastric bypass (RYGB) became the procedure of choice for bariatric surgery.

In Italy, in the meantime, Scopinaro had developed and popularized the biliopancreatic diversion (BPD) in the early 1980s.³² This procedure, described in more detail later, has been, along with its modification to include duodenal switch (DS),³³ the only major malabsorptive operation to enjoy long-term success. BPD and DS are both still used by a fairly select few surgeons throughout the world and have traditionally represented and continue to represent less than 5% of operations performed in the United States.

Fixed banding of the stomach, besides the VBG, was also described by other surgeons in the 1980s and 1990s. Kuzmak is credited with describing the fixed gastric band procedure, which later led to the development of the adjustable gastric banding operation.³⁴

The laparoscopic alternative to bariatric surgery became available in the 1990s. Belachew performed the first laparoscopic adjustable gastric banding (LAGB) operation in 1994.³⁵ Wittgrove and Clark performed the first laparoscopic RYGB the same year.³⁶ Since the former operation is technically much easier than the latter, it was not surprising that it became very popular and frequently performed in Europe and Australia during the late 1990s. In 2001, LAGB was approved for use in the United States. Its popularity increased annually until 2009, but since then, it has decreased in popularity. Sleeve gastrectomy (SG) has enjoyed a rapid increase in popularity both in the United States and internationally since 2008. Buchwald and Oien³⁷ have recently described the international trends in the performance of bariatric operations.

The Bariatric Revolution

The Bariatric Revolution is a term applied to the 5-year stretch from 1998 to 2003 during which the number of gastric bypass operations performed in the United States, membership in ASMBS, and public recognition and interest and professional respect for the field dramatically increased. Few medical centers in the United States offered a laparoscopic approach to bariatric surgery prior to 1998. Several centers, most notably Schauer and colleagues at Pittsburgh, then began numerous programs to teach many bariatric surgeons the procedure. Simultaneous improvement in the laparoscopic instruments for bariatric procedures combined with these programs to allow the performance of laparoscopic Roux-en-Y gastric bypass (LRYGB) in numerous centers over the next few years. The field then literally exploded in terms of growth in the United States. Figure 27-1 illustrates the volume of LRYGBs performed during the years prior to and during the Bariatric Revolution. Operative procedures increased nearly eight-fold. Membership in the American Society for Bariatric Surgery (the name of the ASMBS at that time) tripled during these years. The number of minimally invasive fellowships offered to graduating residents, most of whom included bariatric surgical procedures as a major component of the case load, increased from about 25 to 125 during these years. ­Public recognition of the procedure markedly increased due to public figures in the media undergoing bariatric surgery. The widespread availability of the Internet to prospective patients allowed much more information to be relayed. Patients who had or were contemplating surgery were able to communicate via the Internet. Videos of bariatric operations became available via several media outlets including television and the Internet. Many U.S. surgical departments that had previously shunned the field of bariatric surgery recruited bariatric surgeons and established programs. Hospitals without programs recruited surgeons so they could offer the service. Bariatric surgery presentations at national surgical meetings became common instead of rare.

Indications

The indications for performing bariatric surgery remain as described in the NIH Consensus Conference of 1991.²² The only major difference is the procedures that are now recognized as standard procedures. These were defined by the CMS in 2005 as those listed in Table 27-2, with the exception of SG. SG did not receive approval until 2012, when after a controversial initial rejection of coverage, the CMS decided to allow coverage based on the discretion of regional carriers. The standard and somewhat conservative indications for performing bariatric surgery are summarized in Table 27-3.

Contraindications

Of all the reasons a patient who desires bariatric surgery cannot have an operation, insurance coverage, or lack thereof, is the most common reason. This factor, however, is normally beyond surgeon control. Assuming the patient does have coverage or financial means to qualify for surgery, then application of the NIH criteria is the next consideration. Once a patient qualifies according to those criteria, then consideration of medical, social, and psychological issues can determine reasons to avoid surgical therapy.

The NIH criteria do not set limits for age, and surgeon opinion on this issue varies widely. Surgeons have variable practice patterns as to performance of surgery in the older patient. The philosophy for age restriction is two-fold: A large number of younger patients are interested in and eligible for bariatric surgery, and there is a greater likelihood that a longer period of postoperative benefit in terms of improved quality of life and longevity will occur with a younger patient population. Alternatively, older patients are more likely to have debilitating comorbid conditions and thus have immediate benefit in quality of life but not necessarily enhanced longevity.

Medical issues that preclude patients from being good surgical candidates include American Society of Anesthesiologists class IV disease of a nature that makes surgical therapy extraordinarily high risk. Psychological instability or the inability to understand the implications of the proposed operation and what changes will result from it in terms of the patient’s lifestyle are also contraindications. Known and documented drug or alcohol addiction is a contraindication to surgery. Smoking is a relative contraindication, and requirement of cessation of smoking varies by surgical practice. A poorly controlled eating disorder, especially bulimia, is also a contraindication to surgery. Nonambulatory status is a relative contraindication to surgery, especially if the obesity is so severe that the patient cannot normally do self-care or would not likely be able to do so after surgery. Such patients have excessive morbidity in our experience, and placement in care facilities postoperatively after recovery from surgery is often impossible due to their size and limitations of physical ability. Although hard to determine on a single visit, an accumulation of evidence that suggests the patient views the operation as a “magic bullet” for which they must only show up and after which they will not be required to make any substantive changes in eating or lifestyle is a potential valid reason to deny surgery. Finally, lack of sufficient social support, an extremely poor or unsupportive home environment, or hostile spouse or relatives can be contraindications to surgical care, since such supportive environmental factors are important to optimize outcomes once discharged from the hospital. Table 27-4 summarizes potential contraindications for surgery.

Patient Selection

Patient selection for surgery should be based on a multidisciplinary team evaluation. The patient has usually been screened by his or her primary care physician prior to referral, with major medical issues addressed prior to referral. Qualification by NIH criteria and availability of insurance coverage can be handled by office administrators to document and confirm prior to the first appointment.

The preoperative assessment of the patient for bariatric surgery must include input from the nutritionist as an important independent evaluation. Careful assessment of the patient’s eating habits, knowledge, self-awareness, and insight are important. An estimation of the patient’s motivation to change eating habits is important. The nutritionist should have at least one assessment session with the patient and an educational session preoperatively once the decision to proceed with surgery has been determined. The operation to be performed requires specific nutritional counseling and education.

Psychological assessment is required by most insurance carriers. One major benefit of the psychological assessment is to determine the patient’s understanding of the operation and whether he or she has a realistic understanding of the changes that are needed in lifestyle for optimal outcomes. The psychologist or psychiatrist often may diagnose previously unappreciated depression, which is prevalent in nearly 40% of our preoperative patients when carefully screened. Its treatment is felt to improve postoperative outcomes.

Most of the patients referred for surgery who have been screened for qualification by NIH standards will be appropriate candidates for bariatric surgery. Some will decide against the procedure after thorough educational and counseling sessions. Such sessions are imperative for improving outcomes. Providing both written detailed information and a verbal presentation by the multidisciplinary team to educate patients preoperatively regarding bariatric surgical procedures and expected outcomes and potential complications is recommended. Informed and prepared patients will likely be much more compliant with perioperative and postoperative requested behavioral and eating changes. Some patients who decide against the procedure will return in the future after their obesity comorbidities worsen. Reevaluation for continued appropriateness as a good surgical candidate is equally indicated at such time.

Preoperative Preparation

Preoperatively, current comorbid and other medical problems and their optimal therapy are confirmed. Potentially undiagnosed medical problems are sought. Screening for “hidden” diseases such as coronary artery disease in those patients over age 50 is important. For such patients, or those with known cardiovascular disease, a preoperative cardiology consultation is recommended. Such consultation usually then involves electrocardiogram (ECG), echocardiogram, and stress test, with the results of these at times suggesting need for cardiac catheterization. Another condition often underdiagnosed preoperatively in the severely obese patient population is obstructive sleep apnea (OSA). The Epworth Sleepiness Scale, a standard set of questions evaluating daytime sleepiness, is often used as a screening tool for OSA.³⁸ Many institutions are routinely employing it for all surgical patients, given the recognition that OSA increases postoperative morbidity after all operations. Patients who give a history of loud snoring, morning tiredness on waking, and falling asleep easily while driving or sitting likely have OSA. A diagnostic sleep study is indicated for these individuals. One report suggests that the incidence of sleep apnea in severely obese patients, when all are routinely subjected to sleep studies, may approach 80%.³⁹ Once diagnosed with sleep apnea, patients should use their positive airway pressure appliance as treatment. Use of this system in the immediate postoperative period is especially important to prevent episodes of hypoxia and potentially resulting cardiac arrhythmias. Asthma and hypoventilation syndrome of obesity are other significant pulmonary diseases often requiring preoperative management. Hypoventilation syndrome of obesity is defined as resting arterial partial pressure of oxygen less than 55 mmHg and partial pressure of carbon dioxide greater than 47 mmHg, with accompanying pulmonary hypertension and polycythemia. Pulmonary consultation is indicated for patients with hypoventilation syndrome. Postoperative intensive care unit hospitalization, rarely used after bariatric surgery, may be indicated for these patients.

For patients with active GERD on medication, a preoperative screening upper endoscopy to rule out Barrett’s esophagus and to rule out intrinsic lesions of the stomach or duodenum is recommended. This is especially true for patients planning LRYGB, where the distal stomach and duodenum will be precluded from easy inspection postoperatively. Several studies have documented the considerable incidence of preoperative pathology on flexible upper endoscopy for this patient population, as well as a small but not insignificant incidence of pathology resulting in alteration of the originally planned surgical procedure.^40,41 At Virginia, our experience was that such pathology was present in 4.6% of examinations.⁴² The presence of a hiatal hernia detected on preoperative esophagogastroduodenoscopy will alert the surgeon for the need to perform intraoperative repair.

Patients who are on anticoagulation medication for prosthetic cardiac valves or history of recent venous thromboembolism must have their anticoagulation managed perioperatively. Options include total cessation of oral warfarin therapy 5 days prior to surgery, bridging this time with subcutaneous low-molecular-weight heparin, or, more rarely, preoperative admission for intravenous heparin anticoagulation, which is then stopped 6 hours prior to surgery.

Patients with a strong history of previous venous thromboembolism or who are felt to have multiple risk factors for postoperative venous thromboembolism are potential candidates for preoperative placement of a temporary inferior vena cava filter. Such filters are placed the day prior to surgery by our interventional radiology colleagues and removed 3 to 6 weeks postoperatively. However, a report on a large experience of collected hospitals has shown this procedure has potential complications and morbidity, which may outweigh its use in all but the most high-risk patients.⁴³

Some surgeons routinely perform screening ultrasound of the abdomen for patients planning to undergo LRYGB with an intact gallbladder to rule out the potential presence of gallstones. Should gallstones be discovered, simultaneous laparoscopic cholecystectomy is one option, whereas deferring until after weight loss is another reasonable option. Recent analysis of our experience with simultaneous cholecystectomy at the University of Virginia has shown the average increase in operative time to be approximately 30 minutes for both LRYGB and RYGB with no increase in hospitalization or morbidity.⁴⁴ An earlier study at Pittsburgh did demonstrate an increased length of hospitalization for patients having simultaneous cholecystectomy.⁴⁵ When a patient does not have gallstones on preoperative ultrasound, use of prophylactic ursodiol in a dose of 300 mg twice a day will decrease the incidence of gallstone formation after RYGB to approximately 4%.⁴⁶ Controversy currently exists as to the proper role of simultaneous laparoscopic cholecystectomy at the time of LAGB. The conservative approach is to not perform such an operation, given the small potential for gallbladder bile spillage resulting in an infection of the prosthesis. However, some reports have shown that this risk may be very low.⁴⁷

Another value of a preoperative ultrasound of the abdomen is the assessment of liver size and composition. An ultrasound that reveals a large fatty liver in a patient planning to undergo either LAGB or LRYGB should alert the surgeon to the high potential for technical difficulty in liver retraction and exposure. We have converted to an open incision and even deferred persisting with the operation altogether when confronted with an excessively large or a tremendously large liver, respectively. Knowledge of this prior to surgery allows the patient to follow a low-calorie diet to shrink the liver preoperatively.

Some surgeons require patients to follow a low-calorie diet in the immediate preoperative period, requiring weight loss prior to proceeding with surgery. Some data exist indicating that preoperative weight loss by patients may improve outcomes.⁴⁸ Such studies suffer from the fact that the patients who are most compliant and lose weight preoperatively may be the most compliant postoperatively, accounting for the improved outcomes. Preoperative weight loss is not necessary to achieve good outcomes from surgery. Requiring preoperative weight loss raises the dilemma of whether patients who do not achieve weight loss should be then denied the benefit of surgical therapy.

Another controversial area is the requirement for cessation of smoking by patients prior to undergoing surgery. Some surgeons make this an absolute requirement, while others do not. Certainly the risk of marginal ulcer after RYGB, which is more difficult to treat and has a higher recurrence rate in smokers,⁴⁹ should be considered as a factor in whether to offer the smoking patient this operation.

Other preparation for bariatric surgery includes the performance of a baseline arterial blood gas measurement. This is especially important in any patients with significant pulmonary disease or hypoventilation syndrome of obesity, since a baseline value of “normal” for the patient must be appreciated if ventilator management postoperatively is necessary.

Baseline evaluation of thyroid function is indicated preoperatively, since hypothyroidism is not uncommon in this patient population. Serum chemistries, liver function tests, and usual screening blood tests are done. Blood tests to determine baseline nutritional parameters are not uncommonly abnormal for low iron and vitamin D levels. The former finding is common in the menstruating female population, obese or not, while the latter has been reported for the population in general but especially for the obese patient population.⁵⁰ The necessity to treat low vitamin D levels preoperatively is unclear in terms of its influence on clinical outcomes. However, the primary reason to correct low vitamin D is improved long-term bone disease health.

Preoperative education is important to reemphasize important points of likely events of the perioperative period, expected postoperative course, and instructions for postoperative activity and diet. Expectations for patients include ambulation on the day of surgery, following postoperative dietary instructions, taking recommended vitamin and mineral supplements, and following a regular exercise plan.

Anesthesiology Issues

A preoperative anesthesiology assessment is indicated for all patients undergoing bariatric surgery. This assessment confirms the optimal assessment and management of ongoing comorbid medical problems. It also includes the aforementioned cardiopulmonary evaluation to determine any underlying pathology that requires preoperative treatment to decrease perioperative morbidity from cardiopulmonary complications.

It is important that the anesthesiologist be experienced in performing general anesthesia management for the bariatric patient. There is no question that the consistent participation of a few selected and experienced anesthesiologists who specialize in the care of the bariatric patient will minimize morbidity of surgical outcomes. Perioperative and intraoperative communication between the anesthesiology team and the surgical team is particularly important during bariatric operations to facilitate the smooth flow of the operation and avoid complications from the procedure.

Two major difficulties that the anesthesiologist faces when performing a general anesthetic for the severely obese patient are vascular access and airway management. Both are significantly more difficult in the obese patient population than the normal-weight population. Central venous access is at times the only available route for establishment of a reliable intravenous access. Access to both arms during the procedure is standard in our operating rooms; this allows for additional larger bore intravenous access should an episode of intra-abdominal hemorrhage occur. Jugular cannulation is often very difficult due to neck adipose tissue. However, ultrasound guidance can facilitate this procedure. Subclavian access is performed when other central access routes are not feasible.

Management of the severely obese patient airway is often a major challenge for the anesthesiologist and must be done well to avoid potentially significant morbidity. Videotelescopic intubation systems are successfully used in some institutions to manage difficult airway intubation. Fiberoptic laryngoscopy is more commonly used for the difficult airway should standard laryngoscopy provide an inadequate view. For the most difficult class IV or even class III airways, a fiberoptic guided intubation is used. Experience is key in performing smooth intubation of this patient population. Significant preoxygenation for 3 minutes or longer prior to intubation is used for the severely obese patient to provide a longer safe duration for intubation should difficulties be encountered. However, desaturation must be immediately addressed with reestablishment of oxygenated ventilation because this patient group does not tolerate any prolonged desaturation without potential adverse cardiopulmonary consequences.

The anesthesiologist must be adept at understanding and managing alterations in cardiopulmonary function from the use of a pneumoperitoneum during laparoscopic bariatric procedures. These alterations include the effects of carbon dioxide absorption on required minute ventilation, the potential for bradyarrhythmias, and the potential for decreased systemic pH with longer procedures in patients with preexisting cardiopulmonary disease. Arterial monitoring of the latter group of patients may be necessary by the anesthesiology team, and a radial arterial line is standard for such patients.⁵¹

Drug pharmacokinetics differ in severely obese patients as well. Changes in volume of distribution include smaller-than-normal fraction of total body water, greater adipose tissue content, altered protein binding, and increased blood volume. Possible changes in renal function and hepatic function must be considered when administering drugs.

Specific anesthetic drug metabolic alterations in the severely obese include a larger volume distribution of thiopentone, resulting in a prolonged effect of the drug.

Calculation of the dosage should be done by lean body weight. Benzodiazepines also exhibit a prolonged elimination phase, causing persistence of their effects. Increased pseudocholinesterase activity is present in the severely obese patient, requiring increased dosages of pancuronium. Enflurane metabolism is increased over the average-sized person, requiring a lower dosage of this agent.

Laparoscopic versus Open Procedures

The procedures in this section will be described using a laparoscopic approach as the default or typical approach. RYGB, BPD, and DS may still be performed by some surgeons using an open approach, but this has now become the exception. Minimization of the morbidity of the open incision, especially incisional hernias and wound complications, as well as earlier hospital discharge and lower 30-day complication rates have all been clearly shown to favor using a laparoscopic approach when feasible.^52,53,54 In addition, the logical assumption that avoiding the major tissue trauma associated with a lengthy abdominal wall incision is beneficial to patient recovery has been confirmed. Most importantly, patient interest in bariatric surgery increased dramatically once a laparoscopic approach was available for these procedures, especially RYGB.⁵⁵ In the twenty-first century, most prospective bariatric patients are informed enough about the options for surgery that they seek out a surgeon who does laparoscopic bariatric surgery.

When an open surgical approach is used for any of these procedures, an upper midline incision is the most commonly used approach. Some surgeons have had excellent success with a left subcostal incision for performing RYGB.⁵⁶ Mechanical retractors afford additional exposure for open surgery and are indicated. Wound closure for midline incisions usually is performed using heavy monofilament suture for the midline fascia, but surgeon preferences vary. Any concerning drainage from a postoperative open surgical incision line requires opening of the wound in that area and confirmation that a more severe deep-seated fascial tissue infection does not exist.

Laparoscopic surgery requires a basic core set of knowledge and skills that have now become a standard part of surgical training. Successful completion of the Fundamentals of Laparoscopic Surgery (FLS) unit developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)⁵⁷ is now mandatory for all surgical residents in the United States.

Laparoscopy begins with the safe creation of a pneumoperitoneum, often a difficult step in the bariatric patient. We have found the use of a tracheostomy hook inserted through a trocar-sized incision to elevate the fascia in the left subcostal region to be of great assistance in facilitating the insertion of a Veress needle into an appropriate location for pneumoperitoneum creation. In general, the use of a Hasson approach for creating a pneumoperitoneum in the bariatric population is limited by the thick body wall. In the patient with an extremely thick body wall, extra long trocar ports can be used for laparoscopic surgery.

The pneumoperitoneum pressure that is used when performing bariatric surgical procedures is generally in the 15 to 18 mmHg range. A high-flow insufflator is mandatory to maintain the pneumoperitoneum for adequate and safe visualization. An angled telescope is quite helpful. Instrumentation for performing laparoscopic bariatric surgery has dramatically improved in the past 15 years and continues to improve. We now favor using certain laparoscopic instruments, such as the staplers and harmonic scalpel, even if conversion to an open approach occurs.

Conversion to an open incision is appropriate in circumstances where patient safety would potentially be compromised by persisting with a laparoscopic approach. Table 27-5 lists appropriate reasons for conversion to an open incision as well as consideration for beginning with open surgery if certain conditions are known, such as an existing large upper abdominal incisional hernia or known severe intra-abdominal adhesions. Conversion to an open incision should not be viewed as a failure by the surgeon, nor should such an attitude bias the surgeon in favor of persisting with a laparoscopic approach if the operation is not progressing or if a complication is worsening when it could be corrected more quickly using an open approach. Patient safety is the gold standard for determining the timing and appropriateness of conversion. Usually, if conversion is needed, it is best to do so as early in the course of the operation as possible.

Postoperative Follow-Up

Short-term follow-up is defined as follow-up of up to 2 years. Unfortunately, even in the best of practices in the United States, because of the lack of a centralized health system or registry, 1-year follow-up of 90% or greater is a laudable achievement and rarely reported in most case series. Recommendations for bariatric centers wishing to be COEs are that 75% of patients are followed for 5 years with restrictive operations, and 90% are followed if they have malabsorptive operations. Those recommendations, however, are based on having a system that attempts maximum possible follow-up that should yield such results. Although a system may be in place that generates multiple attempts at having the patient return for postoperative checkups, without patient compliance, all such systems are fallible.

The goals of short-term follow-up are to maximize care of the patient in the postoperative period; assist in adjustment to new eating, exercise, and lifestyle patterns; be on the alert for and treat postoperative complications; and recommend measures to limit such complications. Objective data that should be obtained after all bariatric operations include weight loss, change in BMI, resolution or improvement in medical comorbidities, and any adverse events or complications that occur. Optimally, assessment of quality of life can help gauge efficacy as well, with the Short Form-36 (SF36) questionnaire being one standard, frequently used example. Short-term follow-up data do give a good reflection of the safety of the procedure, but only an estimate of the efficacy regarding weight loss and effect on resolution of medical comorbidities.

Medium-term follow-up is defined as that from 2 to 5 years. Medium- and long-term follow-up, defined as greater than 5 years, are the only means by which the true long-term efficacy of bariatric surgical operations can be assessed. Operations that initially appear quite promising, such as the VBG or even the jejunoileal bypass, were shown with long- and medium-term follow-up, respectively, to have significant deficiencies in efficacy for the VBG²³ and safety²⁵ for the jejunoileal bypass. Other stapled gastroplasties similarly did not demonstrate efficacy on medium-term follow-up.²⁵

Unfortunately, to date, there has been no conventional method of reporting outcomes after bariatric surgery. The ideal publication includes quantitation of number of patients, a description of the operative technique, incidence of conversion to open if applicable, number of patients included in ­follow-up data per year, percentage of patients lost to follow-up, weight loss usually expressed as percentage of excess weight, initial and subsequent BMI, complications, mortality, resolution of medical comorbidities, and any quality of life data. Few publications have met these criteria. There are also only a few studies in which a prospective randomized comparison either between bariatric surgery and medical management or between different bariatric surgical operations or approaches (laparoscopic vs. open) have been performed. Improvement in study design and more complete data in future publications are indicated.

A multidisciplinary team approach to follow-up is as essential, if not more so, postoperatively than preoperatively. Regular counseling sessions with the nutritionist are always helpful. Psychological support should be available as needed to assist the patient in adjustment to major life changes. All programs should offer a frequent support group forum for patients to discuss issues on a less formal basis and receive encouragement from other patients as well as staff.

Experience of performing bariatric surgery for several decades between the co-authors has led us to conclude that whatever the operation performed, its long-term success is only achieved by patients if they embrace the eating and lifestyle changes the operation allows them to adopt. Continuation of exercise as part of the daily lifestyle is associated with a high incidence of preservation of weight loss. Diligence to avoid snacking and returning to other poor eating habits is also important. The majority of patients do embrace the metamorphosis their bariatric operation produces such that they maintain their new eating, lifestyle, and exercise habits to the benefit of their continued improved health, self-image, and well-being.

Laparoscopic Adjustable Gastric Banding

Background

LAGB involves placement of an inflatable silicone band around the proximal stomach. The band is attached to a reservoir ­system that allows adjustment of the tightness of the band. This reservoir system is accessed through a subcutaneously placed port, similar in concept to ports used for chemotherapy via central venous catheters. Figure 27-2 shows the LAGB apparatus in place.

Two major types of bands have been used for this procedure. The original Lap-Band, most recently marketed by Apollo Endosurgery, has been used most frequently. The Swedish Band, now remarketed as the Realize Band by Ethicon, is slightly wider than the Lap-Band.⁵⁸ The port systems have differences as to profile and methods of attachment to the fascia.

Technique

Port placement for LAGB has varied among surgeons. Figure 27-2 shows a common configuration used. Usually some combination of two ports for the surgeon’s hands, one or two for the assistant, a port for the telescope, and a liver retractor site are needed.

With the patient placed in reverse Trendelenburg position, the procedure begins with division of the peritoneum at the angle of His and then division of the gastrohepatic ligament in its avascular area (the pars flaccida) to expose the base of the right crus of the diaphragm. If a hiatal hernia is present, it must be repaired at this point, using a standard posterior esophageal dissection to expose the crura and perform suture repair. A grasper (Lap-Band) or specially devised instrument (Realize Band) is inserted along the base of the anterior surface of the diaphragmatic crura, from right to left, emerging at the angle of His in the area of the divided peritoneum (Fig. 27-3). The device is then used to pull the band underneath the posterior surface of the gastroesophageal junction. This technique, by passing the band through some fibrous tissue in this plane, serves to anchor the band more securely posteriorly. During the initial years of band placement, a retrogastric location of the posterior half of the band in the free space of the lesser sac caused an unacceptably high incidence of slippage and prolapse of the band. The adoption of the pars flaccida technique decreased the incidence of such slippage.⁵⁹

Once the band is passed around the proximal stomach, it is locked into its ring configuration through its own self-locking mechanism. This involves the tubing end being passed through the orifice of the buckle for the Lap-Band and the suture on the end of the flanged end of the band site being passed through for the Realize Band. Once the band is securely locked in place, the buckle portion of the band is located on the lesser curvature of the stomach (Fig. 27-4A,B). Now the anterior surface of the fundus and proximal stomach is imbricated over the band using several sutures (Fig. 27-5).

The tubing of the band system is brought out through the desired site for placement of the port portion of the system. Usually this is a trocar site near the upper abdomen or xiphoid region to place the port most superficially such that it can be palpated postoperatively. The port is secured to the anterior abdominal wall fascia. Access to the port for subsequent addition of fluid to the band system is percutaneously achieved using a Huber or noncutting type needle. The band is initially placed empty of fluid in most circumstances.

Patient Selection and Preparation

Most LAGB procedures are done on an outpatient basis. Technically the operation is not as difficult as the other operations described later. Because the gastrointestinal tract is not violated, the relative risk of the procedure is lower than most other bariatric operations, making this procedure more amenable to offer to older, more medically ill, or higher risk patient populations. However, efficacy of the operation in the superobese (BMI >50 kg/m²) is less impressive, with average BMI remaining over 40 kg/m² after 5 to 8 years of follow-up.⁶⁰ It has been our impression that optimal results occur with this operation in a patient population who is motivated, needs to lose less than 50 kg to achieve a BMI less than 30 kg/m², is willing and able to exercise regularly, is amenable to changing eating patterns as recommended, and is within a geographically close enough area for ease of follow-up. Patients who are impatient to lose weight, immobile, unable or unwilling to exercise, or confirmed “grazers” or “nibblers” on high-calorie sweets who expect to be able to continue their dietary habits without great alteration are not good candidates for this operation. Similarly, patients who have had previous upper gastric surgery, such as a Nissen fundoplication, are relatively poor candidates for LAGB due to the potential tissue compromise in taking down the wrap to place the band.

Important points of preoperative preparation specific to the procedure include being nil per os (NPO), receiving preoperative appropriate venous thromboembolism prophylaxis, appropriate broad-spectrum intravenous antibiotics, and having appropriate intravenous access and monitoring. An orogastric tube is inserted into the stomach. These preoperative measures are recommended in all the procedures described later as well.

Postoperative Care and Follow-Up

The majority of LAGB procedures are performed on an outpatient basis. Insurance requirement and pre-existing medical issues are usually the only reason for overnight hospitalization. Diet instructions, wound care, pain medications, and instructions on time schedule of resuming other preoperative medications should all be explained to the patient as well as to a family member (who has not just undergone general anesthesia) prior to discharge. Arrangements for a postoperative follow-up visit, phone numbers to call for emergencies, and indications to call should all be explained as well.

The first postoperative evaluation after LAGB generally occurs 2 to 3 weeks after surgery. By this time, patients have begun to tire of the blenderized diet recommended, are often eager to return to work if they have not done so, and are amenable to discussions of an exercise plan and diet progression plan. Wounds are assessed, as are medical problems, oral intake, and adherence to diet. Since LAGB does not preclude absorption of any specific nutrients, we only recommend a multivitamin for patients whose preoperative lab values are normal. Use of ursodiol (300 mg twice a day) for gallstone prophylaxis after LAGB is variable from surgeon to surgeon. Weight loss after LAGB often does not occur as rapidly as after gastric bypass, and data regarding gallstone formation after LAGB are lacking. However, rapid weight loss after LAGB will occur in some patients justifying prophylaxis with ursodiol.

Band adjustments and postoperative support group sessions are extremely important for good outcomes after LAGB.⁶¹ Band adjustments are paramount as part of the operation. The actual performance of the LAGB procedure is really only a small part of the care of the patient. Frequent postoperative visits, band adjustments as necessary, and participation in an appropriate exercise program are all important for postoperative success for these patients. Recommendations for timing of band adjustments vary from practice to practice. In general, there is agreement that losing less than 2 lb per week is an indication to increase the restriction of the band by adding fluid. Patients who can easily eat most solid foods and have little satiety and a fairly pronounced appetite need additional restriction from the band.

Band fills usually are accomplished in the outpatient clinic setting. Occasionally fluoroscopic radiology is needed to assist in accessing the port, based on the depth of the port from the skin and its ease of palpation. Experience by the person doing the band fill is an important factor in increasing the percentage of patients able to be accessed in clinic without radiology assistance. A careful record should be maintained of the amount of fluid in each patient’s band. Some surgeons will withdraw all the fluid at each fill, reinserting the desired amount. Many will just add additional fluid as indicated. The amount of fluid added is based on hunger, weight loss, and ability to eat meat or bread. Figure 27-6 shows an in-office algorithm adjustment scheme used by Ren and colleagues at New York University.⁶² Ideally, adjustments are performed over approximately a 2-year period after surgery. However, changing life and clinical circumstances can require adjustments at any time thereafter.

An optimal situation for LAGB success is a program whose patients all live within an easy drive of the center, will and do participate in frequently available support groups and use exercise facilities supplied by the program, have access to band adjustment visits as needed, and are carefully selected for appropriateness and motivation for the procedure preoperatively.

Outcomes

Medium- to long-term (8-year follow-up) outcomes have been reported for LAGB from Weiner et al.⁶³ At 5 and 7 years after LAGB, an average of published studies in the literature showed that patients lost 60% and 58% of excess weight, respectively.⁶⁴ Resolution of comorbidities after LAGB has been reported as overall very good, with hypertension resolving in 55% at 1 year,⁶⁴ observed sleep apnea decreasing from 33% to 2%,⁶⁵ GERD improving in over 50% of cases,⁶⁶ and asthma,⁶⁷ depression,⁶⁸ and quality of life⁶⁹ improving for patients after LAGB. Dixon and colleagues⁷⁰ published a landmark article describing the vastly superior results of managing patients with diabetes using LAGB versus optimal medical management. Resolution of diabetes was 13% in the medical group versus 73% in the surgical group after a 2-year follow-up.

Large institutional series of LAGB results have been published from centers in Europe and Australia, with good results^71,72 for the Lap-Band. Similarly excellent results have been published for the Swedish adjustable band.⁷³ Buchwald and colleagues⁷⁴ performed a meta-analysis of all bariatric surgical papers published from 1990 to 2003. Overall mortality for LAGB was given as 0.1%. Table 27-6 shows the data from this paper and another meta-analysis⁷⁵ for weight loss, morbidity, and mortality for LAGB compared with RYGB and the malabsorptive procedures. Table 27-7 also shows data also from Buchwald and colleagues⁷⁴ regarding the percentage of resolution of four major comorbidities associated with obesity after the most common types of bariatric operations, including LAGB.

Specific complications that may occur after LAGB include prolapse, slippage, erosion, and port and tubing complications. In addition, just plain failure to lose weight is more commonly seen with this procedure than with other common bariatric procedures.

Prolapse is perhaps the most common emergent complication that requires reoperation after LAGB. The incidence of reoperation is generally around 3%. Postoperative vomiting predisposes to this problem. The lower stomach is pushed upward and trapped within the lumen of the band. Typical patient symptoms include immediate dysphagia, vomiting, and inability to take oral food or liquid. Either anterior or posterior prolapse may occur.⁷⁶ The initial evaluation for prolapse involves obtaining a plain film radiograph. If the band is in a horizontal position, prolapse must be strongly suspected. This orientation differs from the normal angulation of the band in the 1 to 2 o’clock and 7 to 8 o’clock positions of the two ends of the band on plain radiograph. Initial treatment for a prolapse is to remove all the fluid from the system. This often allows reduction of the prolapse and resolution of symptoms. If symptoms resolve, the necessity of performing an upper gastrointestinal series is lessened. If they do not, an upper gastrointestinal series is indicated, and if prolapse persists, then reoperation laparoscopically to reduce the prolapse and resuture the band in place is indicated.

Slippage has been greatly reduced by the pars flaccida technique, and operative need for repair now occurs in about 3% of cases in most series of short-term follow-up. Longer-term follow-up rates may show higher rates of prolapse. In our experience, a symptom-related need for band deflation, with suspected prolapse, occurs in 10% of patients.

Band erosion is uncommon, reported in 1% to 2% of most series. The patient usually becomes ill but not floridly ill, developing either a port site infection or systemic fever and a low-grade abdominal inflammatory sepsis. Endoscopy can be diagnostic. The presence of otherwise unexplained free air on computed tomography (CT) scan should alert the surgeon to this diagnosis as well. Laparoscopic removal of the band is indicated, with repair of any gastric perforation. Often the perforation is already sealed by an inflammatory process, but if not, appropriate management of a gastric perforation must be followed.⁷⁶

Port and tubing problems occur in approximately 5% of patients undergoing LAGB. These require revision of the port/tubing system due to perforation, leaking, or kinking of the tubing or turning of the port such that access to the surface of the port for adding fluid is precluded. Usually a procedure under local anesthesia is all that is required to repair or realign the tubing or port.

The incidence of band removal for patient dissatisfaction or lack of weight loss is difficult to assess, since this number is increasing annually at a not small rate. The figure also is likely related to patient follow-up and may be artificially low if the patient seeks a second surgeon to remove a band. The true incidence probably varies widely. Angrisani et al⁷⁷ reported a 40.9% incidence of band removal after 10-year follow-up.

One of the positive outcomes of LAGB is the safety of the procedure. While complications are not rare, most of them involve non–life-threatening events. Nutritional complications are uncommon and easily treated. Based on worldwide data, the results appear to be optimal in those practices and centers where continued optimal follow-up and encouragement of appropriate behavioral lifestyle changes occur.

The Lap-Band also has its limitations, which may be the cause of its reduced popularity. It is often ineffective in producing adequate weight loss. Restriction of high-caloric liquids, easily digested snacks, and other foods that tend to negate dietary efforts is not adequately achieved with the Lap-Band. Patients must have enough willpower to avoid such foods. If weight loss remains poor, patient frustration and dissatisfaction increase as time passes postoperatively. In centers where suboptimal conditions exist for support and follow-up, the rate of band failure in terms of poor overall weight loss is significant. Reports in the literature tend to only include patients who still have their bands in place and exclude patients who have had bands removed for failure to lose weight. While the latter group of patients probably varies widely from center to center, the trend in many centers to now perform more LRYGB or SG and less LAGB than 5 years ago suggests that LAGB outcomes may rest as much on the postoperative support setting as the operation itself. Centers should reassess their ability to provide optimal follow-up and should do so if possible for optimal long-term results after LAGB.

Laparoscopic Roux-en-Y Gastric Bypass

Background

LRYGB was first described in 1994,²⁵ but by 1998, only a few centers had accumulated any significant experience with the procedure. The University of Pittsburgh was one of those centers, with Schauer and colleagues performing the procedure, and instituted a large number of training courses from 1998 to 2001, which trained many of the bariatric surgeons who adopted the laparoscopic approach. By 2003, over 130,000 gastric bypasses were done in the United States, with more than half of them being done laparoscopically. Currently over 90% of gastric bypass operations nationally are performed laparoscopically.

Figure 27-7 depicts the configuration of the LRYGB. The major feature of the operation is a proximal gastric pouch of small size (often <20 mL) that is totally separated from the distal stomach. A Roux limb of proximal jejunum is brought up and anastomosed to the pouch. The pathway of that limb can be anterior to the colon and stomach, posterior to both, or posterior to the colon and anterior to the stomach. The length of the biliopancreatic limb from the ligament of Treitz to the distal enteroenterostomy is 20 to 50 cm, and the length of the Roux limb is 75 to 150 cm. Longer Roux limb lengths are performed but considered to have more malabsorption than the standard gastric bypass.

Experience has resolved several controversies about gastric bypass, but others are still debated. It is clear that creating the proximal gastric pouch by totally dividing it from the distal stomach is superior to simply stapling the stomach, since the latter is associated with a high incidence of staple breakdown.⁷⁸ The size of the proximal gastric pouch must be small to create adequate restriction and should be based on the lesser curvature of the stomach to prevent dilation over time. Length of the Roux limb is associated with higher short-term weight loss for longer length limbs,⁷⁹ but this difference becomes less on long-term follow-up.⁸⁰ Some surgeons doing LRYGB will create a longer (150 cm) Roux limb for patients with a BMI over 60 or even 50 kg/m². Antecolic position of the Roux limb is associated with a lower incidence of internal hernias leading to obstruction in most series with short-term follow-up.⁸¹ However, reports with longer follow-up suggest later internal hernia incidence may increase with an antecolic approach.⁸² Despite the plethora of enthusiasm for reoperative endoscopic narrowing of the gastrojejunostomy opening,^83,84,85 good long-term data do not yet exist to confirm that size of the gastrojejunostomy can be related to weight loss. The gastrojejunal anastomosis can be constructed in a variety of ways. Smaller diameter circular staplers are associated with a higher incidence of postoperative stenosis, and linear stapling is associated with a lower incidence of stenosis compared to circular stapling.^86,87

Technique

The operation generally is performed using five ports plus a liver retractor. Both the surgeon, who stands on the patient’s right, and the first assistant, who stands on the patient’s left, have two ports for instruments. The telescope requires a port, usually in the supraumbilical region. The assistant’s ports are in the left subcostal and flank areas, while the surgeon may have both ports in the right upper quadrant (Cleveland approach) or one on each side of the camera (Virginia approach, Fig. 27-8). Division of the proximal jejunum at 40 to 50 cm distal to the ligament of Treitz is performed with the linear stapler, using the white stapler cartridge. Further division of the mesentery at that location is performed either with the stapler or harmonic scalpel, such that adequate mobilization of the Roux limb is achieved. A Penrose drain or suture is sutured to the proximal Roux limb (Fig. 27-9) for identification and facilitation of advancement to the gastric pouch.

The length of the Roux limb (usually 100–150 cm) to be created is now measured. A jejunojejunostomy is then created to the proximal end of the biliopancreatic limb at the above-determined location along the Roux limb. A side-to-side stapled anastomosis is performed (Fig. 27-10). Either single- or double-fired staple technique (the latter using a stapler fired in each direction) is used. The stapler defect is optimally closed with sutures but can be closed with a stapler if great care is taken not to narrow the lumen of the alimentary tract at this location. Once the stapler defect is closed, the mesenteric defect is then also closed with running permanent suture.

Passage of the Roux limb toward the stomach is now performed. If an antecolic route is to be used, the end of the Roux limb is brought up so as to confirm its ability to reach the stomach. If a retrocolic route is to be used, a defect is made in the transverse colon mesentery just to the left and slightly above the ligament of Treitz. The Penrose drain and the proximal end of the Roux limb are placed into the retrogastric space (Fig. 27-11).

The left lobe of the liver is now retracted using any one of several retractor types. The patient is moved to a reverse Trendelenburg position. The harmonic scalpel divides the peritoneum in the area of the angle of His. Then it is used to open an area along the lesser curvature of the stomach approximately 3 cm down from the gastroesophageal junction. Another approach for creating access to the lesser curvature of the stomach is to use a white or gray load (vascular load) of the stapler and divide the lesser curvature vessels up to the surface of the stomach. Then a blue load of the stapler is fired one time transversely from the lesser curvature side partially across the stomach, followed by multiple subsequent firings of the stapler upward in the direction of the angle of His, to completely separate the proximal gastric pouch from the remainder of the stomach (Fig. 27-12). Use of an Ewald tube passed by the anesthesiologist and maneuvered to lie against the lesser curvature of the proximal stomach can help calibrate the pouch size.

Once the pouch is created, the Roux limb is brought up to the proximal gastric pouch. For the linear stapled anastomosis, the proximal end of the Roux limb is aligned with the distal gastric pouch end, and the sides of the organs are sutured together to maintain their side-by-side position. A blue load of the stapler is introduced through a gastrotomy and an enterotomy for the two legs of the stapler, and the anastomosis is created (Fig. 27-13). The stapler defect is closed with sutures and often reinforced with a second layer of sutures. At this point, the gastrojejunostomy is tested for security by using either methylene blue injected under pressure through the Ewald tube or a flexible upper endoscopy intraoperatively to test for air leakage from the anastomosis. The latter technique has been shown to decrease the incidence and seriousness of anastomotic leaks postoperatively.⁸⁸ The final step of the operation involves suture closure of all mesenteric defects using permanent suture.

Circular anastomosis for the gastrojejunostomy is accomplished through placement of the anvil of the stapler through the anterior wall of the proximal gastric pouch. This is accomplished by pulling the anvil transorally via an endoscopically placed guidewire (Fig. 27-14), making a gastrotomy in the pouch that is later closed, or making a gastrotomy in the lower stomach before completing gastric division to create the pouch, allowing the anvil to be placed into the lumen of the stomach and then be brought through the anterior stomach in an area that is subsequently included in the proximal gastric pouch (Fig. 27-15).

Hand-sewn gastrojejunostomy is usually created using two layers of absorbable suture to anastomose an approximately 1-cm gastrotomy and enterotomy.

Patient Selection and Preparation

LRYGB is an appropriate operation for consideration for most patients eligible for bariatric surgery. Relative contraindications to LRYGB include previous gastric surgery, previous antireflux surgery, severe iron deficiency anemia, distal gastric or duodenal lesions that require ongoing future surveillance, and Barrett’s esophagus with severe dysplasia. Contraindications to a laparoscopic approach to RYGB should cause the surgeon to choose an open RYGB or other open procedure instead.

Preoperative flexible upper endoscopy is indicated in all patients contemplating undergoing RYGB to rule out lesions of the stomach or duodenum noted earlier.⁴² Preoperative low-calorie diet for patients with hepatomegaly can decrease liver size and thus improve the chances of completing the operation laparoscopically. We use a mechanical bowel prep to decrease bowel weight and the chance of an inadvertent tear with handling using the laparoscopic graspers.

Postoperative Care and Follow-Up

LRYGB patients are usually hospitalized for 2 to 3 days. Major concerns on the night of surgery include adequate analgesia, adequate fluid resuscitation to provide adequate urine output, and early ambulation. We still routinely employ a postoperative oral contrast study on the first postoperative day. Numerous studies have advocated abandoning this practice due to its lack of accuracy and cost-effectiveness.^89,90 The study’s value to us has been to alert us to edema or stenosis of the enteroenterostomy or any other obstructive pattern of the proximal bowel. Obstruction of the enteroenterostomy or beyond can result in distal gastric dilatation over just a period of several hours, which, if untreated, can cause distal gastric staple line rupture with fatal consequences.

Aside from early ambulation, postoperative prophylaxis against venous thromboembolism includes compression shoes and low-molecular-weight subcutaneous heparin. Discharge on a blenderized diet is standard for our practice.

Diet advancement occurs after the first clinic visit, usually approximately 3 weeks after surgery. At that time, an exercise plan is initiated if not already started.

Patients on insulin for type 2 diabetes and on antihypertensive medications should be monitored to determine whether reduction of their medication is indicated. Subsequent follow-up visits are usually scheduled for 3 months, 6 months, and 1 year after surgery, and then annually thereafter. The focus of later postoperative visits is documentation of outcomes and testing for postoperative nutritional deficiencies.

Outcomes

Patients undergoing LRYGB usually lose between 60% and 70% of excess body weight during the first year after surgery. This has held true since the earliest large series of this operation was reported.⁹¹ Resolution of comorbidities varies, but is over 90% for GERD and venous stasis ulcers and over 80% for patients with type 2 diabetes of less than 5 years in duration. Hyperlipidemias are almost always improved and resolve totally in about 70% of cases. Hypertension resolves in 50% to 65% of cases (see Table 27-7). Even superobese patients who do not achieve an ultimate BMI of less than 35 kg/m² can experience significant improvements in comorbidities after LRYGB or open RYGB.⁹²

Mortality after LRYGB is now consistently less than 0.5% in most large reported series. Recent data from centers applying to be centers of bariatric surgery excellence showed a mortality rate of approximately 0.3% overall. The Bariatric Surgery Center Network (BSCN) of the ACS database showed a mortality of 0.14% at 30 days.⁹³

Overall morbidity after LRYGB has been acceptably low. In the BOLD database of the ASMBS, it was 14.87% for 30,864 gastric bypass procedures.⁹⁴ In the BSCN database, the 30-day morbidity rate was 5.91% for 14,491 LRYGB procedures.⁹³ LRYGB avoids most wound and incisional hernia problems. Complications that do occur include a 0.3% incidence of anastomotic leak,⁹⁵ 0.33% incidence of venous thromboembolism,⁹⁶ a 3% to 5% incidence of wound infections or problems,⁹³ a 3% to 15% incidence of marginal ulcers,⁹⁷ an approximately 7% incidence of bowel obstruction,⁹⁸ a 4% incidence of postoperative transfusion,⁹⁹ and a 1% to 19% incidence of anastomotic stenosis,⁸⁷ based on the type of anastomosis created.

Postoperative nutritional complications after LRYGB include a 66% incidence of iron deficiency, a 5% incidence of iron deficiency anemia, a 50% incidence of vitamin B₁₂ ­deficiency,¹⁰⁰ and an at least 15% incidence of vitamin D deficiency,¹⁰¹ which usually is present preoperatively.

Several complications that are specific to LRYGB must be emphasized. One of the most important is small bowel obstruction. This complication must be treated differently than in the average general surgery patient, whose complication is usually from adhesions and often will resolve with conservative, nonoperative therapy. Patients who have had LRYGB who present with obstructive symptoms generally require surgical therapy on an emergent basis (Table 27-8). This is because the etiology of the bowel obstruction after LRYGB is often an internal hernia from inadequate or nonclosure of the mesenteric defects by the surgeon at the time of operation. Thus, treatment for these patients differs from most patients with small bowel obstruction. One of the most important points of this chapter is to emphasize to general surgeons to be aware of the need to emergently operate on patients after LRYGB who present with small bowel obstruction. Currently, centers that perform small bowel transplantation are seeing patient referral for that procedure after small bowel obstruction after LRYGB, where patients developed infarction of most of the bowel from an internal hernia and have short gut syndrome.¹⁰² Other patients, for whom surgery is delayed and the bowel infarcts, do not survive. When the surgeon does encounter bowel obstruction after LRYGB, he or she can expect to see proximally dilated bowel. Cutoff of passage of contrast on CT scan at the enteroenterostomy is particularly suggestive of this diagnosis (Fig. 27-16). The surgical treatment of this particular problem can, if addressed early in the course of the obstruction, be treated laparoscopically. The surgeon must place a trocar for the telescope low enough in the abdomen to adequately survey most of the small intestine. The cecum and terminal ileum are identified, and the bowel is followed retrograde from the terminal ileum to determine the anatomy. Often much of the small bowel is herniated through a mesenteric defect, and only this technique allows the surgeon to reliably identify the bowel and decompress it appropriately. If the bowel is viable, suturing the mesenteric defect is all that is needed for treatment. It should be emphasized that either an antecolic or retrocolic placement of the Roux limb can result in this complication, as internal hernias can arise from either approach.

Marginal ulcers are another complication relatively specific to RYGB, either LRYGB or open RYGB. The patient presents with pain in the epigastric region that is not altered by eating. Diagnosis is by endoscopy. Treatment is medical with proton pump inhibitors, which are effective in 90% of cases. Only those with a gastrogastric fistula to the distal stomach, severe stenosis of the lumen of the gastrojejunostomy, or acute perforation require surgical therapy.

Stenosis of the gastrojejunostomy has been remarkably reduced by the use of a linear stapling technique in our experience.⁸⁶ Stenosis symptoms usually appear from 6 to 12 weeks postoperatively, but less commonly can occur later. Diagnosis is by upper endoscopy. Treatment is balloon dilatation. Resolution normally occurs with one or two treatments. Less than 10% of patients require reoperation, and those are almost always associated with concurrent marginal ulcers.¹⁰³

In the immediate postoperative period, anastomotic leak is the single most feared complication after RYGB, either open or laparoscopic. Careful vigilance and a high index of suspicion for this problem are the only appropriate approach, since its presentation may be insidious and the patient’s demise, if untreated, sudden and complete. Tachycardia, tachypnea, fever, and oliguria are the most common symptoms that arouse suspicion for this problem. The treatment is surgical except in rare circumstances where a drain is already in place, no hemodynamic or clinical deterioration is present, and the leak is contained.¹⁰⁴ Usual surgical treatment involves repair as feasible, drainage, and creation of a reliable feeding access through a distal Stamm gastrostomy.

In the first few hours or day after surgery, hematemesis indicates bleeding from the gastrojejunostomy unless proven otherwise. The dangers to the patient include aspiration, life-threatening hemorrhage, or more commonly intraluminal hematoma of the Roux limb and enteroenterostomy, which then causes an obstruction of the biliopancreatic limb leading to distal gastric staple line rupture. In fact, any obstructive symptoms in the first few weeks after surgery or any signs of obstruction of the biliopancreatic limb on postoperative swallow studies due to stenosis of the enteroenterostomy require immediate surgical intervention to prevent rupture of the distal gastric staple line. Some reports show that percutaneous decompression of the distal stomach can ameliorate the danger.¹⁰⁵ Alternatively, operative therapy to decompress the stomach and treat the obstructive problem is also a reasonable option.

Overall, LRYGB has the significant advantages over open RYGB of avoiding incisional hernias and severe wound infections. Table 27-9 shows the data on these problems, comparing outcomes for laparoscopic versus open procedures at the University of Virginia. Compared with other bariatric surgical procedures, the LRYGB offers a reliable and powerful operation to allow the severely obese patient to lose weight. Although more reliable and greater, this weight loss does come at a slightly higher complication rate compared with LAGB and SG. However, these complication rates, as well as mortality, have been steadily decreasing for LRYGB in the past decade.

Open Roux-en-Y Gastric Bypass

Background

As described earlier in the chapter, Mason and Itoh²⁶ first described gastric bypass, and Griffin and colleagues²⁷ first described its Roux limb modification. It has been the most time-tested and proven of all bariatric operations. The procedure is now done virtually the same as LRYGB, with the only difference being the access route to perform it. Experienced bariatric surgeons who do not perform laparoscopic surgery still perform this operation with excellent overall outcomes,⁵⁶ but their numbers are diminishing. RYGB was the most popular operation performed in the United States in the 1990s, but is now far exceeded by LRYGB and LAGB in terms of volume due to the preference of patients to undergo a laparoscopic rather than open procedure. However, for the patient for whom a laparoscopic approach fails, RYGB must be an operation that the bariatric surgeon can perform with skill.

Technique

RYGB is performed essentially the same as LRYGB. Some surgeons who use an open approach prefer to perform creation of the gastric pouch as the first part of the procedure, but in essence, the net procedure is the same. Access for open RYGB is usually through an upper midline incision, although a left subcostal incision has been reported to furnish adequate access as well. Closure of the midline wound is performed using a running monofilament suture. Subcutaneous tissues are thoroughly irrigated, and skin is closed with a skin stapler.

Patient Selection and Preparation

Patient selection is essentially the same as for LRYGB, since the operation is the same. Extraordinarily large patients or those with multiple previous abdominal operations, particularly previous gastric surgery, left colectomy, and splenectomy, often require an open incision to perform RYGB. Abdominal wall thickness and liver size are other factors that may require an open incision approach. Patients who have an existing large midline incisional hernia are also candidates for an open approach.

Preparation for open RYGB is identical to LRYGB.

Postoperative Care and Follow-Up

The postoperative care of the patient undergoing open RYGB is very similar to that of the patient undergoing LRYGB. Larger volumes of fluid resuscitation and often more narcotic analgesics are required the day of surgery and often the next as well. Greater attention must be paid to the incision site for potential infection, since an inadequately treated wound infection in these patients can extend easily to the fascial level and cause significant tissue loss before it is fully diagnosed. The perioperative care of open RYGB patients is usually more intense, often because such patients are very large, and concurrently have severe comorbidities, making them higher risk overall for complications of all types. It is interesting, though, that since the era of LRYGB, patients who still undergo open RYGB (usually due to intraoperative conversion) in our practice often are discharged within 1 day of the laparoscopic patients. Our overall length of stay has decreased for RYGB patients based on postoperative pathways geared toward LRYGB.

Postoperative follow-up visits are similar to those of LRYGB patients, with the first visit being timed to appropriately remove skin staples. Other visits, follow-up schedule, and blood testing are identical to LRYGB.

Outcomes

The weight loss statistics and patterns for RYGB are comparable to those of LRYGB, as would be expected. Postoperative deaths are slightly higher for RYGB, but this is almost certainly due to the patient population, which is often among the most severely medically compromised preoperatively. Flum and Dellinger¹⁰⁶ showed that for a patient population on Medicare insurance, and hence largely disabled, RYGB had an across-the-board mortality rate of 2.0%. This rate is considerably higher than the 0.3% to 0.4% incidence that was reported for programs applying at that time as bariatric COEs and is in large part due to the patient population. Interestingly, in the report by Flum and Dellinger, surgeons with the most experience had a mortality rate of less than 1.0% for this patient population, suggesting that surgeon experience and patient selection by experienced surgeons influence mortality for RYGB.

One of the most important population studies showing the benefit of bariatric surgery was done in patients undergoing RYGB. Christou and colleagues¹⁰⁷ showed a lower incidence of mortality (0.68% vs. 6.17%) in the 5-year follow-up of over 1000 patients undergoing RYGB versus over 5000 severely obese individuals who did not have surgery. This was a reduction of 89% in the death rate.

The incidence of postoperative complications for RYGB is higher than that of LRYGB, due largely to increased morbidity from incisional hernias and other wound-related problems (see Table 27-9). Other than incisional hernias, the long-term results of patients undergoing RYGB are similar to those undergoing LRYGB, including nutritional issues, weight loss, and overall resolution of comorbidities.

Biliopancreatic Diversion and Duodenal Switch

Background

BPD was first described by, and remains championed by, Scopinaro in Italy.³² The operation, which is shown in Fig. 27-17, involves resection of the distal half to two-thirds of the stomach and creation of an alimentary tract of the most distal 200 cm of ileum, which is anastomosed to the stomach. The biliopancreatic limb is anastomosed to the alimentary tract either 75 or 100 cm proximal to the ileocecal valve, depending on the protein content of the patient’s diet. This operation met with limited international popularity, due to the technical difficulty to perform it combined with the significant percentage of nutritional complications that arise postoperatively. However, the procedure did develop a devoted following among a few bariatric surgeons.

One complication that plagued the BPD was the development of a high incidence of marginal ulcers postoperatively. Hess and Hess³³ and Marceau and colleagues¹⁰⁸ separately described the adaptation of the DS operation, originally proposed by DeMeester and colleagues¹⁰⁹ for treatment of bile reflux gastritis, to replace the gastric portion of the BPD. This new procedure was originally called BPD with DS. For ease of description, we now simply use the term duodenal switch (DS) to describe this procedure. It is illustrated in Fig. 27-18. ­Currently BPD and DS represent together less than 3% of bariatric operations performed in the United States, and this rate could be as low as 1% to 2%. The lack of a significant number of surgeons offering the operation, especially via a laparoscopic approach, probably has a great deal to do with that statistic. BPD and DS are, however, recognized as standard bariatric operations and approved for coverage by most insurance companies at this time.

Technique

The technique for BPD will be described for the open approach, but the laparoscopic approach essentially reproduces what is done with the open approach, using different access. Laparoscopic BPD and DS are very technically challenging operations, perhaps another contributing factor to the relatively low numbers of surgeons offering these operations.¹¹⁰

The BPD operation begins with performance of a distal subtotal gastrectomy. A residual 200-mL gastric pouch is created for superobese patients, or a slightly larger pouch is created for patients with a BMI under 50 kg/m². The terminal ileum is identified and divided 250 cm proximal to the ileocecal valve. The distal end of that divided ileum is then anastomosed to the stomach, creating a 2- to 3-cm stoma. The proximal end of the ileum is then anastomosed side-to-side to the terminal ileum approximately 100 cm proximal to the ileocecal valve. Some surgeons perform the anastomosis only 50 cm proximal to the valve, but in these patients, the likelihood of good protein intake postoperatively should be high. Prophylactic cholecystectomy is performed due to the high incidence of gallstone formation with the malabsorption of bile salts.

The DS procedure differs from the BPD only in the proximal gut portion of the operation. Instead of a distal gastrectomy, resection of all the stomach except for a narrow lesser curvature tube of the stomach is performed. The diameter of this tube is calibrated with a dilator and, if limited to a 32- to 40-French diameter, produces the optimal amount of weight loss while still allowing adequate oral intake. The duodenum is now divided in its first portion, leaving an approximately 2-cm length of duodenum intact beyond the pylorus. This end of the duodenum is then anastomosed to the distal 250 cm of ileum. This anastomosis is often done in an end-to-end fashion with a circular stapler. It is the most difficult portion of the DS procedure, and leak rates are slightly higher than with other anastomoses. The distal bowel configuration and cholecystectomy are similar to BPD.

Patient Selection and Preparation

Patients who undergo either BPD or DS must be prepared for the consequences of a malabsorptive operation. Frequent and large-quantity bowel movement after any large amount of oral intake is common. Patients who have this procedure must be willing to accept frequent, voluminous bowel movements and will also usually modify their eating pattern to restrict intake if access to a bathroom will prove difficult. Patients who undergo either operation must agree to close follow-up preferably by the surgeon. Internists and family physicians may not appreciate the issues related to protein-calorie malabsorption if they occur and treat the patients instead for congestive heart failure. Disastrous results may then occur. Patients must also have the financial means to afford the large number of vitamin and mineral supplements that must be taken to avoid nutritional problems in this patient population.

Given the increased incidence of postoperative nutritional and other complications relative to any of the restrictive operations, BPD and DS usually are recommended only for patients who have superobesity or for whom it is reasonable to believe they will not succeed with the diet and exercise requirements that form the basis for long-term success with restrictive operations. Patients who have failed a restrictive operation and are considering reoperation are candidates for these procedures.

Contraindications to the procedure include geographic distance from the surgeon, lack of financial means to afford supplements, and preexisting calcium, iron, or other nutrient deficiencies.

Postoperative Care and Follow-Up

Patients undergoing BPD or DS must be followed closely and with absolute completeness for nutritional issues long term. Postoperatively, BPD and DS patients face the same potential complications as seen after RYGB. Anastomotic leaks, pulmonary compromise and complications, gastrointestinal bleeding, anastomotic stenosis or obstruction, and infections are all potential concerns during the index hospitalization. The long gastric staple line and the duodenoileostomy of the DS and the duodenal stump and gastroileostomy of the BPD are all areas of anatomic concern postoperatively. Distal anastomotic problems can occur with either procedure as well. Thorough preoperative and postoperative counseling by a nutritionist versed in the operation and potential nutritional deficiencies is essential. Vitamin and mineral supplements must be taken regularly on follow-up, including oral supplements for iron, calcium, and vitamin B₁₂ and a multivitamin. Fat-soluble vitamins must be supplemented in parenteral form. Careful monitoring of protein intake and serum albumin is necessary. More frequent follow-up than with RYGB is needed; checkups at 2-month intervals for the first year and semi-annual or more frequent visits thereafter are appropriate.

Outcomes

Weight loss results with BPD or DS are both excellent and comparable. They also are very durable. One 18-year follow-up study after BPD showed a mean excess weight loss of 70% persisting for that duration of time.¹¹¹

Although most of the results of BPD or DS are after open operations, one report of laparoscopic DS showed that for 40 patients with an average BMI of 60 kg/m² the mean hospital stay was 4 days, average operation room time was 3.5 hours, and mean excess weight loss at 9 months was 58%.¹¹²

Buchwald and colleagues⁷⁴ showed that the average weight loss after BPD and DS in the literature was over 70%, with mortality rate of 1.1%, complication rate of 27% to 33%, and nutritional complication rate of 40% to 77% (see Table 27-6).

Complications that occur after the BPD include those seen after RYGB, where intestinal anastomoses and gastric division create potential problems. Scopinaro and colleagues¹¹¹ reported obstruction in 1.2%, wound infections in a similar rate, and marginal ulcer in 2.8% of patients. However, others found the incidence of marginal ulcer to be higher after BPD, causing the adoption of the DS. Preservation of the pylorus drastically reduces the significant incidence of dumping (poorly quantitated in most series) after BPD. The duodenoileostomy of DS also has a very low rate of stomal ulcer, unlike the gastroileostomy of BPD.

Nutritional complications are by far the most frequent and concerning after both of these operations, particularly on long-term follow up. Scopinaro and colleagues¹¹¹ reported a protein malnutrition rate of 7%, iron deficiency anemia rate of less than 5%, and bone demineralization at 5 years of 53%. Other problems that may arise include alopecia from inadequate protein absorption, night blindness from a lack of vitamin A, and ­gallstones if the gallbladder is not removed. However, of all these nutritional complications, protein-calorie malnutrition is the most severe and life-threatening. When it is diagnosed, the treatment is parenteral nutrition. Two episodes of required parenteral nutrition are usually considered adequate indication to lengthen the “common channel” of ileum—the ileum between the ileoileostomy of the biliopancreatic limb to the alimentary tract and the ileocecal valve. The amount that the surgeon should lengthen it is poorly documented, but most surgeons will favor making it long enough to be certain to avoid recurrence of the problem, such as doubling the length of the common channel, even if it decreases weight loss somewhat.

It cannot be emphasized enough that patients who undergo either BPD or DS should be impressed with the fact that lifetime nutritional supplements and lifetime follow-up are essential to preserve good health after these operations.

Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy has taken the bariatric surgical scene by storm over the past 5 to 10 years. It is rapidly increasing in popularity, and by the time this book is published, it may be, in some countries and areas, the most popular bariatric and metabolic operation performed. Its rapid rise in popularity coupled with good initial results suggest that it will be a major component of patient care for the treatment of morbid obesity and its comorbid medical problems for years to come in the future.

Since sleeve gastrectomy is performed almost exclusively using a laparoscopic approach, the remainder of this text will use the simple term sleeve gastrectomy (SG) to describe the procedure, with the understanding that it is routinely performed using a laparoscopic approach. SG had its origins in the early days of laparoscopic bariatric surgery. The procedure represents the gastric portion of the DS procedure.³³ Ren and colleagues¹¹² reported an initial experience of performing DS using a laparoscopic approach that had relatively higher mortality than seen with gastric bypass or other treatment options being performed laparoscopically. This was in part due to the fact that patients selected to receive DS often were significantly larger and had more numerous and more severe comorbid medical problems. Gagner began to perform the gastric resection portion of the DS operation as a first-stage procedure. After patients had lost weight, the malabsorptive component of the procedure was then performed. However, many of the patients had such good results after the first stage of the procedure that they refused to proceed to the second portion.¹¹³ Thus, the concept of performing SG as a primary procedure was born.

Until 2009, SG was considered an “experimental” procedure by insurance carriers. That year, the ASMBS reviewed the data on the procedure and published a statement in January of 2010 recognizing the procedure had adequate data and results to support its use as a primary bariatric operation for carefully selected patients.¹¹⁴ Shortly thereafter, SG received a designated Common Procedural Terminology (CPT) code. Since that time, insurance carriers have recognized the procedure as being appropriate for treating severe obesity and its comorbid problems. The final carrier, Medicare and Medicaid in the United States, issued a statement in April 2012 that left the determination of coverage of this procedure to the regional insurance carriers administering Medicare. This happened only after a hearing to determine coverage in which a great deal of data was presented in favor of the procedure. The initial conclusion of that panel was that SG should be reimbursed if performed in the setting of a prospective randomized trial. However, subsequent public opinion and data caused CMS to revise its decision to allow regional carriers to determine coverage.

SG has the advantage of being a technically easier operation to perform than gastric bypass, while achieving better efficacy in treating comorbid medical problems and producing superior weight loss than LAGB. Once the results of the procedure began to be published, understood, and accepted, its popularity rose dramatically. In the United States, the incidence of performing SG has risen rapidly since 2008, as shown in Fig. 27-19. The incidence of SG is increasing at a rate that suggests that within the next 2 years it may pass LRYGB as the most popular bariatric operation performed in the United States.

Throughout the rest of the world, the popularity of SG has also risen dramatically in the past 5 to 8 years. In Asia, where there is a high incidence of gastric cancer in countries such as Japan, SG makes more sense anatomically as an appropriate treatment for severe obesity. In India, where the high incidence of diabetes in the obese population makes metabolic and bariatric surgery a desirable option, SG has gained popularity once its effectiveness in treating diabetes was shown. Figure 27-20 shows the trend in performance of several bariatric operations in Asia from 2003 to 2011, during which the totals of those procedures from surgeons surveyed increased over 500%.³⁷ This rise in bariatric and metabolic surgery was comparable to the same increase in percentage of cases performed seen in the United States from 1998 to 2003. In Europe, the past few years have seen a clear trend away from performing LAGB and a higher incidence of performing both SG and LRYGB.³⁷

Indications

Patient selection for SG is comparable to that for other bariatric and metabolic operations with a few notable exceptions. SG was originally introduced as the first of a two-stage operative treatment for patients with super obesity (BMI >60 kg/m²).¹¹⁵ It remains an effective first- or second-stage treatment for such patients. Whether a second stage is indicated depends on the effectiveness of the SG. SG has been shown to be safe and effective in adolescent obese patients.¹¹⁶ It has also been shown to be an acceptable procedure for the elderly obese patient.¹¹⁷ SG effectively treats most of the comorbid medical problems associated with obesity. The one exception is GERD. Patients with GERD experience less resolution of their symptoms after SG than do patients with LAGB, even when the LABG patients lost less weight overall.⁹³ Patients who have longstanding severe GERD may not be good candidates for SG. Barrett’s esophagus is considered a relative contraindication for performing SG, since the potential for future esophagectomy and the need for an available intact stomach for reconstruction outweigh the potential advantages of the procedure.

Technique

The patient is positioned supine, with foot support to allow reverse Trendelenburg positioning. The surgeon stands to the patient’s right along with the camera driver, while the assistant stands to the patient’s left. Port placement may vary from institution to institution, but our recommended port placement is shown in Fig. 27-21. The 15-mm port, helpful for removal of the stomach, is located in either the camera (just to the patient’s left of the umbilicus) or surgeon’s right hand (right upper quadrant near the midline) location. The other of these ports is a 12-mm port. The assistant has two 5-mm ports available in the left upper quadrant laterally, and the surgeon’s left hand port is a 5-mm port more lateral and superior in the right upper quadrant. A liver retractor is placed in the epigastric region. This can be a Nathanson or T-Boone retractor.

The operation begins by devascularizing the greater curvature of the stomach, beginning 3 to 5 cm proximal to the pylorus. The harmonic scalpel works nicely to perform this tissue division. The division of all vessels adjacent to the greater curvature is continued up to the left crus of the diaphragm. A complete mobilization of the fundus in this area and division of posterior fibrous attachments to the antrum and body of the stomach are then performed such that the stomach is attached solely by the lesser curvature blood supply and the pyloric and esophageal regions. Stapled division of the stomach now follows. The first firing of the stapler occurs from the point of devascularization of the greater curvature at an angle pointing toward a point about 2 cm lateral to the incisura. The antrum of the stomach is at its thickest here, and so it is important to be certain the stapler load used is sufficiently large enough to allow good approximation and closure of the divided stomach. We have favored use of the black load (2.5-mm staple height) in all males with a BMI over 45 kg/m², females with a BMI over 55 kg/m², or anyone whose stomach looks particularly thick. A green load (staple height of 2 mm when closed) is used for less thick stomachs or smaller individuals. We continue the use of this color load for the first two firings, which takes the gastric division to past the incisura. After the first staple firing, some surgeons will engage the anesthesiologist to pass a 32- to 36-French bougie and position it along the lesser curvature of the stomach. This bougie then serves as a guide for further gastric division. Alternatively, some surgeons will insert the endoscope instead of the bougie as a guide for gastric division. It can also be used to test for air leaks, bleeding, or obstruction as it is withdrawn after gastric division. Dividing the stomach adjacent to the bougie or endoscope will produce the desired diameter of the gastric sleeve. It is most important not to narrow the stomach lumen at the incisura. During the second and third firing of the stapler to divide the stomach, it is critical to confirm by visualization of both the anterior and posterior surfaces of the stomach that the incisura area is not narrowed. By the third firing of the stapler, usually the angle of the gastric division is now pointed directly toward the angle of His, parallel to the bougie (Fig. 27-22). At this point, changing staple loads to lower staple height is advisable. We usually switch to gold then blue staple loads as we progress proximally in dividing the stomach. It is essential that with each firing of the stapler, adequate time (10–20 seconds) is allowed for tissue compression to allow optimal staple closure and security of the divided tissue.

Once the stomach is completely divided up to the angle of His, the staple line is inspected for hemostasis and integrity. Some surgeons will reinforce the staple line with a buttress material, while others will invaginate the staple line with a running serosa to serosa suture. Some surgeons will exchange the bougie at this point for a 32-French Ewald tube and perform a methylene blue leak test. Alternatively, if an endoscope is used, it is withdrawn with insufflation, and the staple line is inspected for air leaks while submerged in saline. The specimen is removed through the 15-mm trocar site, usually with only slight enlargement of the site. Figure 27-23 shows the completed operation.

Controversy still exists as to the optimal size of the bougie used during the procedure. One summary of the literature shows that the stenosis rate is lower if a 40-French bougie is used, and the leak rate may also be lower without compromising weight loss.¹¹⁸ However, individual institutional experiences with smaller-sized bougies have shown the potential for exceptionally good weight loss and no increased incidence of stenosis.¹¹⁹ Another controversial area is that of staple line reinforcement with staple buttressing material. Some surgeons advocate routine staple line reinforcement, whereas others advocate none. Still others advocate oversewing of the staple line in areas of bleeding or in selected cases that show a predilection for bleeding intraoperatively. Other experts advocate routine oversewing of the entire staple line.¹²⁰ At this time, there is no preponderance of data to support one approach as being superior to others.

Postoperative Care and Follow-Up

SG usually is performed with an overnight stay of 2 nights after surgery. Longer hospitalizations are indicated for patients with more severe medical problems. Absence of signs of bleeding and a documented intact staple line with good gastric emptying are required prior to discharge. Routine Gastrografin swallow on the first day after surgery is used by many surgeons, but its efficacy and cost-effectiveness have yet to be clearly documented. Follow-up is similar to that after LRYGB. Few nutritional complications occur unless the patient has difficulty taking in enough nutrients or protein or vitamins due to edema or tightness of the sleeve lumen. Most surgeons advocate routine vitamin B₁₂. Iron supplementation may be required as well since iron in the diet is usually drastically restricted by elimination of many foods rich in iron. It is unclear whether the same need for vitamin D supplementation seen after LRYGB is also needed after SG, since there is a high incidence of low 25-hydroxyvitamin D levels preoperatively in patients undergoing SG.¹²¹ Routine multivitamins are usually prescribed to avert any potential other shortages from dietary vagaries.

The other aspect of weight loss that must be considered in the nutritional aspects of postoperative care and follow-up after SG is that patients are at risk of losing significant lean body mass while they are also losing weight. Damms-Machado and colleagues¹²¹ showed that SG patients’ lean body mass decreased from 74.8 kg to 62.3 kg at 1 year after SG. This emphasizes the need for high protein content in the postoperative diet of SG patients to maintain lean body mass.

Outcomes and Complications

Reports in the literature of the success and excellent weight loss after SG have been accumulating since 2006.^122,123 The first very large series from a single institution reported 750 patients undergoing SG as a primary weight loss procedure. Five-year follow-up of some patients was available, and a hospital stay averaging 1.7 days, a major complication rate under 5%, an operative time under 80 minutes, and no conversions or mortality were reported.¹²⁴

Brethauer and colleagues¹²⁵ published an excellent review of the early data on SG through 2009. For the collected number of patients treated with SG (2750 patients), the excess weight loss rate was 55.4%. Studies with 5-year follow-up for SG are not yet common. One highly successful series was recently reported by Rawlins and colleagues¹¹⁹ for 49 patients followed for 5 years after SG with an average weight loss of 86% of excess weight and a decrease in average BMI from 65 to 35 kg/m². One of the longest follow-up studies for SG by Eid and colleagues¹²⁶ demonstrated an average excess weight loss of 48% and BMI decrease from 66 to 46 kg/m² in 74 superobese patients with 6- to 8-year follow-up.

Prospective randomized trials comparing SG with other procedures have shown that SG is superior to LAGB for excess weight loss at 3 years (66% vs. 48%).¹²⁷ One study reported that SG achieved a superior excess weight loss compared with LRYGB (69.7% vs. 60.5%) at 1 year after surgery. This study also found greater appetite suppression and a lower serum ghrelin level for SG.¹²⁸

SG has been included in the results of large databases showing outcomes after bariatric surgery. Data from the ACS BSCN showed that SG was positioned between LAGB and LRYGB for efficacy of weight loss and resolution of comorbid medical problems and for morbidity and mortality.⁹³

As noted earlier, controversy exists as to whether the use of buttress materials with the stapling of the stomach improves outcomes. The overall bleeding rate for the staple line after SG is generally cited as about 2% in collected series.¹²⁵ There have been no studies that have shown a definitive decrease in this bleeding rate with the use of buttress materials; however, a panel of experts has voiced support for a decreased incidence of bleeding from the staple line if buttress material is used.¹²⁰

Measures to prevent staple line leakage are similarly controversial with respect to buttress materials and other measures. It is certain that appropriate stapling technique in dividing the stomach is important. Using an adequately high staple height for the tissue to be divided and allowing an adequate amount of time for tissue decompression within the stapler jaws before firing are essential to minimize the likelihood of a staple line leak. Failure to perform gastric division appropriately in this fashion will lead to an early staple line leak after surgery. Whether buttress materials do decrease the leak rate with SG is very controversial. One meta-analysis did show that there is evidence to suggest buttress materials may decrease this rate.¹²⁹ Other prospective randomized studies have failed to show a benefit of buttress materials.¹³⁰ To date, the literature has not clearly shown a benefit for using buttress materials in terms of leak prevention.

Perhaps the major factor that is different in SG than other gastric stapling procedures is that SG creates a high-pressure gastric tube. This increased intraluminal pressure places the staple line at risk for leakage. If there is a relative obstruction or stenosis of the sleeve, which most often may occur at the incisura due to narrowing there during formation of the sleeve, pressure above the level of the obstruction will be even more elevated and create an increased risk for staple line leak. Leaks of the proximal staple line are the most frequent type seen after SG and often are felt to be related to increased intraluminal pressure distally. They may also be related to stapling too close to the angle of His, with resultant instability of the tissue directly adjacent to the esophagus in this area. It is important not to staple too close to the angle of His during the final stapling division portion of the stomach so as to not further weaken the staple line in this area. Proximal staple line leaks may also present as late leaks. Late leaks are generally felt to be those that occur 6 weeks or longer after surgery. Late leaks are rare in other bariatric procedures, but are seen with SG. The increased pressure of the system may be a reason SG is associated with late leaks. Confirmation and treatment of stenosis symptoms early after SG may prevent such leaks.

Distal staple line leaks are different than proximal staple line leaks, and are usually associated with earlier presentation and related to mechanical failure of the staple line to securely approximate the thicker distal gastric tissue. These leaks are more amenable to successful repair with a reoperation, whereas proximal leaks may not improve with oversewing at a reoperation unless the mechanics of the relative distal obstruction and high intraluminal pressure of the sleeve are also treated. Endoscopic intervention to dilate stenotic areas as well may be beneficial in the setting of a stenosis with or without a proximal leak. Care must be taken by the endoscopist to not excessively dilate the tract beyond the original size of the bougie used. Another factor that may influence stenosis at the incisura is that there may be a relative twisting of the stomach at this location, with the antrum being partially twisted away from the upper portion of the sleeve. Endoscopic treatment can help straighten and markedly alleviate the obstruction in such cases. Thus relatively early endoscopic intervention is appropriate in the patient with a stenosis at the incisura. One study has shown that endoscopic dilation is usually successful in treating stenosis after SG, with a mean of 1.6 dilatations being done an average of 48 days postoperatively.¹³¹

The patient with the proximal gastric staple line leak due to mechanical factors may experience a persistence of the leak for months. Such cases are now only recently being published and discussed in the literature. It is unclear how long one should optimally treat such a leak conservatively with the likelihood it will close. Reports of such leaks persisting for multiple months postoperatively exist. Our own experience has been that eventual closure of such a leak is possible even 4 months postoperatively. However, longer duration leaks are less likely to close. Some experts have now advocated conversion of the patient with a longstanding leak after SG to a RYGB to provide a low-pressure anastomosis above the site of the stenosis. Similarly, persistent stenosis of the sleeve despite conservative therapy and endoscopic dilatation also is an indication for conversion to LRYGB.

Physiology of Weight Loss

SG is a fairly simple technical operation, amenable to performance by many surgeons. The results of the operation for weight loss have been excellent and dramatic. However, the mechanisms of the resolution of comorbidities, such as diabetes, are still not totally clear. While weight loss alone may provide the majority of the physiologic changes that improve comorbid problems such as diabetes and hypertension, it is also possible that other factors may be involved. Certainly SG, through gastric resection, eliminates much of the ghrelin-producing portion of the stomach. The resolution of type 2 diabetes after SG is remarkable, although not as good as that seen after RYGB. The reasons for this are as yet unclear, since lap RYGB has been shown to have independent factors influencing glucose metabolism separate from weight loss alone. The hormonal and peptidergic changes produced by SG in terms of appetite suppression, glucose metabolism, and other metabolic pathways have yet to be clarified. A recent hypothesis summarized by Ed Mason¹³² is that the rapid emptying of the stomach after SG creates a similar exaggerated release of GLP-1 as seen after LRYGB, and this results in the improved carbohydrate metabolism and improvement of type 2 diabetes seen after SG, as after LRYGB.¹³³

There is some concern among the bariatric surgical community that SG, because it is technically not that difficult, could become a procedure performed by surgeons without a full support system and follow-up mechanism for bariatric patients. The bariatric surgery community feels strongly that this procedure should remain a procedure done within the confines of the COE framework. This will ensure optimal patient outcomes.

Bariatric Procedures in Adolescent and Elderly Patients

The incidence of obesity in the U.S. population has risen dramatically during the past two decades. This increase has included children and adolescents as well. The incidence of obesity (BMI >30 kg/m²) is estimated to exceed 25% in the adolescent population. Factors felt to contribute to this include decreased participation in physical sports and activities, increased time playing computer and screen games, and increased consumption of fast food and processed foods.

Obese adolescents have a high likelihood of being obese adults. In one study, 75% of adolescents above the 85th percentile were obese as adults.¹³⁴ The social stigmatization of the severely obese adolescent is often brutal. Comorbid medical problems may already be present in severely obese adolescents, including hypertension and type 2 diabetes. The overwhelming likelihood of a severely obese adolescent facing a lifetime of severe obesity as an adult also implies that an average of 12 years of life for males and 9 years of life for females will be lost due to this medical problem.

The major controversy with regard to adolescents undergoing bariatric surgery includes the general aversion of subjecting an adolescent to surgery as well as the concern of the secondary side effects of bariatric surgery on remaining growth and development. Clearly the younger the patient, the more relevant the latter concern becomes.

The literature to date on the results of outcomes from bariatric surgery on adolescents is generally quite favorable. However, it is still limited. Sugerman and colleagues¹³⁵ reported on results for 33 adolescents, 30 of whom had RYGB (mostly open RYGB). There were two late deaths at 2 and 6 years of follow-up unrelated to surgery. There were 20 early and late complications, including six incisional hernias and five wound infections. Significant weight loss was maintained in the majority of patients for up to 14 years after surgery. Most comorbidities resolved at 1 year after surgery. Self-image was greatly enhanced and social stigmatization greatly decreased. Capella and Capella¹³⁶ reported on 19 adolescent patients treated with a modified version of open RYGB in which a vertical band was added to the pouch. After an average 5.5-year follow-up, average BMI for the group was 28 kg/m². No deaths occurred, but two patients required revisional surgery. No mortality or morbidity was reported, and all comorbidities resolved. Abu-Abeid and colleagues¹³⁷ treated 11 adolescents with LAGB. No late complications occurred, and after a 4-year follow-up, BMI average went from 46.4 to 32.1 kg/m².

A meta-analysis involving 131 adolescents undergoing bariatric surgery demonstrated a 17.8 to 22.3 kg/m² decrease in BMI after RYGB.¹³⁸ They also observed improvement of hypertension in more than half the patients and sleep apnea resolution in all 131 patients. There were four mortalities in this cohort, but only one of them was potentially associated with the procedure (Clostridium difficile colitis 9 months after operation). Morbidity in the adolescent literature ranges from 0% to 38% and tends to be minor in most cases. The most common complication in the meta-analysis was nutrient deficiencies. The weight of the evidence supports adolescent bariatric surgery as a safe and effective treatment of severe obesity in adolescents. The ASMBS pediatric guidelines suggest using BMI criteria similar to the adult population but with some modifications to comorbidity thresholds.¹³⁹ They recommend considering surgery in patients with a BMI of 35 kg/m² or greater with major comorbidities (e.g., type 2 diabetes, severe nonalcoholic fatty liver disease, OSA) or a BMI of 40 kg/m² or greater with minor comorbidities (e.g., hypertension, dyslipidemia, insulin resistance).

The elderly patient population certainly suffers from severe obesity. However, data on the effect of nonsurgical therapies in treating this patient population are lacking. Similarly, it is likely that the patient who becomes obese late in life has a significantly different prognosis than the individual who has been severely obese and does manage to survive to an older age despite the resulting comorbidities.

There has been an increasing tendency to offer bariatric surgery to patients over the age of 60. Studies have documented that this patient population can have the same good outcomes and resolution of comorbidities as younger patients.¹⁴⁰ Nehoda and colleagues¹⁴¹ reported equally excellent results for LAGB in patients over age 50 compared with those under age 50. Excess weight loss of 68%, reoperation rate of 10%, and 97% improvement in comorbidities were reported for this age group. A recent retrospective review of 42 carefully selected bariatric surgery patients over 70 years old looked at the outcomes up to 1 year after surgery. Of these patients, 22 patients (52.4%) underwent laparoscopic gastric banding, 12 patients (28.6%) underwent laparoscopic SG, and 8 patients (19%) underwent LRYGB. They safely achieved a mean weight loss of 47.7% with no mortality and modest improvement in obesity-associated comorbidities.¹⁴² SG for elderly patients is also gaining popularity. In 35 patients ≥60 years of age, Soto and colleagues¹⁴³ demonstrated greater than 60% excess weight loss at 48 months with low morbidity (8.4%) and no mortality with SG.

Although these data show that in selected older patients excellent results can be obtained, surgeons must be cautious to determine which patients have been severely obese for decades and therefore have essentially end-stage organ function in many cases as a result of the comorbid medical conditions that have been present for decades. Flum and Dellinger¹⁰⁶ showed that the older patient population, especially those few patients older than age 70 undergoing bariatric surgery, did have an increased incidence of mortality and morbidity after RYGB.

The concept that bariatric surgery confers an improved quality of life, a longer life, and a life without as many associated medical problems leads to the logical conclusion that the benefits of an operation will be more fully realized in the younger patient. This philosophy, in view of the large number of unserved patients, does justify age limits for individual surgeon practices. While some surgeons do have such limits, patients near or just over the age limit are often reviewed on an individual basis to determine their appropriateness for surgery. However, some surgeons will base their decision on “physiologic” age rather than chronologic age because many elderly patients may be reasonably low risk for major complications. Accumulation of data may also change these limits in the future.

The Female Patient: Pregnancy and Gynecologic Issues in the Bariatric Surgery Patient

Hormonal levels in female patients are related to body weight. Obesity alters the levels of estrogen and progesterone available for normal ovulation, resulting in abnormal ovulation patterns, amenorrhea, and difficulty conceiving. Should an obese woman become pregnant, the increased chances of gestational diabetes and hypertension make the pregnancy high risk. Macrosomia is increased. There is a two- to three-fold increase in the rate of cesarean sections, with more complications. Fetal mortality does not appear to be changed when maternal weight gain is limited.¹⁴⁴ With obesity, there is an increased risk for breast and endometrial cancer in the postpartum mother.

Infertility compounds the difficulties of the obese woman who wishes to have an uncomplicated pregnancy and delivery. The same hormonal alterations that cause an increased incidence of cancer (i.e., increased circulating estrogen levels) also cause infertility. If a severely obese woman becomes pregnant, the pregnancy management is made more difficult by the body habitus and the need for more frequent ultrasounds as opposed to physical examination, which yields limited information.

Women who become pregnant soon after undergoing bariatric surgery can be at risk due to the ongoing weight loss produced by the operation. However, if the pregnancy is quickly recognized and appropriately managed, patients after bariatric surgery may actually have a better prognosis than if they had not had surgery. Wittgrove and colleagues¹⁴⁵ showed that patients who had undergone RYGB had a decreased incidence of diabetes, macrosomia, and cesarean section than those who had not had surgery. However, iron replacement was cited as a critical need for these pregnant women. Despite these good results, there are issues for the female patient who undergoes RYGB and becomes pregnant during the rapid weight loss phase after surgery. Special attention is needed to assure adequate intake of vitamins and essential nutrients during what otherwise would be a period of rapid weight loss. Although no clear consensus exists regarding management of pregnancy after bariatric surgery, Beard and colleagues¹⁴⁶ provide the following sound advice: (a) promotion of reliable contraception for 12 to 18 months after surgery; (b) close nutritional and weight monitoring during and after pregnancy; (c) supplementation to include daily prenatal vitamin, folate 400 μg, iron 50 to 100 mg, calcium 1000 mg, and protein 60 g; and (d) collaboration with high-risk obstetrical colleagues as needed.

Patients who become pregnant after LAGB would seem to have even less likelihood of significant risk to their pregnancy, since the band can be adjusted to allow more food intake during the pregnancy but similarly limit weight gain to a healthy amount. Dixon and colleagues¹⁴⁷ wrote that morbidly obese women do have higher risks during pregnancy, but LAGB allows weight loss, which reduces such risk. The adjustability of the band provides a potential advantage for the pregnant woman.

Weight loss after bariatric surgery can correct the high incidence of gynecologic problems that may exist as a result of severe obesity. Deitel and colleagues¹⁴⁸ found menstrual irregularities in over 40% of patients preoperatively, which became normal in over 95% of patients postoperatively. Infertility problems were present preoperatively in 29% of patients, and medical problems were frequent during previous pregnancies including hypertension in 26.7%, preeclampsia in 12.8%, diabetes in 7%, and deep vein thrombosis in 7%. These problems were virtually eliminated after weight loss. Stress urinary incontinence in the female patients in that study decreased from 61.2% to 11.6% after bariatric surgery.

Polycystic ovary syndrome (PCOS) is another common hormonal dysfunction associated with severe obesity. It is associated with obesity, infertility, hyperandrogenism, dyslipidemia, anovulation, insulin resistance, and abnormal menses.¹⁴⁹ Bariatric surgery improves not only metabolic disease but also menstrual irregularity, hirsutism, and infertility associated with PCOS.^150,151

Stress urinary incontinence is a frequent problem of the severely obese woman, which must be specifically solicited on history. The increased intra-abdominal pressure from severe obesity contributes to the high incidence of this problem in the severely obese population. Obesity may also alter the neuromuscular function of the genitourinary tract, contributing to incontinence. Studies have confirmed the increased incidence of obesity in patients with both true stress incontinence and detrusor instability.¹⁵² Weight loss alone relieves symptoms in many patients with obesity. A recent study involving 72 patients who had bariatric surgery (90% RYGB) showed a nearly 50% reduction in prevalence and severity of urinary incontinence after surgery based on objective urodynamic testing.¹⁵³ A significant improvement in subjective quality of life and sexual function was also achieved.

Metabolic Surgery

Advances in the role of metabolic surgery to treat type 2 diabetes mellitus (T2DM) and increases in the understanding of how surgery improves or resolves T2DM continue to represent the single most prominent change in the field of bariatric surgery since the last edition of this text. Nearly all international bariatric surgery societies have added “metabolic” to their name, including the American Society for Metabolic and Bariatric Surgery (ASMBS), which was formerly the American Society for Bariatric Surgery (ASBS). International meetings on the topic of bariatric surgery and its effects on diabetes have convened during the last 5 years to establish new guidelines regarding indications for metabolic surgery for T2DM as well as research priorities.¹⁵⁴ The entire field of bariatric surgery is now much more focused on the metabolic effects and benefits of bariatric surgery.

Although many comorbidities are improved by bariatric surgery and its resultant weight loss, the metabolic diseases that are most particularly affected are T2DM and the hyperlipidemias and metabolic syndrome. Hypertension and cardiovascular disease are also improved indirectly through metabolic benefits as well as directly through weight loss effects.

Type 2 Diabetes

There has been a dramatic increase in the potential application of surgical therapy to treat T2DM. Much of this stems from the original observations of surgeons performing RYGB concerning the improvement or near resolution of T2DM well before patients who had undergone the operation had achieved maximum weight loss. Pories and colleagues¹⁵⁵ championed these observations in a landmark paper that confirmed RYGB as an effective treatment for T2DM, resolving the condition in 85% of patients who had developed it within the 5 years prior to surgery. MacDonald and colleagues,¹⁵⁶ also from the same institution, showed that treatment with RYGB of patients with T2DM resulted in longer life span. Schauer and colleagues¹⁵⁷ showed that improvement in T2DM after LRYGB is comparable to that seen in Pories’ original work, with fasting insulin levels and glycosylated hemoglobin levels returned to normal levels in 83% of patients and markedly improved in 17% of patients. RYGB has been shown to decrease overall long-term mortality related to diabetes in several large population studies.^158,159

These results and studies, as well as the observation that T2DM resolved quickly after RYGB, led to the general belief that there is an important contribution of the enteric hormonal component of glucose metabolism influencing the disease. Rubino and Marescaux¹⁶⁰ reported the resolution of diabetes in the obese rat model with surgical diversion of the food stream from the duodenum and proximal jejunum. Reversal of the operation led to return of the disease state. The extension of the findings of Rubino and Marescaux to humans has occurred; a duodenojejunal exclusion operation has been performed and shows initial safety and efficacy in a small group of patients.¹⁶¹ Although the majority of patients who have T2DM are obese, approximately 10% of patients with T2DM are not obese, and these data from Brazil may confirm that the resolution of the disease through enteric diversion is not based on associated weight loss.¹⁶²

Surgical therapy that does produce weight loss without diversion of the enteric stream also can be quite effective in resolving T2DM. Dixon and colleagues⁷⁰ reported, in the first randomized controlled trial comparing surgical versus medical treatment of diabetes, that 73% of patients undergoing LAGB and followed for 2 years achieved resolution of T2DM versus 13% of medically treated patients in the control group. An accompanying editorial to Dixon’s article advocated that the treatment for diabetes be reshaped to include consideration of surgical therapy as an option for patients, especially severely obese patients.¹⁶³

Despite these data in the literature, there has been resistance from endocrinologists and internists specializing in the medical treatment of diabetes to accept the use of surgical therapy as an optimal treatment for the disease.¹⁶⁴ One major criticism pertaining to the quality of outcome studies for diabetes surgery has been that except for the Dixon study, none have been randomized controlled trials. In the last few years, ­however, three additional randomized controlled trials have been published in high-impact medical journals. Schauer and colleagues (n = 150) showed superior glycemic control (defined as hemoglobin A1c [HbA1c] <6% with or without medications) after RYGB (42%) and SG (37%) compared to intense medical therapy (12%) at 1 year (P < .001) in patients with mild to moderate obesity (BMI 27–43 kg/m²) and poorly controlled T2DM (average HbA1c 9%).¹⁶⁵ Gastric bypass and SG resulted in greater improvement in other cardiovascular risk factors such as BMI, triglycerides, high-density lipoprotein, and C-reactive protein compared with intense medical therapy. The surgical patients also significantly reduced their dependency on diabetes medications, while medical patients had increased dependency on diabetes medications. Mingrone and colleagues (n = 60) demonstrated that diabetes remission rates (HbA1c <6.5% without medications) were superior after BPD (95%) and RYGB (75%) compared to conventional medical therapy (0%) at 2 years (P < .001) in patients with severe obesity (average BMI 45 kg/m²) and poorly controlled T2DM (average HbA1c 9%).¹⁶⁶ Ikramuddin and colleagues (n = 120) found that RYGB (49%) was superior (P < .001) to intense medical therapy (19%) in achieving the American Diabetes Association goal of therapy (HbA1c <7%, low-density lipoprotein cholesterol <100 mg/dL, systolic blood pressure <130 mmHg) in patients with obesity (BMI 30 to 40 kg/m²) and poorly controlled T2DM (average HbA1c 9.6%).¹⁶⁷ All four randomized controlled trials to date have shown that surgery in the short term (1–2 years) was well tolerated, with few major complications (two serious cases of sepsis), no cardiovascular events, and no operative mortality, and that surgery resulted in both superior glycemic control and greater improvements in cardiovascular risk factors compared to medical treatment alone.

Adoption of metabolic surgery by endocrinologists, internists, and primary care physicians as a treatment of T2DM has gradually increased over the last 5 years. The Diabetes Surgery Summit in 2007 published the first consensus guidelines for the use and study of metabolic surgery.¹⁵⁴ Since 2009, the American Diabetes Association has included bariatric surgery in their position statement on standards of medical care in T2DM. The guideline indicates that “bariatric surgery should be considered for adults with BMI ≥35 kg/m² and T2DM, especially if the diabetes is difficult to control with lifestyle and pharmacological therapy.”¹⁶⁸ In 2011, the International Diabetes Federation (IDF) released its position statement on the role of surgery and other gastrointestinal interventions in the management of T2DM.¹⁶⁹ At this time, the IDF guidelines are the most useful summaries, from the evidence available, for healthcare providers who manage patients with T2DM. The IDF guidelines are the first to recommend that metabolic surgery be considered for patients with a BMI as low as 30 kg/m² if they are not in good glycemic control on optimal medical therapy.

Metabolic Syndrome

The metabolic syndrome is characterized by central obesity, glucose intolerance, dyslipidemia, and hypertension. This is a common finding in patients with severe obesity, occurring in 52% of individuals in one report.¹⁷⁰ All the associated metabolic problems of the metabolic syndrome respond to surgical therapy to produce weight loss. Basic scientists attribute the occurrence of this associated array of diseases to an enhanced inflammatory state in the body resulting from the increased production of cytokines by the adipocyte. These cytokines in turn produce a mild inflammatory reaction that promotes the production of these diseases.

Diabetes and glucose tolerance are effectively treated by bariatric operations as discussed earlier. These operations also are effective in treating the other components of metabolic ­syndrome. RYGB produced a 98% resolution of the metabolic syndrome in patients 1 year after surgery.¹⁷¹

Dyslipidemias improve in over 70% of patients undergoing RYGB. Improvement is 100% and resolution is greater than 90% after any of the malabsorptive operations (see Table 27-7). Overall lipid profiles are improved, and the degree to which this occurs is in part related to exercise levels of the individual as well as genetic components of the disease.

Cardiovascular Disease

Hypertension, a component of the metabolic syndrome, is one of the cardiovascular diseases that are increased in the setting of obesity. Elevated arterial pressure in patients with obesity-related hypertension is associated with increased cardiac output and total peripheral resistance. The elevated output is related to expanded intravascular volume that increases cardiopulmonary volume, venous return, and left ventricular preload; the elevated pressure and total peripheral resistance increase afterload. This dual ventricular overload promotes a dimorphic, concentric, and eccentric hypertrophy in response to the volume and pressure overload. Increased myocardial oxygen demand results from the elevated tension in the left ventricular wall, reflecting its increased diameter and pressure, and provides a physiologic rationale for the greater potential of coronary arterial insufficiency and cardiac failure. There is greater renal blood flow and lower renal vascular resistance in patients with obesity-related hypertension at any level of arterial pressure. This may be offset by an increased renal filtration fraction that may favor protein deposition and glomerulosclerosis.¹⁷⁰

Weight loss results in decreased intravascular volume, decreased cardiac output, and decreased arterial pressure. These manifestations occur after all the various bariatric operations that produce weight loss.

Heart failure also is increased in the setting of severe obesity. Much of the risk is secondary to the processes mentioned earlier, which produce hypertension and cardiac hypertrophy. Hypertension and obesity have significant independent associations with left ventricular hypertrophy and cardiac wall thickness. Obesity is particularly strongly associated with left ventricular internal diameter.¹⁷²

Much data now exists regarding the effect of bariatric surgery on cardiovascular disease. A recent systematic review of long-term cardiovascular risk factor reduction after bariatric surgery involved 73 studies and 19,543 subjects with a mean age of 42 years; 76% of subjects were female, and 44%, 24%, and 44% had a baseline hypertension, diabetes, and hyperlipidemia, respectively.¹⁷³ At a mean follow-up of 57.8 months, the average excess weight loss for all bariatric procedures was 54%, and remission/improvement was 63% for hypertension, 73% for T2DM, and 65% for hyperlipidemia. Echocardiographic results from 713 subjects showed statistically significant improvements in left ventricular mass, E/A ratio, and isovolumic relaxation time postoperatively.

Thus far, there are no long-term randomized controlled trials comparing bariatric surgery with nonsurgical medical treatment of obesity that evaluate cardiovascular endpoints and mortality. However, 12 cohort-matched studies comparing bariatric surgery with nonsurgical controls have recently been reviewed.¹⁷⁴ Collectively, all but two of these studies support a reduced cardiovascular event rate and all-cause mortality rate conferred by bariatric surgery. Of these studies, the Swedish Obesity Subjects (SOS) study has the longest outcomes follow-up at a median of 14.7 years.¹⁵⁸ Cardiovascular mortality in the surgical group was significantly lower than for control subjects (adjusted hazard ratio, 0.47; 95% confidence interval, 0.29–0.76; P = .002) despite the greater prevalence of smoking and higher baseline weights and blood pressures in the surgical cohort. The SOS study has formed the basis of much of our current understanding of medium- and long-term outcomes after bariatric surgery despite the fact that the majority of their surgical cohort received vertical-banded gastroplasty (>70%), a gastric volume reduction procedure that is now rarely performed in the United States.

Resolution of Other Comorbid Medical Problems

Bariatric surgery can produce resolution of many, if not all, of the comorbid medical problems associated with obesity and present at the time of surgery. This is true to some extent for all bariatric procedures, although some are more efficient at reversing specific comorbid problems than others.

GERD is symptomatically present in approximately half of patients with severe obesity and has been objectively proven to be present in 21%.⁹² Unfortunately, obese patients with GERD have a higher chance of failing to obtain symptomatic relief from standard antireflux surgery. The recurrence of symptoms is higher, likely due to a higher incidence of wrap herniation into the mediastinum and other mechanical failure of the fundoplication, which in turn is likely affected by the increased intra-abdominal pressure of the obese condition. The patient with a BMI over 35 kg/m² who has GERD has a better chance of elimination of symptoms by undergoing LRYGB, which is >90% effective in the elimination of GERD.¹⁷⁵ LRYGB creates such a small gastric pouch that it has a very limited volume for acid production. LAGB improves GERD but to a considerably lesser extent than RYGB. A recent prospective analysis of 558 consecutive laparoscopic SG (n = 200) and LRYGB (n = 358) patients demonstrated significantly improved subjective GERD symptoms in the bypass cohort when compared to the SG patients at 1 year (P < .001).¹⁷⁶ In fact, some studies suggest that SG can increase GERD symptoms postoperatively. Zhang and colleagues¹⁷⁷ reported new reflux seen on upper gastrointestinal series in 18% of their 28 patients after SG.

OSA is a disturbance of sleep associated with obesity. It is a measurable problem, quantitated by polysomnography. In one recent study of 349 patients considering bariatric surgery who were referred and tested, only 17% had no sleep apnea, whereas 32% had mild, 18% moderate, and 33% severe sleep apnea.¹⁷⁸ At a mean time of 11 months after RYGB, the mean Respiratory Disturbance Index for all patients decreased from 51 to 15 (P < 0.01). Of 83 patients using continuous positive airway pressure or bilevel positive airway pressure preoperatively, only 31 still required it, and they had decreased setting requirements. A recent systematic review of 13,900 patients (69 studies) showed significant improvement or resolution of sleep apnea in more than 75% of bariatric surgery patients.¹⁷⁹ Comparison of outcomes between procedures demonstrated the most benefit with BPD and gastric bypass and the least with LAGB. However, a recent randomized control trial comparing the effect of medical and surgical weight loss (LAGB) on sleep apnea found no significant difference in apnea events despite major differences in weight loss. The findings suggested that much of the improvement achieved was in the mild to moderate weight loss range, with little benefit of further weight loss.¹⁸⁰

Another pulmonary symptom that commonly occurs in severely obese patients is asthma. Dixon and colleagues¹⁸¹ studied 23 asthmatic patients who underwent bariatric surgery and found a significant improvement in asthma control (e.g., forced expiratory volume in 1 second, forced vital capacity), asthma-related quality of life, and responsiveness to methacholine. Boulet and colleagues¹⁸² found similar results in their cohort of 12 patients with asthma who experienced significant weight loss after bariatric surgery.

Nonalcoholic fatty liver disease (NAFLD) is a metabolically related problem associated with obesity. The disease is a spectrum of liver abnormalities including steatosis, steatohepatitis, fibrosis, and cirrhosis of the liver. It is estimated that 20% of U.S. adults have NAFLD, largely because of the high incidence of obesity. NAFLD is present in an estimated 85% of patients with severe obesity.¹⁸³ Due to the high incidence of this disease, some authorities have advocated routine liver biopsy at the time of bariatric operations. However, since the treatment of the disease is weight loss, patients with mild forms of the disease need no further treatment or follow-up. Biopsy reports showing any degree of fibrosis should be further followed up by a hepatologist. Weight loss after RYGB decreases metabolic disease, hepatic steatosis, inflammation, and in some cases even fibrosis.¹⁸⁴ Although further research is needed to accurately assess the role of bariatric surgery as a potential treatment for NAFLD, there are numerous reports that support its use. A recent systematic review of the available literature found many retrospective and prospective observational cohort studies, but no randomized control trials or case-control series.¹⁸⁵ There did appear to be significant histologic regression of NAFLD in most of these studies; however, steatohepatitis and fibrosis were also observed in rare cases postoperatively. In one prospective study with before and after liver biopsies, residual steatohepatitis did not appear to be associated with the various bariatric approaches; rather, it was related to higher baseline BMI, degree of previous steatosis/fibrosis, NAFLD activity score, ballooning, degree of inflammation, and insulin resistance.¹⁸⁶ The role of bariatric surgery in the treatment in NAFLD remains to be seen.

Musculoskeletal problems, especially degenerative joint disease and low back pain, are among the most common complaints and associated comorbid problems of the severely obese population. Quantitation of their severity, however, is often difficult, making resolution or improvement equally difficult. Symptoms often resolve and usually improve in patients who experience significant weight loss. This is likely a combined effect of the direct lessened work load as well as some secondary resolution of the inflammatory process of the joints brought on directly and indirectly by obesity. A prospective cohort of 50 obese females age 20 to 74 years were followed for 1 year after RYGB using the timed-get-up-and-go (TGUG) and health survey Short Form-36 (SF-36).¹⁸⁷ The results showed a significant improvement in musculoskeletal function and likely enhanced ability to progress in rehabilitation. Patients with osteoarthritis of the neck, shoulder, spine, hip, knee, ankle, wrist, and hand have been shown to have improved or resolved joint pain after bariatric surgery. Reduction in BMI values of 6.2 to 14.7 kg/m² has corresponded with back and knee pain resolution in 5% to 100% of patients, whereas pain severity was reduced in 31% to 94% of patients depending on the joint and study.¹⁸⁸

Plastic Surgery after Weight Loss

Patients who have undergone bariatric surgery are often left with large amounts of hanging skin or rolls of skin and subcutaneous tissue as a result of the weight loss. Additional problems include skin rashes; maceration under folds in the pannus, thighs, and breasts; body odor; and poorly fitting clothes. Excess skin can be a limiting factor in exercise and sexual activity.

Many patients desire to be rid of the extra skin and its associated problems. The major problem they face, however, in accomplishing this is obtaining insurance approval for surgical removal of the excess skin. Most insurance companies consider this “cosmetic” surgery and will not authorize coverage. A few, with appropriate documentation of the conditions and problems from excess skin, do provide coverage for surgery. Plastic surgeons who are experienced in abdominoplasty and body contouring can offer these patients an excellent surgical treatment for the problems of excessive skin.

Reconstructive surgery requires careful preoperative planning and is based on the patient’s deformities and priorities. Excess tissue of the lower torso is the most common deformed area for which patients undergo surgical intervention. A standard abdominoplasty to remove this excessive tissue is performed. More radical body contouring can include a circumferential abdominoplasty and lower body lift.¹⁸⁹ This procedure involves excision of tissue from the buttocks and lateral thighs, with skin undermining down the thighs. Circumferential abdominoplasty removes redundant skin of the lower abdomen, flattens the abdomen, and incorporates the lower body lift. It requires central undermining to the xiphoid and minimal lateral undermining of the superior flap. The central abdominal fascia often requires imbrication. If simultaneous abdominal hernia repair is performed, this performs the function of fascial imbrication by creating a repair with some degree of fascial tension. The closure of the superior flap to the inferior skin edge incorporates lateral tension to narrow the waist and advance the anterolateral thighs. Medial thighplasty also may be needed for patients with significant excess medial thigh skin. This is done transversely.

Excess skin redundancy distal to the mid-thighs requires long vertical medial excision of skin. Mid-back and epigastric rolls, along with sagging breasts, are corrected with an upper body lift. The upper body lift is a reverse abdominoplasty, removal of mid-torso excessive skin, and reshaping of the breasts. For highly selected individuals, and with a well-organized team, a single-stage total body lift, which includes a circumferential abdominoplasty, lower body lift, medial thighplasty, an upper body lift, and breast reshaping, can be performed safely in under 8 hours (Figs. 27-24 and 27-25).¹⁹⁰ While many bariatric surgery programs do not have the accompanying volume, experience, and interest to offer such an extensive single-stage operation, most programs do offer availability of plastic surgery expertise for abdominoplasty and removal of excess skin of the extremities as separate procedures. Increasing numbers of patients undergoing bariatric surgery have provided an increased flow of patients requesting such services, which in turn should lead to improved outcomes with increasing experience for surgeons performing these procedures. One matched control study suggests that plastic surgery after bariatric surgery may actually improve long-term weight loss.¹⁹¹

Endoscopic, Electric, and Other Experimental Procedures

Bariatric surgery has been a field of constant succession of procedures in an attempt to improve safety, minimize invasiveness, and offer better outcomes. Recent experimental procedures in electrical stimulation of the stomach and vagus nerves have been performed to produce weight loss.

The implantable gastric stimulation device, initially marketed by Trasneuronix, Inc., in the early part of the twenty-first century, was a dual-lead implantable gastric electrical ­stimulator that theoretically interfered with the stomach’s innate myoelectric pattern, causing decreased gastric emptying and nausea. A mean excess weight loss of 23% was reported at 16-month follow-up for the second U.S. trial.¹⁹² Longer-term follow-up for the first European study showed a 25% excess weight loss in 91 patients over a 2-year follow-up.¹⁹³ The disappointing aspect of this treatment is that a significant number of the patients lose little weight, whereas a smaller group seem to respond well to the treatment. The ability to select patients who will respond remains a challenge for this technology, which is still in the status of only a proposed potential operation for weight loss.

Vagal stimulation/blockade has recently been proposed as a means of stimulating the neural input to the stomach to achieve decrease in appetite, early satiety, at times nausea, and weight loss. Data to date have been sparse and very preliminary in showing any merits of the potential efficacy of this approach.¹⁹⁴

Endoscopic procedures to decrease gastric pouch size and to limit gastrojejunostomy anastomotic size are currently being performed at several medical centers.^84,195 These are currently reoperative procedures, not initial procedures for weight loss. Long-term weight loss of significant magnitude has yet to be demonstrated by these revisional endoscopic procedures.

Intragastric balloon placement has resurfaced on the bariatric scene in the past few years. The Garren-Edwards bubble of the late 1980s era¹⁹⁶ was prone to migration and bowel obstruction, which led to its early demise. Now this concept has resurfaced as a short-term bridge to weight loss to be followed by a more definitive procedure. While there may be some limited application of this device for such purposes,¹⁹⁷ its ability to produce durable weight loss is unproven. It may have potential use only as a preliminary procedure prior to a more definitive one.

Prototype procedures undergoing trial include one that uses an endoscopically placed sleeve to limit absorption. A small randomized control study out of the Netherlands compared an endoscopically placed intraluminal sleeve extending from the duodenum to the jejunum (EndoBarrier) to a diet modification control group.¹⁹⁸ They successfully placed 26 devices, but were unable to do so in 4 cases. Four implants had to be removed before the end of the study due to migration, obstruction, and continuous epigastric pain. Mean weight loss at 3 months was 19.0% in the study group and 6.9% in the control group. HbA1c was significantly improved after EndoBarrier placement in seven of eight patients with T2DM. An FDA trial is currently under way to determine the long-term safety and efficacy of this experimental gastrointestinal liner.

The eventual ability to endoscopically create a stapled or sutured gastric pouch and hence a completely endoscopically performed restrictive operation is being envisioned. While these proposed procedures speak to the energy and innovation of today’s bariatric surgery community, their implementation into clinical practice has yet to occur. Endoscopic procedures and devices such as the transoral gastroplasty (TOGA) and the transoral endoscopic restrictive implant system (TERIS) did not initially achieve sufficient weight loss to satisfy FDA requirements and thus have been withheld from further development at this time.^199,200

Other investigational procedures under development and performed laparoscopically include the duodenal-jejunal bypass and ileal transposition. These procedures are intended to improve T2DM without intentional weight loss.^201,202 Gastric plication is also a new laparoscopic procedure intended to mimic results of SG but without requiring stapling or stomach removal.²⁰³ Further studies with long-term safety and efficacy data are required before these investigational procedures can be considered for routine clinical use.