Chapter 27: The Surgical Management of Obesity

KEY POINTS

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.

INTRODUCTION

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 ...