Bariatric Surgery: Choosing the Optimal Procedure

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Choosing the right operation for weight loss continues to be a challenging and subjective process. In experienced hands, most operations have the ability to be successful in providing a given patient with meaningful weight loss and impart better health through loss of adiposity, amelioration of comorbidities, and improvement of overall quality of life. Novel treatments for obesity are also on the horizon, including endoluminal sleeves, endoluminal restrictive mechanisms, intragastric balloons, gastric pacing, and variations of current procedures that target metabolic diseases. The future availability of these procedures may further complicate the decision-making process for patients and surgeons.

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The rationale for weight loss surgery

The health risks associated with obesity are complex, multifactorial, and related to the myriad of comorbidities associated with being overweight, having a diminished quality of life, and the risks from impairment in mobility that lead to accidents and injury. An estimated 70% of diabetes risk in the United States can be attributed to excess weight [6], and the prevalence of hypertension in adults who are obese (BMI ≥30) is 41.9% for men and 37.8% for women. The prevalence of high cholesterol

Evaluation of the obese patient for bariatric surgery

In 2004 the American Society for Bariatric Surgery, now the American Society for Metabolic and Bariatric Surgery (ASMBS), published a consensus statement that all patients undergoing bariatric surgery need to be well informed and motivated, compliant with lifestyle changes, and understand the need to participate in long-term follow-up [14]. Most programs now offer a multidisciplinary team approach to patient evaluation and selection, including comprehensive medical, dietary, and psychologic

Minimally invasive options for bariatric surgery

Bariatric surgery can be performed safely and is a highly effective means of producing meaningful weight loss, with a profound effect on comorbidities, often leading to their amelioration and resolution. The most commonly performed procedures have the ability to be performed laparoscopically, offering the same operation with lower morbidity, often due to a large abdominal incision. In the United States, more than 200,000 primary operations are performed for weight loss each year, including the

The laparoscopic Roux-en-Y gastric bypass

The RYGB was first described by Mason and Ito in 1966 [19] and has since become the most commonly performed weight loss operation in the United States (Fig. 1). The components of a successful operation include a small proximal gastric pouch typically less than 30 cm3 based on the lesser curve, a small gastrojejunostomy approximately 12 mm in diameter, and a Roux limb that has ranged from 60 to 250 cm or more in length to alter malabsorption depending on patient factors and surgeon preference.

The laparoscopic adjustable gastric band

The laparoscopically placed adjustable gastric band has been approved by the US Food and Drug Administration since June 2001 and has been increasing in popularity, becoming the second most commonly performed operation for weight loss in the United States (Fig. 2). The LAGB was first described by Belachew and colleagues [28] in 1993 and became the most commonly performed weight loss operation in Europe, Australia, and Latin America. Two types of bands are currently available in the United

Laparoscopic biliopancreatic diversion with duodenal switch

BPD, a malabsorptive procedure, was first described by Scopinaro in 1976 [36] as an operation that included a partial gastrectomy leaving a 250 to 500 cm3 gastric pouch emptying into a 250-cm Roux limb with a 50-cm common channel for absorption. To decrease the incidence of marginal ulceration and metabolic derangements, Marceau and Hess described a modification of the BPD called the duodenal switch (BPD/DS), creating a gastric sleeve and preserving the pylorus (Fig. 3) [37], [38]. The BPD/DS

Laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy is one of the newer, purely restrictive procedures being performed as a primary weight loss operation and can be compared with the gastric segment of BPD/DS (Fig. 4). Sleeve gastrectomy is an embodiment of the Magenstrasse and Mill procedure (MM), which was designed to imitate the VBG by creating a long gastric tube but without a foreign body, eliminating the risk of erosion. Sleeve gastrectomy differs from MM by the resection of the defunctionalized fundus,

Summary

Choosing the right operation for weight loss continues to be a challenging and subjective process. In experienced hands, most operations have the ability to be successful in providing a given patient meaningful weight loss and impart better health through loss of adiposity, amelioration of comorbidities, and improvement of overall quality of life. Surgeons should have a thorough understanding of all operations available regardless of their desire to perform a given procedure to be able to give

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