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Clinical application of laparoscopic bariatric surgery: an evidence-based review

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Abstract

Background

Approximately one-third of U.S. adults are obese. Current evidence suggests that surgical therapies offer the morbidly obese the best hope for substantial and sustainable weight loss, with a resultant reduction in morbidity and mortality. Minimally invasive methods have altered the demand for bariatric procedures. However, no evidence-based clinical reviews yet exist to guide patients and surgeons in selecting the bariatric operation most applicable to a given situation.

Methods

This evidenced-based review is presented in conjunction with a clinical practice guideline developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). References were reviewed by the authors and graded as to the level of evidence. Recommendations were developed and qualified by the level of supporting evidence available at the time of the associated SAGES guideline publication. The guideline also was reviewed and co-endorsed by the American Society for Metabolic and Bariatric Surgery.

Results

Bariatric surgery is the most effective treatment for severe obesity, producing durable weight loss, improvement of comorbid conditions, and longer life. Patient selection algorithms should favor individual risk–benefit considerations over traditional anthropometric and demographic limits. Bariatric care should be delivered within credentialed multidisciplinary systems. Roux-en-Y gastric bypass (RGB), adjustable gastric banding (AGB), and biliopancreatic diversion with duodenal switch (BPD + DS) are validated procedures that may be performed laparoscopically. Laparoscopic sleeve gastrectomy (LSG) also is a promising procedure. Comparative data find that procedures with more dramatic clinical benefits carry greater risks, and those offering greater safety and flexibility are associated with less reliable efficacy.

Conclusions

Laparoscopic RGB, AGB, BPD + DS, and primary LSG have been proved effective. Currently, the choice of operation should be driven by patient and surgeon preferences, as well as by considerations regarding the relative importance placed on discrete outcomes.

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Author information

Authors and Affiliations

  1. Department of Surgery, University of North Carolina, Campus Box 7081, Chapel Hill, NC, 27599-7081, USA

    Timothy M. Farrell

  2. Department of Surgery, University of North Carolina, Chapel Hill, NC, 27599-7081, USA

    D. Wayne Overby & Geoffrey P. Kohn

  3. Consultants in General Surgery, Highland Park, IL, USA

    Stephen P. Haggerty

  4. Ochsner Clinic, New Orleans, LA, USA

    William S. Richardson

  5. Surgical Specialists of Western New England, PC, Pittsfield, MA, USA

    Robert D. Fanelli

Authors
  1. Timothy M. Farrell
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  2. Stephen P. Haggerty
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  3. D. Wayne Overby
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  4. Geoffrey P. Kohn
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  5. William S. Richardson
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  6. Robert D. Fanelli
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Corresponding author

Correspondence to Timothy M. Farrell.

Appendices

Appendix 1: Levels of evidence

 

Level 1

Evidence from properly conducted randomized, controlled trials

Level 2

Evidence from controlled trials without randomization

or

Cohort or case-control studies

or

Multiple time series, dramatic uncontrolled experiments

Level 3

Descriptive case series, opinions of expert panels

Appendix 2: Summary of guidelines

 

Justification for surgical treatment of obesity

• Weight loss surgery is the most effective treatment for morbid obesity, producing durable weight loss, improvement or remissions of comorbid conditions, and longer life (level 1)

Guidelines for selecting validated bariatric procedures

• Laparoscopic RGB, gastric banding by VBG or AGB, and BPD ± DS are established and validated bariatric procedures that provide effective long-term weight loss and resolution of comorbid conditions (level 2)

• LSG is validated as providing effective weight loss and resolution of comorbidities for as long as 3–5 years (level 2)

Guidelines for patient selection

• The 1991 NIH consensus guidelines provide valid but incomplete patient selection criteria for contemporary bariatric procedures including laparoscopic BPD ± DS, RGB, VBG, and AGB (level 2)

• Other well-selected patients may benefit from laparoscopic bariatric surgery by experienced surgeons:

    – Patients with a BMI exceeding 60 kg/m2 (level 2)

    – Patients older than 60 years (level 2)

• Adolescent (age <18 years) bariatric surgery has been proved effective but should be performed in an experienced center (level 2). Patient selection criteria should be the same as the criteria used for adult bariatric surgery (level 2)

• Individuals with a BMI of 30–35 kg/m2 may benefit from laparoscopic bariatric surgery (level 1)

Guidelines for bariatric programs

• Bariatric surgery programs should include multidisciplinary providers with appropriate training and experience (level 3)

• Institutions must accommodate the special needs of bariatric patients and their providers (level 3)

• Participation in support groups may improve outcomes after bariatric surgery (level 2)

Guidelines for preoperative preparation

• A psychological evaluation is commonly part of the preoperative workup for bariatric patients (level 3)

• Treated psychopathology does not preclude the benefits of bariatric surgery (level 2)

• Preoperative weight loss may be useful to reduce liver volume and improve access for laparoscopic bariatric procedures (level 2), but mandated preoperative weight loss does not affect postoperative weight loss or comorbidity improvements (level 1)

Guidelines for laparoscopic BPD ± DS

• In BPD, the common channel should be 60–100 cm, and the alimentary limb should be 200–360 cm (level 2)

• DS diminishes the most severe complications of BPD, including dumping syndrome and peptic ulceration of the anastomosis (level 2)

• BPD is effective in all BMI >35 kg/m2 subgroups, with durable weight loss and control of comorbidities beyond 5 years (level 2)

• Laparoscopic BPD provides equivalent weight loss, shorter hospital stay, and fewer complications compared with open BPD (level 3)

• BPD may result in greater weight loss (level 2, grade A) and resolution of comorbidities (level 2) compared with other bariatric surgeries, but with the highest mortality rate (level 2)

• After BPD ± DS, close nutritional surveillance, and supplementation are needed (level 3)

Guidelines for laparoscopic RGB

• In laparoscopic RGB, a small lesser-curvature-based pouch that excludes the gastric fundus and a 75- to 150-cm alimentary (Roux) limb are effective for most patients (level 2)

• Alimentary limbs (150 cm) may improve intermediate-term weight loss but also may increase nutritional complications (level 3)

• Laparoscopic RGB is similar in efficacy to open RGB (level 1), with reduced early complications and risk of hernia (level 2)

• Long-term follow-up evaluation is recommended and may improve weight loss outcomes after bariatric surgery (level 3)

Guidelines for laparoscopic AGB

• The pars flaccida approach for laparoscopic AGB placement should be used instead of the perigastric approach to decrease the incidence of gastric prolapse (level 2)

• Laparoscopic AGB is effective in all BMI subgroups, with durable weight loss and control of comorbidities past 5 years (level 1)

• Intermediate-term weight loss after laparoscopic AGB may be less than after laparoscopic RGB (level 1)

• Frequent outpatient visits are suggested in the early postoperative period. Band filling should be guided by weight loss, satiety, and patient symptoms (level 3)

Guidelines for revisional bariatric surgery

• Before elective procedures, the anatomy should be defined by review of available records plus radiographic and/or endoscopic assessment (level 2)

• Laparoscopic revisional procedures may be performed safely, but with more complications than with primary bariatric procedures. Therefore, the relative risks and benefits of laparoscopy should be considered on a case-by-case basis (level 3)

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Farrell, T.M., Haggerty, S.P., Overby, D.W. et al. Clinical application of laparoscopic bariatric surgery: an evidence-based review. Surg Endosc 23, 930–949 (2009). https://doi.org/10.1007/s00464-008-0217-1

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  • DOI: https://doi.org/10.1007/s00464-008-0217-1

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