Treatment of Adult Obesity with Bariatric Surgery

 

Am Fam Physician. 2016 Jan 1;93(1):31-37.

  Related Close-ups: Making Lifestyle Changes After Gastric Bypass

  Patient information: See related handout on weight loss surgery, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

In 2013, approximately 179,000 bariatric surgery procedures were performed in the United States, including the laparoscopic sleeve gastrectomy (42.1%), Roux-en-Y gastric bypass (34.2%), and laparoscopic adjustable gastric banding (14.0%). Choice of procedure depends on the medical conditions of the patient, patient preference, and expertise of the surgeon. On average, weight loss of 60% to 70% of excess body weight is achieved in the short term, and up to 50% at 10 years. Remission of type 2 diabetes mellitus occurs in 60% to 80% of patients two years after surgery and persists in about 30% of patients 15 years after Roux-en-Y gastric bypass. Other obesity-related comorbidities are greatly reduced, and health-related quality of life improves. The Roux-en-Y procedure carries an increased risk of malabsorption sequelae, which can be minimized with nutritional supplementation and surveillance. Overall, these procedures have a mortality risk of less than 0.5%. Cohort studies show that bariatric surgery reduces all-cause mortality by 30% to 50% at seven to 15 years postsurgery compared with patients with obesity who did not have surgery. Dietary changes, such as consuming protein first at every meal, and regular physical activity are critical for patient success after bariatric surgery. The family physician is well positioned to counsel patients about bariatric surgical options, the risks and benefits of surgery, and to provide long-term support and medical management postsurgery.

Obesity is a disease that has serious physical, psychological, and economic implications for patients, and poses major challenges for the physicians caring for them.1 Approximately 35% of the U.S. adult population is obese.2  Obesity affects every organ system (Table 11,35); the related pathologic processes create a health burden for patients and an economic burden for the health care system. The U.S. Preventive Services Task Force recommends screening all adults for obesity. Patients with a body mass index (BMI) of 30 kg per m2 or higher should be offered or referred to intensive, multicomponent behavioral interventions.6 These interventions can result in clinically significant weight loss (5% or greater) in patients with obesity and can be initiated by the family physician.6 Surgical treatment of obesity results in greater weight loss, greater reduction in comorbidities, and prolonged survival compared with nonsurgical interventions.3,79 Recent emphasis has shifted from weight loss outcomes to the metabolic effects of these surgical procedures.10 Family physicians are well positioned to counsel patients about bariatric surgical options, as well as provide long-term support and medical management postsurgery.

WHAT IS NEW ON THIS TOPIC: BARIATRIC SURGERY

Remission of diabetes mellitus occurs in 60% to 80% of patients 1 to 2 years after Roux-en-Y gastric bypass surgery, and remission is retained in approximately 30% of patients at 15 years.

In multiple cohort studies, bariatric surgery is associated with relative reductions in all-cause mortality of 30% to 50% after 7 to 15 years.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Bariatric surgery results in greater weight loss than nonsurgical weight loss interventions.

A

1, 3, 16, 22

Bariatric surgery is highly effective in treating obesity-related comorbidities, particularly diabetes mellitus.

A

1, 16, 18, 19, 22, 24

Bariatric surgery reduces obesity-related mortality.

B

1, 79, 16, 27


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Bariatric surgery results in greater weight loss than nonsurgical weight loss interventions.

A

1, 3, 16, 22

Bariatric surgery is highly effective in treating obesity-related comorbidities, particularly diabetes mellitus.

A

1, 16, 18, 19, 22, 24

Bariatric surgery reduces obesity-related mortality.

B

1, 79, 16, 27


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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Table 1.

Conditions with Higher Prevalence in Adults with Obesity

CardiovascularEndocrineGastrointestinalGenitourinaryMusculoskeletalOther

Atrial fibrillation

Hypoandrogenism

Colorectal cancer

Breast cancer

Chronic low back pain

Dementia

Cardiomyopathy

Hypothyroidism

Esophageal cancer

Chronic kidney disease

Immobility

Leukemia

Dyslipidemia

Infertility

Gallbladder cancer

Endometrial cancer

Osteoarthritis

Malignant melanoma

Hypertension

Metabolic syndrome

Gastroesophageal reflux

Kidney stones

Long QT syndrome

Pancreatic cancer

Hiatal hernia

Ovarian cancer

Obstructive sleep apnea

Polycystic ovary syndrome

Irritable bowel syndrome

Prostate cancer

Thromboembolism

Type 2 diabetes mellitus

Liver cancer

Renal cell cancer

Nonalcoholic fatty liver disease

Urinary incontinence


Information from references 1, and 3 through 5.

Table 1.

Conditions with Higher Prevalence in Adults with Obesity

CardiovascularEndocrineGastrointestinalGenitourinaryMusculoskeletalOther

Atrial fibrillation

Hypoandrogenism

Colorectal cancer

Breast cancer

Chronic low back pain

Dementia

Cardiomyopathy

Hypothyroidism

Esophageal cancer

Chronic kidney disease

Immobility

Leukemia

Dyslipidemia

Infertility

Gallbladder cancer

Endometrial cancer

Osteoarthritis

Malignant melanoma

Hypertension

Metabolic syndrome

Gastroesophageal reflux

Kidney stones

Long QT syndrome

Pancreatic cancer

Hiatal hernia

Ovarian cancer

Obstructive sleep apnea

Polycystic ovary syndrome

Irritable bowel syndrome

Prostate cancer

Thromboembolism

Type 2 diabetes mellitus

Liver cancer

Renal cell cancer

Nonalcoholic fatty liver disease

Urinary incontinence


Information from references 1, and 3 through 5.

Indications and Eligibility

Worldwide, more than 340,000 bariatric procedures were performed in 2011.11 According to the American Society for Metabolic and Bariatric Surgery, about 179,000 were performed in the United States in 2013.12 Eligibility criteria were established by the 1991 National Institutes of Health Consensus Development Conference Panel and have changed little in the ensuing years.13  Selection and exclusion criteria are listed in Table 2.10

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Table 2.

Selection and Exclusion Criteria for Bariatric Surgery

Selection criteria

Able to adhere to postoperative care (e.g., follow-up visits and tests, medical management, use of dietary supplements)

BMI ≥ 40 kg per m2 without coexisting medical conditions

BMI ≥ 35 kg per m2 and one or more severe obesity-related comorbidities

BMI 30 to 34.9 kg per m2 with diabetes mellitus or metabolic syndrome (evidence is limited)

Exclusion criteria

Cardiopulmonary disease that would make the risk prohibitive

Current drug or alcohol abuse

Lack of comprehension of risks, benefits, expected outcomes, alternatives, and required lifestyle changes

Reversible endocrine or other disorders that can cause obesity

Uncontrolled severe psychiatric illness


BMI = body mass index.

Information from reference 10.

Table 2.

Selection and Exclusion Criteria for Bariatric Surgery

Selection criteria

Able to adhere to postoperative care (e.g., follow-up visits and tests, medical management, use of dietary supplements)

BMI ≥ 40 kg per m2 without coexisting medical conditions

BMI ≥ 35 kg per m2 and one or more severe obesity-related comorbidities

BMI 30 to 34.9 kg per m2 with diabetes mellitus or metabolic syndrome (evidence is limited)

Exclusion criteria

Cardiopulmonary disease that would make the risk prohibitive

Current drug or alcohol abuse

Lack of comprehension of risks, benefits, expected outcomes, alternatives, and required lifestyle changes

Reversible endocrine or other disorders that can cause obesity

Uncontrolled severe psychiatric illness


BMI = body mass index.

Information from reference 10.

Preoperative Considerations

Evaluation of the surgical candidate is often conducted by a multidisciplinary team with expertise in nutrition, psychology or psychiatry, surgery, and medicine. Components of the preoperative evaluation are described in a 2013 clinical practice guideline from the American Association of Clinical Endocrinologists, The Obesity Society, and the American Society for Metabolic and Bariatric Surgery (Table 3).10 In practice, third-party payers and surgeon preference often determine the scope of presurgical evaluation and preparation.

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Table 3.

Preoperative Evaluation for Bariatric Surgery

Recommended measures

Age- and risk-appropriate cancer screening

Complete history and physical examination (e.g., assess comorbidities, weight loss history, commitment to postsurgical lifestyle modifications, exclusions for surgery)

Laboratory studies* (e.g., A1C level, complete blood count, complete metabolic profile, folic acid, iron studies, lipid profile, prothrombin time, urinalysis, vitamin B12, 25-hydroxyvitamin D), additional evaluation as indicated

Nutrition evaluation

Pregnancy counseling†

Psychosocial and behavioral evaluations

Tobacco cessation counseling for optimal wound healing

Additional evaluations to consider

Cardiopulmonary evaluation (e.g., polysomnography, electrocardiography, additional evaluation if cardiac disease or pulmonary hypertension suspected)

Gastrointestinal evaluation (Helicobacter pylori screening in high-prevalence areas; gallbladder evaluation, upper endoscopy if clinically indicated)


*—Results useful in identification and optimization of the most common obesity-related and postoperative conditions.

†—Pregnancy is not recommended preoperatively and for 12 to 18 months postoperatively because of the degree of weight loss in the first year.

Information from reference 10.

Table 3.

Preoperative Evaluation for Bariatric Surgery

Recommended measures

Age- and risk-appropriate cancer screening

Complete history and physical examination (e.g., assess comorbidities, weight loss history, commitment to postsurgical lifestyle modifications, exclusions for surgery)

Laboratory studies* (e.g., A1C level, complete blood count, complete metabolic profile, folic acid, iron studies, lipid profile, prothrombin time, urinalysis, vitamin B12, 25-hydroxyvitamin D), additional evaluation as indicated

Nutrition evaluation

Pregnancy counseling†

Psychosocial and behavioral evaluations

Tobacco cessation counseling for optimal wound healing

Additional evaluations to consider

Cardiopulmonary evaluation (e.g., polysomnography, electrocardiography, additional evaluation if cardiac disease or pulmonary hypertension suspected)

Gastrointestinal evaluation (Helicobacter pylori screening in high-prevalence areas; gallbladder evaluation, upper endoscopy if clinically indicated)


*—Results useful in identification and optimization of the most common obesity-related and postoperative conditions.

†—Pregnancy is not recommended preoperatively and for 12 to 18 months postoperatively because of the degree of weight loss in the first year.

Information from reference 10.

The patient evaluation should include a complete history and physical examination with attention to obesity-related comorbidities and weight loss–attempt history; three to six months of medical weight management; psychosocial, behavioral, and nutrition evaluations; and appropriate laboratory studies. The purpose of this evaluation is to identify and optimally manage conditions that may negatively affect the perioperative period and increase morbidity. Because patients with obesity may avoid preventive medical visits, age- and risk-appropriate cancer screening should be performed at this time.10 In high-risk patients with an enlarged or fatty liver, preoperative weight loss can reduce liver volume and, therefore, may improve the technical aspects of the surgery.

Choice of Procedure

Most bariatric surgeries are performed laparoscopically; this is preferred to open procedures because of decreased mortality, fewer complications, shorter hospital stays, and more rapid recovery.14 Currently, three procedures are commonly performed: laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, and Roux-en-Y gastric bypass.

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING

In laparoscopic adjustable gastric banding, a hollow, flexible silicone band is placed around the upper stomach, which causes a restrictive effect, reduces stomach capacity, and produces rapid feelings of satiety. The band is tightened by injecting saline into it through a subcutaneous port, which is located just inferior to the sternum or lateral to the umbilicus (Figure 115). Because of a higher complication rate and less weight loss compared with the other two most common procedures, the demand for gastric banding is decreasing in the United States.16

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Figure 1.

Adjustable gastric banding involves inserting an inflatable ring, which can be adjusted via a subcutaneous access port.

Adapted with permission from Schroeder R, Garrison JM Jr, Johnson MS. Treatment of adult obesity with bariatric surgery. Am Fam Physician. 2011;84(7):809.


Figure 1.

Adjustable gastric banding involves inserting an inflatable ring, which can be adjusted via a subcutaneous access port.

Adapted with permission from Schroeder R, Garrison JM Jr, Johnson MS. Treatment of adult obesity with bariatric surgery. Am Fam Physician. 2011;84(7):809.

LAPAROSCOPIC SLEEVE GASTRECTOMY

The laparoscopic sleeve gastrectomy resects most of the body and all of the fundus of the stomach, creating a long, narrow, tubular stomach (Figure 215). This procedure was first used as an initial step before a malabsorptive procedure in very high-risk patients, but is now used as a primary stand-alone procedure and is increasing in popularity.17

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Figure 2.

Laparoscopic sleeve gastrectomy involves removing most of the body of the stomach, creating a narrow gastric structure.

Adapted with permission from Schroeder R, Garrison JM Jr, Johnson MS. Treatment of adult obesity with bariatric surgery. Am Fam Physician. 2011;84(7):809.


Figure 2.

Laparoscopic sleeve gastrectomy involves removing most of the body of the stomach, creating a narrow gastric structure.

Adapted with permission from Schroeder R, Garrison JM Jr, Johnson MS. Treatment of adult obesity with bariatric surgery. Am Fam Physician. 2011;84(7):809.

ROUX-EN-Y GASTRIC BYPASS

In Roux-en-Y gastric bypass, a small gastric pouch is formed by dividing the upper stomach and joining it with the resected end of the jejunum, so that food bypasses the stomach and upper small bowel, thereby restricting the size of the stomach and causing some malabsorption (Figure 315). Roux-en-Y gastric bypass may be a better choice in patients who are more obese and in those with type 2 diabetes mellitus.18,19

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Figure 3.

(A) Stomach, duodenum, and jejunum before bariatric surgery. (B) Stomach, duodenum, and jejunum after Roux-en-Y gastric bypass.

Adapted with permission from Schroeder R, Garrison JM Jr, Johnson MS. Treatment of adult obesity with bariatric surgery. Am Fam Physician. 2011;84(7):809.


Figure 3.

(A) Stomach, duodenum, and jejunum before bariatric surgery. (B) Stomach, duodenum, and jejunum after Roux-en-Y gastric bypass.

Adapted with permission from Schroeder R, Garrison JM Jr, Johnson MS. Treatment of adult obesity with bariatric surgery. Am Fam Physician. 2011;84(7):809.

The choice of procedure depends on patient preference, the expertise of the surgeon and surgical center, and risk stratification.10

In 2013, laparoscopic sleeve gastrectomy was reported to be the most common procedure (42.1%), followed by Roux-en-Y gastric bypass (34.2%) and laparoscopic adjustable gastric banding (14.0%). Six percent of surgeries were for revision of a previous procedure.12

Pathophysiology

These surgical procedures were previously conceptualized as restrictive (create a much smaller stomach), malabsorptive (bypass normal anatomy), or a combination. Research now indicates that the mechanisms of action include multiple physiologic variables that affect endocrine and neuronal signaling.20 Improvements in blood glucose levels, dyslipidemia, and other obesity-related comorbidities occur earlier than can be fully explained by the actual weight loss.

In addition to decreased caloric intake, multiple mechanisms contribute to the dramatic improvement of type 2 diabetes after procedures that alter gastrointestinal anatomy. Levels of glucagon-like peptide-1 and peptide YY, which are secreted by intestinal L cells, increase after Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy procedures. Glucagon-like peptide-1 enhances insulin secretion, whereas peptide YY increases satiety and delays gastric emptying through receptors in the central and peripheral nervous systems. Ghrelin, secreted primarily by the gastric fundus and proximal small intestine, acts via the hypothalamus to stimulate appetite and suppress energy expenditure and fat catabolism. Procedures that bypass the gastric fundus seem to reduce the secretion of ghrelin and reduce appetite. Neurotransmitters and hormones of the gut, brain, central and peripheral nervous systems, and adipocytes interact in a complex neuroendocrine system to regulate energy homeostasis.20

Postoperative Management

The bariatric surgeon generally provides early postoperative management, including surveillance for complications. The progression of diet from clear liquids to regular food over the first four weeks is facilitated by consultation with a dietician.10

After bariatric surgery, patients are encouraged to eat and journal three structured meals and one or two high-protein snacks per day. Each meal should begin with protein to ensure adequate intake of 80 to 90 g per day to minimize the loss of lean body mass. Food intolerances are patient specific, but very dry foods, bread, and fibrous vegetables are often problematic. Patients should be advised to eat slowly and chew thoroughly. Fluids should be avoided for 15 to 30 minutes before, during, and after meals because ingested food will pass easily through the pouch opening if it is mixed with fluid, and sensation of fullness will not be achieved. Carbonated beverages should be avoided because of the added gas. Cold intolerance, hair loss, and fatigue are common but tend to diminish rapidly as weight loss stabilizes.

All patients who have had weight loss surgery should avoid nonsteroidal anti-inflammatory drugs and smoking because they increase the risk of anastomotic ulcerations. Women should avoid becoming pregnant for 12 to 18 months after surgery. This period of rapid weight loss may increase the risk of nutritional deficiencies and small-for-gestational-age status in infants (Table 4).10 Continued lifestyle modification is necessary, including regular physical activity and individualized behavioral interventions to address food impulse control. Ongoing participation in postsurgical support groups is highly recommended.

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Table 4.

Follow-up After Bariatric Surgery

Adjust postoperative medications, as needed

Avoid nonsteroidal anti-inflammatory drugs

Avoid pregnancy for 12 to 18 months

Bone density measurement with dual energy x-ray absorptiometry at 2 years

Laboratory studies (e.g., complete blood count, complete metabolic profile, folic acid, iron studies, intact parathyroid hormone level, lipid profile, vitamin B12, 24-hour urinary calcium excretion, 25-hydroxyvitamin D)

Monitor adherence to dietary, behavioral, and physical activity recommendations


Information from reference 10.

Table 4.

Follow-up After Bariatric Surgery

Adjust postoperative medications, as needed

Avoid nonsteroidal anti-inflammatory drugs

Avoid pregnancy for 12 to 18 months

Bone density measurement with dual energy x-ray absorptiometry at 2 years

Laboratory studies (e.g., complete blood count, complete metabolic profile, folic acid, iron studies, intact parathyroid hormone level, lipid profile, vitamin B12, 24-hour urinary calcium excretion, 25-hydroxyvitamin D)

Monitor adherence to dietary, behavioral, and physical activity recommendations


Information from reference 10.

Quarterly assessment of nutritional status and supplementation needs, food intolerances, and procedure-related symptoms should occur for the first year after bariatric surgery. A variety of micronutrient deficiencies have been identified after malabsorption procedures and even after some restrictive procedures because of decreased capacity for food intake. Vitamin supplementation will likely be required throughout the patient's lifetime, and annual metabolic and nutritional monitoring is recommended (Table 5).10

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Table 5.

Supplementation After Bariatric Surgery

SupplementLaparoscopic adjustable gastric bandingLaparoscopic sleeve gastrectomyRoux-en-Y gastric bypassComments

Calcium citrate

1,200 to 1,500 mg per day

1,200 to 1,500 mg per day

1,500 to 2,000 mg per day

Split doses; monitor for osteoporosis

Elemental iron

45 to 60 mg per day, including multivitamin

45 to 60 mg per day, including multivitamin

45 to 60 mg per day, including multivitamin

Take iron and calcium supplements at least 2 hours apart

Multivitamin with minerals (including iron, folic acid, copper, and thiamine)

1 per day

2 per day

2 per day

Liquid or chewable for 3 to 6 months

Vitamin B12

1,000 mcg per day

1,000 mcg per day

1,000 mcg per day

Sublingual, subcutaneous intramuscular, or oral, if adequately absorbed

Vitamin D3

At least 3,000 IU per day

At least 3,000 IU per day

At least 3,000 IU per day

Titrate to 25-hydroxyvitamin D level greater than 30 ng per mL (75 nmol per L)


Information from reference 10.

Table 5.

Supplementation After Bariatric Surgery

SupplementLaparoscopic adjustable gastric bandingLaparoscopic sleeve gastrectomyRoux-en-Y gastric bypassComments

Calcium citrate

1,200 to 1,500 mg per day

1,200 to 1,500 mg per day

1,500 to 2,000 mg per day

Split doses; monitor for osteoporosis

Elemental iron

45 to 60 mg per day, including multivitamin

45 to 60 mg per day, including multivitamin

45 to 60 mg per day, including multivitamin

Take iron and calcium supplements at least 2 hours apart

Multivitamin with minerals (including iron, folic acid, copper, and thiamine)

1 per day

2 per day

2 per day

Liquid or chewable for 3 to 6 months

Vitamin B12

1,000 mcg per day

1,000 mcg per day

1,000 mcg per day

Sublingual, subcutaneous intramuscular, or oral, if adequately absorbed

Vitamin D3

At least 3,000 IU per day

At least 3,000 IU per day

At least 3,000 IU per day

Titrate to 25-hydroxyvitamin D level greater than 30 ng per mL (75 nmol per L)


Information from reference 10.

Effectiveness

Summarizing and quantifying the comparative outcomes of bariatric surgery have been challenging because of the evolution of surgical procedures, the availability of laparoscopic vs. open techniques, categorization of short- vs. long-term sequelae, and the difference in presurgical risk among patients.3,16,2123 The National Institutes of Health–initiated Longitudinal Assessment of Bariatric Surgery Consortium is conducting prospective, multicenter, cohort studies using standardized techniques to assess the safety and clinical response of bariatric surgery.22

In general, Roux-en-Y gastric bypass seems to lead to the greatest weight loss during the first two postsurgical years, followed by laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding. It is unclear if there is a significant long-term difference in weight loss between Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy (Table 6 710,16,18,19,2127). Increasing evidence that laparoscopic adjustable gastric banding results in more long-term complications, more reoperations, and less weight loss has made this procedure less common.28 Dyslipidemia, type 2 diabetes, hypertension, and perception of quality of life improved after weight loss surgery.3,21

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Table 6.

Comparison of Outcomes for Bariatric Surgical Procedures

OutcomeOverallLaparoscopic adjustable gastric bandingLaparoscopic sleeve gastrectomyRoux-en-Y gastric bypass

Median excess body weight lost (%)*

1 to 2 years

60 to 70

29 to 56

33 to 85

48 to 85

3 to 6 years

50 to 60

39 to 72

46 to 66

53 to 77

7 to 10 years

50

14 to 60

25 to 68

Remission of diabetes mellitus (%)

< 1 year

80

27 to 29

56 to 68

56 to 84

1 to 3 years

72

28

80

46 to 81

15 years

30

Mortality (%)

≤ 30 days

0.08

0.02 to 0.07

0.296

0.20 to 0.50

> 30 days

0.31

0.21 to 0.50

0.11 to 0.34

0.14 to 0.21

7 to 15 years

30% to 50% lower than those not having surgery


*—Excess body weight is the total preoperative weight minus ideal weight.

Information from references 7 through 10, 16, 18, 19, and 21 through 27.

Table 6.

Comparison of Outcomes for Bariatric Surgical Procedures

OutcomeOverallLaparoscopic adjustable gastric bandingLaparoscopic sleeve gastrectomyRoux-en-Y gastric bypass

Median excess body weight lost (%)*

1 to 2 years

60 to 70

29 to 56

33 to 85

48 to 85

3 to 6 years

50 to 60

39 to 72

46 to 66

53 to 77

7 to 10 years

50

14 to 60

25 to 68

Remission of diabetes mellitus (%)

< 1 year

80

27 to 29

56 to 68

56 to 84

1 to 3 years

72

28

80

46 to 81

15 years

30

Mortality (%)

≤ 30 days

0.08

0.02 to 0.07

0.296

0.20 to 0.50

> 30 days

0.31

0.21 to 0.50

0.11 to 0.34

0.14 to 0.21

7 to 15 years

30% to 50% lower than those not having surgery


*—Excess body weight is the total preoperative weight minus ideal weight.

Information from references 7 through 10, 16, 18, 19, and 21 through 27.

Remission of type 2 diabetes occurs in 60% to 80% of Roux-en-Y gastric bypass patients at one to two years postsurgery.18,23-25 Recent longer-term studies indicate that this remission is retained in approximately 40% of patients at 10 years and 30% at 15 years.9,19 Several recent reviews support bariatric surgery for the treatment of diabetes in patients with a BMI less than 35 kg per m2.26

The Swedish Obese Subjects prospective cohort study found that surgery was associated with a 29% lower mortality risk from any cause after 16 years.8 In a retrospective cohort study of almost 8,000 patients undergoing bariatric surgery, mortality from disease, including cardiovascular disease and cancer, decreased by 40% compared with the control group.7 In a more recent retrospective cohort study of 2,500 surgical patients and 7,462 matched controls receiving care in the Veterans Administration system, the surgical patients had a significant reduction in 10-year all-cause mortality.27

Weight regain is a concern in a subset of patients following weight loss surgery; the etiology appears to be multifactorial. A systematic review from 2013 identified nutritional indiscretion, mental health issues, endocrine and metabolic alterations, physical inactivity, and anatomic surgical failure as principal causes.29 Endoscopic or surgical revision is an option in some patients who experience weight regain. Further study is necessary to determine predictors of suboptimal weight loss and weight regain, as well as the effectiveness of treatment with surgical revision or other modalities.2830

Cost

It is estimated that obesity accounts for 16.5% of all medical spending, an estimated $168 billion per year direct cost to the health care system.31 Whether bariatric surgery procedures are ultimately cost-effective or cost saving requires additional long-term study. Measures of improved health and well-being, with direct costs of bariatric surgery and subsequent health care costs, must be compared with those for patients with obesity who do not have surgery to allow for better informed decisions in the future.3133

Data Sources: The following resources were reviewed: the Agency for Healthcare Research and Quality, the Cochrane Database of Systematic Reviews, Essential Evidence Plus, and the U.S. Preventive Services Task Force. References from key articles were also searched. In addition, an OVID Medline search was performed using the keywords obesity, bariatric weight loss, surgery, and diabetes. Search dates: October 2014 and February 2015.

note: This review updates a previous article on this topic by Schroeder, Garrison, and Johnson.15

The Authors

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ROBIN SCHROEDER, MD, is an associate professor in the department of Family Medicine at the Morsani School of Medicine, University of South Florida, and is the medical director of the Weight Management Center at Lehigh Valley Health Network, Allentown, Penn....

T. DANIEL HARRISON, DO, is a bariatric surgeon at Lehigh Valley Health Network.

SHANIQUA L. McGRAW, MD, is a resident in the Department of Family Medicine at Lehigh Valley Health Network.

Address correspondence to Robin Schroeder, MD, 1243 S. Cedar Crest Blvd., Ste. 2200, Allentown, PA 18103 (e-mail: Robin.Schroeder@lvhn.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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1. Colquitt JL, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014;(8):CD003641....

2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA. 2014;311(8):806–814.

3. Gloy VL, Briel M, Bhatt DL, et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:f5934.

4. Dynamed [Internet]. Ipswich (MA): EBSCO Publishing. 2015, Bariatric Surgery. http://www.dynamed.com/home (registration and login required). Accessed November 2, 2015.

5. Essential Evidence Plus. Obesity and weight loss (bariatric surgery). 2015. http://www.essentialevidenceplus.com (subscription required). Accessed October 27, 2015.

6. U.S. Preventive Services Task Force. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(5):373–378.

7. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753–761.

8. Sjöström L, Narbro K, Sjöström CD, et al.; Swedish Obese Subjects Study. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357(8):741–752.

9. Sjöström L, Peltonen M, Jacobson P, et al. Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications. JAMA. 2014;311(22):2297–2304.

10. Mechanick JI, Youdim A, Jones DB, et al.; American Association of Clinical Endocrinologists; Obesity Society; American Society for Metabolic & Bariatric Surgery. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring). 2013;21(suppl 1):S1–S27.

11. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23(4):427–436.

12. American Society for Metabolic and Bariatric Surgery (ASMBS). New procedure estimates for bariatric surgery: what the numbers reveal. Connect. May 2014. http://connect.asmbs.org/may-2014-bariatric-surgery-growth.html. Accessed July 18, 2015.

13. National Institutes of Health. NIH Consensus Statement. Gastrointestinal surgery for severe obesity. http://consensus.nih.gov/1991/1991gisurgeryobesity084html.htm. Accessed February 12, 2015.

14. Banka G, Woodard G, Hernandez-Boussard T, Morton JM. Laparoscopic vs open gastric bypass surgery: differences in patient demographics, safety, and outcomes. Arch Surg. 2012;147(6):550–556.

15. Schroeder R, Garrison JM Jr, Johnson MS. Treatment of adult obesity with bariatric surgery. Am Fam Physician. 2011;84(7):805–814.

16. Chang SH, Stoll CR, Song J, Varela JE, Eagon CJ, Colditz GA. The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003–2012. JAMA Surg. 2014;149(3):275–287.

17. Nguyen NT, Nguyen B, Gebhart A, Hohmann S. Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy. J Am Coll Surg. 2013;216(2):252–257.

18. Schauer PR, Bhatt DL, Kirwan JP, et al.; STAMPEDE Investigators. Bariatric surgery versus intensive medical therapy for diabetes—3-year outcomes. N Engl J Med. 2014;370(21):2002–2013.

19. Davies SW, Efird JT, Guidry CA, et al. Long-term diabetic response to gastric bypass. J Surg Res. 2014;190(2):498–503.

20. Cho YM. A gut feeling to cure diabetes: potential mechanisms of diabetes remission after bariatric surgery [published correction appears in Diabetes Metab J. 2015;39(2):175]. Diabetes Metab J. 2014;38(6):406–415.

21. Puzziferri N, Roshek TB III, Mayo HG, Gallagher R, Belle SH, Livingston EH. Long-term follow-up after bariatric surgery: a systematic review. JAMA. 2014;312(9):934–942.

22. Courcoulas AP, Christian NJ, Belle SH, et al.; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013;310(22):2416–2425.

23. Yip S, Plank LD, Murphy R. Gastric bypass and sleeve gastrectomy for type 2 diabetes: a systematic review and meta-analysis of outcomes. Obes Surg. 2013;23(12):1994–2003.

24. Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366(17):1577–1585.

25. Courcoulas AP, Goodpaster BH, Eagleton JK, et al. Surgical vs medical treatments for type 2 diabetes mellitus: a randomized clinical trial. JAMA Surg. 2014;149(7):707–715.

26. Müller-Stich BP, Senft JD, Warschkow R, et al. Surgical versus medical treatment of type 2 diabetes mellitus in nonseverely obese patients: a systematic review and meta-analysis. Ann Surg. 2015;261(3):421–429.

27. Arterburn DE, Olsen MK, Smith VA, et al. Association between bariatric surgery and long-term survival. JAMA. 2015;313(1):62–70.

28. Coblijn UK, Verveld CJ, van Wagensveld BA, Lagarde SM. Laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy as revisional procedure after adjustable gastric band—a systematic review. Obes Surg. 2013;23(11):1899–1914.

29. Karmali S, Brar B, Shi X, Sharma AM, de Gara C, Birch DW. Weight recidivism post-bariatric surgery: a systematic review. Obes Surg. 2013;23(11):1922–1933.

30. Cooper TC, Simmons EB, Webb K, Burns JL, Kushner RF. Trends in weight regain following Roux-en-Y gastric bypass (RYGB) bariatric surgery. Obes Surg. 2015;25(8):1474–1481.

31. Weiner JP, Goodwin SM, Chang HY, et al. Impact of bariatric surgery on health care costs of obese persons: a 6-year follow-up of surgical and comparison cohorts using health plan data. JAMA Surg. 2013;148(6):555–562.

32. Maciejewski ML, Arterburn DE. Cost-effectiveness of bariatric surgery. JAMA. 2013;310(7):742–743.

33. Wang BC, Furnback W. Modelling the long-term outcomes of bariatric surgery: a review of cost-effectiveness studies. Best Pract Res Clin Gastroenterol. 2013;27(6):987–995.

 

 

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