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

Department of Surgery, University of North Carolina, Chapel Hill, NC 27599-7081, USA.
Surgical Endoscopy (Impact Factor: 3.26). 02/2009; 23(5):930-49. DOI: 10.1007/s00464-008-0217-1
Source: PubMed


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.
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.
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.
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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    • "Several recent reports have demonstrated the efficacy of bariatric surgery in this population[4] [5]. Moreover, the preponderance of data now suggests the superiority of bariatric surgery to medical therapies for sustained weight loss and relief from obesity related metabolic conditions in adults and children [6] [7] [8] [9] [10] [11]. "
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    ABSTRACT: Homozygous or compound heterozygous melanocortin-4 receptor (MC4R) mutations are rare with fewer than 10 patients described in current literature. Here we report the short and long-term outcomes for four children ages 4.5-14 who are homozygous for loss-of-function mutations in the MC4R and underwent laparoscopic sleeve gastrectomy. All 4 patients experienced significant weight loss and improvement in, or resolution of, their comorbidities in the short term. One patient, however, has had significant weight regain in the long term. We conclude that MC4R signaling is not required for short term weight loss after laparoscopic sleeve gastrectomy in children. Behavior modification may be more important for long term weight maintenance, but patients with homozygous MC4R deficiency should not be excluded from consideration for sleeve gastrectomy. However, as at least one copy of functional MC4R is necessary and sufficient to induce long-term postoperative weight loss benefits, patients with complete loss of MC4R functionality might be less likely to exhibit the same benefits resulting from bariatric surgery.International Journal of Obesity accepted article preview online, 05 November 2015. doi:10.1038/ijo.2015.230.
    International journal of obesity (2005) 11/2015; DOI:10.1038/ijo.2015.230 · 5.00 Impact Factor
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    • "Influence of diet and exercise in morbid obese patients is about 10% in long term period; thus, in case of lifestyle modification failure, bariatric surgery could be considered [10]. They need a potential trigger for weight loss like restrictive bariatric surgeries that are effective to preserve diet for about 4 years [11,12]. Other methods have limited and temporary effect. "
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    ABSTRACT: Laparoscopic Gastric Plication (LGP) is a new restrictive bariatric surgery, previously introduced by the author. The aim of this study is to explain the modifications and to present the 12-year experience, regarding early and long term results, complications and cost. We used LGP for morbid obesity during the past 12 years. Anterior plication (10 cases), one-row bilateral plication while right gastroepiploic artery included (42 cases), and excluded from the plication (104 cases) and two-row plication (644 cases). The gastric greater curvature was plicated using 2/0 prolen from fundus at the level of diaphragm preserving the His angle to just proximal to the pylorus. The anatomic and functional volume of stomach was 50cc and 25cc respectively in two-row method. Ordered postop visits also included evaluation of weight loss, complications, change of diet and control of exercise. LGP was performed in 800 cases (mean age: 27.5, range: 12 to 65 years, nine under 18). Female to male ratio was 81% to 19% and average BMI was 42.1 (35-59). The mean excess weight loss (EWL) was 70% (40% to 100%) after 24 months and 55% (28% to 100%) after 5 years following surgery. 134 cases (16.7%) did not completed long term follow-up. The average time of follow up was 5 years (1 month to 12 years). 5.5% and 31% of cases complained from weight regain respectively during 4 and 12 years after LGP. The mean time of operation was 72 (49-152) minutes and average hospitalization time was 72 hours (24 hours to 45 days). The cost of operation was 2000 $ less than gastric banding or sleeve and 2500 $ less than gastric bypass. Eight patients out of 800 cases (1%) required reoperation due to complications like: micro perforation, obstruction and vomiting following adhesion of His angle. Other complications included hepatitis pneumonia, self-limiting intra-abdominal bleeding and hypocalcaemia. The percentage of EWL in this technique is comparable to other restrictive methods. The technique is safe with 1.6% complication (1% reoperated), and 31% regain during 12 years. The cost of operation is less than the other methods.
    Annals of Surgical Innovation and Research 08/2012; 6(1):7. DOI:10.1186/1750-1164-6-7
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    • "First, the prevalence of morbidly obesity increases rapidly, approaching 8% for some populations in the United States [2]. Secondly, there is a growing consensus that bariatric surgery is currently the most efficacious and long-term treatment for clinically severe obesity, accompanied with a low mortality rate [3] [4] [5]. Morbid obesity is associated with a number of comorbidities such as hypertension, dyslipidemia, type 2 diabetes or insulin resistance, sleep apnea, etc [6] [7] [8]. "
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    ABSTRACT: There is a growing consensus that bariatric surgery is currently the most efficacious and long-term treatment for clinically severe obesity. However, it remains to be determined whether poor physical fitness, an important characteristic of these patients, improves as well. The purpose of this pilot study is to investigate the effect of gastric bypass surgery on physical fitness and to determine if an exercise program in the first 4 months is beneficial. Fifteen morbidly obese patients (BMI 43.0 kg/m(2)) were tested before and 4 months after gastric bypass surgery. Eight of them followed a combined endurance and strength training program. Before and after 4 months the operation, anthropometrical characteristics were measured, and an extensive assessment of physical fitness (strength, aerobic, and functional capacity) was performed. Large-scale weight loss through gastric bypass surgery results in a decrease in dynamic and static muscle strength and no improvement of aerobic capacity. In contrast, an intensive exercise program could prevent the decrease and even induced an increase in strength of most muscle groups. Together with an improvement in aerobic capacity, functional capacity increased significantly. Both groups evolved equally with regard to body composition (decrease in fat mass and fat-free mass). An exercise training program in the first 4 months after bariatric surgery is effective and should be promoted, considering the fact that physical fitness does not improve by weight loss only.
    Obesity Surgery 12/2009; 21(1):61-70. DOI:10.1007/s11695-009-0045-y · 3.75 Impact Factor
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