Fig. 5.1
Vertical banded gastroplasty
LAGB is the latest variation of the gastric restriction procedures (Fig. 5.2). Its success is a combination of two innovations: the development of an inert inflatable band that offers the opportunity for precise adjustment of the degree of restriction and the advent of laparoscopy, which allows for a technically simpler operation than VBG or RYGB with minimal surgical trauma. LAGB gained fast and wide popularity in Europe and Australia in the mid- and late-1990s. In the United States, the adjustable band has gained very rapid popularity since its FDA approval in June 2001. To date, more than half a million adjustable bands have been sold by various producers [5].
Fig. 5.2
Laparoscopic adjustable gastric banding
RYGB was first reported in 1968 by Mason, and its popularity significantly increased in the 1980s with technique modifications (Fig. 5.3). It became an attractive alternative to the VBG and surpassed the restrictive procedure in popularity during the 1990s. Indeed, the advent of laparoscopy, specifically of reliable laparoscopic staplers, transformed RYGB to LRYGB, which is currently the mainstay bariatric procedure worldwide.
Fig. 5.3
Roux-en-Y gastric bypass
The latest procedure to hit the bariatric arena is the LSG, originally described in 2003 as the first step preceding BPD/DS in super obese patients. This staged approach was aimed to improve results and lower morbidity in patients with a BMI greater than 50 or 60. LSG is now used as a stand-alone laparoscopic procedure with rapidly increasing popularity (Fig. 5.4).
Fig. 5.4
Sleeve gastrectomy
BPD (and BPD/DS) is probably the most technically challenging bariatric procedure and has followed a course of its own since its description by Scopinaro in 1979 (Figs. 5.5 and 5.6). This procedure has been advocated by a group of surgeons led by Scopinaro himself in Europe (the BPD is often referred to as the Scopinaro procedure) and by Hess in the United States who had described the BPD/DS. Its significant malabsorption and excellent weight-loss and comorbidity resolution results have also made it a first-choice procedure for some surgeons to use in specific situations or with noncompliant patients, such as those with Prader–Willi syndrome [6].
Fig. 5.5
Biliopancreatic diversion
Fig. 5.6
Biliopancreatic diversion with duodenal switch
The latest data available from a worldwide poll in 2008 shows that RYGB and LAGB account for more than 90% of all bariatric procedures in the world [7]. About 90% of primary RYGB in the United States are laparoscopic [8], and LRYGB remains the most frequently accepted and performed bariatric surgery. After its existence as a very popular procedure in the late 1990s and early 2000 in Europe and Australia, LAGB has been losing ground for the past 5–8 years in these regions in favor of the gastric bypass [7]; however, LAGB has gained significant popularity in the United States. This explains the worldwide increase of LAGB, as the United States and Canada account for over two-thirds of all bariatric cases. More than 220,000 procedures were performed in these two countries in 2008, far surpassing the runner up, Brazil, with its 25,000 procedures recorded [7].
Outcomes
Weight-loss results have been reported in a wide variety of ways in literature—percentage of total weight lost, amount of weight lost in pounds or kg, etc. We will report results as a percentage of excess body weight (EBW) lost, as this is the most frequently used parameters and allows easy identification of successful results.
Roux-en-Y Gastric Bypass
The longest-ranging data available today in bariatric surgery is on gastric bypass patients, as it dates back to 1968, even though this procedure has seen significant modifications since its inception. The size of the gastric pouch was originally larger, but Mason soon reduced it, the standard now being a 15–30 cm3 gastric pouch.
The major modification to the RYGB has undoubtedly been the introduction of laparoscopy. For technical reasons—the configuration of laparoscopic staplers—LRYGB has generalized the transection of the gastric pouch from the gastric remnant. This has greatly reduced the rate of postoperative gastro-gastric fistulae as compared with open RYGB. In the latter, the gastric pouch is usually created by stapling the stomach without dividing it.
There are other significant technical variations in performing the RYGB, including the techniques for creation of the gastrojejunal anastomosis (circular stapler, linear stapler or hand-sewn), passage of the Roux limb (retro- or antecolic), and more importantly, a variant called banded RYGB or “Fobi pouch.” Fobi pouch consists of placing a non-expandable prosthetic ring proximal to the gastrojejunal anastomosis in order to avoid gastric pouch dilation over time. Advocates of this technique have shown improved weight loss, but the endoscopist should be aware of the potential for intraluminal erosion or migration of the band.
Weight-Loss Results
The average weight-loss pattern following RYGB is consistent across series. Very rapid weight loss occurs over the first 12 months, with lesser degrees of weight loss over the following year. The weight nadir is usually reached by the second year at the latest, often followed by a small weight regain, to reach the long-term plateau. Of course, deviation from this pattern is not uncommon—for example, a subset of patients regains a more substantial amount of weight, often 2–5 years after surgery.
Reported results fluctuate, but expected percentage of EBW loss at 1 year ranges from 48 to 77% with an average of 67%. Ten-year results range from 43 to 55% with an average of 52% [9, 10].
These results are slightly less favorable, however, in patients with a BMI greater than 50 and 60. In a recent study, Gould et al. compared patients with BMI greater than 60 and those with less than 60. They reported an average EBW loss of 56.9% versus 69.4% at 1 year and 60.8% versus 70.9% at 2 years, respectively. Also, in the group with BMI greater than 60, 75% of patients achieved more than 50% of EBW loss compared with 93.2% at 1 year in the patients with a BMI less than 60 [11].
Comorbidity Resolution
Resolution of type 2 diabetes mellitus is probably the most astonishing feature of RYGB. While 85% have some form of improvement in diabetic status, “resolution” of diabetes (the cessation of all medication, with normal HgA1c) occurs in 80% of patients [12]. This result is not dependent on weight loss and occurs in the initial days or weeks following the procedure [13].
In a meta-analysis, other comorbidities have been shown to follow the same resolution outcome: improvement in hyperlipidemia occurred in 97% of patients, hypercholesterolemia in 95%, and hypertriglyceridemia in 91%. Hypertension improved in 87% and completely resolved in 67%. Similarly, obstructive apnea syndrome improved in 95% and resolved in 80% [10].
Complication and Mortality Rate
Multiple recent studies have shown the 30-day mortality rate for RYGB to consistently be less than or equal to 0.5% [8, 14, 15] with a large meta-analysis reporting 0.2% in LRYGB and 0.5% in open RYGB [16]. The longitudinal assessment of bariatric surgery (LABS) study of 4,776 patients showed a mortality of 0.2% for LRYGB and 2% for open RYGB [8]. Total complication and mortality rates were 4.8% for LRYGB and 7.8% for open RYGB. This apparent difference between open and laparoscopic procedures became statistically nonsignificant when groups were adjusted for patient and center characteristics.
The complication rate is difficult to compare between studies. Most large series concur in reporting severe complication rates of 4–6%, but rates as high as 21% have been reported [14, 15]. This discrepancy reflects as much technical differences between the series as the type and definition of reported complications.
More specifically, a major complication after bypass is a gastrojejunal leak and its consequences. Leak rate, or most importantly reoperation rate, was 3.2% in the LABS study, and this number seems a good average compared with current literature [8]. Indeed, leak rate numbers reported range from 0 to 4.2%, with most series reporting 1.6–2.5% [14, 15, 17–19].
Other major abdominal complications include gastrointestinal bleeding—usually from one of the anastomotic sites, which is reported between 1 and 2% [14, 15, 17, 18, 20], and bowel obstruction due to bowel incarceration in an internal hernia or at the port site, reported between 1.5 and 2.7% [14, 21]. The most lethal systemic complication is pulmonary embolism, occurring in 0.3–0.5% [8, 14] but accounting for about 15% of postoperative deaths [18].
The severity of post-RYGB complications varies with illustrated 0.5% of patients failing to be discharged 30 days after their surgery [8].
Late complications include gastrojejunal stricture and ulcers. These complications and their management are detailed in separate chapters, and their incidence varies from 1.6 to 31% and 0.8 to 16%, respectively. Bowel obstruction can also occur late after surgery, often requiring reoperation at a frequency of 0.2–2.2% of patients [15]. This might become a more visible complication of RYGB as the number of these surgeries increases.
Conflicting evidence has been published regarding complication rates between open RYGB and LRYGB, with some evidence that LRYGB might have an overall lower incidence of complications. However, series have consistently reported lower rates of wound infection and hernias for LRYGB (1.2% versus 6.2% and 0% versus 10%, respectively, in one series) as well as a shorter hospital stay [22–27].
Laparoscopic Adjustable Gastric Banding
Overall, published averaged results of LAGB have been very positive, both in achieving significant weight loss and regarding complication rates. However, these results comprise very high levels of interindividual variability. Some patients will experience weight loss in excess of average weight loss after RYGB, while others will face extremely poor weight loss. Furthermore, published results also see variability in methods of reporting band removal. Some series exclude patients with removed bands from outcome studies. Gastric wall ulceration, intragastric migration, and patient intolerance to the band all call for its removal. Reports of outcome must therefore be analyzed for proportion of band removal, which is often poorly reported.
Some differences exist in the surgical techniques and band type, but they are usually unnoticeable outside of the operation room. Worth mentioning is a modification of the surgical dissection in order to place the band using a technique called pars flaccida, resulting in lower rates of band slippage, especially early on. This technique has been more widely used since 2000 [28].
Weight-Loss Results
As previously mentioned, the best weight-loss results after LAGB are obtained with close conscientious follow-up. Band adjustment needs to be serially reevaluated by health-care providers familiar with these adjustments.
Comorbidity Resolution
Resolution of type 2 diabetes has been reported to occur in 56% of patients, while 80% of cases saw an overall improvement. Mechanisms of this resolution differ from RYGB, however, and no data currently exists as to specific effects on type 2 diabetes occurring independently of weight loss [12].
In the meta-analysis previously mentioned, other comorbidities resolve as follows: improvement in hyperlipidemia in 59% of patients, hypercholesterolemia in 78%, and hypertriglyceridemia in 77%. Hypertension resolved in 43% and saw an overall improvement in 71%. Obstructive apnea syndrome was improved in 95% and resolved in 68% [10].
Complication and Mortality Rate
Reported mortality in large series is zero or one death, and sample sizes range from 100 to more than 1,000 patients [15]. Average mortality reported in a large meta-analysis is 0.1% [16], while the LABS trial reported no deaths in more than 1,000 cases [8].
Severe intra-abdominal complications are exceptional. Gastric perforation or necrosis has been reported on occasion, but the lack of anastomosis and bowel resection averts the risk of leaks. Reoperation for perforation, bleeding, or band slippage accounts for 1.1% in a recent review [15] and 0.8% in the LABS study [8]. Intraoperative conversion to open placement is consistently around 2% [28–30].
For LAGB, pulmonary embolism is the number one cause of death. Its prevalence is about 0.2–0.3% [8, 15, 28].
The LAGB’s Achilles’ heel is the existence of late complications: reoperation has often been necessary as a result of band slippage or erosion, pouch dilation, or less severely, port dislodgment. Late complications have been described in 1.7–50% of patients. Even in the largest series with excellent overall results, band failure has been described in up to 30% of patients. This occurs when bands need to be removed because of loss of tolerance by the patient. Long-term results—up to 12 years—from Europe and Australia confirm a high major reoperation rate of 8–32%, excluding minor intervention for port placement [29–32]. The most interesting finding is that the rate of failure increases with time—40% at 9 years—and reoperations become increasingly necessary after the third postoperative year [31]. These studies, however, also confirm positive long-term weight loss in the non-failure patients. To date, no reliable predictive factor has been identified to determine whether or not a patient will fail.
Laparoscopic Sleeve Gastrectomy
Although this procedure may seem conceptually simpler and is technically less challenging than RYBG, it should not be considered a “lighter” intervention. While providing overall good short-term results, the complication and mortality rates seem comparable to that of RYGB. Most current results are at the 3 years’ outcome, with some 5-year data becoming available. Current results include both series of LSG as the first step of a stepped approach in patients with a BMI greater than 60, as well as a primary procedure in slimmer morbidly obese patients. There is also significant variation in how narrow the gastric reservoir is to be constructed, likely resulting in varying weight loss and complication rates. These factors may account in part for the wide array of results reported in the literature.
Weight-Loss Results
A recent consensus survey of more than 14,000 procedures reported EBW loss results for 240 of these patients: 60.7 ± 15.6% at 1 year, 64.7 ± 12.9% at 2 years, but decreasing to 48.5 ± 8.7% after 4 years [33]. Published series report similar outcomes [34–36]. It should be noted, however, that to date, published results of patients with 5-year follow-up amounts to only about eight patients. Caution is also required as these results are very widespread, with 1- to 3-year results ranging from 36 to 85% EBW loss, again possibly relating to differences in technique.
Comorbidity Resolution
A recent review compiled the data currently available from every published study, but as previously mentioned the small amount of data currently available accounts for wide confidence intervals in the results. Type 2 diabetes improvement ranged from 69 to 100%, and resolved from 14 to 100%. While resolution of hypertension ranged from 15 to 78%, improvement ranged from 31 to 100%, and all but one study reported at least 77% improvement rate. Hyperlipidemia resolution rates vary from 5 to 73% and improvement between 50 and 87% [37, 38].
Complication and Mortality Rate
The 30-day mortality rate is consistently about 0.2%. Complication rates range from 0 to 23.8% with a mean of 9.4% in patients with a BMI greater than 60 and 6.2% if LSG is a primary procedure. In studies including more than 100 patients, complication rates for the latter group ranged between 0 and 4.1% [38].
As for RYGB, the most feared complication is leakage, which after LSG can occur either proximally, near the ex angle of His, or distally, near the pylorus. Interestingly, the studies from staged procedures reported a lower leak rate than the standard group, respectively, 1.2 and 2.7%. The next severe complications are bleeding, reported in about 1.2% of cases, and strictures, which required intervention in 0.6% [38]. The early reoperation rate reported in two studies with 300 patients was 5% (4.9 and 5.1%) [35, 36].
Other severe complications like pulmonary embolism are poorly reported. However, when comparing operating time and patient population, the rate should be equivalent to the one seen after LAGB.
Data regarding long-term complications is not available but will potentially include bowel obstruction including port site herniation and late strictures.
Biliopancreatic Diversion with or Without Duodenal Switch (BPD or BPD/DS)
Despite having the best long-term weight-loss results of all bariatric procedures, BPD and BPD/DS have never been widely adopted in the same way as RYGB or LAGB. Potential explanations include its technical difficulty and the fact that the vast majority of these procedures have been performed in an open fashion. Laparoscopic approaches to BPD/DS have demonstrated their safety [39, 40], but the laparoscopic approach for BPD or BPD/DS adds complexity to an already difficult operation. However, it remains controversial as to whether the higher difficulty and higher complication rate justifies marginal improvement in weight-loss outcomes.
A major concern for patients undergoing the BPD is the long-term risk of malnutrition and vitamin deficiencies and their consequences of anemia and osteopenia [41]. This procedure therefore mandates lifelong close medical follow-up by providers with experience in these consequences. This complication is also the rationale behind the necessity for revisional procedures in experienced hands [42].
Weight-Loss Results
Maximum weight loss is achieved later than with other procedures, even if 1-year weight loss already reaches 64–76% EBW loss with an average of 72% [9]. The weight nadir usually occurs 3 years after surgery, and results range from 61 to 78% EBW loss with an average of 76%. Results of more than 80% EBW loss at 3 years have been reported in some series [43], but long-term results are undoubtedly positive for both procedures. Scopinaro’s 9-year follow-up of more than 100 patients still shows 77% EBW loss [42], and Hess’s 10-year follow-up with only 8% patient loss demonstrates 75% EBW loss [44].
Comorbidity Resolution
As for weight loss, results here outperform other procedures, with improvement of type 2 diabetes in more than 99% of patients and resolution in about 95%. The same can be said for other comorbidities: improvement in hyperlipidemia occurred in 99.5% of patients, hypercholesterolemia in 99.7% of patients, and hypertriglyceridemia in 100% of patients. Hypertension resolved in 81% and had an overall improvement in 92%. Obstructive apnea syndrome was resolved in 87% and improved in 95% [10].
Complication and Mortality Rate
As previously mentioned, BPD and BPD/DS carry the highest mortality rate of current bariatric procedures. Ranges of 0.5–7.6% have been reported, and most series report a mortality rate in the range of 0.5–2% with 0.5% in the largest series [17, 45–49]. The promoters of this technique also admit this procedure carries a steep learning curve [50], and large series report diminishing complications and mortality after a few hundred cases. For example, Scopinaro describes a rate of major surgical complications of 1.2–1.4% in the last 1,000 cases compared with 2.7% in the first 700 [50]. Hess describes a leak rate diminishing from 3.1% in the first 252 cases to less than 1% after a technical modification [43].
Reported rates of gastric leak and fistulae rate are now usually less than 1% in most series [17, 44, 50]. Duodenal leak occurs in 1–1.5% of cases [43, 48]. Acute gastric dilatation has been described in nearly 9% of patients [17, 47, 48]. Systemic complications such as pulmonary embolism are similar to other procedures, with an average incidence of 0.6% [17, 42, 48].
Long-term complications of BPD or BPD/DS are challenging. Occurrence of marginal ulcers is rare for BPD/DS—0.3% [45], but more frequent in BPD—3.4–12.5% [50]. However, it is the nutritional deficiencies that pose the greatest long-term burden on BPD/DS patients. Potentially severe and life-threatening protein malabsorption and general malnutrition arise frequently and have been reported at levels of 30% in early experience [50]. Although technical modifications have considerably lowered the incidence of protein malabsorption, which usually occurs during the first postoperative months, it can develop at any time after surgery and can be triggered by infection or diarrhea. Patients may require extended parenteral nutrition for several weeks, and a non-negligible portion of patients require surgical revision. Scopinaro and Hess report a reoperation rate for elongation of the common limb of 4.7 and 3.7%, respectively, and 2.1 and 0.6% for reversal. They advocate close patient monitoring and sometimes procedure tailoring for high-risk patients—those with high-carbohydrate, low-protein diets [44, 50].
Procedure Selection and Patient Preparation
Bariatric and metabolic surgeries are unique, as they are performed in a patient-driven setting: with the patient deciding whether or not to entertain having the surgery, when to have it, and even which procedure to have. Even with the overwhelming overall health benefits of weight-reduction surgery, the patient must have a strong drive to pursue this route and initiate the process leading to surgery.
The patient, being the major decision maker, must have all the information necessary to make that choice. The role of the surgeon and multidisciplinary team is to ensure the patient is thoroughly informed in making decisions. Although there is currently no formal guideline for choosing a particular procedure, the preoperative workup is designed to determine which procedure best caters to the patient’s needs. During this multidisciplinary workup, the patient’s individual factors, including BMI, perioperative risk factors, metabolic variables, and comorbidities, are collected and will all play a role in deciding which the most appropriate procedure is. The surgeon’s expertise must also be taken into account. Ultimately, the patient chooses a procedure they feel comfortable with. The evaluation includes physical, psychiatric, and nutritional assessments and ensures the patient fulfills the current national criteria for a recognized indication to bariatric surgery. Another aim of preoperative consultation is to assess whether the candidate, often overwhelmed with potential information, is basing decisions regarding prospective procedures on correct and comprehensive information. Most importantly, the patient must clearly comprehend the complexities of a surgical procedure as well as have reasonable expectations for the outcome of the operation. The patient’s preparation therefore includes accurate and precise information regarding postsurgical care. This includes knowledge of short- and long-term complications as well as short- and long-term dietary restrictions, modifications, and supplementation.
Related posts:
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Procedural Sedation in the Obese Patient
Basic Postoperative Management of the Bariatric Patient
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Endoscopic Management of Post-Bariatric Foreign Bodies: Dysfunctional Sutures, Staples, and Bands
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