Epidemic Obesity

At the turn of the twenty-first century, morbid obesity has become a growing epidemic. Worldwide, more than one billion adults are overweight, including those clinically obese.1 Morbid obesity can be defined as being 100 pounds above ideal body weight, or twice the ideal body weight, or, more commonly, as a body mass index (BMI) of 40 kg/m² or greater. Portion control, consumption of a low-fat diet, and regular physical activity are behaviors that protect against obesity; however, it is becoming increasingly difficult to adopt and maintain these behaviors in our modern society.2 A BMI of 40 kg/m² has been shown to be associated with premature death, and obesity is the second leading cause of preventable death in the United States after tobacco use. Obesity has been estimated to cause 280,000 deaths annually in the United States.3 Elevated BMIs are also associated with a heightened risk for heart disease, hypertension, diabetes, hypercholesterolemia, sleep apnea, osteoarthritis, and gallbladder disease.4

Medical therapy for morbid obesity has limited short- and long-term success. Randomized controlled trials employing lifestyle modifications or pharmacologic interventions for weight loss resulted in only approximately a 7-pound loss that was maintained over a 2-year period.5 Diets that are low in fat or low in carbohydrates often yield weight loss that is insufficient to alter comorbid conditions that are secondary to obesity. Pharmacologic therapy also has poor results. The latest antiobesity agent, orlistat, has been shown to produce a maximum weight loss of 10% body weight at 1 year, and weight is often regained within 12 to 18 months.6

Surgery has been proven to be the only effective long-term treatment for morbid obesity. Patients are eligible for bariatric surgery if they have a BMI of 40 kg/m² or greater or have a BMI between 35 and 40 kg/m² with significant comorbidities, and have failed other medically managed weight-loss programs.7 The eligible patient must be 18 to 60 years of age and prove to have the motivation for weight-loss maintenance.7 Approximately 12 million people in the United States currently meet these criteria. Typically, patients are not eligible for surgical intervention if obesity is related to a metabolic or endocrine disorder, if they have a history of substance abuse or psychiatric problems, or if surgery would be considered high risk; women who will attempt to become pregnant in the next 18 months also are ineligible for surgery.

History of Bariatic Surgery

The first bariatric procedure was done in 1954 by Kremen, Linner, and Nelson.8 They performed a jejunoileal bypass to exclude a large segment of small bowel. This decreases the ability to absorb a majority of the nutrients consumed. Bypasses of this nature grew out of favor because patients complained of uncontrollable diarrhea and suffered from dehydration and electrolyte imbalances. Jejunoileal bypass was revised in 1996 to a biliopancreatic diversion by Scopinaro et al.9 Biliopancreatic diversion produces its weight-loss effect mainly by malabsorption, but it also includes a small restrictive aspect. The intestinal reconfiguration promotes malabsorption of fat and protein. Patients often lost and maintained a significant amount of weight but suffered from ulcers, foul-smelling flatus and stool, protein malnutrition, and iron-deficiency anemia. Protein malnutrition is the most serious potential complication of biliopancreatic diversion and may be associated with hypoalbuminemia, anemia, edema, asthenia, and alopecia. Treatment often requires hospitalization with hyperalimentation. The duodenal switch, first presented by Hess and Hess10 in 1998, is a modification of the biliopancreatic diversion that reduces the severity of protein calorie malnutrition, decreases the incidence of dumping syndrome, and prevents ulcers. Gastric bypass has become the gold standard of weight-loss surgery. Mason and Ito11 in 1967 developed the principles of gastric bypass surgery after they noticed that women who had undergone partial gastrectomy for peptic ulcer disease often were underweight and had difficulty gaining weight.

Vertical-banded gastroplasty first reported in 1982 by Mason12 grew in popularity with the advent of mechanical staplers. It was thought to be a safer alternative to gastric bypass. It was the first purely restrictive operation performed for the treatment of obesity. A pouch is created on the lesser curvature of the stomach, and a polypropylene mesh band is placed around the pouch outlet. There are very few complications attributed to this procedure because no anastomosis is created. Hess and Hess13 later described the first laparoscopic vertical-banded gastroplasty. Vertical-banded gastroplasty has gone out of favor because patients are not able to maintain weight loss.

Another purely restrictive bariatric procedure is nonadjustable gastric banding. This procedure was first described in 1978 by Wilkinson and Peloso,14 who placed a 2-cm Marlex mesh around the upper part of the stomach, separating the stomach into a small upper pouch and the remainder of the stomach. This procedure failed secondary to pouch dilation, causing poor weight loss. It was revised in 1986 by Kuzmak,15 who used a 1-cm Silicone band to encircle the stomach. This created a 13-mm stoma and a 30- to 50-mL proximal gastric pouch. The band was then modified by inserting an inflatable balloon to adjust the band and stoma size.

Modern-Day Bariatric Surgery

Since the advent of laparoscopy, there has been increasing patient demand for bariatric procedures. The mass media, the Internet, and pop culture have informed patients about bariatric procedures, engendering its popularity with the public. The surgical community has also altered its perception of bariatric surgery. Advanced laparoscopy is now a growing field among graduating surgical residents. Because of its minimally invasive approach, patients and many referring physicians incorrectly assume that laparoscopic bariatric surgery entails minimal risk and is an easy solution to obesity.

Bariatric surgery can be divided into restrictive procedures and malabsorptive procedures.

Restrictive Procedures

Restrictive procedures employ a small gastric pouch that limits caloric consumption and creates early satiety.16 The three main minimally invasive restrictive procedures used in the United States are the adjustable gastric band, sleeve gastrectomy, and vertical-banded gastroplasty.

Gastric Banding

Gastric banding is the least invasive of the restrictive weight-loss procedures. In the early 2000s, laparoscopic adjustable gastric banding was the operation of choice in Europe and was later popularized in the United States.17 A gastric band is placed around the upper portion of the stomach to create a small pouch and stoma without dividing the stomach or creating an anastomosis18 ( Fig. 1.1 ).

O’Brien et al19 studied 277 patients who underwent laparoscopic banding and found that, after 1 year, the initial excess weight loss was 51%. Over time, this subset of patients was able to continue weight loss and at 4 years had an initial excess weight loss of 68.2%. Several studies have compared the outcomes of gastric banding to bypass surgery. Tice et al20 completed a systematic review comparing gastric banding and bypass and concluded that Roux-en-Y gastric bypass offered greater weight loss and improvements in obesity-related diseases. However, because gastric banding is a less invasive procedure with no staple line, there may be a certain subset of patients that would benefit from this procedure. Possible complications of gastric banding include band leakage, band slippage, and esophageal dilation.21

Related posts:

2 Origins and Psychiatric Management of Compulsive Eating Behaviors 3 Nutrition 4 Anesthesia and Safety Considerations in the Perioperative Period 13 Circumferential Dermolipectomy of the Lower Trunk: Lower Body Fit 32 Combination Circumferential Abdominoplasty with Medial Thigh Lift 36 Facial Rejuvenation: Open Technique

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