Guidelines for Clinical Application of Laparoscopic Bariatric Surgery

SAGES Guidelines Committee
endorsed by the ASMBS

Received: 20 March 2008 / Accepted: 25 March 2008 ©SAGES 2008

Abbreviations

AGBAdjustable gastric band
BMIBody mass index
BPDBiliopancreatic diversion
DSDuodenal switch
EBWLExcess body weight loss
RGBRoux-en-Y gastric bypass
NIH National Institutes of Health
VBGVertical banded gastroplasty

Preamble

Approximately one-third of US adults are obese [1]. The health consequences of severe obesity have been well described [2]. Current evidence suggests surgical therapies offer the best hope for substantial and sustainable weight loss in the extremely obese [3], with resultant mortality reduction [4]. These truths, coupled with improved minimally invasive bariatric procedures, have driven a fourfold increase in the population-based rate of bariatric surgery over recent years [5].

This document is intended to guide surgeons applying laparoscopic techniques to the practice of bariatric surgery. It will not address credentialing of surgeons or centers, which is the focus of SAGES Guideline for Institutions Granting Bariatric Privileges Utilizing Laparoscopic Techniques and ASMBS Guideline for Granting Privileges in Bariatric Surgery. The current recommendations are graded and linked to the evidence utilizing the definitions in appendices A and B.

This statement was prepared by the Guidelines Committee of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), with input from the Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery (ASMBS). The final document was approved by the SAGES Board of Governors June, 2008, and co-endorsed by the ASMBS Board of Governors June, 2008.

SAGES Guidelines Committee Society of American Gastrointestinal Endoscopic Surgeons (SAGES),
11300 West Olympic Boulevard, Suite 600, Los Angeles, CA 90064, USA e-mail: publications@sages.org

SAGES Disclaimer

Clinical practice guidelines are intended to indicate the best available approach to medical conditions as established by a systematic review of available data and expert opinion. The approach suggested may not necessarily be the only acceptable approach given the complexity of the healthcare environment. These guidelines are intended to be flexible, as the surgeon must always choose the approach best suited to the patient and to the variables at the moment of decision. These guidelines are applicable to all physicians who are appropriately credentialed regardless of specialty and address the clinical situation in question.

These guidelines are developed under the auspices of SAGES, the guidelines committee and approved by the Board of Governors. The recommendations of each guideline undergo multidisciplinary review and are considered valid at the time of production based on the data available. New developments in medical research and practice pertinent to each guideline are reviewed, and guidelines will be periodically updated.

ASMBS Disclaimer

Guidelines are not intended to provide inflexible rules or requirements of practice and are not intended, nor should they be used, to state or establish a local, regional, or national legal standard of care. Ultimately, there are various appropriate treatment modalities for each patient, and the surgeon must use judgment in selecting from among feasible treatment options.

ASMBS cautions against the use of guidelines in litigation in which the clinical decisions of a physician are called into question. The ultimate judgment regarding appropriateness of any specific procedure or course of action must be made by the physician in light of all the circumstances presented. Thus, an approach that differs from this guideline, standing alone, does not necessarily imply that the approach was below the standard of care. To the contrary, a conscientious physician may responsibly adopt a course of action different from that set forth in the guideline when, in the reasonable judgment of the physician, such course of action is indicated by the condition of the patient, limitations on available resources or advances in knowledge or technology.

All that should be expected is that the physician will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient, in order to deliver effective and safe medical care. The sole purpose of this guideline is to assist practitioners in achieving this objective.

Introduction and rationale for surgery

The United States of America has experienced a steady rise in obesity prevalence over the last 20 years and currently ranks second in the world [6]. At the turn of the millennium, nearly two-thirds of Americans were overweight or obese, and almost 5% were morbidly obese [7]. This trend is ominous, because morbid obesity predisposes patients to comorbid diseases which affect nearly every organ system. These include: type 2 diabetes, cardiovascular disease, hypertension, hyperlipidemia, hypoventilation syndrome, asthma, sleep apnea, stroke, pseudotumor cerebri, arthritis, several types of cancers, urinary incontinence, gallbladder disease, and depression [8-10]. Obesity shortens life expectancy [11], with increasing body mass index (BMI) resulting in proportionally shorter lifespan [12]. With over 300,000 victims in the USA each year, morbid obesity is projected to overtake smoking as the leading cause of death in the near future [13].

There are now more than nine million morbidly obese Americans who need help. However, nonoperative management with diet, exercise, behavior modification, and medications rarely achieves adequate durable weight loss [14]. Four long-term studies of nonoperative management of obesity showed an average weight loss of only 4% [15-18]. In the recent Swedish Obese Subjects prospective controlled study, medical management over ten years was associated with 1.6% increase in body weight compared with 13.2% weight loss after gastric band and 25% weight loss after gastric bypass [19].

Since the advent of minimally invasive therapies, there has been a dramatic increase in gastrointestinal procedures that produce significant sustainable weight loss with low complication rates [19-22]. Surgically induced weight loss is associated with resolution or improvement of comorbid diseases in 75-100% of patients [22], and reduced mortality compared with medically treated patients [23-25]. Public awareness and demand, along with improved systems for surgeon training and delivery of care, have combined to fuel a national explosion in bariatric procedures. In 2003, 102,798 operations were performed in the USA, compared with only 13,365 in 1998 [26].

Justification for surgical treatment of obesity

  • Weight-loss surgery is the most effective treatment for morbid obesity, producing durable weight loss, improvement or remission of comorbid conditions, and longer life (level I, grade A).

Evolution of contemporary surgical options

Operations to alter the gastrointestinal tract and produce weight loss have been applied for half a century. Weight-loss operations may cause malabsorption, restriction of food intake, or a combination of the two. The original operation for morbid obesity, the jejunoileal bypass, was first performed in 1954. However, this purely malabsorptive operation led to unacceptable morbidity and mortality related to bacterial overgrowth and liver damage [27]. Focus shifted away from purely malabsorptive procedures until the 1970s when biliopancreatic diversion (BPD) was first described [28], with eventual description of duodenal switch (DS) in 1993 [29]. This operation has been applied laparoscopically with effective weight loss [30].

Gastric bypass was introduced by Mason in 1966 as a combined restrictive-malabsorptive procedure [31]. Several variations and modifications of the original procedure have evolved over time, such as complete gastric transection, reduction in gastric pouch size, and application of a Roux-en-Y[32].

As of 2003, Roux-en-Y gastric bypass (RGB) accounted for over 80% of all bariatric procedures done in the USA [26]. Laparoscopic RGB was popularized and validated in the early 1990s by Wittgrove and Clark [33], and several corroborating series have followed [34-37].Differences exist in the technique for laparoscopic gastrojejunostomy as part of the procedure, including transoral circular stapler [33], transgastric circular stapler [35], linear stapler [36], and handsewn [37], but all are supported in the literature as producing similar safety and weight loss results.

Mason and Printen developed a purely restrictive operation, the gastroplasty, in the early 1970s [38]. This operation later developed into vertical banded gastroplasty (VBG) [39], and ultimately laparoscopic VBG by the 1990s [40]. Despite efforts to simplify the procedure [41], gastroplasty operations decreased and only accounted for 7% of US bariatric procedures in 2002 [26]. Stomach banding for weight loss, originally introduced in the 1980s with non-adjustable devices, became popular in the early 1990s [42]. In 1993, Belachew and Legrand placed the first laparoscopic adjustable gastric band (AGB) using the LAP-BAND® system (Allergan Inc, Irvine, CA, USA) [43]. Although there are multiple versions of AGB available for laparoscopic use, most published results derived from the LAP-BAND® system. Laparoscopic adjustable bands quickly became popular worldwide because of the relative ease of placement and safety. The LAP-BAND® system was not approved for use in the USA until 2001, and utilization has increased steadily. A recent worldwide survey revealed the laparoscopic AGB accounted for 24% of obesity operations, while 26% were laparoscopic RGB and 23% were open gastric bypass [44].

Another contemporary restrictive procedure that derives from the concept of vertical gastroplasty is the laparoscopic sleeve gastrectomy (LSG). LSG developed as a first-stage procedure before duodenal switch or gastric bypass in high-risk patients [45, 46]. Studies have shown that LSG used in this manner reduces weight, comorbidities, and operative risk (ASA score) at the time of a second bariatric procedure [47-49]. There is increasing application of LSG as a primary weight loss operation [45, 46, 50, 51]. Evolving data demonstrate LSG provides substantial weight loss and resolution of comorbidities to 3-5 years follow-up [45, 47, 52-54]. Early comparative data demonstrate percent EBWL at 1 year superior to AGB and approaching that of RGB and BPD [55]. There are other minimally invasive weight loss procedures in developmental stages. Gastric pacing, which has been in development in Europe for over 10 years, has shown acceptable safety and early efficacy (<15 months), though its use is appropriately limited to clinical trials until more mature data become available [56].

Guidelines for selecting validated bariatric procedures

  • Laparoscopic RGB, gastric banding by VBG or AGB, and BPD ± DS are established and validated bariatric procedures that may be performed laparoscopically (level II, grade A).
  • LSG is validated as providing effective weight loss and resolution of comorbidities to 3-5 years (level II, grade C).

Patient selection considerations

According to the 1991 National Institutes of Health (NIH) consensus conference on gastrointestinal surgery for severe obesity, patients are candidates if they are morbidly obese (BMI > 40 kg/m2 or ≥ 35 kg/m2 with comorbidities), have failed attempts at diet and exercise, are motivated and well informed, and are free of significant psychological disease [57]. In addition, the expected benefits of operation must outweigh the risks. Surgery for morbid obesity has a low failure rate, with a mean EBWL of 61.2% [22]. Adverse events vary between procedures, but may reach 20% in high risk patients. Mortality rates approximate 0.1% for gastric banding, 0.5% for RGB, and 1.1% for BPD [22]. There are no absolute contraindications to bariatric surgery. Relative contraindications to surgery may include severe heart failure, unstable coronary artery disease, end-stage lung disease, active cancer diagnosis/treatment, cirrhosis with portal hypertension, uncontrolled drug or alcohol dependency, and severely impaired intellectual capacity. Crohn’s disease may be a relative contraindication to RGB [58] and BPD [59], and is listed by the manufacturer as a contraindication to the LAP-BAND® system.

Laparoscopic surgery may be difficult or impossible in patients with giant ventral hernias, severe intra-abdominal adhesions, large liver, high BMI with central obesity or physiological intolerance of pneumoperitoneum. Surgeons performing bariatric surgery should possess the necessary skills to perform open bariatric surgery in the event it becomes necessary to convert to an open procedure [32].

Weight loss surgery for individuals with BMI ≤ 30-35 kg/m2 and comorbidities merits consideration given the poor results of nonoperative weight loss regimens [60]. One controlled trial of laparoscopic AGB in this group found superior weight loss, resolution of metabolic syndrome and improvement in quality of life versus medical management at 2-year follow-up [61]. Another report of 37 patients undergoing RGB showed excellent weight loss and near-complete resolution of comorbidities [62]. Further data are necessary before surgery for BMI < 35 kg/m2 becomes standard practice.

Early in the laparoscopic bariatric era, many traditional programs declined super-obese (BMI > 50 kg/m2) or supersuper-obese patients (BMI > 60 kg/m2) because of perceived high risk and technical challenge. However, as endosurgical techniques and equipment have improved, laparoscopic RGB and AGB have been more liberally applied at extreme BMIs, with consequent health and quality-of-life benefits, acceptable rates of morbidity and mortality, but lower EBWL [63-71]. Laparoscopic BPD+DS may also be appropriate for super-obese patients given the superior weight loss over laparoscopic RGB [72].

Age restrictions are less rigidly employed in the current era of refined anesthesiology, effective critical care, and high quality surgical outcomes. Laparoscopic bariatric surgery has been performed in patients older than 55-60 years [73-75], but with comparatively less weight loss, longer length of stay, higher morbidity and mortality, and less complete resolution of comorbidities compared with younger patients. Still, the reduction in comorbidities supports use of laparoscopic RGB or laparoscopic AGB in well-selected older patients [76-83].

At the time of the NIH consensus conference in 1991, bariatric surgery for morbidly obese children and adolescents was not advised because of insufficient data. However, with pediatric obesity increasing in prevalence and severity, interest in adolescent bariatric surgery is growing [84]. RGB is well tolerated and produces excellent weight loss in patients younger than 18 years with 10-year follow-up [85-91]. Advocates believe weight reduction at an early age will prevent or minimize emotional and physical consequences of obesity [92]. Well-designed prospective studies are just emerging to better define the place for adolescent bariatric surgery [93].

Guidelines for patient selection

  • 1991 NIH consensus guidelines provide valid but incomplete patient selection criteria for contemporary bariatric procedures including laparoscopic BPD ± DS, RGB, VGB and AGB (level II, grade A).
  • Other well-selected patients may benefit from laparoscopic bariatric surgery by experienced surgeons:
    -BMI > 60 kg/m2 (level II, grade A).
    -Patients > 60 years (level II, grade B).
  • Adolescent bariatric surgery (age < 18 years) has been proven effective but should be performed in a specialty center (level II, grade B). Patient selection criteria should be the same as used for adult bariatric surgery (level II, grade C).
  • Individuals with BMI 30-35 kg/m2 may benefit from laparoscopic bariatric surgery (level I, grade B).

Bariatric program and facility

The etiology of morbid obesity seems to involve genetic, environmental, metabolic, and psychosocial factors [94]. Therefore, treatment of the bariatric patient lends itself to a team approach for systematic evaluation and management [95]. Although a multidisciplinary team is seen as an important component of a bariatric surgery practice [32, 56, 96, 97], no comparative clinical trials have proven this. The team leader is the surgeon, who is complimented by nurses, physician extenders and clerical staff for scheduling, insurance precertification, and coordination of patient flow. The surgeon must have acquired the proper education and hands-on training as per the SAGES Guidelines for Institutions Granting Bariatric Privileges Utilizing Laparoscopic Techniques. Other important team members include nutritionists, psychologists with specific training and experience, and medical subspecialists (endocrinologists, anesthesiologists, radiologists, pulmonologists, gastroenterologists, etc.) to help evaluate and optimize patients preoperatively and to provide care postoperatively if necessary [32, 96, 97].

The institutional needs of a bariatric program extend across outpatient and inpatient environments. It is important to have office and hospital furniture, equipment, clothing, fixtures, beds, and wheelchairs that are appropriate and comfortable for patients with morbid and supermorbid obesity. In the operating room, specially rated tables and attachments, extra-long instruments, and appropriate staplers and retractors are necessary [97]. Healthcare providers and staff must be experienced with and sensitive to the special needs of bariatric patients, and protected against ergonomic and lifting injuries.

Postoperative support groups are also an important aspect of a bariatric program and may improve postoperative results and limit relapse [32, 97, 98, 99]. Two nonrandomized studies have shown that patients attending support groups achieve greater weight loss than those who do not [100, 101].

Hospital annual case volume above 100 may be associated with reduced morbidity and mortality and improved costs [102]. Higher surgeon volume has been associated with reduced mortality [103]. Center of Excellence designation programs have gained traction [95] and are maintained by the American College of Surgeons [104] and the American Society for Metabolic and Bariatric Surgery [105].

Guidelines for bariatric programs

  • Bariatric surgery programs should include multidisciplinary providers with appropriate training and experience (level III, grade C).
  • Institutions must accommodate the special needs of bariatric patients and their providers (level III, grade C).
  • Participation in support groups may improve outcomes after bariatric surgery (level II, grade B).

Preoperative workup

The preoperative evaluation is similar for all bariatric procedures. The components include determining a patient’s indications for surgery, identifying issues which may interfere with the success of the surgery, and assessing and treating comorbid diseases. Typical assessment includes psychological testing, nutrition evaluation, and medical assessment [97, 106].

Psychological evaluation

Patients referred for bariatric surgery are more likely than the overall population to have psychopathology such as somatization, social phobia, obsessive-compulsive disorder, substance abuse/dependency, binge-eating disorder, post-traumatic stress disorder, generalized anxiety disorder, and depression [107]. Patients with psychiatric disorders may have a suboptimal outcome after bariatric surgery [107]. However, no consensus recommendations exist regarding preoperative psychological evaluation [106, 108]. A recent survey reported that 88% of US bariatric programs utilize some psychological evaluation, with half requiring a formal standardized assessment [106]. Many insurance companies require such psychological evaluation prior to granting precertification for a bariatric procedure. Nevertheless, the bulk of evidence shows no relationship between preexisting axis I psychiatric diagnosis or axis II personality disorder and total weight loss [106, 109, 110]. It is not certain which psychosocial factors predict success following bariatric surgery [108], yet many programs exclude patients who are illicit drug abusers, have active uncontrolled schizophrenia or psychosis, severe mental retardation, heavy alcohol use, or lack of knowledge about the surgery [106].

Nutrition consult

The nutrition professional is an integral part of multidisciplinary bariatric care [111, 112]. He or she is charged with nutritional assessment, diet education regarding postoperative eating behaviors, and preoperative weight loss efforts [113]. Preoperative very-low-calorie diet for 6 weeks has been shown to reduce liver volume by 20% and to improve access to the upper stomach during laparoscopic surgery [114, 115], with 80% of the volume change occurring in the first 2 weeks [114]. Furthermore, patients who are able to achieve 10% EBWL preoperatively have shorter hospitalization and more rapid weight loss [116].

Despite the wide utilization of preoperative nutritional efforts, and the requirement by many insurance companies for dietary counseling, data are still needed to prove association with postoperative weight loss or dietary compliance [117, 118]. No evidence-based, standardized dietary guidelines exist for either pre-or postoperative nutritional management of the bariatric patient, and no convincing data support the need for routine use of nutrition specialists after operation. Outcome studies and clinical trials are necessary to help define the role of the nutrition professional in the bariatric team.

Preoperative medical evaluation

Medical assessment prior to bariatric surgery is similar to abdominal operations of the same magnitude. Thorough history and physical examination with systematic review is used to identify comorbidities that may complicate the surgery. Consultation with a medical subspecialist is often necessary to optimize medical conditions to reduce perioperative risk.

Routine laboratory evaluation typically includes complete blood count, metabolic profile, coagulation profile, lipid profile, thyroid function tests, and ferritin. Vitamin B12, and fat-soluble vitamin levels may be evaluated if considering a malabsorptive procedure. Cardiovascular evaluation includes electrocardiogram and possible stress test to identify occult coronary artery disease. Respiratory evaluation may include chest X-ray, arterial blood gas, and pulmonary function tests. Sleep apnea may be diagnosed by sleep study and the patient started on continuous positive airway pressure prior to surgery. Upper endoscopy may be used if suspicion of gastric pathology exists. If H. pylori infection is present, preoperative therapy is advised [119]. The liver may be assessed by hepatic profile and ultrasound. In cases of suspected cirrhosis, biopsy may be indicated. Ultrasound may be used to detect gallstones, allowing the surgeon to decide on concomitant cholecystectomy [98, 120].

Guidelines for preoperative preparation

  • A psychological evaluation is commonly part of the preoperative work-up of bariatric patients (level III, grade C).
  • Treated psychopathology does not preclude the benefits of bariatric surgery (level II, grade B).
  • Preoperative weight loss may be useful to reduce liver volume and improve access for laparoscopic bariatric procedures (level II, grade B), but mandated preoperative weight loss does not affect postoperative weight loss or comorbidity improvements (level I, grade B).

Surgical techniques and outcomes (presented in order of introduction above)

Laparoscopic biliopancreatic diversion

Introduction

After jejunoileal bypass was abandoned [121], most of the bariatric community focused on restrictive operations [122]. However, Scopinaro revisited the value of malabsorption in his description of the BPD in the late 1970s [28]. Since then, modifications have included the duodenal switch [123], the sleeve gastrectomy [29], and the laparoscopic approach [124]. DS diminishes the most severe complications of BPD, including dumping syndrome and peptic ulceration of the anastomosis [125]. Sleeve gastrectomy spares the lesser curvature, vagus nerves and pylorus, in contrast to the original distal gastrectomy, though theoretical beneficial effects on eating behavior, weight loss and side-effects are not universally reported [125, 126]. The laparoscopic approach decreases wound complications, pain and hospital length of stay [127].

Technical considerations

Standard technique for BPD+DS involves dividing the small bowel 250 cm above the ileocecal valve with a stapler, and then forming a biliopancreatic limb by connecting the bowel proximal to the transection to a point 100 cm above the ileocecal valve. The bowel distal to the transection is elevated as an alimentary limb to the upper abdomen. Sleeve resection creates a tubularized stomach of approximately 100 cm3. The duodenum is divided 3 cm distal to the pylorus, and duodenoileostomy establishes continuity of the alimentary limb. Limb lengths determine weight loss and complications. A common limb that is too long will provide inadequate weight loss, whereas one too short will cause debilitating diarrhea and nutritional deficiencies. Gastric remnant size should provide some restriction but not prevent initiation of protein digestion.

Whether BPD should be tailored to patient characteristics such as age, size or BMI is uncertain [128]. Scopinaro, in his original animal study [129], found ‘‘insertion of the bypass into the ileum at a distance from the ileocecal valve equivalent to one-sixth of the intestinal length allows adequate weight loss with minimal complications.” However, by the time of his human studies [28], he noted that ‘‘the exact length of the common ileal segment and the length of the jejunum in the biliopancreatic tract required to achieve maximum weight reduction with minimum complications have yet to be determined.” Hess [130] reports excellent results by measuring small bowel length and then distributing 10% to the common channel and 40% to the alimentary limb. A large Spanish series reports excellent outcomes with a common channel of 60 cm and an alimentary limb of 200-360 cm [131, 132].

A US study suggests common channels longer than 100 cm result in inferior results [132]. In a comparative study of outcomes and complications, 100 cm common channel was superior to 50 cm, and sleeve gastrectomy was superior to distal gastrectomy [125]. Though there is a paucity of comparative data between open and laparoscopic BPD, a few comments can be made on the utility of the minimally invasive procedure. Firstly, because the details of the resection and reconstruction are the same, long-term outcomes are likely to be similar. Indeed, at 1 and 3 years follow-up, weight loss is similar to that achieved by open surgery [133, 134]. Laparoscopic BPD has reduced hospital stay and complications, mainly due to a lower rate of wound infections and dehiscence [127]. Laparoscopic BPD is an advanced, complex and feasible technique in bariatric surgery, and one which has a steep learning curve [135].

Outcomes

BPD ± DS initiates dramatic weight loss during the first 12 postoperative months, which continues at a slower rate over the next 6 months. Weight loss is durable up to at least 5 years postoperatively. Ninety-five percent of patients with BMI>50 kg/m2, and 70% of those with BMI>50 kg/ m2, achieve greater than 50% excess body weight loss [29, 136, 137]. Weight may be regained over time [138], highlighting the importance of long-term follow-up.

BPD dramatically impacts comorbidities. At least 90% of patients with type 2 diabetes will cease diabetic medications by 12-36 months [127, 128, 139]. Of hypertensive patients 50-80% will be cured, with another 10% experiencing improvement [140-142]. Up to 98% of patients with obstructive sleep apnea symptoms will have resolution [143, 144].

Although BPD, RGB, and AGB are all superior to nonsurgical therapy, the relative effectiveness of these procedures has not been fully compared. Data available are rarely randomized or controlled, and often compare non-equivalent cohorts. Nonetheless, available data suggest the weight loss effect of BPD is greater and more durable than laparoscopic AGB [143, 145]. Likewise, BPD may be superior to RGB in patients with BMI ≥50 kg/m2 [71].

Percent EBWL after bariatric procedures [145]

OperationMean follow-up (years)
123457810
BPD% EBWL71.875.176.375.573.36975.877.0
Aggregate N896162341041017489405122
# studies43433121
RGB (proximal)% EBWL67.367.562.558.058.255.052.5
Aggregate N16273852855091762194
# studies7544312
AGB% EBWL4257.254.854.555.251.059.3*
Aggregate N445633833104143564029100
# studies1111129521

* 42 patients with 8-year follow-up and band not removed [146]

A meta-analysis examining studies published between 1990 and 2003 found BPD resulted in more weight loss and improvement of diabetes, hyperlipidemia, hypercholesterolemia, hypertriglyceridemia, and obstructive sleep apnea than any other type of bariatric procedure [22].

Despite the favorable reports of the biliopancreatic diversion and duodenal switch procedure for the treatment of morbid obesity, it has been slow to gain widespread acceptance [29].

Postoperative

An upper gastrointestinal series is typically performed in the early postoperative period to exclude contrast extravasation. If normal, a clear liquid diet is commenced, with gradual introduction of solids. Discharge is usually within 4-5 days.

Close follow-up is recommended in the postoperative period. For example, visits at 2 and 6 weeks, then quarterly for the first year, biannually for the second year, and annually thereafter would be one acceptable strategy [126, 131]. Assessments are made by both the surgeon and nutritionist, and biochemical surveillance by complete blood count, chemical metabolic profile, and parathormone level is performed at intervals. An exercise program is helpful, as are multivitamin, iron, vitamin D, and calcium supplements.

Complications

The 30-day mortality of early laparoscopic BPD series ranges from 2.6 to 7.6% [134, 147]. Major complications, which occur in up to 25% of cases, may include early occurrence of anastomotic leak, duodenal stump leak, intra-abdominal infection, hemorrhage, and venous thromboembolism [29, 147-150], or later bowel obstruction, incarceration or stricture [151].

The performance of a sleeve gastrectomy as part of the BPD+DS allows patients two-thirds of their preoperative dietary volume without specific food intolerances. Between 70 and 98% maintain normal serum albumin 3 years after surgery [29, 126]. Diarrhea is a frequent chronic complication of BPD. Common channel length of 50 cm is associated with reports of diarrhea in most patients [126], whereas length of 100 cm is not [29]. Iron deficiency is common, with serious iron deficiency anemia (hemoglobin <10 mg/dl) occurring in 6% of patients [152]. Surveillance of biochemical and hematological markers of iron deficiency should drive replacement. Calcium and vitamin D malabsorption are also common, manifesting as secondary hyperparathyroidism [153]. Supplements do not prevent development of secondary hyperparathyroidism. Increase in bone resorption is known to occur irrespective of parathormone levels, suggesting a phenomenon of bone reshaping parallel to the loss of weight [154]. Due to fat malabsorption resulting from BPD, supplementation of fat-soluble vitamins is recommended. Deficiency of these vitamins is more likely with a shorter common channel.

Cholelithiasis postoperatively occurs in 6% [155] to 25% [28]. Some surgeons advocate for routine cholecystectomy given the alteration in endoscopic accessibility to the biliary tract, whereas others argue for delayed cholecystectomy only if symptoms develop, since cholecystitis occurs uncommonly after BPD [156].

Guidelines for laparoscopic BPD ± DS

  • In BPD, the common channel should be 60-100 cm, and the alimentary limb 200-360 cm (level II, grade C).
  • DS diminishes the most severe complications of BPD, including dumping syndrome and peptic ulceration of the anastomosis (level II, grade C).
  • BPD is effective in all BMI>35 kg/m2 subgroups, with durable weight loss and control of co-morbidities beyond 5 years (level II, grade A).
  • Laparoscopic BPD provides equivalent weight loss, shorter hospital stay, and fewer complications than open BPD (level III, grade C).
  • BPD may result in greater weight loss (level II, grade A) and resolution of comorbidities (level II, grade B) than other bariatric surgeries, but with the highest mortality rate (level II, grade A).
  • After BPD ± DS, close nutritional surveillance and supplementation are needed (level III, grade C).

Laparoscopic Roux-en-Y gastric bypass

Introduction

Gastric bypass was first developed in the 1960s as a means to combine restrictive, malabsorptive, and behavioral components to achieve weight loss. Physiologic changes in the gastrointestinal tract after gastric bypass (dumping, neuroendocrine responses, etc.) also appear to influence weight loss and comorbidity improvements which may precede weight loss. Since then, modifications have included use of a small lesser curvature-based gastric pouch, gastric transection, Roux-en-Y reconstruction, and variations in length of the alimentary limb [157, 158]. Feasibility of the laparoscopic approach to RGB was first shown in the early 1990s [33].

Technical considerations

The stomach is divided to form a small proximal gastric pouch and the small intestine is reconstructed using a Roux-en-Y to form an alimentary limb. Although accurate measurement of pouch volume is difficult and prospective data are lacking, a retrospective study has suggested that smaller pouches may be associated with greater weight loss [159]. Most surgeons choose the transection point by measuring from the esophagogastric junction or by counting vascular arcades.

When creating the Roux en-Y bypass, the jejunum is typically divided below the ligament of Treitz, and the distal segment is elevated and surgically connected to the gastric pouch to create the alimentary (Roux) limb, with variations on the path and method for anastomosis. The proximal bowel segment, also called the biliopancreatic limb, is usually connected to the alimentary limb 75- 150 cm distal to the gastrojejunostomy. This reconstruction serves to bypass the distal stomach, duodenum and a portion of jejunum to create malabsorption [157].

Several authors have addressed the issue of limb length during RGB. In BMI ≤ 50 kg/m2 patients, both retrospective [160] and prospective [161, 162] data fail to show a benefit for alimentary limbs longer than 150 cm. However, BMI >50 kg/m2 patients who were randomized to a 250 cm rather than a 150 cm alimentary limb did show improved weight loss at 18 months, though the study was not powered to confirm this benefit at longer follow-up [162]. Other studies have examined the use of alimentary limbs longer than 300 cm for BMI > 50 kg/m2 patients, and have found improved weight loss over standard RGB, but with increased nutritional deficiencies and need for reoperation [163, 164].

Laparoscopic RGB is a technically demanding procedure; the available literature suggests an experience of 50- 150 cases is required for surgeons to become safe and proficient [34, 36, 165-168].

Outcomes

The literature comparing laparoscopic RGB to open RGB and to contemporary medical and surgical treatments for obesity includes several prospective randomized controlled trials [161, 169-175], a large prospective case-controlled cohort study [19], numerous case series, and four metaanalyses [2, 21, 22, 176].

Surgical therapy is clearly more effective than medical therapy in terms of weight loss and resolution of comorbidities. Morbidly obese patients employing behavioral and medical therapies alone actually gain weight in the long term [2, 19]. Surgical patients have lower 5 year mortality versus nonsurgical patients (0.68% versus 6.17%), despite 0.4% perioperative mortality [177].

Patients who undergo laparoscopic RGB typically experience 60-70% EBWL, with >75% control of comorbidities [2, 19, 21, 22]. In general, these outcomes are better than banding procedures, which have 45-50% EBWL and less predictable improvement of comorbidities, but are less than BPD ± DS which has 70-80% EBWL with excellent control of comorbidities [22].

Improvement of comorbidities after bariatric procedures [22]

OperationDiabetes resolvedHypercholesterolemia improvedHypertension resolvedSleep apnea resolved
Banding47.8%71.1%38.4%94.6%
RGB83.8%93.6%75.4%86.6%
BPD97.9%99.5%81.3%95.2%

Open and laparoscopic RGB have similar efficacy. In prospective randomized trials [169-171, 174], there are no significant differences in weight loss up to 3 years follow-up. Similar results have been reported in cases series [176].

Postoperative

Close, long-term follow-up is recommended for patients after bariatric surgery [57]. A typical example for recommendations of follow-up after laparoscopic RGB would be at 1-3 weeks, followed by quarterly visits during the first year and annually thereafter, to assess weight loss, resolution of comorbidities, long-term complications, and need for continuing education and support. Patients are counseled to eat small, frequent meals of high protein and low carbohydrate content.

They should take long-term vitamin supplements (multivitamins, Vitamin B12, and calcium with some patients requiring iron supplementation) and undergo periodic blood testing to identify and treat deficiencies early. Patients should be encouraged to develop regular exercise practices. Two retrospective studies on the impact of follow-up on outcomes after laparoscopic RGB have been done; one suggests patient follow-up does not play an important role while the other reports improved weight loss in patients compliant with follow-up at 1 year [178, 179].

Complications

The mortality rate after RGB ranges from 0.3% in case series to 1.0% in controlled trials, and the rate of preventable and nonpreventable adverse surgical events is 18.7% [21]. The mortality rate in a review of selected laparoscopic RGB series ranged from 0.5% to 1.1% [180]. Safety of laparoscopic RGB has been compared to open RGB, with laparoscopic patients having reduced incidence of iatrogenic splenectomy, wound infection, incisional hernia and perioperative mortality, but higher rates of bowel obstruction, intestinal hemorrhage, and stomal stenoses [181].

The most frequently reported perioperative complications associated with laparoscopic RGB are wound infection (2.98%), anastomotic leak (2.05%), gastrointestinal tract hemorrhage (1.93%), bowel obstruction (1.73%), and pulmonary embolus (0.41%), while the most frequently reported late complications are stomal stenosis (4.73%), bowel obstruction (3.15%), and incisional hernia (0.47%) [181].

Guidelines for laparoscopic RGB

  • In laparoscopic RGB, a small lesser-curvature-based pouch that excludes the gastric fundus and a 75-150 cm alimentary (Roux) limb are effective for most patients (level II, grade B).
  • Alimentary limbs longer than 150cm may improve intermediate-term weight loss but also may increase nutritional complications (level III, grade C).
  • Laparoscopic RGB is similar in efficacy to open RGB (level I, grade A), with reduced early complications and risk of hernia (level II, grade B).
  • Long-term follow-up is recommended and may improve weight-loss outcomes (level III, grade C).

Laparoscopic adjustable gastric banding

Introduction

In the 1980s, gastroplasty was the most common restrictive bariatric procedure, with the most commonly performed iteration being the vertical banded gastroplasty. However, due to poor long-term weight loss [182, 183] and a high rate of late complications, alternatives to this operation were sought [184].

Open gastric banding procedures inspired laparoscopic AGB, first described in 1993 [43], which involves the placement of a restrictive inflatable balloon device around the gastric cardia, approximately 1 cm below the gastroesophageal junction. This balloon is connected by tubing to a subcutaneous port which is attached to the rectus sheath. Saline injected into the port will cause balloon inflation which results in narrowing of the stomach at the level of the balloon.

Various brands of laparoscopic AGB exist, though only the LAP-BAND® system and the REALIZE™ adjustable gastric band (Ethicon Endosurgery, Cincinnati, OH) currently have Food and Drug Administration (FDA) approval for use in the USA. The equivalence between the two FDA-approved devices in the USA has been demonstrated [185], but comparative trials with others devices do not yet exist.

Technical considerations

The laparoscopic AGB is best placed via a pars flaccida approach, that is, via a retrogastric tunnel between the pars flaccida medially and the angle of His laterally. This has equivalent efficacy to the initially described perigastric approach, but has a significantly decreased rate of band slippage (i.e., gastric prolapse) [186-188]. The pars flaccida approach results in more extraneous tissue, particularly the lesser curvature fat pad, being incorporated into the band. Compensation by placing a band of greater diameter may be required to limit stomal obstruction.

At the time of placement, a peroral calibration balloon may be placed into the stomach, filled with 15-25 cc of saline, allowing the band is to be fastened below this level. A 15-25 cc pouch is thereby created.

AGB avoids the risks of gastrointestinal stapling and anastomosis and allows complete reversibility. Most authors agree laparoscopic AGB is less technically demanding and less morbid than laparoscopic RGB [71, 189]. However, potential disadvantages of laparoscopic AGB compared to laparoscopic RGB include the ongoing need for band adjustments, delayed or unsatisfactory weight loss [190], and unique indications for reoperation such as pouch dilation, esophageal dilation, band slippage, band erosion, port-site complications, or leaks from the device [185].

Outcomes

Laparoscopic AGB has been compared to intensive pharmacotherapy, behavioral modification, diet modification, and exercise in patients with BMI 30-35 kg/m2. In this population, laparoscopic AGB was seen to be more effective in reducing weight, resolving metabolic derangements, and improving quality of life [61].

Laparoscopic AGB is very effective at producing weight loss, with patients losing approximately 50% of their excess body weight [22, 191]. This weight loss occurs in a gradual manner, with approximately 35% EBWL by 6 months, 40% by 12 months, and 50% by 24 months. This percentage appears to remain stable after 3-8 years based on the few studies providing this length of follow-up [145, 192-194]. However, as many as 25% of laparoscopic AGB patients fail to lose 50% of their excess body weight by 5 years [22, 190].

Laparoscopic AGB has positive effects on the comorbidities of obesity. Type 2 diabetes is improved in about 90% of patients, due to increased insulin sensitivity and increased pancreatic beta-cell function [195], and diabetic medications are eliminated in 64% [196, 197]. Following AGB, resolution of type 2 diabetes mirrors weight loss, and therefore is slower to occur than after RGB or BPD where the diabetes is seen to begin to improve before significant weight loss [196, 198].

Symptoms of gastroesophageal reflux disease may be eliminated in at least 89% at 12 months, even in patients with large hiatal hernias [199, 200], but with the side-effect of impaired lower esophageal sphincter relaxation and possible altered esophageal motility [201]. Rate of obstructive sleep apnea drops from 33% to 2% in laparoscopic AGB patients [202]. Major quality-of-life improvements are seen after AGB placement, with all subscales of the SF-36 general quality-of-life questionnaire significantly improved, particularly in areas of bodily pain, general health perception, and mental health perception [203-205].

The short-term (< 12 months) weight loss of laparoscopic AGB is inferior to RGB [206]. This discrepancy is seen to continue, with a randomized controlled trial illustrating that EBWL at 5 years was 47.5% for AGB versus 66.6% for RGB [207]. Still, life-threatening complications are less frequent in laparoscopic AGB as compared to laparoscopic RGB.

Postoperative

Successful weight loss after laparoscopic AGB requires close follow-up for band adjustments, education, and support. In the absence of comparative data, guidelines for follow-up and adjustment are based on manufacturer recommendations and expert opinion. Physicians with extensive experience placing and managing the AGB adhere to a number of basic tenets necessary for successful weight loss. Immediately after operation, oral intake is restricted to liquids and soft foods to prevent vomiting and dislodgment of the band. After a recovery period, the diet is transitioned to solid foods that induce satiety and no-calorie liquids between meals. Eventually, a wide range of foods is tolerated, though whole meats and heavy breads may always cause dysphagia or regurgitation. To avoid protein-calorie malnutrition and loss of lean body mass, diets should focus on protein and complex carbohydrate intake, with a limited quantity of simple sugars and fats. Physical activity is recommended to maintain lean body mass and to improve cardiovascular fitness and total weight loss.

In the initial postoperative period, most advocate leaving the band unfilled. The first adjustment usually occurs about 6 weeks after placement with initial and subsequent fill volumes determined by band type and patient factors. Fluid should be added if weight loss falls below expectations, or if meal volumes increase with loss of satiety. Adjustment is not needed if there is adequate weight loss, satiety, and tolerance. Fluid should be removed for vomiting, coughing, choking, or significant solid food intolerance. Bands may be adjusted with or without radiographic guidance with acceptable results [208].

Complications

Case series and systematic reviews put early mortality rates after laparoscopic AGB at 0.05-0.4% [21, 209], compared with laparoscopic RGB at 0.5-1.1% [180], open RGB at 0.5-1.0% [21, 22], open BPD at 1.1% [21], and laparoscopic BPD at 2.5-7.6% [134, 147, 148].

Regarding relative morbidity rates, comparative data are few. Overall complications and major complications are less common in laparoscopic AGB than laparoscopic RGB or laparoscopic BPD, in a single-center experience [151].

Mortality/morbidity after laparoscopic bariatric procedures

Operation30–day mortality [21, 95, 134, 147,148, 180, 208]Overall complications[151]Major complications[151]
Lap AGB0.05-0.4%9%0.2%
Lap RGB0.5-1.1%23%2%
Lap BPD2.5-7.6%25%5%

Recent review of a multicenter, prospective US trial of laparoscopic AGB placement by the perigastric approach [205] found uncommon occurrence of gastrointestinal perforation (1%) or other visceral injury (1%). Band-related complications accumulated over 5-year follow-up, such as slippage/pouch dilatation (24%), esophageal dilatation (8%) and stomal obstruction (14%). Port-site complications, including pain, port displacement, and leak, arose in about 7% of patients. Mean explantation or major revision rate by 9 years was 33%.

In contrast, parallel review of a subsequent trial which implemented the pars flaccida technique [205] found reduced slippage/pouch dilatation (7%), esophageal dilatation (1%), and stomal obstruction (2%) at 1-year. Non-US surgeons have also championed the pars flaccida method [186-188, 210, 211] to reduce band-specific complications. One pure pars flaccida series with 7-year follow-up reported 12% slippage/pouch dilatation, however the cumulative reoperation rate was 32% [211].

Guidelines for laparoscopic AGB

  • The pars flaccida approach for laparoscopic AGB placement should be used in preference to the perigastric approach in order to decrease the incidence of gastric prolapse (level II, grade A).
  • Laparoscopic AGB is effective in all BMI subgroups, with durable weight loss and control of comorbidities past 5 years (level I, grade A).
  • Intermediate-term weight loss after laparoscopic AGB may be less than after laparoscopic RGB (level I, grade A).
  • Frequent outpatient visits are suggested in the early postoperative period. Band filling should be guided by weight loss, satiety, and patient symptoms (level III, grade C).

Revisional surgery

Patients may require revision of prior bariatric procedures because of: (1) anatomic failure with persistent or recurrent obesity, (2) development of secondary complications, or (3) need for reversal.

Anatomic failure

In planning revisional bariatric operations, surgeons must have an understanding of the prior procedures and typical anatomic complications, as well as the current state of the relevant anatomy. In past decades, several procedures have been employed and have since fallen out of favor [212]. A number of pure restrictive procedures that involved gastric partitioning with staples have been limited by stomal dilation or recanalization of nondivided staple lines [213, 214]. Even procedures acceptable by today’s standards, such as VBG [215], RGB [216], and AGB are at risk for anatomic derangement that may be amenable to surgical revision [217, 218, 219]. In recent years, the explosion of bariatric surgery has also resulted in application of interventions that may create unfamiliar anatomy and complications for surgeons performing revisional procedures [220]. For all these reasons, it is vital the surgeon makes every effort to define the prior procedure(s) performed by medical record review and preoperative radiographic and endoscopic assessment [221, 222].

Upper GI contrast studies may define the location and integrity of gastric staple lines, as well as the nature and patency of outflow from the proximal stomach [223]. Endoscopy will assess for ulcers and internalized foreign bodies, and may allow for therapeutic dilatation in some cases. Indirect evidence of gastric or intestinal motor dysfunction may also be appreciated. Finally, in some cases, imaging by CT scan will allow for visualization of pathology in excluded portions of the anatomy or suggest internal hernias.

Patients who never lose weight may have had a technical complication such as incomplete stapling [224, 225], or an inappropriate operation. Those who regain weight after years may have suffered staple line recanalization or behavioral failure [226]. Reoperation on a previous gastroplasty usually involves creating a Roux-en-Y, if not already present, to a newly stapled proximal stomach pouch above all prior gastric interventions [227-230]. However, BPD, AGB, and other operations have also been employed in this setting [231-233]. Likewise, most authors advocate RGB for revision of AGB because of complications or insufficient weight loss [217-219], although other operations have been applied [234, 235]. Finally, in cases of failed BPD+DS some have advocated use of a pouch reduction procedure [236], and in failed RGB use of either AGB to improve the restrictive component [237] or lengthening to improve the malabsorptive component [238]. Comparative data are lacking.

Secondary complications

In some cases, bariatric procedures require revision when unexpected complications emerge over time. For example, the jejunoileal bypass resulted in dramatic weight loss, but became marred by the occurrence of malabsorptive complications including renal and hepatic failure [122, 239]. The importance of long-term follow-up is a lesson that must not be forgotten as new procedures are introduced.

Contemporary bariatric patients may seek revision due to evolution of other conditions or complications, such as gastroesophageal reflux (GER), bile reflux, complicated ulcers, or obstruction [240]. Severe GER may occur after gastroplasty or VBG in the absence of outflow obstruction [229], whereas bile reflux may occur in procedures that utilize Bilroth II gastrojejunostomy [220]. In either case, conversion to RGB is therapeutic [241]. Easily treated marginal ulcers are common in the healing phase [242], but later should raise concern for salicylate or NSAID abuse [243], or gastrogastric fistula [224]. Late gastrogastric fistula closure may be a difficult procedure requiring laparotomy, sometimes with resection [225], whereas marginal ulcer perforation is more easily managed with a laparoscopic approach [244]. Obstruction due to internal herniation may require major resection and intestinal reconstruction [245].

Excessive weight loss, steatorrhea, or evolution of severe nutritional complications, particularly protein-calorie malnutrition, may indicate an excessively long malabsorptive component. Proximal relocation of the pancreaticobiliary secretions by intestinal reconstruction should be considered [164]. One option is to relocate the junction of the biliary and alimentary limbs more proximally, with a 50 cm distance being suggested by Hamoui [246]. An alternative, and a technically easier operation is to leave the original anastomosis intact and to create another enteroenterostomy 100 cm proximally, allowing for more proximal partial mixing of biliary and pancreatic secretions with the alimentary limb contents. This is effective in resolving malnutrition and diarrhea, while causing minimal weight gain [246]. However, complication rates are high even in this simple procedure, presumably due to the poor physiological state of the malnourished patient.

Desire for reversal

Ease of reoperation after laparoscopic AGB is one of the putative benefits, and up to 33% of patients may come to reversal or major revision [210, 211]. Laparoscopic RGB and BPD cause more dramatic anatomic changes that trade ease and possibility of reversal for better weight loss outcomes and independence from an implantable device [246, 247].

Role of laparoscopy in revisional procedures

Revisional bariatric operations may be performed laparoscopically [248-250] or via open technique [251, 252]. Complications are more common after reoperations than after primary bariatric procedures [253]. Surgeons may prefer an open approach to address severe adhesions, or to permit tactile localization of prior partitions in the stomach to avoid creating undrained or ischemic segments during restapling [230]. Foreign-body removal and partial gastric resection may also be required [216]. Drain placement is often performed in response to a recognized increased possibility of leak [254].

Guidelines for revisional bariatric surgery

  • Prior to elective procedures, anatomy should be defined by review of available records, plus radiographic and/or endoscopic assessment (level II, grade B).
  • Laparoscopic revisional procedures may be performed safely, but with more complications than primary bariatric procedures, therefore the relative risks and benefits of laparoscopy should be considered on a case-by-case basis (level III, grade C).

Summary

Bariatric surgery is medically indicated for morbidly obese patients who fail to respond to dietary, behavioral, nutritional, and medical therapies, with clear evidence of efficacy and safety. BMI and age-based candidacy guidelines should not limit access for patients suffering with progressive or poorly controlled obesity-related comorbidities if the risk-versus-benefit analysis favors surgery. Laparoscopic RGB, AGB, and BPD have all been proven effective.

Given the marked paucity of prospectively collected comparative data between the different bariatric operations, it remains impossible to make definitive recommendations for one procedure over another. At the present time, decisions are driven by patient and surgeon preferences, as well as considerations regarding the degree and timing of necessary outcomes versus tolerance of risk and lifestyle change.

Until the emergence of additional randomized controlled comparative studies, decisions between procedures will depend upon the present evidence and the relative importance placed by patients and surgeons on purported discriminating factors.

Relative strengths of laparoscopic bariatric surgical procedures

AGBRGBBPDComparative trials and meta-analysesNoncomparative trials
Objective
Lowest perioperative risk++++++[22, 208][21, 36, 134, 147, 165, 166, 210]
Most effective durable weight loss++++++[72, 143, 145, 206, 207][2, 19, 21, 29, 136, 137, 145, 193-195]
Best comorbidity resolution++++++[22, 208][126, 128, 139-141, 195, 199, 200]
Most reversible+++++[210, 211, 246, 247]
Best procedure to avoid reoperation due to:
Technical complication – early++++++[21, 181, 205]
Technical complication – late++++++[181, 210, 211]
Metabolic complication – late++++++[29, 126, 152-154]
Inadequate weight loss++++++[22, 207][190]
Subjective
Lowest need for outpatient visits++++++[57, 138, 178, 179]
Fewest metabolic consequences of poor follow-up++++++
Durable weight loss with poor patient compliance++++++[138]

Relative scale +++ > ++ > +

Acknowledgement Printing costs of this guideline were supported by Karl Storz.

Appendix A: Levels of evidence

Level IEvidence from properly conducted randomized, controlled trials
Level IIEvidence from controlled trials without randomization
Or
Cohort or case-control studies
Or
Multiple time series, dramatic uncontrolled experiments
Level IIIDescriptive case series, opinions of expert panels

Appendix B: Scale used for recommendation grading

Grade ABased on high-level (level I or II), well-performed studies with uniform interpretation and conclusions by the expert panel
Grade BBased on high-level, well-performed studies with varying interpretation and conclusions by the expert panel
Grade CBased on lower-level evidence (level II or less) with inconsistent findings and/or varying interpretations or conclusions by the expert panel

Appendix C: 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 I, grade A).

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 co-morbid conditions (level II, grade A).
  • LSG is validated as providing effective weight loss and resolution of comorbidities to 3-5 years (level II, grade C).

Guidelines for patient selection

  • 1991 NIH consensus guidelines provide valid but incomplete patient selection criteria for contemporary bariatric procedures including laparoscopic BPD ± DS, RGB, VBG and AGB (level II, grade A).
  • Other well-selected patients may benefit from laparoscopic bariatric surgery by experienced surgeons:
    – BMI > 60 kg/m2 (level II, grade A).
    – Patients > 60 years (level II, grade B).
  • Adolescent bariatric surgery (age < 18 years) has been proven effective but should be performed in an experienced center (level II, grade B). Patient selection criteria should be the same as used for adult bariatric surgery (level II, grade C).
  • Individuals with BMI 30-35 kg/m2 may benefit from laparoscopic bariatric surgery (level I, grade B).

Guidelines for bariatric programs

  • Bariatric surgery programs should include multidisciplinary providers with appropriate training and experience (level III, grade C).
  • Institutions must accommodate the special needs of bariatric patients and their providers (level III, grade C).
  • Participation in support groups may improve outcomes after bariatric surgery (level II, grade B).

Guidelines for preoperative preparation

  • A psychological evaluation is commonly part of the preoperative work-up of bariatric patients (level III, grade C).
  • Treated psychopathology does not preclude the benefits of bariatric surgery (level II, grade B).
  • Preoperative weight loss may be useful to reduce liver volume and improve access for laparoscopic bariatric procedures (level II, grade B), but mandated preoperative weight loss does not affect postoperative weight loss or comorbidity improvements (level I, grade B).

Guidelines for laparoscopic BPD ± DS

  • In BPD, the common channel should be 60-100 cm, and the alimentary limb 200-360 cm (level II, grade C).
  • DS diminishes the most severe complications of BPD, including dumping syndrome and peptic ulceration of the anastomosis (level II, grade C).
  • BPD is effective in all BMI >35 kg/m2 subgroups, with durable weight loss and control of comorbidities beyond 5 years (level II, grade A).
  • Laparoscopic BPD provides equivalent weight loss, shorter hospital stay, and fewer complications than open BPD (level III, grade C).
  • BPD may result in greater weight loss (level II, grade A) and resolution of comorbidities (level II, grade B) than other bariatric surgeries, but with the highest mortality rate (level II, grade A).
  • After BPD ± DS, close nutritional surveillance and supplementation are needed (level III, grade C).

Guidelines for laparoscopic RGB

  • In laparoscopic RGB, a small lesser-curvature-based pouch that excludes the gastric fundus and a 75-150 cm alimentary (Roux) limb are effective for most patients (level II, grade B).
  • Alimentary limbs >150 cm may improve intermediate-term weight loss but also may increase nutritional complications (level III, grade C).
  • Laparoscopic RGB is similar in efficacy to open RGB (level I, grade A) with reduced early complications and risk of hernia (level II, grade B).
  • Long-term follow-up is recommended and may improve weight-loss outcomes (level III, grade C).

Guidelines for laparoscopic AGB

  • The pars flaccida approach for laparoscopic AGB placement should be used in preference to the perigastric approach in order to decrease the incidence of gastric prolapse (level II, grade A).
  • Laparoscopic AGB is effective in all BMI subgroups, with durable weight loss and control of comorbidities past 5 years (level I, grade A).
  • Intermediate-term weight loss after laparoscopic AGB may be less than after laparoscopic RGB (level I, grade A).
  • Frequent outpatient visits are suggested in the early postoperative period. Band filling should be guided by weight loss, satiety, and patient symptoms (level III, grade C).

Guidelines for revisional bariatric surgery

  • Prior to elective procedures, anatomy should be defined by review of available records, plus radiographic and/or endoscopic assessment (level II, grade B).
  • Laparoscopic revisional procedures may be performed safely, but with more complications than primary bariatric procedures, therefore the relative risks and benefits of laparoscopy should be considered on a case-by-case basis (level III, grade C).

References

  1. Hedley AA, Ogden CL, Johnson CL et al (2004) Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. JAMA 291(23):2847-2850
  2. Colquitt J, Clegg A, Loveman E et al (2005) Surgery for morbid obesity. Cochrane Database Syst Rev 4(4):CD003641
  3. Fisher BL, Schauer P (2002) Medical and surgical options in the treatment of severe obesity. Am J Surg 184(6B):9S-16S
  4. Sjostrom L, Narbro K, Sjostrom CD et al (2007) Swedish Obese Subjects Study. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 357(8):741-752
  5. Nguyen NT, Root J, Zainabadi K et al (2005) Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 140(12):1198-1202
  6. Ogden CL, Fryar CD, Carroll MD, Flegal KM (2004) Mean body weight, height, and body mass index, United States 1960- 2002. CDC National Center for Health Statistics, Number 347
  7. Flegal KM, Carroll MD, Ogden CL, Johnson CL (2002) Prevalence and Trends in obesity among US adults, 1999-2000. JAMA 288:1723-1727
  8. Must A, Spadano J, Coakley EH et al (1999) The disease burden associated with overweight and obesity. JAMA 282(16):1523- 1529
  9. Overweight, obesity, health risk: National Task Force on the prevention and treatment ofobesity (2000) Arch Intern Med 160:898-904
  10. North American Association for the study of obesity (NAASO), the National Heart (1998) Clinical Guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. National Institutes of Health, Bethesda, MD, NIH publication 98-4083
  11. Mizuno T, Shu IW, Makimura H, Mobbs C (2004) Obesity over the life course. Sci Aging Knowledge Environ 2004(24): re4 (ISSN 1539-6150)
  12. Fontaine KR, Redden DT, Wang C et al (2003) Years of life lost due to obesity. JAMA 289(2):187-193
  13. Allison DB, Fontaine KR, Manson JE et al (1999) Annual deaths attributable to obesity in the United States. JAMA 282:1530-1538
  14. Goodrick GK, Poston WS 2nd, Foreyt JP (1996) Methods for voluntary weight loss and control: update 1996. Nutrition 12:672-676
  15. Davis BR, Blaufox MD, Oberman A et al (1993) Reduction in long-term antihypertensive medication requirements. Effects of weight reduction by dietary intervention in overweight persons with mild hypertension. Arch Intern Med 153:1773-1782
  16. Stamler R, Stamler J, Grimm R et al (1987) Nutritional therapy for high blood pressure. Final report of a 4-year randomized controlled trial-the Hypertension Control Program. JAMA 257:1484-1491
  17. Hypertension Prevention Trial Research Group (1990) The Hypertension Prevention Trial: three year effects of dietary changes on blood pressure. Arch Intern Med 150:153-162
  18. The Trials of Hypertension Prevention Collaborative Research Group (1997) Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in overweight people with high-normal blood pressure. The Trials of Hypertension Prevention, phase II. Arch Intern Med 157:657-667
  19. Sjostrom L, Lendroos A, Peltonen M et al (2004) Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 351(26):2683-2693
  20. Pories WJ, Swanson MS, MacDonald KG et al (1995) Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 222:239
  21. Maggard MA, Shugarman LR, Suttorp M et al (2005) Meta-analysis: surgical treatment of obesity. Ann Intern Med 142(7):547-559
  22. Buchwald H, Avidor Y, Braunwald E et al (2004) Bariatric surgery, a systematic review and meta-analysis. JAMA 292:1724-1728
  23. Oluseun AS, Yood SM, Courtney J et al (2007) Natural history of morbid obesity without surgical intervention. Surg Obes Relat Dis 3:73-77
  24. Busetto L, Mirabelli D, Petroni ML et al (2007) Comparative long-term mortality after laparoscopic adjustable gastric banding versus nonsurgical controls. Surg Obes Relat Dis 3(5):496-502
  25. Adams TD, Gress RE, Smith SC et al (2007) Long-term mortality after gastric bypass surgery. N Engl J Med 357(8): 753-761
  26. Santry HP, Gillen DL, Lauderdale DS (2005) Trends in bariatric surgical procedures. JAMA 294(15):1909-1917
  27. Buchwald H, Rucker RD (1987) The rise and fall of jejunoileal bypass. In: Nelson RL, Nyhus LM (eds) Surgery of the small intestine. Appleton Century Crofts, Norwalk, CT, pp 529-541
  28. Scopinaro N, Gianetta E, Civalleri D et al (1979) Bilio-pancreatic bypass for obesity: II. Initial experience in man. Br J Surg 66(9):618-620
  29. Marceau P, Biron S, Bourque R-A et al (1993) Biliopancreatic diversion with a new type of gastrectomy. Obes Surg 3:29-35
  30. Gagner M, Patterson E (2000) Laparoscopic biliopancreatic diversion with duodenal switch. Dig Surg 17:547-566
  31. Mason EE, Ito C (1967) Gastric bypass in obesity. Surg Clin North Am 47:1845-1852
  32. Buchwald H et al (2005) Consensus conference statement bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. J Am Coll Surg 200:593-604
  33. Wittgrove AC, Clark GW (2000) Laparoscopic gastric bypass, Roux-en-Y 500 patients: technique and results, with 3-60 month follow-up. Obes Surg 10:233-239
  34. Schauer PR, Ikramuddin S, Gourash W et al (2000) Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 232:515-529
  35. de la Torre RA, Scott JS (1999) Laparoscopic Roux-en-Y gastric bypass: a totally intra-abdominal approach: technique and preliminary report. Obes Surg 9:492-498
  36. DeMaria EJ, Sugerman HJ, Kellum JM, Meador JG, Wolfe LG (2002) Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. Ann Surg 235(5):640- 645; discussion 645-7
  37. Higa KD, Boone KB, Ho T et al (2000) Laparoscopic Roux-en-Y gastric bypass for morbid obesity: technique and preliminary results of our first 400 patients. Arch Surg 9:1029-1033
  38. Printen KJ, Mason EE (1973) Gastric surgery for relief of morbid obesity. Arch Surg 106:428-431
  39. Mason EE (1986) Vertical banded gastroplasty. Arch Surg 152:413-416
  40. Chua TY, Mendiola RM (1995) Laparoscopic vertical banded gastroplasty: the Milwaukee experience. Obes Surg 5:77-80
  41. Champion JK, Hunt T, DeLisle N (2002) Role of routine intraoperative endoscopy in laparoscopic bariatric surgery. Surg Endosc 6:1663-1665
  42. Kuzmak LI (1991) A review of seven years’ experience with silicone gastric banding. Obes Surg 1:403-408
  43. Belachew M, Legrand MJ, Defechereux TH et al (1994) Laparoscopic adjustable silicone gastric banding in the treatment of morbid obesity: a preliminary report. Surg Endosc 8:1354-1356
  44. Buchwald H, Williams SE (2004) Bariatric surgery worldwide 2003. Obes Surg 14(9):1157-1164
  45. Hamoui N, Anthone GJ, Kaufman HS, Crookes PF (2006) Sleeve gastrectomy in the high-risk patient. Obes Surg 16:1445-1449
  46. Moon Han S, Kim WW, Oh JH (2005) Results of laparoscopic sleeve gastrectomy (LSG) at 1 year in morbidly obese Korean patients. Obes Surg 15:1469-1475
  47. Himpens J, Dapri G, Cadie`re GB (2006) A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 16:1450-1456
  48. Cottam D, Qureshi FG, Mattar SG et al (2006) Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc 20:859-863
  49. Milone L, Strong V, Gagner M (2005) Laparoscopic sleeve gastrectomy is superior to endoscopic intragastric balloon as a first stage procedure for super-obese patients (BMI C50). Obes Surg 15:612-617
  50. Braghetto I, Korn O, Valladares H et al (2007) Laparoscopic sleeve gastrectomy: surgical technique, indications and clinical results. Obes Surg 17:1442-1450
  51. Roa PE, Kaidar-Person O, Pinto D et al (2006) Laparoscopic sleeve gastrectomy as treatment for morbid obesity: technique and short-term outcome. Obes Surg 16:1323-1326
  52. Silecchia G, Boru C, Pecchia A et al (2006) Effectiveness of laparoscopic sleeve gastrectomy (first stage of biliopancreatic diversion with duodenal switch) on co-morbidities in super-obese high-risk patients. Obes Surg 16:1138-1144
  53. Vidal J, Ibarzabal A, Nicolau J et al (2007) Short-term effects of sleeve gastrectomy on type 2 diabetes mellitus in severely obese subjects. Obes Surg 17:1069-1074
  54. Weiner RA, Weiner S, Pomhoff I et al (2007). Laparoscopic sleeve gastrectomy-influence of sleeve size and resected gastric volume. Obes Surg 17:1297-1305
  55. Lee CM, Cirangle PT, Jossart GH (2007) Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results. Surg Endosc 21:1810-1816
  56. De Luca M, Segato G, Bussetto L et al (2004) Progress in implantable gastric stimulation: summary of results of the European multi-center study. Obes Surg 14(Suppl 1):S33-S39
  57. NIH conference Consensus Development Conference Panel (1991) Gastrointestinal surgery for severe obesity. Ann Intern Med 115:956-961
  58. Ahn LB, Huang CS, Forse RA et al (2005) Crohn’s disease after gastric bypass surgery for morbid obesity: is there an association? Inflamm Bowel Dis 11(6):622-624
  59. Pretolesi F, Camerini G, Marinari GM et al (2006) Crohn disease obstruction of the biliopancreatic limb in a patient operated for biliopancreatic diversion for morbid obesity. Emerg Radiol 12(3):116-118
  60. Parikh M, Duncombe J, Fielding GA (2006) Laparoscopic adjustable gastric banding for patients with body mass index of ≤ 35 kg/m2. Surg Obes Relat Dis 2(5):518-522
  61. O’Brien PE, Dixon JB, Laurie C et al (2006) Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program. Ann Intern Med 144:625-633
  62. Cohen R, Pinheiro JS, Correa JL, Schiavon CA (2006) Laparoscopic Roux-en-Y gastric bypass for BMI <35 kg/m2:a tailored approach. Surg Obes Relat Dis 2(3):401-404
  63. Gould JC, Garren MJ, Boll V, Starling JR (2006) Laparoscopic gastric bypass: risks vs benefits up to two years following surgery in super-super obese patients. Surgery 140(4):524-529
  64. Farkas DT, Vemulapalli P, Haider A et al (2005) Laparoscopic Roux-en-Y gastric bypass is safe and effective in patients with a BMI > 60. Obes Surg 15(4):486-493
  65. Helling TS (2005) Operative experience and follow-up in a cohort of patients with a BMI [ or + 70 kg/m2. Obes Surg 15(4):482-485
  66. Taylor JD, Leitman IM, Hon P et al (2006) Outcome and complications of gastric bypass in super-super obesity versus morbid obesity. Obes Surg 16(1):16-18
  67. Bennett JC, Wang H, Schimer BD, Northup CJ (2007) Quality of life and resolution of co-morbidities in super-obese patients remaining morbidly obese after roux-en-y gastric bypass. Surg Obes Relat Dis 3(3):387-391
  68. Techansky DS, DeMaria EJ, Fernandez AZ et al (2005) Postoperative complications are not increased in super-super obese patients who undergo laparoscopic roux-en-y gastric bypass. Surg Endosc 19(7):939-941
  69. Dresel A, Kuhn JA, McCarty TM (2004) Laparoscopic Rouxen-Y Gastric bypass in morbidly obese and super morbidly obese patients. Am J Surg 187(2):230-232
  70. Mognol P, Chosidow D, Marmuse JP (2005) Laparoscopic gastric bypass versus laparoscopic adjustable gastric banding in the super-obese: a comparative study of 290 patients. Obes Surg 15(1):76-81
  71. Bowne WB, Julliard K, Castro AE et al (2006) Laparoscopic gastric bypass is superior to adjustable gastric band in super morbidly obese patients: a prospective, comparative analysis. Arch Surg 141(7): 683-689
  72. Prachand VN, Davee RT, Alverdy JC (2006) Duodenal switch provides superior weight loss in the super-obese (BMI ≥ 50 kg/m2) compared with gastric bypass. Ann Surg 244(4): 611-619
  73. Hazzan D, Chin EH, Steinhagen E et al (2006) Laparoscopic bariatric surgery can be safe for treatment of morbid obesity in patients older than 60 years. Surg Obes Relat Dis 2(6):613-616
  74. Papasavas PK, Gagne DJ, Kelly J, Caushaj PF (2004) Laparoscopic Roux-en-Y gastric bypass is a safe and effective operation for the treatment of morbid obesity in patients older than 55 years. Obes Surg 14(8):1056-1061
  75. Frutos MD, Lujan J et al (2006) Results of laparoscopic gastric bypass in patients C55 years old. Obes Surg 16(4):461-464
  76. St Peter SD, Craft RO, Tided JL et al (2005) Impact of advanced age on weight loss and health benefits after laparoscopic gastric bypass. Arch Surg 140(2):165-168
  77. Varela JE, Wilson SE, Nguyen NT (2006) Outcomes of bariatric surgery in the elderly. Am Surg 72(10):865-869
  78. Dunkle-Blatter SE, St Jean MR, Whitehead C et al (2007) Outcomes among elderly bariatric patients at a high-volume center. Surg Obes Relat Dis 3(2):163-169
  79. Flum DR, Salem L, Elrod JA, Dellinger EP, Cheadle A, Chan L (2005) Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. JAMA 294(15):1903-1908
  80. Sosa JL, Pombo H, Pallavicini H, Ruiz-Rodriguez M (2004) Laparoscopic gastric bypass beyond age 60. Obes Surg 14(10):1398-1401
  81. Sugerman HJ, DeMaria EJ, Kellum JM et al (2004) Effects of bariatric surgery in older patients. Ann Surg 240(2):243-247
  82. Taylor CJ, Layani L (2006) Laparoscopic adjustable gastric banding in patients C60 years old: is it worthwhile? Obes Surg 16(12):1579-1583
  83. Quebbemann B, Engstrom D, Siegfried T (2005) Bariatric surgery in patients older than 65 years is safe and effective. Surg Obes Relat Dis 1(4):389-392
  84. Allen SR, Lawson L, Garcia V, Inge TH (2005) Attitudes of bariatric surgeons concerning adolescent bariatric surgery. Obes Surg 15:1192-1195
  85. Sanford A, Glascock JM, Eid GM et al (2003) Laparoscopic Roux-en-Y gastric bypass in morbidly obese adolescents. J Pediatr Surg 38:430-433
  86. Inge TH, Garcia VF, Daniels SR et al (2004) A multidisciplinary approach to the adolescent bariatric surgical patient. J Pediatr Surg 39:442-447
  87. Strauss RS, Bradley LJ, Brolin RE (2001) Gastric bypass surgery in adolescents with morbid obesity. J Pediatr 138:499-504
  88. Breaux CW (1995) Obesity surgery in children. Obes Surg 5:279-284
  89. Rand CS, Macgregor AM (1994) Adolescents having obesity surgery: a 6 year follow-up. South Med J 87:1208-1213
  90. Sugerman HJ, Sugerman EL, Demaria EJ (2003) Bariatric surgery for severely obese adolescents. J Gastrointest Surg 7:102-108
  91. Barnett SJ, Stanley S, Hanlon M et al (2005) Long-term follow-up and the role of surgery in adolescents with morbid obesity. Surg Obes Relat Dis 1:394-398
  92. Capella JF, Capella RF (2003) Bariatric surgery in adolescence. Is this the best age to operate? Obes Surg 13:826-832
  93. Inge TH, Xanthakos SA, Zeller MH (2007) Bariatric surgery for pediatric extreme obesity: now or later? Int J Obes 31:1-14
  94. Bouchard C (1991) Current understanding of the etiology of obesity. Am J Clin Nutr 53:1561S-1565S
  95. Lehman Center Weight Loss Surgery Expert Panel. Commonwealth of Massachusetts Betsy Lehman Center for Patient Safety, Medical Error Reduction Expert Panel on Weight Loss Surgery (2005) Executive report. Obes Res 13(2):205-226
  96. Sauerland S, Angrisani L, Belachew J et al (2005) Obesity surgery, evidence-based guidelines of the European Association for Endoscopic Surgery (E.A.E.S.). Surg Endosc 19:200-221
  97. Statement by the American College of Surgeons (2000) Recommendations for facilities performing bariatric surgery. Bull Am Coll Surg 85(9):20-23
  98. Collazo-Clavell ML, Clark MM, McAlpine DE et al (2006) Assessment and preparation of patients for bariatric surgery. Mayo Clin Proc 81(10 suppl):S11-S17
  99. Marcus JD, Elkins GR (2004) Development of a model for a structured support group for patients following bariatric surgery. Obes Surg 14:103-106
  100. Heldebrandt SE (1998) Effects of participation in bariatric support group after Roux-en-Y gastric bypass. Obes Surg 8:535-542
  101. Elakkary E, Elhorr A, Aziz F et al (2006) Do support groups play a role in weight loss after laparoscopic adjustable gastric banding? Obes Surg 16:331-334
  102. Nguyen NT, Paya M, Stevens CM et al (2004) The relationship between hospital volume and outcome in bariatric surgery at academic medical centers. Ann Surg 240(4):586-593
  103. Flum DR, Salem L, Elrod JA et al (2005) Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. JAMA 294:1903-1908
  104. Shirmer B, Jones DB (2007) The American College of Surgeons Bariatric Surgery Center Network: Establishing Standards. Bull Am Coll Surg 92(8):21-27
  105. http://www.surgicalreview.org/. Accessed 15 March 2008
  106. Bauchowitz AU, Gonder-Frederick LA, Olbrisch ME et al (2005) Psychosocial evaluation of bariatric surgery candidates: A survey of present practices. Psychosom Med 67:825-832
  107. Kinzl JF, Schrattenecker M, Traweger C et al (2006) Psychosocial predictors of weight loss after bariatric surgery. Obes Surg 16(12):1609-1614
  108. Van Hout GC, Verschure SK, van Heck GL (2005) Psychosocial predictors of success following bariatric surgery. Obes Surg 15:552-560
  109. Powers PS, Rosemurgy A, Boyd F, Perez A (1997) Outcome of gastric restriction procedures: weight, psychiatric diagnoses, and satisfaction. Obes Surg 7:471-477
  110. Herpertz S, Kielmann R, Wolf AM et al (2004) Do psychosocial variables predict weight loss or mental health after obesity surgery? A systematic review. Obes Res 12:1554-1569
  111. Sullivan CS, Logan J, Kolasa KM (2006) Medical nutrition therapy for the bariatric patient. Nutr Today 41(5):207-214
  112. Coughlin K, Bell RM, Bivins BA et al (1983) Preoperative and postoperative assessment of nutrient intake in patients who have undergone gastric bypass surgery. Arch Surg 118:813-816
  113. Thomason P (2004) Preparation of the gastric bypass surgery patient for post-operative dietary changes. Nutr Clin Care 7(1):37-39
  114. Colles SL, Dixon JB, Marks P et al (2006) Preoperative weight loss with a very-low-energy diet: quantitation of changes in liver and abdominal fat by serial imaging. Am J Clin Nutr 84(2): 304-311
  115. Lewis MC, Phillips ML, Slavotinek JP et al (2006) Change in liver size and fat content after treatment with Optifast very low calorie diet. Obes Surg 16(6):697-701
  116. Still CD, Benotti P, Wood GC et al (2007) Outcomes of preoperative weight loss in high-risk patients undergoing gastric bypass surgery. Arch Surg 142(10):994-998
  117. Jamal MK, DeMaria EJ, Johnson JM et al (2006) Insurance mandated preoperative dietary counseling does not improve outcome and increases dropout rates in patients considering gastric bypass surgery for morbid obesity. Surg Obes Relat Dis 2(2):122-127.
  118. Alami RS, Morton JM, Schuster R et al (2007) Is there a benefit to preoperative weight loss in gastric bypass patients? A prospective randomized trial. Surg Obes Relat Dis 3: 141-145
  119. Csendes A, Burgos AM, Smok G, Beltran M (2007) Endoscopic and histologic findings of the foregut in 426 patients with morbid obesity. Obes Surg 17(1):28-34
  120. Benotti P, Martin L (2004) Preoperative evaluation and preparation of bariatric surgery candidates. In: Martin L (ed) Obesity surgery. McGraw Hill, pp 95-109
  121. Weismann RE, Johnson RE (1977) Fatal hepatic failure after jejunoileal bypass: clinical and laboratory evidence of prognostic significance. Am J Surg 134(2):253-258
  122. Griffen WO Jr, Young VL, Stevenson CC (2005) A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity. 1977. Surg Obes Relat Dis 1(2):163-172
  123. DeMeester TR, Fuchs KH, Ball CS et al (1987) Experimental and clinical results with proximal end-to-end duodenojejunostomy for pathologic duodenogastric reflux. Ann Surg 206(4):414-426
  124. de Csepel J, Burpee S, Jossart G et al (2001) Laparoscopic biliopancreatic diversion with a duodenal switch for morbid obesity: a feasibility study in pigs. J Laparoendosc Adv Surg Tech A 11(2):79-83
  125. Marceau P, Hould FS, Simard S et al (1998) Biliopancreatic diversion with duodenal switch. World J Surg 22(9):947-954
  126. Dolan K, Hatzifotis M, Newbury L et al (2004) A clinical and nutritional comparison of biliopancreatic diversion with and without duodenal switch. Ann Surg 240(1):51-56
  127. Gagner M, Matteotti R (2005) Laparoscopic biliopancreatic diversion with duodenal switch. Surg Clin North Am 85(1): 141-149
  128. Marceau P, Biron S, Hould FS, Marceau S (2006) Changing intestinal absorption for treating obesity. In: Sugerman HJ, Nguyen NT (eds) Management of morbid obesity. Taylor & Francis, pp 153-166
  129. Scopinaro N, Gianetta E, Civalleri D et al (1979) Bilio-pancreatic bypass for obesity: 1. An experimental study in dogs. Br J Surg 66(9):613-617
  130. Hess DS (2003) Limb measurements in duodenal switch. Obes Surg 13(6):966
  131. Resa JJ, Solano J, Fatas JA et al (2004) Laparoscopic biliopancreatic diversion: technical aspects and results of our protocol. Obes Surg 14(3):329-333
  132. Resa JJ, Solano J, Fatas JA et al (2004) Laparoscopic biliopancreatic diversion with distal gastric preservation: technique and three-year followup. J Laparoendosc Adv Surg Tech A 4(3):131-134
  133. McConnell DB, O’Rourke RW, Deveney CW (2005) Common channel length predicts outcomes of biliopancreatic diversion alone and with the duodenal switch surgery. Am J Surg 189(5):536-540
  134. Paiva D, Bernardes L, Suretti L (2002) Laparoscopic biliopancreatic diversion: technique and initial results. Obes Surg 12(3):358-361
  135. Baltasar A, Bou R, Miro´ J, Pe´rez N (2001) Cruce duodenal por laparoscopia en el tratamiento de la obesidad mo´rbida: te´cnica y estudio preliminar. Cir Esp 70(2):102-104
  136. Anthone GJ (2005) The duodenal switch operation for morbid obesity. Surg Clin North Am 85(4):819-833
  137. Anthone GJ, Lord RV, DeMeester TR, Crookes PF (2003) The duodenal switch operation for the treatment of morbid obesity. Ann Surg 238(4):618-627
  138. Biron S, Hould FS, Lebel S et al (2004) Twenty years of biliopancreatic diversion: what is the goal of the surgery? Obes Surg 14(2):160-164
  139. Marinari GM, Papadia FS, Briatore L et al (2006) Type 2 diabetes and weight loss following biliopancreatic diversion for obesity. Obes Surg 16(11):1440-1444
  140. Carson JL, Ruddy ME, Duff AE et al (1994) The effect of gastric bypass surgery on hypertension in morbidly obese patients. Arch Intern Med 154(2):193-200
  141. Adami G, Murelli F, Carlini F et al (2005) Long-term effect of biliopancreatic diversion on blood pressure in hypertensive obese patients. Am J Hypertens 18(6):780-784
  142. Adami GF, Papadia F, Carlini F et al (2005) Effect of biliopancreatic diversion on hypertension in severely obese patients. Hypertens Res 28(2):119-123
  143. Dolan K, Hatzifotis M, Newbury L, Fielding G (2004) A comparison of laparoscopic adjustable gastric banding and biliopancreatic diversion in superobesity. Obes Surg 14(2):165-169
  144. Simard B, Turcotte H, Marceau P et al (2004) Asthma and sleep apnea in patients with morbid obesity: outcome after bariatric surgery. Obes Surg 14(10):1381-1388
  145. O’Brien PE, McPhail T, Chaston TB, Dixon JB (2006) Systematic review of medium-term weight loss after bariatric operations. Obes Surg 16(8):1032-1040
  146. Weiner R, Blanco-Engert R, Weiner S et al (2003) Outcome after laparoscopic adjustable gastric banding -8 years experience. Obes Surg 13(3):427-434
  147. Kim WW, Gagner M, Kini S et al (2003) Laparoscopic vs. open biliopancreatic diversion with duodenal switch: a comparative study. J Gastrointest Surg 7(4):552-557
  148. Ren CJ, Patterson E, Gagner M (2000) Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients. Obes Surg 10(6):514-523
  149. Hess DS, Hess DW, Oakley RS (2005) The biliopancreatic diversion with the duodenal switch: results beyond 10 years. Obes Surg 15(3):408-416
  150. Scopinaro N, Gianetta E, Civalleri D et al (1980) Two years of clinical experience with biliopancreatic bypass for obesity. Am J Clin Nutr 33(2 Suppl):506-514
  151. Parikh MS, Laker S, Weiner M et al (2006) Objective comparison of complications resulting from laparoscopic bariatric procedures. J Am Coll Surg 202(2):252-261
  152. Marceau P, Hould FS, Lebel S et al (2001) Malabsorptive obesity surgery. Surg Clin North Am 81(5):1113-1127
  153. Chapin BL, LeMar HJ Jr, Knodel DH, Carter PL (1996) Secondary hyperparathyroidism following biliopancreatic diversion. Arch Surg 131(10):1048-1052
  154. Moreiro J, Ruiz O, Perez G et al (2007) Parathyroid hormone and bone marker levels in patients with morbid obesity before and after biliopancreatic diversion. Obes Surg 17(3):348-354
  155. Michielson D, Van Hee R, Hendrickx L (1996) Complications of biliopancreatic diversion surgery as proposed by Scopinaro in the treatment of morbid obesity. Obes Surg 6(5):416-420
  156. Bardaro SJ, Gagner M, Consten E et al (2007) Routine cholecystectomy during laparoscopic biliopancreatic diversion with duodenal switch is not necessary. Surg Obes Rel Dis 3(5): 549-553
  157. Demaria EJ, Jamal MK (2005) Surgical options for obesity. Gastroenterol Clin North Am 34(1):127-142
  158. Buchwald H (2002) Overview of bariatric surgery. J Am Coll Surg 194(3):367-375
  159. Roberts K, Duffy A, Kaufman J et al (2007) Size matters: Gastric pouch size correlates with weight loss after laparoscopic Roux-en-Y gastric bypass. Surg Endosc 21(8):1397-1402
  160. Feng JJ, Gagner M, Pomp A et al (2003) Effect of standard vs extended roux limb length on weight loss outcomes after laparoscopic Roux-en-Y gastric bypass. Surg Endosc 17(7):1055- 1060
  161. Inabnet WB, Quinn T, Gagner M et al (2005) Laparoscopic Roux-en-Y gastric bypass in patients with BMI <50: A prospective randomized trial comparing short and long limb lengths. Obes Surg 15(1):51-57
  162. Choban PS, Flancbaum L (2002) The effect of Roux limb lengths on outcome after Roux-en-Y gastric bypass: a prospective, randomized clinical trial. Obes Surg 12(4):540-545
  163. Nelson WK, Fatima J, Houghton SG et al (2006) The malabsorptive very, very long limb Roux-en-Y gastric bypass for super obesity: results in 257 patients. Surgery 140(4):517-522
  164. Brolin RE, LaMarca LB, Kenler HA, Cody RP (2002) Malabsorptive gastric bypass in patients with superobesity. J Gastrointest Surg 6(2):195-203
  165. Andrew CG, Hanna W, Look D et al (2006) Early results after laparoscopic Roux-en-Y gastric bypass: Effect of the learning curve. Can J Surg 49(6):417-421
  166. Kligman MD, Thomas C, Saxe J (2003) Effect of the learning curve on the early outcomes of laparoscopic Roux-en-Y gastric bypass. Am Surg 69(4):304-309
  167. Flum DR, Dellinger EP (2004) Impact of gastric bypass operation on survival: A population-based analysis. J Am Coll Surg 199(4):543-551
  168. Nguyen NT, Rivers R, Wolfe BM (2003) Factors associated with operative outcomes in laparoscopic gastric bypass. J Am Coll Surg 197(4):548-555
  169. Westling A, Gustavsson S (2001) Laparoscopic vs open Rouxen- Y gastric bypass: A prospective, randomized trial. Obes Surg 11(3):284-292
  170. Nguyen NT, Goldman C, Rosenquist CJ et al (2001) Laparoscopic versus open gastric bypass: A randomized study of outcomes, quality of life, and costs. Ann Surg 234(3):279-289
  171. Lujan JA, Frutos MD, Hernandez Q et al (2004) Laparoscopic versus open gastric bypass in the treatment of morbid obesity: A randomized prospective study. Ann Surg 239(4):433-437
  172. Lee WJ, Huang MT, Yu PJ et al (2004) Laparoscopic vertical banded gastroplasty and laparoscopic gastric bypass: A comparison. Obes Surg 14(5):626-634
  173. Olbers T, Fagevik-Olsen M, Maleckas A, Lonroth H (2005) Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic vertical banded gastroplasty for obesity. Br J Surg 92(5):557-562
  174. Puzziferri N, Austrheim-Smith IT, Wolfe BM et al (2006) Three-year follow-up of a prospective randomized trial comparing laparoscopic versus open gastric bypass. Ann Surg 243(2):181-188
  175. Olbers T, Bjorkman S, Lindroos A et al (2006) Body composition, dietary intake, and energy expenditure after laparoscopic Roux-en-Y gastric bypass and laparoscopic vertical banded gastroplasty: A randomized clinical trial. Ann Surg 244(5):715-722
  176. Shekelle PG, Morton SC, Maglione M et al (2004) Pharmacological and surgical treatment of obesity. Evid Rep Technol Assess (Summ) 103(103):1-6
  177. Christou NV, Sampalis JS, Liberman M et al (2004) Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg 240(3):416-423
  178. Shen R, Dugay G, Rajaram K et al (2004) Impact of patient follow-up on weight loss after bariatric surgery. Obes Surg 14(4):514-519
  179. Harper J, Madan AK, Ternovits CA, Tichansky DS (2007) What happens to patients who do not follow-up after bariatric surgery? Am Surg 2007;73(2):181-184
  180. Nguyen NT, Wilson SE (2007) Complications of antiobesity surgery. Nat Clin Pract Gastroenterol Hepatol 4(3):138-147
  181. Podnos YD, Jimenez JC, Wilson SE et al (2003) Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 138(9):957-961
  182. Ramsey-Stewart G (1995) Vertical banded gastroplasty for morbid obesity: weight loss at short and long-term follow up. Aust NZ J Surg 65(1):4-7
  183. Papakonstantinou A, Alfaras P, Komessidou V, Hadjiyannakis E (1998) Gastrointestinal complications after vertical banded gastroplasty. Obes Surg 8(2):215-217
  184. Howard L, Malone M, Michalek A et al (1995) Gastric bypass and vertical banded gastroplasty-a prospective randomized comparison and 5-year follow-up. Obes Surg 5(1):55-60
  185. Suter M, Giusti V, Worreth M et al (2005) Laparoscopic gastric banding: a prospective, randomized study comparing the LAPBAND and the SAGB: Early results. Ann Surg 241(1):55-62
  186. O’Brien PE, Dixon JB, Laurie C, Anderson M (2005) A prospective randomized trial of placement of the laparoscopic adjustable gastric band: comparison of the perigastric and pars flaccida pathways. Obes Surg 15(6):820-826
  187. Wolnerhanssen B, Kern B, Peters T et al (2005) Reduction in slippage with 11-cm Lap-Band and change of gastric banding technique. Obes Surg 15(7):1050-1054
  188. Khoursheed M, Al-Bader I, Mohammad AI et al (2007) Slippage after adjustable gastric banding according to the pars flaccida and the perigastric approach. Med Princ Pract 16(2):110-113
  189. Cottam DR, Atkinson J, Anderson A et al (2006) A case-controlled matched-pair cohort study of laparoscopic Roux-en-Y gastric bypass and LAP-BAND® patients in a single US center with three-year follow-up. Obes Surg 16(5):534-540
  190. Angrisani L, Di Lorenzo N, Favretti F et al (2004) The Italian group for LAP-BAND®: predictive value of initial body mass index for weight loss after 5 years of follow-up. Surg Endosc 18(10):1524-1527
  191. Galvani C, Gorodner M, Moser F et al (2006) Laparoscopic adjustable gastric band versus laparoscopic Roux-en-Y gastric bypass: Ends justify the means? Surg Endosc 20(6):934-941
  192. O’Brien PE, Brown WA, Smith A et al (1999) Prospective study of a laparoscopically placed, adjustable gastric band in the treatment of morbid obesity. Br J Surg 86:113-118
  193. Angrisani L, Alkilani M, Basso N et al (2001) Laparoscopic Italian experience with the Lap-Band (R). Obes Surg 11:307-310
  194. DeMaria EJ, Sugerman HJ, Meador JG et al (2001) High failure rate after laparoscopic adjustable silicone gastric banding for treatment of morbid obesity. Ann Surg 233:809-818
  195. Dixon JB, O’Brien PE (2003) Improvements in insulin sensitivity and beta-cell function (HOMA) with weight loss in the severely obese. Homeostatic model assessment. Diabet Med 20(2):127-134
  196. Dixon JB, O’Brien PE (2002) Health outcomes of severely obese type 2 diabetic subjects 1 year after laparoscopic adjustable gastric banding. Diabetes Care 25(2):358-363
  197. Abu-Abeid S, Keidar A, Szold A (2001) Resolution of chronic medical conditions after laparoscopic adjustable silicone gastric banding for the treatment of morbid obesity in the elderly. Surg Endosc 15(2):132-134
  198. Rubino F, Gagner M (2002) Potential of surgery for curing type2 diabetes mellitus. Ann Surg 236:554-559
  199. Dixon JB, O’Brien PE (1999) Gastroesophageal reflux in obesity: the effect of lap-band placement. Obes Surg 9(6):527-531
  200. Angrisani L, Iovino P, Lorenzo M et al (1999) Treatment of morbid obesity and gastroesophageal reflux with hiatal hernia by Lap-Band. Obes Surg 9(4):396-398
  201. Weiss HG, Nehoda H, Labeck B et al (2000) Treatment of morbid obesity with laparoscopic adjustable gastric banding affects esophageal motility. Am J Surg 180(6):479-482
  202. Dixon JB, Schachter LM, O’Brien PE (2001) Sleep disturbance and obesity: changes following surgically induced weight loss. Arch Intern Med 161(1):102-106
  203. Horchner R, Tuinebreijer MW, Kelder PH (2001) Quality-of-life assessment of morbidly obese patients who have undergone a Lap-Band operation: 2-year follow-up study. Is the MOS SF-36 a useful instrument to measure quality of life in morbidly obese patients? Obes Surg 11(2):212-218
  204. Weiner R, Datz M, Wagner D, Bockhorn H (1999) Quality-oflife outcome after laparoscopic adjustable gastric banding for morbid obesity. Obes Surg 9(6):539-545
  205. Martin LF, Smits GJ, Greenstein RJ (2007) Treating morbid obesity with laparoscopic adjustable gastric banding. Am J Surg 194(3):333-343
  206. O’Brien P (2006) Outcomes of laparoscopic adjustable gastric banding. In: Sugerman HJ, Nguyen NT (eds) Management of morbid obesity. Taylor & Francis, 2006, pp 181-190
  207. Angrisani L, Lorenzo M, Borrelli V (2007) Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized trial. Surg Obes Relat Dis 3(2):127-132
  208. Favretti F, O’Brien PE, Dixon JB (2002) Patient management after LAP-BAND placement. Am J Surg 184(6B):38S-41S
  209. Chapman AE, Kiroff G, Game P et al (2004) Laparoscopic adjustable gastric banding in the treatment of obesity: a systematic literature review. Surgery 135(3):326-351
  210. Favretti F, Segato G, Ashton D et al (2007) Laparoscopic adjustable gastric banding in 1,791 consecutive obese patients: 12-year results. Obes Surg 17(2):168-175
  211. Balsiger BM, Ernst D, Giachino D et al (2007) Prospective evaluation and 7-year follow-up of Swedish adjustable gastric banding in adults with extreme obesity. J Gastrointest Surg 11(11):1470-1477
  212. Fobi MA (1993) Operations that are questionable for control of obesity. Obes Surg 3:197-200
  213. Kaminski DL (2001) Gastric restrictive procedures to treat obesity: reasons for failure and long-term evaluation of the results of operative revision. Int J Surg Invest 2:413-421
  214. Westling A, Ohrvall M, Gustavsson S (2002) Roux-en-Y gastric bypass after previous unsuccessful gastric restrictive surgery. J Gastrointest Surg 6:206-211
  215. Sugerman HJ, Kellum JM Jr, DeMaria EJ, Reines HD (1996) Conversion of failed or complicated vertical banded gastroplasty to gastric bypass in morbid obesity. Am J Surg 171:263-269
  216. Capella JF, Capella RF (1996) Staple disruption and marginal ulceration in gastric bypass procedures for weight reduction. Obes Surg 6:44-49
  217. van Wageningen B, Berends FJ, Van Ramshorst B, Janssen IF (2006) Revision of failed laparoscopic adjustable gastric banding to Roux-en-Y gastric bypass. Obes Surg 16:137-141
  218. Weber M, Muller MK, Michel JM et al (2003) Laparoscopic Roux-en-Y gastric bypass, but not rebanding, should be proposed as rescue procedure for patients with failed laparoscopic gastric banding. Ann Surg 238:827-833
  219. Lanthaler M, Mittermair R, Erne B et al (2006) Laparoscopic gastric re-banding versus laparoscopic gastric bypass as a rescue operation for patients with pouch dilatation. Obes Surg 16:484-
  220. Johnson WH, Fernanadez AZ, Farrell TM et al (2007) Surgical revision of loop (‘‘mini”) gastric bypass procedure: multicenter review of complications and conversions to Roux-en-Y gastric bypass. Surg Obes Relat Dis 3:37-41
  221. Brethauer SA, Nfonsam V, Sherman V et al (2006) Endoscopy and upper gastrointestinal contrast studies are complementary in evaluation of weight regain after bariatric surgery. Surg Obes Relat Dis 2:643-648
  222. Clapp B, Yu S, Sands T, Wilson E, Scarborough T (2007) Preoperative upper endoscopy is useful before revisional bariatric surgery. JSLS 11(1):94-96
  223. Mondeturo F, Cappello I, Mazzoni G et al (2004) Radiological contrast studies after vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGBP) in patients with morbid obesity. Study of the complications. Radiol Med (Torino) 107:515-523
  224. Carrodeguas L, Szomstein S, Soto F et al (2005) Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surg Obes Relat Dis 1:467-474
  225. Filho AJ, Kondo W, Nassif LS et al (2006) Gastrogastric fistula: a possible complication of Roux-en-Y gastric bypass. JSLS 10:326-331
  226. Behrns KE, Smith CD, Kelly KA, Sarr MG (1993) Reoperative bariatric surgery. Lessons learned to improve patient selection and results. Ann Surg 218:646-653
  227. Macgregor AM, Rand CS (1991) Revision of staple line failure following Roux-en-Y gastric bypass for obesity: a follow-up of weight loss. Obes Surg 1:151-154
  228. Hunter R, Watts JM, Dunstan R et al (1992) Revisional surgery for failed gastric restrictive procedures for morbid obesity. Obes Surg 2:245-252
  229. van Gemert WG, van Wersch MM, Greve JW, Soeters PB (1998) Revisional surgery after failed vertical banded gastroplasty: restoration of vertical banded gastroplasty or conversion to gastric bypass. Obes Surg 8:21-28
  230. Gonzalez R, Gallagher SF, Haines K, Murr MM (2005) Operative technique for converting a failed vertical banded gastroplasty to Roux-en-Y gastric bypass. J Am Coll Surg 201:366-374
  231. Menon T, Quaddus S, Cohen L (2006) Revision of failed vertical banded gastroplasty to non-resectional Scopinaro biliopancreatic diversion: early experience. Obes Surg 16(11):1420-1424
  232. Wenger M, Piec G, Branson R et al (2005) Salvage of gastric restriction following staple-line dehiscence after vertical banded gastroplasty by insertion of an adjustable gastric band. Obes Surg 15(2):216-222
  233. Wang W, Huang MT, Wei PL et al (2004) Laparoscopic mini-gastric bypass for failed vertical banded gastroplasty. Obes Surg 14(6):777-782
  234. Bernante P, Foletto M, Busetto L et al (2006) Feasibility of laparoscopic sleeve gastrectomy as a revision procedure for prior laparoscopic gastric banding. Obes Surg 16(10):1327- 1330
  235. de Csepel J, Quinn T, Pomp A, Gagner M (2002) Conversion to a laparoscopic biliopancreatic diversion with a duodenal switch for failed laparoscopic adjustable silicone gastric banding. J Laparoendosc Adv Surg Tech A 12(4):237-240
  236. Gagner M, Rogula T (2003) Laparoscopic reoperative sleeve gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg 13(4):649-654
  237. Bessler M, Daud A, DiGiorgi MF et al (2005) Adjustable gastric banding as a revisional bariatric procedure after failed gastric bypass. Obes Surg 15(10):1443-1448
  238. Brolin RE, Cody RP (2007) Adding malabsorption for weight loss failure after gastric bypass. Surg Endosc 21(11):1924-1926
  239. Requarth JA, Burchard KW, Colacchio TA et al (1995) Long-term morbidity following jejunoileal bypass. The continuing potential need for surgical reversal. Arch Surg 130:318-325
  240. Yang CS, Lee WJ, Wang HH et al (2006) Spectrum of endoscopic findings and therapy in patients with upper gastrointestinal symptoms after laparoscopic bariatric surgery. Obes Surg 16:1232-1237
  241. Balsiger BM, Murr MM, Mai J, Sarr MG (2004) Gastroesophageal reflux after intact vertical banded gastroplasty: correction by conversion to Roux-en-Y gastric bypass. J Gastrointest Surg 4:276-281
  242. Gumbs AA, Duffy AJ, Bell RL (2006) Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Surg Obes Relat Dis 2:460-463
  243. Wilson JA, Romagnuolo J, Byrne TK et al (2006) Predictors of endoscopic findings after Roux-en-Y gastric bypass. Am J Gastroenterol 101:2194-2199
  244. St Jean MR, Dunkle-Blatter SE, Petrick AT (2006) Laparoscopic management of perforated marginal ulcer after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2:668
  245. Higa KD, Ho T, Boone KB (2003) Internal hernias after laparoscopic Roux-en-Y gastric bypass: incidence, treatment and prevention. Obes Surg 13:350-354
  246. Hamoui N, Chock B, Anthone GJ, Crookes PF (2007) Revision of the duodenal switch: indications, technique, and outcomes. J Am Coll Surg 204(4):603-608
  247. Himpens J, Dapri G, Cadie`re GB (2006) Laparoscopic conversion of the gastric bypass into a normal anatomy. Obes Surg 16(7):908-912
  248. Goergen M, Arapis K, Limgba A et al (2007) Laparoscopic Roux-en-Y gastric bypass versus laparoscopic vertical banded gastroplasty: results of a 2-year follow-up study. Surg Endosc 21:659-664
  249. Muller MK, Wildi S, Scholz T et al (2005) Laparoscopic pouch resizing and redo of gastro-jejunal anastomosis for pouch dilatation following gastric bypass. Obes Surg 15:1089-1095
  250. Calmes JM, Giusti V, Suter M (2005) Reoperative laparoscopic Roux-en-Y gastric bypass: an experience with 49 cases. Obes Surg 15:316-322
  251. Khaitan L, Van Sickle K, Gonzalez R et al (2005) Laparoscopic revision of bariatric procedures: is it feasible? Am Surg 71:6-10
  252. Nesset EM, Kendrick ML, Houghton SG et al (2007) A two-decade spectrum of revisional bariatric surgery at a tertiary referral center. Surg Obes Relat Dis 3:25-30
  253. Cates JA, Drenick EJ, Abedin MZ et al (1990) Reoperative surgery for the morbidly obese: A university experience. Arch Surg 125:1400-1403
  254. Serafini F, Anderson W, Ghassemi P et al (2002) The utility of contrast studies and drains in the management of patients after Roux-en-Y gastric bypass. Obes Surg 12:34-38

This statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) on Jun 2008.

SAGES publication #30

For more information please contact:

SOCIETY OF AMERICAN GASTROINTESTINAL ENDOSCOPIC SURGEONS (SAGES)
11300 West Olympic Blvd., Suite 600
Los Angeles, CA 90064
Tel:
(310) 437-0544
Fax:
(310) 437-0585
Email:
publications@sages.org

Guidelines for clinical practice are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations will be based on existing data or a consensus of expert opinion when little or no data are available. Guidelines are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only acceptable approaches due to the complexity of the healthcare environment. Guidelines are intended to be flexible. Given the wide range of specifics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision.

Guidelines are developed under the auspices of the Society of American Gastrointestinal and Endoscopic Surgeons and its various committees, and approved by the Board of Governors. Each clinical practice guideline has been systematically researched, reviewed and revised by the guidelines committee, and reviewed by an appropriate multidisciplinary team. The recommendations are therefore considered valid at the time of its production based on the data available. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research knowledge, and practice.