Guidelines for the Clinical Application of Laparoscopic Bariatric Surgery

INTRODUCTION

Clinically severe obesity and/or morbid obesity are recognized as major public health risks throughout the world. In the U.S.A. alone, over six million people suffer from this chronic disease. Much of the associated morbidity and mortality is related to co-morbid conditions which include, but are not limited to, cardiac disease, type II diabetes mellitus, obstructive sleep apnea, [Pickwickian syndrome], hypertension, dyslipidemia, gastroesophageal reflux disease, stress urinary incontinence, arthritis of the weight bearing joints, infertility and some cancers.

Surgical treatment of morbid obesity (bariatric surgery) has been well established as being safe and effective (1,2). Long-term improvement of co-morbid conditions has been well documented (2-8). Medical treatment for this disease has included dietary manipulation, behavior modification and medications. These therapies have been tried individually and in combinations, but with only limited long-term success (9). The National Institutes of Health consensus conference in 1991 established widely accepted guidelines and indications for the surgical management of severe obesity (1). The indications for surgical management of obesity are summarized below.

INDICATIONS FOR SURGERY

Surgical therapy should be considered for individuals who:

• have a body mass index (BMI) equal to or greater than 40 kg/m2

OR

• have a BMI equal to or greater than 35 kg/m2 and significant co-morbidities.

AND

• can show that dietary attempts at weight control have been ineffective.

PERI-OPERATIVE AND LONG TERM MANAGEMENT CONSIDERATIONS

The overall care of patients undergoing operatively induced weight loss (bariatric surgery) requires programs that address both perioperative care and long-term management. Careful preoperative evaluation and patient preparation are critical to success. Patients should have a clear understanding of expected benefits, risks, and long-term consequences of surgical treatment. Surgeons must know how to diagnose and manage complications specific to bariatric surgery. Patients require lifelong follow-up with nutritional counseling and biochemical surveillance. Surgeons also must understand the requirements of severely obese patients in terms of facilities, supplies, equipment and staff necessary to meet these needs, and should ensure that the specialized staff and/or multi-disciplinary referral system is included in treatment of these patients. This multi-disciplinary approach includes medical management of comorbidities, dietary instruction, exercise training, specialized nursing care and psychological assistance as needed on an individual basis. Post-operative management of co-morbidities should be directed by a practitioner familiar with relevant bariatric operations

SURGICAL TECHNIQUES

Bariatric procedures rely on two primary mechanisms to promote weight loss: gastric restriction and intestinal malabsorption. Purely restrictive operations include various gastric banding procedures and the vertical banded gastroplasty. In the adjustable gastric band the amount of restriction can be adjusted while in the vertical banded gastroplasty it remains fixed. The gastric bypass and biliopancreatic diversion procedures also cause gastric restriction but rely on varying amounts of intestinal malabsorption as an additional weight loss mechanism. Increasingly, hormonal changes are being recognized as an important mechanism of postsurgical weight loss; recent studies have demonstrated that gastric bypass results in altered release of hunger-causing hormones, such as ghrelin. (Cummings 2002)

The NIH conference of 1991 recognized the vertical banded gastroplasty and gastric bypass as acceptable procedures based on available outcome data (1). Regardless of whether restrictive or combined restrictive-malabsorptive procedures are utilized, follow up is imperative to monitor for potential serious sequelae and operative failure. These operations should only be performed within the setting of an obesity treatment program committed to maintaining long-term follow up for evaluation of outcomes (23).

Minimally invasive approaches have been used in bariatric surgery since 1993 (14, 15). The benefits of a laparoscopic approach appear to be similar to those realized with laparoscopic cholecystectomy, including but not limited to a shorter recovery with an earlier return to normal activity. In addition, wound complications such as infection, abdominal wall hernia, seroma and hematoma (16) are significantly reduced. Overall outcome following laparoscopic weight loss surgery appears to be comparable to that following equivalent open procedures (17).

The indications for laparoscopic treatment of obesity are the same as for open surgery, and have been outlined earlier in this document. Not all patients are suitable for laparoscopic weight reduction surgery, and conversion to an open bariatric procedure is sometimes necessary. Surgeons performing bariatric procedures laparoscopically must have the skills, experience and equipment necessary to convert to and perform open bariatric operations.

Virtually all bariatric operations can be performed with laparoscopic techniques (14-21). For safe and effective laparoscopic treatment of obesity, advanced laparoscopic skills are required. Therefore, appropriate training in advanced laparoscopic techniques is mandatory. These skills are most appropriately acquired through a residency or fellowship, or in courses that teach the indications for surgically inducing weight loss, the various surgical approaches (both open and laparoscopic) and the advanced technical skills necessary to perform these operations. Additionally, the long-term care of these patients needs to be understood. Prior to performing laparoscopic bariatric operations, surgeons must meet all local credentialing requirements for the performance of open bariatric procedures and advanced laparoscopic operations (22). Credentialing guidelines for both open and laparoscopic bariatric procedures have been made available by several national surgical organizations (24, 25). Finally, these procedures require a well-trained operating team familiar with the equipment, instruments and techniques of weight loss surgery.

SUMMARY

Morbid obesity is a significant health concern. Medical management usually fails to achieve sustained weight loss, and medical management of obesity-related morbidities remains expensive and largely ineffective. Currently, bariatric surgical procedures are the most effective means to achieve significant, sustained weight loss, and thereby provide effective and durable treatment of the obesity-associated morbidities. Laparoscopic approaches, based on their "open" counterparts, are available. When performed by appropriately trained surgeons, laparoscopic approaches appear to speed the patient's recovery and return to normal function. Experience and training in weight loss surgery, advanced laparoscopic surgery skills, and a commitment to long-term patient care are required for successful treatment of these patients.

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REFERENCES

1. Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin Nutr 1992; 55: 615S-9S.

2. Mun EC, Blackburn GL, Mathews JB. Current Status of Medical and Surgical Therapy for Obesity. Gastroenterology 2001; 120: 669-681.

3. McGoey BV, Deitel M, Saplys RFJ et al. Effect of weight loss on musculoskeletal pain in the morbidly obese. J Bone Joint Surg (Br) 1990; 72-B: 322-3

4. Charuzi I, Ovnat A, Peiser J et al. The effect of surgical weight reduction on sleep quality in obesity-related sleep apnea syndrome. Surgery 1985; 97: 535-8.

5. Herrera MF, Deitel M. Cardiac function in massively obese patients and the effect of weight loss. Can J Surg 1991; 34: 431-4.

6. Pories WJ, MacDonald KG, Flickinger EG, et al: Is type II diabetes mellitus (NIDDM) a surgical disease? Ann Surg 1992; 215:633-643.

7. Deitel M, Stone E, Kassam HA et al. Gynecologic-obstetric changes after loss of massive excess weight following bariatric surgery. J Am Coll Nutr 1988; 7: 147-53.

8. Carson JL, Ruddy ME, Duff AE et al. The effect of gastric bypass surgery on hypertension in morbidly obese patients. Arch Intern Med 1994; 154: 193-200.

9. Glazer G. Long-term pharmacotherapy of obesity 2000: a review of efficacy and safety. Arch Int Med 2001; 161:1814-24.

10. Mason EE, Doherty C, Cullen JJ et al. Vertical banded gastroplasty: evolution. World J Surg 1998; 22: 919-24.

11. Linner JH, Drew RL. Why the operation we prefer is the Roux-Y gastric bypass. Obes Surg 1991; 1: 305-6.

12. Scopinaro N, Adami GF, Marinari GM et al. Biliopancreatic diversion. World J Surg 1998; 22: 936-46.

13. Lagace M, Marceau P, Marceau S et al. Biliopancreatic diversion with a new type of gastrectomy: some previous conclusions revisited. Obes Surg 1995; 1: 411-18.

14. Kuzmak LI. A review of 7 years experience with silicone gastric banding for morbid obesity. Obes Surg 1991; 1: 403-08

15. Wittgrove AC, Clark GW, Laparoscopic Gastric Bypass, Roux-en-Y 500 patients: Technique and results with 3-60 months follow-up. Obes Surg 2000; 10: 233-9.

16. Nguyen NT, Ho HS, A Comparison Study of Laparoscopic versus Open Gastric Bypass for Morbid Obesity. J AM Coll Surg 2000; 191: 149-55.

17. Schauer P, Ikramuddin S, Gourash W, Ramanathan R, Luketich JD. Outcomes after Laparoscopic Roux-en-Y gastric bypass. Ann Surg 2000; 232; 515-529.

18. Belachew M, Legrand M, Vincent V, Lismonde M, LeDocte N, Deschamps V. Laparoscopic adjustable gastric banding. World J Surg 1998: 22: 955-63.

19. Chua TY, Mendiola RM. Laparoscopic vertical banded gastroplasty: the Milwaukee experience. Obes Surg 1995; 5: 636-38.

20. Lonroth H, Dalenback J, Haglind E et al. Laparoscopic bypass: another option in bariatric surgery. Surg Endosc 1996; 6: 500-04.

21. Catona A, La Manna L, Forsell P. The Swedish adjustable gastric band: laparoscopic technique and preliminary results. Obes Surg 2000; 10: 15-21.

22. Society of American Gastrointestinal Endoscopic Surgeons (SAGES). SAGES publication #0017, Framework for Post-Residency Surgical Education & Training; January, 1994, revised April 1998; [Surgical Endoscopy 8:0 (Sept/94) p. 1137-1142].

23. Cummings DE, Weigle DS, Frayo RS et al. (2002) Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery. N Engl J Med 346(21):1623-1630.

24. American Society of Bariatric Surgeons (ASBS). ASBS Guidelines For Granting Privileges In Bariatric Surgery. ASBS 2003

25. Society of American Gastrointestinal Endoscopic Surgery (SAGES) Publication #31, 2003.

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This statement was reviewed and approved by the Boards of Governors of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) July, 2003. It was originally prepared jointly by members of SAGES and the American Society of Bariatric Surgeons (ASBS).

Requests for reprints should be sent to:

Society of American Gastrointestinal Endoscopic Surgeons (SAGES)
11300 West Olympic Boulevard, Suite 600
Los Angeles, CA 90064
Tel: (310) 437-0544
Fax: (310) 437-0585
E-mail: sagesweb@sages.org

SAGES Publication #0030

 

 

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