Surgical options

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Surgical intervention is an option for patients with clinically severe obesity (BMI >40kg/m2 or >35kg/m2 with comorbid conditions) judged by experienced clinicians to have a low probability of success with non-surgical measures, as demonstrated by failure in established weight control programs. There are currently no defined criteria for a specified length of time or description of what constitutes such treatment, although many consider formal participation in a medically supervised diet and exercise program for at least 6 months or longer. The surgery should be considered only for well-informed and motivated patients with acceptable operative risks. The patient should be able to participate in long-term follow-up. Patients should be evaluated by a multidisciplinary team comprised of professionals with medical, surgical, psychiatric and nutritional expertise.

Surgical procedures for weight loss range from restrictive, to restrictive with malabsorption to primarily malabsorptive. The Roux-en-Y gastric bypass (RYBG) (see Fig. 9.2) is the most commonly performed procedure in the U.S. It provides a small gastric pouch for oral restriction in combination with some degree of small bowel malabsorption. It has a maximum weight loss of approximately 68% of the excess body weight. This plateau is reached between 12 and 18 months, postoperatively.

Weight loss with a malabsorptive procedure, such as ileal bypass (see Fig. 9.3) is reported to be greater than with a restrictive procedure, but with a greater incidence of metabolic complications. These complications include vitamin deficiency, mineral deficiency, electrolyte deficiency, dehydration and liver failure.

Multiple studies have demonstrated complete resolution or improvement of obesity-related comorbid conditions following obesity surgery including type 2 diabetes, hypertension, obstructive sleep apnea and hyperlipidemia [54]. The Swedish Obese Subjects (SOS) Study [55] compared obese subjects who underwent gastric surgery and contemporaneously matched, conventionally treated obese control subjects. The study followed the participants for 2 to 10 years to determine if short-term benefits seen with gastric surgery persist over

Fig. 9.3. Ileal Bypass Surgery.

time. It did not demonstrate a difference in the incidence of hyperlipi-demia and hypertension when compared to conventional therapy at 2 or 10 years. Quoted mortality rates range from 0.1 to 0.2% (adjusted in-hospital mortality) [56] to 2.0%, 2.8% and 4.6% for 30-day, 90-day and 1-year mortality, respectively [57].

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